The Chinese experience with malaria is a powerful example of the role that robust public health infrastructure can play in achieving significant health outcomes. Notably, China’s success in achieving what the WHO describes in detail as the “cessation of local transmission in 2017” is linked to a multi-pronged approach implemented over several decades. In this context, this article explores, through specific examples, the vital role of public health infrastructure in this important chapter of public health history. Furthermore, this history drew upon a combination of strategies, innovations, and partnerships that have collectively resulted in a remarkable public health victory.
Historical Context and the Challenge of Malaria in China
Malaria was the bane of life in China. Millions of Chinese people were victims of the disease in the past. Malaria, which spreads between people through the bites of Anopheles mosquitoes infected with the Plasmodium parasite, kills or disabled people, especially in rural and poor areas of China, where poverty is both a cause and consequence of malaria. Plasmodium parasite results in fever, chills, and flu-like illness or even severe consequences, such as death, if untreated.
Despite this persistent public health hazard, by the turn of the millennium, with a large population dispersed across diverse geographic and climatic landscapes, the nation faced the arduous task of eradicating malaria. A multi-stranded approach – backed by a system of well-functioning infrastructure and personnel – became a critical success factor that drove China down the path to elimination. It was the investment in and expansion of a comprehensive public health infrastructure as part of a long-term global view of national development.
Key Components of China’s Public Health Infrastructure
China’s eventual malaria eradication was the outcome of a combination of several factors: The success China achieved was partly due to the foundation of its public health infrastructure.
1. Surveillance Systems
China will establish some of the world’s most sophisticated malaria surveillance systems. For example, an early monitoring mechanism will track the geographical spread of malaria, offering political scientists a valuable resource for analyzing spatial data. It would be great to further refine this dataset.
The surveillance system includes:
Case Detection and Reporting: All local health facilities that receive patients can promptly diagnose and report to a centralized electronic database the malaria cases that they receive. Rapid diagnostic tests (RDTs) are also available for quick detection of malaria cases.
Data Integration: Manually entered data and break-even analysis collected from hospitals, clinics, and community health workers (CHWs) are integrated into the main database. This integration facilitates health facility workers, as well as individuals at the village level and other locations, to periodically monitor and analyze malaria trends and patterns. Moreover, by providing access to real-time data, this system empowers local health practitioners to make informed decisions and adapt their strategies effectively. As a result, it enhances the overall responsiveness of malaria control efforts, contributing to more effective public health interventions.
Geographic Information Systems (GIS): Identifying high-risk areas for malaria through GIS mapping of all malaria cases aids in targeting interventions and allocation of resources.
2. Vector Control Measures
Controlling the Anopheles mosquito, the vector of malaria prevents the spread of the disease. China’s vector control measures include:
- Insecticide-treated Nets (ITNs): ITN distribution is one of the cornerstones of malaria prevention, containing mosquitoes and reducing transmissibility.
- Indoor Residual Spray (IRS): is the application of insecticide on the interior walls of homes to kill mosquitoes that come into contact with those surfaces. This technique can be effective in areas where mosquito numbers are very high.
- Larviciding: mosquitoes breeding larvae destroyed. Larvicides are applied in stocks of water where mosquitoes breed.
Environmental management, such as draining places where mosquitoes breed by getting rid of standing water – including eliminating flower vases and pet bowls – and consistent sanitation, is also crucial for vector control.
3. Health Education and Community Engagement
Involving the community to prevent and treat malaria requires raising awareness of malaria prevention and treatment. China has increased health education about malaria prevention and treatment, and community engagement, such as:
- Public Awareness Campaigns: The government runs a country-wide public health campaign that conveys the message about the preventive methods, symptoms, and early treatment of malaria.
- Community Health Workers: Community health workers should be trained, mobilized, and empowered to deliver malaria education, disseminate ITNs, and, if they take no medicines home, provide elementary treatment and advice.
- School Programs: school programs raise children’s awareness about malaria and measures to prevent it. The children then share the information with their families and communities.
4. Access to Diagnosis and Treatment
People need to have timely diagnosis and proper treatment to prevent malaria, and China has greatly improved access to malaria healthcare services:
- Antimalarial medicines are available: China has a reliable supply of good antimalarial drugs, including artemisinin-combination therapies (ACTs), which are first-line treatments for malaria.
- Healthcare infrastructure: Investment in infrastructure and trained personnel has improved the capacity to diagnose and treat malaria. These improvements have been particularly important in rural areas.
- Free Treatment Policies: Where malaria diagnosis and treatment are free, fewer people have constraints on access to formal treatment.
5. Research and Innovation
Interesting patterns and unique local knowledge crop up sporadically, keeping attention alive and relevant to local customs But without ongoing research and innovation and, most importantly, continued political commitment, malaria elimination efforts will dwindle and unforeseen challenges could follow. Research supported by China has covered several topics.
- Drugs and vaccines: New antimalarial drugs and vaccines are in the pipeline. International collaborative research to develop and test new interventions are underway.
- Vector Control Innovations: Work on new insecticides and vector control technologies is expanding the toolkit available to us for malaria prevention.
- Epidemiological Studies: Such as an association between malaria prevalence and blood group genotype, can be used to improve surveillance and response strategies.
6. Policy and Governance
The approach taken with strong policy and governance requirements includes, for China:
National Malaria Control Program: Coordination and integration with other sectors and levels of government is enabled by the National Malaria Control Program, by serving as a unified and strategic arbiter for the work going on in all of these spheres.
Legislation and Regulation: This component includes all relevant laws and regulations that support malaria control activities such as vector control, drug distribution, and health education.
Global collaboration: China has collaborated with WHO and other international organizations to join global malaria elimination efforts, and pool knowledge and resources.
Challenges and Future Directions
But despite this roaring success, the challenges of maintaining malaria-free status and the mismanagement of risk persist for China:
- Importation of Cases: Cases may be imported into a country and possibly sustained in small pockets of mosquito habitat from outside the country, and perhaps supported by the cross-border host or vector populations (eg, birds) until local control is effective.
- Drug resistance: Putting in place strong monitoring and management for drug resistance to ensure sustained activity of antimalarial treatments.
- Climate change: Changes in climate and environmental conditions affect mosquito populations and the transmission of malaria.
Going forward, China’s public health infrastructure will need to remain at the center of efforts to not only tackle these challenges but also maintain malaria-free status. Ongoing investment in surveillance, vector control, research, and community engagement will continue to be of vital importance in making sure that malaria remains firmly in China’s past.
China’s journey to malaria-free status is only possible because of the maturity of its public health system. Thanks to its sophisticated global epidemic surveillance system, effective vector control, strong health education programs, accessible diagnosis and treatment with high-quality medicines, and continued independent research, China continues to lead the world in demonstrating that strategic and sustained investment can translate into large-scale public health victories. Looking ahead to new challenges, China’s experience holds important lessons for the rest of the world seeking to eliminate malaria and achieve other public health miracles.
