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Speech Urges Sustained Effort to Eradicate Malaria

Prepared Remarks by Bill Gates

Thank you, Melinda.

Melinda told you about some of the people we met in Tanzania recently. I was impressed by a man named Prosper Chaki, who runs a larviciding project in Dar es Salaam. He spends his days wading into the standing water where anopheles mosquitoes breed, so he can poison them. It’s not so surprising that he’s gotten malaria 20 times.

“Mosquitoes are smart,” Mr. Chaki said. Then he told us, “We have to be smarter.”

I believe we will be smarter. One reason is that you have come from all over the world to this forum—to challenge each other, to disagree with each other, and to learn from each other. When you leave tomorrow, our team at the foundation will move forward with the benefit of the most rigorous thinking in the world. We are grateful to you for that, and I hope each of you will take inspiration back with you as you continue your personal fight against malaria.

The other reason I believe we will be smarter is that human beings have a spectacular ability to innovate. Innovation is one of the most powerful forces in the world. It can make the impossible, possible.

Melinda talked about the innovations that have changed the course of malaria and saved a million lives in the past 10 years.

But innovations are only as good as our commitment to delivering them. We have to get better at using the innovative tools we have.

Intermittent preventive treatment with drugs during pregnancy and infancy are two proven methods of protecting those most at risk from malaria, but they’re not saving as many lives as they should be. For example, most countries in sub-Saharan Africa provide IPTp in less than 20 percent of pregnancies. That is not good enough.

We have to demonstrate the same level of commitment as new tools come online. I am very optimistic that Seasonal Malaria Chemoprevention will be available starting early next year, when the WHO’s approval process is complete. We must be aggressive in launching pilot studies to understand how this intervention should fit into control strategies, so we save as many lives as possible, as quickly as possible.

We also have to be thinking simultaneously about the next generation of tools. If we think big, bring more partners into the fold, and take smart risks, we will invent novel tools—powerful ways of fighting malaria that don’t exist now. This is the kind of innovation that will enable us to plan for the eventual eradication of malaria.

Eradication is an ambitious goal—and a long-term goal. It is also a goal to which we remain 100 percent committed.

We are committed to it for moral reasons. My children will not die from malaria, thank God. Since that is true, no child should die. It should never be too expensive or too inconvenient to give the poorest a chance to survive when the richest already have it. Equity is not yet a reality, but it is what we believe in and what we are striving for.

We are also committed to eradication for strategic reasons. The only alternative to charting a course to the end of malaria is an eternity of trying to stay just one step ahead of the parasite and the mosquito. If we have to fight in perpetuity, the cost in lives will be enormous. The opportunity cost of never being able to divert our attention to other challenges will be incalculable.

I know some people in the malaria community worry that focusing on the uncertain goal of eradication could distract us from control measures that are working today. I understand the desire to stay focused on saving lives. But I don’t see eradication and control as two separate approaches to the fight against malaria. Instead, they are two compatible parts of a single approach. To achieve elimination and eradication, we need to start with control, drive it up to high levels, and sustain it. But if we don’t target elimination and eradication, control will lapse, and malaria will continue taking lives.

It will take leadership and innovation and money to extend the recent success. It will also take leadership and innovation and money to plan for malaria’s eventual eradication. The conclusion is daunting, but inescapable: We will need enough leadership and innovation and money to do both. We do not have the luxury of choosing one or the other.

I am an optimist. I believe we are capable of setting our sights on an ambitious goal with a generation-long time horizon and multiple, shifting milestones along the way. But eradication will never happen as long as it remains a general aspiration. We must turn it into a specific plan, and our job now is to lead the constant search for new and better tools that will help us execute our plan, step by step.

The best tool we have now is bed nets. Nets are a fantastic innovation, but they’re not perfect and they won’t be sufficient. They are expensive, they are unpleasant to sleep under, and they don’t protect against outdoor- and daytime-biting mosquitoes. There is a clear need for cheaper, easier to use, and more powerful vector control methods.

I am enthusiastic about spatial repellants, chemicals that can keep mosquitoes away from treated areas. Repellants could be a big improvement over nets, because the people benefitting from them wouldn’t have to make the choice to sleep under them every single night. The likelihood of human error or human resistance would shrink by a lot. And spatial repellants would be effective against all types of mosquitoes, no matter when or where they bite.

Recent trials in China showed that mosquito coils containing a chemical repellent decreased people’s odds of contracting malaria by about 80 percent—and coils plus nets were much more effective than coils or nets alone. Right now, additional trials are taking place in Indonesia to confirm the impact of coils on transmission and to measure their impact on the mosquito population. We expect data from this critical proof of principle study in the middle of next year.

Researchers are also busy identifying potential active ingredients for spatial repellants. Larry Zwiebel of Vanderbilt University just isolated a compound that is 1,000 times more powerful than DEET. Other researchers are looking at other formulations, and results from these studies will be available in two or three years.

ACTs are the second tool that has changed the course of malaria control over the past several years. Obviously, they represent a vast improvement over the old drugs that weren’t effective, but, like nets, they are not ideal. Artemisinin is expensive, the course of treatment lasts several days, and resistance is already developing.

The Medicines for Malaria Venture currently has a drug candidate in phase II trials, OZ 439, that has the potential to be a single-dose cure. This could solve many of the problems with ACTs. It should be cheaper, since the total amount of drug needed for treatment will be lower. Adherence will be much higher, since people will have adhered completely as soon as they swallow the pill. This will decrease the risk of treatment failure and slow the development of resistance.

OZ 439 could be licensed as early as 2016, depending on the suitability of the quinolines currently being tested as partner drugs. In addition to finishing the trials, MMV is working to find a partner from the pharmaceutical sector to help it make and market OZ 439 when the time comes.

One of the most important innovations for the future of the fight against malaria will be a tool we don’t yet have: a vaccine. A vaccine is a wonderful thing. It’s the simplest, most cost-effective way to save lives. The smallpox vaccine, plus the innovative approach of ring vaccination, led to the eradication of smallpox. The polio vaccines have pushed the world to the threshold of eradicating polio. Vaccines have slashed the number of deaths caused by diphtheria, measles, tetanus, and a host of other diseases.

But the search for a malaria vaccine has been a long and frustrating process. There has never been a vaccine for a parasitic disease. The scientific complexity is dizzying.

Today, however, we are closer than ever before to tackling that complexity. Four years ago, I announced interim results from phase II trials of the RTS,S vaccine. Today, I am pleased to announce the interim results from the phase III trials. Among five to seventeen month old children, the vaccine prevented clinical malaria in 55.8 percent of trial participants over a period of one year. RTS,S prevented severe malaria in 47.3 percent of trial participants aged five to seventeen months. It prevented severe malaria in 34.8 percent of the entire study population, including infants.

These are only interim results. We need to study the data over a longer period of time to understand whether the effect of the vaccine diminishes. We also need to evaluate the impact of a booster dose. Leaders must have all this information before they can make decisions about how to use the vaccine if and when it’s approved.

Nevertheless, these results signal a huge milestone, and I want to congratulate the many partners that have been working on this project for decades. First, this is proof that it is possible to create a vaccine that is effective against malaria. For a long time, we didn’t know. Now, we know. Second, if RTS,S continues to show effectiveness of around 50 percent—above and beyond bed nets—it has the potential to protect millions of children and save thousands of lives.

And RTS,S is a first-generation vaccine. It is an early outcome of a long process of innovation that will ultimately yield more effective vaccines. Researchers are currently recruiting participants for the phase I trials of a second-generation RTS,S vaccine.

There are many vaccines that work according to completely different mechanisms in various stages of development. I am particularly excited by the potential of transmission blocking vaccines, vaccines that prevent mosquitoes from picking the infection up from human hosts. In the drive toward elimination and eradication, these vaccines will be invaluable.

But the fact is there are still many basic science questions about malaria that we need to answer to make the search for vaccines less challenging.  We know there are mechanisms by which people become immune to malaria. We can even produce that immunity artificially, but we don’t understand it. If we get a better sense of what underlies immunity in those cases, we will have a much better chance of filling the vaccine pipeline with good products.

As we develop these new tools, we also have to develop a more sophisticated understanding of how to deploy them. When you have several ways to fight more than one species of parasite, carried by many species of vector, you can’t afford to guess about strategy. What is the smartest way to combine our interventions so they have the maximum effect? We need to be able to answer these questions with evidence.

I believe modeling can help generate that evidence. I want to walk you through some charts from one malaria model to give you a sense of the kinds of answers they can provide.

When our friend and mentor Warren Buffett made his gift to our foundation five years ago, he was clear about the purpose philanthropy should serve. One of his famous quotes about finance is, “I don’t look to jump over 7 foot bars. I look around for 1 foot bars that I can step over.” Philanthropy is the other way around, he tells us. We should be looking around for the 7 foot bars; that’s why we exist.

Malaria eradication is a high bar. To reach it, it will take a constant, concerted effort to innovate. But we can do it. We can drive down the number of cases, lower and lower. We can keep introducing new and better tools, until we interrupt transmission like we’ve done in dozens of countries already. And, eventually, with relentless focus, we can eradicate malaria. We’ve already shrunk the malaria map considerably. We can make it disappear.

It won’t happen in four years, or in eight years. But the decisions we make now will determine what happens to malaria in the future.

The parasite has been killing children and sapping the strength of whole populations for tens of thousands of years. It is impossible to calculate the harm malaria has done to us. Now, we can chart a course to end it.

Thank you.

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