THE ‘E’ WORD

It was Gates and his wife Melinda who on October 17, 2007 first dared to revive what in health circles is known as the “e-word” in relation to malaria. Seizing the moment at a meeting of malaria specialists in Seattle, Gates declared: “We will not stop working until malaria is eradicated.” Melinda added that to aspire any lower would be “timid”. The World Health Organization went on to endorse the same ambitious goal.

Talk of eliminating malaria from endemic countries, or eradicating it from the face of the planet, had been considered dangerous and naive ever since a previous project, the Global Malaria Eradication Program, was abandoned in 1969. That campaign had succeeded in eliminating malaria from Europe, North America, the Caribbean and parts of Asia and South-Central America, but failed to achieve anything like global reach. What was the point of calling for something that was virtually impossible and almost prohibitively expensive?

Richard Feachem, a malaria specialist and director of the Global Health Group at the University of California, San Francisco (UCSF) said the Gates’ speeches were a “shock to the system” for the malaria community. “For a couple of decades before that, the e-words were simply not used in polite company,” he told a recent meeting of malaria specialists in London. “And then suddenly, here were the richest couple in the world with a foundation largely dedicated to global health saying let’s go for eradication.”

Three years on, it’s too early to judge progress - most experts say wiping out malaria could take another 50 years. But scrutinizing the economic realities of eradicating versus controlling malaria has become a pressing question.

One person who has taken a hard look at the costs and benefits of eliminating malaria, versus controlling it at low levels, is the Clinton Health Access Initiative’s Sabot. In a paper published in The Lancet in October, Sabot looked at four malaria-endemic countries - China, Mauritius, Swaziland and Tanzania - to assess the likelihood that, over 50 years, eliminating malaria would save more money than controlling it. He concluded that elimination had a low chance of saving costs in the first three. In Tanzania, he found only a moderate chance that elimination would be cost-saving.

Sabot and others say countries could focus instead on achieving “controlled low-endemic malaria”, where the disease still infects and might still kill, but no longer ranks as a major health concern. “We know that controlling malaria and bringing it from high levels down to negligible levels is a fantastic investment - one of the best buys in global health,” he says.

Several malarial countries - including some in Africa - have already managed to fight the disease down to levels where death rates barely register. South Africa had 37 deaths from malaria in 2007; Swaziland had 14; Botswana only six. In comparison, South Africa had 350,000 AIDS-related deaths in the same year, while Swaziland had around 10,000 and Botswana had around 11,000.

Why pour so much cash into an ideal whose economic benefits can pale against other health problems? That question is especially relevant when you understand it’s the jump from keeping malaria at low levels to eradicating it altogether that makes things really costly. Every single last case has to be tracked down and treated, thousands of blood tests conducted and analyzed for infection; every border crossing and airport monitored to stop new cases coming in.

It is an issue that divides experts. MVI’s Loucq thinks it is a price worth paying and draws a comparison with smallpox. “We know that the first 50 percent is easy - that’s the low-hanging fruit. The next 25 percent are very convenient and only a little bit more difficult to get. But the final 1 percent requires a lot of money and doesn’t look very cost effective,” he says. “For the detection of the last cases, when people were running all over the globe chasing those last few - the costs of that were enormous - but they still did it.”

Sabot says it’s at the point where malaria is barely a problem - even if it remains - that the economic questions get tougher. “How should the global community be spending its limited pot of resources in malaria?” he asks. “It’s a very open question given this uncertainty on cost-benefit, whether those international institutions would want to invest in elimination as opposed to focusing their investments in control, where there is a very well-known and visible high rate of return.”

MALARIA-FREE TOURISM

Of course there are reasons to get rid of malaria - billions of them. In the first part of the 20th century, 178 countries had endemic malaria; now 99 do. Britain and the United States eradicated it in 1952, Australia in 1970. Morocco is the latest place to rid itself of the disease, declaring victory in 2005.