A hot debate among scientists, health workers and donors used to center on the question of whether malaria could be eradicated or if it was more feasible to devote time and resources to controlling it.
Now, however, the discussion has shifted. With the Global Malaria Action Plan committed to fighting the disease worldwide, with the aim of almost eradicating it by 2015, the issue is not so much whether eradication can be achieved but how it might best be accomplished.
One of the key questions is where to focus first. Some believe it is best to start in the more severely affected countries, while others support initially choosing nations where there is less malaria in order to build momentum.
Brian Greenwood of the London School of Hygiene and Tropical Medicine, believes it is important to tackle the less threatening enemy first, in countries where there is the least possibility of malaria returning across the borders of neighboring states.
“It certainly makes sense to start where you don’t have malaria behind you,” he said. “You start where the transmission is very low and then move progressively forward. Then at least you don’t have the enemy behind you, you just have the enemy in front. That may be easier than if you’re completely surrounded with people coming into your country from all sides.”
For example, he said, there have been preliminary discussions about focusing on West Africa with Mauritania, Senegal, The Gambia and Guinea-Bissau. To the north of those countries there are deserts and to the west the Atlantic Ocean.
“Then you would have just two sides from which you might get migration back into the country, and you try to push forward from there,” he said. “At one time there was a suggestion that Rwanda might be one of the first countries to go for elimination. But I don’t think that would be sensible. You’re much better off starting on the edges.”
Dr. Donald Hopkins, vice president of health programs at the Carter Center, believes tackling the big enemy first is the best approach.
“I think you are very, very well advised to start in the worst affected areas first or very, very early. Sometimes you see folks want to get rid of the easier areas first to establish momentum but that’s a mistake in my view,” he said.
“Do the easy areas when you can but the priority should be to start in the most difficult areas first for the very simple reason that by definition the most heavily-affected areas are going to take the longest time to get rid of [malaria] and the odds are that they’re also going to be the most difficult areas.”
Greenwood has said it is indefensible to attempt to eliminate malaria in countries with neighbors that have ineffective healthcare systems and intense transmission of the disease.
He said The Gambia, for example, has been doing well with its malaria control program and could consider the possibility of eliminating the disease in the next decade.
“But to do that when the country is completely surrounded by Senegal without Senegal also taking major efforts to control malaria would not be a sensible thing to do… There are many other examples of that in Africa, particularly where you have landlocked countries surrounded by different countries. So this has to be a sub-regional or regional effort if it is going to work.”
But even if countries such as Senegal, The Gambia and Mauritania did manage to achieve elimination in the next 10 years, Greenwood questions whether it would be possible to maintain that achievement.
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“Would it really be possible to stop people with malaria from coming in from other West African countries, and would you be starting the whole thing off again? I don’t know what the answer is to that and we probably won’t find out until people try,” he said.
“Lots and lots of people go through formal border posts where it would be possible to check them. But the majority just go across the border.”
He also noted, “You’ve got to start somewhere first.” That has already happened, in both the most severely affected countries, as well as those with lower malaria prevalence. As more insecticide-treated bed nets are distributed, more homes are sprayed and more people are treated for the disease, the momentum has already accelerated
