Cross-border malaria elimination: A shared responsibility for neighbouring nations
This article is authored by SY Quraishi, former chairperson, FDEC India, former special secretary, MoHFW and former Chief Election Commissioner of India.
The chairmanship of G20 has provided India with a unique opportunity to organise international interactions on a variety of subjects. One subject of international concern that has remained under the radar has been the elimination of malaria. On April 24, India hosted an Asia - Pacific conference of health ministers to deliberate on the subject.
The global health community has faced unprecedented challenges in managing the Covid-19 pandemic. The impact of this health emergency on other disease control programmes was also a policy focus. In the case of malaria, there was nervousness whether the pandemic would negate the progress made over that last two decades. The good news is that countries across the globe held the line against malaria, avoiding the worst-case scenario and averting 185 million cases and 997,000 deaths, as revealed in the World Health Organization’s World Malaria Report 2022. We have also remained resilient and connected in our efforts to eliminate malaria in the Asia Pacific.
But defeating malaria in the last mile will require more than resilience. Take India for example, the sharp and drastic reduction in malaria cases and deaths in recent decades is a significant achievement. Out of India's 36 states and union territories, 29 states are nearing elimination. Yet, in 2021, India had 161,753 malaria cases and bore 9% of the malaria burden in the Asia Pacific region. Over 1.3 billion people in India are still at risk of contracting malaria, especially in hard-to-reach tribal regions.
While Bangladesh and Pakistan saw a 19% and 7.6% increase with 7,288 and 400,316 cases, respectively; Bhutan and Nepal reported just 23 and 32 malaria cases respectively in 2021 -- more than a 50% reduction in one year. Many of these remaining cases occurred in border areas.
With national goals to end indigenous transmission of malaria by 2030 (India, Bangladesh, and Pakistan) and 2025 (Nepal and Bhutan), there is a need for the neighbouring governments to engage with each other to also achieve zero-transmission in border areas well before their respective malaria elimination targets.
Both the malaria parasites which cause the disease as well as the mosquitoes which transmit the infection do not recognise internal or international borders. Irrespective of how strong the malaria programmes of individual nations are, complete elimination of malaria will not be achieved until we wipe out this infectious agent, fully from all nations in the region.
The data is clear: 17% of Bhutan's malaria cases and 83% of Nepal's in 2020 were imported. Hence, cross-border malaria becomes particularly important as states and nations approach the near-malaria elimination stage.
Sri Lanka and China, two countries with vastly different geographies, have both successfully eliminated indigenous transmission of malaria. In fact, China heavily invested in cross-border malaria issues for years to become malaria-free, identifying hotspots of imported cases and running malaria posts, staffed with trained experts. The elimination of malaria requires shrinking the malaria map nationally, preventing cross-border infection through robust surveillance and prompt treatment to prevent outbreaks.
For eliminating transmission of cross-border malaria, active engagement, real-time data collection and data sharing would be a requirement. Borders may not stop malaria, but robust surveillance systems, co-operation at all levels of government and ensuring no one is left behind, can.
Although most Indian states are nearing malaria elimination, a few continue to face challenges, including domestic cross-border malaria. Real-time sharing of local-level malaria data is paramount here.
For example, one of the lessons from the Malaria Elimination Demonstration Project (MEDP) in Mandla, which was conducted through a public private partnership between the government of Madhya Pradesh, Indian Council of Medical Research, and the Foundation for Disease Elimination and Control (a CSR initiative of Sun Pharmaceuticals), was that over 50% of malaria cases were from, Telangana, a state over 600kms away from Mandla.
This was an insightful revelation as it was expected that transmission of most cross-border cases would happen along physical borders. This knowledge allowed the MEDP to plan their surveillance and response mechanisms more effectively with a few simple tactical steps that did not require many systemic changes or permissions from the state government. The results of this malaria elimination project have been published (https://www.biomedcentral.com/collections/mandlaelimination), so that rest of the states in India and other nations in the region can benefit from these learnings and experiences.
In fact, data-sharing and surveillance principles apply at international borders as well. However, the situation becomes challenging with respective regulations and protocols of national governments on both sides of the border. Success of any coordinated response would require multi-country clearances between countries where borders are shared and from respective foreign, home, and health ministries.
The 2030 malaria elimination goal is a commitment made by the Prime Minister Shri Narendra Modi and the heads of States of several neighbouring countries. Hence, the onus of elimination should not fall solely on the ministry of health and family welfare. Success will require inter-sectoral coordination among the ministries of health, foreign affairs, defence (border control), tribal affairs, and more.
Such inter-sectoral coordination has been demonstrated in the region. In 2017, Timor-Leste and Indonesia initiated a bilateral and multi-ministry response to cross-border malaria under a Memorandum of Understanding since 2017. This agreement facilitates cross-border malaria joint planning under more general health cooperation activities promoted by the ministries of health and foreign affairs of both countries.
We are only as strong as our weakest link, and this is particularly true for malaria elimination. Remote regions, such as India’s border areas near Bangladesh, Myanmar or Pakistan, face high incidences of malaria, significant cross-border movement, and limited programmatic outreach due to a variety of factors including distance, lack of infrastructure, political instability or national emergencies. Together, these conditions allow for widespread cross-border malaria cases and drug-resistant malaria strains, such as the strain which once plagued the Mekong region.
South Asia is steadily progressing towards malaria elimination. This is an opportunity for the region to look back on its many achievements over the past decades and decide how this decade of malaria elimination will end. Success is possible if India takes the lead and seriously combats the issue of imported malaria by building domestic and international real-time data-sharing systems, organising a whole-of-government approach, and ensuring all programme support, even in the hardest to reach communities. With demonstrable, replicable, and sustainable domestic evidence of the science of malaria elimination, India is uniquely poised to take leadership by ending cross-border malaria at home and abroad.
This article is authored by SY Quraishi, former chairperson, Foundation for Disease Elimination and Control of India (FDEC India), former special secretary, ministry of health and family welfare and former Chief Election Commissioner of India.