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More people died of malaria in 2020 than in 2019. Here's why

El Salvador and China have now been declared malaria-free.

That's one of the encouraging takeaways from the new annual report on malaria issued on Monday by the World Health Organization. But the sobering news is that despite progress in some countries, this debilitating and lethal disease took a greater toll in 2020 than in the recent past.

The number of cases and deaths were up in 2020, compared to 2019. Overall, cases jumped from 227 million in 2019 to 241 million in 2020. Deaths went from 558,000 to 627,000.

The pandemic shoulders some of the responsibility – but it's not just that.

"We became a little too complacent," says Dr. Pedro Alonso, director of the Global Malaria Programme at the World Health Organization in Geneva since 2014 and a malariologist for nearly four decades.

In the words of the report, "The situation remains precarious." We talked to Dr. Alonso, about the future of malaria and the effect of COVID-19 – and the potential impact of a new vaccine approved just this year, the first for this parasitic disease.

What happened to malaria control when COVID-19 hit?

In March 2020, we thought, what on earth is going on here? Our biggest threat was with everything locked down, the supply of commodities was down and people weren't going to health facilities. It was like going back to the times when there was no malaria control.

Our worst case scenario was that in 2020 alone, we could potentially double the number of deaths due to malaria. But many countries made a massive effort to keep on deploying bed nets and drugs to prevent malaria, not to the level that they had actually planned, but they managed. So it was not as large an impact as could have been the case. Nonetheless, an extra 47,000 people died of malaria because of COVID-19 disruptions.

Were you surprised things weren't worse?

To be honest, yes. I've worked and lived in Africa for many, many years. In normal circumstances things are tough and rough, and I was just imagining what could happen with lockdowns, with lack of provisions, of commodities. It could be a real disaster. So in that sense, I'm happy.

What would the situation have been with no pandemic?

If we remove the COVID-19 impact, the picture we get is pretty much what we have been getting over the last three or four years, which is we've plateaued at the global level. We're not making any further progress.

That hides the fact that some countries are further reducing cases and deaths, other countries are not making any further progress and 39 countries actually either made no progress in the last five years or actually went backward.

So why do you think things had been getting worse in some places even without COVID's impact?

We became a little bit too complacent. We thought, oh, you know, we've got the tools, all we need to do is put in some money and then everything will be fine. And indeed, for the first 10, 15 years of this century, where there had basically been nothing before in Africa in terms of malaria control, we saw a massive impact from the creation of the President's Malaria Initiative and the establishment of the Global Fund to Fight AIDS. We could start reaching out with prevention tools and treatment tools.

This is now four or five years in which we're simply stuck. I think what we're seeing now is the limits of what can be achieved with those tools and those financial resources. Do we need more money? Yes. Do we need more robust health systems in the countries? Yes. Do we need a revision of how our financing mechanisms operate? Yes. Do we need new tools? Absolutely, yes. Urgently. And that's the significance of the new malaria vaccine. What worked for the last 15 years is not necessarily what is going to work and help us move forward in the coming 10 years.

What needs to be done to get back on track?

We have to recognize that this is not just a matter of an unfinished agenda. We have a major malaria crisis, and this report calls on the world to step up its efforts in a decisive way. Doing the same thing over and over again and expecting a different result is what I'm told Einstein called insanity. 2020 has to be taken as a wake-up call.

What changes would you like to see?

Countries need to be put in the driver's seat. They know best what their problems are, how to address them. WHO and other partners can help them improve on their planning, but once [countries] say this is what we want to do, financing mechanisms should be about supporting them, not about revising whether they're right or wrong with groups of people sitting here in Geneva as if they knew best. The countries themselves have to increase their financial commitment; we have to start shifting away from a donor dependent effort to one in which the countries take the leadership. What has worked up to now is one of the best global health success stories, but what has brought us here is not what we're going to need to move forward in the coming 10 years.

WHO has just recommended the use of a new malaria vaccine for children in areas where there's lots of infections, citing a 30% reduction in deadly, severe malaria. That sounds low. Can this vaccine make a difference?

The vaccine has been received very well. I personally attach massive importance to it because it shows the power of science. This is not just the first vaccine against malaria. It's the first vaccine against a human parasite which is biologically orders of magnitude different than a virus like that which causes COVID, or a bacterium. The fact that we have a parasite vaccine to be used that can save lives is massive.

Our estimate is this vaccine could avert somewhere between 40,000 and 80,000 deaths every year. I think that's very significant. Is this vaccine an eradication tool? No. But it is going to help us save lives.

Will malaria ever be eradicated?

The mood in 2014, when I came to work as director of the malaria program here at WHO was that over the next five years, we would continue making such extraordinary progress that what will come next is designing a new eradication program. Well, seven years down the line, I don't think we're there under any stretch of the imagination. Perhaps we're just too naive thinking that we were going to go on making the type of progress we had seen originally and that by 2020 we would be in a position to say it's clear we're on a trajectory that leads to eradication.

What we now need to do is acknowledge that this is a very hard enemy, that it's probably been the biggest killer of mankind along its entire history. We need to design a new plan and launch it acknowledging the challenges, the biological challenges, the medical challenges, and the challenges of inadequate health systems that are associated with poverty. We need to get the best minds and the best efforts and the international solidarity to help us push forward.

You are 62 years old and have been working on malaria for more than half your life. It sounds like there's a long haul ahead. Are you frustrated?

I am energized. One cannot afford to be frustrated at my age. In the first 20 years of this century, 10 million deaths [from malaria] have been averted. That's a huge success. Those are 10 million more people that have been given the chance to live a healthy, productive life. We need to go on saving lives. I am convinced that we can defeat malaria, but we should not be naive. We need to go on fostering research and development and aspire to come up with the tools that allow us to then say, You know what? Now we are ready for eradication.

Joanne Silberner is a freelance journalist and former health policy correspondent for NPR. She has covered global health issues since the outbreak of HIV.

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Joanne Silberner
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