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A wake-up call for all of us

December 27, 2012 - 12:34 -- Bart G.J. Knols

Last week showed unambiguously that unless the world pulls up its sleeves, the hard-won gains of the last decade may go up in smoke. 'The world' in the previous sentence is you, us, all of us engaged as professionals in the field of malaria. MalariaWorld has put out warning signals over the last three years, about the problems with drug resistance, about artemisinin resistance in SE Asia and the risk of it escaping to other parts of the world, about impregnated bednets being shipped to parts of Africa where full-blown resistance against pyrethroids occurs, about counterfeit drugs undermining curative treatment and increasing the risk of resistance popping up, about the difficulties of vivax elimination, about the problems with zoonotic malaria, about...the list is endless I'm afraid... 

The annual World Malaria Report published by WHO spoils my festive season I have to admit. Year after year we noticed gains around the world, fewer deaths, less disease. But this year's report reveals a shocking truth, amplified by Dr. Robert Newman's statement 'we would have to prepare for major malaria resurgences'. In spite of the fact that some 1,1 million lives were saved over the last decade, this statement seems to prepare us for a coming storm. Newman points out that we have less than half the 5.2 billion dollars needed annually to combat malaria, and part of the storm ahead may be caused by dwindling funds in the years to come. So who then will provide new nets to those that received protection over the last three years but now see their nets full of holes and worn out? Isn't this something we saw coming and warned for? Yes we did.

Although the press release from WHO still portrays a lot of optimism and enthusiasm that we're on the right track, the signs are on the wall and have been picked up by the international press. Read what the UN News Centre,  BBCNew York TimesWashington PostThe Guardian, and numerous other newspapers and online sources have to say about where we're at.

If we are indeed facing difficult times ahead then two things can happen. A fingerpointing exercise may start and we may be as embedded in a blame culture as we were during the late 1960s when WHO realised that their global malaria eradication plan was a self-fulfilling prophecy. This is very likely going to happen, but we should do everything to avoid it. Now, how then can we avoid such thing from happening?

The answer is simple: face the truth. Face the truth that we don't have enough funds and will not fulfill the promises we pledged at the dawn of this century (zero deaths by 2015), face the truth that the sole reliance on chemicals (in drugs or insecticides) is similar to betting on a horse with two legs. Face the truth that nets will save lives but are by far not enough to move anywhere closer towards elimination in the heartland of malaria: Africa. Face the truth that it is unlikely that the RTS,S vaccine that yielded 30% protective efficacy in the under 1's is going to reach the market anytime soon (if ever). And face the truth that unless we start doing things better and differently, we are fighting a battle we will ultimately lose.

How then should we move forward?

First, in my humble opinion, we should strip global initiatives, well-meant projects, and large-scale interventions from the grips of those that studied marketing instead of a discipline that matters when we talk malaria. Marketeers have pushed us into believing things that sell ('donate a net, save a live') and do well in the general public, but poison our own realism of what interventions can really accomplish. If we continue to 'sell' malaria the way we do at present, it will blow up in our face.

Second, let's focus on things that matter. On research of which the results can be valorised rather than end up in scientific publications that do nothing more than filling libraries. Remember: we publish some 3000 scientific articles on malaria each year, but spray DDT that was discovered in 1939. I cannot conclude otherwise than that something is wrong, somewhere. I see numerous articles that acknowledge generous support from the Bill & Melinda Gates Foundation, but where are the new tools that were promised by those that submitted their research proposals to the Gates Foundation in the first place? No doubt, Bill and Melinda gave us money to make a difference in the real world, in the lives of the poorest on the planet, and not to increase the publication list on our CV...

Third, let's get together and discuss how we can eliminate malaria from a region or country to show the world that it can be done. Control is not enough if we are talking about elimination. If Sri Lanka indeed eliminates its malaria by the end of 2014 you will hear a sigh of relief from my side. Because we need such examples if we are to maintain the interest of donors. Picking a region or country somewhere in Africa and masterplanning elimination there and actually do it may be better than spreading meagre resources over the vastness of the continent and achieve nothing more than temporary control.

Fourth, let's not forget that we eliminated malaria before - from continents. So it can be done. Learning from past successes (and not just focus on why the global malaria eradication campaign of the 50s and 60s failed) can bring a lot to the table and teach us how to become better (again) at gaining success. History is not a favourite topic of those that practice state-of-the-art science in biotech labs, but boy there's a lot to learn from what we did before. This year you read about Kligler on MalariaWorld and how he succeeded in eliminating malaria from Palestine. Malaria that was worse than that seen in many parts of Africa today.

I know many MalariaWorld members personally. I know that they 'live' malaria 24/7. Are dedicated and passionate about ending it. But now, more than ever before, do we need to step up efforts and stand up in the face of the harsh reality in front of us - and speak up.

Dialogue and discussion provide the very basis of why we set up MalariaWorld. We hope that you will appreciate this opportunity and use it, and in 2013 we will certainly stimulate more discussion on where we're heading with malaria.

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Comments

Submitted by Dr. C. Nagaraj (not verified) on

I agree with the article on Wake up ...

I find there is lack of commitment at various levels. I now work in an area at the trijunction of three states of India - Andhrapradesh, Karnataka and Tamilnadu. In the hospital I work, I have number of positives of P. falciparum, followed by P. malariae, P. ovale and P. vivax in that order. But the local authorities do not report any malaria from the area. I had worked in Karnataka before taking this assignment and the adjoining area in Karnataka is PHC Kamasamudram of Kolar District where I have done number of chloroquine sensitivity and had demonstrated the presence of Chloroquine resistance as early as 1980s. In the area I am presently working, we have P. falciparum (> 93 %). There are cases resistant to ACT, Quinine and few multi drug resistant P. falciparum. There are quite a number of cases of mixed infection. As per records of Karnataka, there is no malaria cases reported. With this attitude of Health Authorities, how do you expect control, let alone elimination of malaria.

When I was working for GOvernment of India, in the South India, we used to see that in addition to taking up antimalarial sensitivity studies, other cases of malaria were given adequate treatment with appropriate drugs. It had paid dividends in te form of immediate reduction of cases which I had shown to the government. But I feel that many do not like malaria to be brought under control since it is the bread and butter of many practitioners including those in government service. So I was a villain to them all. So proper attitude is required for those in service.

Submitted by Michael Bangs on

Dear Bart, A very timely piece but I have seen this missive before. Not the specific words per se, but the echoed sentiments, concerns and calls for action from malariologists/entomologists of past (L Bruce-Chwatt, MA Farid, M., PF Russell, G. Macdonald, RC Muirhead-Thomson, J de Zulueta, among so many others). My personal library is replete of malaria subject history, particularly the heady times of the 50s and 60s – the undisputed heyday of global reach malaria control (eradication). I also fear we are on that delicate line of possibly heading down a similar path we faced 50-60 years ago. The expectant technological innovation and straining political-social will struggling to support laudable, albeit sometimes unrealistic, goals is again a palpable threat to the global effort. Let's hope not. If we let this slip through our hands once again, we as a global society will have much to answer for regard the renewed and unremitting despair that follows.

Kind regards, Michael J. Bangs, PhD
Papua, Indonesia bangs_michael@yahoo.com

Submitted by Wallace Peters on

Congratulations Bart on your eloquent and provocative editorial which sets out clearly what many of us who have been involved in various aspects of malaria research and control operations over the years would wholeheartedly endorse. We do not have to regard the future with pessimism but with open eyes and open minds. I am confident that new discoveries and inventions during the coming decades will provide the means of eliminating malaria from many areas that are currently endemic, but only if those concerned, and especially those who have to administer any future activities bear your words in mind. I recently concluded a talk I gave to a meeting of our colleagues in MMV with the following comments:
"THE LAST WORD The role of the individual with imagination is always vital to the development of new tools to manage malaria (computers are not everything). We should always be prepared to return to basics and not discard the lessons of the past. Money is not everything – but it helps. Don’t forget the ecology – it often hinders. Never forget that Man is his own worst enemy, "
Best wishes to the continuing success of Malaria World in 2013. Wallace Peters

Wallace Peters