We spoke to Dr Sarthak Das, Chief Executive Officer of the Asia Pacific Leaders Malaria Alliance (APLMA), about the region’s progress towards malaria eradication and the organisation’s priorities, now that its target date for a malaria-free Asia Pacific is just eight years away.
… if you compare [malaria] to other infectious diseases, which have received a lot of global attention, whether that is HIV or TB, or even the pandemic that we are living in now, malaria is preventable, treatable and can be eliminated. 40 countries in the world have done it.
Dr Das, your experience in the infectious diseases field before joining the APLMA as CEO in 2020 is vast. What brought you to the organization and what would you say is unique about malaria with respect to other infectious diseases?
Sixteen years ago, while living in Papua New Guinea, my eldest son contracted P. vivax malaria during a trip to coastal areas. He recovered eventually, though it took some time to diagnose and treat, but countless families are not so fortunate. Despite all the available tools and evidence—whether through vector control or antimalarials, the world’s oldest pandemic persists. It is disproportionate in places like Indonesia, Papua New Guinea and India including the Greater Mekong subregion, affecting mostly vulnerable, rural, and tribal populations. The fact that malaria continues to devastate these communities, where I have personally witnessed success in battling other infectious diseases such as TB and HIV, was core to my desire to join the fight towards malaria elimination in Asia Pacific.
I have worked for many years on other infectious diseases like HIV and TB, and I am very interested in how we can better leverage infectious disease interventions to strengthen community-based health systems in the most difficult to reach places.
What do I think is unique about malaria? Well, if you compare it to other infectious diseases, which have received a lot of global attention, whether that is HIV or TB, or even the pandemic that we are living in now, malaria is preventable, treatable and can be eliminated. 40 countries in the world have done it. We are not going to be eliminating COVID and we are not on our way to eliminating HIV anytime soon. However, malaria is something we can solve, and I think we have known that for a long time.
The Asia-Pacific region has made significant progress against malaria. Where do we stand today? Can you give our readers a snapshot of the malaria globally and specifically in Asia Pacific?
We were making tremendous progress globally, but the fight against malaria faces new and growing challenges. COVID-19 and other obstacles such as increasing drug, insecticide resistance and humanitarian emergencies led to an increase in malaria deaths for the first time in over a decade. We are talking about 627,000 deaths in 2020, which is a staggering 12 percent increase over 2019. The majority of global malaria deaths (96 percent) are happening in the Africa region, resulting in a child dying every minute from malaria. Worldwide, malaria cases have also increased to 241 million in 2020 alone which translates to a 6 percent increase in cases compared to 2019.
The picture is vastly different when we look at Asia Pacific where two countries have eliminated malaria entirely. China attained malaria-free status last year and Sri Lanka has managed to maintain malaria-free status since 2016.
Overall, countries in Asia Pacific have seen a 63 percent drop in cases and an 87 percent drop in deaths. Even more striking is the progress in the Greater Mekong subregion: in Laos, Thailand, Cambodia, Myanmar, and Vietnam, we have seen an 89 percent reduction in cases and a 99 percent reduction in deaths over the last decade. Despite this good news, at APLMA we are very focused on the fact that we still have 2 billion people at risk of malaria in Asia Pacific. We also have a very concentrated epidemic across the region where 91 percent of the malaria is in just five countries: Indonesia, India, Pakistan, Afghanistan, and Papua New Guinea. According to the latest World Health Organization’s (WHO) World Malaria Report, Papua New Guinea accounts for 86 percent of all cases in 2020 in the WHO Western Pacific region.
It is very important for us to remember that we have a regional goal – to eliminate malaria by 2030. That is what our secretariat is designed to support. Just as we see every day with COVID cases arising and sub-variants emerging, we cannot say that it is over anywhere until it is over everywhere; that is certainly true for malaria.
With less than a decade left to reach the 2030 malaria elimination goal committed to by 18 Asia Pacific Heads of States at the 9th East Asia Summit, and later by 4 additional Heads of State in 2018, what are the priorities of the APLMA today?
We have four goals. The first goal is to ensure that there is a focus on those high burden geographies I mentioned, and to keep elevating the plight of not just those countries, but the remote places within those countries where malaria is centred. For example, in countries like India, and Indonesia, malaria is quite focused with high pockets of endemicity in just a few states in India and a couple of provinces in Indonesia.
A second focus area is making sure that we do what we can to help elevate the cause of near elimination. Countries like Bhutan, or Timor-Leste are on the precipice of malaria elimination but may be held back from that due to the importation of malaria across their respective borders.
The third is to continue to ensure that we think about malaria as something that requires a whole-of-government approach. It cannot be a health alone approach and there will not be a health alone solution. For malaria elimination to happen, we need to bring in finance ministries and foreign affairs because there are cross-border issues. There is also a need to increase the envelope of domestic financing, as well as sustaining high level political leadership to bring those various areas of the government together. In addition, it is important not to leave out the private sector. Not only is it a huge part of the commodities associated with malaria, but it also plays a critical part of the service delivery apparatus.
The last thing is not to lose sight of our 2030 goal. Eight years may sound like a long time, but it is not. Despite the ongoing global pandemic, we must keep the importance of ending malaria highly visible. And we must not lose sight of accelerating progress towards the commitment governments and heads of state have made to reach this goal.
You mentioned, the private sector. What role does or could the private sector play in eradicating malaria?
Besides the basic humanitarian principle, I think it is also important to remember that it is in the private sector’s interest to end malaria and there is a strong business case for investment. As we have experienced with COVID-19, sickness can disrupt supply chains and decrease labour productivity. A 2017 study in Asia Pacific, estimated a ROI of six to one for every dollar that invested in malaria; the same analysis estimated that malaria elimination in the region by 2030 would save over 400,000 lives and avert 123 million malaria cases, translating to almost USD 90 billion in economic benefits. Clearly, it is in both the private sector and government’s interest to protect people from this disease.
The private sector is involved and often supports various aspects of malaria programmes. Firstly, they have the resources and access to important channels through their supply chains to procure and distribute necessary tools like bed nets, test kits, and treatments to communities which malaria programmes could tap into. What is important though is streamlining those areas with existing national and local government strategies.
Finally, there is also a very large space for the private sector to lead in terms of innovation, from finding new ways to diagnose to developing new treatments and vaccines. In fact, the RTS,S vaccine is a case in point; such a scientific breakthrough would not have been possible without the scientific community and collaborations between governments, pharma companies, WHO, and NGOs.
You mentioned the RTS,S vaccine. What are the hurdles involved in deploying the vaccine? What are your expectations for deploying it in Asia Pacific?
There are two main malaria parasites: plasmodium falciparum and plasmodium vivax. The RTS,S vaccine, targets falciparum malaria in young children in sub-Saharan Africa in high transmission areas. In Asia Pacific we have a mix of both parasites, but more than half of all global vivax infections occur in Asia Pacific. While the vaccine is a huge milestone and a welcome springboard for next-generation innovations, given the different picture for Asia Pacific, we would need locally-generated evidence to understand how it could be applied.
Children must receive four doses with the first three doses administered every month and then the fourth 15 to 18 months post 3rd dose. Ensuring systems are in place for patient retention be it through expanding immunization programs, community engagement and/or local community health workers will be critical.
The vaccine does give hope after decades of effort and is already proving to be life-changing for countless families in Africa, but it is important to note that vaccines alone are not the only solution to the problem of malaria. There is a suite of measures in terms of vector control, like bed nets, long-lasting insecticide treated nets, indoor residual spraying, diagnostics, drugs, a functional surveillance system and education around water sanitation. If we optimise and apply these tried-and-true tools to the local context, we can make huge progress towards elimination as well. The point is, there are 40 countries that eliminated malaria even before so many of the tools we have now.
Malaria, also considered a pandemic, was overshadowed by the COVID-19 crisis, and comparing the annual investment into malaria R&D with that invested in COVID-19, it seems like a neglected area. Is the alliance advocating for research in the field?
As the region gets closer to the elimination goal, the remaining malaria cases are increasingly concentrated in vulnerable communities located in hard-to-reach geographies and tribal areas.
As a regional advocacy organisation and platform, we play a critical role in focussing attention on the last mile challenges of malaria elimination which includes everything from gaps in service delivery, to a need for more research and innovation to reach mobile, migrant populations to testing and treatment options. There is also the accompanying challenge of drug and insecticide resistance emerging which requires attention.
Through our platform we bring together Heads of Government, national malaria programs, product development partnerships, implementing partners, donors and research institutions and facilitate discussions to advocate for all the issues we face in the region. This engagement is essential to catalyse capacity building efforts, investments in research and partnerships that can inevitably address these challenges.
Similarly, our platform enables the sharing of country data, local research findings, best practices, and the opportunity to connect the dots with other vector borne diseases to improve service delivery, facilitate integration and cross-disease approaches for last mile populations. We might have the tools we need but if we do not know how to integrate and deploy them in a coordinated manner, we are not going to get to the end game.
Certain countries in the region have tried to maintain the spotlight on malaria whilst preventing COVID-19 outbreaks. Their approaches to malaria elimination were covered in a recent paper. Can you walk our readers through some of their successful measures?
Yes absolutely. Our recent paper ‘Sustaining progress towards Malaria Elimination by 2025: Lessons from Bhutan and Timor-Leste’, published in The Lancet Regional Health-Western Pacific highlights key lessons drawn from Bhutan and Timor-Leste’s sustained malaria elimination efforts since their re-commitment to the WHO E-2025 initiative last year. We aimed to highlight the resilience and approaches adapted by both countries to maintain the spotlight on malaria whilst preventing large COVID-19 outbreaks. For example, Bhutan, set up a dedicated team that was responsible for the overall COVID-19 response that was specifically devoted to ensuring that essential health services would remain uninterrupted. They used a variety of methods like hotlines and mobile clinics to continue to deliver essential healthcare services in strategic and hard-to-reach areas. Now they are planning to continue that beyond this current pandemic phase. Another example is in Timor Leste, where they have intentionally integrated malaria into private sector clinics, setting up task forces to look at malaria, TB, and HIV. These are just some of the initiatives that came out of this desire to continue the fight on malaria and other diseases, despite the competing challenge of COVID.
What is important to remember is, whilst there are existing and future threats that can reverse the progress of malaria elimination made to date, key elements such as sustaining political commitment, systematically collaborating across borders, empowering communities and strengthening health systems particularly through surveillance and data management are imperative for countries to remain on track.
We hope the lessons and examples shared by Bhutan and Timor-Leste provide inspiration for other near-elimination countries working towards malaria-free status by 2025. As a regional platform and voice, we stand committed to support government and country partners and to help them mobilise innovations and tailored solutions to realise our goal to end malaria, a devasting yet preventable disease.