Q&A: Gates experts on how to beat malaria with data

SAN FRANCISCO — The news that progress in the fight against malaria has stalled signals the need for a new strategy, according to Bill Gates — and data and surveillance should be at the heart of it. “I view data as the lifeblood of how we’re going to be smarter,” he said at the Bill & Melinda Gates Foundation’s Malaria Summit in London on Wednesday, where he announced commitments including $1 billion for research and development efforts to end malaria. Gates emphasized the importance of leveraging data in making continued progress against the disease — from the geographical detail made possible by technologies such as mobile phones and satellites, to the genetic sequencing of geolocated mosquito and parasite samples. “There is pretty broad agreement from most of the actors over here, whether it be on the drug or the vector front, that without getting this data they are not able to target their interventions and these resources are wasted,” Trevor Mundel, president of global health at the Gates Foundation, told Devex. “I would say the challenge is almost everyone agrees surveillance is a good thing, a healthy thing for the system, but to actually get action on surveillance is a little bit more difficult.” Devex spoke to Mundel and his colleague Philip Welkhoff, the foundation’s new malaria program director, to learn more about the role of data and surveillance in turning the tables on the disease. The conversation has been edited for length and clarity. The Malaria Summit on April 18 saw major commitments to the Global Fund to Fight AIDS, Tuberculosis and Malaria: The United Kingdom announced it will match new contributions from private donors up to 100 million British pounds ($140.7 million); the Gates Foundation pledged a further 50 million pounds in matching funds; and the Global Fund announced commitments totaling $2 billion from 46 countries affected by malaria between 2018 and 2020. Can you expand on what you hope to see from the Global Fund moving forward? Mundel: It’s a pretty exciting year for the Global Fund, with Peter Sands coming on board. We’ve had some preliminary discussions with him about some of the systematic approaches that he might bring to bear. The most important one is a triangle between the Global Fund, NGO partners, and the national governments. In the past, in some cases, national plans were not tailored to the particular situation in those countries, or were not monitored or measured in terms of those outcomes. Some countries have quite strong national programs and can tap into regional resources, like the Elimination 8. But in other cases, there needs to be some strengthening, and building of capacity in the national program. A number of key governments are quite dependent on donors for malaria funding, and because many of them rely on the Global Fund, it has strong leverage. If the country plans can be well designed, and have milestones that need to be met and measured, and if the Global Fund can encourage and facilitate the development and evaluation of those plans, that is a magical circumstance for moving forward. The Gates Foundation has been a leader in bringing the lessons of polio eradication to bear on other global health priorities. In his talk at the Malaria Summit, Bill Gates said that one of those lessons is the importance of data. Can you expand on this? Welkhoff: One of the things that becomes very clear when we try to tackle malaria is that there isn’t a one-size-fits-all approach. Depending on the local situation — what are the mosquitos, how intense is the transmission, and what is the level of the health system — a different set of approaches will be needed. Because malaria has such a high level of local variability, and because there are limited resources, we need the right level of data to be able to come up with this tailored mix of interventions that can be targeted not just at a country level but at a subnational level to have the biggest benefit possible. There’s a very strong role for improving the collection of data, in terms of sampling the mosquitos and looking for insecticide resistance; sampling the parasite and monitoring drug resistance; and monitoring whether the current diagnostics will continue to be effective. This is more than just understanding at a global level what the general trends are. It has to be actionable at the country program level, to make decisions about how to prioritize and target interventions. There are three parts of the problem: One is new tools for collecting data, two is the collection of data, and three is putting it in a format that is most useful to countries. If we don’t have all three parts of that value chain, it’s incomplete. Once it becomes clear which interventions are needed, the question becomes: Are they happening? Polio taught us that it’s not just the numbers on national coverage or state level coverage that matters. The polio vaccine was being distributed repeatedly in some of these difficult areas, and yet transmission persisted. When we went and mapped out where are the houses, where are the people, at a very granular level, and then overlaid that using GPS tracking of where the vaccine was being delivered, it became clear that there were spatial gaps that the vaccine wasn’t reaching. And those spatial gaps corresponded to where transmission was being sustained and preventing elimination. We need to learn from that example for malaria. Not only do we need to collect data in terms of where we need to target interventions. We also need to measure where those interventions have gone — where did we give out nets, where did we spray, where did community health workers get established. It’s an iterative process, but it’s about the research and development, the collection of data, then using and applying the data, and then measuring to make sure the data was used to target interventions appropriately. We’ll be working on that with partners both internationally and at a national level. In his talk, Gates mentioned Zambia as a country that points the way forward on surveillance. While seven of the Elimination 8 countries had an uptick in malaria last year, Zambia continued to make progress against the disease, due in part to its data-driven decision-making. What makes these stories of positive outliers in global health so important? Welkhoff: Working with partners to demonstrate how investing in surveillance, and using some of these new tools, can push the burden lower, can be incredibly helpful. The evidence has to be built that this can be done, and that it can be done at national and multinational scale. Once that’s demonstrated, it’s very possible to show that a certain fraction of a country’s malaria budget should go toward implementing these tools, because you can see how it translates into saved lives and higher impact. There is a catalytic effect of demonstrating this at scale. Mundel: We’ve been focused here on the nation states. But some countries, like Namibia and Swaziland, that have been fairly rigorous in their own internal programs are hampered by the impact of hotspots — Angola in the case of Namibia, and Mozambique principally in the case of Swaziland. That is a situation where you absolutely have to have a regional approach because no matter how systematic your national approach, the migration pattern overcomes any of your interventions. Welkhoff: One of the lessons, again from polio, is when you get into the last countries it becomes increasingly difficult and this last mile is tremendously challenging. Some of the things that will be needed to succeed in the difficult places will take over a decade to build up, in terms of improving the surveillance systems, the ability to gather data, and use it. There is a real opportunity across the malaria community to help shape these questions of how we can use data; what data is required; and how we can collect it in a way that translates in a timely way to national action, and regional action, and accountability for leadership. Gates also talked about the need for a new strategy whether the aim is to save lives in the short term or eradicate the disease in the long term. Can you expand on the need for more collaboration among those working on the fight against malaria? Mundel: There is this notion that there really are two camps: One focused on eradication and another focused on day-to-day case control management, which have been somewhat moving along their own trajectories. But Bill was clear in his opening address that there is really one camp. We all ultimately want to eradicate malaria. Welkhoff: What are the things we need in place to achieve eradication, which means elimination in the hard places? We need to have the ability to deploy enough targeted prevention of transmission, and we need to have good case management. Those two things, which are fundamental enablers for elimination everywhere, are also the two powerful levers for reducing cases. In order to do them effectively, you need improved data and surveillance. So, if we improve our ability to prevent transmission, and our ability to detect and manage and cure cases, all guided by improved data and surveillance, that triplet is essential for reducing burden everywhere, including the difficult places. It’s also the necessary prerequisite for eradication. So, I think we need to unify those camps. We all are on the same trajectory and need to cooperate and collaborate to actually drive forward over the next several years on malaria.