For millennia, India suffered greatly from smallpox. In 1977, the country declared smallpox vanquished for good. Similarly, India was burdened by polio. In 2014, India declared polio eliminated. These are stunning achievements from which all Indians benefit immensely. Now is the time to take on malaria.

At the East Asia Summit in 2015, Prime Minister Narendra Modi committed India to eliminating malaria by 2030, and last year, India launched its national strategic plan for malaria elimination.

However, India faces daunting challenges in the fight against malaria. Just this month, reports cited that in 2017, there was an 18 per cent increase in malaria cases in Tamil Nadu — a State that has otherwise been a leader in fighting the disease. These malaria upsurges could jeopardise the successful elimination that neighbouring Sri Lanka has sustained, particularly given the frequent travel between south India and the island nation.

Other large, but surmountable, challenges exist. The first is that the true numbers of malaria cases and deaths are not known. Estimates range from 1 million to 18 million cases and from 400 to 48,000 deaths per year.

Malaria exists in all States in India, and 95 per cent of Indians are at risk. Most cases are reported from Chhattisgarh, Jharkhand, Madhya Pradesh and Odisha. Arunachal Pradesh, Meghalaya, Mizoram and Tripura also have high transmission. However, the scale and distribution of this devastating disease is not well documented.

Private concerns

A related problem is that the majority of malaria in India is diagnosed and treated (or commonly misdiagnosed and mistreated) in the private sector. Private doctors and clinics have no obligation to follow government guidelines, use recommended drugs, or report malaria cases to State authorities. Malaria treatment by the private sector is especially problematic. In 2015, 86 million malaria treatments were procured in the private sector, compared to just 2 million in the public sector. In the private sector, all types of drugs are used, including those that are either worthless or harmful.

For example, each year, the private sector procures nearly 10 million injections of artemisinin monotherapy — a treatment that is strongly discouraged in India and elsewhere because it accelerates the development of deadly drug resistance. The misuse of malaria drugs in India is an irony, given that India is by far the largest supplier of high-quality approved malaria drugs to the rest of the world.

What needs to be done? First, India must declare a campaign and a determination to get the job done. National initiatives must promote innovative strategies, incentivise the appropriate use of diagnostics, drugs and insecticides, and ensure that all malaria cases are reported.

The most affected States must aggressively bring their malaria down using effective vector-control and case management practices, combined with robust surveillance systems. This fight against malaria will require partnership between communities, civil society, private sector, and public health agencies.

States must step in

The spotlight is now on States nearing malaria elimination, a goal that could be achieved as early as 2022. In the North, Haryana, Himachal Pradesh, Jammu and Kashmir, Punjab, Rajasthan and Uttarakhand could quickly establish a malaria-free zone benefiting 160 million people. Meanwhile, in the South, Kerala and Tamil Nadu can also eliminate malaria rapidly, followed by Andhra Pradesh and Karnataka. A quick win in Goa will bring benefits to tourism. Rapid elimination in these low-burden States is possible with aggressive statewide mobilization and strong collaboration among neighbouring States. Punjab is hoping to be first.

States will have to tailor their programmes to achieve elimination, especially in tribal areas where the burden of malaria is often the highest. A single approach to malaria elimination will not work in any large country, especially in India where the biology, entomology and epidemiology of the disease vary considerably.

India has been central to the fight against malaria since the beginning of the battle. The breakthrough discovery that malaria is transmitted by mosquitoes was made 120 years ago in Secundrabad, India. Since then, half of the world’s countries have banished malaria. Now is the time for India to do the same.

Feachem is Director, The Global Health Group, University of California San Francisco. Ahmed Lal is Senior Advisor Global Health and Innovation, Sun Pharma, India

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