Perhaps it was the title of the panel (“Engineering Mosquitos to Fight Malaria”) right before I was to speak that caused me to feel that I was at the wrong event. Or maybe it was because I had just met several senior health ministers from across the developing world. The “Rethinking Malaria Leadership Forum” hosted last week at Harvard Business School brought together delegates from many different disciplines to explore emerging strategies to combat this awful disease.
Malaria wasn’t a disease that I had ever particularly focused on, even though as a child I had lived and traveled in parts of the world confronting this scourge, so I was passingly familiar with it. What little I knew about malaria suggested that some of the healthcare technologies proliferating today (telehealth, connected devices, analytics) might actually have an impact. But what a complicated situation.
Per World Health Organization estimates, there were 212 million malaria cases in 2015 which tragically resulted in 429k deaths – and some believe there may be another 60 million cases which go unreported. Staggering. Furthermore, it is believed that 3.2 billion people are susceptible to the disease – nearly half the world’s population. In 1955, the World Health Assembly launched the first coordinated global effort to eradicate the disease, and while there has been marked improvement over the ensuing decades, malaria is proving to be one of the most complex biological disease systems.
In 2000, there were 262 million cases and 839k fatalities, which had been nearly cut in half 15 years later. As is evident by the map below, there are now 91 countries battling malaria. Thirteen countries, mostly in sub-Saharan Africa, accounted for 75% of all cases. Quite clearly the regions most afflicted are arguably the least equipped to battle this disease. For instance, given the political instability and the failure of government, Venezuela now has more cases than all the other South American countries combined.
In 2000, funding globally for prevention and treatment was estimated to be $200 million and is now running approximately $2.5 billion annually. It is estimated that the United States accounts for 35% of this amount. For many of last week’s participants at Harvard, the U.S. presidential election has now introduced yet another very disturbing risk to the global response to malaria – where does the U.S. stand going forward? Foreign aid the past few years has declined as attention was redirected to disease outbreaks such as Ebola and Zika.
Notably, while there are a handful of therapeutic treatments and effective antimalarial drugs, adequate diagnostic tools in the field are limited, leaving prevention as the approach that has had the most significant impact on lowering incidence levels. Insecticide-treated mosquito nets (known as “ITNs”) have a dramatic impact on transmission rates. Efficient distribution of ITNs require basic in-country logistic capabilities, which is often times the most challenging issue. This “last mile” of care delivery in territories ravaged by war and poverty are often non-existent. The heterogeneity of country responses demand a more coordinated strategy while respecting trans-boundary issues.
Vector control. What a fascinating framework to manage a disease, which in this case is to eradicate all mosquitos in an affected region. As was pointed out repeatedly, mosquitos have been around for 200 million years and are marvelously adaptive. There are more than 400 different species of mosquitos. The average life span for a male mosquito is between 1- 2 weeks and 6 – 8 weeks for females. In fact, in many countries mosquitos are exhibiting high levels of insecticide resistance, which is obviously very troublesome. Going after mosquitos does not even address the underlying cause of the disease which is the parasitic protozoa that are carried by mosquitos (so disease eradication is premised on wiping out the “messenger”).
For such a disease, healthcare technologies potentially serve as a great democratizing force for access to quality care delivery. Most of the health ministers and foundations who participated at this forum had significant experience with sophisticated predictive models. Of course, such tools, while potentially very powerful, are dependent on credible and timely data from the field. In addition to better data capture and reporting, the promise of greater penetration of cellular infrastructure, low-cost sensors and connected devices like digital thermometers offer potentially more effective management of distributed populations and “care-at-a-distance” models. For example, the Malaria Elimination Initiative at the University of California, San Francisco has developed evidence-based solutions by country and in so doing has built a very sophisticated malaria map.
Another interesting map was created by NASA using “gridded population data” which slices the globe into 28 million cells (each cell is approximately 3 x 3 miles). The yellow regions below are comprised of cells with more than 8,000 people each which equates to nearly 900 people per square mile (or about what we see in the Commonwealth of Massachusetts – which to be clear is a blue state, not a yellow state). When superimposing the two maps, one initial reaction is that malaria does not necessarily correlate to areas of high population densities.
As the health ministers from Namibia and Kenya pointed out several times to me, public health is often viewed as an unattractive career for many of their brightest minds, and yet initiatives around increasing awareness through robust community activities, delivering ITNs, and indoor spraying programs have shown outsized impact. Many of the forum participants were looking to pharma to discover and make available break through therapeutics and/or sophisticated genetic tools to modify mosquitos – undoubtedly essential and promising advances. Others seemed to be searching for low cost surveillance technologies. Others struggled with how to architect appropriate funding schemes to support public health initiatives and build local innovation ecosystems.
Harder to satisfy was the desire for competent and effective government in many of these countries that would marshal the resources to eradicate such a devastating disease.