Sunday Times 2
Keeping malaria away- the work is not over yet
Visiting Kataragama a few months ago, we stopped at a small wayside boutique selling small antique figurines and regional artifacts, to ornate trays of fruits and flowers to be sold as offerings to the gods. We struck up a conversation with the shop owner, a well-built man possibly in his early thirties and I waited for the right moment to pose the question which was foremost in my mind – “Do people here get malaria now?” He looked at me quizzically and said “No, we don’t have it here anymore”.
“I haven’t seen it in many years…” he went on, “… although as a child I remember suffering from it all the time – it interrupted my schooling, someone in our family was always ill with malaria fever, but strangely we have only a faint memory of it now – people here just don’t get it anymore.”
I knew quite well the story of malaria, but it was gratifying to elicit these words from a resident of a formerly highly malarious area of Sri Lanka where I had spent, with colleagues, a good part of my researcher life seeking and pursuing knowledge that might help control this disease. What a remarkable transition in this most challenging of all infectious diseases, malaria – from being a centuries-old scourge that is even incriminated in the fall of ancient civilisations, a disease that has robbed millions of Ceylonese, and then Sri Lankans of their health, that affected 5 million and sent 80,000 (or more) of our countrymen to their graves in the years 1934/45 during the Ceylon epidemic, and impoverished the country as no other disease has done, – to now, when malaria is no more.
The last case of locally acquired malaria in Sri Lanka was recorded in October 2012, and since then the country has been free of malaria. Technically speaking, malaria has been eliminated from Sri Lanka, meaning that it is no longer being transmitted from person to person by a mosquito in this country.
Official certification of malaria elimination by the World Health Organisation requires three consecutive years of interrupted transmission, which the country will seek in due time. Keeping Sri Lanka free of malaria for over a year is a national achievement that very few countries in the tropics and indeed in this part of the world have succeeded in. It is a cause to celebrate but the work is not done yet. Sri Lanka needs to strive much further to prevent the disease returning, and to continue keeping the country free of malaria.
In the 1980s when I started working on malaria in the deep south, the number of malaria victims reported in a year reached highs of 600,000. They were people in the dry and intermediate zones, mainly poor villagers, but every once in a while an unsuspecting visitor from big cities to Yala or a pilgrim to Kataragama, would suffer and even die of it, sending ripples of anxiety through the capital.
Our studies have documented households in which every single member had suffered malaria many times over during the course of a single year. Traditional farming communities were devastated because malaria struck during the rainy season, depriving them of work at the only productive period of the year. Those who could not make it to a health facility in time lost their lives due to severe malaria. Malaria showed itself as the classical “poverty trap” -poor people are more prone to malaria, and malaria in turn makes them much poorer. It weakened and impoverished our population year after year despite health services making an effort to control the disease.
Economists, Attanayake and co-workers, estimated the cost to Sri Lanka of malaria in 1993 exceeded Rs 7 billion a year, taking into consideration health services costs for diagnosis and treatment, cost of insecticides for mosquito control, people’s household expenses on illness, and their work days lost. But because the macro economic costs of malaria such as losses in trade, commerce and tourism were overlooked, these were at best, underestimates.
Economic costs alone are overshadowed by other more serious effects of malaria – studies carried out by Sri Lankan scientists showed that malaria impedes school performance in children- those who suffered malaria scored significantly lower at school examinations than those who did not.
Over 18 months have gone by without a single case of locally acquired malaria in Sri Lanka, but what looms large is a question – can Sri Lanka sustain this achievement and continue to keep the country malaria-free? Foremost in this consideration are the several impending threats that could cause malaria to re-emerge in this country, as it did 50 years ago when Ceylon (then) was close to eliminating the disease. In 1963 there were a mere 17 cases of malaria in the country, many of them imported but elimination was not achieved, and malaria returned with a vengeance to cause persistent havoc for several decades thereafter. The near elimination of malaria from Ceylonin the 1960s was the”great missed opportunity” which is deeply etched in the world chronicles of public health.
The threats to sustaining a malaria-free Sri Lanka are many: Sri Lanka still has in abundance, the mosquito that transmits malaria although the parasite that causes the disease has been eliminated. Though a person cannot acquire malaria in Sri Lanka just now, the disease is being carried to Sri Lanka by infected people entering the country – among them, foreign migrant workers, tourists, business travellers, refugees from neighbouring countries, Sri Lankan peace keeping forces returning home from Africa, and even Sri Lankans returning from holidays in malaria endemic countries in Asia and beyond. If a mosquito vector comes in contact with any of them, the disease could be transmitted to another, and there could begin an epidemic that will make the country eventually endemic again.
To avert this danger such patients must be detected early and treated effectively. Whether it will be done will depend entirely on the health policy makers who must now ensure that a high quality surveillance and rapid response system is maintained- to monitor incoming travellers for malaria, to detect and treat them early before they transmit the disease further, and in the event of a focus of transmission, to mount an effective operation to break the cycle of transmission at its early stages.
This may not be difficult for a health system that has achieved malaria elimination. However, if, as in the past, resources are moved from malaria on the grounds that it is no longer a public health problem to other competing diseases such as dengue, malaria is likely to re-emerge to cost the country dearly.
Malaria is now a forgotten disease – not least by physicians in Sri Lanka on account of its rarity in the country. Consequently there have been unacceptably long delays in diagnosing imported malaria patients placing their lives at risk, because malaria, unless detected early and treated, can be fatal. Keeping malaria within the consciousness of the medical profession would be paramount to achieving a malaria-free Sri Lanka, as would be alertness at ports of entry to detect malaria among travellers, and the necessary legislative framework to screen foreign labour and refugees for malaria.
The answer is clear – technically, it is entirely feasible to sustain a malaria-free Sri Lanka now that the cycle of malaria transmission has been interrupted. But it will need a strong political will at the highest levels of Government to muster resources, and strengthen the institutions that could do this – the Anti Malaria Campaign and relevant bodies within the Ministry of Health, centrally and in the provinces. The shop owner I talked to, and millions of Sri Lankans do not expect to return to a life of misery and suffering. The cost of a failure at this stage will indeed be high.
(The writer was formerly a senior official of the Global Malaria Programme, World Health Organisation, Geneva, and a Senior Adviser to the Director-General of the World Health Organisation).