Bill Gates: 2011 Malaria ForumOctober 18, 2011
Prepared remarks by Bill Gates, co-chair and trustee
Thank you, Melinda.
Melinda told you about some of the people we met in Tanzania recently. I was impressed by a man named Prosper Chaki, who runs a larviciding project in Dar es Salaam. He spends his days wading into the standing water where anopheles mosquitoes breed, so he can poison them. It’s not so surprising that he’s gotten malaria over a dozen times.
“Mosquitoes are smart,” Mr. Chaki said. Then he told us, “We have to be smarter.”
I believe we will be smarter. One reason is that you have come from all over the world to this forum—to challenge each other, to disagree with each other, and to learn from each other. When you leave tomorrow, our team at the foundation will move forward with the benefit of the most rigorous thinking in the world. We are grateful to you for that, and I hope each of you will take home some inspiring messages about this fight against malaria.
The other reason I believe we will be smarter is that human beings have a spectacular ability to innovate. This is really behind most of the improvements in the human condition. Innovation is one of the most powerful forces in the world. It can make the impossible, possible.
We have room for more innovation in this malaria space. In fact there’s a lot innovation happening already.
But innovations are only as good as our commitment to delivering them. We have to get better at using the innovative tools we have.
Intermittent preventive treatment with drugs during pregnancy and infancy are two proven methods of protecting those at risk from malaria, but they’re not saving as many lives as they should be. For example, most countries in sub-Saharan Africa provide IPTp, the pregnancy approach, in less than 20 percent of pregnancies. That is not good enough.
We have to demonstrate the same level of commitment as new tools come online. I am optimistic that Seasonal Malaria Chemoprevention for children will be available starting early next year, when the WHO’s approval process is complete. We must be aggressive in launching pilot studies to understand how this intervention should fit into control strategies, so we save as many lives as possible, as quickly as possible. These IPT interventions are actually fairly straightforward and low cost compared to other things.
We also have to be thinking simultaneously about the next generation of tools. If bring more partners into the fold, if we think big, take risks, we will invent novel tools—powerful ways of fighting malaria that don’t exist now. This is the kind of innovation that will enable us to plan for the eventual eradication of malaria.
Eradication is an ambitious goal—and a long-term goal. It is also a goal to which we remain 100 percent committed.
We are committed to it for moral reasons. All of our children will not die from malaria, thank God. Since that is true, no child should die. It should never be too expensive or too inconvenient to give those most in need a chance to survive when the well-off already have it. Equity is not yet a reality, but it is what we believe in and what we are striving for.
We are believe eradication is important for strategic reasons. The alternative is an eternity of trying to stay just one step ahead of the parasite and the mosquito. And this would be very difficult because both the parasite and the mosquito continue to change. If we take this approach, the cost in lives will be enormous. The opportunity cost of never being able to divert our attention to other challenges will be incalculable.
I know some people in the malaria community worry that focusing on the uncertain goal of eradication could distract us from control measures that are working today. I understand this desire to stay focused on saving lives. But I don’t see eradication and control as two separate approaches to fighting against malaria. Instead, they are two compatible parts of a single approach. To achieve elimination and eradication, we need to start with control, drive it up to very high levels, and sustain it. But if we don’t target elimination and eradication, control will lapse, and malaria will continue taking lives.
It’s going to take new leadership and innovation and money to extend the recent successes. It will take the same things to plan for malaria’s eventual eradication. The conclusion is daunting, but inescapable: We will need enough leadership and innovation and money to do both. We don’t have the luxury of simply picking one or the other.
I am an optimist. I believe we are capable of setting our sights on an ambitious goal with a generation-long time horizon and multiple, shifting milestones along the way. But eradication won’t happen as long as it remains a general aspiration. We must turn it into a specific plan, and our job now is to lead the constant search for new and better tools that will help us execute our plan, step by step.
An important tool we have now is the bed net. Nets are an important innovation, but they’re not perfect and they alone won’t be sufficient. They are expensive, they are unpleasant in some cases to sleep under, and of course they don’t have an effect against outdoor- and daytime-biting mosquitoes. We need to work on cheaper, easier to use, and more powerful vector control methods.
I am enthusiastic about spatial repellants, chemicals that can keep mosquitoes away from treated areas. Repellants could be a big improvement over nets, because the people benefitting from them wouldn’t have to make the choice to sleep under them every single night. The likelihood of human error or rejection would shrink significantly. And spatial repellants would be effective against all types of mosquitoes, no matter when or where they bite.
Recent trials in China showed that mosquito coils containing a chemical repellent decreased people’s odds of contracting malaria by about 80 percent—and coils plus nets were even more effective. Right now, additional trials are taking place in Indonesia to confirm the impact of coils on transmission and to measure their impact on the mosquito population. We expect data from this proof of principle study by the middle of next year.
Researchers are also busy identifying potential active ingredients for spatial repellants. Larry Zwiebel of Vanderbilt University just isolated a compound that is 1,000 times more powerful than DEET. Other researchers are looking at additional formulations, and results from these studies will be available in the next few years.
ACTs are another tool that we have today that are changing the course of malaria control over the past several years. Obviously, they represent a vast improvement over the old drugs that weren’t effective, but, like nets, they are not ideal. Artemisinin is expensive, the course of treatment lasts several days, and we do see some resistance beginning to develop in Southeast Asia.
The partnership that works on malaria drugs, Medicines for Malaria Venture, currently has a drug candidate in phase II trials, OZ 439, that has the potential to be a single-dose cure. This could solve many of the problems with ACTs. It should be cheaper, since the total amount of drug needed for treatment is lower. Adherence will be much higher, since people are in adherence once they take the pill. This will decrease the risk of treatment failure and slow the development of resistance.
OZ 439 could be licensed as early as 2016, depending on the suitability of the quinolines currently being tested as partner drugs. In addition to finishing the trials, MMV is looking for a partner from the pharmaceutical sector to help it make and market OZ 439 at the appropriate time.
One tool we don’t have yet today and that will be important in the future fight is a vaccine. A fully effective vaccine is a wonderful thing. It’s the simplest, most cost-effective way to save lives. The smallpox vaccine, plus the innovative approach of ring vaccination, led to the eradication of smallpox. The polio vaccine has gotten us quite close to the threshold of eradicating polio. Vaccines have slashed the number of deaths caused by diphtheria, measles, tetanus, and a host of other diseases.
But developing a malaria vaccine has been a long and frustrating process. There have been certainly more failures than success, because this a parasitic disease, quite a different target than most vaccines go after, and the scientific complexity is significant.
Today, however, we are closer than ever before to tackling that complexity. Four years ago, I announced interim results from phase II trials of the RTS,S vaccine. Today, I am pleased to announce the interim results from the phase III trials. Among five to seventeen month old children, the vaccine prevented clinical malaria in 55.8 percent of trial participants over a period of one year. It prevented severe malaria in 47.3 percent of trial participants aged five to seventeen months. It prevented severe malaria in 34.8 percent of the entire study population, both infants and children.
These are only interim results. We need to study the data over a longer period of time to understand whether the impact of the vaccine wanes such that we’re only seeing a delay rather than a reduction. We also need to evaluate the impact of a booster dose. In fact that’s one of the arms of the phase III trial that we’ll get information about in the years ahead.
I do think the results represent a huge milestone, and I want to congratulate the many partners that have been working on this project for decades. First, this is proof that vaccines can have an effect in a large phase III trial. For a long time, we didn’t know. Now, we know. Second, if RTS,S continues to show effectiveness of around 50 percent—above and beyond bed nets—it has the potential to protect millions of children and save thousands of lives.
And RTS,S blazing the way for other vaccine work. It is a first-generation vaccine. It is an early outcome of a long process of innovation and long-term investments that will ultimately yield a fully effective vaccine. Researchers are currently recruiting participants for early trials of one of these second-generation RTS,S vaccine.
There are many vaccines that work in a very different way. I am particularly excited by the potential of transmission blocking vaccines, vaccines that prevent mosquitoes from picking the infection up from human hosts. I think this will be an extremely valuable tool in an eradication plan.
But the fact is there are still many basic science questions about malaria that we need to answer to make the search for vaccines less challenging. For example, we understand that after significant exposure to malaria, you develop some level of immunity. We can even produce that immunity artificially, but we don’t understand how to measure it or what causes it. If we get a better sense of what underlies immunity in those cases, we will have a much better chance of filling the vaccine pipeline with good products.
As we develop these new tools, we also have to develop a more sophisticated understanding of how to deploy them. When you have several ways to fight more than one species of parasite, carried by many species of vector, you can’t afford to guess about strategy. What is the smartest way to combine our interventions so they have the maximum effect? We need to be able to answer these questions with evidence.
I believe modeling can help generate that evidence. I want to walk you through some charts from one malaria model to give you a sense of the kinds of answers they can provide.
Now we’re talking about doing something hard, but I think we all know how important it is. Some people have said, Why take on something so difficult? It caused me to reflect on what our friend and mentor Warren Buffett said when he made his gift to our foundation five years ago. One of his famous quotes about finance is, “I don’t look to jump over 7 foot bars. I look around for 1 foot bars that I can step over.” Philanthropy is the other way around, he told us. We should be looking around for the 7 foot bars; that’s why we exist.
Malaria eradication is a high bar. To reach it, it will take a constant, concerted effort to innovate. But we can do it. We can drive down the number of cases, lower and lower. We can keep introducing new and better tools, until we interrupt transmission like we’ve done in dozens of countries already. And, eventually, with relentless focus, we can eradicate malaria. We’ve already shrunk the malaria map considerably. We can make it disappear.
It won’t happen in four years, or in eight years. But the work we’re doing now will determine whether that’s possible.
The parasite has been killing children, injuring children, and sapping the strength of whole populations for tens of thousands of years. It’s really hard both in terms of deaths or morbidity is impossible to calculate the harm malaria has done to us. Now, we can chart a course to end it.