Foreign aid cuts threaten global fight against malaria

The 25th of April is World Malaria Day. It’s an opportunity to examine a devastating disease that still claims over half a million lives each year, most of them young children in Africa. It comes as the World Health Organisation warns that huge funding cuts threaten to derail hard-won gains in the global fight against the disease, pointing out that, since the year 2000, these investments have helped to prevent 2 billion malaria cases and 12 million deaths. I’ve been speaking with Jane Carlton, director of the Johns Hopkins Malaria Research Institute at the Johns Hopkins Bloomberg School of Public Health. I put it to her that these are very big numbers, so malaria must account for a significant disease burden internationally…

Jane - Oh, absolutely it does. Over 260 million cases in 2023 is what the World Health Organization annual report came up with. And in fact, this is an increase over the cases from 2022 and about half a million deaths too, mainly in Africa. So approximately 40% of the world's countries have malaria and many of those are in the poorest regions of developing countries where access to healthcare is limited. It's quite a debilitating disease. So it really does have an impact on the economies of those countries. In fact, it's been estimated that about $12 billion is lost in Africa each year due to malaria.

Chris - It's spread by Anopheles mosquitoes. So is the disease everywhere where those mosquitoes are or are there areas where the mosquitoes are but the disease isn't yet and therefore those could be getting it soon?

Jane - That's one way of putting it. Another way of putting it is that there are the mosquitoes, Anopheles mosquitoes species present. For example, in the United States, we have the species which can transmit malaria parasites but we are not endemic for malaria. We used to be all the way up until about the 1950s when malaria was finally eliminated from our shores. And that's not to say that we don't continue to have some cases. In particular, we have malaria cases brought back in travelers and we get about 2000 cases of those in the US each year but we also occasionally get what's called locally transmitted malaria which is where the, because we have the Anopheles mosquitoes that can transmit parasites, people who've never left the country may come down with malaria and that's because there's been this local transmission of malaria. So I like to think of it more that we do still have those Anopheles mosquitoes but we can mitigate the effect of those by global health means to eliminate the malaria parasite from those areas.

Chris - Are there new areas opening up though with things like climate change? Will this make areas of the world more hospitable to the right source of mosquitoes so we could see countries that thought they're off the hook, malaria is not a problem and it becomes a problem?

Jane - The interesting thing about the malaria parasite is that she only develops within quite a narrow temperature range within the Anopheles mosquito. If it gets too hot, the parasite won't develop. So you may see a shift with areas in terms of their mosquito populations so that the range of malaria changes. So that's certainly possible. But actually the plasmodium parasite is quite finicky and as I say, it can only develop in a certain temperature range. So if it gets too hot, then it won't develop.

Chris - You mentioned there'd been an uptick compared to last year in terms of cases. Now, is that a sustained change or was it a one-off and actually the general direction of travel is that it's staying the same or shrinking?

Jane - Yes, that's a very good point actually. Malaria map as we know it is shrinking. So over the past 20 or 30 years, we have seen real gains in the number of malaria-free countries. For example, Egypt was announced as malaria-free under the terms of the World Health Organization last year. It's been malaria-free, no malaria cases for the past three years. So we are decreasing from year to year. There are upticks in particular when there are wars, for example, or ecological disasters. But overall, I think we are gradually managing to shrink the malaria map.

Chris - So why is the World Health Organization worried?

Jane - Because of the cuts in global health funding that the new administration in the United States have made. So the USAID, which funds the president's malaria initiative is one such organization which has really been decimated over the past several months. PMI was started in 2005 and its efforts have been focused in about 30 countries which account for 90% of the world's malaria cases. And PMI has been instrumental in reducing the burden of malaria in those African countries. For example, last year it delivered 37 million bed nets, 15 million preventive malaria treatments, 103 million rapid tests for the detection of malaria parasites. So having PMI no longer exist is something that the World Health Organization is very worried about.

Chris - WHO is a pretty powerful organisation though. And if it's just money, and I don't mean that in a belittling way, if it's just money, that is a relatively simple problem to solve, isn't it? Because couldn't other countries, given the enormous burden, be encouraged to step up and fill the void?

Jane - Well, we do know that some countries in Africa have stepped up. Nigeria, for example, has proposed to put forward $200 million in addition to its current malaria surveillance pot of money. But the problem is, as a colleague said to me, I think a lot of Western countries feel that because malaria is not endemic to their countries, why should they necessarily be providing funds for something that happens so far away?

Chris - What do you think is the solution then? Are there some other sort of things on the horizon if we put the bad news to one side? Where might we be making inroads, perhaps in novel ways, that might bear huge fruit?

Jane - There are definitely some really good initiatives which have been rolled out over the past year or so. Dual action bed nets to make sure that mosquitoes, which have become insecticide resistant, now will be caught by these double action bed nets. There are two new vaccines which the World Health Organization also just approved, RTSS and R21. And those are starting to be rolled out. I think 19 countries in December last year had already started those vaccination programs. So that's very good. And then other initiatives such as seasonal malaria chemoprophylaxis. So treating all of the children during the malaria season. And then in terms of some of the research that's ongoing, there are improved vaccines which are being looked into and researched. The development of genetically modified mosquitoes as well, especially those which then would not transmit malaria parasites. And repurposing anti-malarial drugs as well. These are all areas which are just ripe, I think, for malaria control.

Chris - Presumably your hope is that one day we're not going to need a World Malaria Day.

Jane - Absolutely. I hope that I'm going to be out of a job actually, maybe about the time that I retire, not sooner than that.

Chris - You don't want it to go any sooner than that, Jane.

Jane - So I really hope that that will be the case.