23 August 2019 | Transcript
CL Christian Lindmeier
PA Pedro Alonso
MT Marcel Tanner
CL Welcome and hello from the Geneva headquarters of the World Health Organization. My name is Christian Lindmeier and I'm welcoming you to our embargoed virtual press conference on the question of whether we can eradicate malaria. Let me first say a few words on the dial-in connections. As you are online that means you gladly found the new instructions. Apologies again for this hiccup in case you have colleagues who couldn't dial in. We will also of course send out the audio files under embargo right after this briefing.
Again if you need to or want to dial in for questions, if you want to register to be in the queue for questions please dial 0 1 on your keypad at any moment. We also have an additional speaker here with us today. First of all let me welcome, Dr Pedro Alonso, the director of WHO's global malaria programme. Additionally we managed to get on the line Professor Dr Marcel Tanner, who's the chair of the strategic advisory group on malaria eradication. Welcome to the two speakers. I hope we can keep the lines open today and not have the same problems as we had yesterday.
Eradicating malaria has been a major global and public health objective for decades. Three years ago WHO established this strategic advisory group to look at what it might take to make this dream a reality. They have just completed their report and Dr Pedro Alonso, the director of the global malaria programme, will walk you through their findings initially. Then after that we will ask Professor Tanner to add some comments before we open up for questions. Dr Alonso, over to you.
PA Thank you very much and good morning or afternoon to all those on the lines. As Christian has just mentioned, what we are releasing today is an executive summary of a very large report that has been put together on the subject matter of malaria eradication. Malaria eradication is - just to get the terminology absolutely clear - the disappearance of every malaria parasite from the face of this planet. It is the permanent interruption of malaria transmission at a global level and that is a major aspiration that the public health community has had for the last 100 years.
Indeed WHO embraced it soon after its foundation in the 1940s and as such a first plan to eradicate malaria was launched in 1955, the first major public health operation that the recently-constituted World Health Organization launched.
There is renewed interest, or has been for a while renewed interest, in examining whether malaria eradication was feasible - what would the benefits look like? - and what the future scenarios for the overall malaria landscape could look like. It was on these grounds and at the request of the director-general of WHO that we brought together a group of leading malaria experts, public health scientists, supported by a large group of WHO collaborating centres and partners to examine these future scenarios, these economic cases, the biological threats and multiple determinants of malaria to better inform this discussion.
I daresay that this has been a very deep, thorough work that has taken three years. It is the most authoritative piece of work in this space and what we're releasing today is the executive summary. We wanted to put it out there and later in the year we will be able to release all the documents and all the evidence and analysis that underpin this summary.
Therefore the first thing to say is eradication and the concept of malaria eradication are not new to WHO. As I said, it's been there since the mid 1950s and different World Health Assembly resolutions have reaffirmed that goal since 1955 up to, most recently, 2015. All of this is to say that the question is not, eradication, yes or no. We are unequivocally in favour of eradication as a vision that has been there for the last nearly 70 years. It's a question of the how and the when.
In that regard the strategic advisory group reaffirms the concept that there are no biological barriers to the concept of eradicating malaria; it can be done. That's a very clear statement.
The second one is that the economic and societal benefits of eradicating malaria would be massive so both in terms of the numbers of lives that would be saved as well as the return on the investments that would happen and the economic benefits that would be generated through the permanent disappearance of this disease from the planet. That also is important in terms of laying out very clear health benefits and economic benefits from achieving this goal.
The third thing is that the committee has conducted a very thorough analysis and modelling exercise looking at what malaria will look like over the coming years and taking into consideration what we've now termed mega-trends, which involve projections on changes in agricultural use patterns of land, electrification, urbanisation, migrations, climate.
The summary of this really thorough work shows that overall all these mega-trends, including the economic development and urbanization that we expect will be happening throughout the world and particularly in Africa play in our favour. In other words all of them lead to reductions of malaria transmission.
If on top of that we factor in the scale-up of our currently available tools to an absolute maximum, above 90%, the message that we get, the picture that we get is a remarkable reduction in malaria over the next 30 years. But in the face of all these positive developments even by 2050 we would still have in excess of 11 million malaria cases; in other words we would still be quite short of having eradicated this infection.
Therefore in the absence of a clear end date, in the absence of a final strategy to entirely rid... the disease the committee group says we cannot formulate a precise and reliable plan for the eradication and we therefore cannot calculate its absolute cost. So major improvements, coming close to eradication but not quite achieving it, therefore hard to put a price tag or a concrete plan together.
Many of you will be aware of our World Malaria Report over the last couple of years that shows that the world is at a crossroads, that the historical progress that has been achieved over the last decade is clearly slowing down and that we still have in excess of 400,000 deaths every year and 200 million cases.
In order to get back on track to meet our global strategies, targets of 2020 and 2030, in order to lay the foundations for a future eradication effort we need to put in place a number of things. We need the real, true, deep commitment of political leaders to provide the adequate funding from international sources and domestic sources to ensure access to affordable healthcare and this goes to the heart of the universal healthcare agenda that WHO is putting at the centre of its strategy, building on a primary system.
So there's a major health systems component that needs to be in place and that needs to be funded; that's number one.
Number two; we need to further improve the quality and the use of data and surveillance data to detect changes in malaria transmission and adequately respond so the use of data, the surveillance systems, agile surveillance and response systems are the second major building-block, without which eradication will not be achieved.
The third one becomes terribly apparent at this point; that with the tools we have today, with the imperfect tools that we have today we can go a long way. We can get within sight of what could potentially be a malaria eradication space but we don't get there and therefore the recognition that we need a re-energized research and development effort to develop the knowledge base, the strategies and the tools - be these vector control tools, drugs, improved vaccines or other technologies - that will allow us to walk the last mile or even accelerate our road to eradication is the third key building-block of what a potential successful eradication effort would look like.
In closing this brief introduction, we're reporting a deep, authoritative, unprecedented effort in mapping out what the malaria world will look like over the next decades, in examining the specific question of malaria eradication. We recognise conceptually malaria eradication is biologically feasible but that, even with all the positive developments of global mega-trends and the scale-up of our current tools, we fall short of getting there.
Also this committee lays out the foundations of what needs to be done to get back on track to meet our World Health Assembly-approved targets and the key three building-blocks that would potentially make eradication a goal that can be reached. Within them political and financial commitments are a major block; within that the health systems component.
The second one is the data and the use of data and the third one, one that we would particularly like to underscore, is the need for a revitalized research and development effort to deliver the type of tools and approaches that we will need if we truly want to eradicate malaria. I'll stop here, Christian. Over to you and perhaps to Professor Tanner.
CL Correct. Thank you very much for this very good intro. Professor Tanner; first of all I hope you hear us. Then welcome. Please, over to you for your remarks or additions.
MT Thank you very much and hello everybody; Christian and Pedro Alonso. Thank you very much. I hope you hear me and I am very happy to join briefly this teleconference. I would like to add to Pedro Alonso's very clear introduction a few points from the view of SAGme, our group, and how we followed through this process and how we see the results.
First of all I would like to reiterate what Pedro Alonso has said; it's really a scientific process, it was not a political justification of whatever public health actions but it was an assessment of to what extent we can really think of eradication of malaria, as Pedro Alonso clearly pointed out.
It was very good to see that we as the members of the group, scientists as well as people actively involved in public health action at the various levels, were fully committed to really pursue this question on a scientific ground. It's very important to understand that when one puts these results into perspective - the results that Pedro Alonso has already very well summarized.
I do not reiterate the point but reiterate only one thing; that we really considered as a feasible eradication [unclear]. It's not just a very noble goal; it's also what Pedro Alonso stated; having a huge impact, not only in terms of number of cases or reduction of [unclear] in different countries but also a much broader effect on societal development with regard to equitable development and much more.
The second point I would like to add or specify is this important issue of what needs to be done besides the scientific protections [?] that resulted in very clear commitments, in very clear results and we see that there is a commitment needed which is not just a political commitment in general but it is really that we find at the national and even subnational level a commitment to pursue the GTS, the global technical strategy that was endorsed by all member councils in 2015; that this is not only lived at the global level but it is broken down to the national situation and pursued.
One of the commitments that we see that we achieved with this aim is that there is a much closer follow-up. It's not a new global technical strategy; that closer follow-up with regard to results obtained, success achieved as well as what it entails for a country or even a subnational level in many cases.
So it is in addition to that an important step that we also can achieve what Pedro Alonso has outlined and in addition he also outlined this one but this is very important for these more national and subnational levels; you really have the pillar of the global technical strategy of surveillance response installed not as a slogan or as a vision but as an active tool that helps the decision-makers, the actors really to pursue.
I think it is this bringing together, this feasibility, technical and operational feasibility through the national commitment and the surveillance responses, the working that we carry as far and it will carry us even further, as Pedro Alonso has also pointed out. Research and development is not just allowing people to work on malaria but really that with the huge efforts that have been made by scientists as well as by public health specialists, programme leaders to establish a research and development agenda, that we really pursue this one not as scientists alone but also funders actually invest in this agenda so that this renewed effort and this needed renewed effort that Pedro Alonso pointed out is actually achieved in the field of developing new tools.
These two elements, which I wanted to add on this more national/subnational/regional necessary commitment, as well as the R&D agenda, the [unclear] of that one; these two elements make it very clear; that is not something which needs to be elaborated more. Today we can say it is feasible, if we do this, to reach eradication but we cannot say an exact date for eradication. But we can show that with these efforts that are summarized in this report, based on these scientific results, we can come very close to the moment when we can say, now we are in the position to make a clear statement.
This is what I wanted to add and of course I'm open to all the questions but again, a scientific assessment put into the context of the sociopolitical realities leads to these conclusions that in a positive way show that eradication is possible. We also know that we have currently - and hopefully also in future - the commitment of all the different levels to pursue that. Thank you.
CL Thank you very much, Professor Marcel Tanner, chair of the WHO strategic advisory group on malaria eradication. With this I open the lines for questions. Again please dial 0 1 on your keypad in order to get into the queue. We'll start with the first in line here which is AFP, Agence France Press in Geneva. Agnes, please.
AG Yes, hello, good morning, all.
CL Hear you well.
AG In the press release you say that you are calling for a US$34 billion for the fight against malaria. The question would be, this $34 billion should be given for how many years? You need this money for how many years? Is it an investment for now, for ten years, how many years? Thank you.
CL Thank you. Pedro Alonso.
PA Thanks so much for the question and the opportunity to clarify that. The $34 billion is the estimated cost of scaling up our current interventions over the next 11 years, up to 2030, to achieve the type of coverage with our tools that would result in a reduction of 90% of malaria, which the World Health Assembly has approved is where we need to be by 2030.
This $34 billion, which would be a combination of both international donors as well as domestic funding by the affected countries themselves, would result in saving four million deaths, two billion malaria cases and in terms of economic gains would result in an economic gain of 283 billion in total gross domestic product.
So this is up to 2030, ie, the next 11 years and is what would allow us to remain on track to the approved targets so we're not asking this 34 billion from any one donor in particular; it's the price tag of what it would take to get us there.
CL Thank you very much for this clarification. Agnes, does that answer? Anything else? Thank you for the question, Agnes. The next in line is Martin Ensuring from Science. Martin, go ahead, please.
MA Yes, hello, thank you for taking my question. Reading between the lines of your report, you're really saying, let's stop talking about eradication for now. Right? You say that unrealistic goals can frustrate people and cause a lack of confidence and it's just not going to happen in the next 30 years, maybe more. So is the bottom line of your report let's put that aside, let's not talk about eradication for a while?
CL Thank you for the question.
MA And I have a follow-up question also if I may.
CL We'll come back to you.
PA Thanks, Martin. We wouldn't put it in exactly those terms but there are some really important elements in what you've said. The answer is yes, we clearly need to get on, rather than talk too much about eradication which is a non-issue - we all agree that that's our final goal - let us not get lost in byzantine discussions about this. Yes, eradication is the goal.
Number two; history has taught us - speaking from WHO, believe me, this is still very well-ingrained in our DNA - the first malaria eradication campaign did achieve some successes but clearly fell short of achieving its goal of eradicating malaria. High expectations have been raised and the perceived failure of the eradication campaign led effectively to the abandonment of the fight against malaria.
It is often said that the first eradication campaign failed to eradicate malaria but nearly succeeded in eradicating malariologists and research into malaria. This was followed by a major rebound in malaria globally that resulted in millions of deaths and it took a good two to three decades to get back malaria squarely on the agenda.
In other words we're very aware that setting dates when we have no evidence for them or setting unreasonable expectations can result in frustration and backlashes and we don't want to do that.
On the positive side - and this is not about being negative - eradication can be achieved and we think it's pretty clear from the work of our strategic advisory group and all the collaborating centres and stakeholders which are the three key components that we need to get in place if eradication is to be achieved within the foreseeable future and within those R&D is a key one.
All three are essential but an area that we perhaps haven't called out enough is, with the tools we have today it is most unlikely that eradication would be achieved and therefore we need new, transformative tools. This calls for a renewed effort so, to summarize a long answer to a really important question, we need to focus on getting back on track; the malaria situation globally is not a good one.
We need to get back on track and only if we get back on track and if we develop the health systems that would support this, if we develop the data use that would support this and, very importantly, if the research and development community delivers the type of tools that would be transformative then let's have this conversation again in 2030 and see whether we can envisage a time when eradication would be a reality. Does that help you, Martin?
MA Yes but maybe I can ask my follow-up then because it's related to this question. You explained how WHO has supported malaria eradication since the 1950s but it was also off the table for a very long time, I think for decades and it came back very precisely in 2007 when Bill and Melinda Gates at the Gates Foundation Malaria Forum suddenly said, let's eradicate malaria.
Then a lot of people came on board, including Margaret Chan, then the director-general of WHO, but also many scientists at the time said, we don't think that's possible any time soon. Now ten years later you've done this very exhaustive study, it looks like, but shouldn't that have been done back in 2007 when this goal was embraced so widely after Bill and Melinda Gates launched it?
PA Right, Martin; you cannot see me but I'm smiling because what you're alluding to are a lot of things that are really close to my heart. I was actually in 2007 in the room when the call was made and the following day I was brought into a room together with a number of other colleagues and asked by colleagues at the Gates Foundation - pretty high-level members of the Gates Foundation - you've heard the challenge, can it be done?
We unanimously said, no, not with the tools we have. I was then asked to lead an effort, which I did, called the malaria eradication research agenda, that involved Tony Fauci and the NIH, NIID, the Wellcome Trust and the Gates Foundation and others, to come up with what are the tools we need. This was eventually published in a large series in Plus Medicine, which has been refreshed very recently, just last year and charts out what are the knowledge base and the tools that we need.
So what I think this group has added - the strategic advisory group on malaria eradication - is all the other components that have not yet been looked into in sufficient detail, including the financing and economic benefits, the case for eradication, the health systems component, what needs to be in place from a people-centred, equitable health system, without which eradication will not be achieved.
It has done the type of projections in how trends outside the malaria space or even the health space - urbanization and electrification and land use patterns and deforestation and climate - how all of that will impact on malaria. Therefore I believe it strongly complements the work that had been done.
Should it have been done before? Perhaps but it's been done now. So I agree with many of the things you say. Just another footnote; I was also in the room, as I said, at the 2007 Malaria Forum in Seattle. By the way, Professor Tanner was also in the room there at the time and so was Margaret Chan, the director-general at the time and it is true, what you've said.
Many of us were worried about using what was then called the E-word, the eradication word, because we felt that it couldn't be achieved in the near future and it could be a bit of a distraction. We were still heavily influenced by the first failed eradication attempt and the knowledge of what happened with the first eradication campaign which, as you said, led to the abandonment of the fight against malaria and millions of deaths taking place.
We clearly want to avoid that happening but I believe we can now have a reasonable, data-informed discussion about eradication that will allow us to manage expectations in a much more thoughtful way, moving away from high-advocacy, inspirational declarations that can be useful at times but that's not what is expected from WHO. We're a technical agency.
We root our opinions in the best scientists informing us and in the best data available and what we're saying is eradication is conceptually feasible, it is not something that we're going to be able to achieve with the tools we have now in the next 30 years and therefore for this conversion to progress adequately we need to get back on track. We need the political statements to translate into financial statements that ensure equitable health systems in the endemic countries. We need to effectively use data and importantly we need new tools, without which this will not be accomplished.
CL Thank you very much. I think with this we move to the next question and I have here Sarah from the Daily Telegraph.
SA Hello, thank you. I just wonder; you've spoken a lot about the fact that we need new tools in the next 30 years. Is that largely because of growing resistance to both insecticides and antimalarials and how concerned are you about resistance from mosquitoes and malaria parasites?
PA Thank you. Sitting where I'm sitting, if I said I'm not concerned about resistance it would result in two things. One, you could rightly say, this man is not looking at data; and secondly this man doesn't understand basic science because since the times of Darwin we have known that living organisms will evolve under selective pressure.
So resistance is a fact; it will happen and it is happening. Therefore until the war is over - and the war being over means eradication - we will need to come up with new drugs and new insecticides because the ones we have will eventually become less effective.
However the call for a reinvigorated research and development effort is not specifically -
or, I would even daresay, majority-driven by the resistance agenda, if I could use that term. It is driven by the recognition that the tools that we have today are very imperfect. They have allowed us to make huge progress over the last 15 years but they're far from being a silver bullet in any shape or form.
Our current vector control relies by and large on insecticide-treated bed nets. Insecticide-treated bed nets, at the best time when there was no resistance; their efficacy was on the order of 40%. In other words there's a lot of malaria transmission that takes place outside the bed nets.
We don't have good chemoprevention tools, we don't have good drugs that could provide long-term protection to individuals in endemic countries. We have a first-generation vaccine and this is fantastic news and we're super-excited at three countries having started deploying this vaccine in Africa in routine use. We believe that this vaccine can make a big difference but its efficacy is only 40%.
In other words with our current armamentarium we can go far but we will always fall short of eradicating because our tools are very imperfect. Think of smallpox, a disease that has been eradicated. It had a very safe, highly efficacious vaccine. Polio has a very safe vaccine which again is highly efficacious.
We don't have anything that remotely resembles that type of safety and efficacy in our current armamentarium and so the drive, the call, the challenge for the research and development community to come up with new tools, transformative tools is one driven by the imperfect nature of our current armamentarium much more than from the resistance threat.
CL Thank you very much, Dr Pedro Alonso. I really love this discourse here. I think with this we'll move to the next question, which is from Liz Ford at the Guardian. Liz, can you hear us? I'll try again. Liz Ford from the Guardian. We seem to have lost her or she's dropped out of the queue so maybe anyone else from the Guardian in the UK. Maybe we got the name wrong.
LU Lucy Lambo here from the Guardian.
CL Let's try with this one; sorry. Please introduce yourself again.
LU Hi, thanks very much, everybody. I'm Lucy Lambo also at the Guardian. Thank you for an excellent overview. I was wanting to ask a really deliberately naive question which is, when you have to explain in very simple terms to non-experts why this is so difficult and why we've failed in the past how do you do that?
PA Thanks, Lucy. I was told many years ago that the most difficult questions are the ones that start by saying, this is a very naive question. That's how you started. It's hard because we're talking of a parasite and the biology of the parasite and of the transmission of that parasite is orders of magnitude more complex than anything we've confronted and a disease that would be eradicated before.
So a virus like that of polio or smallpox is a relatively simple organism. A bacterium is several orders of magnitude more complex. The parasite, the plasmodium, the five species of plasmodium that infect humans are like the space shuttle and they are transmitted by a vector, a mosquito.
So the first response to your question is, we're dealing with a biologically very complex organism that mutates, that evades the immune response, that is transmitted by a mosquito and for which several of the biological clues we still don't quite well understand simply because of its complexity. So I would say that's number one; we're dealing with a really complex enemy.
The second one is, this enemy takes place often in the hardest-to-reach areas, affecting impoverished communities with little access to health systems and therefore the second big issue is contextually this is the place where you don't want to have this type of fight; where it's hard to reach, poorer communities, impoverished with lack of health systems.
The third one is because we don't have good tools, we don't have the type of vaccines that other diseases have, highly efficacious and very safe. We have very imperfect tools. So all of this put together means we're fighting what some have termed the biggest enemy of mankind in history - some have even dared to say that half of mankind that has died up to now has died of malaria so we're talking of a big one, a very complex one that takes place in a very complex environment and for which we don't really have tools.
So I suspect I haven't succeeded in answering a simple, naive question but I may ask my colleague and chair of the committee, Professor Tanner, if he would also like to have a go at providing a simpler and clearer explanation than I. Marcel.
LU Thank you.
MT Thank you very much. Yes, I'm happy to add a few points. Point number one, as Pedro started to say, is that it is the virtuous [?] parasite that we have. A malaria parasite, as Pedro says, is really complex. It's much more interesting than any boring virus or bacterium, if you want to say that, because it has so many changes of stages in its life cycle, in the human host as well as in the vector host, and this makes it complex, as he said.
Secondly and, I think, very importantly is one point we emphasized also during the analysis and had to relate why we are not definite about saying it's then when we will achieve it; it's because of the systems context, health and social systems context that is not just weak but is different in the different settings.
Therefore implementing a strategy, although we know what the strategy is, in a given national or subnational setting makes it really complex and therefore one cannot say we can do the job within two or three years. But with the measures that we are proposing we need to tailor it to the setting, we need to for instance take, as we said at the beginning, the surveillance response system.
This is actually a strange thing of the health system; how you can really bring this to a large country, to remote areas, even with E and M health and whatever you have. It's really leading to sometimes very specific regional or national difficulties that have to be overcome and this makes the difficulty.
On the one hand, in order to overcome it, I often say malaria is a fascinating parasite but we are only frustrated from the public health side because it's a virtuous disease and how dynamic it is makes it really fascinating for a biologist [inaudible] reaching the public health problems that we mentioned.
I think I would like to go back to one question that came up. The SAT has actually looked very closely also at the question of resistance; not that we are not looking at that. But the question of resistance has very clearly pointed at the other issue that Pedro Alonso already emphasised, we both emphasised; that actually the R&D agenda really needs to be pursued as it has been established jointly, not just through the ideas of a few, in order to really to not just study resistance but really understand how we look at mechanisms, but also what this means, mechanisms of resistance, to translate it to an endemic setting, to a public health setting.
This again closes the circle to the difficulties that you asked about and we tried to answer. This [unclear] to sometimes very specific operational questions on how to use a tool and a strategy in a given health or social system setting - not to talk about those of the population maybe where I have not touched on enough.
But it's not always what we have beautifully in our strategies and our tools; the acceptance of an approach, the acceptance of a tool, that we can really reach high coverage and be effective. I think here in the past we have made a few mistakes on this issue and it's in our report very clearly reflected how important not just the general acceptance of control is but that a tool is accepted in order to really gain the momentum to reach high coverage.
CL Thank you very much, Professor Marcel Tanner, chair of the strategic advisory group on malaria eradication. I have no more questions in the queue on my screen so with this I want to thank our two speakers and presenters, Dr Pedro Alonso, director of WHO's global malaria programme, here in the studio at WHO's headquarters in Geneva, and on the phone Professor Dr Marcel Tanner, the chair. Thank you all very much.
Please be reminded that this is still under embargo until shortly after 0:00 GMT tonight, which is 2:00 Geneva time, early Thursday morning. Sound files will be sent soon after this briefing and with the rest I thank you very much for your interest.