The end of malaria

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I wasn’t always a boring newsroom-bound editor. Back in my days as a Time magazine foreign correspondent, I used to fly to far-flung places, recorder and notebook in hand. That’s how, in the summer of 2005, I found myself in Mae Sot, a small city in Thailand near the border with Myanmar, tasked with contributing to a major cover package the magazine was producing on heroes of global health. 

I was there to visit a rural medical clinic largely run by and for refugees from Myanmar’s military government. The patients were overwhelmingly there for one reason: malaria. While southeast Asia had made significant progress against the disease, malaria was still highly active in Mae Sot. I saw rows and rows of feverish patients laying motionless in their net-covered beds. And then, when I got back to my home in Hong Kong a few days later, I became one of them.

After a few extremely unpleasant days of shaking chills alternating with high fevers, my case resolved itself. I was lucky. Hundreds of thousands of people each year aren’t so fortunate. Over 260 million people contracted malaria in 2023, and nearly 600,000 died — the vast majority of them young children in sub-Saharan Africa. 

Malaria has been killing human beings for at least 10,000 years, if not longer. And for millennia, it was treated as a miserable fact of life. But today, malaria is no longer inevitable. Not just in places like the southern US, where it has long since been eradicated, but anywhere. 

Since 2000, the global malaria death rate has been cut roughly in half. The World Health Organization (WHO) estimated that, between 2000 and 2023, malaria treatment and prevention programs averted about 2.2 billion cases and 12.7 million deaths worldwide. Countries from China to Sri Lanka to Paraguay have been certified malaria-free, and many more now report only a scattering of cases each year. A child born in Africa today is far less likely to die of malaria than one born in 2000.

But the news isn’t all good. Since the mid-2010s, the declines in malaria cases and deaths have largely plateaued. Mosquitoes are evolving to resist the insecticides used on most bed nets, and the malaria parasite carried by the insects has developed partial resistance to the most common malaria medications in parts of East Africa. Climate change is lengthening transmission seasons and nudging mosquitoes into new areas. Covid-19 disrupted bed net campaigns and routine care.

You can see it in the global data. The latest WHO figures show 263 million cases and 597,000 deaths in 2023 — about 11 million more cases than 2022 and, essentially, the same number of deaths. The graph that once sloped downward now looked uncomfortably flat.

A new generation of tools arrives — but will we choose to use them?

But, this is the Good News newsletter, and I have some good news for our fight against malaria.

In November, researchers announced results from a major trial of a new malaria treatment called GanLum, a combination of ganaplacide and a once-daily formulation of lumefantrine. GanLum achieved a 97.4 percent cure rate.

Ganaplacide works differently than past malaria treatments, disrupting the parasite’s protein transport system, and the combo appears to work well even against partially drug-resistant strains that have been emerging in Rwanda, Uganda, and Eritrea. Novartis calls it the first major innovation in malaria treatment since artemisinin-based combination therapies (ACT) were introduced more than 25 years ago, and it plans to seek regulatory approval, with a commitment to provide it on a not-for-profit basis in endemic countries.

That’s the sword once malaria invades your body. But, we also have new shields to stop the parasite from getting in.

For the first time, we now have two malaria vaccines that work well enough to roll out across high-burden African countries: RTS,S/AS01 and R21/Matrix-M. Both target the malaria parasite in children in areas with moderate to high transmission. 

RTS,S has already been given to more than 1.8 million children in Ghana, Kenya, and Malawi in WHO-coordinated pilots. The vaccine is not hard to deliver and safe, and it reduces childhood malaria, hospitalizations, and deaths.

R21, developed by the University of Oxford and the Serum Institute of India, has shown more than 70 percent efficacy in certain highly seasonal settings — meaning times and areas with particularly intense malaria transmissions — and can be manufactured more cheaply and at larger scale. The Serum Institute said it already has capacity for 100 million doses a year, with plans to double that at a price under $4 a dose.

More than 20 African countries have either introduced or are preparing to introduce at least one of the vaccines into their routine childhood immunization schedules. Global health agencies estimate that vaccinating around 50 million children over the next several years could save well over 100,000 young lives.

The bottleneck of politics

So, why are we still losing 600,000 people a year? Why aren’t cases plunging again? Because, none of these breakthroughs deploy themselves. The limiting factor is money — and political will.

The WHO estimates that global spending on malaria remains several billion dollars a year short of what’s needed to meet internationally agreed-upon targets. Funding from rich governments has flattened or declined in real terms this year. As part of President Donald Trump’s war on foreign aid, US programs like the President’s Malaria Initiative (PMI) have faced repeated attempts at cuts or freezes.

These aren’t abstract line items. When the Global Fund or PMI buys fewer mosquito nets, nets simply don’t show up in the villages that need them. When orders for rapid tests or ACTs get delayed, frontline clinics run out. When new vaccines aren’t fully funded, manufacturers don’t ramp up production, and health ministries plan for smaller, slower rollouts.

Researchers estimate that underfunding could mean millions of extra malaria cases and tens or hundreds of thousands of additional deaths by 2030, compared with a fully funded scenario. Some southern African countries are already seeing malaria resurgences tied to funding gaps and campaign disruptions.

So, this is where we are: Malaria today is more solvable than ever, scientifically speaking. The remaining obstacles are political and budgetary. Whether malaria keeps killing hundreds of thousands of children each year, or resumes the decline we saw from 2000 to 2015, is now a matter of choice.

When I think back to that clinic in Mae Sot — the rows of beds, the heat, the fear of parents waiting beside children burning with fever — it no longer feels inevitable, as it did to me then. We already know the story can go another way. The question is which ending we choose.

A version of this story originally appeared in the Good News newsletter. Sign up here!