Defeating malaria is within our grasp

Ten years ago, faced with nearly 1 million lives lost to malaria each year, 53 African heads of state came together in the Nigerian capital, Abuja, to declare the ambitious goal of halving the number of malaria-related deaths on the continent over the next decade.

Although the international community pledged its full support for this bold, but achievable goal, the necessary financing did not immediately materialise. Five years after the Abuja declaration came the shocking news that progress had been minimal, provoking condemnation and sharp editorials about "How not to roll back malaria".

As critics at the New York Times observed at the time: "We know what needs to be done to control malaria. What is lacking is the drive and resourcefulness to do it."

Indeed, an arsenal of potent technologies was at the ready. Insecticide-treated bednets had been shown to protect against malaria-carrying mosquitoes, which are active primarily at night. Indoor residual spraying with insecticides remained a safe and effective alternative. And a new generation of powerful drugs had been developed for the treatment of malaria. Despite this arsenal, the fight against malaria had stalled.

Against this backdrop, it is all the more remarkable that, at the end of 2010, the battle against malaria is viewed as a landmark success story in the making. While much hard work lies ahead, the number of malaria-related deaths is finally in decline. According to the World Health Organisation's World Malaria Report 2010, published this afternoon, malaria-related deaths have fallen from 985,000 in 2000 to 781,000 in 2009. In 11 African countries, the malaria burden has dropped by more than 50% over the same time period.

The explanation for the turnaround is threefold: the commitment of Africa's leaders, generous financial support from donor countries and institutions, and enlightened leadership and co-operation among the more than 500 partners that make up the Roll Back Malaria Partnership.

Since 2008, more than $5bn in new money has been provided for malaria control, primarily from the Global Fund to fight Aids, TB and malaria, the US, the UK, the Bill and Melinda Gates Foundation, and the World Bank.

This support has contributed to a dramatic increase in the delivery of interventions, including insecticide-treated bednets. By early 2011, the total number of nets distributed in sub-Saharan Africa over the past three years will approach the initial target of 350 million needed to reach the goal of universal coverage declared by the UN secretary general, Ban Ki-moon, in 2008. This achievement represents the largest scale-up of a malaria control intervention in Africa's history.

Over the past few years, Nigeria and the Democratic Republic of the Congo (DRC) – which account for more than 40% of the malaria burden in Africa – have made tremendous strides in malaria control through large-scale distribution of bednets: 71 million in Nigeria, and 27 million in DRC. The impact of these recent efforts will protect nearly 200 million people and is expected to translate into a historic rate of decline in malaria-related deaths in future years.

Technologies are also getting better. With the advent of rapid, reliable and inexpensive diagnostic tests, the WHO now strongly recommends that all suspected malaria cases undergo diagnostic confirmation prior to treatment. Doing so improves the quality of care for individual patients, cuts down the overuse of drugs, protects their therapeutic life and allows for timely and accurate malaria surveillance. It is also a marker of success. As transmission declines, past assumptions that most African children with a fever have malaria no longer hold true.

Serious concerns

The development of parasite resistance to antimalarial drugs and mosquito resistance to insecticides are perennial threats; the development of new generations of these compounds is critical for sustained success. Ambitious communication and educational efforts are needed to carry the message of the importance of malaria prevention and treatment to the most isolated African villages. And the network of clinics and community health workers in rural areas must be greatly strengthened to provide ready access to rapid diagnosis and effective treatment.

Rwanda offers a glimpse of the benefits of a successful malaria control campaign, and the persistence that is needed if these gains are to be more than ephemeral. It has significantly scaled up malaria control interventions, including distributing 6.4 million nets in the last three years. Malaria inpatient cases and deaths fell by more than 50%. Despite these impressive gains, Rwanda noted an upsurge in cases beginning in 2009.

A new mosquito net campaign was launched in April 2010 to replace older nets, and this appears to have reduced malaria cases and deaths.

The crucial question is whether, in the face of challenging economic conditions, donor nations and institutions will stay the course – committing the nearly $2bn currently allocated to the malaria effort each year. The impact the investment in malaria control is having on reducing not only malaria deaths, but all child mortality indicates the positive ripple effect that ending malaria deaths can have. The model established with malaria not only addresses multiple millennium development goals, but also provides a blueprint that can be followed to confront similar global health challenges.

The historic opportunity to end all deaths from malaria by 2015 is within our reach – and it is affordable. If the effort succeeds, it will save millions of lives. If the international community does not stay the course, the human costs will be incalculable.