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Visualizing zero malaria, whatever zero might be

Spraying DDT in Italy, during World War II

By Nancy Fullman, special to Humanosphere

In 2007, Bill Gates threw down the E-word (eradication) at a packed malaria forum in Seattle, a word that the malaria community had quietly retired decades earlier due to unsuccessful earlier attempts to fully rid the world of this major killer.

“We should declare the goal of eradicating malaria because we can eradicate malaria,” Gates said, to some consternation among the malaria experts. He challenged the audience to wipe out malaria for good, as the world did with smallpox in 1980, rather than continuing to simply contain the disease.

An advocacy poster from Malaria No More.

An advocacy poster from Malaria No More.

And just like that, eradicating malaria was back on the table.

Over the past seven years, ending malaria has been the mobilizing mantra across advocacy organizations and research centers. How to actually achieve the malaria end-game has been hotly debated, from Richard Feachem’s guide on Shrinking the Malaria Map to more recent discussions about mass administration of the drug primaquine to halt ongoing transmission.

At a recent infectious disease research conference technically known as the annual meeting of the American Society of Tropical Medicine and Hygiene (which NPR describes as a “Burning Man for doctors and virus geeks”), Gates announced that his foundation will increase funding by 30 percent in order to reach zero malaria during his lifetime.

Reaching zero malaria, in theory, should be easy to define and track over time … right? Zero is zero, or least that’s what I learned in grade school.

But as it turns out, zero can mean a lot of things in the malaria world – and has some very important implications for truly achieving malaria eradication.

Achieving zero malaria deaths has been a primary goal in the fight against malaria. In many places, this goal has been attained, or at least very nearly attained. The screen-shot below demonstrates this impressive feat in four malaria-endemic Latin American countries, Panama, Nicaragua, Peru and Brazil.

Malaria deaths in select countries in Latin America Malaria IHME1

But if you switch to tracking malaria cases (also known as malaria incidence), a different story can emerge.

Based on this screen-shot, Brazil and Peru have shown minimal progress in reducing malaria cases per 100,000 since around 2000. Panama has had a rockier road toward zero malaria, with the country experiencing a massive malaria outbreak between 2001 and 2005. From this angle, it would appear that greater efforts are needed to reach zero malaria cases.

Malaria incidence in select countries in Latin America

Malaria IHME 2


So what happens when you actually reach zero malaria?  It’s an intensive process to become certified as malaria-free, but essentially the World Health Organization (WHO) says that you, as a country, have eliminated malaria if no locally acquired malaria cases occur for three consecutive years.

Sri Lanka just celebrated its second year without malaria, and experts are looking to Swaziland as the next big malaria eliminator. Eliminating malaria is a long, hard journey for every country that takes it on, but here’s the thing: once a country is certified as malaria-free, it’s malaria-free for the long haul.

Mauritius, a small island off of Madagascar, successfully eliminated malaria in 1969 only to have the disease make a comeback in the mid-1970s and 1980s. Greece rid itself of malaria in 1973; nearly 40 years later, it returned. Yet neither country officially lost their malaria-free certification status, technically recognized as achieving zero malaria at the same time they were fighting to wipe out the disease again.

“Accelerating to zero malaria” has been a major theme at this year’s ASTMH meeting. However, until we have a clearer understanding of what truly constitutes zero malaria, it will be quite challenging to know how to achieve this bold goal – and if we ever do.

Nancy FullmanNancy Fullman is a policy translation specialist at the University of Washington’s Institute for Health Metrics and Evaluation. Her areas of expertise include malaria research, policy, impact evaluations and health system assessment.


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