By Zheng Qi 2020-09-13

Based on its comprehensive, multi-year analysis, the World Health Organizations Strategic Advisory Group on Malaria Eradication (SAGme) concluded that ‌malaria can, in principle, be truly eradicated.‌ This means that, like smallpox, it is biologically and technically plausible to achieve a permanent, global zero incidence of the disease, with no risk of reintroduction. The groups landmark 2019 report, "Malaria Eradication: Benefits, Future Scenarios & Feasibility," arrived at this foundational "yes" after rigorously examining the parasites biology, transmission dynamics, and the lessons from past eradication campaigns.

‌The Biological "Yes": No Insurmountable Barrier‌

The advisory group determined that, crucially, ‌there is no specific biological or environmental barrier that makes malaria eradication an impossible goal.‌ Unlike some diseases with persistent animal reservoirs that perpetually seed human infections (a key challenge for diseases like yellow fever), the primary human malaria parasites, Plasmodium falciparum and P. vivax, rely overwhelmingly on a human-mosquito-human transmission cycle. Humans are the essential reservoir. This creates a critical vulnerability: if human-to-human transmission can be interrupted completely across all endemic areas for a sufficient duration, the parasite chain can be broken permanently. Furthermore, the parasite does not form environmental spores that can survive for decades, and its complex life cycle offers multiple stages for targeted intervention. The precedent of smallpox eradication proves that a concerted global campaign can eliminate a human-specific pathogen forever.

‌The Operational "No": A Gap in Todays Capability‌

However, the group drew a sharp, critical distinction between ultimate biological feasibility and immediate operational readiness. To the pivotal question — ‌"Do we have the tools, programmes and financing that could actually drive an eradication effort now?"‌ — the advisory groups answer was a definitive ‌no.‌

A successful global eradication campaign is not simply a scaled-up version of current control programs. It requires a suite of capabilities we currently lack:

‌Next-Generation Tools:‌ We lack tools consistently effective for interrupting transmission in the most challenging "last-mile" settings. Current interventions—insecticide-treated nets, indoor residual spraying, and artemisinin-based combination therapies (ACTs)—are increasingly challenged by insecticide and drug resistance, and they often fail to reach or protect populations in remote forested areas, conflict zones, or among highly mobile groups. We do not have a highly effective transmission-blocking vaccine, a single-dose radical cure for P. vivax, or novel vector control methods impervious to existing resistance.

‌Programmes for Universal, Sustained Coverage:‌ Eradication demands that surveillance and intervention systems achieve and maintain near-perfect coverage in all populations indefinitely. Current health systems in many high-burden countries are not equipped to deliver this level of quality and reach consistently, especially while managing competing health priorities.

‌Predictable, Long-Term Financing:‌ Eradication is a multi-decade financial undertaking requiring funding far beyond current levels, with guaranteed support for the long "tail" of post-elimination surveillance to prevent reintroduction. Todays financing is fragmented, volatile, and insufficient for this guarantee.

‌The Critical Path Forward: Accelerated R&D‌

This gap between the possible and the practical ‌speaks directly to the critical importance of an accelerated research and development (R&D) agenda,‌ which the advisory group strongly emphasized. The path to eradication must be built on innovation. The group called for urgent investments to develop the transformative tools needed for the final push: novel vaccines, new drug classes, advanced diagnostics for asymptomatic carriers, and innovative vector control. Simultaneously, operational research is needed to design delivery models that work in the hardest-to-reach communities.

In essence, the WHO advisory groups position is one of ‌optimistic realism.‌ They affirm that eradication is the rightful goal and is biologically achievable, providing a "yes" that justifies the long-term mission. However, their "no" regarding current tools is a crucial call to action—a directive to focus relentlessly on innovation and health system strengthening today, to make the feasible goal of tomorrow an attainable reality.

Edited by: Secretariat of the Asia-Pacific Network for Drug and Diagnostics Innovation
Produced by: Zheng Qi
Reviewed by: Zhang Haobing
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