Africa: Anti-Malarial Drug Resistance Is Making Malaria Normal Again

As Egypt is certified malaria-free, the parasite is developing resistance to treatments, costing the continent $127 billion in lost GDP by 2030, 600,000 lives a year and, potentially, the return of the old misery.

Malaria is such an inherent part of many African people’s lives that any kind of fever or general feeling of malaise is often referred to as malaria. Any health worker who has practiced on the African continent will tell you that they have observed this assumption. About 94 percent of malaria cases and 95 percent of deaths from malaria, a disease that was long-eliminated in many parts of the world, occur in Africa.

Even though there has been progress in the fight against malaria — including Egypt’s recent certification as being malaria-free — over 600,000 people die of malaria every year. Those who survive, especially young children and pregnant women, risk life-long morbidities.

Still, “I think I have malaria” is not a statement African people make with dread. It is often stated with nonchalance and the resignation of a people who have accepted the disruption malaria brings to their lives.

What communities do not always fully appreciate is that malaria is not only continuing to kill but it is also evolving and becoming resistant to some of the existing treatments. In September, on the sidelines of the UN General Assembly, the Gates Foundations, the US Presidential Initiative on Malaria, Unitaid and the Global Fund got together to highlight the urgent need to address anti-malarial resistance. These key malaria funders got together to draw attention to the emergence of resistance to artemisinin-based combination therapies (ACT), which is the most used malaria treatment line in Africa.

These donors have variously invested in interventions such as supporting the production of affordable generic drugs, subsidising countries so that they can afford to provide people with more diverse and effective options to treat malaria and research to develop alternative treatments and monitor the progression of resistance.

They further highlighted that while there are alternatives to artemisinin-based treatments, they are three to four times more expensive. Endemic countries throughout Africa cannot afford these treatments.

“We urgently call on bilateral and multilateral donors, philanthropic foundations, and the private sector to join us in heeding the call from malaria endemic countries to make existing alternative ACTs available and affordable,” they said in their statement.

Already, African countries that are hardest hit by malaria also lie at the lower side of the development index. A recent study showed that if Africa gets back on track to meet its malaria goals by 2030, the continent could increase its GDP by $127 billion. Malaria lies at the core of African problems. For decades, it has strained health systems, as governments invest resources to respond to a disease that is, in some countries, responsible for over half of patient admissions.

Malaria also means that resources that could go into responding to other illnesses have to go to malaria. This is especially true in the face of pandemics. During COVID-19, we saw malaria deaths rise as governments dedicated their public health budgets to managing the pandemic. During the 2022 Ebola outbreak in Uganda, we witnessed the ways in which the existence of malaria made it harder to diagnose Ebola, further compounding the epidemic. We are seeing similar scenarios with mpox as affected countries struggle to respond both to its sudden outbreak and malaria.

Even as the World Health Organisation reports that malaria funding has decreased by 10 percent and funding for malaria research is at the lowest recorded level in 15 years, it is safe to say that the malaria parasite is only getting smarter – evolving to outsmart existing interventions and bringing with it a heavy sense of déjà vu.

The use of artemisinin-based treatments as the malaria parasite grew resistant to chloroquine contributed to the halving of malaria deaths in the past decade. In 2004, British medical doctor and tropical medicine researcher, Nicholas White wrote:

“Resistance is the most likely explanation for a doubling of malaria-attributable child mortality in eastern and southern Africa. Resistance has already developed to all the antimalarial drug classes with one notable exception — the artemisinins. These drugs are already an essential component of treatments for multidrug-resistant falciparum malaria.”

Resistance to antimalarial drugs has been linked to several factors, including the use of poor-quality drugs, a weak supply chain that compromises the efficiency of drugs and poverty that forces people into practices that can drive resistance. For instance, self-medication, taking incomplete drug doses and sharing drugs.

Following the catastrophic deaths that came with resistance to chloroquine, Dr White further warned:

“If we lose artemisinins to resistance, we may be faced with untreatable malaria.” And that, “The effects of resistance on morbidity and mortality are usually underestimated.”

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When a patient in Africa comes into the medical centre on suspicion that they have malaria, the community health workers, most of them women, who form the bedrock of national malaria responses move fast. They know that the disease is a matter of life and death. They also know that many times, people feel ill and, for various economic, social and cultural reasons, do not seek treatment. They welcome the patients who decide to go to the medical centre.

And while malaria may be part and parcel of the lives of African people, with anti-malarial resistance, we are yet to see the worst of the disease. Without urgent intervention, which includes adequate funding to enable endemic countries to prevent and treat the disease, the perfect storm of antimalarial drug resistance coupled with other challenges is brewing even as African people soldier on – many unaware of the consequences awaiting them. The first step in staving off the storm is for donor countries to honour their pledges and adequately replenish the global fund for the next grant cycle. The next is for Africa to determine once and for all to not normalise the existence of a disease that continues to shackle the continent and take steps to eliminate it once and for all.

Dr Michael Adekunle Charles is the CEO of RBM Partnership to End Malaria.

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