Forty-one percent of the world’s population live in areas where malaria is transmitted, such as parts of Africa, Asia, the Middle East, Central and South America, Hispaniola, and Oceania. The global malaria eradication program of the 1950s and 1960s concentrated to a great extent on areas in Asia and South America, but never included Continental sub-Saharan Africa.
According to the World Health Organization, every year 350–500 million cases of malaria happen worldwide, and over one million people die, most of them young children in sub-Saharan Africa. In some areas of Africa with high rates of malaria transmission, an estimated 990,000 people died of malaria in 1995; over 2700 deaths per day, or 2 deaths per minute. For example, in the nation of Malawi in 2001, malaria made up 22% of all hospital admissions, 26% of all outpatient visits, and 28% of all hospital deaths. But many in Malawi don’t go to hospitals when ill, and many die in their home. So the true numbers of death and disease caused by malaria are probably much higher.
The upsurge of malaria in many parts of Africa is likely due to multiple factors, including quickly spreading resistance to antimalarial drugs, climate changes, changing rainfall patterns and water development projects such as dams and irrigation schemes, which create new mosquito breeding sites, and forced population movements due to armed conflicts and civil unrest in many countries.
Malaria is caused by a protozoon of the genus Plasmodium, with four subspecies, falciparum, vivax, malariae, and ovale. The species causing the most death and illness in Africa is Plasmodium falciparum. Individuals exposed repeatedly to the disease acquire a degree of immunity, although this is unstable and disappears after approximately one year away from the endemic-disease environment.
Malaria is a complex disease. It exhibits a nonuniform distribution pattern and has symptoms that vary from one area to another within an endemic-disease area. The epidemiology of malaria is not well understood needs further research, as does the disease itself. Controlling malaria in Africa will require more knowledge about the disease and its determinants.
Presently, the strategy for malaria control consists of a two-prong approach. The first uses drugs for early treatment of the disease, managing severe and difficult cases, and prophylactic use in vulnerable populations, such as pregnant women. Chloroquine is still the preferred therapy for malaria, but the startling rise in resistance in eastern and southern Africa necessitates that sulfadoxine-pyrimethamine replaces chloroquine. In these areas, 20% to 30% of strains are highly resistant.
If the African strains of malaria parasites developed the pattern of drug resistance now seen in Southeast Asia, it would be a major health disaster.
The second prong is using insecticide-treated nets for protection against mosquito bites. Research done in Gambia proved the effectivity of such nets for reducing infant death, this has been confirmed by six other large scale studies across Africa. The problem on this front is the cost of the nets, which hold back wide-scale use.
A bed net that can protect a family of four costs $10 currently, which, although it seems inexpensive to us, it out of reach for most Africans who are at risk for malaria. Numerous NGOs and charities have launched public campaigns in the west to raise money for mosquito net programs. The UN, World Health Organization and UNICEF are working with the governments of various African countries to distribute nets in endemic zones and where most needed, but wide scale use is still to be achieved.
The above strategy needs to be coupled with awareness of local cultures for maximum effectiveness. Populations in Africa have traditional ideas about causes of diseases and how to manage them. Some diseases are seen as being properly treated with western medicine, others are considered the select domain of traditional local health practitioners, and often, seeking western medicine for any illness is a last resort.
Perceptions of malaria may need to changed, communities engaged with, and strategies modified. Community and socioeconomic studies are necessary to understand the degree to which communities will take part in any new malaria control measure. Last but not least, cost recovery of health care, including costs of drugs( the Bamako Initiative), has been the subject of many recent studies and probably holds the key to health care in rural populations.
Health service organization, function, and governing policies are also important to malaria control. Many studies are researching different ways to integrate vertical malaria control programs into the general health-care system.
Economic evaluation of different interventions is important, and the techniques are continually being refined and improved. They require much local capacity since they tend to be country specific. Studies in this area have now caught up with the current trend favoring decentralization of services, giving more power to the districts. Such studies include ways of improving case management where health services have been decentralized, sustaining effective interventions, and ensuring that drug supply chains function optimally.
Image by Damien du Toit, Creative Commons Attribution License.