The Proboscis

notes on medical entomology

Back in 2004 malaria control was at a crossroads – my old lecture notes say so

Chris Thomas called it. But then so many others did.

 

It just so happened that Chris Thomas was lecturing on influenza and I imagine that anyone lecturing on influenza at the turn of the century was inclined to tell students ‘this is the thing you need to be frightened of most’. He was right. But then so many others who knew a thing or two about flu viruses were.

 

I have thought about this lecture – Durham, circa 2004 – a lot over the past 18 months. Not necessarily because of covid, but rather, we knew a pandemic was coming one day. We were being taught this at that time. Yet, we were never truly prepared.

 

I think a lot about what I learned ‘then’ versus what I would have learned ‘now’. For instance, we barely scratched the surface of genomics or genetics in Biology at A-level (2001, for those counting). A quick look at today’s syllabus and three of the eight core contents are ‘genetic information’, ‘genetics and populations’ and ‘control of gene expression’. Of course, this is simply progress in our understanding of the world. But it is interesting to reflect on what we learn and the context of that learning 20 years apart.

 

Last week we did a garage clear out. Amongst the damaged sofa bed, a battered hoover and a bizarre picture of a couple called Ted and Irene of whom I have absolutely no knowledge of – was a stack of lecture notes from my Masters degree.

 

I love seeing what I thought was worthy of a highlighter pen back then and whether I would annotate the same passages or bullet points now. In the box of notes are a series of printed (yes, printed) papers with barely intelligible scrawl. More telling are the papers I decided to keep – the most notable of which are from a 2004 Nature Outlook series on malaria.

 

Skim reading the series I forget the how critical a period this was for malaria control. There was little to celebrate in 2004.

 

Malaria was becoming a ‘public health disaster’ at the turn of the century. Deaths from malaria were, in fact, increasing whereas all cause mortality in Africa had declined.

 

No one had a true idea of the scale of the problem. It is easy to recall the regurgitated party line statistics at the time. ‘Over a million, mainly children, die of malaria every year’. ‘A child dies of malaria every minute’. But, in reality, there was no substance to this. These were merely rallying calls. The data on malaria cases were weak, if not available at all. This is spelled out in two articles by Brian Greenwood (“No knows precisely what the clinical or economic burden is”) and Bob Snow (“some 90% of the world’s malaria deaths probably occur in Africa. But many of our assertions about baseline data for Africa and elsewhere are couched in terms of ‘probably’ and ‘likely’ because the simple truth is we do not know”).

 

There is a real sense of how did this happen in the commentaries (see ‘Where did it all go wrong?‘). The funding required to make significant progress was way off the mark (by extra zeros). Donors had failed to deliver. Drug and insecticide resistance were on the rise. A vaccine was not imminent. Something needed to change. And, on reflection, around about that time – it did.

 

Between 2000 and 2015 the case incidence of malaria in Africa declined by 40%1. That is quite remarkable. Did the authors foresee anything close to this feat? Not really. There is hope and repeated rallying cries for funders and the malaria community to get their act together. Bill & Melinda Gates were new on the scene. Funding mechanisms and political commitment were about to rise. Notably, nowhere in the series do you see the words ‘long-lasting insecticidal nets’. Commercially available nets with longer insecticidal activity were not yet ready nor distributed widely. Their potential impact was known but not yet realised. Richard Klausner & Pedro Alonso, “But although they are inexpensive and effective, fewer than 2% of Africans sleep under them [nets]. Massive campaigns to increase their use are required as a matter of urgency“). Touchè.

 

Now is probably as good as any time to draw lessons from this period.

 

Malaria deaths rates have stalled from 12 to 10 per 100,000 between 2015 to 20192. Covid has taken resources away from other disease programmes (including malaria) and the impact could be significant. Mosquito behaviour is evolving. A vaccine, while closer, is still not imminent. New impetus and innovation is needed. Sound familiar?

REFERENCES:

  1. Bhatt et al. Nature (2015).   https://www.nature.com/articles/nature15535
  2. WHO world malaria report 2020 https://www.who.int/publications/i/item/9789240015791

 

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