On this year’s World Malaria Day, I find myself in a taxi in snarled traffic in downtown São Paulo, one of my favourite cities in the world. This is far from the front lines in the fight against malaria, where I spend much of my time, but what’s happening here in Brazil’s amazing, vibrant cities may well provide a critical template for how we can adapt to a rapidly changing malaria landscape.
The primary challenge in Brazil is dengue, a disease transmitted by an urban vector, Aedes aegypti, which thrives in urban environments and quickly evolves resistance to chemical pesticides. How we’ve learned to combat this threat lends a set of direct lessons and tools that we must quickly deliver to the front lines in malaria’s newest battlefield – Africa’s many large, growing cities.
The malaria threat is changing, and quickly. Characteristically fought in rural areas in Africa and Asia, malaria on the African continent is now being transmitted by a spreading urban mosquito, Anopheles stephensi. Climate change, rapid urbanisation, increased international movement of people and goods, and the persistent use of decades-old vector control tools has allowed this mosquito to spread across much of Africa. The result? Millions more people are under threat of malaria as An. stephensi continues its march and, as of now, we have yet to adapt our malaria control strategies to effectively address it.
Of course, this invasive mosquito and the new challenges it poses are part of a broader narrative about the global fight against malaria. It has stalled, in no small part because we’re continuing to use 20th century mindsets and toolkits to combat a highly adaptive enemy. Traditional vector control tools are losing effectiveness as mosquitos adapt; resistance to malaria drugs is on the rise; and now, critically, we have a new front in the war which we are ill-equipped to fight, let alone win. Coupled with diminishing contributions by donor nations and an aging and fatigued international public health infrastructure, the outlook of many is bleak.
But as I sit in this small taxi crawling at 3 mph, I’m incredibly optimistic that we can reverse these trends and get back on track to elimination of malaria in our lifetimes. Here’s why: I’m about to step out of my taxi and into a favella where my colleagues and I are using new strategies and tactics to root out the urban-dwelling dengue mosquito.
Of the many lessons we’re learning on the ground in Brazil, some can be applied directly to the front lines in the fight against the spreading urban malaria vector.
Shift mindsets. A major collective shift in mindset is needed amongst the public health community and in ministries of health. The simplest way to explain what I see, on a daily basis, is that we’re using a traditional 20th century handbook in a very different 21st century war. We must reposition our strategic planning to include urban settings, where relatively little malaria control has taken place. We must adapt vector control operations and expand our toolsets to succeed in both rural and urban settings, and we need to do so quickly.
Expand and adapt resources. Yes, we need more funding for malaria. That’s not news. The same is true for the dengue fight. But rather than simply appeal for more funding to an increasingly fatigued donor community, we have activated the private sector in new, promising ways here in Brazil, both in securing direct funding or participation for new vector control programs but also in support of the creation of new health financing initiatives.
Strengthen monitoring and surveillance. Great work is being done on this front now as governments and international organisations are sharing data about the ongoing spread of Anopheles stephensi. But as this vector ignores international boundaries, continued work to build robust surveillance systems across the African continent will give us a much more accurate understanding of where this threat is. That then allows us to target our efforts precisely and conserve the precious resources we need to protect millions more people. In the dengue fight, we’ve generated a range of new technologies to track Aedes aegypti, share information and ultimately understand where it is, and much of that can port to malaria efforts.
Empower the public. Not just with brochures and public service announcements, but with actionable roles and sustainable tools they can use to take up the fight themselves. This new battlefront against malaria is a door-to-door fight in African cities and it will require building deep trust with the public and empowering them. Here in Brazil, we’ve re-written the playbook for building trust and activating the public – we’ve effectively organised communities, the private sector, local governments and civil society to take on dengue – and we can do that in malaria-impacted communities.
Move new technologies to the front, faster. Today, it takes years and years for new malaria control tools to be validated and ushered to the front lines. We don’t have that kind of time now. In light of how quickly the international community developed and approved COVID vaccines, we should reset our expectations about what it takes to validate and deploy novel solutions and streamline how the WHO and other international and national institutions assess them. As we’ve shown in Brazil, we can build, validate, approve, and deploy at scale novel technologies like Oxitec’s Friendly™ Aedes aegypti in just a matter of a few years.
To sum it up: the war against malaria is changing rapidly. To re-position our efforts for success in the coming years, we will need to adapt quickly. Leveraging lessons from the dengue fight will help us as the malaria battlefront moves into cities. If we do it right, I have every belief we can still win.
Author: Grey Frandsen, CEO of Oxitec