• Safety net

    Malaria has devastated sub-Saharan Africa for generations, but it appears inroads are finally being made against the disease.

    Safety net

    Chances are, malaria isn’t something you give much thought to. You know that you can get it from mosquitoes, and that they are downright irritating – especially in summer, when their buzzing and bites keep you awake.

    No problem. Just slap on lotion or plug in an insect repellent: out of sight, out of mind.

    If you live in an urban area – or at least one that is not a malaria hotspot – you don’t have to contend with the dangers of the disease, let alone the devastation it can wreak in all spheres of life, which includes physiological, emotional and economic.

    If you happen to live in rural Nigeria, though, you would almost certainly have been touched by the disease. At least one person in your family (probably a child) would have died from it. That’s if you’re lucky. And that’s not counting the deaths outside of your direct family, friends and neighbours – or in the wider community.

    The same applies in Ghana, Mozambique, the DRC and Sierra Leone. In fact, almost anywhere in central sub-Saharan Africa.

    Malaria is one of the most severe public health problems in the world; but Africa is hardest hit. The Johns Hopkins Malaria Research Institute says: ‘The World Health Organisation currently estimates that each year malaria causes 300 million to 500 million infections and over one million deaths.’

    Some 90% of these deaths occur in Africa, and of those, the vast majority are children under the age of five. But why is Africa so hard hit?

    It is partly due to geography. The tropical and subtropical conditions of sub-Saharan Africa are a natural breeding ground for malaria. A lack of infrastructure, education and funding also plays a role.

    Thanks to these efforts (and much more), there have been an estimated 500 million fewer cases and 3.3 million less deaths between 2001 and 2012

    Daniel Feikin, a medical epidemiologist at the Kenya branch of the Centres for Disease Control and Prevention (CDC), told the Irin news agency: ‘All the risk factors are here.

    ‘Crowding, malnutrition, no access to safe water, living in an area with a lot of mosquitoes carrying malaria, and HIV epidemics – they’re all here.’

    Predictably, the poor are worst affected. In fact, not only are they at greater risk of contracting the disease due to a lack of access to preventative measures and treatment, but malaria impoverishes them even further.

    For most, the expense of drugs; travelling to and obtaining treatment from health facilities; absenteeism from work or school and, ultimately, burial expenses, can decimate a struggling family’s meagre finances.

    On a broader level, the disease places an enormous strain on African economies, affecting them on multiple levels. Countries with a heavy malaria burden may allocate as much as 40% of health expenditure to maintain infrastructure, promote education and conduct research.

    National productivity is affected when, for example, the incidence of malaria infection increases during the rainy season, resulting in decreased agricultural production. Children affected by the disease are more likely to fall behind and drop out of school – if they survive. Lastly, tourism is impacted when visitors are discouraged by fear of infection.

    No one can say whether it is poverty that precipitates the high rates of infection or vice versa. The two problems are closely connected, and solving one will greatly contribute to resolving the other. It isn’t that far-fetched to say, in fact, that the eradication of malaria could be the continent’s saving grace.

    The CDC has estimated that malaria costs Africa US$12 billion a year. Just imagine what could be achieved if that money were allocated into developing better infrastructure and providing education.

    So what is being done about it? The short answer: quite a lot, but not enough. Initiatives contributing to the cause in the last decade include the World Bank’s Malaria Control Booster Programme; Global Fund to Fight Aids, Tuberculosis and Malaria; Global Malaria Action Plan. In addition to campaigns by the UN and WHO, all have made great strides in countering the disease.

    Between 2000 and 2012, malaria mortality rates fell by 45% globally and 49% in Africa. This means that the measures taken once governments receive assistance and funds are effective.

    Practical strategies include the roll-out of insecticide-treated nets; indoor residual spraying; preventive treatments; and artemisinin-based combination therapy, a treatment that aims to outfox drug-resistant strains of the disease. Other approaches include increased awareness and education, as well as early diagnosis.

    Mining firms that operate in Ghana, Mali, Guinea and Tanzania have also undertaken to help combat the spread of malaria. AngloGold Ashanti has ‘in-house programmes focusing on employees to large-scale, community-based interventions whose design, planning and implementation is undertaken in partnership with governments, NGOs and the communities involved’, says the company.

    The AngloGold Ashanti Malaria Control Programme has also reduced cases of the disease. Since 2006, Obuasi in Ghana has experienced a 79% reduction in malaria cases. The model is so effective that it has been rolled out to 22 districts in Ghana.

    In Zambia, the Mopani and Konkola copper mines have seen the number of malaria cases in company clinics plummet by 94% over a 10-year period as a direct result of their anti-malaria programmes.

    Thanks to these efforts (and much more), there have been an estimated 500 million fewer malaria cases and 3.3 million less deaths between 2001 and 2012, says WHO. However, the organisation warns that ‘international targets for reducing malaria cases and deaths will not be attained unless considerable progress is made in the 17 most-affected countries, which account for an estimated 80% of malaria cases’.

    Nigeria, Tanzania, Uganda, Mozambique, the DRC and Côte d’Ivoire are six of the worst-affected African countries that still need urgent intervention.

    Apart from the lack of funding and awareness, there are other challenges to overcome, such as the illegal sale of bad drugs, which significantly contributes to high malaria mortality rates.

    Along with a welcome influx of antimalarial drugs from China and India, came a scourge of counterfeits. About 20% of all malaria deaths are due to fake or substandard medicines.

    To the naked eye, pills made from chalk or flour are virtually indistinguishable from the genuine medicine. In certain cases, expired medication is repackaged and sold. Another growing concern is that the disease is developing a resistance to existing medications.

    ‘In the newspapers, we read a lot about artemisinin resistance being detected in Southeast Asia, and this is a concern since artemisinin derivatives are the workhorse of malaria control,’ says Tim Wells, chief scientific officer at Medicines for Malaria Venture (MMV), a non-profit public-private partnership.

    ‘Fortunately there are always two medicines in the tablets. This is one thing that the World Health Organisation has really put a lot of work into making sure it happens. However, we see resistance emerging to some of the partner drugs, and this again is a warning sign that we do need to accelerate the availability of new classes of medicine. Fortunately, again as with the insecticides, there are new classes of medicine in clinical development. We currently have five – ferroquine, artefenomel or OZ439, cipargamin or KAE609, DSM265, and MMV048 – that are being tested in early studies in human patients in what used to be called phase II studies.

    As the continent’s most developed country, South Africa plays a pivotal role in the fight against the disease

    ‘These could be available to patients in the next five to 10 years, and so it’s a race against time, knowing that the new drugs have to be available before the resistance to the current medicines hits Africa.’

    As the continent’s most developed country, South Africa plays a pivotal role in the fight against the disease.

    A recent example is the development of a potential antimalarial drug by H3-D at UCT, in collaboration with MMV, says Dr Margaret Blackie, researcher at the department of chemistry and polymer science at Stellenbosch University. ‘This drug is currently in clinical trials. However, beyond this, there are many scientists in South Africa who are currently doing research on various aspects of malaria, from the development of novel drug molecules and insecticides, to the study of the pathways of resistance of both drugs and insecticides, to social and socio-economic issues associated with malaria and malaria-intervention strategies.

    ‘All of this research is valuable and provides good, solid scientific information which can be used to inform decisions made by those in countries and communities that are more closely affected by malaria.’

    The cost of prevention and treatment runs into the billions each year. What Africa needs is committed, major investment from the global community, as well as improved delivery of existing measures, new strategies and skills.

    Without this, the phenomenal progress that has been made over the last 10 years will grind to a halt, and then begin to decline. With it, will go a brief window of opportunity that would allow sub-Saharan Africa to gain the upper hand in the battle.

    By Rachel McGregor
    Image: Photos Greatstock/Corbis