Sub-Saharan Africa accounts for 96% of global malaria deaths

The World Health Organization released its annual malaria report in early December 2021, and the numbers told a stark story about global inequality in disease burden. Sub-Saharan Africa, a region of roughly a billion people, carried nearly the entire weight of the world's malaria crisis: 228 million cases out of 241 million globally, and 602,000 deaths out of 627,000. In percentage terms, that meant the region accounted for 95 percent of all cases and 96 percent of all deaths from a disease that remains one of the world's most preventable killers.

The pandemic had made things worse. COVID-19 disruptions—lockdowns, overwhelmed health systems, interrupted supply chains for antimalarial drugs and bed nets—added an estimated 47,000 deaths to the global toll in 2020 alone. The year before, malaria had killed 558,000 people worldwide. By 2020, that number had climbed to 627,000. Public health officials had feared far worse. The most pessimistic projections suggested the pandemic could double malaria deaths in some regions. That catastrophe did not materialize, but the damage was real and concentrated almost entirely in one part of the world.

Within Sub-Saharan Africa, the crisis was even more concentrated. Just six countries—Nigeria, the Democratic Republic of Congo, Uganda, Mozambique, Angola, and Burkina Faso—accounted for more than half of every malaria case recorded on Earth. Nigeria alone represented 27 percent of global cases. When it came to deaths, four countries bore the heaviest toll: Nigeria at 31.9 percent of global deaths, the Democratic Republic of Congo at 13.2 percent, Tanzania at 4.1 percent, and Mozambique at 3.8 percent. The disease was not evenly distributed even within the continent most affected by it.

The human cost fell hardest on the youngest. Roughly 80 percent of malaria deaths in Sub-Saharan Africa occurred in children under five years old. A child in that region faced a disease that could be contracted repeatedly throughout life, that could stunt development if survived in early childhood, or that could kill outright. The parasite responsible travels through mosquito bites—a transmission method as old as human settlement in tropical climates, yet still largely uncontrolled across much of Africa.

Progress had been made, but it was fragile and uneven. Between 2000 and 2019, the WHO's African region had reduced malaria incidence from 368 cases per thousand people to 222 per thousand. Mortality had fallen even more dramatically, dropping 63 percent over the same period. But 2020 reversed some of those gains. Incidence ticked back up to 232 cases per thousand, and mortality rose from 56 deaths per 100,000 people to 62. The pandemic had not erased two decades of progress, but it had interrupted momentum at a critical moment.

The WHO had set an ambitious target for 2020: a 40 percent reduction in malaria incidence compared to 2015 levels across the African region. The region as a whole failed to meet it. Only five countries succeeded—Cape Verde, Ethiopia, Gambia, Ghana, and Mauritania—while Algeria had already been certified malaria-free in 2019. Among the remaining 43 African countries, the picture was mixed and troubling. Eighteen countries, including Mozambique and São Tomé and Príncipe, managed to reduce incidence compared to 2015, though not by the required 40 percent. Five showed no significant change. Sixteen registered increases of up to 40 percent, including Guinea-Bissau. Five countries saw incidence surge by more than 40 percent, with Angola among them.

On mortality, the story was similarly uneven. Three countries—Cape Verde, Eswatini, and São Tomé and Príncipe—recorded zero malaria deaths in 2020. Ethiopia and South Africa achieved reductions of 40 percent or more. But twelve countries, including Guinea Equatorial and Mozambique, fell short of the 40 percent target. Fourteen showed no improvement in mortality rates. And twelve countries, among them Angola and Guinea-Bissau, saw death rates actually increase. The disease was not retreating uniformly. In some places it was being pushed back. In others it was advancing.

Pedro Alonso, director of the WHO's Global Malaria Programme, framed the challenge plainly at a press conference presenting the report: this was fundamentally an African problem. The statistics bore him out. The world's malaria crisis was not distributed across the globe. It was concentrated in one region, in one set of countries, affecting one population disproportionately. As the world moved forward from the pandemic, malaria remained where it had always been—a disease of poverty, of weak health infrastructure, of tropical climates without the resources to control the mosquitoes that carry it. The question was whether the disruptions of 2020 would become permanent setbacks or temporary interruptions in the long, unfinished work of bringing malaria under control.