Swaying slightly under the weight, about a dozen porters hoisted onto their shoulders sacks of mosquito nets, bags of food, medical supplies and a fragile, 16-year-old laboratory microscope carefully packed into a wooden crate. With that, they set off into the Philippines jungle, walking through thigh-high grass, burrs sticking to their legs, scrambling up and down muddy paths, wading through small rivers and staggering across an unsteady wooden suspension bridge, until they eventually reached a large shack in a clearing. There, around 200 people had gathered from nearby Indigenous communities for their monthly malaria test.
Malaria, which is caused by a parasite spread by mosquitos, is one of the leading causes of death around the world, killing around half a million people every year. As recently as the 1990s, the Philippines recorded close to 100,000 infections every year, resulting in hundreds of deaths and many more people suffering the brutal sweats, fatigue and muscle pain common with malaria infection.
Since 1999, as a result of concerted effort by health care workers, the government and local and foreign NGOs, there has been an 87 per cent reduction in the number of cases, and a 93 per cent drop in deaths from malaria. Out of 82 provinces, 72 have been declared officially malaria-free, while nine others have zero cases of local infection (meaning any positive cases originated elsewhere).
Volunteers carry supplies across a suspension bridge en route to a remote mountain village southern Palawan province. After decades of public-health efforts, this is the only part of the Philippines with active malaria transmission.
Only one province is still grappling with active malaria transmission, the last mile of a 25-year marathon: Palawan, a mountainous, 14,650-square kilometre cluster of islands which split the South China and Sulu Seas like a dagger pointing from the main Philippines archipelago toward Borneo in the southwest.
In the first half of this year, Palawan recorded around 2,300 malaria cases, according to the Movement Against Malaria (MAM), a public-private fund that supports activities in the region. That’s on track to come in well under the 6,188 recorded for all of 2023, when weather patterns – heavy rain followed by intense heat – were ideal for mosquito breeding and cases spiked significantly.
“Different places have different conditions,” said Dr. Antonio Bautista, an MAM program manager who has spent years fighting malaria across the Philippines. “We have been doing all the strategies that all other provinces have been doing. We’ve been disseminating medication and supplies, we’ve been monitoring, we’ve been doing active case findings, and yet we still have so many cases.”
While media reports often focus on experimental anti-malaria tactics such as genetically modifying mosquitoes to stop them breeding, most eradication programs function as they have for decades: using nets, screens and bug repellant to protect against bites, and suppressing mosquito populations by removing standing water (where they breed) and using insecticide. Mosquitos do not naturally carry the malaria parasite, and must bite an infected human in order to transmit it, so by controlling cases and tracking infections, it’s possible to gradually bring numbers down to zero without wiping out the insects themselves.
One of the challenges in Palawan is tracking, treating and suppressing cases among the island’s eponymous Indigenous people, many of whom still live in remote communities in the southern highlands.
In June, The Globe and Mail joined an MAM team trekking up into the foothills of 2,000-metre Mount Mantalingajan, to carry out testing and do outreach work. Over several hours, dozens of men, women and children queued up patiently to be given a finger-prick test, their blood smeared onto glass plates, stained with purple dye, and then examined under the microscope, the results tallied and carried down the mountain for encoding in a centralized government database.
Microscopist Charia Fuerte oversaw the careful unpacking of her machine, relieved to discover that nothing in the fragile mechanism had cracked or dislodged during the hike. The 52-year-old has spent more than two decades fighting malaria, and said she had seen cases shrink from being common all over Palawan to now just a handful of barangays – parish-sized administrative units – in the southwest.
Ms. Fuerte regularly walks for up to five hours to reach a testing site, where she and a partner will go through hundreds of slides, searching for signs of the malaria parasite, often using a phone flashlight or mirror to provide the light needed to see through the microscope.
“It’s very challenging,” she said. “But you have to do it with heart, despite all the challenges.”
Ms. Fuerte was trained at a microscopy institute in the Palawan capital Puerto Princesa, and still returns regularly for refresher courses. At one recent seminar, 16 trainees were undergoing a week-long course, revising how to distinguish between the two main strands present in the Philippines: P. falciparum and P. vivax, both of which look almost identical under a microscope to a novice, but have tell-tale differences in size and stippling.
Trainee Florinda Ruiz said at first, she also struggled to tell the varieties apart, but after almost 24 years, it’s now second nature. Like Ms. Fuerte, Ms. Ruiz is a volunteer, paid a small stipend by the local government, but largely driven by a sense of mission over anything else.
“I feel happy,” Ms. Ruiz said of her long career. “I’ve seen a drop in cases. In my barangay there are now no cases at all.”
Dr. Bautista said ultimately the situation in Palawan is a success story – apart from the blip in 2023, cases are steadily declining – but that getting from minimal cases to zero cases is easier said than done.
“The final leg is always the hardest,” he said. “There really is no manual to tell you what to do, when to tone things down. If it was up to me, we would keep doing everything until we get to zero. So far, every time we reach a new low, it’s followed by an upsurge.”
One way the government hopes to make progress is by encouraging Indigenous communities to move to centralized villages in the lowlands, where they can grow crops and keep animals, but still commute to the forests to carry out traditional slash-and-burn agriculture and harvest resin from the Almaciga tree, which they sell for around 50 cents a kilo.
Bernie Lumnos sits in his 'ambulance,' provided by the local government, which he can use to ferry patients from his village in the hills to a nearby health clinic.
At one such village in Rizal, resident Bernie Lumnos said he used to live up in the mountains, where malaria was common, with his entire family catching the disease three times.
“It was very hard to come down for treatment,” he said. “And when you do, you’re not in the fields planting or gathering food, it was very hard to get enough food when we were sick.”
Mr. Lumnos now lives in the government-run village, where he volunteers for a malaria outreach program and drives a motor-tricycle ambulance, ferrying more serious cases to a nearby town for treatment. Life in the village is not much different than it is in the mountains, he said, dismissing concerns that it could result in a loss of traditional practices.
“I tell my children there are good things in our culture, but also some things we need to change,” Mr. Lumnos said.
Malaria is a major problem in indigenous areas of Palawan, the last Philippines province where the disease has yet to be stamped out.
According to Survival International, which advocates for tribal peoples, Indigenous groups in Palawan have seen their traditional homelands encroached upon by mining and palm oil companies, and suffered from pollution and infectious diseases as a result of the increasing development of the region.
Many of the malaria volunteers are from the same Indigenous communities as those they are helping, and appeared highly sensitive to local concerns, though occasionally outside medical workers could be heard using patronizing or colonial language, referring to tribal people as backwards or ignorant.
“We’re here to help, not harm,” said nurse Rutchel Laborera, who comes from an Indigenous community in Mindanao, an island in the southern Philippines. “People in the community are very responsive. We could not do what we have to do alone.”
Like other workers, Ms. Laborera pointed to the incredible success of the Philippines anti-malaria program over her 17-year career, and was optimistic about its future.
“In my first year, I only counted deaths,” she said.
Editor’s note: A previous version of this article incorrectly described malaria as a parasite spread by mosquitoes. It is a disease caused by a parasite spread by mosquitoes. This version has been updated.
James Griffiths travelled to the Philippines as a guest of The Global Fund to Fight AIDS, Tuberculosis and Malaria, which supports anti-malaria programs in Palawan. Global Fund did not review this article.