The Centre has issued another ambitious elimination deadline, this time targeting malaria. Marking World Malaria Day on April 25, the government has announced its intentions to eliminate the disease from the country by 2030.
Statistics indicate around one million people suffer from malaria annually in India. World Health Organization (WHO) data suggests 400,000 deaths occur globally every year due to the condition. Seven percent of these deaths occur in India.
The sudden announcement of the elimination of malaria by 2030 seems to be highly, and perhaps unrealistically, optimistic. The fight against malaria has been ongoing for decades. While there has been a significant reduction in the number of cases, the malaria burden remains high in India.
Disparities in disease numbers?
One issue that may cause issues in determining whether the disease has truly been eliminated is the considerable disparity in malaria figures between studies.
The WHO Malaria Report 2014 estimates that, in the entire South East Asia region, there were 41,000 malaria related deaths. Some studies contradict these figures. One, conducted by teams from the office of the Registrar General of India along with the Centre for Global Health Research at St Michael’s Hospital and University of Toronto, Canada, found far higher figures. In 2010 they said that the death toll in India may be as high as 205,000, with 90 percent of these cases occurring in rural locations. Many deaths, they said, take place without intervention from health services. Lack of healthcare treatment may have resulted in these deaths not being recorded as malaria related.
The total death toll may be between 30,014 and 48,660 deaths, according to the estimates of a 16-member committee set up by the National Vector Borne Disease Control Programme. . This same committee estimated a far higher figure for the number of overall cases of malaria, suggesting 9.7 million people contract the disease annually.
Such disparities suggest that surveillance systems for official figures may be lacking, with a potential for a large portion of the figure estimated based on averages taken elsewhere. This may link in with the lacking healthcare infrastructure typical of rural locations in India, which may result in large numbers of cases going unrecorded.
The poor surveillance systems were noted by Dr Neena Valecha, director of the National Institute of Malaria Research. “Improving surveillance and taking care of difficult to reach areas play a crucial role in controlling spread of the disease,” she says.
Geography as a limiting factor
Difficult areas to reach will likely have a major impact on the effectiveness of the campaign to eliminate malaria. If the campaign is not rolled out in all affected states, any with areas still affected by the disease could cause fresh outbreaks elsewhere. In India this is a considerable issue due to the number of states affected. The disease is most prevalent in eastern states, though isolated cases are found across almost every other region.
The vast geographic area in which malaria cases may occur make it a logistic impossibility to assess each and every outbreak. This is particularly true of isolated rural areas. The short time frame in which elimination is now expected highlights this issue and so the target may be seen as no more than political point scoring. Other similarly optimistic deadlines have been put in place recently, such as the 2025 deadline for the elimination of tuberculosis, five years in front of the global deadline. Many have questioned the feasibility of those targets as well.
“Different areas need different kind of attention. In a research project in a low endemic state like Punjab, for example, we are trying to see whether molecular diagnosis will be useful to detect submicroscopic cases or not,” says Dr Valecha. Molecular tests allow for more sensitive detection of asymptomatic cases. In more endemic states such as Odissa, a more effective strategy may be the use of mass surveys to identify the specific areas of the state where transmission rates are high.
The possibility of drastic reduction in mosquito populations in order to stem the tide of malaria is unrealistic. India provides the perfect environment for the Anopheles mosquitoes to breed. Subtropical temperatures along with rainy seasons provide ample opportunity for mosquito populations to occur across the vast majority of the nation.
These breeding populations may occur in both rural and urban environments. The mosquitoes find their habitats in any area with stagnant water. This may be irrigated areas in rural locations or in manmade containers that hold rain water within the cities. As such, it is incredibly difficult to control mosquito populations and any attempt to do so must be viewed as a long-term endeavour.
Insecticide-treated nets and financial assistance
Mosquito nets have long been shown to be an effective means of reducing disease incidence. However, access to the nets in rural areas is lacking. According to Donna Glass of India Partners, “The greatest problems exist in rural villages because the people cannot afford to have what’s called a long-lasting insecticide net.”
If India attempts to rid itself of malaria in such a short period of time, investments into insecticide-treated nets and distribution among the poor may be an effective means of producing short term results. The mosquitoes that spread malaria are known to bite between dusk and dawn. As such, sleeping under an insecticide treated nest is a highly effective prevention strategy.
Such strategies produce feasible long term results but would require government assistance. As Glass notes, for a family living on USD $2 a day, a $10 insecticide net may not be their first priority.
The goal to eliminate malaria in such a short time frame is ambitious. It will require a considerable amount of financial investment if the government wishes to even come close to succeeding.