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Dreams Die Hard

 Chris Hartlove

Dreams Die Hard

Mention “eradication” among malariologists, and you likely will spark a hot debate. All agree that the goal is noble—but from there controversy ensues. Is eradication manifest destiny? Or is it a pipe dream that does more harm than good?
           

It's Complicated

“I can’t stand this word,” says Clive Shiff, associate professor in Molecular Microbiology and Immunology (MMI) and a veteran of the long war on malaria. One among many, he believes that malaria is a human public health problem that will require attention for as long as we inhabit the earth. Control yes, eradication no.

In the malaria lexicon, “control” refers to vigilant, coordinated programs of drug therapy, spraying, research and education, which can reduce the disease burden to a manageable level. Further along the continuum, elimination is the interruption of malaria transmission in a region. Eradication is a global, permanent reduction to zero.

“When we talk about eradication,” says Shiff, PhD, “we relay to people in endemic areas that this is achievable, and then they think they don’t have to plan or budget for malaria control. It’s an excuse to stop the effort.”

In fact, a November 2010 Lancet series endorsed control as a near-term goal, arguing that it appears more realistic and cost-effective than elimination or eradication.

Over the last 60 years, there have been dozens of success stories in control—and stories of devastating defeat when control programs were halted. “Malaria can be controlled,” says Shiff, “with sufficient resources…. If done extensively, it will work.” New tools like cell phones and rapid diagnostic tests are enabling health officers to target interventions in real time.

Donor money can help endemic regions to bring down the parasite load, but after that, ministries of health must take on responsibility for long-term control programs. “Governments have to realize that they have to run the show,” says Shiff. “We can control malaria. But we tried eradication. It wasn’t achievable.”

Let’s Get Together

Scientists like Rhoel Dinglasan, MMI assistant professor, respectfully disagree. Victory may be 30 or more years away, but he believes that with the right cocktail of collaboration, openness and inspiration, it can happen. “Early efforts failed at eradication, but it’s not original sin. It doesn’t mean we’re going to fail,” he says.

 In 2009, the molecular biologist was asked to create and co-chair the Young Investigators consultative group of the Malaria Eradication Research Agenda, or MalERA (malera.tropika.net), to outline research priorities toward the long-term objective of eradication.The Young Investigators produced a paper specifying research that would augment current eradication efforts—urging frank conversation and the sharing of raw data.

 Candid about the role of basic science in malariology, Dinglasan, PhD, MPH, admits that not all research in the discipline is directly applicable to solving the questions of elimination and eradication. “However, we also haven’t really applied ourselves,” he says. One of the goals of MalERA was to guide public and private enterprises in prioritizing the research that should get funding. One example: Use a team to complete the life cycle of the parasite in vitro so labs could  test new drugs and interventions against all stages of the parasite in high throughput. “It’s not a hypothesis, it’s a to-do list,” says Dinglasan.

“We want to get data and approaches to feed into this effort now, so that in five to 10 years, the community will be armed with this ‘tool’ that can quickly move discoveries from bench to the field. Then people will start to believe.” 

Dinglasan may be called naïve—but he clings to his vision: “How do I continue to be optimistic and inspire people despite the huge challenges ahead? I don’t know. Maybe it’s the caffeine.”

Comments

This forum is closed
  • Jaime Chang

    Peru 01/20/2011 02:10:36 PM

    Personally, I don't favor rising flags like "malaria elimination" or "malaria eradication", even though elimination –arguably, depending on definitions – is obviously possible (e.g. there is no malaria transmission now in Foggy Bottom, Washington D.C. – way things go, that might change for the worse in the future). Eradication is a different animal, and I believe proposing it as a goal is even of less practical purpose than raising the flag of elimination. We tend to drop all and run behind the flag held by the “influential ones”. The way it happens, no matter how powerful, well intentioned, positive, etc. the promoters are when they raise the flags, more frequently than candidate partners (i.e. countries) have systems very much far from the level of performance they would need for seriously aiming to malaria elimination as it has been discretionarily defined. Elimination is a construct that describes a situation that may or may not be reached. Many countries in Latin America have now areas of “unstable zero transmission” where no malaria transmission is detected in an unstable situation since all factors but the parasite are present (hence outbreaks), very much like in the 1990s. If elimination is feasible, the best way to eventually get there is through sustained and sustainable improvement of the performance of the health system (comprehensively defined from minister through citizen) in charge of surveillance, prevention and control, the three of which would have to continue also after the “elimination milestone” is reached. One thing is for sure: Systems and programs must continuously evolve to address the malaria context before them, maintain the capacity to appropriately react in case of a set back.

    Jaime Chang, M.D., M.Sc.

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