Malaria: The Stubborn Foe
"Those involved in smallpox eradication disagreed about the right approach—and indeed whether eradication was even feasible—until the very last case." (Cohen, 2019, p. 14)
Red blood cell infected by malaria
Electron micrograph of a red bllod cell infected by Plasmodium falciparum-- the parasite that causes malaria in humans-- taken in 2016 by Rick Fairhurst and Jordan Zuspann
Malaria is a potentially deadly parasitic disease spread by mosquitos that causes shaking chills, high fevers, and flu-like symptoms which can be deadly. Malaria principally affects sub-Saharan Africa and, to a lesser extent, tropical regions in Asia and Latin America, but 2,000 cases of malaria are diagnosed each year in the United States, imported from countries where the disease is endemic. The spread of malaria is highly dependent on the climate-- the malaria-causing parasite cannot complete its life cycle at temperatures below 68° F-- and even in countries where the disease is endemic, malaria's spread can be constrained by high altitudes, cold seasons, and vast deserts. In 2019, the WHO estimated that approximately 409,000 people were killed by malaria, mostly children.
Although the WHO vowed to eradicate malaria back in 1955, the disease has proven difficult to eliminate entirely, and the WHO officially reconsidered its goals in 1969 but has never formally suspended its campaign to totally eliminate malaria. Indeed, the leader of the WHO's campaign against smallpox, Dr. Donald A. Henderson, concluded at the end of the smallpox eradication project that malaria could not be defeated at the time. Years later, anti-malaria campaigns still lack a trump card as mighty as vaccination, which offers years-long immunity from a one-time injection. Malaria prevention, meanwhile, relies on complex tools that must be regularly redeployed to effectively control mosquitos and parasites.
Nigerian scientist at a malaria training event
Nigerian lab scientist attending a microscopy training event conducted by eHealth Africa/EHA Clinics in 2018
Seeking to chart the future for malaria eradication efforts, epidemiologists have studied smallpox eradication efforts for any insights that could advance their work. For instance, those more optimistic about the prospects of malaria eradication can look to the skepticism and lukewarmness that surrounded smallpox eradication efforts as encouragement that contemporary pessimism about the feasibility of malaria eradication may not necessarily doom their mission. The WHO initially had so little faith in their smallpox eradication program that they appointed a man from the CDC as its leader (the aforementioned Dr. Henderson) so the program's inevitable failure could be attributed to the Americans, not the WHO itself. Opposing the WHO's pessimism was the United States and the Soviet Union, as well as Dr. Henderson himself, who regularly published reports on the progress of smallpox eradication to keep it in the minds of influential figures. Those working on malaria eradication nowadays likewise publish an annual World Malaria Report.
The success of smallpox eradication also required health officials to play international politics. Eradication required the buy-in of every country on Earth, and nations that were less willing to do the work of constructing a vaccination program needed to be incentivized through funding specifically for smallpox eradication efforts. These straggler countries were also supported by international agencies by sharing best practices with their health officials, ensuring all vaccines and support devices were top-of-the-line, and offering personnel for operational support. Anti-malaria campaigners have imitated these support and quality control networks, and it has been proposed that they could do more by supporting mosquito net production in key countries, so local health officials would be less reliant on donations. When considering international logistics, some have taken to heart the advice of Dr. Henderson, who viewed smallpox eradication "as something they achieved despite WHO’s structures and procedures" (Cohen, 2019, p. 7); thus, those skeptical of excessive bureaucracy favor making the central eradication coordination team flexible and agile.
Indian stamp honoring J.R.D. Tata
1994 stamp from India honoring industrialist J.R.D. Tata, who advocated for smallpox eradication in his country
Malaria eradication campaigners must also ensure support from national and local officials. Although smallpox and malaria are both deadly diseases, health officials may consider other health issues to be a higher priority. Likewise, both malaria and smallpox have strains that range in lethality, and officials may disagree whether they should exterminate all forms of the disease or just target the deadliest strains. Smallpox campaigners have also noted the importance of establishing personal connections with major figures in affected countries: an Austrian physician secured the creation of a smallpox vaccination program in Ethiopia through his connection to Emperor Haile Selassie, and Indian industrialist J.R.D. Tata lobbied Prime Minister Indira Gandhi to continue fighting smallpox despite dispiriting setbacks. Organizations like the African Leaders Malaria Alliance have attempted to replicate these successes and identify individuals who can champion their cause.
Health officials must balance the need to get national authorities to care about a particular disease with the need to engage with local communities with a variety of health problems. Smallpox campaigners had more success when they were able to address health crises affecting communities besides smallpox (e.g., cholera, vitamin deficiencies); malaria campaigners expect to be more successful when they are able to be more to a community than deal with one disease. Overly aggressive approaches-- vaccinators in Bangladesh recount sometimes chasing down and cornering reluctant individuals in order to achieve sufficiently high vaccination coverage-- are both ethically dubious and poisonous to long-term healthcare relationships. Trust is particularly important to malaria eradication, as it requires repeated interactions with affected areas and their inhabitants.
Cameroonian children with a mosquito net
2015 photo by the U.S. President's Malaria Initiative depciting Cameroonian children underneath a mosquito net, used to prevent the spread of malaria
Additionally, it is worth bearing in mind that simply dumping resources in a country does not guarantee a victory against disease. In the campaign to eradicate smallpox, mass vaccination was not always the wisest strategy. 95% vaccination is a remarkable feat, but it is not especially meaningful for the 5% of people who remain vulnerable to smallpox. Studies of malaria campaigns have encountered a similar problem, in which mosquito nets are delivered to people who already have a surplus of nets, while mosquito nets are not delivered to high-risk people who are in greater need of nets. A "surveillance-containment" strategy, by which the remaining cases of a disease are identified then quashed with an enthusiastic intervention, is more helpful to achieving total elimination.
Pakistani stamp honoring the global anti-malaria campaign
1962 stamp from Pakistan commemorating the Interntional Year Against Malaria, with an Urdu caption reading "The world united against malaria"
Finally, there is the factor of luck. Dr. Henderson admitted that "had the [smallpox eradication] effort begun a year earlier or later, it might have failed… In almost every country there were periods when neither surveillance nor eradication programmes were possible" (Cohen, p. 14). Malaria campaigners will not be able to predict everything, nor will they be able to overcome every twist of fate. To a certain extent, success will depend on circumstances simply be serendipitously advantageous.