A malaria trailblazer through the decades

Mark Henley/ WHO 2018

At the end of 2018, you will step down as a member of the Malaria Policy Advisory Committee (MPAC), after nearly 7 years on the committee. How do you feel as your time serving on this body comes to an end?

As a founding member of MPAC, it has been very rewarding to participate and contribute to how the committee has developed. MPAC has radically changed the approach to providing the global malaria partnership with strategic advice and technical input through the development of a transparent process for recommending and changing policy. This is one of the most important and useful activities that the committee has undertaken during my time.

Your career in public health spans more than 5 decades, and you have devoted much of your time and energy to malaria. What was it like working on this disease when you started out?

It was very lonely! To give you an even more recent example, when we organized the first Multilateral Initiative on Malaria (MIM) meeting in 1997 we had to work really hard to convince people to attend, and interestingly, there were few participants from across the African continent. Malaria was very much a neglected disease, and it has really been in the last 2 decades that interest has developed. I am not sure why malaria did not receive the attention it deserved, although, I think it was partly the effect of the end of the Global Malaria Eradication Programme. When that finished, a lot of people just gave up on the disease. Fortunately, we are in a very different place now.

One of your very first malaria research projects was on bed nets in the Gambia; in fact, you were a trailblazer in looking at their efficacy in preventing mosquito bites. Fast forward to today – insecticide-treated bed nets are a key tool in the WHO-recommended malaria prevention arsenal, yet not everyone that could benefit from one has access. Why is this so and what needs to be done to expand coverage and use?

Insufficient financial resources is a big reason for low coverage rates because most bed net programmes have been funded from international donors, and as we know, investments for malaria have stagnated. Also, there continues to be some resistance from communities; it is not a secret that many people do not like using them.

Looking back at my early days in the Gambia, I was initially surprised to see people using bed nets because that was not the case in northern Nigeria where I had been for 10 years. In the Gambia, people had a tradition of using nets, purchased with their own money. Today, we can certainly do more, but in the long term, such programmes have to be domestically sustainable.

After an unprecedented period in reducing the global malaria burden, progress in fighting the disease has stalled, including funding as you pointed out. What is needed to get the response back on course?

We need to focus on those countries in Africa where it has been extremely difficult to reduce malaria transmission levels. I was in Sierra Leone a month ago doing work on the Ebola virus disease and every child in the paediatric ward had severe malaria, and several more with anaemia, which is almost certainly due to malaria – and that was in a community with insecticide-treated bed nets and reasonable access to malaria treatment.

We definitely have to scale up the malaria response and ensure malaria control programmes do not run out of resources. We also need to be a bit more imaginative in the way we use antimalarial drugs, like Ivermectin. This is an example of using a drug developed for something else but that does have an effect on malaria-carrying mosquitoes.

Speaking of innovation and applying different approaches to fighting malaria, what new tools could we expect in the coming years?

First, we can do much better in using the existing tools that we already have at our disposal. I hope that ways will be found of using the partially effective malaria vaccine RTS,S, about to be evaluated in 3 large pilot studies, to have the maximum impact because vaccines have been hugely successful public health tools. Take measles: when I first started my research work in the Sahel, half of the paediatric wards were full of patients with this disease. Fortunately, it is a very different situation today. An exciting development is gene drive mosquitoes, which could really be the game changer for malaria. It remains early days but the potential is there.