Malaria elimination or eradication vs control – what is the big deal?

About one month ago an interesting (and quite bold) article appeared in the British Medical Journal without much fanfare. Three faculty of the Swiss Tropical Institute wrote about why we should pursue a strategy of universal coverage with key interventions rather than an elimination plan. One name on the paper stood out to me – Allan Schapira is one of the handful old style malariologists around today. We have a good number of malaria scientists who research aspects of the disease, but a malariologist is competent in programmatic issues of malaria control in addition to having a strong grasp of the biology and epidemiology of the disease. Basically, I would listen very carefully to what he says. Back to the article – first, it’s important to understand that no one is talking about eradicating malaria within the next few years. Gates foundation and other proponents acknowledge a 50 year horizon which will require new tools – which the authors note may be possible (through new interventions and broader changes in economic development, education, health access, etc). The question then, is does the focus on or discussion of elimination in certain areas right now cause harm? I think that is the crux of the controversy.

Lines et al. describe the potential risks of promoting elimination – inequitable distribution of resources, resistance to drugs and insecticides, and management challenges present when deploying multiple interventions. In a rapid response Gosling and Chandramohan point out the risks attributed to elimination programs are not unique and apply to sustained control efforts as well (including resurgence and epidemics). While one could debate the magnitude of those risks in each type of program, Gosling and Chandramohan are essentially right. I felt the article could have been stronger if the authors had instead elaborated on some of their summary points, namely:

Nevertheless, there are important practical differences between elimination and control, notably in the relative priority given to high and low burden target areas, the choice and timing of interventions, and the need for integration with general health services.

In high burden areas, where elimination is currently not feasible, health impact will be maximized by aiming to develop universal coverage in the context of health systems.

The impact that a re-orientation towards elimination would have on generalized health systems is an important concern. For areas without an effective health system it is a moot point, but in many countries components of malaria control are effectively (and inexpensively) delivered through primary care. Finally, the biggest concern may be a question of managing expectations which was not fully discussed. Expectations related to the concept of elimination among donors, policy makers, health workers, and communities are bound to be much higher than what is realistic and a nuanced explanation of a long term vision is unlikely to temper those beliefs. Vision is a beautiful thing but we need proper communication to maintain trust, and proper execution to really benefit lives.


1 Response to “Malaria elimination or eradication vs control – what is the big deal?”

  1. 1 barmak April 7, 2009 at 10:08 pm

    very important post and topic. look forward to reading, and commenting soon.

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