Malaria is on the ropes in Bangladesh. But the parasite is punching back By Ari Daniel Published September 20, 2023 at 3:22 PM EDT Facebook Twitter LinkedIn Email Listen • 6:43 Fatima Tuj

Johora for NPRBulbul Aktar, a shasthya kormi, or community health worker, with the malaria elimination program in Bangladesh, goes door to door to treat malaria patients. "This is my job, my

duty," says Aktar. "Every single home, I have to know about them and visit them."

The soft footfalls of thousands of moccasins along unpaved rural roads across Bangladesh could be considered the soundtrack to this country's astonishing success in its battle against

community by foot. It's a crucial task given the historic difficulty of gaining ground in the fight against malaria — a fight that could soon be flaring up once more.

Wrapped in a crimson shawl, Aktar approaches one of the households and shouts the standard greeting: "As-salamu alaykum!"

Asha Gudin lives here with his family. A month earlier, after working a construction job a few miles away along the border with Myanmar, Gudin spiked a fever and felt awful.

Johora for NPR / Fatima Tuj Johora for NPRBulbul Aktar is one of thousands of community health workers in Bangladesh — all of them women — who to go door to door to diagnose and treat

people for malaria.

So he sought out Aktar. She's what's called a shasthya kormi — a community health worker. Bangladesh employs thousands of these workers, all of them women, to go door to door to treat people

for malaria, a disease transmitted by mosquitoes.

"This is my job, my duty," says Aktar. "Every single home, I have to know about them and visit them."

When Aktar tested Gudin for malaria, he was positive. So she gave him a drug called artemisinin.

"That night, I called him," she says, to see "how he's feeling and [if] he took his drug properly or not. After that, I called him every day at 10."

Over the three-day regimen, Gudin made a full recovery.

days, thanks to a quick diagnosis from a local health worker and an effective drug called artemisinin. Here, Gudin displays his treatment card.

"It's really pretty remarkable," says Kasturi Haldar, a microbiologist at the University of Notre Dame who studies the malarial parasite. "I mean, [the shasthya kormi] find the malaria.

That's what it comes down to. And then they treat it, one person at a time, one family at a time. And then if it comes back, they come back. They're the foot soldiers of this fight."

Gudin isn't alone in his healing. Health workers say artemisinin almost never fails. "This drug is a marvelous drug. It's a perfect drug," says Dr. Ching Swe Phru who's devoted his life to

treating patients with malaria in Bangladesh. (There is a malaria vaccine that's been deployed in parts of Africa, but Haldar says it won't yield rapid elimination.)

Within 12 hours, after a typical patient with high fever and excruciating pain has taken just the first four pills of artemisinin, Haldar says, "their fever was gone. I mean, that is an

amazing outcome for a drug."

Artemisinin has produced astounding results across Bangladesh. And by treating infected people quickly enough to clear the parasites from their bodies, there are fewer individuals with

malaria available for the mosquitoes to bite. That reduces transmission. Between 2008 and 2020, malaria cases in Bangladesh plummeted by 93%, thanks largely to this drug.

It allowed government officials in Bangladesh and elsewhere in the region to dare to imagine something audacious — malaria elimination.

"Our Prime Minister is committed. Our Health Minister is committed," says Mushfiqur Rahman, who's with Bangladesh's National Malaria Elimination Program. "We are expecting we could eliminate

malaria by 2030."

But the disease won't give up easily.

A strain of the parasite turned up in neighboring Myanmar that was resistant to artemisinin. Health officials worry it's only a matter of time before a resistant strain shows up in

Bangladesh.

malaria but adds, "I'm afraid that malaria has a certain history of coming back."

"You have to be alert," says Dr. Phru. "You have to be afraid of it. The parasites always have an inborn tendency to fight off the killing drug."

It wouldn't be the first time.

"I'm afraid that malaria has a certain history of coming back," says Phru.

The malarial parasite has plagued humanity for thousands of years. That history is written into our blood, which has evolved strategies to defend itself — think sickle cell disease and other

kinds of anemia, which themselves can cause illness but also convey protection from malaria. "Our blood has been profoundly shaped by malaria infection," says Haldar.

Despite centuries of battling the disease, people continue to get sick from malaria, with more than 600,000 deaths every year, mostly in Africa. And its footprint is expanding as our climate

changes, allowing the mosquitoes that transmit the disease to thrive in previously inhospitable regions, such as the higher altitudes of Ethiopia, Colombia and parts of Asia.

The fact that malaria is entering new terrain means the human suffering caused by the disease is also growing. Dr. Phru knows well what that's like.

In his final year of medical school some three decades ago, just before a big exam, he got hit with a terrible bout of the disease. It was his fourth tangle with malaria in a year, but this

one was especially bad. "It was a very difficult time," he recalls.

While Phru tried to study, inside his red blood cells, the parasite was reproducing, eventually causing those cells to rupture. The result was agony.

Tuj Johora for NPRBed nets treated with insecticide to ward off mosquitoes are distributed in Chakaria, Cox's Bazar, Bangladesh.

"High fevers, chills and severe headaches, vomiting and nausea," he says. "The nausea was the worst. I couldn't study. My partner would recite me all the studies, and I would listen to him.

And then I went for the exam with 101 or so Fahrenheit of fever. So I had to face it."

Phru was treated with a couple of drugs, including one called chloroquine. "It's a very nauseating drug and a terrible drug," says Phru. Despite the rough side effects, he was cured.

For decades, chloroquine was one of the most valuable malarial treatments worldwide. But then, gradually, the parasite stopped responding. It had developed resistance to chloroquine.

That resistance originated in southeast Asia and spread through Bangladesh to Africa until it was pervasive.

"We consider our region an important route for transmitting drug resistance," says