Beating malaria in the GMS

Though malaria still poses a major threat to millions of people around the world, there has been significant progress toward eliminating the disease in severely affected areas. By working together across borders, six Southeast Asian countries have created a model that the world should follow, write Poonam Khetrapal Singh and Shin Young-soo.

In Southeast Asia’s Greater Mekong Subregion (GMS), the battle against malaria is advancing at a rapid pace. Between 2012 and 2017, reported malaria cases fell by a staggering 84 percent, with deaths from the disease down by 93 percent. In Cambodia, China’s Yunnan Province, the Lao People’s Democratic Republic (Lao PDR), Myanmar, Thailand, and Vietnam, more people are free of malaria’s deadly menace than ever before.

To understand the magnitude of this achievement, it helps to go back to 2008, when artemisinin-resistant malaria parasites were first confirmed along the vast, densely forested Thai-Cambodian border. That finding immediately became a source of deep concern, because artemisinin is a critical ingredient in treatments for Plasmodium falciparum malaria, the deadliest form of the mosquito-borne parasite.

The discovery of resistant strains of malaria meant not just that it would be harder to treat, but that the overall approach to fighting the disease would have to change. National malaria prevention and treatment programs were fortified, and monitoring at field operations in affected areas was tightened significantly.

At the same time, greater cross-border collaboration, along with up-to-date information about emerging multidrug resistance in the GMS, became essential. At first, cross-border collaboration was limited to Thailand and Cambodia, the two countries where drug-resistant parasites were first confirmed. But, by 2011, China, Myanmar, Vietnam, and Lao PDR – with support from the World Health Organization’s South-East Asia and Western Pacific offices – were also on the case. Public-health authorities throughout the region were providing actionable, up-to-date parasitological data, and taking clear steps to address the problem.

In 2013, the WHO launched its Emergency Response to Artemisinin Resistance in the GMS. As support from Australia’s Department of Foreign Affairs and Trade, the Bill & Melinda Gates Foundation, The Global Fund, the UK Department for International Development, the US Agency for International Development, and the US President’s Malaria Initiative was being provided, resolve to confront the challenge was crystallizing throughout the subregion.

Then under the WHO’s Strategy for Malaria Elimination in the Greater Mekong Subregion 2015-2030, the emphasis shifted from controlling drug resistance to pursuing total malaria elimination. The WHO provided public-health authorities in the GMS with the technical and strategic guidance needed to make the dramatic, life-changing advances that we have seen in recent years.

Although there have been challenges along the way, the GMS’s progress so far suggests that it could eliminate the Plasmodium falciparum parasite by 2025, and eliminate malaria completely by 2030, at the latest. To succeed, however, all of those involved in the fight against malaria will need to focus on five core areas.

First, we must maintain high-level political commitment. Any lapse on the part of one country can and will have consequences elsewhere, so it is crucial that leaders remain resolute. Fortunately, at a high-level meeting last December in Nay Pyi Taw, Myanmar, delegates from all six GMS countries explored ways to accelerate malaria reduction in the region. Looking ahead, they must continue to build on what they discussed.

Second, we need to pay special attention to high-burden areas. National malaria programmes should allocate more resources to hard-to-reach communities that lack access to health care. They also need to extend all of the services they provide to non-citizens, which will require building trust within remote communities.

Third, we must do more to eliminate poor-quality antimalarial medicines. To that end, the GMS’s region-wide ban on the production and marketing of oral artemisinin-based monotherapies, which actually contribute to drug resistance, is to be commended, as is the strengthening of national supply chains to improve the availability of high-quality medicines.

Fourth, GMS countries need to establish more robust surveillance systems and fully leverage existing channels for sharing information at the regional level. With improved surveillance – and with the WHO’s regional data-sharing platform – national malaria programmes will be better positioned to redirect resources as needed, especially in the event of an outbreak.

And, finally, the GMS countries must embrace research and development, to improve their understanding of malaria parasites and the mosquitoes that spread them. Specifically, there is a need for more high-quality data on the performance of programmatic interventions, and on the efficacy of current treatments.

The GMS must take full advantage of the opportunity it now has to eliminate malaria. The subregion’s national leaders are paying attention to the problem, international partners are offering their support, and local public-health agencies have a wide range of effective tools at their disposal.

Given that malaria still threatens millions of people, there is no room for delay or loss of focus. We must build on the GMS’s remarkable progress and eliminate malaria once and for all. Copyright Project Syndicate 2018

Poonam Khetrapal Singh is the World Health Organization’s regional director for South-East Asia and Shin Young-soo is WHO’s regional director for Western Pacific.

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