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Bangladesh has been effective at fighting malaria. Can it eliminate the disease?

A MARTÍNEZ, HOST:

Malaria has plagued humanity for millennia. According to the World Health Organization, it kills more than 600,000 people a year, mostly in Africa. And that's despite enormous efforts to develop treatments and control the mosquitoes that carry the disease. There are some bright spots, though. Reporter Ari Daniel takes us to Bangladesh, a country that's slashed its malaria numbers drastically, though the parasite isn't going down without a fight.

(SOUNDBITE OF ARCHIVED RECORDING)

UNIDENTIFIED MUSICAL ARTIST: (Singing in non-English language).

ARI DANIEL, BYLINE: In the heart of Dhaka, Bangladesh's thronging capital, deep inside a laboratory, Kasturi Haldar stares down the barrel of a microscope.

KASTURI HALDAR: If you look down here, you will see red blood cells. And then you'll see the lovely little parasites that are purple.

DANIEL: Haldar is a visiting microbiologist from the University of Notre Dame. For much of her career, she's been like a sentinel tracking this parasite that causes malaria to help develop new drugs.

So how do you think of those things there? You think of them as your foe?

HALDAR: No, no, no. I think about them as microbes you have to understand better. They're complex, and they deserve your respect.

DANIEL: Because they're a formidable opponent. Much of what we've attacked them with, the parasites have managed to outmaneuver, all the while causing tremendous amounts of human suffering.

CHING SWE PHRU: It's a public health problem.

DANIEL: A problem that Dr. Ching Swe Phru knows well. It's dusk in rural southeastern Bangladesh, and Phru rests outside on a bench after a full day of work. For 24 years, he's devoted his life to treating people with malaria.

Did you ever get malaria?

PHRU: Yes, I did. I did. When I was in medical school, I suffered four times in a year. It was a very difficult time.

DANIEL: That last bout hit him especially hard, and it came right before a big exam. While Phru tried to study, inside his red blood cells, the parasite was reproducing, eventually causing those cells to rupture. Each time that happened, agony.

PHRU: High fevers, chills and severe headaches, vomiting and nausea. The nausea was the worst. I couldn't study. And then I went for the exam with 101 or so Fahrenheit of fever. So I had to face it.

DANIEL: Phru was treated with a couple of drugs, including one called chloroquine. The side effects were rough.

PHRU: It's a very nauseating drug and a terrible drug.

DANIEL: But he was cured. For decades, chloroquine was one of the most valuable malarial treatments worldwide. But then in Africa and Asia, something happened. The parasite stopped responding. It had developed resistance to chloroquine.

PHRU: Once malaria parasite is resistant to drug, people start dying 'cause it's a lethal disease.

DANIEL: The fatalities surged into the millions, hitting sub-Saharan Africa especially hard. So doctors turned to another drug called artemisinin. It had taken decades to puzzle out how to make it and how to do so affordably. Once the drug became available, health officials in Bangladesh were so hopeful, they enlisted thousands of community health workers to go door to door to make sure people with malaria were being treated with artemisinin. On a Friday morning, one of these workers - Bulbul Aktar - walks along an unpaved country road wrapped in a crimson shawl. She approaches a household.

BULBUL AKTAR: As-salamu alaykum.

DANIEL: Thirty-year-old Asha Gudin lives here with his family. A month earlier, after working a construction job along the border with Myanmar, Gudin spiked a fever and felt terrible. So he sought out Aktar, his local health worker. Sure enough, he was malaria positive, so she gave him artemisinin.

AKTAR: (Through interpreter) That night I called him, how he's feeling and he took his drug properly or not.

DANIEL: Over the three-day regimen, Gudin made a full recovery. He's not alone. Artemisinin almost never fails. Dr. Ching Swe Phru.

PHRU: This drug is a marvelous drug. It's a perfect drug.

DANIEL: And it's produced astonishing results. Between 2008 and '20, malaria cases in Bangladesh plummeted by 93%. It decimated the parasites, and government officials dared to imagine something audacious - elimination of the disease. But malaria wouldn't give up so easily. Across the border in Myanmar and elsewhere in Southeast Asia, new strains of the parasite were turning up - ones resistant to artemisinin. Health officials knew if resistance was bubbling next door, it was only a matter of time before it showed up in Bangladesh.

PHRU: You have to be alert. You have to be afraid of it. The parasites always have a inborn tendency to fight off the killing drug.

DANIEL: So Phru and others started a monitoring program in the parts of the country where malaria still circulates. They draw blood from people who have the disease but aren't responding well to artemisinin treatment. And then they put the samples on a bus headed for the capital.

HALDAR: They come overnight in a cooler.

DANIEL: On the bus?

HALDAR: On the bus.

DANIEL: They're then brought here to this lab at the International Center for Diarrhoeal Disease Research, Bangladesh. And in one of those samples, Kasturi Haldar says they found it.

HALDAR: Ah.

DANIEL: She points to the glass slide under the microscope.

HALDAR: If you look down here, you will see.

DANIEL: Oh, yeah.

HALDAR: Yeah.

DANIEL: Yeah. Wow.

HALDAR: Yeah.

DANIEL: So - but what I'm seeing is malaria in the red blood cells.

HALDAR: Yeah. Yeah. And this strain we found to be resistant.

DANIEL: Evidence that a resistant strain of malaria was in Bangladesh. So far, it's just one sample.

HALDAR: If you only find, like, one strain that's resistant, it doesn't matter, as long as it doesn't spread. But that's what we need to be able to see, is whether we are getting dissemination.

DANIEL: For Dr. Ching Swe Phru, all this discussion of resistance pains him, but he's not surprised.

PHRU: I'm afraid that malaria has a certain history of coming back.

DANIEL: So for Bangladesh, the question becomes, is the promise of malaria elimination still within reach, or will the parasites gain the upper hand once again?

Ari Daniel, NPR News.

(SOUNDBITE OF MUSIC) Transcript provided by NPR, Copyright NPR.

NPR transcripts are created on a rush deadline by an NPR contractor. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

Ari Daniel is a reporter for NPR's Science desk where he covers global health and development.