[Ip-health] New York Times: Eradicate Malaria? Doubters Fuel Debate

[Thiru Balasubramaniam]

March 4, 2008
Eradicate Malaria? Doubters Fuel Debate
By DONALD G. McNEIL Jr.

Last year, challenging global health orthodoxy, Bill and Melinda Gates
called for the eradication of malaria.

That is, for exterminating the parasite everywhere and forever, except
perhaps in laboratory storage, as has thus far happened to just one
disease in history, smallpox.

Their call, delivered at a malaria conference that they had convened
in Seattle, was, in Mrs. Gates=92s language, =93audacious.=94 Her husband
went further, asking, =93Why would anyone want to follow a long line of
failures by becoming the umpteenth person to declare the goal of
eradicating malaria?=94

To many public health leaders, that remains a good question. While
some, including the heads of the Global Fund to Fight AIDS,
Tuberculosis and Malaria and the President=92s Malaria Initiative, have
lauded the Gateses=92 call as inspirational, others call it noble but
quixotic, because the tools to eradicate malaria do not yet exist. A
few, including the combative chief of malaria for the World Health
Organization, have even argued that it could do harm.

Dr. Margaret Chan, director general of the W.H.O., backed the call,
telling the audience from the dais in Seattle, =93I dare you to come
along with us.=94

Last month on his swing through Africa, President Bush implicitly
endorsed the idea without mentioning the Gateses, saying the United
States would lead the eradication effort.

The Bill & Melinda Gates Foundation has spent $1.2 billion to fight
malaria, which is thought to cause as many as 500 million infections a
year in 107 countries, a million of them fatal.

Virtually no experts expect it to be eradicated in the lifetimes of
the Gateses or the Bushes. Dr. Regina Rabinovich, the foundation=92s
head of infectious disease, said the Gateses knew it was a long-term
undertaking, not possible without more money, better health systems
and probably a vaccine, which is still far off.

Dr. Arata Kochi, the W.H.O. malaria chief, went further than other
skeptics, arguing that the specter of eradication is
counterproductive. With enough money, he said, current tools like
nets, medicines and DDT could drive down malaria cases 90 percent.

=93But eliminating the last 10 percent is a tremendous task and very
expensive,=94 Dr. Kochi said. =93Even places like South Africa should
think twice before taking this path.=94

False hopes, he said, lead governments to hope for miracles instead of
accepting the mundane budget-draining control policies that he
endorses. For example, health officials from Rwanda and Zanzibar,
having drastically cut malaria within their borders, have asked him
about seeking money for elimination.

Even relatively wealthy countries rarely succeed at that. South
Africa, Saudi Arabia and Mexico all control cases but see new ones
imported =97 from Mozambique, Yemen and Guatemala, respectively, he said.

Dr. Awash Teklehaimanot, director of the malaria program at the Earth
Institute of Columbia University, said he worried that calls for
eradication raised expectations too high, inviting frustration and a
loss of political will.

=93Maybe 10, 15 years from now, we should consider this,=94 he said.

This debate occurs more in the hallways of malaria conferences than in
public, because some scientists fear that a zeal for eradication is
now compulsory.

Dr. Rabinovich denied that, saying foundation decisions were not based
=93on whether or not people agree with public statements made by Bill
and Melinda.=94

Nonetheless, nervousness persists. One week after the Gates
announcement, the head of an organization financed by the foundation
joked in front of a small audience that eradication was =93the new
marching order.=94

=93Go along with it if you want to get funded,=94 he said, adding that it
was viable only if linked =93to a date like 2050, or far enough in the
future so that none of us can be held accountable.=94

Asked about that afterward, he asked that he not be quoted. In
subsequent forums, he stopped joking and repeatedly said eradication
was his organization=92s goal. The history of eradication, however,
favors the skeptics.

The International Task Force for Disease Eradication at the Carter
Center in Atlanta lists candidates for extinction. Malaria is not even
near the top.

The top two, polio and guinea worm, both cling stubbornly on. The last
push on polio, begun in 1988 with the funeral planned for 2000, has
consumed $5 billion.

In the early 1900s, another of the world=92s richest men, John D.
Rockefeller, tried to wipe out hookworm and yellow fever. In the
American South, he was victorious. Globally, he was not.

Malaria, a parasite that changes shape and hides in multiples organs
in mosquitoes and humans, is fiendish compared with polio, a short
virus that can be blocked in the gut.

And its death has been predicted before. In 1600, cinchona bark, the
source of quinine, was found in the New World. Struggles to monopolize
cinchona and sales of counterfeit bark, problems that bedevil drug
companies today, quickly emerged.

The best opportunity probably existed in 1955, the year Mr. Gates was
born and the year the W.H.O. said it would eradicate malaria. With
weapons then new, DDT and chloroquine, a fast-acting synthetic
quinine, annual deaths were driven down below 500,000.

But as an old bitter joke among parasitologists goes: =93We didn=92t wipe
out malaria. We wiped out malariologists.=94 It was working so well that
young scientists chose other fields.

Then, slowly, it fell apart. Chloroquine-resistant parasites and
pesticide-resistant mosquitoes emerged. Rachel Carson=92s 1962 book
=93Silent Spring=94 made DDT a pariah.

And the world changed. Before the 1960s, colonial governments and
companies fought malaria because their officials often lived in remote
outposts like Nigeria=92s hill stations and Vietnam=92s Marble Mountains.
Independence movements led to freedom, but also often to civil war,
poverty, corrupt government and the collapse of medical care.

The best-known example of defeat snatched from the jaws of victory is
Sri Lanka, which went from one million malaria cases in 1955 to a mere
18 in 1963. Spraying was cut back, and cases surged to 537,000 by
1969. By 2005, the country was again down to 1,640 cases.

The civil war=92s cease-fire of 2001 has broken down, and the disease
could surge again.

Sir Richard G. A. Feachem, former director of the Global Fund and now
head of the Global Health Group, a policy institute at the University
of California, San Francisco, founded with Gates Foundation money,
says malaria can be squeezed to death by moving control downward from
southern China, up from southern Africa and up across the South
Pacific. He hopes for elimination by 2050.

=93We=92ll use today=92s tools today,=94 he said, =93and tomorrow=92s tools
tomorrow.=94

By contrast, Clive J. Shiff, a malaria expert at the Johns Hopkins
Bloomberg School of Public Health who fought malaria in the 1950s in
what was then Rhodesia, says flatly that unless Africa can end both
its poverty and its civic strife, =93eradication is a pipe dream.=94

With smallpox or measles, he explained, a single childhood bout
usually confers lifetime immunity. Vaccines, made from weakened virus,
confer the same.

With malaria, however, children who survive multiple bouts receive
just a quasi-immunity. Adults become mildly ill.

Without repeated =93doses=94 from mosquitoes, that fades. If an adult
leaves for a few years and returns, a single bite can kill. So
creating a lifelong vaccine may be impossible.

Malaria is also a tempting political weapon. In southeastern Rhodesia,
Dr. Shiff said, local eradication failed because nearby South Africa
and Mozambique would not cooperate.

In Nyasaland, now Malawi, rebels against the white government ejected
or fought spraying teams. Nowadays, African tribal rivalries have
replaced black-white conflicts.

Most countries finally suppress malaria only when wealth arrives.
Their houses have windows, and their swamps are not just treated but
paved for malls. The disease could return even to the United States.
There are susceptible mosquitoes from Florida to Canada.

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Thiru Balasubramaniam
Geneva Representative
Knowledge Ecology International (KEI)
thiru@keionline.org


Tel: +41 22 791 6727
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