Q: I wanted to ask about the sterile insect technique. The International Atomic Energy Agency had some good success with this technique, for instance with fruitflies, and I wondered if there's anything similar underway with malaria.
Gwadz: The best example of the sterile male program I think was the screw-worm fly in the United States. I don't think there's any meaningful research going on right now to make sterile mosquitoes. I think the population dynamics are such that it does not lend itself to sterile male technologies and it's just not being done.
Q: Are there countries that have in place already a good system of research institutions well coordinated with control efforts in the field?
Toure: Honestly, if we except countries like South Africa, most of the other countries you may find the research institutes doing even quite a good job and generating the biological information needed, but on the other side you don't always get very good collaboration or interaction with the control services. Most of the research capacity may be concentrated in the universities and it may be needed in the ministries or the district, and there just isn't a good distribution of people and information. The overall structure is not designed for optimal use of the information. It doesn't mean there is nothing, there is some information there, but what is there is not properly used.
Ridley: Getting true collaboration between research and control is always incredibly difficult, but I think with efforts like MIM the situation is getting much better. If you want to point to countries that have sort of "done it" and are already there, I don't think you can do it, but if you want to name some countries that have shown great improvement in the last four or five years I think there are many, and I think both Mali and Tanzania are in that category.
Gwadz: Money is really a major issue here. The US just signed a bill where they're going to put 50 million this year and 50 million next year for malaria control. Now whether this money will actually filter down to the countries that need it remains to be seen, but I would say that if you wanted a truly effective complete malaria control program just for Mali, just for that one country I think that would cost 50 million dollars a year. The money is just not there to do these things, and it's certainly my impression that Mali has no money, and I'm sure Tanzania has no money, and there's so much chaos in half these countries that even if they had the money, they couldn't spend it. Is there pessimism? Yeah. Is there optimism? Yes. I'd like to go back to Martin's graph of Sri Lanka, and you'll see that there was almost no malaria in 1963. That was, if you went back a few more years, the numbers started at 600 or 700 thousand cases of malaria a year, and that number went down to 17 cases of malaria in 1963. A couple of years later they stopped the DDT spraying program, and it shot back up. And when they decided to use DDT again, because of agricultural use simultaneous with public health use, the mosquitoes had built up resistance and the program didn't work. They could not reinstitute the program. Nothing like that was ever started in Africa. There was a worldwide malaria eradication program, which became a control program. Worldwide -- with the exception of Africa, because it was felt that Africa was just too complex. So programs that worked everywhere else were never really tried in Africa, in the main. And in the few small areas where it was tried, it was very successful. So the door is open to starting these things again if there is the will and the finance. But there's not necessarily the will and there's not necessarily the finance and we're all looking for magic bullets like vaccines.
Q: Dr. Alilio made a comment that Africa had less malaria than other continents at one point, or that less was known about malaria in Africa. Could anyone clarify what the situation in Africa has been compared to other continents historically, and what would be the reasons why malaria has increased so dramatically in Africa?
Gwadz: It's not clear that malaria in Africa has increased so dramatically as that our knowledge about Africa has increased. I think malaria has always been in Africa and it wasn't well documented. It's safe to say that with the exception of the cities and some highland areas that everybody in Africa has malaria. It is the natural consequence of life there. It shouldn't be that way but that's the way it is. As more and more data is collected, and as populations increase, a lot of it has to do with the fact that the population has doubled and tripled over the last decades, and those are poor people at risk so there are more cases of malaria. But control has not been implemented.
Ridley: I think another point though is just the sheer level of transmission that you have in Africa, compared to the other continents. You've seen reductions around the periphery, but to really make an impact in the center of Africa is going to take something quite "gi-normous."
Toure: Clearly, I think we have to recognize that something has fallen apart in Africa after the independence days. There were some control services or control infrastructure that hasn't been kept after independence, because suddenly we have to face our own problems and we don't have enough resources to cope with it.
Q: Has there been a major focus on pregnant women and malaria so far?
Gwadz: The whole of the AID programs in many countries is maternal and child health, youth initiatives and all that, so yeah there is a lot of interest in drugs for pregnant women, there were a number of major research efforts on malaria and pregnancy, and there may not be any overriding program to look at it but it is certainly a major interest within a lot of research efforts and I'm sure there's a lot of interest in implementing programs to target women and malaria.
Q: Is there anything being done to ensure the appropriateness of pesticides?
Toure: About policies for pesticides, in fact, in some countries there are some principles but it's not always easy to apply them. But recently there has been a kind of gathering for the Sahelian countries and this will involve ministers of health and agriculture to come together to have an understanding and agreement about the use of these insecticides. In terms of insecticides for the impregnated materials, there is an agreement about three insecticides to use, not to use too many at the same time, and pay attention to cross resistance development. At the level of WHO-Afro, we are just developing a network about insecticide resistance monitoring and management and within this network there will be information sharing, but also careful monitoring of resistance development.
Gwadz: The whole use of insecticides in public health is very complex. Nobody produces insecticides for public health use. Public health gets the poor offshoots of what is left over or has been proven to be efficacious in agriculture. So frequently you go into a country and say let's try this insecticide on mosquitoes and you find that they've developed a resistance because they've been spraying cotton crops, or coffee, or tobacco or or something like that for decades. There was just the signing of the POPS Treaty, the Persistent and Organic Pesticides Treaty, and after a big fight from the public health people, DDT was given a waiver from removal for public health use. I think it's safe to say that DDT use in public health did not contribute to any kind of significant or even insignificant environmental pollution yet it's saved millions and millions of lives. To remove that from where it could be used would really be a criminal act. On the other hand, even though DDT was never banned, countries who had public health emergencies and asked for loans to buy DDT were denied those loans because bureaucrats and other agencies said "ahh, the sky is falling, DDT will kill us all, we will not loan you the money." So people are dying because science has no role in this, it has to do with public perception and things like that.
Q: How effective do you think DDT could be today, and is there an effort to bring it back on a large scale right now?
Gwadz: Nobody is pushing the use of DDT, and nobody is pushing the use of any particular compound right now. As I say, these things come out, and somebody says let's try it for public health because it's worked very well for agriculture. I don't know where pesticides are going other than the impregnated materials. Are countries going to find alternatives? Only if somebody offers them the alternatives. I don't think there's a real research program in Africa to come up with an alternative, it's going to have to be suggested to them, unfortunately by people who have vested interests.
Ridley: All I can say from a WHO perspective is there is increasing recognition of the need for an enhanced pesticide, and there has been a lot of talk, as there often is at WHO, but I think there may be something happening in that area within the next year or two. And I don't think we should forget the huge interest in the drive to use pesticides in the impregnated nets.
Q: What kinds of efforts are made to deal with the issue of making research priorities for malaria?
Alilio: One of the issues that came up about three years ago, there was a meeting about the strategy for MIM and there was a discussion of the issues that could be picked up and followed up by MIM. One of the issues was the issue of research management, and research management is different than, say, managing a company. From that meeting it was agreed that attempts should be made to develop a training program where you bring together research leaders of institutions to discuss and share programs, and to bring in managers from other areas to discuss with them. So the program was developed, and is almost funded by the Bill Gates Foundation -- almost in the sense that we don't have the actual check yet -- which will be starting this year, and the idea will be to bring together research managers from at least 25 initial countries to sit together and discuss the problems of running a research program. The key issues that will be addressed are many, but one will be the question of setting research priorities, mobilization of funds for the research, maintaining good staff, making sure they don't run off to other places, and the whole issue of communication of research results. So this is at least the first or second attempt to bring together research leaders and people with experience and impart some kind of management skills to these people who are essentially just scientists.
Gwadz: I was just going to make one other comment and that is as all these programs kick in, I bet we'll find a reduction in research productivity in Africa. And I say this because Yeya is here today, and from here he goes to Geneva to sit on another committee, and from there he goes to Harare for two other meetings, and he's just come from Harare from another meeting. As we have more and more meetings and more and more committees, and more and more working groups, and more and more training programs, the people trying to do the work in Africa are not working anymore. They're traveling on airplanes, accumulating frequent flier miles. [laughter]
Toure: He is right. What he said is true. But fortunately, it is also part of research, and I can do it only because I trained several people, and in fact those who are really doing the work are there, they are my young collaborators, and this is what we have to do. [laughter]
Alilio: I also do not really agree with Bob, and I'm not supposed to say that because he is my boss, but the issue here is if you look at, for instance, take a leader at NIH and see how much he travels around getting ideas about what is happening in the world. Take my leader where I work, you hardly see him in the office, and the idea is you know you can only come up with the ideas if you do extensive travel and share experience with other people. So I don't think you have to worry too much about people like Yeya traveling, so long as they bring together good experiences and good ideas. But what I would worry about is keeping good scientists, and this is where the program for management I mentioned comes in, how do you keep these people motivated and keep them working in a way so they feel their achievement is not frustrated. Of course there are also other issues, such as how do you get good research results published, or how do you get people to communicate, and these will have to be addressed subsequently.
Gwadz: OK, the session is over, and I'd like to thank you all for coming and I'd like to thank the participants, thank you very much.