Malaria Summit

Bill Gates
London, United Kingdom
April 18, 2018
AS PREPARED

Thank you for that kind introduction.

It is fitting that we're talking about the way forward in the fight against malaria while the Commonwealth Heads of Government are meeting. The Commonwealth includes some of the highest burden countries in the world—and some of the most generous donors. The Commonwealth has been and will continue to be on the front lines.

It's especially fitting that we're doing this in the United Kingdom. The British people's ongoing generosity has helped reinvigorate the malaria fight. And more than a century after Sir Ronald Ross discovered that mosquitoes transmit the parasite, British R&D is still giving us the tools we need to win it.

I don't use superlatives lightly. But thanks to the commitment and strategic vision of so many of you in the audience, progress against malaria has been one of the most impressive successes in global health in this generation.

The global situation has changed so much that it's hard to remember what it was like before the turn of the millennium. But it's worth looking back, to see how far we've come.

• Back then, insecticide treated bed nets existed but weren't used at any kind of scale. The insecticide sprays that had helped control the disease in the 1950s and 1960s had lost their effectiveness or posed safety risks, and nothing had replaced them.
• Detecting malaria required a microscope and the wherewithal to take blood samples, prepare slides, and interpret the results. Even then, it was rarely rapid and only sometimes accurate.
• Treatments we'd relied on for decades, chloroquine and SP, were no longer working in many places.
• Finally, there was very little money available to pay for innovation to fill these gaps or scale up any of the solutions that were available.

In 1999, our foundation's first malaria investment, to help set up the Malaria Vaccine Initiative, nearly doubled global malaria funding. That year, almost 1 million people died of malaria.

But then, in 2000, the world adopted the Millennium Development Goals. In 2002, the Global Fund was created to help achieve the MDG targets. The U.S. President's Malaria Initiative was also launched in 2005. And the world turned a page on that sad chapter in the history of malaria and started writing a new chapter.

Since then, malaria funding has increased by 1,000 percent. This increase has financed the massive delivery of interventions—highly effective artemisinin combination therapies, rapid diagnostic tests, indoor residual spraying, and especially insecticide treated bed nets. These innovations, along with improved case management, have saved almost 7 million lives.

Let me show you two pictures of what this change looks like.

This is a map of the world showing the countries where the disease was endemic in 2000.

Since then, six countries have been certified by WHO to have eliminated malaria, 12 additional countries have attained zero malaria status, and more than 40 countries have fewer than 10,000 cases. Essentially half the world is now malaria-free.

But, as Melinda and I have always said, we can't accept a world where malaria has been eliminated in some places and children continue to die in other places. Not when the disease is preventable, treatable, and beatable.

This is a map of Africa in 2000.

The swaths of red represent high transmission areas, which were much of the continent. The patches of blue are lower transmission areas. Look at how the picture changes as we delivered new tools. In 2010, the Democratic Republic of Congo was still bright red. Some experts wondered whether we could be successful there. But when nets were rolled out in DRC, it started turning blue, too.

Here is the map now. It's a different world—a world with less illness, less death, and more potential. It's the world you created.

If there is one lesson we have learned, though, it's that we have to keep innovating to control malaria, because conditions evolve. The mosquito and the parasite develop resistance to the interventions we use to fight them. People move around and constantly change the patterns of transmission. Attention and funding go up and down.

Because conditions evolve, we must evolve, too. Today, I would like to talk to you about how our collective response can evolve in the next several years to keep on saving and improving more lives.

What got us where we are today—blanket coverage with a small handful of tools—will not get us where we want to go tomorrow.

Global malaria funding is flat. Much of it is going toward replacing worn-out nets and re-spraying houses, which means we're using a significant portion of our money just to keep up. In the meantime, the nets, sprays, and drugs aren't working as well as they used to. Pyrethroid resistance is widespread. We're seeing pockets of resistance to artemisinin—and even more to its partner drugs. Finally, human migration is continually importing the disease from high burden areas to lower burden areas.

In 2016, for the first time in years, the number of malaria cases in the world went up. This is not a blip. It is not noise. It is signal. What it signals is this: We have reached the point of diminishing returns from our current strategy.

And despite the success of the past 15 years, the malaria burden is still unacceptable. More than 200 million people suffer from the disease every year. They are vulnerable to co-infection with other debilitating diseases and chronic anemia. And a child still dies from malaria every minute of every day. Together, we can stop this from happening.

To do that, we must write another new chapter in the story of our fight against malaria. The crux of the next chapter must be precision, based on data.

Right now, generally speaking, we apportion bed nets by counting up the population at risk in a given country and dividing by a certain amount. That was the right strategy for getting from no coverage to progress against the disease. It is the wrong strategy for building on progress.

Even with the small handful of tools we've been using, we can get better results by targeting delivery based on the epidemiological complexities on the ground. For example, we want our nets going to areas in a country with heavy indoor biting, but currently they're just as likely to go to areas with more outdoor biting. We need to prioritize delivery to highest impact areas within a country. Given that we have limited resources, we can't afford anything less than maximum impact.

Moreover, thanks to our community's wise investments in research and development, more tools are coming. These will provide even better opportunities to tailor our solutions to the conditions we're encountering in the field—but to do that we need much more sophisticated understanding of those conditions.

This will not be an easy undertaking. We must invest in high-quality data and surveillance, so that we have the insights we need to optimize our planning. And then we must design and build systems that are prepared to execute on precision plans that mix and match interventions in ways we've never done before at scale.

Let me emphasize that we need this new strategy whether our aim is to save lives now or eradicate the disease later. These goals are not mutually exclusive; they are mutually reinforcing. Preventing transmission and managing cases in the highest burden areas in the world saves lives and lays a strong foundation for eradication. No matter where you come down on the question of eradication, our job is to save as many lives as possible as soon as possible.

SURVEILLANCE

So what will this improved surveillance look like? To respond to malaria with a tailored package of interventions, we need surveillance with much more geographic detail, we need it in real time, and we need it to capture more information.

First, geographic detail. In many cases, we're working with national level surveillance data—how many people in a country are at risk? We need to start stratifying risk instead of behaving as if it is a single category of analysis. Who, specifically, is at risk of what, specifically?

Malaria is a patchy disease. We need to understand the patches. This requires data down to the district level or even lower. Advances in satellite imaging and machine learning will make it much easier to build surveillance systems that operate at this kind of resolution.

Malaria isn't just patchy. It's also spiky. We need to know when those spikes happen, so that we can mobilize. In elimination settings, we need to know about every diagnosis right away, so that we can prevent large-scale reinfection. Electronic reporting through handheld devices can turn our current surveillance system, with its months of lag time, into a real-time system that's also geolocated.

Some innovative countries are pointing the way forward on surveillance. Zambia has invested in the core of its surveillance system, training health workers to report and track infections accurately as well as provide treatment. It is also investing in new tools; one-third of the health facilities in the country now provide near real-time reporting.

All this is fed into national, provincial, and district risk maps. Zambia also uses visualizations like the one I'm showing here to help leaders identify problem areas and track case management. I'm showing the IRS coverage for Southern Province, where improved surveillance and data for decision-making has led to a 92 percent reduction in malaria deaths since 2014.

Despite pioneers like Zambia, there are many outstanding questions about how to design and build these improved surveillance systems. We haven't needed them until now, and we haven't had the technology to support them until recently. Our foundation is eager to partner with you to start answering these questions and setting us up for success in the next chapter of the story.

INNOVATION

The great news is that, unlike 15 years ago, when we were emerging from decades of stagnation, the innovation pipeline is producing results—in prevention, detection, and treatment.

First, prevention.

The IVCC here in the UK has partnered with crop protection companies to develop new insecticides. We finally have enough new IRS agents to set up a rotation to slow the development resistance.

And we have a new generation of bed net that's treated not only with a pyrethroid but also with a second class of insecticide.

Second, detection.

Highly sensitive rapid diagnostics can detect malaria in people who aren't sick and don't know they're a reservoir for the parasite. This is especially promising for areas where the malaria is less dense, but stubborn.

Third, treatment.

Thanks to new drugs developed through the Medicines for Malaria Venture, we have more options for managing cases, especially severe cases. Two new ACTs give us options to address resistance. And we look forward to a single-dose regimen for treating relapsing vivax malaria, currently in development by GSK. Compared to the current 14-day regimen, the single dose will be much easier for patients to adhere to and finally accelerate progress on vivax malaria.

All these improved tools are in our cache already—or will be very soon.

In the medium- and long- term, there are tools in development that could fundamentally transform the fight against malaria.

For example, early results suggest that we may be within five years of an innovation that could do for outdoor biting what bed nets did for indoor biting. I'm holding it here. It's an Attractive Targeted Sugar Bait, or ATSB.

This is basically fruit juice mixed with an insecticide. The bait attracts at least 30 percent of the standing mosquito population every day. And because it's stored in a special polymer that only mosquitoes can get through, it doesn't kill pollinators.

RTS,S, the first approved malaria vaccine, will be used in the field starting later this year.

We're working with GSK and other partners to find ways to make RTS,S more durable. In the meantime, the search for next-generation vaccines, including vaccines that block transmission as well as prevent infection—continues.

I'm very energized about the potential of gene drive, a method of self-sustaining genetic change that can make mosquitoes infertile or prevent them from carrying the malaria parasite.

Gene drive is the kind of breakthrough we need to support while simultaneously deploying other more incremental tools. The African Union endorsed a report on gene drives in January, encouraging Member States to harness the technology for development. This comes as researchers continue to perfect the science and developers work with regulators in endemic countries to set up field trials as soon as possible.

To me, this long list of new and future tools is exciting.

It will be a challenge to cross-reference a whole suite of tools with a mountain of data and update our logistical systems according to what we learn, but this is the challenge we must meet in the next several years.

CONCLUSION

Since I started my second career almost 20 years ago, I've seen a lot more suffering than I ever planned on. It's haunting. It's also motivating. It reminds me exactly why the work we're doing together is so important and so urgent.

One of the worst things I've ever seen, years ago in Tanzania, is a child having seizures from cerebral malaria. I didn't know if he would survive. I did know that, even if he did, his brain development would be impaired.