As World Malaria Day is marked this week, it will be an opportunity to celebrate the significant progress that's been made, but it will also be a time to question why there are still so many challenges in trying to eradicate this deadly disease.
First the progress - in the last ten years cases in Africa have reduced by a third and globally over twenty countries are on the path to eliminating malaria once and for all. However, this preventable disease is still responsible for the deaths of over 600,000 people every year, mainly young children in Africa.
Whilst mosquito nets have proven to be hugely effective, reducing cases by up to 90% in some areas, other factors mean they can sometimes be misused. A few years ago I was in Malawi and saw farmers using mosquito nets to protect their crops from pests. These were not big-scale farmers, but desperately poor people with families to feed, whose crops were failing because the rains hadn't come on time. One infestation from a hungry pest could mean a family being left with literally no income for the rest of the year and no food on the table, so you can see why they might risk getting malaria in order to protect their precious crops. Poverty is such a huge factor, putting people at a much greater risk of contracting the disease, so it's crucial that free bednets are regularly distributed in the poorest communities.
There's also the issue of resistance both to insecticide and malaria medicines. In countries with low levels of malaria, mainly in South East Asia, there are pockets of the disease where tried and tested methods of prevention don't seem to be working. A report in the Lancet last week said most of these cases were in areas where men are working outdoors; sleeping outside at night to protect their crops, or working in the forest to gather wood.
Oxfam's big concern is how Artemisinin Combination Therapy (ACT), currently the most effective anti-malarial treatment, is being distributed. The Global Fund to Fight Aids, TB and Malaria set up a scheme called the Affordable Medicines facility for malaria (AMFm) to subsidise the cost of these drugs for sale via shopkeepers. Oxfam is worried about the scheme because selling malaria medicines, even at a small cost, excludes poor people who cannot afford to pay for a full course of treatment. It also relies on unqualified shopkeepers to diagnose and sell drugs, meaning there's a real danger of people being misdiagnosed given that children's fevers are usually due to other causes, especially chest infections.
Oxfam spoke to people in Ghana about their experiences. One woman, Christiana, told us how her 12-year-old daughter Gloria had been misdiagnosed by a shopkeeper. Gloria had fever symptoms, which the shopkeeper assured Christiana was malaria, so he sold her malaria drugs. Gloria seemed to get better for a few days, enough so for her to visit her sister for a weekend in Accra. But over the weekend she rapidly deteriorated, ending up in hospital because she was finding it difficult to breathe and keep any food down.
Luckily for Gloria she was in the capital city, where there are hospitals. The doctors found her to have been suffering from typhoid for quite some time and she ended up staying in hospital for over two weeks. Christiana spent the whole time by her daughter's bedside, which meant she was not able to go out and earn any money. She also spent all the money she needed to run her business, as a cosmetics seller, on medical expenses. In the end Gloria spent several months off school recovering and has now fallen behind with her studies.
Christiana told us: "The malaria drug is very good, if you have malaria. But they should not give it to the drug peddlers; they should give it only to clinics. They [drug pedlars] sell it to you when you tell them you have a head ache, they will just give you the medicines without any diagnosis. This is very dangerous...If I had taken Gloria to a doctor from the onset when she was sick I don't think both of us would have suffered as we have done."
As well as cases like this, there is concrete evidence to show that using trained health workers is the safest and best option. In Ethiopia malaria deaths have halved in the last three years thanks to investment in community health workers, who are able to reach the most vulnerable people in remote areas. Moreover, most of those community workers are invariably women from the local community, which makes it easier for them to be more understanding of patients and their family's needs.
The Global Fund opted to allow countries to decide for themselves how best to distribute medicines, at its annual board meeting in the autumn of 2012. It is important now that it supports country choice and does not push for continuation of AMFm.
The fact is that there is no cheap option or easy short cut to ending malaria. The only way is to make sure people have access to all the means of prevention and treatment and the AMFm continues to be a dangerous distraction.