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Malaria is a serious public health threat and a killer, a disease that largely ravages warm areas with low levels of income and yet it can be eliminated and has been eliminated from large areas of the world.

The SADC Malaria Elimination initiative is meeting in Harare this week to examine the progress in eliminating malaria from Southern Africa by the target date of 2030, work out how the effort must be directed, and to make sure that all countries are on board.

The need for a regional approach has been seen for many years, since mosquitoes can fly across international frontiers, but the formal ambitious regional programme was launched by eight countries in 2009 with the 2030 elimination target date set in Windhoek in 2015, and solid progress has been made since then.

The need for regional action is obvious when you look at Zimbabwe.

We have managed to push malaria into the lower lying regions in the north of the country, but progress on elimination needs similar progress in Mozambique, which wraps itself around a lot of that malaria endemic zone, Zambia, which borders most of the rest, and even in Botswana and Namibia if the northwest is to be free.

The southeast threat remains besides progress in Mozambique, progress in South Africa.

So for us to be safe, we need six countries to be safe, and they in turn need their immediate neighbours to be free, hence the region.

A malaria-free SADC will still need continual action in its northern border areas, as malaria is eliminated in the next belt of Africa, and continual watchfulness as people move around, but that will be a lot easier than the elimination phase, and in any case many of the measures taken to eliminate malaria will be also prevent its re-invasion.

To show the sort of progress that is possible, malaria used to be endemic in the southern United States and a large swathe of southern Europe.

The US eradicated the disease in the early decades of the last century and southern Europe saw a similar success in the years following the Second World War, as did what was then the Soviet Union.

More recently, China was declared malaria-free in 2021 after a determined and successful campaign that was coupled to, and financed out of, its economic miracle, along with the major public health network established earlier. Three African countries, Algeria, Mauritius and Cape Verde, are now declared malaria-free by the World Health Organisation with most of the rest of North Africa on the brink and now Southern Africa, which has made considerable progress, entering the stages that should see the end of the menace.

Elimination needs a combination of approaches. Malaria occurs where there is a reasonably dense population, a reasonably density of anopheles mosquitoes, and a pool of infection that all those mosquitoes can transmit to the people.

Break just one of those conditions and you are close to elimination.

When we look at the three conditions for endemic malaria there is not much that can be done about population densities. People need somewhere to live and work.

Mosquito densities can be tackled, although there are limits in tropical Africa, so the effort is largely on seeing how to minimise contact between humans and mosquitoes as well as lower mosquito densities close to where people live.

This has seen residual spraying of housing, the programme to get treated bed nets over every sleeping person, the elimination of breeding close to houses, and the simple measures that are possible once housing reaches certain standards, such as screened windows and covered water supplies, which is where the link with poverty reduction comes in.

Those are measures that form one strand of the SADC initiative.

The other strand is tackling the third condition, the pool of infected people who can be bitten by mosquitoes who then fly on to infect others.

If no one within range has malaria, it does not really matter how many mosquitoes bite you as none of them can be carrying the parasite. But it does need quite a large malaria free area to work.

Here early and universal diagnosis and almost immediate treatment is the effective way of eliminating the pool of infection, hence that fairly extensive coverage by village health workers in Zimbabwe’s malaria areas.

The same village health workers can also get the more severe cases moved up the chain for additional treatment, cutting the severity of malaria as well as reducing the pool of infection.

This dual strand of better housing and sanitation on one hand and no one nearby with untreated malaria is how the disease has been pushed back in much of Zimbabwe.

A few years ago transmission within Harare was finally confirmed, with two cases. But it never exploded because of the low mosquito density, the solid housing and the prompt treatment of those two.

Growing resistance to several anti-malarial drugs has made routine prophylactic dosing less effective and often ineffective, although the first anti-malarial vaccines are now coming through the pipeline and have been cleared by WHO.

The usual problem of malaria being a disease grossly disproportionally suffered by poor people in poor countries probably slowed commercial vaccine development and once again shows the need for Africa to develop high-tech vaccine research.

That growing resistance also makes a determined regional effort essential, using the gap we presently have to get rid of the disease before this becomes an even more severe problem. If there is no malaria then drug resistance ceases being an issue.

These meetings of experts and policy makers, as we are seeing in Harare, do not always grab headlines, but they are essential. We hope that they can accelerate the progress and we wish them well.