Last week, everyone who's anyone in global health was in New York City for a series of meetings capped by the United Nations General Assembly. Among the crowds, one gathering stood out. Bono, the activist rock star, was on hand to "set the tone," and Jeffrey Sachs, the Columbia professor and key thinker in efforts to fight poverty, lent his support. The occasion was the unveiling of the most ambitious program in half a century to fight malaria, a disease that kills a million people each year. The Global Malaria Action Plan (GMAP) sets out in detail what health officials hope to achieve over not just the next five or 10 years, but the next 50.
The cooperative mood of the meeting was in marked contrast to a smaller, and sometimes more combative, gathering almost a year ago in Seattle, where the Bill & Melinda Gates Foundation had brought together almost every major malaria researcher and health official in the world in one room for the first time. At the heart of most of the debates was one major question: whether to think big and try to eradicate the disease, à la smallpox, or to settle for what seemed to be the more realistic option of controlling it. On the second day of the gathering, Melinda Gates settled the question for good. The world, she said, now faced "a historic opportunity, not just to treat malaria or control malaria"—the participants shifted in their seats—"but to chart a long-term course for eradicating malaria." One delegate, a philanthropist at a major corporation, said the Gateses had "changed the game" with one word: Where they went, he said, the world would go.
After decades of neglect, African and Western nations are now attacking malaria with a fervor that borders on obsession. The West has boosted funding from $50 million in 2000 to $1.1 billion this year, and it is starting to get results. In Ethiopia, a country once racked by the disease, case reports have fallen to 1.2 million, the lowest number since 2001, down from as many as 9 million in previous typical years. The country is now held up as one of several models for worldwide progress. The goal—to wipe malaria off the rest of the map—is audacious in scope, for the simple reason that malaria is one of the most stubborn of diseases. But the men and women pursuing this goal are some of the world's most powerful; they include British Prime Minister Gordon Brown, News Corp. honcho Peter Chernin and Gates, who has called efforts to combat malaria "the most repeated failure in all of global health." He does not intend to fail this time.
If the new efforts are successful, they will save millions of lives and help lift an entire continent out of poverty. Moreover, they will open the door for future fights against many other diseases such as HIV, TB and pneumonia. "It's a little like putting the first mammal into orbit," says Scott Case, vice chairman and CEO of the nonprofit Malaria No More. "Once you see that it can be done, it opens up a whole new set of possibilities."
But success is not guaranteed. Eradication is probably the greatest challenge in all of public health; it requires that commitment remain high even as infection rates drop and other causes start to look more compelling. Vaccine development will also be daunting; there is very little precedent for immunization against anything as tricky as the malaria parasite. And then there is the sheer difficulty of collecting enough money to pay for what needs to be done. Last week, as part of the GMAP rollout, world leaders committed $3 billion to malaria prevention—but also announced that to fully implement their plan, they'd actually need $5.3 billion for 2009, followed by $6.2 billion for 2010, plus another $900 million or so each year for scientific research. Eradication may turn out to be a luxury we can't afford.
This won't be the first time the world has gone after malaria. After World War II, widespread spraying of the pesticide DDT killed the parasite-bearing mosquitoes in many developed nations. In 1963, at least one developing nation had come close to becoming malaria-free: Sri Lanka, home to a million cases annually in 1955, was down to a measly 18. The world rejoiced—and then abruptly gave up.
The public-health community reversed course on malaria partly because of a reluctance to continue using DDT. But the effort also failed precisely because it came so close to succeeding. Policymakers decided they were finished before they actually were. "They wanted to use their resources on something else that had more cases," says Kimberly Thompson, a risk analyst at Harvard University who has worked on other eradication campaigns. As spraying stopped, malaria staged a comeback. By 1969, Sri Lanka's 18 cases had rocketed back to half a million a year. Disheartened, public-health workers turned away. "One of the selling points had been that this was going to be a relatively time-limited effort," says David Brandling-Bennett, a senior program officer in infectious diseases at the Gates Foundation. "The only thing the effort really succeeded in doing was eradicating malariologists."
As the research community fell into disarray, the malaria parasite gained new ground. A notorious shape-shifter, the parasite is a complex organism with 5,000 genes and a multistage life cycle—perfectly designed to find a human host, infiltrate it and evade any weapons, natural or pharmaceutical, used against it. It enters its victims when mosquitoes bite at night; it slips into the bloodstream and cloaks itself in proteins that the immune system does not recognize. Thus disguised, it makes its way to the liver, where it reproduces rapidly below the radar. By the time the immune system mounts a response, it's often too late.
Drugs may be ineffective because malaria, like many of the world's most dangerous diseases, is highly mutable. Some of its many strains may survive treatment, then spread as hapless doctors watch their drugs become useless in the population at large. That happened in the 1980s, when the malaria parasite developed resistance to chloroquine, the drug most commonly used against it. At the same time, HIV began to ravage Africa, providing newly weakened victims for malaria while drawing away public-health resources. Westerners were largely unaware: by 2000, most thought the disease, which killed 1.1 million people that year—90 percent in Africa—"just wasn't a problem," says Regina Rabinovich, director of infectious diseases at the Gates Foundation.
Change, however, was coming. In 2002, a major new source of financing appeared: the Global Fund to Fight AIDS, Tuberculosis and Malaria, which is now the largest malaria funder in the world. There were technological breakthroughs as well. The most common type of bed net at the time had to be dipped in pesticides every three months to stay effective. In real life, it was largely useless. In the early 2000s, though, scientists developed new nets with long-lasting pesticides woven into the fibers that remain potent up to five years. A new drug also gained prominence in the early 2000s: Coartem, based on a Chinese herb called artemisinin. It was expensive and inconvenient, requiring multiple doses. But unlike chloroquine, it worked. Suddenly, one of the major reasons for inaction was gone: now there were weapons. "In the past, we could say, 'We don't have the nets, we don't have the science, we don't have the technology'," says Prime Minister Brown. "Now, gradually, we were developing the science and the technology, so there was no excuse."
Malaria began to attract high-profile business leaders eager to do good. Raymond Chambers, the reclusive billionaire, had been talking to Sachs. "Jeff showed me photos of little children sleeping in a room, and I commented on how cute they were," says Chambers. "He said, 'You don't understand. They're all in malaria comas. They all subsequently died'." He began to think of malaria as "genocide by apathy" and threw himself into the cause. Meanwhile, Chernin, the COO of News Corp., had become co-chair of Malaria No More, and he leveraged his professional resources: in 2007, he got the producers of a charity "American Idol" episode to feature the disease. Celebrities started visiting Africa on missions. By the 2007 meeting in Seattle, malaria prevention had major momentum. The world's second effort to stamp out the disease was fully underway.
Today, Ethiopia is not the only success story. Many other countries have designed their own plans and used donor money to pay for them. Eritrea, São Tomé and Principe, and Zanzibar have all cut malaria deaths by 50 percent or more since 2000. A tenfold increase in bed nets in Kenya has yielded a 44 percent reduction in child mortality. Even Rwanda, with its grim recent history, says it has reduced deaths from malaria by two thirds. President Paul Kagame says the key has been checking up on local leaders: "The mayors, the counselors, they all have signed performance contracts. They go to homes and follow up to be sure that mosquito nets have actually been used."
Still, not all the news out of Africa is good. Coverage levels (the measure of how many people are benefiting from bed nets and pesticide spraying) in many countries hover around 10 percent. In two nations—the Democratic Republic of Congo and Nigeria—the situation is especially dire. Neither country has much of a health budget. Congo is currently sending bed nets out by trucks, bicycles and canoes, but even so it is vulnerable. And since, as the saying goes, "mosquitoes don't respect borders," the whole continent could still backslide.
To succeed in the long term, scientists eventually will have to develop new drugs and a vaccine. Drug research is already showing some potential. One intriguing candidate mimics the action of Coartem, but unlike that drug, it can be given in a single dose and thus would be much more practical for use in developing countries. Unfortunately, malaria will ultimately evolve around whatever new drug is used against it—so widespread use of any medicine can work for only so long. Without a vaccine, we will be condemned to a never-ending cycle of outbreaks.
There is some reason to hope that a malaria vaccine could be developed. "We know there is potential to create an immune response [against malaria], because our bodies do it if assaulted by this disease repeatedly in childhood," says Sachs. How our bodies build that immunity, however, is still a mystery. There has never been a vaccine for any parasitic disease, let alone one as complex as malaria. Today, more than 30 serious candidates are in development. One, from GlaxoSmithKline, may progress to large human trials in Africa within the next few months. Even so, Gates himself—probably the world's biggest proponent of vaccination—says no vaccine is likely to be available for at least two more decades. By then, who knows what the fight against malaria will look like?
The idea of outlining the 50-year Global Malaria Action Plan is to harden people's resolve for the battle ahead. The report advocates "front-loading" money, or spending a lot in the first few years, a strategy that proved successful in Ethiopia. It addresses all the nations where malaria is a serious threat, but reserves a special focus for Nigeria, Congo, Ethiopia, Uganda and Tanzania, which account for half of malaria deaths worldwide.
Even if $11.5 billion somehow comes through, even if it's all well used, even if malaria deaths drop by 95 percent in the next 20 years, there is yet another possible pitfall: that success will once again breed failure.
The responsibility for eradicating malaria, then, will rest not just on the shoulders of the researchers and the public-health workers. It will be on everyone: the donors who may turn to other causes, the villagers who receive nets but don't or can't use them properly, the Westerners who could so easily again forget about the disease and assume it's "just not a problem." If the world is to succeed in wiping out malaria this time around, all parties will have to stay in the fight. The malaria parasite certainly will.