The Long-Term Bet on Innovation for Malaria

[This article has been written by Matiana González-Silva and Regina Rabinovich, Coordinator and Director, respectively, of the Malaria Elimination Initiative at ISGlobal]

The recently announced conclusions of the Strategic Advisory Group on Malaria Eradication (SAGme) led by the World Health Organization (WHO) is that, in view of current projections of environmental, economic and political factors, malaria eradication remains a long-term goal in the global agenda. The report points to the gap in resources, and the need for innovation, new strategies and sustained commitment to tackle the areas with highest disease burden.

Translating innovation into everyday practice is a key element to accelerate progress towards malaria eradication

Innovation has proved central to historical advances in global health over the past 150 years. Beyond the fundamental understanding of the germ theory of infectious diseases, advances that are today taken for granted – including antibiotics, anaesthesia or oral rehydration therapy – are the result of good science: a complex system that includes not only researchers and their institutions, but also funders, regulatory bodies, policy makers and a society that invests in scientific research and welcomes innovation.

Science led to the heat-stable smallpox vaccine and the bifurcated needle used to deliver it, which allowed smallpox to become the first and only human disease eradicated from the planet. The currently available tools against malaria –bednets treated with insecticide, indoor residual spraying, rapid diagnostic tests, drugs containing artemisinin, and the malaria vaccine that is being piloted in ‘real life’ conditions in Africa- are also the result of the rigorous generation of scientific evidence and the concurrence of actors ranging from research institutions to Ministries of Health, international organisations, civil society, the private sector and affected populations.

However, history warns against the dangers of underestimating the role of science in global health. The Global Malaria Eradication Programme (1955 to 1969) led by the World Health Organization relied too much on the effectiveness of spraying with the then new insecticide DDT, and chloroquine treatment, to the point that malaria research virtually stopped and new malariologists were no longer trained. When the mosquito developed resistance to DDT, the pipeline for innovative tools was empty, human resources were lacking, and malaria resurged.

History warns against the dangers of underestimating the role of science in global health

Other experiences show the importance of science in guiding public health interventions and international campaigns. The Global Polio Eradication Initiative (GPEI) has used scientific evidence to change its immunisation strategies throughout its long lifespan, while developing and implementing novel tools such as genetic epidemiology. A key lesson from the polio experience is the need to link scientific priorities with the actual challenges in the field. Scientists were key, of course, in developing the vaccines used to prevent polio, but also in understanding why the programme was failing in certain areas, solving operational gaps, developing targeted surveillance techniques, identifying transmission pathways or performing modelling to support decision-making.

Given the adaptive capacity of malaria parasites and vectors, it is clear that we will not eradicate malaria without the analytical and innovative capacities of the scientific community. The opportunities range from developing novel tools to prevent, treat, and diagnose the disease; inventing new ways of using the tools we already have, and finding how to effectively reach the most at-risk and often distant populations.

Given the adaptive capacity of malaria parasites and vectors, it is clear that we will not eradicate malaria without the analytical and innovative capacities of the scientific community

For laboratory-based scientists, epidemiologists, anthropologists, economists and physicians, the challenge is to work with those on the frontline to identify the problems, create new solutions, and keep a vibrant innovation and development community actively funded and engaged. There are encouraging products in development: repurposing drugs from other diseases to kill malaria vectors (endectocides), identification of new drug targets across different malaria species and different stages of their life cycle, and the potential use of monoclonal antibodies for disease prevention, among others. None of these were in development a decade ago.

The SAGme report, together with the 2018 World Malaria Report describing the stall in malaria funding and impact, is a clarion call for action towards tackling malaria in the highest burden areas, elimination in very low endemic countries and the long-term goal of eradication. Achieving this will require both hearts and minds: as a community we have to prioritise, invest, and depend on national leadership to get the job done.

The biggest driver for action is perhaps not a date, but the overwhelming number of children that keep dying from a preventable and treatable disease

SAGme concludes that, with the available technical, human and financial resources, it is not feasible to set a target date to achieve malaria eradication, whereas the Lancet Commission on Malaria presses for setting a timed goal to ensure engagement and prioritisation. The tactics vary, but the long-term aspiration, after much work and reflection by two groups with different mandates, is aligned. The biggest driver for action is perhaps not a date, but the overwhelming number of cases and children that keep dying from a preventable and treatable disease. Let’s take up the innovation challenge with the urgency and commitment required to get the job done.