Progress towards ending malaria has stalled. Are we on the brink of a resurgence?
In the 2017 World Malaria Report, the World Health Organization sounded the alert warning the world that progress towards ending malaria has stalled in many regions and has even increased in many countries. This situation is potentially serious and could be devastating to all. The reasons for this change are many and too complicated to elucidate in a few lines of text, but they include: donor fatigue; significant reductions in the public health and disease prevention and control budgets of national campaigns and international aid programs; lack of career progressions for public health professionals, especially in countries carrying the burden of malaria; development of insecticide resistance in mosquito vectors; and an apparent aversion to exploring new materials and tools deployed using proven methods.
This last point is especially troubling when considering that the history of the hostilities between humans and mosquitoes provides us with countless examples where environmental management and larval source management (LSM) and larviciding eradicated malaria vectors from over one hundred countries before 1975 -not that long ago. Fred Soper, for instance, eradicated malaria vectors from an area in northern Brazil the size of Togo, West Africa in just under eighteen months almost exclusively with LSM. Though this may not sound like a significant accomplishment in current terms, he declared victory against malaria in 1939 as the Second World War was ravaging Europe and with none of today's materials or technology; not even have a calculator. Other examples of public health heroes who's names and contributions to public health have fallen off the pages of history books include Israel Kligler, William Gorgas, Carlos Finlay and Sir Walter Reed, just to name some.
The 2017 World Malaria Report generates two very fundamental questions: Are we doing the right thing? Are we doing things right? The latter is perhaps the more vital one. It reminds me of an article published in 2012 in Malaria World: Malaria: A full-time problem addressed on a part-time basis by amateur entomologists.
While the world continues to struggle with malaria and its possible resurgence, public health entomologists have been unable to convince UN public health agencies and organizations that LSM and larviciding are viable tools. Unfortunately, failure to deploy truly integrated vector control programs that attack all developmental stages of all mosquito vectors from different flanks and continuing to hold on to the position that considers LSM and larviciding effective only when sources are "few, fixed and findable" will only help pave the way for malaria's return. This position contradicts previous recommendations provided by WHO Offset Publications No. 66 & No. 1.
The current malaria situation requires a rethinking of vector control interventions, especially as Dengue fever, Chikungunya, Zika and other arboviruses have made their presence known in Africa, continue to affect Asia and other parts of the world and is poised to return in South America and the Caribbean Basin. Continuing the current position with regards to mosquito control fails to protect those who do not have the means or resources to protect themselves and their families from the devastating effects of mosquito-borne diseases; and not just malaria. It is time to rethink vector-borne disease control. The world needs to fund integrated vector control operations and place active vector population suppression methods and procedures back in the public health agenda.
The 2017 World Malaria Report must be considered shots across the bows of national and international public health programs. The presence of Yellow fever in Brazil and Nigeria is a serious public health threat, especially in light of the lack of adequate amounts of vaccine. Unfortunately, there is a good chance that active mosquito surveillance and control efforts will be implemented only in response to an outbreak. Should Yellow fever spread beyond its current area, hundreds, perhaps thousands will perish.
Sir Ronald Ross, winner of the Nobel Price in medicine in 1903 for his momentous work linking malaria to a mosquito voiced his concern about malaria shortly after receiving the Award by stating that "Malaria will continue to afflict millions until the mosquito is taken seriously".