The Bill & Melinda Gates Foundation‘s Malaria Forum in Seattle comes to an end today and has certainly lived up to its theme of “Optimism and Urgency.”
There is legitimate cause for optimism, especially if you look at where the world is today in its efforts to combat this leading killer as compared to where we were a decade ago.
Malaria deaths are down, an experimental vaccine is showing modest success against the parasite and this once-neglected disease and poorly funded field is now big news with a lot more money behind it. I think it’s fair to say the Gates Foundation, which has spent $1.5 billion on (and advocated for) malaria efforts over the past decade, is responsible for much of that transformation.
But the Gates Foundation, and to some extent the entire global health community, has a tendency to only want to talk about good news — to be optimistic. It’s understandable, but that also poses a risk.
“It’s been a bit like singing ‘Kumbaya‘ around the campfire,” said one top malaria researcher. It’s nice to celebrate progress, he said, but the structure of the meeting — which included the Gateses’ call for a ‘re-commitment’ to eradication — somewhat tended to discourage dissent and debate.
Many of those attending the Malaria Forum this week were here for the first such meeting, in 2007, when Bill and Melinda Gates called for eradicating malaria. That upset a lot of experts in the malaria community who felt it was setting them up for failure, again, which would in the long run undermine the more modest, life-saving efforts aimed at just reducing the disease burden.
As Bill Gates said Tuesday at the Seattle meeting, the goals of malaria control and eradication can work together:
“To achieve elimination and eradication, we need to start with control, drive it up to very high levels, and sustain it,” Gates said. “We believe eradication is important for strategic reasons … The alternative is to just try to stay one step ahead of the mosquito and the parasite.”
Settling for merely “controlling” malaria, he said, would eventually again lapse and “the cost of lives would be enormous.”
Melinda Gates, taking a cue from World Health Organization Director-General Margaret Chan, compared the long and frustrating fight against malaria to the Greek myth of Sisyphus — eternally pushing a boulder up a hill every day only to watch it roll back down. Eradication, she said, offers hope of escaping this Grecian treadmill:
“We’re not stuck in a Greek myth. We do control our own destiny,” said Melinda Gates. “We will push the boulder … until it crests the mountain and rolls down the other side and every child is safe.”
That sounds like a good plan, but the difficulty comes from the complexity of the malaria challenge. It’s not so much like pushing a boulder up the mountain as it is like trying to push a number of boulders up the mountain while other rocks keep coming down on your head.
Here are five such head-clangers, the reason for the sense of urgency rather than optimism:
- Yes, malaria deaths are reported to be down by about 20 percent since 2000, according to the WHO. But, as many at the Malaria Forum noted, the numbers on malaria are terribly squishy due to lack of adequate disease surveillance and accurate diagnoses. It’s possible we really don’t know what’s going on with malaria. Even with the decline, some 800,000 people (mostly children) are still dying every year.
- Many experts, including those attending the Malaria Forum, still don’t think eradication is possible. They don’t say so very loudly (perhaps wishing to avoid irritating one of the field’s top funding sources), but a number of factors — including the ability for the parasite to rapidly evolve and adapt — make this a distant hope at best, many say.
- The preliminary results on the experimental malaria vaccine, known by the terrible acronym RTS,S, are similar to other earlier results on this long-studied vaccine — about 50 percent efficacy. Unless something changes, this means it will protect about half of those who get it from getting malaria. Will this be acceptable? And at what cost? The manufacturer, GlaxoSmithKline, has refused to say what it will charge but poor countries have trouble adding even fully effective new vaccines that cost a dollar.
- None of the malaria control and/or elimination efforts will be sustainable unless poor countries get more health workers. This came up again and again at the Malaria Forum, usually termed as “human capacity” (why do these folks talk like this?), but was sort of the elephant in the room nobody wanted to talk about that much.
- Significant progress has been made against malaria (if the numbers are right) — getting treated bed nets out to hundreds of millions of people, spraying insecticides, expanding access to drugs and throwing more money at research for vaccines or other tools to combat malaria. Now the trick will be sustaining these gains given the growing problem of drug and insecticide resistance, given that some countries (like Zambia) who saw substantial gains have seen malaria cases increase again and so on. “Now comes the hard part,” said Melinda Gates.
Many speakers at the Malaria Forum, from Melinda Gates to Margaret Chan, repeated what WHO’s malaria chief Robert Newman said at the opening of the meeting:
“There’s no excuse for anyone in 2011 to die of malaria,” said Newman.
And yet they do. A few weeks ago, when the world was paying attention to the catastrophe in East Africa, many said there’s no excuse in 2011 for anyone to die of famine. And yet they do.
There’s enough food in the world to feed everyone just as there is, arguably, the means and existing tools today to prevent anyone from dying of malaria. Finding an effective vaccine, new drugs and innovative methods for controlling, possibly eradicating, malaria will help.
But ultimately the success or failure of this fight will be determined by how well we all do at reducing one of malaria’s primary modes of transmission — poverty.