Fight intensifies against malaria

This will be a decisive year for malaria. From the jungles of the Greater Mekong or the urban shanties of Haiti, new tools and tactics are being used to counter the spread of the disease and to alleviate its huge economic and human costs.

It still infects 200m people each year and kills nearly 600,000, yet enormous progress has been made since the start of the millennium - the death rate has halved and an estimated 4.3m lives have been saved but there are concerns over funding and biological resistance.

Pedro Alonso, director of the World Health Organisation's global malaria programme, says: "Malaria has been a success story. The progress made is really unprecedented. But we are at a tipping point. We are worried about losing the gains achieved over the past decade."

Meanwhile, 19 countries are moving towards elimination. Argentina is set to be declared malaria-free this year, while other nations including Sri Lanka and Saudi Arabia are close.

Leaders of countries where malaria is endemic have stepped up their cross-border commitments spearheaded by organisations such as the African Leaders' Malaria Alliance and the Elimination Eight of southern African countries as well as the Asia Pacific Leaders Malaria Alliance. Some prominent business people have also increased support, such as Aliko Dangote in Nigeria.

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GlaxoSmithKline's RTS,S, a vaccine it is developing against the parasite, is being scrutinised regulators. Meanwhile, Oxitec is developing genetically modified sterile mosquitoes to eradicate the insects that transmit the infection.

There is fresh momentum on yet more ambitious goals. The Bill & Melinda Gates Foundation is reviving a decades-old discussion about eradication. "The great debate now is a malaria-free world," says Alan Magill, in charge of work on the disease at the Seattle-based organisation. "Do we just accept the status quo or start to chart paths towards a new vision?"

Already the World Health Organisation is set to seek approval next month from ministers of health at the World Health Assembly in Geneva of a bolder plan for 2016-2030 that envisages elimination of malaria in at least 35 more countries, with a 90 per cent reduction in death and infection.

In the Greater Mekong, a growing number of studies have shown that the parasite has become resistant to artemisinin and the other drugs with which it is combined on the Thai-Cambodia border. There are plans for a rapid shift towards elimination of the disease using techniques including mass drug administration to the entire population.

The aim is a $4bn decade-long effort to wipe out the parasite in the region where resistance to drugs has emerged in the past and further resistance risks spreading around the world today. The danger is malaria's ability to adapt - there are well documented past failures of widespread elimination programmes that ultimately only spurred resistance. Migrant and often clandestine workers on contested borders in the region will add to the complications.

Still more troubling, notably in Africa, is a growing pattern of resistance to existing insecticides used to spray indoors and to impregnate bed nets. Manufacturers and academic teams are working on alternatives, but are concerned at slow progress

Luke Lucas, in charge of global vector control at Sumitomo Chemical, says: "It's like we are steaming on the Titanic towards the iceberg but having to wait until we sink and large numbers of people die before there is a willingness to change." He and others raise the alarm about counterfeit, substandard and inappropriate insecticides, bed nets and drugs that accelerate resistance. Despite international guidelines against the use of "monotherapy" artemisinin drugs, for instance, eight countries still authorise their use and two dozen Indian companies manufacture them.

In the absence of stronger public health systems, there are also continued worries about the role of the private medical sector.

But if tougher controls and incentives for appropriate use of newer technologies are important, so are more targeted approaches to stretch existing resources further. Nigeria and the Democratic Republic of Congo alone account for 40 per cent of total global malaria deaths each year, yet progress has been slow.

In Haiti, older chloroquine drugs remain effective while bed nets are less useful than elsewhere, given that mosquitoes in Haiti tend to bite earlier in the evening. That suggests the need for different approaches to malaria in different locations.

Increased funding will be fundamental to continued progress.

The WHO's own plan envisages that annual spending on malaria needs to rise from $2.5bn currently to $6.5bn by 2020 and $9bn by 2030.

In September, the UN general assembly is set to adopt Sustainable Development Goals to replace the Millennium Development Goals (MDGs) that expire at the end of 2015. The fear is that the new objectives will distract attention from health in general and malaria in particular.

Ray Chambers, the businessman and UN secretary-general's special envoy for financing the health MDGs and the fight against malaria, says: "We've been working hard to retain quantifiable and measurable outcomes. We're a bit concerned about the number of additional draft goals and how to keep the focus."

Whatever the outcomes, there are growing calls for fast-growing emerging economies with a significant malaria burden to pay more themselves.

To complicate matters, there is debate about the explanations for reduced malaria cases in recent years, and hence how best to respond in the future. Case numbers in parts of Africa began falling before the big upsurge in funding from the early 2000s. That implies other factors than health programmes - such as infrastructure and broader economic and social development - were at least partly responsible for the decline in cases.

"We need to think more about joining forces with other sectors," says Fatoumata Nafo-Traore, head of the Roll Back Malaria partnership. "Construction and small-scale irrigation create breeding sites for mosquitoes. Improving housing, education and tackling malaria through tourism ministries are all important."

In the fight against malaria, health responses alone will not be enough.

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