GENEVA — Leading global efforts to control and eliminate malaria is not a position for the fainthearted. The fight against this disease, which threatens nearly half of the world’s population, is up against three major roadblocks: the need to double funding to $6.4 billion by 2020, the rapid spread of resistance to drugs and insecticides, and the entrenchment of the infection in hard-to-reach areas, especially in high-burden countries.
Pedro Alonso, at the helm of the WHO Global Malaria Program since October 2014, is no stranger to those challenges. He has been instrumental in the development of the most advanced candidate vaccine globally — to be piloted in three African countries in 2018. In 1991, he showed for the first time the impact of insecticide-treated nets, paving the way to the 60 percent reduction in mortality rates since 2000.
Upon taking up position as director, Alonso vowed to bring the WHO’s program closer to the needs in the field. Ahead of the release of the World Malaria Report 2017, Devex caught up with him to discuss how the program is tackling its most pressing challenges and to unveil progress in crucial initiatives such as vector control.
He also shared his views on the role of the private sector, domestic contributions and partnerships, and explained what the expansion of the President's Malaria Initiative programs means to global efforts. Our conversation has been edited for length and clarity.
The World Malaria Report 2016 stressed the need to accelerate interventions to fill gaps in coverage. What actions have been taken and now should be taken to reach vulnerable populations, especially in the countries with the highest burden of malaria?
Our upcoming World Malaria Report 2017 will stress, once more, that the problem of malaria is a very long way from being solved. Any feeling of complacency or of ‘mission accomplished’ is profoundly mistaken.
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To tackle it, we must progress toward universal coverage, so that all at-risk populations have access to basic prevention, diagnostic and treatment tools. By universal coverage we mean reaching the most remote, abandoned populations. It is among this hard-to-access communities where the bulk of the problem persists.
Achieving this takes three things: political commitment of affected countries and their ministries of health, an extension of primary health services, and adopting community-based approaches such as the deployment of community health workers — mechanisms that are not new, but that we now intend to strengthen.
The Global Technical Strategy for Malaria 2016-2030 aims to reduce case incidence and mortality rates by at least 40 percent by 2020. How important are financial contributions by affected countries to advancing towards these milestones?
Domestic contributions are key. International aid is extraordinarily important, but it should not obscure the need for affected countries to take ownership of the problem.
Each country must take the driver’s seat in the fight against malaria in its own territory, and this must go beyond a political rhetoric of the kind ‘we will implement it, but give us the money’. This leadership must be translated into a financial effort, into a greater use of each country’s resources.
Given the importance of mobilizing additional resources to step up the fight against malaria, is WHO exploring innovative finance mechanisms?
We do take part in discussions about innovative financing; we try to encourage them, and we support the development of new financing tools. However, we believe that none of these mechanisms will replace either the efforts required by affected countries or international aid, which must play a complementary role.
Sri Lanka, for example, is a medium to low-income country, but it managed to eliminate malaria and, to a great extent, it did so with its own resources. It received some support from the Global Fund, but it achieved elimination mostly through its own means, just like other countries had previously done. Many other countries are also experiencing remarkable progress towards this goal.
What role should the private sector play in the global efforts to eliminate malaria?
The private sector is absolutely indispensable, especially in the development of innovative tools such as vaccines, medicines, insecticides and diagnostic tests. To a lesser extent, it also plays a role in terms of capacity-building and financial support.
Yet, what we need is a strong public sector that looks after public health at the national and global levels, and that is capable of articulating the participation of the private sector.
How important are innovative partnerships in eliminating malaria?
A number of partnerships in malaria, tuberculosis and HIV/AIDS have been around for the last 20 years, so partnerships are nothing new. Are we still seeking new formulas? We are, but I would not say this falls within my scope of priorities.
Partnerships are great as long as their role is to support — never replace — national and global health agencies. They must respect the central role of countries in leading their own efforts. Historically, this is one of the elements that has proved most challenging to partnerships, as they face the risk of being unduly influenced by one actor or another.
We know that countries are accountable to citizens, and that UN agencies are accountable to the General Assembly, but who are partnerships accountable to? Hence, it is key to clearly define the roles and responsibilities of each actor and to establish accountability mechanisms.
Development of resistance in both parasites and mosquitoes is one of the most pressing challenges. What strategies does WHO and its partners employ to tackle it?
The fight against malaria faces financial and political challenges, but also biological ones. This includes the capacity of parasites to become resistant to drugs and that of mosquitoes to become resistant to insecticides. Additionally, we are now observing the capacity of parasites to mutate and become invisible to most of the rapid diagnostic tests we are using.
First of all, we must remember that this is purely a matter of evolutionary biology. It should not come as a surprise because, consistent with basic biological laws, organisms develop resistances as a survival strategy.
Now, what can be done about it? First of all, we are monitoring the emergence and spreading of resistances. This information, in turn, allows us to rotate the drugs, insecticides and diagnostic tests we are using at a given moment.
The third step is a crucial one: acknowledging that, when it comes to living beings, you can win battles, but not the war — that is, not unless you eradicate them, as was done with smallpox.
This requires an ongoing research effort to always be a step ahead of the organism, meaning that we must have developed new insecticides and drugs by the time resistance to the current ones emerges.
This May, WHO launched the Global Vector Control Response 2017-2030, which provides guidance on an integrated approach to counter the growing burden and threat of vector-borne diseases (i.e. transmitted by insects and other organisms). What steps have been taken toward the implementation of this approach?
WHO is translating the guidance provided by the GVCR into regional frameworks which, in turn, will give place to national ones. We will see this unfold within the next 12 months and, by that time, I believe we will have national vector-control programs, which is what we aim for.
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Some countries were already implementing some of these recommendations 30 or 40 years ago. The GVCR, then, is an enormous call for attention to remind the international community that vector-borne diseases are still the first cause of premature death and disability in many parts of the world.
In public health, we always fall prey to mistaken feelings of ‘mission accomplished’ and to false dichotomies such as: the problem now is not infectious diseases anymore, but non-communicable ones.
Vector-borne diseases are not a thing of the past, but the world must face tragedies such as zika and dengue epidemics to remember that the problem has not yet been solved. The problem with such false dichotomies is that they lead — as happened in the fight against vector-borne diseases — to the abandonment or even the dismantling of the structures and services that enable an effective response.
What key strategies must be rolled out to fight vector-borne diseases?
To effectively prevent and fight against these diseases we need a research agenda; integrated mechanisms that encompass urban planning, municipal hygiene services and national health systems; and capacity-building, which has been enormously debilitated worldwide.
We have a huge human resource crisis in the fields of entomology and anti-vectorial fight. People just stopped pursuing education in these areas, because they were thought to be a thing of the past. What a big mistake!
The U.S. President’s Malaria Initiative has just announced the launch and expansion of programs in West and Central Africa. What is your take on this announcement and how critical is the ongoing support of the U.S. in the fight against malaria?
It is vital. We believe that, at this moment in time, such an announcement constitutes an extremely important sign — the fact that, not only is the U.S. not cutting down its contribution to international malaria programs, but it is actually increasing it. The U.S. is, by far, the largest donor to global malaria efforts.
What are the next steps in terms of research and innovation and which paths are especially promising?
The priority is to keep a wide perspective and pursue multiple lines of research. We need new medicines, vaccines, diagnostic tests, tools to fight the vector, and operational strategies, for example, with regards to massive drug administration.
Holding that one line of research is more important than others would be a mistake. This has often been the case, and it has resulted in a bias toward one line at the expense of others: financial resources have been primarily allocated to one area, while other important ones have been more or less neglected.
Upon taking up position as Director of the WHO Global Malaria Program, you spoke about delivering a more action-oriented program that better served countries. What strategies are you using to bring this commitment to life?
We want to be a lot closer to countries, and I think we are succeeding. First of all, WHO should not only be about more or less smart people churning out guidelines in Geneva, but about getting them implemented in the field. This has actually become our indicator of success: how many guidelines and policies get implemented, rather than how many we produce.
Secondly, we are a lot more involved in hot issues, starting with the Greater Mekong Subregion — the epicenter of malaria drug resistance. We are clearly leading the efforts to eliminate malaria in this part of the world.
A third aspect is the opening of a very new phase based on participating — and to a great deal leading — the response to humanitarian crises. This phase started with the Ebola outbreak, but it now has a hotspot in Boko Haram-affected areas. WHO teams recently implemented massive malaria control measures in northeast Nigeria. Unsurprisingly, malaria is the leading cause of death among this population.
It is about delivering on our core function to develop guidelines and to monitor progress, but it is also about climbing out of a sort of ivory tower and directly supporting countries from the field.
What is your vision for the future of the WHO Global Malaria Program?
The program should remain a lighthouse, while also being present in the field. We also have an extraordinarily powerful malaria team from both a technical and a scientific perspective. Maintaining and further strengthening WHO’s credibility and technical leadership is another goal. There is a lot to do, but I believe we are moving in the right direction.
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