The “Ride” To Eliminating Malaria In Haiti

The town of Dame Marie on the southwestern tip of Haiti, is 225 miles from the country’s teeming, chaotic capital Port-au-Prince. But getting there by car—on a good day—can easily take eight hard-fought, kidney-bashing, hairpin-turning hours.

That may seem like a random or irrelevant fact until you understand this: Dame Marie is a malaria hotspot and time matters since my job at CDC is to work with the countries of Haiti and the Dominican Republic to eliminate malaria by 2020.

As we celebrate World Malaria Day, my experiences in Haiti can highlight hard-won achievements which are even more precious in a challenging environment. But at the same time, they also serve as a sobering reminder of what’s left to do.

That’s why the drive to Dame Marie is useful.

And as far as metaphors go, it’s a good one to suggest what we confront in the effort to eliminate malaria. The drive takes longer than it should; for comparison’s sake the distance between Atlanta and Charlotte, NC, is 250 miles and that trip by car usually takes four hours. There’s a lot of other traffic going in the same direction for the same purpose but not always in a manner that’s efficient and cohesive. And there are detours, both literally and figuratively. Most of all, you’re never sure what you might encounter along the way.

Yet we all know that, with persistence, we’ll get there; eventually.

That begins to paint a picture of our efforts to eliminate endemic malaria from Hispaniola, malaria’s last major holdout in the Caribbean. While Hispaniola includes the Dominican Republic and Haiti, Haiti is the frontline. Of the 17,500 cases of malaria on the island, Haiti is home to 17,000.

Anybody who pays attention to global health knows the terrible scourge that is malaria. Nearly half of the world’s population is at risk for getting the disease, with the vast majority living in countries that are poor and ill-equipped to respond. It’s not an overstatement to say that a mosquito, which carries and spreads malaria, is the most lethal “animal” on earth. In 2015, for example, there were 214 million new cases and 438,000 deaths worldwide.

By those standards, the raw number of cases in Haiti isn’t large. But the fact that Hispaniola (the island shared by Haiti and the DR) is the last holdout in the Caribbean means that eliminating malaria there holds symbolic importance and will provide refined practices and tools that will help fight malaria in other places.

For those reasons and others, an ambitious group has come together to achieve the goal. It even has an official name: Malaria Zero: The Alliance for A Malaria-Free Haiti.

Malaria Zero supports the leadership of the Ministries of Public Health in Haiti and the Dominican Republic in their malaria elimination efforts, and is led by the U.S. Centers for Disease Control and Prevention (CDC), and includes the Pan American Health Organization, The Carter Center, the Clinton Health Access Initiative, the London School of Hygiene & Tropical Medicine, Tulane University School of Public Health and Tropical Medicine and the CDC Foundation.

One other critical partner is the Bill and Melinda Gates Foundation, which provided a $29.9 million grant last year that was used to build this partnership and launch the effort.

Even with so many strong and capable partners, strong commitment from the countries, and the Gates Foundation’s generosity, getting Haiti to zero malaria cases is not easy. Maybe, that’s because we are trying to accelerate the timeline – instead of taking the ten or twenty years to get there, Malaria Zero intends to finish the job by 2020.

We do have some advantages that will make our work a little easier. The mosquito that transmits malaria on Hispaniola is highly inefficient compared to other mosquito species that carry and spread malaria in other areas of the world. Best of all, the mosquitoes in Haiti remain vulnerable to almost all insecticides.

We’re also benefitting from new ways of thinking about malaria elimination and applying better tools and technology, such as using GPS to map areas of malaria transmission and new laboratory methods to identify people who are infected with the malaria parasites and have no symptoms, but who still contribute to ongoing transmission.  An example of the exciting opportunities we have to use the latest scientific innovations to reach the countries’ 2020 goal, is the use of new serology lab techniques that can help us identify communities of people that have a higher risk for malaria transmission.  Being able to map where people are most likely getting infected is especially important in a country like Haiti where zooming in on these “malaria hotpots” will allow us to focus our efforts and resources.

But challenges persist. Even with the new technology and practices, we still don’t have the complete surveillance system that we need. It’s why there are still “hotspots” in Haiti where transmission rates are high. And because Haiti has very limited resources, the health care system is stretched thin which adds to the gaps in our knowledge that we must close if we are going to end malaria for good. All of these are real life challenges in a country that is the poorest in the western hemisphere.

That’s not to say we can’t do anything about it. We are constantly finding ways to have impact despite the constraints.  One example of how we’re doing this is by making sure that diagnostic tests for malaria are available and in use at all the clinics and hospitals across the country.  We worked with our Ministry colleagues in Haiti to adopt the use of malaria rapid diagnostic tests – simple tests that can be used in settings without a laboratory.  We worked together to do a field trial of the tests, and then developed a sound national policy using this local experience along with the best evidence from global studies.  Now, we see that most people are getting tested for malaria at the clinics and not simply getting treated based on symptoms alone.  In fact, we saw a 65% drop in the use of chloroquine—the main medication to treat patients suspected to have malaria—because the clinicians could more readily diagnose people with malaria, and therefore didn’t need to treat everyone who had a fever (the most common sign of malaria and many other diseases). In the end, people get the right treatment, and our surveillance for malaria hotspots is much improved.

This is all hard work that takes time, commitment, and partnership. As hard as it is, as incremental as success might be, seeing the impact on people who no longer have to live with and fear malaria instantly removes any doubt about why we’re doing this work. This effort demands our attention, pure and simple.

Because we know that successfully eliminating malaria from Hispaniola will lead to a better life for people who live there, not just a healthier life. Eliminating malaria will help the Dominican Republic and especially Haiti to grow their economies and attract foreign investment. It will erase malaria from the last place in the Caribbean, which means we will be one step close to the ultimate goal—eliminating this terrible disease everywhere.

These are inspiring thoughts to have on World Malaria Day and every day, and it’s something that will sustain me on those long and bumpy drives to Dame Marie.