How an army of volunteers helped Paraguay to conquer malaria
Paraguay is the first South American country to eradicate malaria. But neighbouring cases are mounting – and climate change threatens to spread the disease
One recent morning, the halls of Senepa – Paraguay’s National Malaria Eradication Service – echoed to the sounds of folk songs and a violin. The health minister handed out medals, and a dancer, balancing a bottle on her head, swished her skirts around the room.
The traditional celebrations marked Paraguay’s official elimination of malaria in June – the only country in South America to have eradicated the infectious, life-threatening disease, and the first in the western hemisphere to do so since Cuba in 1973.
For many, it is an achievement akin to a military victory after 60 years of struggle.
The campaign began in 1939, when a grueling war with Bolivia, an outbreak of malaria infected 80,000 people out of a population of 1 million.
“It had a huge social and economic impact,” said Mónica Ozorio, a biochemist and the director of Senepa’s anti-malaria programme. “It affected all the regions – we even had it in the Chaco.” Tens of thousands died.
The epidemic prompted Paraguay to establish its health ministry – and, in 1957, the anti-malaria agency. It was the beginning of six decades of sustained eradication, said Luis Escoto, the WHO representative in Paraguay.
“Passing through different political moments and governments of different colours, it has become a policy of state,” Escoto said.
A lasting commitment to spending of a fixed portion of income from the country’s social security programme – first 0.5%, later 1.5% – on battling the disease was a “decisive factor,” he added.
So too were shifts in strategy – from a top-down, Senepa-led effort that focused on mass fumigation of mosquito breeding grounds, to one that incorporated the national health service and focused on diagnosis, treatment, and monitoring of cases.
Senepa clustered dozens of diagnosis laboratories in malaria-prone regions, and those adjacent to Brazil. Private and public clinics are required to treat cases, free of charge. Businesses and media outlets run information campaigns.
“If there’s an imported case of malaria these days, it’s national news – all the ministries are informed,” said Ozorio.
But most point to the key factor as being a network of up to 5,000 unpaid volunteers – including urban community organisers and indigenous leaders – that is still working to educate fellow citizens, eliminate mosquito habitats, and stay alert for new cases.
Everyone has a grandparent or cousin who did their bit, Ozorio explained. “We feel proud that a small country has done it, with our own resources and everyone working together,” she added.
By the turn of the last century, these efforts were bearing fruit. The last case of Plasmodium falciparum malaria, the deadliest form of the disease, was registered in 1995. The Plasmodium vivax variety was eliminated in 2011.
A five-year program with the support of the WHO and the Global Fund thereafter worked to prevent re-transmission and boost community education, prevention and treatment.
Finally, in April this year, the country was certified as having been free of home-grown malaria cases for three years, the first of 21 countries – including Mexico, Belize and El Salvador – that were earmarked by the WHO as on course do so by 2020.
The victory is a much-needed success story, both for Paraguay and the region. The country’s health service is fragmented and otherwise short on funding, often making the headlines for shocking reason, such as Paraguay’s high rates of child pregnancy.
And despite long-term progress, malaria cases have spiked worldwide in recent years – to 216 million cases in 2016 – with much of the increase in Latin America. At least 445,000 people died from the disease in 2016.
The disease has erupted in crisis-ridden Venezuela, where the government has refused offers of outside help to contain it. In Brazil – which shares 2,200km of largely uncontrolled borders with Paraguay – malaria infections grew by 80% between January and June, said Ozorio.
“The risk of importation is very high, it’s undeniable,” she added. “30,000 people, especially students, cross the border every day.”
Senepa is boosting coordination between migration officials, hotels, universities, and clinics; two Paraguayan nationals who returned from Africa with malaria in June were treated rapidly.
And there are global trends that could see malaria return to Paraguay – and spread to nearby countries unused to the disease, catching doctors unprepared. “Climate change is a worry for everyone,” said Escoto. “We can’t let our guard down.”
Rising, fluctuating temperatures, heavy rainfall and flooding all create hospitable environments for disease-carrying vectors in previously malaria-free areas, he explained.
“In northern Argentina, provinces where mosquitoes once didn’t exist are now natural habitats,” he added. “Chile and Uruguay are now at risk.”
But Paraguay remains vigilant, Ozorio said, and ready to share the lessons of six decades in eradicating the illness.
“It’s a national achievement,” she added, describing heroic clinicians sent off to the countryside in decades past with little more than a microscope and a motorbike.
“There’s a kind of mystique to Senepa,” she laughed. “There’s a lot of history to tell.”