A woman and children under a mosquito net in Cambodia. Photo by: Richard Nyberg / USAID / CC BY-NC

MANILA — In 2017, 26 experts comprising the Lancet Commission on malaria eradication were confronted with a question: How close is a future with no malaria at all?

In a new report published Sept. 8, the commission answers the question: The world can be malaria-free by 2050.

There are a number of measures needed for this to happen, the experts said in the report: better use of data and partnerships with the private sector; country, regional, and global leadership and accountability; new and better drugs, insecticides and diagnostics; and more financing.

The world will need an additional $2 billion investment per year for malaria, on top of currently estimated annual spending levels of $4.3 billion. The experts recommended dividing the bill between external donors and domestic country financing: a quarter or $500 million of the additional resources will be shouldered by external financing, while the rest of the $1.5 billion come from the governments of countries where malaria remains endemic.

The date and dollar requirements will help achieve the goal, Richard Feachem, head of the commission, said. “Having an aggressive timeline, setting a date, being committed to it, actually encourages donors,” he said.

“In that context, the upcoming replenishment of the Global Fund, which will be taking place next month in France, is really critical. And we are hoping that the Global Fund will receive an extra $200 million per year — $0.2 billion — for malaria specifically as a contribution to that extra $2 billion that we're calling for in total,” Feachem said.

Feachem described the malaria research and development pipeline as being “very healthy at the moment.” But even with a new drug, tafenoquine, beginning to be rolled out, and another one or two new drugs expected to be available by 2024, there is still a need for drugs that are faster acting and easier to administer. Ongoing research is also needed for more sensitive diagnostics, new insecticides as well as new vector technologies that will help address the problem of “outdoor biting,” which is common in Southeast Asia.

“Current vector control technologies — indoor spraying and insecticide-impregnated bed nets — are really effective primarily against areas where the mosquito bites indoors in the evening. But if the mosquito bites outdoors, earlier in the afternoon, as is common in Asia, then our current technologies are not very effective,” he said.

But given the challenges and failure of past eradication attempts, some experts have called for caution in once again setting end dates for malaria eradication.

Is it still too soon to assign an end date for malaria?

Even with the scale-up of current tools to fight malaria, by 2050 Africa will still have about 11 million people infected with the disease, according to a new WHO report.

Devex spoke to Feachem about these concerns.

This conversation has been lightly edited for length and clarity.

You mentioned some really exciting new tools and technologies. How close or far are we to having them available and ready to use?

The report sets out the timelines that we anticipate. New diagnostics will become available over the next three, four years. New drugs by 2024 as I mentioned. Molecular surveillance is improving all the time. New insecticides, well we already have one or two new insecticides under trial, and more are expected before 2025.

It's an ongoing process. Obviously the R&D won't stop. We'll still be doing R&D in 2035 and in 2045, so we want to constantly revise and update our technologies, and discover new technologies … [That] brings us more and more opportunities. But I would say every year some new technology is rolled out and we expect that to continue over the next two or three decades.

Two weeks ago a group of experts commissioned by WHO published an executive summary saying that even with the scale up of currently available tools, we still won't be able to eradicate malaria by 2050. Does that go contrary to what you're saying in this report?

No, I don't think so. The commission itself [did this] detailed modeling and future forecasting work on what malaria might look like in 2050. And the commission found that with the impact of global trends — socioeconomic trends, climatic trends, environmental trends plus the scale-up of today's interventions, and I emphasize today's interventions — we could expect the world in 2050 with essentially no malaria outside Africa.

Malaria in Africa [will be] reduced to foci: low prevalence, low transmission pockets of malaria or foci of malaria, that of across equatorial Africa roughly from Senegal in the northwest through to Mozambique in the southeast ... hugely reduced.

The focus then of the commission was, how can we bend the curve? How can we convert that model of the future into a different future, a future with no malaria at all?

So the commission confronted the question, if we do those things [strengthening software, new technology, increase spending, and strengthening leadership and accountability], can we create a 2050 with no malaria? And the commission's answer to that question is yes we can. Therefore we should commit to that and set a date and get on with the job.

Taking a look at the current polio eradication push, is it possible for the eradication date of 2050 to change as well as we move forward?

You mean as we learn from experience? I think it could change in both directions. I would hope that it would change by becoming sooner rather than later. But with all big goals like this, we set the goal, we set the intermediate milestone — where do we need to be in 2025, 3035, 4045 — and then of course we measure and we monitor and we watch things very carefully. And we may arrive in 2030 in a position where we say, 'Well we were too pessimistic. We can do better than 2050. We should revise our goal to 2045.' Or we might arrive at 2030 and conclude that things were not quite on track.

And then we have two options. We can get more vigorous. We can get more aggressive to get back on track. For example, accelerating the R&D agenda. Find solutions to some particular problem that has raised its head, which we didn't expect. Or, I think disappointing and I hope not, we could change the end date and say we're now shooting for 2055.

But I think the best response is if we find ourselves a little off track by 2025 or 2030, or if we find an unexpected challenge — and in all of these multiyear efforts, there will be unexpected challenges. There were unexpected challenges with smallpox and have been with polio, et cetera — we can then rise to that challenge and focus on solving that unexpected problem, and hopefully keep the 2050 date.

One of the worries of some of the experts is the potential of fatigue or disengagement by the malaria community if the push for eradication doesn't happen by 2050. Have you considered that as a potential consequence of putting a date to malaria eradication?

Yes, we have. The commission membership included senior representatives from the Global Fund and the most senior person in the U.S. President's Malaria Initiative and others who represent the funding side of things. Former ministers of health, for example, who can speak to the domestic funding, the funding by endemic country governments. And we considered this question in some detail.

Our conclusion was that having an aggressive timeline, setting a date, being committed to it, actually encourages donors. And to be open ended, to be vague about when this task is going to be finished, to be vague about the goal precisely is actually a way to ... discourage donors, because they're left with a feeling this will go on forever. Does this have an end?

Showing that it can be done by 2050, encouraging a commitment to that timeline, our judgment is that that is inspiring to donors, encourages them, and as important or more important than donors, it's inspiring to national governments.

If I can come back to the Philippines for a moment, the Philippines will eliminate [malaria] by maybe 2025, and that aggressive timeline stimulates the Philippine government to continue to spend its own money on getting this task done. And my hunch is that if it was all open-ended, and the Philippines didn't have a goal and wasn't sure when the job would be completed, then the urgency and the commitment to spend the money to get the job finished would decline.

If not everyone's sold with the idea this will be eradicated by 2050, do you think that will have an impact on the goal that you're trying to achieve?

Yes. Well, the Lancet Commission, it's the collective opinion of 26 commissioners and about 20 additional authors. And we've put forward a scientific case, an evidence-based case. And that must now be debated. Over the next few months, we will discover where the consensus lies.

Now we very much hope that the consensus will lie in the place where the commission proposes, that there will be a broad consensus and commitment to eradication by 2050. But that question has to be debated, should be debated. The debate starts in Geneva on Monday.

Then we're discussing our findings all around the world over the next six months. It'll be a vigorous debate.

First and foremost, we need to hear from experts and politicians and leaders of the endemic countries and particularly the highly affected endemic countries such as many African countries or India or Papua New Guinea, to hear their views about whether they want to take on an ambitious goal of this kind. Do they feel they can do it? What would they need in external assistance to allow them to do it?

In other words, how ... do the recommendations of the commission dovetail with or chime with national and regional ambition. And one thing that struck the commission very strongly in its work is the rise of national and regional ambition in the past 20 years. Since the year 2000, countries have become much more ambitious, which has led to elimination in China, Malaysia, and Sri Lanka, for example.

What lessons have you incorporated from the previous malaria eradication effort decades ago?

This is the 50th anniversary, as you probably know. The global malaria eradication program started in 1955 ran to 1969, and was abandoned exactly 50 years ago in July 1969. And the commission looked in detail of that experience. And interestingly, the challenges are rather familiar. The challenges similar to the challenges we face today. But the opportunity to overcome those challenges is completely transformed.

We went through those challenges one by one, and asked the question: How is the world different in 2019 to how it was in 1969? What has changed in the last 50 years that helps us to overcome those specific challenges that caused the abandonment of the program 50 years ago? And we were very encouraged by that exercise. Every challenge you look at, you conclude that the armory of weapons, and the approaches and tools and technologies, that we have to overcome those problems today are hugely superior, I mean transformed from 50 years ago.

And you can see the evidence of that in the progress that individual countries are making. Mortality from malaria has come down by 60% since the year 2000. Twenty countries have eliminated since the year 2000. If you ask the question, could China have eliminated [malaria] in 1969? The answer is surely no, it couldn't have. But three years ago, China did eliminate [malaria].

So this is [a] concrete illustration of how our techniques and technologies have so vastly improved to enable us to overcome problems, which 50 years ago, seem to be insurmountable and dramatically caused WHO to abandon the program.