Is it possible to eliminate malaria in South Africa?

At a meeting in Johannesburg in April, African Ministers of Health endorsed the African Union’s plan to eliminate malaria from the continent. Subsequently, at a malaria conference in Durban, the question of whether malaria elimination is feasible was raised but, for many countries in Africa, the question remains unanswered. The debate over eradication versus control has been played out before and politicians hoping to hitch their wagons to the eradication star would do well to understand some of the important disease control history.

Malaria was a serious global health concern until the mid 20th century. In the 1940’s the successful application of DDT as part of indoor residual spraying (IRS) programmes, coupled with the effectiveness of anti-malarial drugs such as chloroquine, gave countries the impetus to attempt to eradicate the disease. In 1955, the Eighth World Health Assembly resolved to begin a worldwide eradication campaign and although the campaign was ultimately abandoned and considered a failure, it achieved some great successes, saving millions of lives.

Countries that were developing and becoming wealthy eradicated malaria most rapidly and have subsequently kept it at bay. From the late 1800s malaria declined in most of Europe and the US because mosquito-breeding areas were being drained for farmland. People could afford better housing with windows, screens and shutters, and to treat themselves and kill off the deadly parasites. All of this happened before anyone realised that the disease was being transmitted by mosquitoes.

South Africa is a world leader in malaria control thanks to good scientists and researchers that base policies on scientific evidence. SA’s relative wealth allows the government to pay for the best interventions for our circumstances without interference from donor agencies. As was the case with the eradication campaign of the 50’s, a cornerstone of the SA programme has been the successful use of DDT for IRS, now supported by new highly effective artemisinin based combination therapies (ACTs) for the treatment of malaria. These policies are in place because they have been shown to be effective on the ground with IRS using DDT being an essential element of the programme. Indeed, it is the success and leadership of the SA government in the fight against malaria that prompted other African countries to either re-introduce DDT to malaria control or to seriously consider the move.

South Africa has also been instrumental in initiating and aiding neighbouring countries with their malaria control programmes. Arguably the most successful cross border malaria control programme has been the Lubombo Spatial Development Initiative (LSDI). The LSDI is a tri-lateral agreement between the governments of Mozambique, South Africa and Swaziland and has substantial input from South Africa’s Medical Research Council (MRC). Since its inception in 1998 the programme has reduced the incidence of malaria on the border between South Africa and Swaziland from over 25% to less than 2%. In Maputo province the number of infections declined from over 625 per 1,000 persons to less than 200 per 1,000 within three years of implementation of the programme.

The African Union malaria elimination plan targets a handful of southern African countries, including South Africa, for a complete halt to malaria transmission by 2015. The proposal will no doubt gain significant political mileage but from a practical perspective the objective seems overly ambitious. Despite the significant successes the South Africa government has achieved both domestically and internationally through its cross border initiatives there is only so much it can do regarding developmental and infrastructural obstacles in neighbouring countries.

The lack of infrastructure will continue to hamper efforts – making control campaigns extremely cumbersome but not impossible. As long as people continue to cross over our borders from highly endemic countries we will continue to see the concomitant flow of disease. So, is the elimination of malaria possible in South Africa?

In the short term the South African government can continue its comprehensive malaria control programme as well as the very successful programmes in neighbouring countries to stem the flow of disease into SA. In the long run, however, it will only be possible to eradicate malaria in SA if eradication is also occurring successfully in neighbouring countries. Mozambique’s malaria control is improving impressively, but in Zimbabwe, social, political and economic upheavals have caused malaria control to take a giant step backwards.

Ultimately, malaria eradication will depend on long-term economic development. Economists such as Jeffrey Sachs make the argument that controlling malaria is essential for economic development. To a certain extent they are right, but if the history of malaria eradication around the world is anything to go by, wealth and development precede malaria eradication (and the control of other diseases) not the other way around.

Anyone committing to malaria eradication would do well to examine how previously malaria-prone countries grew wealthy. They would find that growth stems from economic freedom. The foundations of economic freedom are personal choice, voluntary exchange, freedom to compete and security of privately owned property – foundations that are fundamentally lacking in many African countries where the burden of malaria is greatest. Malaria and general disease control programmes should consequently be adjuncts to policies aimed at achieving high economic growth; policies that will not succeed unless they are built on economic freedom foundations.

Author: Jasson Urbach is an economist with the Health Policy Unit (a division of the Free Market Foundation) and a director of Africa Fighting Malaria. This article may be republished without prior consent but with acknowledgement to the author. The views expressed in the article are the author’s and are not necessarily shared by the members of the Foundation.

FMF Feature Article/ 19 June 2007