Hamilton Nascimento remembers missing months of school as a child when he repeatedly got sick with malaria. It used to be an unavoidable part of life in São Tomé and Príncipe, a nation of two tiny islands in West Africa’s Gulf of Guinea, where Nascimento grew up. But not anymore.
“Most people in São Tomé knew someone who died from malaria, but now we haven’t had a death in years,” says Nascimento, who leads the government’s anti-malaria office and has helped steer the islands through a dramatic turnaround.
São Tomé and Príncipe is best known for stunning beaches, Galapagos-caliber birdwatching and historic coffee plantations. But in recent years, the maritime nation has acquired a new reputation as one of Africa’s most successful countries in fighting malaria, a disease that kills more than 400,000 people across the continent every year. According to the World Health Organization:
Since 2014, the nation of São Tomé and Principe has had zero malaria deaths, making it the only country in sub-Saharan Africa to maintain that achievement for several consecutive years.
Nonfatal infections are also dropping drastically, from a high of more than 50,000 in 2002 — in a population of 200,000 — to fewer than 4,000 in 2016. That rate of decline is three times faster than the average for Africa, which as a continent has seen the world’s slowest gains against malaria despite having by far the largest share of cases.
These figures put São Tomé at the vanguard of a small, elite group of African countries that are poised to eliminate malaria within the next five years. Behind the success is the world’s highest per-capita level of spending by the government and international donor organizations — $16 — on anti-malaria measures like indoor mosquito spraying and free treatment clinics.
Nascimento’s office opened in 2003, and since then the war against malaria has reached nearly every corner of the islands: 355,000 bed nets distributed; 76,000 people given free treatment; and 222,000 structures sprayed, making it the only country in Africa where 100 percent of the population is covered by preventative measures, according to the U.N.
You can significantly reduce the burden of malaria without necessarily needing some new vaccine or strategy.
William Moss, Johns Hopkins School of Public Health
São Tomé’s small size and natural isolation give it an advantage in fighting malaria compared to a large mainland country like Nigeria, which shoulders the majority of West Africa’s malaria burden. Other African islands, such as Cape Verde, Comoros and Zanzibar, are also close to eliminating malaria.
Rebekka Ott, a public health official with the U.N. Development Program in São Tomé, said the country’s government and populace have shown an exceptional commitment to the long-term, tedious work needed to drive out infected mosquitoes and keep up a variety of interventions. “If one part of the malaria response isn’t working, it can bring the whole thing down,” she says. “But in São Tomé, it works, because all of the factors are in place.”
São Tomé offers proof that existing solutions to malaria elimination can work if pursued aggressively, said William Moss, a malaria expert at Johns Hopkins School of Public Health. “That’s an optimistic lesson,” he says. “You can significantly reduce the burden of malaria without necessarily needing some new vaccine or strategy.”
But the fight is far from over. “Eliminating” malaria means ending not just deaths but also domestic transmission of the disease for at least several years, which São Tomé has yet to do. And Ott warned that, ironically, the country’s success in reducing malaria may cause international funding for prevention programs to dry up. If that happens, the islands could be just one airplane full of tourists and disease-carrying mosquitoes away from another outbreak.
“This is the most challenging part in malaria elimination,” she says. “As long as São Tomé is surrounded by endemic countries, there’s a high risk that malaria can be reintroduced.”
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