Gates has an audacious battle plan
• Southern Africa is in the frontline of the war to wipe out malaria
Malaria is low priority healthcare risk in Southern Africa, but it is testimony to how hard it is to get a solid grip on the disease that SA is one of the countries targeted for its eradication by 2020 but also recorded a shocking 678% increase in cases in 2017.
Compared with SA’s health headaches tuberculosis and HIV, malaria is small potatoes. Globally, however, it’s an enormous issue, particularly on the African continent. Partly for this reason, Central America, Southern Africa and Southeast Asia are set to become the frontline of an audacious battle: eradication.
The campaign is underpinned by a kind of military strategy: attack the fringes and work towards the centre.
The centre is tropical Africa, particularly the Democratic Republic of Congo, but also West Africa and northern Mozambique, where malaria has been endemic for centuries.
About half-a-million people, mostly children, die from malaria every year. The campaign has the potential to save a breathtaking number of lives.
Historically, the battle against malaria was something of a forgotten war. It only marginally affected the developed world, so the incentive for pharmaceutical companies to innovate new drugs was low. Between 1990 and the turn of the century, the incident rate increased from 31 to 71 new cases per thousand of the global population.
Now all that has changed. Pharmaceutical companies have responded to the criticism and are providing discounted drugs. Spending on medical research has hugely increased.
Malaria has become an important focus for health interventionists including donors in The Global Fund, an amalgam of public and private funders aimed at combating HIV, TB and malaria. Global funding amounts to about $2.7bn, split almost evenly between the governments of countries where the disease is endemic.
The biggest chunk of the Global Fund’s funding comes from the US government.
At the World Economic Forum meeting at Davos, malaria was a focus of presentations by the Bill and Melinda Gates Foundation. About 216-million people got malaria in 2017, compared with 263-million in 2010. The 50-million decline resulted in a 25% decrease in the death rate — almost 750,000 people whose lives were saved.
Dozens of countries have eliminated malaria. In 2017, Algeria and Sri Lanka were certified malaria-free by the World Health Organisation (WHO).
In the same year, the WHO identified 21 countries with the potential to eliminate malaria by 2020, which it dubbed E-2020 countries. While some E-2020 countries remain on track to achieve their goals, 11 countries reported increases in indigenous malaria cases from 2015 to 2017 and five reported an increase of more than 100 cases in 2016 compared with 2015.
By far the biggest increase was in SA — up from 555 cases in 2015 to 4,323 in 2016. This is a huge decrease on the 64,000 cases in 2000 and 11,700 cases in 2014 in SA, but it does mean that the goal of eliminating malaria in the country by 2018 is slipping away.
Globally, 29 new cases of malaria per 1,000 people were recorded in 2016, while there were 140 new cases of TB per 100,000 people. The incidence of malaria is high but the death rate is low compared with some diseases, and that creates some peculiar problems.
The average adult living in a high-risk malaria area could be bitten 200 times a year by a malaria-carrying mosquito. But many Africans have built up a resistance to the disease, which is why children are by far the highest risk group and why
eradication brings risks of a deadly resurgence.
The Bill and Melinda Gates Foundation is the big hitter in nongovernment, philanthropic healthcare, but governments remain a crucial part of the healthcare equation.
Despite its size, the foundation is essentially an interventionist force in relation to global healthcare spend on the huge, global elephant that is malaria.
Bill Gates says he crafted his intervention by first looking at the inequity in health between rich countries and poor countries. “I was hoping it wouldn’t be like 200 diseases and, fortunately, it’s about 20 diseases. I was hoping it was two but it’s about 20,” he says in an interview. (Gates has exactly the kind of geekiness I expected, but is a lot funnier than I expected.)
He says the obvious market failure is that people who suffer from these 20-odd diseases do not have much money. “So there is a market signal which says ‘do research and development on their behalf and build products on their behalf’.
“Because our money is very finite, we have two models of impact. The first is where the foundation funds innovation because once you get a new tool, and you know it’s available, you make sure it’s low-cost and the impact is high.
“The other is for when we can go in to help a system that is low-functioning [to] work better, ideally without increasing the money that goes into it.
“So if you look at primary healthcare in Nigeria, they spend more money than Ethiopia, which is a lot poorer.
“But the outcomes in terms of maternal deaths, vaccine coverage and under-five mortality, particularly in the north, is quite a bit worse than, say, Ethiopia or Rwanda.”
One of the bracing things about Gates is the extraordinary depth of his knowledge. He occasionally diverts into interesting historical byways, like the origins of the drug artemisinin and the way malaria briefly returned to Portugal after Mozambique and Angola became independent and Portuguese citizens flooded back to the homeland.
He integrates the organisational culture of a modern tech company with healthcare systems — and this is not a common thing. Modern healthcare has been moving gradually in this direction, but it’s very obvious that he brings something different to the field.
The obsession with data collection, monitoring, supply chain management and the use of models are all predominantly tech culture tools.
Another characteristic is also a bit tech-culture: the sheer audacity of the goals.
There is a kind of rigour about Gates. He is often harsh about countries in a way you never hear from the hyperdiplomatic representatives of the international healthcare set. For example, he’s very explicit about making sure the foundation is not a permanent fixture. The interventions are just that.
“If you can go in, you know, over a six-year period and figure out what’s going on with personnel, with the supply chain, with training, with data ... if you can get it to function as well as, say, Rwanda, that’s a phenomenal thing,” says Gates.
“Once these systems function well, like in Senegal and Tanzania, which actually do quite well for their income level, it tends to stick because you get a culture going.
“But we never go into something saying, ‘hey, we are here for all time so people should count on us’.
“Change has to be about increasing the government capacity and making it stick.”
Malaria is an extraordinary disease in some ways, and the tools for attacking it are bizarre as they are both very simple and very complicated.
The simple process of supplying insect-repellent bed-nets has been an enormous help.
According to the WHO, up to 582-million bed nets have been supplied in the past two years but there is still a long way to go. The WHO estimates that only about half of the people at risk of malaria sleep under bed nets. Bed net costs have came down but in some cases cheap nets are becoming less effective.
Spraying houses in rural areas with insect repellent is another effective tool, but monitoring remains scatty. Spraying demonstrates the need for an effective basic healthcare system, which includes monitoring, which is increasingly done by tracking cellphones.
The complicated side is somewhat controversial.
The foundation’s leader in efforts to develop high-impact interventions, South Africanborn scientist Trevor Mundel, says researchers are pretty close to testing two different variations of laboratory-created mosquitoes that would limit the spread of malaria.
The mosquitoes created were through gene-substitution. One system would decrease the fertility of mosquitoes and the other would block the parasite that carries malaria within the mosquito.
The technology is controversial because of fears that ecosystems could be altered in unpredictable ways.
Mundel’s concern is a little different; with these systems you are fighting against evolution. It is up to the WHO to design ethics rules for this kind of intervention, which it is doing. But this hot potato is being assiduously tossed backwards and forwards.
Gates talks wryly about the “mosquito lobby”, which is, he suggests, irrationally supporting deadly insects over people. The concerns are obvious: people want to be sure the effects will be predictable and that is what is being tested.
Work is also going into immunisation and fast diagnostic tests.
Gates says it is now up to Central America, Southern Africa and Southeast Asia. The malaria incident rates in all three areas are comparatively small. “Those are the three areas where we’re going to get our eradication learning,” he says.
The issues are multiple: how to get villagers to take part in the programmes; how well the diagnostic tools work; how well the model for different mosquito species works, and more.
And the benefits are not just to citizens’ health. “There’s a huge benefit to those countries economically if they can say to tourists ‘come here’, for example,” he points out.
Gates says his foundation has modelled trying to get rid of malaria in Swaziland, but the movement of people through Mozambique is so high that it’s practically impossible to focus on one country alone.
Southern African countries will have take up the fight jointly, and SA will probably be called on to play an important role in what could be a joint effort with the Southern African Development Community and funding agencies, says Gates.
“It would be a great opportunity,” he says.
“And, at least, there is no malaria denial.”