New Advances against Old Disease
A study published this month in Science magazine about a recent vaccine trial for malaria has raised fresh optimism about a solution for an illness that has plagued humanity since ancient times. Scott Filler, the Global Fund’s senior specialist on malaria, says the results of the trial are encouraging because the vaccine, developed by biotechnology company Sanaria, achieved 100 percent success in early tests. But he cautions that it doesn’t mean the battle is over. Actually eradicating malaria, he said, will require sustained engagement from all partners. “This finding is encouraging in the sense that the science is developing,” said Filler, a San Francisco native who once contracted the disease as a student in Kenya. “But malaria is a long slog. The medical community often says a landmark development is needed to eradicate malaria. We are not there yet.”
In a clinical trial, volunteers who received the highest dosage of the Sanaria vaccine did not get malaria when bitten by mosquitoes infected with the lethal Plasmodium falciparum – one of the five distinct species of the malaria parasite that affect humans. However, the vaccine must be administered in several doses and intravenously – conditions that will be difficult to meet for large numbers of people in many countries. “Malaria is well entrenched in communities,” said Filler. “The mosquito parasite and humans have evolved side by side. It is going to be very hard to interrupt that cycle.” Malaria has been around longer than anyone can remember: its symptoms are described in Chinese medical writings in 2700 BC. Its name in English originates from medieval Italian, mal aria, or bad air. In French and Spanish, paludisme and paludismo derive from palus, or swamp, in Latin. More than 100 years ago, it was proved that it is the mosquito that transmits malaria to humans. Today, this preventable and treatable disease kills 600,000 people a year, mostly children under the age of five, and costs US$12 billion in lost productivity in Africa alone. Malaria is endemic in 104 countries, and only six of them have 47 percent of malaria cases – Democratic Republic of the Congo, Cote d'Ivoire, Mozambique, Nigeria, Tanzania and Uganda.
“Malaria is the disease of poverty,” Filler says. “It keeps people in poverty and does not allow development to occur. And it is a complicated illness with unique characteristics that make it very difficult to fight.” When a mosquito bites, it delivers a small number of malaria parasites into the body. They travel on to the liver, where they remain hidden and multiply rapidly until they infect red blood cells. The parasite returns to a mosquito when it bites an infected person. Huge progress has been made against malaria over the past decade, driven by scientific advances, with rates of morbidity and mortality falling. Better implementation in programs supported by the Global Fund has led to the distribution of more than 310 million long lasting insecticide-treated nets, broader access to rapid diagnostic tests and treatment with artemisinin-based combination therapy. Another malaria vaccine called Mosquirix, developed by GlaxoSmithKline, has also shown successful results in trials and could be on the market by late 2015. But these hard-fought gains could lose ground. A resurgence of malaria is always possible, especially if funding falls short and efforts to control the disease are hampered. Poverty and political instability add to the mix.
Another major challenge is the emergence of resistance to artemisinin-combination therapies in South East Asia, where the Global Fund is financing a Mekong Artemisinin-Resistance Initiative. Filler sees the opportunity for major advances against malaria in the coming years, and stressed the need to attack it from more than one angle. “We are at an exciting juncture,” Filler said. “We want to keep moving forward. We have to work on several fronts, to get there. There is no magic bullet against malaria.”
On many mornings, Dr. Minni Khetarpal, a Deputy Executive Health Officer in Mumbai, India’s most populous city, meets with a small army of community health workers who are preparing to start their job of leading tuberculosis control efforts in the city. Dr. Minni manages a program ran by these frontline workers, whom she calls the “eyes and ears of the primary health system in Mumbai.”
India accounts for around one fifth of world all new TB cases every year. Close to 1,000 people die from TB every day in India, or about one every minute. Many who fall ill with the disease seek treatment late or at an inadequate healthcare provider. This can spell disaster for the patient – substandard diagnostics or incorrect TB treatment. And people infected with TB who either do not receive the correct treatment or who are unable to complete their course of treatment very often go on to develop multidrug-resistant TB, a form of the disease which is much more difficult and much more expensive to diagnose and treat.
Andreas Tamberg, senior fund portfolio manager for India at the Global Fund, says that the crisis of tuberculosis in India “could become like AIDS in sub-Saharan Africa in the 90s.” But there is hope. “With people like Dr. Minni on the frontlines, the fight against deadly TB and other diseases will be won,” he says. “The critical thing we have to do in the next few years,” he adds, “is to make sure that there are people like Dr. Minni—people who are available to lead the work on the ground. If you get the right people, the systems will work.”
With resistant strains of the disease emerging, Mumbai authorities are striving to provide universal access to TB care, particularly among the city’s poor. Dr. Minni and her colleagues made improvements in the city’s healthcare infrastructure, diagnostics and treatment capacities, resulting in vastly improved detection of MDR-TB: from 53 cases diagnosed in 2010 to 2429 cases in 2012. Treatment improved as well.
Dr. Minni was named after a 1960s Bollywood movie character, and is as vivacious and loving as the movie heroine. “When I see the joy of relief from pain on the faces of vulnerable beneficiaries, I know I have contributed a little bit of myself to the cause,” Dr. Minni says. “Their joy and gratitude motivate me to give my best.” She adds that her team has to work hard under pretty challenging circumstances. “They are my real inspiration,” she says.
On 30 July 2013, Hindustan Times reported that in Mumbai “between 2008-09 and 2011-12, one in four people who had TB died.” This is the situation that Dr. Minni is seeking to change. She is determined to revitalize Mumbai’s fight against TB, especially the resistant form of the disease. Tamberg says that the Global Fund has an important role, making funding available and monitoring performance of the programs. But ultimately, he asserts, it is people like Dr. Minni who make the difference. “If we can support people like her, half the job will be done.” India has a lot of challenges, Tamberg adds, but people like Dr. Minni and others like her can make “a decisive impact in defeating tuberculosis” in the world. “If we can beat TB in India, we can beat TB anywhere.”
From the Frontlines: South Sudan
In a dining hall in a newly-constructed dormitory at the Juba College of Nursing & Midwifery in South Sudan, Suzi Nyathil eats her lunch a few paces away from a group of fellow students immersed deep into meal-time banter. She and other students may share classes, and the pink-and-white college uniform, but not the deep pain that befell her two years ago and made her choose nursing as a career.
The day was 25 May 2011. She was working in a health facility in the Abyei – a war-ravaged region disputed by Sudan and South Sudan – when a group of South Sudanese soldiers who worked with her husband were wheeled in with severe injuries sustained in an attack. Nyathil was a subordinate at the health facility but was involved in receiving the injured soldiers, including her husband’s best friend. The friend couldn’t gather the courage to talk about Nyathil’s husband “until he felt he was dying,” she says. It is then that he told her that her husband had been killed in the attack. As the friend lay there in the hospital bed, he bid her farewell, saying that he too was dying. Despite the shock, Nyathil controlled herself and wanted to do her best to save her husband’s friend.
But she was not a trained health care worker. The health facility was badly understaffed. “I watched him die,” she says. “Helplessly.” That day, as she mourned her husband and friends, she made a decision to study nursing, hoping to “gain skills that would help save my people.” A month later, she left Abyei and travelled south to Kampala in Uganda, where she knew people she could stay with as she pursued her studies in nursing. Unfortunately, she could not get a place in Uganda’s medical colleges. She decided to go back to South Sudan.
In Juba, hundreds of kilometers south of her village in Abyei, she was admitted to the college of nursing and midwifery. The school, which admitted its first students in May 2010, is funded by a number of donor organizations, including the Global Fund. The college is scheduled to graduate its first group of nurses and midwives this month. Repent Khamis, the Acting Principal of the school, says that only with the support of many partners can the college train these health workers. Nyathil is determined to gain as much knowledge as she can and return to Abyei. She believes it to be the best way to honor her husband, his slain friends and her son, who asks endless questions about his father. “If God helps me to finish,” she says, teary-eyed, “I will return home to help my people.”