What can we learn about malaria from Timor-Leste and West Timor?

What Timor-Leste’s and West Timor’s differing approaches to malaria can tell us

For Hare Haro, being sick with malaria felt like being on fire one minute and freezing the next.

“I was sick for about a week,” she tells me. “The first couple of days I actually couldn’t get up and walk – I couldn’t move around without assistance from my family.”

Haro lives in Papua New Guinea, where malaria has been a part of life for generations. But despite significant efforts being made to rid this part of the world of the Plasmodium parasite that causes the infection, cases are still a regular occurrence, and can be deadly.

“The thing about malaria is that it affects your whole system,” Haro says. “You lose your sense of taste, and you lose your appetite, you don’t want to eat much. You just feel generally weak.”

“I do worry about family members or relatives back in the village, who can’t access health care facilities regularly.”

Hare Haro, PNG resident

Haro, who works in the media in Port Moresby, is a mother of three – two bubbly twin girls and an independent bright-eyed teenage boy. Many people in PNG think of malaria as a disease that rarely kills. However, Haro knows that not to be the case.

“My biological mother actually passed away from cerebral malaria,” she says. “I do worry about family members or relatives back in the village, who can’t access health care facilities regularly.”

Although it’s hard to ensure accurate numbers, in 2020, WHO estimated 241 million cases of malaria worldwide and 627,000 deaths. Even worse, 80% of all malaria deaths in Africa were in children.

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Haro with her kids. Credit: Hare Haro

For a disease as tricky to eradicate as malaria, there’s no shortage of solutions. Insecticide-treated bed nets, antimalarial drugs, prophylaxis – preventative – treatments and even vaccines are all part of the picture to help fight a disease that globally still kills more than half a million people a year.

“This group of parasites have been parasites for a very, very long time, probably back to the time of the dinosaurs,” says Professor Ivo Mueller, a researcher who studies malaria and the Plasmodium parasite. “They’re very good at what they do, and they have evolved with us and other vertebrate animals over a long period of time.” Mueller works at WEHI, previously known as Walter and Eliza Hall Institute of Medical Research.

Malaria is transmitted only through the bites of the female Anopheles genus of mosquito. This may seem like a comfort, but there are 100 species of this genus which can transmit human malaria, and there are over 200 species of Plasmodium. Human versions of Plasmodium can also sometimes infect other animals like livestock, meaning that even if every human was protected, malaria can wait in other animals and wait to strike again. 

“This group of parasites have been parasites for a very, very long time, probably back to the time of the dinosaurs.”

Professor Ivo Mueller, WEHI microbiologist

WHO first planned to eradicate malaria in 1955 and, in some areas, the effort has been immensely successful. Australia declared malaria eradicated in 1981; Europe and the US managed to rid themselves of the disease even earlier.

But for those countries without comprehensive health systems, and the financial backing that supports them, malaria isn’t an easy beast to slay. Worst still, is that malaria has its own economic and social burden, meaning that without eradicating the disease, the developing countries have lower rates of economic growth.

“There isn’t one single tool that works for malaria, you have to combine many different tools,” says Mueller.

Take bed nets and indoor spray, for instance. “[They] don’t work everywhere,” Mueller says. “They don’t work particularly well in Southeast Asia, for instance, or even in PNG. They’re only partially efficacious because a lot of the vectors in these areas are outdoors. So, when people are not under their bed nets yet.

“Also, they’re biting not just humans but other animals, so that means that the vectors can survive at a certain level because they’re not biting humans.”

Read more: Are we finally getting malaria vaccines?

Some countries still have huge numbers of malaria case presentations. WHO’s African Region was home to 95% of malaria cases and 96% of malaria deaths in 2020. Papa New Guinea managed to bring cases down to just over 50,000 in 2014, but by 2019 case numbers had rebounded to almost 650,000.

However, other countries like South Africa, Thailand and the Dominican Republic are at the final hurdle – with under 1000 indigenous cases reported every year. Groups like the Asia Pacific Malaria Elimination Network are trying to eliminate malaria across the entire Asia Pacific by 2030.

If PNG wants to get on top of its malaria outbreak urgently, it has a close neighbour it can turn to for inspiration.

Timor Island is another of Australia’s neighbours – just 800 kilometres to the northwest and consists of West Timor – a part of Indonesia, and Timor-Leste, an independent nation since 1999.

Timor Island is only 470 kilometres long – about half the driving distance from Melbourne to Sydney – but only one of the two countries has managed to eradicate malaria. While the two nations have now teamed up to finish the job, it highlights how important investment in malaria protections and healthcare are to nations fighting this disease.

Timor and wetar endemic bird area
Map of islands belonging to the Timor and Wetar Endemic Bird Area. Credit: Lencer/Wikimedia/CC BY 3.0

“Timor island was one of the high malaria-endemic areas in Indonesia and Timor-Leste,” says WHO Representative to Indonesia, Dr N. Paranietharan. “Based on a 1999 report, the parasite rate in Indonesia’s West Timor was lower than Timor-Leste’s.”

“However, after intensive interventions by national governments with support from WHO, UNICEF and other partners, malaria cases in Timor Island have been significantly reduced.”

Timor-Leste has not seen local transmission of malaria since 2018. Any recent cases have been imported, or occurred in Oecusse, a small enclave of Timor-Leste that’s surrounded by Indonesia. Timor-Leste is working towards getting a WHO malaria elimination certificate.

“Several efforts have been undertaken over the years including distribution of long-lasting insecticidal nets, indoor residual spraying, larval source management to prevent mosquito breeding among others,” says Dr Arvind Mathur, WHO representative to Timor-Leste.

“More importantly, extensive efforts have been taken to spread awareness and prevent the disease among the high-risk communities, especially in the border areas, so that people seek medical advice as soon as they experience any malaria-like symptoms.”

“Malaria elimination in Timor Island is a cross-border concern.”

Dr N. Paranietharan, WHO Representative to Indonesia

A paper published in 2020 highlights Timor-Leste’s immense success, noting that in the early 2000s, when the newly independent country had a health sector in a non-functional state, this would have seemed almost impossible.

“With the setting up of the National Malaria Control Programme just after independence in 2003 with two officers the programme expanded over the years and strategic malaria control activities in an organized manner commenced in 2009 with funding from the Global Fund to fight AIDS, tuberculosis and malaria,” the authors write.

“The incidence of malaria declined dramatically from 223,002 cases in 2006 with the last indigenous case being reported in June 2017.”

Indonesia has been slower off the mark, however they’ve still managed to lower cases significantly using similar solutions – insecticide-treated nets, deploying rapid diagnostic tests, and treating cases as soon as possible to disrupt transmission.

“As a result of massive vector control and case finding, malaria cases in West Timor declined from 20,000 in 2010 to 131 indigenous cases in 2022,” says Paranietharan. “In 2022, West Timor also recorded 50 imported cases from Papua and other provinces.”

The difference in results was partially a reflection of the amount of money and resources Timor-Leste was able to put into stopping the spread. In the early days the country was dependent on other countries and the UN agencies to help it carry out malaria control activities.

Timor-Leste now has an extensive, well-organised community health volunteer network attached to its Ministry of Health, as well a greater ability to run their own programs based on WHO guidelines.

Currently both Timor-Leste and Indonesia are developing a joint strategy and roadmap to eliminate malaria across the whole island – this is in both nations’ best interests as neither will be able to stay malaria free for long without the other’s success.

“Malaria elimination in Timor Island is a cross-border concern,” Paranietharan adds.

While ‘world changing’ vaccines and prophylaxis treatment for kids are still slowly coming online, countries like those in Southeast Asia are forging ahead with less high-tech approaches, knowing that persistence and success can save countless lives.

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