The US eradicated malaria in 1951. Until then, this parasitic disease, transmitted largely by infected mosquitoes, had been endemic across much of the country. In the Tennessee River Valley, for example, malaria affected almost a third of the population in 1933. By the time the US National Malaria Eradication Program was launched on July 1, 1947, malaria had become concentrated in thirteen southeastern states. The program was led by the newly created federal Communicable Disease Center (now the Centers for Disease Control and Prevention, or CDC) based in Atlanta.
Justin M. Andrews, the CDC’s director at the time, was also Georgia’s chief malariologist. The CDC had itself evolved from the Office of Malaria Control in War Areas, which had been created to defeat malaria in the United States during World War II. Perhaps surprisingly to a modern audience that thinks of it as a disease of poor countries, the histories of American health and malaria are tightly bound. As the historian Margaret Humphreys has revealed, malaria “shaped southern and western [American] history in particular through its impact on labor patterns, mortality rates, and settlement choices.”1
It is easy to forget today how dangerous malaria continues to be. Ninety-nine countries (40 percent of the world’s population, or about three billion people) live under the threat of malaria. The World Health Organization (WHO) reported 225 million cases worldwide in 2008, with 781,000 deaths. These figures are almost certainly underestimates. Most deaths—85 percent—are in children under five years of age.
For a disease that exacts such an enormous toll of human death and misery, it remains shocking that so little has been done by affected countries and large international donors to control malaria. This long epoch of neglect is gradually coming to an end. As Bill Shore explains in his survey of “baffling and surprising” strategies to eradicate the world’s most devastating parasite, “a small number of heroic idealists” are beginning to reverse decades of failure. They have recognized that traditional approaches to malaria control “always fall short.” Instead, defeating malaria requires “moral vision and imagination,” “a deeply intrinsic drive to achieve what others have dismissed as unachievable,” “a willingness to take risks,” and “irrational self-confidence.”
But Shore also shows an aspect of the organizations concerned with malaria that is less heroic, less moral, and certainly not at all idealistic. He exposes how a spirited culture of creativity, confidence, and competition in malaria research too often expresses itself as hyperbole, hubris, and personal enmity. There are frequent examples of scientists who confidently ridicule the work of fellow scientists: “Rival researchers are polite but mostly dismissive of one another,” Shore notes. As he concludes, “In each branch of the malaria war, there are many who believe their own approach embodies the best mix of compassion, realism, and effectiveness, and therefore occupies the moral high ground.” This extreme rivalry fosters islands of scientific inquiry separated by seas of bitter disagreement. Such a fetid environment is weakening the international effort to defeat malaria. This is the hidden story behind the “unreasonable men” Shore so admires.
When Melinda Gates stood up at the Gates Foundation’s Malaria Forum on October 17, 2007, no one expected her to use a word—“eradicate”—that more experienced malaria experts had feared for almost forty years. She said of malaria that there was
an historic opportunity not just to treat malaria or to control it—but to chart a long-term course to eradicate it…. To aspire to anything less is just far too timid a goal for the age we’re in. It’s a waste of the world’s talent and intelligence, and it’s wrong and unfair to the people who are suffering from this disease.
The WHO’s director-general, Margaret Chan, immediately backed this call to action.2 But others saw Melinda Gates’s words as inflammatory. Ann Veneman, UNICEF’s executive director, demurred, furious that Gates had failed to consult UN agencies before claiming moral leadership in eradicating one of the world’s most politically sensitive diseases.3
Shore is sympathetic to those who see Gates’s intervention as valuable additional pressure to mobilize more resources for malaria. “Not believing that malaria could actually be eradicated was a failure of imagination that distorted and undermined the way the malaria community went about its work,” he writes. Shore seems to view the Gates approach as little short of transformational. It is, he writes, spearheading a new attitude toward disease at “the intersection where science, philanthropy, and entrepreneurship are converging.” The Gates Foundation is “the catalyst for investing in global health…the modern day NASA of the global health field.” Many scientists who work in global health today—from those investigating new drugs for tuberculosis to those searching for an AIDS vaccine—would agree. Bill Gates has made the diseases of poverty fashionable.
But there is another view about the influence that modern philanthrocapitalists, such as Bill and Melinda Gates, have had on the fields they choose for their attention. The medical researcher David McCoy and his colleagues have argued that much of the Gates money is not invested where the foundation claims to show its greatest concern—in low-income settings, such as sub-Saharan Africa.4 Instead, over 80 percent of the cash that does not go to supranational organizations (the WHO, the Global Alliance on Vaccines and Immunisation, the Global Fund to fight AIDS, Tuberculosis, and Malaria, and the World Bank) goes mostly to organizations in the US. Worse, the patterns of Gates funding do not match the burden of diseases endured by those in deepest poverty. As a result, worthwhile programs—in child health, for example—suffer.5 The Gates billions, these critics argue, divert political priorities away from the needs of the poor.
Shore would say that these criticisms miss the point: “It is the character of the people doing the work that is the key.” The status quo of traditional programs led by well-intentioned but ultimately failing institutions should be swept aside. Instead, we need people who can fill “the imagination gap…[a] vitally important space between the impractical and the impossible.”
What Shore emphasizes is that the central problem in attacking malaria is the lack of a market mechanism to deliver technical solutions—a vaccine, for example, or efficient ways to produce and distribute effective medicines. The economic and political incentives to defeat it are simply absent. For Shore, what is right about the Gates approach is their use of “market mechanisms to accomplish social objectives.” If innovators in treating malaria can expect higher rewards for doing so, the results, in his view, will inevitably be better. And to be fair, Shore is just as critical of modern business as he is of governments and international agencies. “Imagination,” he observes, “cannot be bought and installed like the latest software, or taught in an MBA program.” That is why people like Bill Gates matter. Their “leaps of imagination are not so much about new ideas as about a new conviction of what is possible.”
The exemplar of the Gates approach, so strongly endorsed by Shore, is the medical researcher Stephen Hoffman. He is trying to create a vaccine against malaria and has been supported with almost $30 million of Gates investment to do so. Shore’s chief unreasonable man is Hoffman: he is “the classic entrepreneur,” someone who is “impatient with conventional wisdom,” a “counterculture rebel.” Shore tells Hoffman’s story as “our best modern example of how imagination…can lead to breakthroughs.”
Hoffman’s approach to creating a malaria vaccine is highly original. He is trying to devise one based on a weakened version of the entire malaria parasite. It is a live vaccine, similar to those that have been so successful against measles, smallpox, and polio. Announcing the first human trial of Hoffman’s whole-parasite malaria vaccine in 2009, the Gates-funded Malaria Vaccine Initiative described Hoffman’s study as a “watershed event,” one that “highlights the strength of public-private collaboration in tackling international health challenges.”
Shore portrays the quest for a malaria vaccine as a war between two competing philosophies—the market-based, entrepreneurial approach versus more traditional methods of vaccine discovery. Shore’s preference is “to find or create markets to enable nonprofit goods and services to get to scale and sustain themselves…. This means creating commercial markets.” He also sees it as a competition between individuals. Hoffman is the outsider, forced to create his own laboratory—Sanaria, Inc.—to overcome the wall of skepticism he faced from less audacious colleagues.
By contrast, the American vaccine scientist Pedro Alonso “does not talk much about market mechanisms.” Yet he is the more acceptable “public face of malaria vaccine development,” based in one of those old-fashioned institutions—the University of Barcelona—that represent the “incremental progress [that] has led to a frustrating plateau” in malaria research. On Shore’s visit to Alonso’s offices, he reports a place that “looked like that of many mission-driven non-profits, with walls sporting maps of Africa and photos of children at medical clinics in small villages.” Although the Gates Foundation, together with GlaxoSmithKline, has supported Alonso’s work, Alonso rejects Shore’s (and Gates’s) emphasis on a competitive social-marketing approach. Instead, he says, finding a vaccine “is something we simply must do,” irrespective of commercial gain. For him the answer to the question of which philosophy is right will not be found in abstract arguments about the efficiency of the private sector or the altruism of universities. What counts are the results.
In 2008, Alonso and his colleagues reported that their vaccine, which targets a protein on the malaria parasite, halved the number of malaria episodes among children of five to seventeen months of age.6 A larger trial to confirm this result is currently underway. Most malaria experts believe that the efficacy of Alonso’s vaccine will be confirmed, in which case it should be available within the next three to four years. By contrast, when the results of Hoffman’s much-applauded vaccine trial were reported in September, the vaccine failed. Only five out of eighty volunteers were protected. As one report noted, “the numbers were so bad that Dr. Stephen Hoffman did not even want to say them out loud.”7
Is Melinda Gates’s call for eradication the only way to defeat malaria? There are other approaches that deserve consideration. The first is elimination. Eradication is the permanent reduction to zero of the worldwide incidence of malaria—the parasite will disappear from the planet. Elimination is the interruption of malaria transmission so that in a given geographic area there will be no locally contracted cases. The disease can be eliminated but only by a determined application of such measures as draining mosquito swamps, distributing bed nets and insecticides, and providing antimalarial drugs, all within a working system of public health and medical care. Elimination does not erase the threat of malaria completely. It can be reintroduced either by humans infected with the parasite or by infected mosquitoes.
In new work recently reported by the Malaria Elimination Group (and partly funded by the Gates Foundation), Richard Feachem and his colleagues showed how optimistic one might be if the goal is more modest than the one set by Melinda Gates in 2007.8 Of the ninety-nine nations that suffer from endemic malaria, thirty-two have adopted the goal of elimination. Most are not in zones where malaria causes the majority of deaths. Instead, they are countries where malaria is already under reasonable control. The question for any government when faced with this situation—good, but not complete, control—is what to do next. Should a government keep investing in intensive control efforts or should it switch to a different strategy—elimination? The benefits of turning to elimination instead of control are clear. If elimination is the objective, unprecedented political commitment will likely be mobilized against malaria. This political support is essential if investments are to be focused on malaria rather than on other diseases. The spur to such a commitment should be the awareness that defeating malaria will deliver economic benefits—a more physically fit working population.
1 See Margaret Humphreys, Malaria: Poverty, Race, and Public Health in the United States (Johns Hopkins University Press, 2001), p. 1. ↩
2 See Leslie Roberts and Martin Enserink, "Did They Really Say...Eradication?," Science, December 7, 2007. ↩
3 Ending the advance of malaria is one of the Millennium Development Goals, a set of eight commitments made by world leaders in 2000 and intended to be achieved by 2015. The goal for malaria is to halt and begin to reverse the incidence of the disease. ↩
4 See David McCoy et al., "The Bill and Melinda Gates Foundation's Grant-Making Programme for Global Health," The Lancet, May 9, 2009. ↩
5 See Robert E. Black et al., "Accelerating the Health Impact of the Gates Foundation," The Lancet, May 9, 2009. ↩
6 See Philip Bejon et al., "Efficacy of RTS, S/AS01E Vaccine Against Malaria in Children 5 to 17 Months of Age," The New England Journal of Medicine, December 11, 2008. ↩
7 See Maggie Fox, "Sanaria's Malaria Vaccine Disappoints," Reuters, September 29, 2010. There is also a new generation of malaria vaccines under development. These vaccines offer the promise of greater protection against infection. ↩
8 See Richard Feachem et al., "Shrinking the Malaria Map: Progress and Prospects," The Lancet, November 6, 2010. ↩
See Margaret Humphreys, Malaria: Poverty, Race, and Public Health in the United States (Johns Hopkins University Press, 2001), p. 1. ↩
See Leslie Roberts and Martin Enserink, “Did They Really Say…Eradication?,” Science, December 7, 2007. ↩
Ending the advance of malaria is one of the Millennium Development Goals, a set of eight commitments made by world leaders in 2000 and intended to be achieved by 2015. The goal for malaria is to halt and begin to reverse the incidence of the disease. ↩
See David McCoy et al., “The Bill and Melinda Gates Foundation’s Grant-Making Programme for Global Health,” The Lancet, May 9, 2009. ↩
See Robert E. Black et al., “Accelerating the Health Impact of the Gates Foundation,” The Lancet, May 9, 2009. ↩
See Philip Bejon et al., “Efficacy of RTS, S/AS01E Vaccine Against Malaria in Children 5 to 17 Months of Age,” The New England Journal of Medicine, December 11, 2008. ↩
See Maggie Fox, “Sanaria’s Malaria Vaccine Disappoints,” Reuters, September 29, 2010. There is also a new generation of malaria vaccines under development. These vaccines offer the promise of greater protection against infection. ↩
See Richard Feachem et al., “Shrinking the Malaria Map: Progress and Prospects,” The Lancet, November 6, 2010. ↩