The State of the Fight against Malaria
It should be shocking that, in 2022, a preventable disease like malaria still kills. Deaths are disproportionately concentrated among young children and pregnant women, and in the poorest countries. 627,000 people are estimated to have died of malaria in 2020, and 95% of these deaths occurred in Africa.
The burden of malaria does not fall equally within countries either: refugees, internally displaced people and migrants face increased risk of exposure and decreased access to malaria services due to high levels of mobility, movement to or through malaria-endemic areas, poor living conditions where standard mosquito control tools may not be practical, feasible or available. Within affected communities, women and girls bear the brunt of the health, social and economic impacts of malaria as patients, caregivers and healthcare providers. In malaria endemic countries, women and girls provide unpaid labor to households and communities as volunteer Community Health Workers and as caregivers to family members with malaria. Malaria can recur multiple times a year throughout and over a lifetime. This reduces the chance of girls staying in school, takes them out of the formal workforce, and removes their opportunities for full participation and leadership in society – ultimately perpetuating malaria as a leading driver of poverty and gender inequality.
Put bluntly, the burden of malaria is shouldered by the world’s poorest and most marginalized communities.
In the past two years, the COVID-19 pandemic has added further challenges to the fight against malaria. The malaria response was disrupted at all levels – prevention, diagnosis and treatment. COVID-19 wreaked havoc in supply chains, scared people away from service centers, and damaged the functioning of the overall health system, both from larger volumes of patients and staff falling sick (the UN Foundation). This all translated in 2020 in an estimated 69,000 additional malaria deaths. In Global Fund implementing countries that same year, there was a 4% decrease in malaria testing, and a stagnation in the number of pregnant women receiving preventative treatment.
At the same time, other indicators saw some growth – there were 17% more mosquito nets distributed by Global Fund programs in 2020 than in 2019, and even a slight increase in indoor residual spraying (Results Report). Overall, COVID-19 disruptions were felt less in malaria programs than in the response to HIV and TB, both because of the resilience of these programs and the epidemiological profile of COVID-19 in the countries most affected by malaria – which had most of their cases and disruption after 2020.
In the fight against malaria, 2020 saw further stagnations in most countries. Whereas low burden countries are continuing to make progress towards elimination and while eight countries achieved elimination since 2016, the momentum of progress has slowed considerably in the highest burden countries.
The state of the fight against malaria is all the more frustrating because the tools we have been using are old and well-known & there are significant advances to meet the modern challenges such as the first malaria vaccine and better performing nets. Malaria is one of mankind’s oldest scourge, and has successfully been driven out of most countries. We have the tools to accelerate progress. And this is where some of the most essential lessons of malaria for pandemic preparedness and response lie – the importance of community-led surveillance.
Preparing for Pandemics by Learning the Right Lessons
The challenge of ending malaria is not without commonalities with the fight against COVID-19. Not only do both diseases often first present themselves as fever (at least with early strains of COVID), they also are often benign and ignored, even while they present a significant threat to important groups in our societies. The often benign and unspecific symptoms of both diseases make surveillance – in the absence of large-scale, population-wide testing and genomic sequencing – challenging, and allows it to hide and come back in waves once we leave our guard down.
A key difference of course is that malaria has been pushed out of most high and middle income countries, and has to be fought in contexts with limited resource, whereas COVID-19 remains, for now, a global pandemic. There are lessons to learn from our experience with malaria that can be carried over in the fight against COVID-19 and pandemic preparedness generally.
Fever surveillance is the backbone of malaria programs. Because malaria disproportionally affects hard-to-reach groups, surveillance systems need to be embedded within communities. This has been achieved through community health worker programs (that exist under a diversity of names), which aim to give individuals within communities the training and the tools to effectively engage in local disease surveillance. They rely on simple and inexpensive tools, and are trained to focus on a narrow set of symptoms – and they treat and detect 250 million suspected malaria cases a year. In countries where the Global Fund invests, there are over 2 million community health workers, most of them funded through Global Fund grants.
During the COVID-19, community health workers were able to be redeployed to detect and report COVID-19 cases, supplementing testing centers and hospitals as cases were surging. And because they are embedded in their communities, they could be mobilized to relay trustworthy sources and fight disinformation. The Global Fund throughout 2020 and 2021 secured provided malaria program workers with PPE and COVID-19 tests to allow them to continue their work during the successive waves, identify malaria and COVID-19 cases in the communities and provide treatment locally when possible to reduce the surge in patients in the health systems. The Global Fund supported the redeployment of community health workers as COVID-19 cases were rising; In South Africa, 30,000 workers went door to door to screen people for COVID-19 symptoms, and in Kenya 63,000 workers were mobilized to monitor home-isolation and provide home-based care.
Networks of community workers need to become a model in our redesigned approach to pandemic preparedness. Previous metrics weighted too heavily country’s capacity to provide emergency care and have access to top-of-the-line laboratories. COVID-19 revealed that in the face of a disease infectious enough to become a pandemic, the capacity to rapidly mobilize a population to fight the disease was more important that idle care capacity – because the formal health systems of even the best-prepared countries simply could not cope with the exponential growth of an unchecked disease. The capacity for mobilization has been lost in countries with fully formalized health systems, where there a wall exists between health professionals and the public, and where health management is understood not as a communal endeavor but a professional one. This capacity for mobilization can be fostered through targeted interventions, as shown by the way Global Fund investments in community-based malaria programs have been able to be leveraged to create more care and prevention capacity during the pandemic.
The pandemic preparedness and response that we want and that we need has be grounded in these realization. It can learn from malaria not to be narrowly focused on care and technological bells and whistles and instead build resilient communities through investment in education, prevention, and a trusted presence of the health system at the local level through community health workers. These workers need to be compensated for their work and integrated with the broader health system to remain effective over the long-term and empower communities to make empowered decision regarding their health. Placing affected communities at the center has been at the core of the Global Fund mission since its founding, and is reflected in its approach to investing in the fight against malaria. After the 7th Replenishment, it’s crucial that the Global Fund be able to continue investing in the community-based systems that should be the backbones of our approach to pandemic preparedness and response.
It will take $7.8 billion of investment by the Global Fund in the fight against malaria to put us on track towards eliminating malaria as an epidemic by 2030, and a total of $24 billion across the three diseases to meet our 2030 commitments. To the unprecedented challenges of ending the three diseases in a COVID world, we must answer with unprecedented ambition and commitment.