Four years ago, Bill and Melinda Gates shocked, and to some degree dismayed, many in the global health community by calling for the eradication of malaria.
Starting today in Seattle, four years to the day after the Gateses’ made the call for eradication, the world’s richest couple will host the Bill & Melinda Gates Foundation’s second global Malaria Forum aimed at celebrating progress, confronting the remaining challenges and re-committing to eradication.
It’s mostly that last bit, eradication, which tends to stick in some folks’ craw.
At the 2007 meeting, many of the top malaria experts in attendance were critical (privately, for the most part) of the Gateses’ call to eradication. Some said it was irresponsible, or at best naïve, given the sorry history of earlier attempts at eradicating this global killer. I covered the 2007 meeting for the Seattle PI and quoted two leading experts:
“Everyone is in favor of eradicating malaria,” said Dr. Brian Greenwood, a malaria expert at the London School of Tropical Medicine and Hygiene. What has so often bedeviled such good intentions, Greenwood said, is the hazard of raising expectations too high and creating a culture of impatient demand rather than steadfast progress.
“We will have to be extremely careful how this is translated into action,” said Dr. Marcel Tanner, director of the Swiss Tropical Institute in Basel, Switzerland. Unless the international community also is willing to help improve the poor health systems of these countries, Tanner said, the noble goal of eradicating malaria is unlikely to succeed.
“If we don’t do that, though I hesitate to say it, we will surely fail,” Tanner said.
The problem, as Greenwood said, isn’t the sentiment. Everyone would like to see malaria go the way of smallpox. The problem is that if eradication fails, again, many are concerned the more modest but life-saving efforts aimed at controlling the disease will be abandoned, again.
“There are people who are skeptical and we need to listen to them,” said David Brandling-Bennett, head of the malaria program at the Gates Foundation. “But the call for eradication has really created a sea change in the malaria community, getting us all to think about what can be done and what needs to be done.”
Much has been done already thanks to a massive, multi-pronged attack on the killer by the international community. According to a recent report by Roll Back Malaria, deaths from malaria overall have declined by 38 percent (to about 800,000 deaths annually) with nearly a dozen African countries seeing their malaria mortality cut in half.
Meeting of the minds and a mindset
This three-day Gates Foundation Malaria Forum, Brandling-Bennett said, is primarily for organizations that have received grants from the philanthropy to combat malaria by exploring new methods of control, investigating potential vaccines and considering the challenges ahead.
The Gates Foundation has spent $1.5 billion on efforts aimed at defeating malaria, an amount that has, as the World Health Organization has noted, helped to re-invigorate the malaria community after decades of mostly limping along.
Most of the 300 or so attendees at the invitation-only Seattle confab may be expected to be preaching to (or from?) the eradication choir. But one of those attending is DA Henderson, who despite his leading role in the smallpox eradication campaign is famously skeptical of other efforts in disease eradication.
Has Henderson, who recently softened his criticism against the polio eradication campaign, endorsed the Gates Foundation’s call for malaria eradication?
“I’m not sure DA endorses eradication of anything,” said Brandling-Bennett. “He’s a bit of a skeptic about these things.”
Henderson was invited to offer perspective on eradication efforts in general, he said, and help the community learn from both the successes and the failures. Nobody expects to beat malaria quickly or easily, Brandling-Bennett said, but the Gates Foundation intends for this meeting to be a clear-eyed re-dedication to this ambitious goal.
“We are already making progress around the world,” he said. “This is the first time we’re seeing high-level control of malaria in a number of African countries. That’s an important step toward eventual eradication.”
By 2015, Brandling-Bennett noted, 10 more countries (none in Africa, however) are expected to have eliminated malaria. “I don’t think there’s any question we’re making progress.”
Of numbers and knowing
Yet beyond the ongoing debate about the feasibility of malaria eradication, there are also some who contend these reports of progress, of declining malaria deaths and caseloads, in many Sub-Saharan African countries and elsewhere are a bit questionable. A recent report in The Lancet, for example, contended India had grossly undercounted its malaria caseload.
Part of the problem with estimating success in combating malaria comes from the difficulty in accurately identifying the disease burden.
Malaria is often not diagnosed or misdiagnosed, especially in poor countries, because its symptoms are somewhat generic – fever, fatigue — and most of its fatal victims are children in poor communities where health services, let alone data collection, are poor or non-existent.
Another difficulty of assessing progress is, counter-intuitively perhaps, caused by the many different efforts underway at the same time. Malaria is being fought aggressively on many fronts today – the massive distribution of treated bed nets, by household insecticide spraying programs, by expanding access to malaria drugs and so on.
Are all these methods equally effective? Is an observed decline in malaria deaths due to more people gaining access to effective treatment or to all the bed nets? Is it possible, as some contend, that the bed nets are making a positive difference while indoor insecticide spraying is not? How do we sort this out?
And what of this weird report by scientists who say mosquito populations are rapidly declining in parts of Africa where none of these anti-malaria efforts are underway? Is the recent decline in malaria due to climate change or some natural cycle?
Most experts agree that the international community’s big push against malaria is having a positive impact at reducing malaria cases and deaths worldwide. But whether we have a clear understanding of exactly what is going on, and if it can be sustained is another matter.
At a recent debate among public health experts at Harvard, the consensus was that the Gateses’ call for malaria eradication was unlikely to succeed but the call itself has so far had a positive “aspirational” impact — even if eradication is never achieved.
Eradication is unlikely to succeed based on the tools we have today, said Brandling-Bennett. That’s why the Gates Foundation is so heavily investing in finding new tools, he said, such as an effective vaccine, new methods for controlling mosquitoes (including genetic modification strategies or even microwaves) and new, more effective drug treatments.
“We believe eradication is difficult but possible,” Brandling-Bennett said