Global investments in malaria control and elimination are now at risk of being rapidly reversed. Cambodia is where malarial drug resistance historically emerges and spreads globally; it appears we are currently watching history repeat itself. Radical action must be taken immediately to stop these nearly incurable strains of the disease from evolving and spreading.
Considerable investments have averted millions of malaria-attributable deaths since 2000. Nevertheless, one person (usually a child) still dies every 1.2 minutes from this disease. There was no reduction in mortality overall between 2015 and 2016, and mortality actually increased in some regions. In the most recent World Malaria Report, 219 million cases were reported in 2017, an increase of two million.
Information generated and compiled by the Consortium for Health Action, a U.S.-, Cambodia- and Vietnam-based organization I founded to eliminate emerging incurable malaria from the source in Southeast Asia, suggests the risk of spread of drug-resistant malaria from Asia into Sub-Saharan Africa significantly increases the likelihood of the next global pandemic.
Despite large investments and recent success in driving down overall rates of malaria, high levels of resistance to nearly all antimalarial drugs are now widespread in Cambodia, the main source of drug-resistant strains previously. Malaria cases were again rising in forested areas of Cambodia in 2017 and early 2018. Plasmodium falciparum, the parasite species that causes the deadly form of the disease, is also a species against which most drugs are ineffective. Incurable malaria spreading from this region is a real and present threat that must be stopped.
I developed my initial awareness of malaria as a college student visiting Tanzania in the early 1980s. There, I learned about the arrival of chloroquine resistance from Cambodia with the large numbers of resulting deaths. After training in internal medicine, I joined the U.S. Army as it was the only organization at that time pursuing new drugs for malaria. I went to the Thai-Cambodian border in 1991 to study the nearly incurable malaria that was endemic there at the time. The last drug (one invented by the U.S. Army) had just failed and no good alternates were available.
Throughout my career, I’ve spent extensive time in the field in Africa and Asia to understand the malaria situation. I’ve also spent much of my career developing the newly FDA-approved drug tafenoquine, because I saw it had the potential to enable elimination of all species of malaria. After retirement from the U.S. Army in 2013, I returned to Southeast Asia to address the largest remaining unmet need to eliminate malaria—quality implementation of standard interventions at scale. I firmly believe there are at least six organizations that can take urgent corrective action to address the ongoing poor-quality implementation of interventions, especially those focusing on the mosquitoes that transmit the disease in order to minimize drug pressure that make the parasites evolve.
In a recent chapter in a book titled Towards Malaria Elimination: A Leap Forward, my co-authors and I recommend critical actions needed to stop this threat, including:
- Commitment and real sense of urgency through declaration of a “Public Health Emergency of International Concern” or a similar set of directives.
- Establishing leadership with sufficient authority, respect, expertise and operational funding.
- Engaging affected security forces to stop disease transmission and support elimination operations.
- Utilizing surveillance as a core intervention with result-based funding targeting malaria transmission foci with rapid and effective action.
In Southeast Asia, malaria is only transmitted in and near the forest. “Forest islands” are now getting much smaller, but usually cross multiple administrative districts and sometimes international borders. Rapid elimination is possible if we take immediate decisive action in these areas.
The chapter highlights persistent gaps in the region and recommends methods to rapidly address them. In 2015–2016, the Vietnam National Malaria Control and Elimination Program pilot tested tools to intervene in actual forest transmission foci. The study district saw a 96 percent decrease in malaria from 2014 to 2017, with the entire province seeing the largest decrease in Central Vietnam in this same time frame. In the book chapter, we describe methods to tackle transmission foci, with both an integrated prevention and screening package.
We call on all stakeholders—specifically, the Bill & Melinda Gates Foundation, the Global Fund, the Presidential Malaria Initiative, the World Health Organization and importantly, the U.S. Army and U.S. Navy—to urgently take corrective action to address this critical challenge.
If the few key organizations could commit to effectively implementing a straightforward multisectoral approach, the WHO’s goal of eliminating multidrug-resistant falciparum malaria from Southeast Asia near the 2020 target can be achieved. The alternative—continued poor quality implementation, wasteful spending and investigator-oriented research—will mean that the nearly incurable and still evolving parasites will reach Africa, with the potential to start the next global pandemic.