12 December 2012

Africa: Remarkable Strides, Formidable Challenges, Says Malaria Fighter

Photo: American Society of Tropical Medicine and Hygiene
Dr. Carlos 'Kent' Campbell

interview

In receiving the distinguished Joseph Augustin LePrince Medal in recognition of outstanding work in the field of malariology, Carlos (Kent) Campbell said last month that the world was witnessing "a true renaissance, an awakening about malaria". Campbell has been instrumental in developing malaria control strategies, particularly through his leadership at the Malaria Control and Evaluation Partnership in Africa (Macepa), a program at PATH funded by the Bill & Melinda Gates Foundation.

The program's efforts in Zambia have included nationwide distribution of insecticide-treated bed nets, the selective use of indoor spraying of insecticides, and the provision of new diagnostics and medications. As a result, there was a 50-percent reduction in malaria cases, hospitalizations and prevalence in children in Zambia between 2006 and 2008. The approach, called Scaling Up for Impact (SUFI), has been implemented in more than 40 African countries and is the standard for malaria control. AllAfrica spoke with Campbell to learn more about the fight against malaria and efforts at eradication. Excerpts:

Early in your career you started asking, 'What is malaria?' Did you ever get an answer?

Oh yeah. Malaria is an illness that is caused by an infection with a plasmodium parasite. So it's not just the infection. What we've been trying to control up to this point is the disease that is caused by human infection with a parasite. Now, as things have evolved, malaria is certainly more and more the infection itself irrespective of disease symptoms. From an epidemiologic standpoint, it's all in the definition. Up until last year malaria had been the disease and that disease has many different features, but it is a disease caused by the infection.

How did you decide to take on malaria as your life's work?

I was doing my pediatric residency at Harvard, and - being sort of a latter-day conscious objector through college and medical school - I hadn't taken any military deferments that would have allowed me to finish my residency. And so it became clear that I was going to be called up in six months. Here I was in the middle of my residency, married with two young children, and really not interested in going into the military. I rapidly began looking at options, and one option was the Centers for Disease Control (CDC). I somehow talked my way into the Epidemiology and Intelligence Program, and through that got a deferment to finish my residency and then go to the CDC. It was better than being a general medical officer in Vietnam!

Nine months into my stint an opportunity came open to go to El Salvador, where there was a huge amount of malaria. I knew nothing about malaria. I did not know Spanish. But I went through a crash course in both of them. My wife Liz thought this would be a great experience for our kids. We went, and that's where it all began.

Malaria was eradicated in El Salvador and most of Central America through a fairly simple means - effective water drainage and water management. Why isn't that possible in Africa?

It is different because of the mosquito vector. Mosquitoes that can transmit malaria - 40 or 60 species - are all known as Anopheles mosquitoes. But they vary drastically in their ability to transmit malaria. This has to do with biology, habitat, when they bite, whether they prefer human blood versus animal blood and other sort of things. The mosquito in Central America is a very poor transmitter of malaria.

It actually would prefer chickens and a variety of other non-human warm-blooded animals to get its blood meal. And it feeds at times when humans are not really available. The vector in Africa is basically a single species that is distributed all over the continent called Anopheles gambiae. It is like the superstar of transmitters. It only takes blood from humans. It only breeds in water that is right around where humans live. And once it takes in a malaria parasite in a blood meal, the efficiency of those parasites actually maturing and then making the female mosquito capable of transmitting, which takes about a week, makes it the most efficient of any known vector in the world.

How did momentum shift in the global fight against malaria in the 1990s, leading to calls for eradication?

Malaria got included into the portfolio of the Global Fund to Fight AIDS, Tuberculosis and Malaria. The presumption was that the big issue of malaria had to do with drugs, had to do with making drugs more available and affordable - just like the issue was presumed to be with HIV/Aids. Malaria was put in with HIV/Aids and tuberculosis and that opened up a huge amount of potential funding if countries knew how to propose malaria control strategies that made sense in Africa. That was what we'd been working on.

Also the results from a number of things became very clear. One was the incredible power that insecticide-treated bed nets had in terms of decreasing malaria transmission and thereby malaria child deaths in Africa, at least in a controlled trial setting. These were trials done in the late 90s and early 2000s. It wasn't clear if this was scalable but it was very enticing. And then there was the work on malaria and pregnancy, as well as a whole new class of anti-malarial drugs.

All of these things started coming together - the money was available and boom! The CDC funded me to be detailed to Unicef, and I worked there for two years as a senior advisor, developing malaria strategies. That became the platform by which we began to think about the structure of the program.

The problem was - and it was always a problem - malaria had no advocates. Nobody was marching in the streets complaining that nothing was being one about malaria, whereas that was happening with HIV/Aids. HIV/Aids didn't kill nearly as many people as malaria, but the people who were being killed by malaria were voiceless because they're poor women in rural villages with their children and they don't have any advocates.

So malaria largely had been, to use a bad term, 'accepted' - and it had been accepted forever. Generating enthusiasm about something being done about malaria on the parts of ministries of health was extremely hard to do. Everybody could identify it as the biggest health problem but nobody had ever seen anything positive happen. And there was no funding. The reason there was no funding wasn't because the potential wasn't there. It was because nobody had the components to be able to put together a good grant application to the Global Fund or to USAID. Nobody knew the structure of that sort of thing.

That was when I and the chief of heath and Rick Steketee, who was then the chief of malaria at the CDC, got together for a long weekend and sketched out what a program needed to look like. We realized that until people understood and evaluated what happened when a program was in the hands of national government, there wasn't going to be any traction with malaria. That's when I began working with the Bill & Melinda Gates Foundation as an internal consultant to lobby and to try to make the case for what was essentially a 'proof of principle'. We decided we had to turn the model around and look at transmission. We identified that you had to rapidly scale up use of insecticide-treated bed nets to high levels. We proposed that you had to get 70 percent of the population using bed nets and then you would see this drop of childhood deaths.

We also said it would not take a thousand USAID consultants running around your country. This could be done by national governments with good support and with good funding. Finally, we got the resources to try this approach, and the first country turned out to be Zambia. Our sense was that it was going to take four or five years of coverage and then we would begin to see this turnaround.

What was the attitude of the Zambian government toward malaria?

Zambia was and continues to be a remarkable country from a health standpoint. The minister for health was very, very excited about malaria. He gave complete support, did everything possible and was a cheerleader for the whole thing. He mobilized the program, and the government moved throughout almost all the provinces in about 18 months to get to about 50 percent bed net coverage in a Herculean effort.

It's possible to document over the period of the first 24 months a 29-percent decrease in child mortality. To put that in perspective: there's nothing matching that, which is reflective of how much death malaria caused in Zambia and how powerful bed nets are to decrease transmission.

That's all it really took. It was just remarkable. Clinics emptied out during the transmission season. We worked with a number of partners to document the story and then to disseminate the approach to other countries so it could be adopted and adapted.

Within three years there were a dozen other countries that had embarked upon the same strategy and program. And within 12 months they were seeing almost identical decreases in childhood mortality. These results were more striking than anyone could imagine: this could be done by national governments and it was not something that was idiosyncratic to Zambia. It happened in the hands of other governments, with other partners and it seemed pretty much predictable.

It seems that this early success in Zambia was foundational to later successes. Is that fair to say?

I think so. There were other groups doing bed net trials, and we were working with them. But I think it is fair to suggest that our work was critical to the sort of group effort that went into the operational research and the evidence that had to be presented to be able to package what became this thing called Scaling Up for Impact, which is a sort of simple strategy that emerged.

It's rare to have a runway that long to solve a pressing problem.

It is quite remarkable that the traction around malaria occurred very rapidly. There was a period of about three or four years that was required to get everybody to understand that malaria could be controlled with available interventions, with available money and in the hands of national governments. We had to demonstrate impact and to demonstrate that there was return on investment that caught the attention of people outside of malaria.

The malaria partner community realized that we had to work very consciously with national governments to get their applications to be competitive at the Global Fund, where malaria was - and continues to be - one of three entities [for which funding is provided]. We worked to understand what it was going to take to have benefits accrue tangibly and visibly for communities and national governments. To be successful in getting money, governments had to put a program together, and they had to have an evaluation tool to document impact. Those are the things we put into place - a whole group of partners banded together to take that forward.

Then came funding cuts at the Global Fund - just when a second wave of countries were ready to embark upon malaria control, and at a time when many countries that had moved forward needed to replenish their programs, particularly bed nets. This has produced a period of uncertainty. But we have been finding ways to bridge at least some of that, and we're working to make sure that funding by the Global Fund gets going again.

Has the President's Malaria Initiative that was launched by President George W. Bush in 2005 made a difference?

The President's Malaria Initiative has done amazing things. It has just been a remarkable success and a very atypical U.S.-government-funded program in the sense that it's un-bureaucratic and has been managed incredibly well.

The battle against malaria is far from finished. What's next?

Like they say, every success leads to a larger issue. What our group is focusing on now is strategies for eliminating malaria transmission in defined parts of Africa. That's the only strategy with which we'll be able to make sustainable progress, and it's a huge challenge.

We have countries like Nigeria, which have yet to make good progress. And we have countries like Zambia, which have made remarkable strides. There are a number of countries that have made quite a bit of progress and are trying to figure out what to do next. We've got malaria transmission down to a lower level, but it's still there. What do we do next has become a very complex set of formidable issues and challenges.

In part two - maintaining the momentum and bringing more countries on board.

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InFocus

Global Efforts Paying Off in Malaria Fight

Long-lasting insecticide-treated bed nets.

The world is on the brink of something great in the battle against one of the world’s most stubborn and cunning parasites - malaria, says Dr Carlos 'Kent' Campbell, who has been ... Read more »