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Melinda French Gates - Malaria Forum Keynote Address

October 17, 2007
Prepared remarks by Melinda French Gates, co-chair

Editor's note: View Bill Gates' portion of the keynote speech, which followed Melinda Gates' remarks.

Melinda Gates: Thank you for that very warm greeting. Bill and I welcome you here to Seattle—and we thank you for dedicating your lives to fighting malaria. You were working on these issues when no one was watching. The fact that so many more people know and care about malaria today is a testament to your vision, your persistence—and to the faith the world has in your work.

In the history of humanity, it's likely that no disease has ever caused more suffering, more sickness, and more death than malaria. Malaria symptoms were described in Chinese medical texts written nearly 5,000 years ago. The disease caused the decline of city-state populations in Ancient Greece, and untold deaths during World War II.

Even now, a century after Nobel prizes were awarded for discoveries relating to malaria and its transmission, malaria is epidemic in many parts of the world. Malaria deaths worldwide peaked in the 1930s at nearly three and a half million and then began to drop with global efforts to fight the disease, reaching a low of about half a million at the end of the 1960s.

But then anti-malaria efforts dropped off, and the disease has been on the rise ever since. Now there are five hundred million cases of malaria every year and more than one million people die from it, mostly children. That's the equivalent of losing every student in the New York City public school system each year.

We wouldn't let it happen here. We shouldn’t let it happen anywhere.

But over the course of the last century, malaria changed from a disease that afflicted a broad range of countries to a disease that affected only poor countries. It changed from a celebrated cause of our scientists and politicians to a source of suffering that the rich world was willing to accept and the poor world was helpless to prevent.

Today, though, the world is coming back to this cause in large and enthusiastic numbers. UNICEF's report, released just yesterday, describes record levels of spending, distributing bednets, and delivering medicine. Global procurement of artemisinin-based combination therapies grew from 4 million doses in 2004 to 100 million doses in 2006. We also have record funding for research, more coordinated control efforts, and greater scientific tools than we’ve ever had before.

Bill and I believe that these advances in science and medicine, your promising research, and the rising concern of people around the world represent an historic opportunity not just to treat malaria or to control it—but to chart a long-term course to eradicate it.

We know that the word "eradication" is troubling to many people with deep knowledge of malaria. It's an...audacious goal—to reach a day when no human being has malaria, and no mosquito is carrying it.

This is a long-term goal; it will not come soon. But to aspire to anything less is just far too timid a goal for the age we’re in. It's a waste of the world's talent and intelligence, and it's wrong and unfair to the people who are suffering from this disease.

The goal of eradicating malaria has the power to create great expectations, grand efforts, and record funding.  When you ask people to donate time and money to save lives, they can be very generous.  When you ask them to give time and money to eradicate a disease, their generosity can multiply.  Those are the benefits. They are also the risks. If high energy and high expectations don't lead to success—it saps money and morale. People give up. Governments, foundations, and corporations cut their funding, malaria surges back—and gains can be quickly wiped out.

In 1955, the WHO vowed to eliminate malaria from the earth.

The U.S. Congress put record sums of money behind the eradication effort–beginning in 1958. President Eisenhower was behind it, as was George Marshall, and Senator John Kennedy.

Armed with DDT, chloroquine, money, and enthusiasm, the world made dramatic advances against the disease.

In Sri Lanka, malaria cases dropped from 1 million in 1955 to 18 cases in 1963. Not 18,000—eighteen. Other countries showed similar gains. Optimism was so high that the young graduate student Andrew Spielman, who would later become an expert at Harvard on mosquitoes and disease, was told by his mentor at Johns Hopkins that he had chosen the wrong field. His mentor said, "By the time you've finished your thesis, all the insect-borne disease problems will be solved."

But the world was not ready for a long fight. As President Eisenhower said in a special message to Congress in 1957: "I propose that the United States join with other nations and organizations which are already spending over $50 million a year on anti-malaria activities. In five years, these activities are expected to eradicate this disease."

The fight turned out to be more difficult than expected. Mosquitoes developed resistance to DDT and the parasite developed resistance to chloroquine. Gains were made, but eradication seemed remote—and so enthusiasm faded, funding slowed—and then everything unraveled. Control efforts were cut back, and when the disease began spreading again, populations were especially vulnerable—because people in areas where malaria had been made scarce had lost their immunity. Meanwhile, research into malaria had stopped because the world had been so confident of eradicating it—and so there were no new medicines, insecticides or insights. Over the next ten to fifteen years, the number of malaria cases increased by a factor of six in India and by a factor of nine in China.

Based on this history, some might argue that it's better simply to try to control malaria than to try to eradicate it—since trying to eradicate and then failing could be worse than never trying to eradicate at all.

Why should we embrace the goal of eradicating malaria instead of controlling it? Or reducing it?

The first reason to work to eradicate malaria is an ethical reason—the simple human cost. Every life has equal worth. Sickness and death in Africa are just as awful as sickness and death in America.  In Africa and other areas of the developing world, malaria keeps adults from going to work, students from going to school, and children from growing up. Any goal short of eradicating malaria is accepting malaria; it's making peace with malaria; it's rich countries saying: "We don't need to eradicate malaria around the world as long as we've eliminated malaria in our own countries." That's just unacceptable.

If the first reason to eradicate malaria is the human cost, the second reason is the financial cost: If we plan only to control malaria, we will never eradicate it. That means we will keep bearing forever the human costs of malaria, even as we keep paying forever the financial costs of trying to treat and control it. To provide even 80 percent control coverage globally, we will need to spend billions more—each year, every year—than we do today. If, on the other hand, we have a plan to eradicate, we can look toward a time when the human cost of malaria and the financial cost of fighting malaria are both gone for good.  In the end, the goal of total eradication is the only way to address the classic problem in disease prevention:  how do you ensure that prevention remains a funding priority as you get fewer and fewer cases?

The third reason to go for eradication comes from epidemiology: the ability of the parasite to develop resistance to insecticides and medicines tells us that no set of control strategies can control malaria for very long. Malaria is smart—deadly smart. Fighting it is like playing chess against a computer that changes the rules as soon as it starts losing. This means that without eradication, we will continuously adapt our strategies to the parasite and the parasite will continuously adapt to us—in a back-and-forth battle that will never end.

When I think of what it would mean to eradicate malaria, it brings a memory to mind from a trip I took some years ago to Mozambique. I was visiting a small rural clinic, where I saw a number of children waiting for treatment. One of them, a little girl, was very sick, and the doctors were sending her on to a district hospital, where she could get better care. A physician from our Global Health team was with us. He took a look at the child and said, sadly, that it was a very advanced stage of malaria.

We ended our visit, and I left the clinic. I never learned if that little girl made it to the district hospital, or ever made it home again.  It had taken her a long time to get to a doctor.  And yet, I couldn't help thinking: she had a better chance than most—because most of the kids with advanced malaria in Africa never even end up in a rural health clinic, much less a district hospital. They die at home with their families—without ever seeing a doctor or getting any treatment.

That is why we have to eradicate malaria. Because little boys and girls in Africa are going to get bitten by mosquitoes. Even if they have bednets, some children will still get bitten when they're out playing at dusk, and some of them are still going to get malaria. And because we can’t fix the whole health care system in all of Africa, they're going to die in their village or die on their way to the doctor.

No child should die from malaria.  No child. And the only way to end death from malaria is to end malaria.

It’s fair to ask how is such a thing possible? Is such a thing possible?

Here's how we see it. To eradicate malaria, you have to end transmission–and there are multiple points where you can intervene. Reduce the number of infected mosquitoes. Keep mosquitoes from biting people. Keep people who are bitten from getting infected. Keep people who are infected from transmitting malaria back to mosquitoes.

Those are the intervention points. If we could find a tool that was one hundred percent effective, and if we could implement it completely at any one of these points, we would break the cycle of transmission and eradicate the disease.

This is just not possible today with the huge numbers of cases and the current tools. But it is possible—using the tools we have today, and addressing all the steps in a multi-pronged approach—to dramatically drive down the number of cases. Then, if we make the cases few enough, and the map of malaria small enough, we could—theoretically—with a new vaccine, or a new medicine, or a new insecticide—identify and target one step in this cycle, totally stop transmission, and end the disease.

What will that take? If we're going to eradicate malaria, we have to persist and succeed in three crucial areas.

We have to take on and solve the complexity of this disease. Conquering malaria is one of the most ambitious medical quests of all time. The resistance to insecticides and drugs means the mosquito and the parasites are moving targets. Winning will take intelligence, agility and speed. Above all, it will take relentless research into vaccines, new medicines, and insecticides by some of the top scientific minds in the world.

We will also have to have tremendous coordination–in every aspect of the effort. This means coordinating research, so different laboratories aren't duplicating the same work and can do research with the benefit of each other's insights.  It also means coordinating the work in the field so that we use every tool that we have in the most effective combinations, and no area gets neglected.

Finally, eradicating malaria will take commitment. Not a commitment simply to reduce malaria deaths, or eliminate malaria from certain regions. Those are important milestones—but they are only milestones. A commitment to eradication means a commitment to intensifying the effort as fewer and fewer people get infected. It is counter-intuitive, but absolutely essential.

We understand the risks of declaring a goal of eradication. We understand the mistakes of the past and the obstacles of today. But your work gives us confidence and makes us optimistic. Bill will talk about the promising developments we see–and why we are confident that this generation can succeed where past generations have failed.

Bill?

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