WHO Director-General assesses prospects for malaria control

Dr Margaret Chan
Director-General of the World Health Organization

Keynote address at the Bill and Melinda Gates Foundation 2011 Malaria Forum: Optimism and Urgency
Seattle, Washington, United States of America

17 October 2011

Distinguished scientists, colleagues in public health, ladies and gentlemen,

As we all know, the previous malaria forum organized by the Bill and Melinda Gates Foundation in 2007 created a sensation. The Goal Whose Name Must Not be Spoken (eradication) was mentioned, and this unspeakable ambition stimulated considerable scepticism.

Moreover, there was dismay, as I, the head of a respected and technically exacting health agency, took up the challenge. I endorsed eradication as the ultimate goal for the future.

Sceptical reactions were entirely understandable. After all, malaria had been soundly outwitting and defeating control efforts for centuries, and most spectacularly so in the global eradication initiative launched by the World Health Assembly in 1955.

As with Sisyphus, the boulder was painstakingly rolled upwards only to tumble back down again in an absurd exercise of futility. Malaria always resurged and often roared back with a vengeance, causing deadly epidemics in areas where control had almost been achieved. Periodic epidemics took an even heavier toll on communities, causing more cases and deaths.

At the close of the previous century, ambitions for malaria control had been reduced to holding the disease at bay, aiming to keep a very bad situation from getting any worse. Back then, the one good thing that could be said about malaria was that the situation was stable. It could hardly get any worse.

As the African Leaders Malaria Alliance, or ALMA, stated last month: “In Africa, we used to track malaria by metrics of despair: cases and deaths, wasted life and squandered opportunity. We tracked numbing statistics like the million Africans who died annually from this preventable disease a decade ago.”

Now, what we are tracking is progress, some very recent progress, and some stunning gains on age-old fronts. Since 2007, endemic countries have seen record-breaking progress in terms of funding, intervention coverage, and public health impact.

This is not linear step-by-step progress, the boulder gradually nudged up the slope, but progress characterized by huge leaps and bounds forward.

As set out in the World Malaria Report 2010, the annual number of malaria cases and deaths continues to decline, especially in Africa. The number of countries that have successfully cut their malaria burden in half over the past decade continues to rise.

Let me repeat some figures that support the revival of optimism.

Between 2008 and early 2011, nearly 300 million treated mosquito nets were delivered to sub-Saharan Africa, enough to protect 578 million people.

Over the past decade, scaling up the delivery of existing interventions is estimated to have saved more than one million lives in Africa alone, with the majority of these deaths averted since 2007. That was the year when the big push to improve coverage really hit the ground.

The malaria map is shrinking. In 2009, for the first time, not a single case of falciparum malaria was reported in the European Region, and this trend continues. WHO procedures for certifying a country as malaria-free, abandoned in the 1980s, were reinstated in 2004.

Since 2007, Morocco, Turkmenistan, and United Arab Emirates have been certified as malaria-free.

Today, I have great pleasure in announcing that Armenia has been certified by WHO as malaria-free. This happens only when a country has excellent surveillance and response capacity, able to detect every imported case and ensure that it does not ignite a re-establishment of transmission.

We have much to learn from success stories, as well as from places where things have not gone so well. Today, WHO, the Roll Back Malaria Partnership, and PATH are issuing a report on Eliminating malaria: learning from the past, looking ahead.

Malaria now benefits from considerable investment in the research required to develop tomorrow’s transformative tools. Several new R&D initiatives show how the development of new medical products is accelerated when public and private efforts join forces.

Examples include the Medicines for Malaria Venture, the Foundation for Innovative New Diagnostics, or FIND, the Innovative Vector Control Consortium, and the Malaria Vaccine Initiative.

One of these products, the RTS,S candidate malaria vaccine, is now undergoing a very large phase III trial in Africa. Malaria has never had a vaccine get this far. If licensed, it would be the very first human vaccine against a parasitic disease.

WHO has established a Joint Technical Expert Group to ensure accelerated review of data emerging from this and other trials of malaria vaccines. The RTS,S trial is scheduled for completion in 2014. A WHO recommendation based on the full results will follow shortly in 2015.

Ladies and gentlemen,

What is behind these gains? More money, for sure, but also much better interventions, better evidence, and strongly unifying policies and strategies that keep partners working on the same track.

The landscape for making inroads in the malaria situation is dramatically different today than it was in the 1980s. In fact, the landscape is dramatically different from that of just a decade ago.

Let me pinpoint some of the changes that have created hope and stimulated ever-higher aspirations in the midst of great urgency.

First, the importance of strengthening health systems is now recognized. Malaria cannot be controlled, much less eradicated, when health infrastructures are weak. This is a problem that must be faced head-on. It cannot be circumvented. This was attempted during the failed eradication programme.

That programme used oversimplification and highly standardized, rigid operational procedures in an effort to compensate for weak health infrastructures in the vast majority of endemic countries.

That approach ignored the extraordinary complexity of malaria and the striking variety of its epidemiological patterns. It suppressed the need to stimulate indigenous and ingenious solutions to local problems.

It assumed that success in one part of the world could be replicated elsewhere using the same tools and strategies. Moreover, it assumed that existing tools were good enough to get the job done and did nothing to confront rapidly shrinking investments in malaria research and new product development.

In many countries, tremendous inroads were made in the control of all vector-borne diseases, and countless lives were saved. But the programme eventually failed.

In contrast, China’s impressive success in controlling malaria has at least one historical reason. China first developed an effective peripheral health infrastructure before tackling its huge malaria problem.

The failure of the eradication programme created a belief, held by many, that malaria was impregnable to any kind of frontal attack. The disease would always find a way to sneak out of any trap, whether through vectors adapting to a new ecology, or the development of resistance to front-line medicines and insecticides.

This conventional wisdom no longer applies. I can think of at least three reasons why.

First, we are not blindsided by illusions.

Ambitions such as near-zero malaria deaths by 2015 and eventual eradication are extraordinary ambitions that must be matched by an extraordinary intensification of current efforts.

Our eyes are wide open to the realities, the formidable challenges, the inevitable threats, and the fragility of progress. We know that eradication will take at least four decades. This is a long-term investment, not a quick win.

We know that, using currently available tools, malaria can be eliminated from the fringes where prevalence is already low. But we also know that these tools are insufficient to defeat malaria in its heartland and eventually interrupt transmission.

We know this is impossible right now, but we also know the kind of game-changing tools needed and the research agenda that will get us there. We know that we must first reduce the human disease burden before attempting worldwide eradication. And we know that, in the process, the public health successes that will stack up will be amazing.

Second, we are strong in our shared conviction that this is a job worth doing. The goals of near-zero deaths and eventual eradication are idealistic and aspirational, but not foolhardy as some critics suggested in 2007.

The vast harm done by malaria, those “metrics of despair”, now has much greater political and public awareness, almost outrage. In this day and age, no one should be dying from a disease that is entirely preventable and treatable, and certainly not more than three-quarters of a million people each year, mostly very young or pregnant.

Third, this time we are staying one step ahead of malaria.

We have strategies in place for protecting the effectiveness and lifespan of existing interventions. We have better surveillance that picked up the earliest signs of parasite resistance to artesunate in the Mekong Region. WHO has developed a detailed plan for stopping the survival and spread of resistant parasites.

Today’s toolkit for combating malaria is better, also because it is more varied. As we have learned, malaria is an extremely complex disease that can be defeated only through a comprehensive mix of multiple interventions.

Today, the governments of endemic countries are respected as the most important parties in collaborative efforts. National malaria control programmes are at the centre of everything, and I am pleased to see so many participants representing these programmes, especially in Africa.

Today, action is immediate and proactive, not passive and reactive. Most important, the groundwork is being laid in systematic fashion. When new tools arrive, countries and their partners will have already lowered the malaria burden dramatically. They will be ready to finish the job.

We have new policy recommendations that take advantage of better tools that already exist.

In March 2010, WHO introduced a major policy change that recommends diagnostic testing for malaria in all suspected cases before initiating treatment. This policy marks a striking change from previous practice, when malaria was so common that every child with fever was presumed to have the disease and was given antimalarial drugs.

Such a practice is straightforward, but no longer defensible as cases continue to drop dramatically, especially in Africa.

Antimalarial treatment without diagnostic confirmation means poor care for patients. It masks other deadly childhood illnesses, wastes precious medicines, hastens the inevitable emergence of drug-resistant parasites, and makes it impossible to know the true burden of malaria.

The 2010 policy change was made possible by the availability of rapid diagnostic tests that can be used right down to the community level.

With transmission now dropping in so many areas, it no longer makes sense to treat malaria in shotgun fashion. In Africa, just a decade ago, fewer than 5% of suspected cases in the public sector were tested. By 2009, that figure had risen to 35%.

We have a long way to go to reach the goal of universal access to diagnostic testing. But rapid scale-up of diagnostic testing is entirely feasible. Senegal rolled out diagnostic testing in all health facilities within 18 months and is now saving a quarter of a million ACT courses each and every year.

As yet another value-added benefit, widespread testing is giving us, for the first time in history, precise data on the malaria burden. In some areas, for example, we are learning that the malaria burden is actually much lower than has long been presumed.

The tests and the related policy recommendation support another new target. That is: achieving accurate surveillance in all endemic districts. One statistic indicates the magnitude of the challenge.

At present, some 85 countries, representing 65% of the world’s population, do not have reliable cause-of-death statistics. This means that causes of death are neither known nor recorded, and health programmes are left to base their strategies on crude and imprecise estimates.

With more countries using diagnostic tests to confirm malaria, we are no longer working in the dark in terms of actually seeing the real disease burden and where it is concentrated. We are not yet in broad daylight, but at least we see the dawn.

Good surveillance means knowing where the enemy lies. The better we know the enemy, the better we target human and financial resources, and shape the research agenda for the future.

In terms of staying one step ahead of malaria, I have a warning. Modern vector control for malaria is exceptionally dependent on a single class of molecule, the pyrethroids. These are probably the best insecticides ever developed for public health purposes, but this exceptional dependence is dangerous.

To ensure a coordinated response to this threat, WHO is working with multiple partners, including industry, to develop a Global plan for insecticide resistance management, which will be released in early 2012.

WHO operates a scheme, WHOPES, for testing and evaluating the safety, efficacy, and operational performance of public health insecticides and developing specifications for use in quality control and international trade.

Products that make it through this rigorous scheme of testing and evaluation earn a seal of approval that makes them eligible for public sector procurement.

With thirteen new products now under review for malaria control, this scheme needs greater support. We cannot afford the risk of losing a class of first-rate insecticides with no suitable replacements ready to step in and do the same job.

We must never forget. Vector control is by far our most important tool for preventing malaria.

Ladies and gentlemen,

WHO has kept pace every step of the way with practical how-to technical advice and operational manuals, whether for monitoring the durability of insecticidal nets or selecting and procuring the best rapid diagnostic tests. Technical guidance on these and many other issues has been produced from a distinct, and I believe, absolutely essential vantage point.

It combines the insights of the academic world, the capacities of the research-based pharmaceutical industry, and the experience of implementing agencies with their feet on the ground in some very rough places.

It includes the passion and courage of civil society organizations, and the self-interests of businesses and multinational corporations, their methods of problem-solving, and their enviable track-records for getting things done. It includes the generosity of philanthropies and of governments in countries where malaria vanished ages ago.

Above all, it includes the perspectives and will of African leaders. As ALMA recently stated: “We know that continued partnership and funding will allow us to sustain the gains we’ve made. Global dollars are essential to this success, but the buck stops with us.”

The statement continues: “As heads of state and government, we are ultimately responsible for demonstrating that aid is being used wisely, effectively and efficiently. We are responsible for the wellbeing of our citizens, who have put their trust in us.”

This is what is meant by stewardship and accountability.

Ladies and gentlemen,

In 2000, the Millennium Development Goals brought malaria into sharp focus. The work of this Foundation has broadened that focus with added dimensions of hope, inspiration, and ever-higher ambitions.

The course we are jointly pursuing is not a blunt assault, but a diversified multi-pronged approach.

It draws on lessons learned in the past, as you will be doing during this forum, and it looks ahead to the innovations that can launch a final confrontation with this ancient foe, this ancient cause of so much human misery, in its heartland.

Thank you.