International Collaboration and Malaria as a Re-Emerging Disease

Martin Alilio

A Re-Emerging Disease

I've been asked to talk about two things. One is about malaria as a re-emerging disease, and the other is about international collaboration in research on malaria control. My job has been made very easy by the previous speakers, who have provided some excellent background on what I was supposed to be doing.

Talking about malaria as a re-emerging disease is difficult. There is a paradox. On the one hand you have a hundred years of research on malaria, and malaria is actually one of the diseases that has been heavily researched, at least if you look at the amount of research that has gone into malaria cumulatively since the life cycle of the parasite was first identified. At the same time, after 102 years we are still talking about malaria as a re-emerging disease. This is what the paradox is. On the one hand we have an enormous amount of research that has already been done and on the other hand we have a disease that is growing. That is the challenge of malaria.

A lot of issues I was supposed to be talking about have already been covered, so I will just use this opportunity to summarize what has been said so far.

This graph shows the pattern of malaria over the last hundred years, and you can see that at times we are almost winning the battle. But further down the line, something started changing, and there was quite a lot of increase in malaria. Why should it be, when at one time we were almost winning the battle, that now we are losing, or at least we are still talking about malaria?

One key issue is that if we look at the disease globally, most areas are not suffering from malaria. In Africa, unfortunately, malaria is on the increase. One of the paradoxes is that in the past Africa had less malaria, or at least less was known about malaria in Africa, but now it is on top of the world in terms of deaths from malaria and prevalence of malaria. Maybe one of the issues that is not often discussed when one is talking about malaria resurgence is that a lot of effort goes into researching death from malaria. Or at least we look at the death as an outcome, so we quantify how many deaths happen as a result of malaria and we use that as an indicator of the problem of malaria. Maybe what is only now emerging is looking at other complications that come as a result of malaria, and maybe developing a mechanism to try to quantify this. So basically what we know about malaria is more about death and maybe prevalence or issues related to morbidity, and we know very little about other consequences of malaria, say for instance as a chronic disease, and how it impairs growth and development. Again, if we take into account all of this, certainly the burden of malaria is going to be much larger, and this is where perhaps when we talk about malaria as a re-emerging disease we have to focus our attention.

Malaria is a function of a large number of things. There is biology, the biology of transmission and infection and control. There are environmental issues. And there is the issue of policy, which is important because as we have seen there was malaria in the United States, but with a concentrated effort it was possible to do something about it and basically eradicate the disease. If you look at the biology of transmission, there are many issues related to parasites and vectors. Another issue is a very drastic increase in drug resistance and insecticide resistance. In terms of environmental factors, there was a study done in Tanzania, where I come from, where it showed that in one area where there were many cattle, the mosquitoes would feed on both man and cattle. When the drought came, the cattle moved out, and the mosquitoes began to feed much more on the people, and you can see that there was an epidemic that resulted at that time. There is also the issue of mosquitoes changing their range. There are areas where we know mosquitoes cannot breed, because of the climate or elevation. We know also from history that mosquitoes tend to change and adapt to new climates. It is not frequent but it does happen. The issue everyone is concerned about is drug resistance. If you look at the literature, it is clear that a large part of the malaria problem can be attributable to the increase in drug resistance.

A subsequent issue, and this is an area where we are starting to put our attention, is environmental change and global warming. Global warming is mentioned quite a bit as a reason for environmental change. The increase in malaria may be partly related to the change in climate. But beyond that, and earlier we had a question about what is the relation between borders and malaria, people moving from areas that are malaria-safe into areas that are full of malaria represents an issue that is potential dynamite in terms of increasing malaria. The refugees from Rwanda and Burundi, for example, led to a worse malaria epidemic in Tanzania.

This slide is an illustration of a combination of factors in malaria emergencies. It comes from Mendes in Sri Lanka. What is really interesting is that in the late 1960s they had a very effective use of DDT, some really very effective spraying of DDT and they almost eliminated malaria in Sri Lanka. But then they stopped spraying DDT for some reason, and what you see is a drastic resurgence of malaria there now almost to epidemic levels. And as if that were not enough there was also civil unrest breaking out at that time contributing to the resurgence, so this is an example of having several factors interplaying to contribute to the problem. Again there is the paradox where there is a good amount of scientific knowledge and potential for success but also a rising problem with malaria.

Beyond that is another issue that we don't have enough research on and which may be interesting to study, is the consequences of the economic problems. As Bob mentioned earlier, malaria and poverty are kind of one and the same. And when you have some of the countries going into economic crisis, we don't have data showing what are the linkages, but we know at least that Structural Adjustment Programs in some of these countries, which were one way of dealing with the crisis, cut the investment in the social sector. And the social sector goes with health. And that means quite a drastic cut in public money available to control malaria, in terms of vector control but also in terms of drugs and health services. And what you see beyond that is also a drastic deterioration in facilities, and as a result there is a great increase in the malaria problem.

So there are also issues related to politics, and DDT is one example where a huge controversy emerged in the past about how safe it is, and we almost abandoned using it. Now at least they are re-evaluating and saying it is not that unsafe, so people can go back to using it. But what that does is really sort of allow malaria to gain ground in areas where otherwise they should have wiped it out.

Again, malaria is not just a problem of Africa. In Eastern Europe, what you see is that malaria is actually back in a large way. These are data from CDC showing a lot of malaria cases in areas thought to be malaria-free. So although we may see malaria as a distant problem, it may not stay that way for long, especially if we are not responsible in dealing with it in the long term.

International Collaboration

Now I'll talk about an area that is really interesting and where there is some more optimism, and that is the area of international collaboration. In spite of all the negatives that we see, if you look at the level of international cooperation, malaria is an example of an area where people are really making a serious attempt to collaborate in research, and perhaps even in terms of bringing money to bear on the problem.

International collaboration in general tends to aim at a certain number of issues, sometimes in combination and sometimes alone. One, for instance, especially in the US, is introducing leading scientists, very good scientists from the West, and getting them interested in the diseases of developing countries, which otherwise they wouldn't pay attention to because there hasn't been a lot of interest.

A subsequent issue, which is also exciting, is the growing recognition that malaria is not just an issue for biologists to solve, but in fact it is more than that. It requires somebody to translate the biological results into the field, and that will require very drastic new types of skills, or at least linking research and clinical issues and rapid application of whatever is available into the field. So there are a number of areas where international collaboration has been taking place.

Within this context of giving the issue a global perspective, there are regional issues that require regional collaboration and local issues that require local solutions and perhaps require local collaboration. What we are talking about therefore is whatever the collaboration, you have to match the level and the resources and the needs, and you can have local issues that fit in at the global level, or regional issues that can be dealt with at the local level, and decisions must be made there.

If you look at the programs you see around the world today, you see that there are a lot of efforts involved with translating malaria research results and making malaria research results known to the people who can use them effectively. There are programs of regional collaborations that deal with the organization of clinical trials and this is where big research institutions like NIH, with enormous amounts of resources, have been very welcome.

An issue we don't talk too much about is community participation. And if we're going to be a little bit critical, this seems to be an area where there is limited interest, because it's not mainstream science but it's extremely crucial for developing countries. When malaria is happening in the village the people want to know something to do now, and it's not about what has been discovered somewhere else, it's about an action they can take today. This is where you see communities where drugs are becoming an issue, the problem of drug resistance and the problem of overdosing on these drugs. This is a defect really in training in many cases, and this is an area where a substantial amount of investment is needed. Development and deployment of a vaccine, regional cooperation, development of drugs, maternal and child health, engagement of local governments, these are the kinds of key areas you see a lot of programs built around. But community participation will also be crucial.

If you look at the overall level of funding for malaria, it is not great, and this is the unfortunate part. Generally, looking at the 1990s, the annual level of funding for malaria is very poor compared to other diseases. As a result of a lot of advocacy, this might actually be improving. In recent years NIH has really improved its level of funding.

A subsequent issue in international collaboration is really that you have so many programs and these programs don't necessary work together. And there is very stiff competition for funding, so you have a problem of secrecy and a lack of transparency. There is also because of the competition a problem with communication, and actually not just funding but in general the problem of communication is an issue. And because of that, you also have problems with duplication of efforts. You kind of miss an important interface and complementarity between different programs. And this is an issue that we as international collaborators have to address, how can we overcome these barriers so as to make alliances and work well together.

The Multilateral Initiative on Malaria

I'll just finish my talk by telling you about the Multilateral Initiative on Malaria, which is one such model of trying to network the alliances that exist. Basically MIM is a kind of global collaboration to increase research capacity but also focuses on maximizing the impact of the results that are available in malaria. So far MIM has essentially focused on Africa where malaria is worst, and has focused on bridging the gap between research and control efforts. In terms of objectives, there are many, and maybe it's enough here to say that the overall goal is to promote international collaboration, and not just North-South collaboration but also South-South collaboration, which is also a big problem. You find all sorts of projects between African countries and Europe or the United States, but very little cooperation between Mali for example and Ghana, which might even make more sense. There is a question of supporting research as a sustainable activity and ensuring that the findings can be made available so they can have the desired effect. In terms of rationale, the reason why MIM came about some four years ago, was based on advocacy. Somebody needed to wave the flag about the problem of malaria to raise the level of investment in the problem. I won't recount the whole MIM history, but in terms of initial partners, there was some generous support from some governments initially, from research institutions in Africa, from donors like NIH and foundations, and there was a lot of interest when it first started. There still is a lot of interest.

The long-term vision or dream for MIM is some kind of joint resource mobilization. This is seen as a way in which you can address the problem of duplication, or people doing research without knowing what else in the world is going on. MIM also makes a significant contribution in building capacity. In terms of results, what has been achieved in the last five years, there are 23 projects going on in different countries dealing with all kinds of issues. You can say it is very modest in terms of the level of need but at least it is going in the right direction. MIM has also been active in advocacy for malaria and has done a lot of work in terms of organizing conferences and making information available through its website. And beyond that, with support from the National Library of Medicine, MIM has been very helpful in setting up email capability and related technology at African research centers and making sure they are all linked with email communications. I want to underscore that communication is really a major problem in Africa in general.

One of the other big things is the development of the Malaria Research Center, which is an attempt to standardize the reagents that are used in malaria research. This is in a way an attempt to ensure quality of results, and also an attempt to do an inventory of what there is and what is needed. Wellcome Trust also did an interesting study of what capacity there is in Africa and what is needed.

In terms of the future, MIM hopes to improve further the communications and collaborations between various research centers in the South, and develop more training and research capacity at these centers. It is really getting these institutions that work on malaria to talk together, people doing different things, so at least they can understand what each other are doing and how different activities can complement each other.

Thank you.

Dr. Martin Alilio is presently a program officer at the Multilateral Initiative on Malaria, based at the Fogarty International Center. He also remains Head of Department of Health Systems and Policy Research at the National Institute for Medical Research in Dar es Salaam, Tanzania.

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