Q&A: Focus on vulnerable communities to achieve malaria elimination

The Asia-Pacific region is close to eliminating malaria, but to “finish the job” there must be a focus on the most vulnerable communities, said Sarthak Das, CEO at the Asia Pacific Leaders Malaria Alliance.

According to the Organisation for Economic Co-operation and Development, some 2.31 billion people remain at high risk of malaria in the region. Yet the malaria narrative for Asia-Pacific tends to only focus on the successful progress, which leaves out voices from those people still at risk, Das explained.

“It's crucial we remember that elimination doesn't happen as a region unless it happens across the entire region,” he said. “Looking across Asia-Pacific, there are areas of high endemicity in countries where modest levels of control must be attained before preparing for elimination.”

Over 90% of the region’s burden is concentrated in five countries: Afghanistan, Indonesia,  India, Pakistan, and Papua New Guinea. Within these countries are high burden subregions, Das said, usually in areas with the lowest incomes and weakest health systems. Access to good quality health care, testing, and treatment continues to be a challenge for these communities, he added.

Das highlighted the example of Papua New Guinea, which in 2020 accounted for 41% of cases in the region and faced severe limitations in resources for health delivery, with barely one doctor per 1,000 people.

Speaking to Devex, Das warned that “the fight is far from over” and stressed that there is still much to be achieved in the last stretch toward malaria elimination by 2030. He explained how to reach vulnerable communities, the challenges standing in the way of regional elimination, and what the international community can do to support the final push toward elimination.

This conversation has been edited for length and clarity.

What are the main challenges the Asia-Pacific region faces when it comes to preventing and treating malaria?

Where we find malaria is where we find weak systems. So context is important. We're in Asia-Pacific, which [has almost] 60% of the world's population … Rural extreme poverty rates [in some areas of the region] are significantly higher than urban extreme poverty rates — up to eight times higher in places such as Papua New Guinea, Solomon Islands, and Myanmar, and up to five times higher in Pakistan. We have 350 million people who are estimated to be undernourished. That's 51% of the global total … All of that sets the stage when thinking about malaria and what we need to do to eliminate it.

The challenge is a lack of quality health infrastructure where the pavement ends. By that I mean both hardware — primary and referral facilities, diagnostic and vector control tools, antimalarials, etc. — and software — surveillance and data tools, strong public health management systems, etc. On the hardware side, we often gloss over the need to reinvigorate the basic health care infrastructure required to rebuild community trust in health systems. Electricity and clean water in rural facilities — around which we find much of the malaria pockets we have — should accompany sophisticated diagnostic tools. And by public health software, I mean the system in which all this hardware operates — the flow of data, bed nets, and drugs, using data to manage outbreaks. It is ultimately a team, a system which is well mentored, supported, and managed.

We have to pay attention to systems building … because it requires relentless focus — particularly as we get closer to the end. If there are any lessons to be learned from COVID-19 for malaria and other emerging communicable diseases, it is the need to build robust health care systems to meet current and future threats particularly where the systems are the weakest.

Are there certain approaches to tackling malaria that you think have been particularly impactful?

We should recognize that there has been tremendous progress, not just over time on malaria, but even in the past two years towards malaria elimination research and treatment.

First, let’s begin with the basics. Tried and true tools such as bed nets, other vector control products, diagnostics, drugs, a functional surveillance system, and a supply chain all built upon sound sub-national public health management has yielded remarkable results — leading to elimination in places like Sri Lanka and, most recently, China.

Second, there are important new steps such as on the vaccine front. The RTS,S vaccine, which targets malaria in young children in sub-Saharan Africa in high transmission areas is a huge milestone. Having said that, it's important to note that mosquitos are complex. There are more than 3,000 species globally. This vaccine targets the parasite P. falciparum, one of the two most deadly types of malaria, the other being P. vivax.

We have quite diverse malaria across the region compared with other parts of the world, so it's not the case that the vaccine is going to end the pandemic of malaria. But it gives hope after decades of effort. It's an exciting tool, and it gives hope for other vaccines in the future such as mRNA malaria vaccines or others that can address P. vivax.

Another important area to watch is in terms of treatment, including the important development of single-dose treatment tafenoquine for children with P. vivax malaria and other efforts around monoclonals. For the single dose, or “radical cure” there is still critical work around G6PD enzyme testing and its scale up to enable the right diagnostics to be in place. But with patient retention a perennial issue, an alternative to a longer course of treatment would be a major boon.

There are also interesting new developments on the bed net front. We know the effectiveness of long-lasting insecticide-treated nets is threatened by pyrethroid resistance, which can severely compromise malaria control efforts. A new study released last month from a large trial in Tanzania revealed strong data for some alternatives. When we look at some of our high endemic areas, for example in Papua [province in] Indonesia and Papua New Guinea, where the efficacy of nets has been questioned, this is important science.

But I can’t overemphasize: While new innovations and trends are a bonus and provide added hope for Asia-Pacific, we must ensure that even the weakest communities and systems can access, integrate, and utilize them. We have to keep reminding ourselves there is no one-size-fits-all approach to eliminating malaria.

Demographic shifts [and] changes in mosquito behavior related to global warming are just a few examples. To stay ahead of malaria, we must continue to optimize, harness, and tailor our existing tools to evolve our approach faster than the malaria itself. We must truly commit to supporting local leadership and integration of innovation with local plans and solutions. Tackling the last remaining cases requires systems that can ensure a relentless and consistent approach that are fit for purpose and well managed at subnational levels. 

How important is an intersectional approach to providing malaria prevention and treatment?

For a problem like malaria, as is the case in most of public health, intersectional and interdisciplinary approaches are critical. Three important areas come to mind.

First is climate change; shifts in where we find malaria and changes in the behavior of the vector itself, such as timing and patterns of biting being affected by global warming, mean that we need to double down on ensuring that interventions are adapted.

Second, we should be thoughtful about how we are incorporating a gender lens in malaria programming in Asia-Pacific. Do we have access to gender-disaggregated data? Are there interventions such as addressing malaria among pregnant women that could benefit from more research and study, particularly on the social and behavioral side? Malaria programs should adopt interdisciplinary approaches across other health programs.

Historically, malaria programs have remained vertical, where services are malaria-specific. Malaria interventions such as intermittent preventive treatment during pregnancy, or IPTp, LLIN distribution, and malaria screening for pregnant women can be better delivered in tandem with existing efforts. Malaria programs can leverage the maternal and child health services network to reach pregnant women and children.

And third, a “whole of government approach” is crucial. Battling malaria involves not just the health ministry for the program or finance for the funding, but also, for example, foreign affairs to work on cross-border malaria issues such as the prevention of reintroduction. Sri Lanka has been a model in this regard. And, for APLMA, maintaining political leadership and commitment towards malaria elimination is paramount.

On World Malaria Day, what is your message to the international community about how to support the Asia-Pacific region in tackling malaria?

We urgently need more investments to stop the resurgence of malaria and accelerate efforts to end the disease. With less than a decade left on the 2030 elimination goal and mounting uncertainty around COVID-19, the role of the Global Fund partnership has never been more essential.

APLMA has previously estimated the cost of elimination in Asia-Pacific for 2017-2030 to be $29 billion, with $3 billion needed annually. This investment would result in averting 123 million cases and [more than] 386,000 deaths in 22 Asia-Pacific countries.

The Global Fund’s seventh replenishment later this year is an opportunity to demonstrate this collective political leadership and will. Commitment will back an ambitious $18 billion plan, of which a third will be dedicated to reinforcing systems for health and pandemic preparedness, in addition to specific malaria interventions designed to accelerate the pathway to elimination.

The international community needs to remember that malaria elimination around the globe requires elimination by region, by country, and then at a subnational level. Within Asia-Pacific, we're getting closer, but we're looking at a handful of countries now that have 90% of the disease burden.

It’s also important to remember that investing in malaria is a six-to-one return on investment. We're talking about a disease that results in an estimated $88 billion in lost wages and productivity. Investing in finishing the job will then enable us to use those resources on other things. So if we can put in the incremental cost that's been estimated at around $14 billion, we will see that money come back to the region and to the world.

These investments are not just dual use, they're multivalent. When you invest in malaria, you invest in surveillance and you improve the overall capacity to not only detect diseases, including COVID-19 but also strengthen local public health program management. From data to planning and analysis, to supply chain management, malaria presents numerous opportunities to strengthen other community-based approaches for infectious diseases.

There will need to be some level of verticality until we eliminate malaria, but that knowledge and surveillance capacity won’t be lost. Public health history has shown us this through global efforts in smallpox eradication and polio.

A World Malaria Day column in 2032 where we discuss the elimination of malaria from Asia-Pacific and discuss how the savings are being redeployed in health systems — that would be a great conversation!

Malaria is a preventable, curable disease, and we have the tools to eliminate it, just as 40 countries in the world have shown. Let’s recommit to a world without malaria and, in the process, leave behind health systems improvements, particularly for those most vulnerable, that can endure.