In a blog on LinkedIn yesterday, Ray Chambers, the Special Envoy for Malaria to UN Secretary General Ban Ki-moon, sent out a public statement titled 'Saving the lives of 4 million children in 1000 days'. Making reference to the fact that the Millennium Development Goals end by December 2015, Chambers still holds the conviction that we can bring malaria mortality down to zero by the end of 2015. He asserts that the key players to accomplish this are in place, that the solution is simple and not expensive, and that we should do this. It sounds great - and given the comments under his blog ('Inspiring', 'Absolutely will join in an effort to save children', 'Few things could be more important') Chambers will certainly reach the goal of drawing more attention to malaria. Indeed, if you're not familiar with the malaria world, than it simply sounds outrageous that the world has not succeeded in putting every soul under a net in endemic settings, that we have not eliminated malaria in the south just like we did in the north half a Century ago, and that evidence (ca. 1 million deaths averted) over the last decade has clearly shown that we CAN save many lives. But is this realistic?
Robert Newman, WHO's Director of the Global Malaria Programme, not so long ago claimed that 'Zero deaths by 2015 was a wildly ambitious goal'. Does this mean that Newman and Chambers disagree? If Chambers whistles in Ban Ki-moon's ear that we are making great progress and that the ship is sailing well, does he then ignore Newman? Did Chambers read the World Malaria Report 2012, on the basis of which it was is stated that 'We have to prepare for a major come-back of malaria' (Newman's words in the press)? Even Margaret Chan, Director General of WHO, expressed her concerns over the fragile gains of the past decade and our likely inability to sustain those gains in the years to come if we can't boost funding levels and deal with major problems like drug- and insecticide resistance.
Noteworthy in Chamber's writing is his mention of the fact that many (northern) countries got rid of malaria 'thanks to draining mosquito-breeding swamps, indoor residual spraying and effective medicines'. It is beyond doubt that these methods were key in eliminating malaria in those countries and freed almost 1 billion people from the risk of contracting malaria. But it wasn't just the tools. It was also the strategy - a strategy that was based on area-wide concepts and not merely on personal protection.
During a meeting I had at the IVCC headquarters in Liverpool this week, we came to the same conclusion: that environmental and larval source management were key ingredients for successful elimination in the West. And furthermore, that the current sole reliance on house-based methods in Africa (nets and IRS) are not going to be sufficient to eliminate malaria there.
Chambers also doesn't seem to be aware of the changes we see (on an increasing scale) in the behaviour of malaria vectors. He claims solidly that biting takes place after 10 pm and that all children will then be under their nets. Simple - don't bother lay people with difficult messages. Just like economist Jeffrey Sachs, who in a talk I attended in Washington DC a few years ago claimed 'the seatbelt for us is the bednet for an African child'. Simple - use a metaphor that lay people understand.
But in places where it has been measured, as much as 20% of all transmission now takes place outdoors. No surprise: You induce biting early in the evening and outdoors if you exert a large selective pressure inside the house. This significant amount of transmission outdoors simply means that without area-wide control tactics (e.g. larval source management) we will never succeed in bringing transmission (and thus deaths) down to zero in the heartland of the disease. And Sachs should have known that a seatbelt is not a biological system that evolves over time and that it will work 100 years from now as good as today but that pyrethroids will long be gone by then...
Chambers has been hugely instrumental in getting 300 million nets distributed in Africa - through fundraising, lobbying, and getting that job done. Alex Perry's book 'Lifeblood' clearly shows Chambers' passion and determination to change the world to become a better place (with much less malaria). As a former and highly successful business man he clearly shows that success in malaria control is feasible. This, no doubt, is to be applauded.
Now we need to move beyond that - we need to move beyond nets and IRS and start appreciating the underlying factors that made elimination possible in the West half a Century ago. The concepts based on area-wide integrated pest management, the ruthless larval control campaigns executed by large teams of well-trained people, and the meticulous management and evaluation of these campaigns. Read the stories of how Taiwan, the Caribbean, and Egypt got rid of malaria - no doubt these are eye openers.
The problem we face with this is that area-wide control doesn't sell like 'Donate a net, save a life'. Area-wide control cannot be chopped into 10$ donations - you do it well or you don't do it. Coverage, determination, management and logistics are key elements - and it will be costly. Nevertheless, it will be the only way.
As the Editor of MalariaWorld, I would love to discuss the above with Mr. Chambers in person. I have the feeling that (being eternal optimists) we would get along well. If he would invite me, I'd be on a plane tomorrow. And report the outcome of our meeting to our 8300+ MalariaWorld subscribers. Better still, I would record the discussion/interview on video and share it with you that way... The question is: Will he?