{"id":45846,"date":"2019-10-10T17:39:55","date_gmt":"2019-10-10T16:39:55","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=45846"},"modified":"2019-10-10T17:39:55","modified_gmt":"2019-10-10T16:39:55","slug":"were-succeeding-in-our-fight-against-malaria-now-its-time-to-plan-for-failure","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2019\/10\/10\/were-succeeding-in-our-fight-against-malaria-now-its-time-to-plan-for-failure\/","title":{"rendered":"We\u2019re succeeding in our fight against malaria\u2014now it\u2019s time to plan for failure"},"content":{"rendered":"<p><a href=\"https:\/\/www.thelancet.com\/commissions\/malaria-eradication\"><span style=\"font-weight: 400\">The Lancet Commission on Malaria Elimination<\/span><\/a> <span style=\"font-weight: 400\">recently published a new report on the state of malaria globally, with special attention to ongoing attempts to eliminate the disease in sub-Saharan Africa. The report shows there is much for the global health community be proud of: the number of malaria cases and deaths have decreased dramatically in the past decade. At present, malaria activities have international support, are well funded, and are working to integrate new technologies such as a partially-effective vaccine and genetically modified mosquitoes. Yet despite all these gains, there is one area where global health agencies remain woefully unprepared: planning for the eventual failure of their campaigns.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Why should scientists plan for failure at a moment when it looks like we\u2019re winning the war against malaria? Because history shows that this campaign, like past ones, is likely to fail. As a historian who studies global health and medical interventions in East Africa, I see striking similarities between today\u2019s activities and past ones. For example, the island of Zanzibar, where I work, has been, and remains, at the center of global malaria elimination efforts. International aid organizations describe the disease as nearly eliminated and with<a href=\"https:\/\/stories.usaid.gov\/zanzibars-malaria-hunter\/#page-13\"> prevalence rates of less than 1% today<\/a>.<\/span><span style=\"font-weight: 400\">\u00a0Zanzibar is frequently invoked as an example of malaria conquered in tropical Africa. Yet, this isn\u2019t quite right. Malaria has been <\/span><i><span style=\"font-weight: 400\">nearly<\/span><\/i><span style=\"font-weight: 400\"> eliminated multiple times, which is the same as saying it has never<\/span> <span style=\"font-weight: 400\">been eliminated. The mosquito vector and malaria parasite remain entrenched in the local environment and local bodies. Since the 1950s, malaria rates have plummeted and then rocketed back up at least three times, with prevalence rates being reported at under 1% to 63%. [1-3]\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">This sine wave oscillation of malaria rates is more than just a marker of the Global North\u2019s waxing and waning interest in Africa: it also has real health implications. Malaria is uniquely terrible in that there are risks that accrue to local people when the disease is effectively controlled for a number of years and then allowed to return unchecked. A temporarily successful control campaign can unintentionally create a more dangerous disease environment by stripping people of their acquired immunity. That immunity is gained only by being exposed repeatedly and regularly to malaria infections and surviving it as a young child. Acquired immunity can also be lost if a person is not regularly exposed. As the report itself succinctly explains, \u201cIn highly endemic areas of Africa, children who survive constant <\/span><i><span style=\"font-weight: 400\">P falciparum <\/span><\/i><span style=\"font-weight: 400\">malaria infections develop substantial protection against death, moderate protection against illness, and little or no protection against infection.\u201d It is sad and ironic that\u00a0 a temporarily successful programme can create a situation ripe for resurgent malaria\u2014when the disease returns to communities where immunity has been lost. Resurgent epidemics have extremely high mortality rates but are preventable with good planning. [4] That type of planning acknowledges that campaigns always end and that many end in failure.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">The realities, challenges, and ethical dilemmas of rebound malaria are not new\u2014scientists debated the risks of trying to eliminate the disease in the 1940s. Zanzibar\u2019s history is again instructive. In the late 1950s and early 1960s the World Health Organization tried to eradicate malaria globally, and they failed. They also had high hopes for Zanzibar: WHO scientists called it a \u201cmodel malaria eradication programme\u201d where the goal was to demonstrate the feasibility of eradication in all of tropical Africa. Unfortunately, that didn\u2019t happen. Instead, the WHO\u2019s abrupt departure led to an epidemic of rebound malaria in the 1970s. Zanzibar is not a lone example. In fact, <\/span><a href=\"http:\/\/www.shrinkingthemalariamap.org\/resources\"><span style=\"font-weight: 400\">UCSF\u2019s research shows<\/span><\/a><span style=\"font-weight: 400\"> the true scope of the problem. They count 75 cases in 61 countries over the past 70 years, with Sri Lanka and India as notoriously terrible sites of rebound epidemics. The evidence is clear: despite good intentions, it was the failure of these programmes\u2014and their reluctance to plan for that failure\u2014that led to <\/span><a href=\"https:\/\/malariajournal.biomedcentral.com\/articles\/10.1186\/1475-2875-11-122\"><span style=\"font-weight: 400\">deadly rebound epidemics<\/span><\/a><span style=\"font-weight: 400\"> that <\/span><a href=\"http:\/\/www.shrinkingthemalariamap.org\/resources\"><span style=\"font-weight: 400\">killed tens of thousands of people<\/span><\/a><span style=\"font-weight: 400\">.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Critics might say it\u2019s overly pessimistic or unrealistic to plan for failure. But the truth is most disease elimination campaigns end in failure. The only human disease we\u2019ve succeeded in eradicating is smallpox; the only animal disease is rinderpest. During the WHO\u2019s global malaria eradication attempt in the 1950s, very significant gains were made in southern Europe; the disease disappeared from Italy and Greece. In sub-Saharan Africa, however, the failures were resounding and have been well documented by historians. In our current state of malaria eradication activities, we\u2019re yet to contend with what this history of failure means. To me, it indicates that international attention and funding will eventually wane, control strategies will be reduced or stopped, and malaria will come roaring back. By refusing to responsibly plan for failure, global health agencies put African communities at risk.<\/span><\/p>\n<p><span style=\"font-weight: 400\">As a global community, we should feel proud about the substantial gains made in reducing this disease. We should also take this opportunity to learn from the history of very real failures and acknowledge the ethical questions raised by the loss of acquired immunity and the threat of rebound malaria. These are questions that have lurked around the edges of malaria control activities\u2014and been privately debated by scientists without the involvement of African community members\u2014for nearly a century. Strikingly, we still often present malaria interventions as public health activities rather than as a form of research with risks. The organizations and scientists involved in today\u2019s fight against malaria should be lauded for their dedication. We should also insist that past failures, the potential for failure in the near future, and the risks of rebound malaria be addressed publicly and with an eye to involving affected African communities.\u00a0 As a historian, it\u2019s clear to me that we have an obligation\u2014and the potential\u2014to do better than we have in the past.\u00a0\u00a0<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><em><span style=\"font-weight: 400\"><strong><a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2019\/10\/Melissa-Graboyes-Portrait.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-thumbnail wp-image-45848\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2019\/10\/Melissa-Graboyes-Portrait-150x150.jpg\" alt=\"\" width=\"150\" height=\"150\" \/><\/a>Melissa Graboyes<\/strong>, Assistant Professor of African History &amp; Medical History, University of Oregon.<\/span><\/em><\/p>\n<p><em><strong>Competing interests<\/strong>: None declared<\/em><\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<ol>\n<li style=\"font-weight: 400\"><span style=\"font-weight: 400\">Barbiero, V. K., et al. &#8220;Project completion report: Zanzibar malaria control project.&#8221; Arlington, VA: Vector Biology &amp; Control Project, The Medical Service Cooperation International (1990).<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"font-weight: 400\">Archival References: WHO\/M2\/372\/3TAN (A) Plan of Operation and Related Correspondences , Malaria Eradication in Tanzania. M2\/372\/3 (a) ZANZ<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"font-weight: 400\">H.M. Haji and J. Garden. 1989. \u201cStatistical Tables for Health Planners and Administrators.\u201d MOH\/GOZ.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"font-weight: 400\">Bruce-Chwatt LJ: Resurgence of malaria and its control. J Trop Med Hyg 1974, 77:s62\u2013s66.<\/span><\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>The Lancet Commission on Malaria Elimination recently published a new report on the state of malaria globally, with special attention to ongoing attempts to eliminate the disease in sub-Saharan Africa. [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2019\/10\/10\/were-succeeding-in-our-fight-against-malaria-now-its-time-to-plan-for-failure\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":39030,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[263],"tags":[],"class_list":["post-45846","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-global-health"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>We\u2019re succeeding in our fight against malaria\u2014now it\u2019s time to plan for failure - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2019\/10\/10\/were-succeeding-in-our-fight-against-malaria-now-its-time-to-plan-for-failure\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"We\u2019re succeeding in our fight against malaria\u2014now it\u2019s time to plan for failure - The BMJ\" \/>\n<meta property=\"og:description\" content=\"The Lancet Commission on Malaria Elimination recently published a new report on the state of malaria globally, with special attention to ongoing attempts to eliminate the disease in sub-Saharan Africa. 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