In July 2018, Ethiopia and Eritrea signed a monumental peace treaty to reopen diplomatic relations, travel, and trade between the two nations. The end of nearly three decades of conflict was internationally heralded as a great success. As the countries reconcile, families will reunite, and the two nations will begin a new era of openness. Yet an increase in migration and travel opportunities will complicate the countries’ fight against an enemy of a different kind: malaria. To prevent the spread of the disease, Ethiopia and Eritrea must develop a coordinated approach to malaria control.
After over 30 years as an Ethiopian province, Eritrea established independence relatively peacefully in 1993. However, a minor border dispute in 1998 erupted into open conflict, and diplomatic relations and travel between the neighbors had been shut off ever since. Eritrea’s strict exit visa requirements limit legal out-migration, and the highly militarized border makes fleeing the country a dangerous and potentially fatal endeavor. Ethiopia only receives up to 2,500 Eritrean refugees per month, and many of those who do make it there are en route to final destinations in North Africa and Europe.
The recent détente dramatically shifts this situation by increasing bidirectional travel volume. Ethiopia and Eritrea have now resumed inter-country flights and officially reopened the border, allowing both trade and personal travel. Eritrea has also removed troops from its border, erasing the primary obstacle to international movement facing both Eritrean refugees and Ethiopian pastoralists. In fact, the Eritrean refugee inflow into Ethiopia has grown to seven times its pre-rapprochement level.
But with the movement of people comes the movement of disease: In this case, it’s malaria, a potentially fatal illness that claimed 445,000 lives worldwide in 2016. Malaria is caused primarily by two parasite species, Plasmodium falciparum and Plasmodium vivax. Though P. falciparum poses the greatest health burden across sub-Saharan Africa, a genetic trait required for P. vivax infection that is common among the Eritrean and Ethiopian populations has allowed P. vivax to constitute a relatively greater share of the malaria burden than in other areas.
Malaria is often transmitted by mosquitoes, but the movement of people exacerbates the disease’s spread. When an infected individual travels to a mostly malaria-free community, local mosquitoes can pick up the parasite and pass it along to unaffected residents. Conversely, an uninfected person moving to a highly-endemic area can contract the illness and add to the local disease burden. The increased transmission frequency associated with migration can increase the genetic diversity of the parasite, potentially introducing drug-resistant forms of malaria that can spread globally and complicate international efforts to tackle the disease.
While Ethiopia and Eritrea have substantially reduced the prevalence of malaria-induced mortality within their own countries over the last two decades, the disease is still a significant concern. Eritrea, a country of five million, sees about 31,000 new cases each year, and Ethiopia, with 102 million inhabitants, suffers roughly 2.1 million cases annually. Moreover, 71 percent of Eritreans and 27 percent of Ethiopians live in high transmission areas.
Increased migration presents a new obstacle in reducing these numbers. Ethiopia has already contended with P. falciparum entering the country from its other neighbors, but P. vivax from Eritrean migration will present a novel challenge. With a lower incidence of P. vivax malaria and no history of dealing with in-migration, Eritrea will be hit hard as new infectious cases cross the border. Since Eritreans have less exposure and poorer immunity to P. vivax, Ethiopia’s own vivax malaria incidence will rise as it takes in at-risk individuals. Both countries must now also contend with the threat of drug-resistant strains associated with migration and the difficulty of extending control measures to transitory populations.
Ethiopia and Eritrea must build a stronger approach to control in order to address migration’s challenges. Since research on malaria has heavily focused on P. falciparum, Ethiopia and Eritrea must address the P. vivax issue with policies and control methods that reflect the boundary-defying nature of the parasite. To do so, they should follow the example of the Elimination 8 Initiative (E8)—a regional development initiative among eight southern African countries designed in part to fight malaria.
The E8 program has a strong surveillance component and shares data between countries to identify outbreaks and allocate resources appropriately. Ethiopia and Eritrea should build their own surveillance practices by exchanging genetic sequences of parasites found in malaria infections, incidence and prevalence data, and population census data. This information would assist control experts in both countries with tracking the emergence of drug resistance, the origins of cases, and the locations of susceptible populations.
Recognizing migration’s impact on the spread of the disease, the E8 program established 50 border malaria clinics, each equipped for diagnosis and basic treatment. Ethiopia and Eritrea should establish similar clinics at border checkpoints to diagnose and treat people who may otherwise spread the disease.
The E8 program has also facilitated the movement of materials to alleviate supply shortages. Following E8’s model, Ethiopia and Eritrea should transfer antimalarial drugs, tools, and personnel where appropriate. With Ethiopia and Eritrea both relying on the Global Fund—a multilateral health aid agency—to finance malaria control, a policy of sharing would stabilize control efforts in times of economic uncertainty.
But sharing drugs will only be effective if both countries treat the disease in the same way. Currently, Ethiopia treats P. vivax with chloroquine and treats P. falciparum with an artemisinin combination therapy (ACT). When the strain is misdiagnosed, the effectiveness of treatment suffers and the parasite can become resistant to the drug. Eritrea, however, uses one ACT that is effective against both malaria species. Ethiopia should adopt Eritrea’s treatment protocol to make sharing antimalarial drugs easier and allow medical professionals to focus on administering treatment.
A comprehensive malaria program would be an expensive endeavor, but fortunately, Eritrea and Ethiopia should be able to leverage their new relationship to attract foreign donors. In June, for example, the United Arab Emirates pledged $3 billion in aid and investment to Ethiopia and Eritrea in a bid to solidify its influence. Ethiopia and Eritrea may be able to channel this aid towards malaria control, as the UAE donated $5 million to a global malaria program in 2017 and has previously worked with other Gulf nations to combat malaria in Yemen. Using their newfound peace to broker similar investments will only bolster the two countries’ control efforts.
The new status quo in the Ethiopian–Eritrean relationship complicates efforts to control vivax malaria in the two countries. However, with diplomatic ties restored, interstate malaria control is well within the realm of possibility. To effectively cope with the side effects of reconciliation, Ethiopia and Eritrea must seize this opportunity together and move toward a cooperative approach to malaria eradication.
Photo: “Joint declaration 2”