This week, an important meeting on the monitoring and evaluation of malaria control policies is taking place. The Monitoring & Evaluation Reference Group (MERG) meeting, convened by the Roll Back Malaria Partnership is taking place in Namibia. In advance of this meeting, I had the chance to e-interview Dr. Roly Gosling. Dr. Gosling is an international expert on malaria and currently leads the Malaria Elimination Initiative at the University of California, San Francisco, Global Health Group. His group advises countries trying to eliminate malaria and conducts research developing and testing cost effective tools and approaches for decreasing malaria cases in countries with low levels of the disease. I have asked him to answer a few questions for us regarding malaria elimination, its importance, and why the Global Fund is critical to achieving that goal worldwide.
Feature video on Malaria: Ignatius Ally Nuwuha on the importance of the Global Fund in the fight against malaria in Uganda.
Interview With Dr Roly Gosling
Many people don't realize there is a significant difference between malaria control, elimination and eradication. As an expert in malaria elimination, can you tell me and my readers what the differences are and why elimination is such an important public health goal?
Dr Roly Gosling: At the end of World War II, malaria was found on every continent and in almost every country in the world. Thanks to major investment, particularly in the last two decades, over 90 countries today are malaria free , and an additional 34 (known as eliminating countries) are close to achieving that status.
To answer your question about definitions: malaria control focuses on reducing sickness and death from malaria where there is a high burden of disease. Interventions include increasing access to prevention and treatment measures, such as insecticide-treated bed nets, household spraying with insecticides, and access to quality diagnostics and treatment. Once a country has reduced its burden to a very low level, malaria elimination focuses on ending local malaria transmission (e.g. if one person gets malaria, it does not get passed on to others). Countries that are pursuing elimination still use the prevention and treatment measures found in malaria control, but must also implement additional, more sophisticated systems and tools, such as a strong health system and a robust surveillance system that rapidly reports every case of malaria to health authorities. The program must be able to follow up on every malaria case, and if necessary, search for and treat other malaria cases in the area. The final goal is malaria eradication, when malaria transmission is ended worldwide, similar to the global eradication of smallpox in the 1970s.
Why is elimination important? Malaria causes a vicious cycle of disease and poverty. In high burden countries it causes thousands of deaths, reduces economic productivity and leads to poor health within the general population. Many countries that have little malaria today have invested substantial resources into decreasing their cases to low levels, an investment that can be erased very quickly. For instance, when Sri Lanka and Zanzibar almost eliminated malaria in the 1960s and '80s, their governments reduced investments in malaria control, thinking the job was finished. Malaria came back almost immediately, and many people died as a result.
The global community is pursuing eventual eradication of malaria through a three-part strategy: 1) control malaria in high burden countries to reduce death and disease; 2) eliminate malaria from low-burden countries on the geographic periphery of the disease to "shrink the malaria map;" and 3) invest in research and development to bring about new tools (better diagnostics, or in the future, a vaccine) to stay one step ahead of emerging resistance to current drugs and insecticides.
There is an important technical meeting going on at the moment -- what relevance does this Monitoring & Evaluation Reference Group (MERG) meeting, convened by the Roll Back Malaria Partnership, have to those who want to fight malaria?
Dr Roly Gosling: The MERG brings together international malaria experts to develop guidelines and monitor effectiveness of malaria control strategies. Given the great progress that has been made in controlling malaria worldwide, and particularly in the malaria heartland in sub-Saharan Africa, the MERG is shifting its attention to a new question during this meeting: how do we move forward to eliminate malaria from this region of the world? This week they will review and discuss what measures should be adopted by countries that have succeeded in controlling malaria to low levels, to help them prepare for elimination. This is an exciting development, as until recently, malaria elimination was thought by many to be impossible in this region.
What role has the Global Fund played in malaria control and elimination?
Dr Roly Gosling: The Global Fund has played a major role in the fight against malaria, disbursing almost U.S.$5 billion in malaria grants since 2002 , substantially advancing global efforts to reduce malaria. The Fund has not only had a major impact in countries that are currently in the control stage (e.g. Cambodia, Tanzania, Zambia), but also in countries striving for elimination (e.g. Sri Lanka, Swaziland).
Unfortunately, the World Health Organization noted an alarming trend last month in its 2012 World Malaria Report: international funding for malaria peaked at just U.S.$2.3 billion dollars in 2011 -- an amount substantially below the estimated $5.1 billion/year needed to continue reducing the global malaria burden. With donor governments considering decreasing their commitments to the Global Fund, malaria funding is at tremendous risk -- and many countries around the world could experience major resurgence of the disease.
Does malaria elimination figure in the Global Fund's strategy and/or the new funding model and replenishment efforts currently underway?
Dr Roly Gosling: It is hard to predict what the long-term impact of the Global Fund's new funding model will be, but it appears that future funding will target the poorest countries with the highest burden of disease, potentially bypassing many of the countries that are closest to eliminating malaria. Although these countries are growing economically, they still need external support to end malaria.
In short: the job isn't finished. Elimination requires a long-term investment, and discontinuing financial support now will leave countries at major risk for resurgence. Billions of dollars have been spent and millions of lives have been saved; it is critical that we sustain our commitment and investment in both high and low burden countries to help them get the job done.
It is clear that accelerated partnerships are critical to ensuring elimination goals, thanks to Dr. Roly Gosling and the Global Health Group at UCSF for this timely insight.
Lucy Chesire: TB-HIV advocate from Kenya, Alternate Board Member of the Global Fund Board Communities Delegation
About the Here I Am campaign: The Here I Am campaign is a global call on world leaders to save millions of lives by supporting a fully funded Global Fund to Fight AIDS, Tuberculosis and Malaria. Here I Am brings the voices of people that are directly affected by AIDS, TB and malaria into dialogue about decisions that affect their lives and the lives of millions of others in their countries. Through video testimonies from all over the world, campaign ambassador advocacy, online actions and on-the-ground mobilizations, the Here I Am campaign is building collective power to end three of the world's most deadly diseases.