“The only way forward is to accelerate”
Pedro Alonso was just out of medical school when he first visited Africa, an experience that was to change his life forever. “I woke up to the realization that malaria is a massive health problem and a neglected disease in certain parts of the world,” he said. “Three out of four patients were malaria, and that was very hard for a young doctor to see. So it became my driving force.” Since then, this Madrid native has spent three decades going back and forth to Africa, conducting medical research in Gambia, Tanzania and Mozambique, where he has lived for long stretches with his wife and five children, some of whom, like himself, have contracted the disease. He was appointed director of WHO’s Global Malaria Program in Geneva six months ago. This week, he answered our questions and talked about special challenges.
Where are we today in the fight against malaria?
The last 10 years have witnessed extraordinary progress. The mortality rate has decreased by 30 percent, malaria transmission has dropped by at least 30 percent and overall 4 million lives have been saved. There has been an increased coverage of WHO core malaria interventions, including insecticide-treated nets, diagnostics and access to treatment with artemisinin-based combination therapy in a way never seen before, the consequence of the increased funding. But the glass is half empty. Today, 50 percent of households that should be covered do not have long lasting insecticide-treated nets, there are still 60 million malaria cases that go undiagnosed and untreated and there are 15 million pregnant women who are not getting IPTp (Intermittent preventive treatment of malaria in pregnancy). This massive unfinished agenda means we still have 600,000 deaths per year and about 2 million cases every year, and transmission going on in 97 countries.
What is the strategy for the next years?
The WHO Global Technical Strategy aims to bring a new vision. It has goals, targets and milestones from 2016 to 2030. By 2030 we should have reduced morbidity and mortality by at least 90 percent and have eliminated malaria from a further 35 countries. These are not aspirational goals, but goals and targets that can be achieved with currently available tools. If we scale up, if we are smart about control and if we are aggressive towards elimination we can actually achieve that. Personally, I think they are conservative targets because we have a very active pipeline of new products, new drugs, new diagnostics, potentially new vaccines, and new active ingredients to be used as insecticides that could transform the fight against malaria in the coming years.
What are the main pillars of this strategy?
Increasing towards universal coverage the core malaria interventions, such as mosquito nets, diagnostics and treatment, and the recognition that not one size fits all. Therefore, being smart about malaria control and elimination. Our second pillar is how can we actually accelerate and be innovative, either with new tools or with new strategies that can actually help us bend the curve and go faster towards an elimination scenario. Approaches like mass drug administration, focal screening and treatment are the type of strategies that might help us do that. The third pillar is transforming surveillance into intervention. Surveillance has been the biggest forgotten element. A lot of our work is heavily dependent on mathematical modelling. I think that in the next years we should focus on having real data, so that countries primarily use that information to adapt their own programs and respond. As a knock-on effect, it will allow WHO and others to track real progress based on real data rather than on modelling. Having an enabling environment from a regulatory perspective and a financial perspective is another pillar.
What do you see as the main challenges?
There is a massive financial gap. We have the tools but we need the funding. Only 50 to 60 percent of what is required to achieve global targets for control and elimination is available. The next wave of resources will have to come from countries themselves given the assumption that funding from external donors may plateau or not increase. Countries like India, Brazil or China will have to pay to eliminate their own malaria. Nobody else is going to do it. If we don’t continue to invest and scale up we won’t finish the agenda. We can predict what will happen because it happened in the past: malaria will come back. The model suggests that if we are now at 50 percent coverage and we just keep it there our numbers will go worse. This is like cycling. You have to pedal even faster to remain where we are. We are in many ways in a race and the only way to go further is to pedal faster. Drug resistant, and possibly even more importantly insecticide resistance, are also main challenges. We also need to make sure that innovation and research continue to underpin progress. That is one of the lessons of the first eradication campaign in the late 1950s and early 1960s, when essentially research was abandoned because there was an assumption that we already had all the tools and knowledge that we needed and we just had to finish the job.
Given that resources are limited, where should the malaria community focus its efforts? On saving lives in the hardest-hit areas or shrinking the malaria map?
I think this is often a false dichotomy. The priority number one is to go to the hardest-hit places, where the biggest morbidity and mortality is, and address the unfinished agenda. It is the primary ethical mandate. Our biggest investments should go where the biggest burden is. Shrinking the map is a nice image about how elimination and eradication will eventually happen, but we do not know if that is how things will work. If you save lives today, you will drive down transmission and therefore accelerate elimination. Having said that, there is also a need for the Global Fund and other key funders to pay special attention to some elimination areas, where strictly looking at the burden of disease one might not do that type of investments, but represent special cases. An example is the greater Mekong sub-region, where the threat of multi-drug resistance eventually spreading to other parts of the world including Africa makes it a point in case.
What type of interventions do you favor in the fight against malaria?
Most of the gains achieved over the last decade have been through vector control, so mosquito nets are probably responsible for over 60 percent of the gains seen. That is our key tool for prevention. In terms of further contributing to the reduction of morbidity and particularly of mortality, access to proper case management, to diagnosis and treatment is very important. We tend to fall into false dichotomies on the issue of sequential prioritization, or where we should first start investing. It’s about getting our prevention tools out there, our vector control approaches and then scaling up case management and diagnostics and treatment. If we can reach a 90 percent coverage that will bring us pretty close to our target of a malaria-free world
How serious a challenge is resistance?
We take drug resistance very seriously. It happens with every drug or antibiotic you use. What is really worrying us now is that in the Greater Mekong sub-region we are starting to see resistance to the partner drugs used with artemisinin, so we can talk of multi-drug resistance, rather than artemisinin resistance. Probably no one has died yet of artemisinin resistance. What we are seeing is delayed clearance. What will actually start killing people is that you will have resistance to both elements. It is on the basis of that threat and the risk it poses to the rest of the world that our top advisory bodies have suggested that containment is not an option, but that you should go for elimination. We are finalizing a regional strategy for malaria elimination in the Greater Mekong sub-region. The only sustainable strategy in that part of the world is to go for falciparum elimination. That will mostly likely include mass drug administration as one of the strategies.
How important are resilient health systems?
They are of critical importance. Sometimes we find ourselves in these false dichotomies, such as vertical programs versus horizontal programs. A friend of mine says it is not about horizontal or vertical, it is diagonal. The truth of the matter is that no matter what program we are talking of it operates in a health system. So in the case of malaria access to a well-functioning health system is critical to success.
How do you see the partnership with the Global Fund evolving?
The partnership with the Global Fund is probably the most strategic for us. There is a recognition that if we work together and align closer we can really achieve impact and support countries. For me the next few years are about working even closer with the Global Fund, make sure WHO is responsive to what the Global Fund needs in terms of working with the countries.
What role will the RTS,S malaria vaccine play in the fight against the disease?
This vaccine is a huge success story. Ten years ago there was still scepticism over whether a malaria vaccine was feasible. It also shows that when you bring together big pharma, academic groups, research centres in Africa and the vision and support of philanthropy, you can take on one the most complex biological and medical problems. It is a great step forward but this is not the magic bullet. But we can confidently say this is a first generation malaria vaccine, which means also it may very well be a very good platform. This is not the end of the research. In many ways it is the beginning of the continuation of research. Hopefully in the not-too-distant future we can have a vaccine with an 80 or 90 percent protection that will really become a major game changer.