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Melinda Gates: 2011 Malaria Forum

October 18, 2011
Prepared remarks by Melinda French Gates, co-chair and trustee

Thank you, David.

And thank you all for coming to our second malaria forum. The first forum stands out as one of the highlights of our work at the foundation so far. It was thrilling for Bill and me to talk about a big idea like eradicating malaria.

We were inspired by the commitment of the people doing the work—all of you. You dedicated yourselves to battling malaria when almost no one else would. For decades, you struggled against the parasite on one front, and apathy on another.

And you broke through. You ended a generation of inertia. Four years ago, we could feel your optimism, and your boldness stoked our ambition. It is an honor to have so many of you back to talk about the advances that have been made—and about the work we’re going to do together to keep pushing toward the ultimate goal.

I first started learning about malaria just over 10 years ago, when Bill and I created our foundation. I still remember the relevant facts about the disease from back then.

  • It killed more than 1 million people year after year after year.
  • The world was spending less than $100 million a year to stop it. There was no Global Fund, no President’s Malaria Initiative, no World Bank Booster Program.
  • We were barely doing anything to control mosquitoes. We didn’t have very many bed nets, most weren’t treated with insecticide, and the few that were didn’t last more than several months.
  • There were no rapid diagnostic tests. The only diagnostic tool was the microscope, which of course isn’t practical in most places where malaria is a threat.
  • And the drugs we had weren’t effective. The parasite had developed resistance to chloroquine and SP, but no country was using artemisinin combination therapy.
I recite this history, even though you know it better than I do, because it’s worth lingering over one point. If you had asked any reasonable person to review the facts, acquaint themselves with the history of malaria and the biology of the parasite, and then project the course of the disease over the next 10 years—what would they have predicted?

More sickness and more death. How could they have predicted otherwise? The situation was already dire, the trend was negative, and the interventions that could reverse it didn’t exist.

But you averted that disaster. Your work generated a whole host of new tools and the political commitment to deploy them aggressively.

By the time of our first forum, the leading indicators were positive. But the real impact was still in the future.

In my speech in 2007, I said, “It is possible using the tools we have today to dramatically drive down the number of cases.”

Today, I can say with absolute certainty that it is not merely possible. It is happening.

Worldwide, malaria deaths are down 20 percent since 2000.

What’s just as impressive is where this progress is happening—in sub-Saharan Africa.

During the eradication era of the 1950s and 1960s, the global health community pursued an everywhere-but-Africa strategy. The plan was to start at the margins, where there was less disease; build momentum; and finish with the hardest cases. Unfortunately, we lost momentum quickly and never made it to the hardest cases. There were various successful pilot projects in sub-Saharan Africa, but it wasn’t until about five years ago that we saw most countries across the region scaling up malaria control simultaneously.

This summer, Bill and I went to Tanzania to see what progress looks like. It looks like this.

This line is the amount of money spent by the Global Fund and PMI to fight malaria in Tanzania.

This line is the percentage of households that own a bed net in Tanzania.

And this third line is the number of malaria deaths prevented in Tanzania over the past decade.

As you can see, all three lines have risen sharply, and risen together.

Progress also looks like this. This is Said Shukru. He is two years old, and when his mother brought him to the hospital, he was unconscious with malaria. But he is alive today because he received the treatment he needed.

Several years ago, his older sister got sick with malaria, too. She didn’t get treatment, and she died. Said’s mother has felt the difference between then and now more keenly than any one of us. For her, it is the difference between her daughter’s tragic death and her enormous hopes for her healthy son.

We can’t change the past, but Said’s recovery is proof that we are changing the future.

When I reflect on the progress since 2000, I am filled with optimism about what we can accomplish next. I say what we can accomplish because, while today’s advances show us what’s possible, they are not an accurate predictor of what will happen tomorrow. What matters is our staying power. We need to keep on seizing the opportunity to make new progress against malaria every single day.

F. Scott Fitzgerald said “the test of a first-rate intelligence is the ability to hold two opposed ideas in your head at the same time, and still retain the ability to function.” The malaria community must pass this test.

The first idea is that this is a time for celebration. You deserve to be proud of everything you’ve accomplished. Your devotion helped turn a hopeless situation into an opportunity, so you can be confident that your continued devotion will turn the opportunity into success.

But there is an opposed idea that you also must hold in your head. It is this: We are at the early stages, and we cannot feel satisfaction. The road ahead is long and arduous. We always said we knew this wasn’t going to be easy. Now we are going to find out how hard it really is.

So what do we have to do?

First, we have to move even faster. In the past decade, the amount of money raised for malaria has increased by more than a factor of 10. That is stunning. But funding needs to double yet again to fill the gap between what is available and what is needed.

We have produced more than 300 million bed nets, enough nets to cover 80 percent of the population at risk in Africa.

We have to deliver all those nets. Given that we have enough nets to cover 80 percent of those at risk in Africa, it’s worrying that bed net ownership is hovering around 50 percent. That’s tens of millions of nets that aren’t getting to the people who need them.

Why not? What causes delays in procurement? Where are the bottlenecks in the supply chain? We must ask those questions, answer them, and then act. Right now, across sub-Saharan Africa, it’s a coin flip whether a child is sleeping under a net. We have more work to do.

The averaged figures I just cited obscure the wide range of coverage from country to country. Many countries are doing very well. Mali, for example, is well above 80 percent coverage. But some countries are failing, pure and simple. There are countries where the percentage of children sleeping under nets is under 20 percent.

That means tens of millions of children still have no protection whatsoever. As far as they’re concerned, nothing has changed since 2000. We must devise the plan to rectify that now. We cannot leave the hardest cases until the end. We’ve seen what happens under that strategy.

After we speed up progress, the second thing we have to do is maintain it. As you know better than anybody, malaria fights back. Progress against malaria is by definition fragile progress.

Resistance to artemisinin is already developing along the Thai-Cambodia border. The problem is now spreading into Myanmar and Vietnam. Ominously, chloroquine resistance developed in the same area—and it followed the same path, until it reached India and jumped to Africa. The WHO set up a special unit recently to help lead the response, and the data indicates that the problem is being contained. It is critical that the world put a stop to the use of oral artemisinin monotherapies that accelerate resistance. We cannot afford to lose this drug so soon.

Resistance is not the only threat. In Zambia, where progress against malaria had been steady, the number of deaths edged up in 2010. While annual fluctuations in malaria are normal, an investigation revealed that the increase was centered in two provinces where worn-out bed nets weren’t replaced.

The resurgence in Zambia is especially scary because it is so typical. In June, the researcher David Smith and his collaborators wrote a piece for Science about Zanzibar’s up-and-down history with malaria. They included a graph of the malaria burden in Zanzibar, and it oscillated like a sine wave. They headlined the article, “Solving the Sisyphean Problem of Malaria in Zanzibar.”

Now, Margaret Chan is not the only reader of Homer out there. Our son Rory also loves Greek mythology, so when I think about the history of malaria, the image of Sisyphus pushing a heavy boulder up a mountain pops into my head, too.

The lesson is clear: the boulder of malaria control can come crashing down if we lose focus.

And it’s not just Zanzibar. You see this pattern over and over again, all around the world. Here’s a picture of Bhutan. Looks the same. Here’s a picture of Paraguay. Looks the same. Mexico. The same.

The good news in these three countries is that they got back on track, levels are currently low, and they are included among the group of 32 countries currently planning to eliminate malaria.

Still, the challenges the malaria community faces are enormous. How do we not only maintain but increase funding in the worst financial crisis in six decades? How do we help countries scale up even when they don’t seem to have the will to do so? Once we’ve gotten malaria levels down, how do we keep them down?

The answer to all these questions is leadership.

When ordinary responses aren’t good enough, leaders inspire us to do the extraordinary.

Methodist Bishop Thomas Bickerton believes the meaning of the scripture is the service rendered by millions of Methodists, so his church created the “Imagine No Malaria” campaign. He took something that was none of his business and made it his business. Now Methodists from all over the United States have made it their business, too, by donating to the cause.

Dr. Salim Abdullah is the director of a research institute in Tanzania—and a principal investigator on the RTS,S vaccine trial. Bill and I were struck by his ability to think two, three, or four steps ahead. He does not focus on the single scientific problem in front of him. Instead, he’s constantly strategizing about how the scientific community can solve the big problems in the field.

President Kikwete of Tanzania helped create the African Leaders Malaria Alliance. ALMA releases a scorecard to make the progress of all member countries a matter of public record. Malaria ran rampant for 30 years because no one felt accountable. President Kikwete asked to be held accountable, and he encouraged dozens of his peers to volunteer to do the same.

President Kikwete of Tanzania helped create the African Leaders Malaria Alliance. ALMA releases a scorecard to make the progress of all member countries a matter of public record. Malaria ran rampant for 30 years because no one felt accountable. President Kikwete asked to be held accountable, and he encouraged dozens of his peers to volunteer to do the same.

In this room, there are leaders like Awa Coll-Seck, who has led the Roll Back Malaria Partnership for the past eight years. The amount she has been able to accomplish in that time is incredible, but incredible will have to become the standard if we hope to defeat this disease.

I am confident that we will.

Because we are not stuck in a Greek myth. We are not eternally doomed like Sisyphus. We control our own destiny. We learn from our past. We have ambition and courage and passion. We will push the boulder, and push it, until it crests the mountain and rolls down the other side—until every child is safe.

Thank you.

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