My name is Professor Bob Snow, I work at the Kenya Medical Research
Institute Wellcome Trust Programme, and I am a malaria epidemiologist.
Briefly to describe the history of malaria over 100 years would require more than five minutes,
but in essence what's happened is that at the turn of the last century, about 1900,
malaria probably reached its natural extent in Africa which included all of north Africa,
all the offshore islands, quite a long way south in South Africa,
as well, Southern Africa, and then in the first 50-60 years or so, fantastic progress was made
malaria was eliminated for all of north Africa, there was no malaria in Réunion,
Mauritius so control efforts had actually shrunk the map of malaria in Africa down to a section
below the Sahara running all the way across, and all the way down into South Africa.
South Africa had also made progress, it shrunk its map of malaria further and further
east to a constrained area around KwaZulu-Natal and Mpumalanga,
but largely there was a huge number of people still living under intense malaria transmission
from about 1970 all the way to today, and the map hasn't really shrunk very much since.
Within there, there has been a big reduction in the likelihood of being bitten by a
mosquito infected with malaria, so the number of people who have malaria in their blood has also
dropped dramatically, but it's gone in waves; so the first wave was when we introduced DDT and
chloroquine in the 1940s after the second world war, there was a big drop then, and it remained
quite low for a long time until we had the perfect storm when there was El Niño epidemics in the 90s,
increased rainfall, big flooding, and we had emerging resistance to chloroquine,
so then we had a massive peak, a huge epidemic across the whole continent,
and that's when the world woke up and realized that we had to do something,
and then the big efforts made to raise more money, global fund support, roll back malaria initiative,
things like that, and we introduced two other magic bullets: insecticide treated bednets,
and artemisinin-based combination therapy, and malaria you saw then began to drop,
and we're at a stage now where it's much lower, it's the lowest it's ever been for over 100 years,
the thing is it's probably stagnated - so now what we've seen today is a bubbling along
at a lower level but still there, and still infecting millions of people across Africa.
Africa is home to 98% of all the malaria burden worldwide;
over 90% percent of all the deaths that occur in the entire world occur in Africa, and there's been
a lot to talk about eliminating malaria from the planet, several people have said in their
lifetimes they don't want to see malaria anymore on the globe, but to be fair, Africa still has
nearly 800 million people living in a belt across Africa where malaria is part of their daily lives.
Half of them, 400 million people, live in areas where there's one in four children walking around
with malaria in their blood today, and really, the cradle of the world's problem is still in Africa,
so you can't ignore Africa, Africa has other issues, other problems, which allow us to be in
a situation where there's still lots of malaria including poverty, poor governance, conflict,
lack of economic investment and things but that's why there needs to be a focus on Africa.
I think we're doing everything we can currently with the tools that we have available, but if I
had to look to the future, we need more tools - one thing that we can learn from
the history of malaria is that malaria parasite and malaria mosquitoes are incredibly clever and
very adaptable, so that we will and we are seeing resistance emerge to both drugs and insecticides,
so we need more effective insecticides, more effective drugs
to combat what will happen in the future, which is an emerging resistance to both.
We need vaccines; vaccines that we currently have and we're currently trying
are okay, but they may not go to scale, they may not be good enough
to implement at a wide population level, so we need continued investment in vaccines.
The two things I think that would make the biggest difference, and this is from history
outside of Africa, is the economic development - when you reach a point of all your females
going to school, there's electricity, there are paved roads, malaria does disappear
and I think that's the one message that we need to fully understand that the future
of malaria in Africa depends largely on how well Africa develops as a continent economically.
Allied to that is how well is the health system invested in, so governments across the continent
need to invest in a strong health system. I don't believe that malaria will be eliminated from
Africa in my lifetime or anybody else's lifetime, but there should be no deaths from malaria;
that is unacceptable because children should be treated quickly, they should
get access to emergency care in hospitals when they need it and no one should die,
so if I was to think of a future and I was to think of a future milestone, it would be that
no child, no individual in Africa, dies of malaria and I think that's achievable.
I think for our group here it's been investing in mapping, the risk of malaria
in Kenya to begin with then across Africa and globally, and I think that work has really
transformed the way we think about disease, think about investing in interventions, so we
work very closely with national governments and the World Health Organisation to try and identify
areas where you might get the biggest bang for your buck
and areas where maybe giving everyone bed nets is a waste of money, so using the cartography,
the geography of malaria, to design control, design investment I think has been one of
our biggest achievements and I think that that's a space that will continue to grow.
The other area that is largely the work that I'm now funded to do that I think is obviously
important, is the relationship between how often you get bitten by a mosquito carrying parasites,
and your speed of developing immunity, because we really don't understand, properly still to
this day after hundreds hundred years or so of research, the relationship between infection and
disease outcome, so how likely are you to develop severe disease given how often you are bitten by
an infected mosquito and how likely you are to die, that is a whole concept and a whole body of
research that's been neglected for a very long period of time, and to design what the future
of malaria looks like we need to understand that so I think that that's an important area as well.
As we said malaria is still a major killer, you can't neglect malaria from a research
point of view, there's been a massive increase even announced this week or last week in donor
assistance to malaria, the UK government for example, has increased its budget to the global
fund, it recognises and the world recognises how important it is to get on top of malaria.
There has been a shift as well which I'm really grateful to, in making sure that a
lot more of that investment goes into Africa, for disease prevention and disease control.
Obviously as I said we need new tools - we need a better understanding of malaria,
I cannot imagine why you wouldn't increase the amount of money going into malaria research,
if you increase the amount of money that's being spent on its control,
knowing that that will only last for a short period of time.
Since about 2009, we've worked very closely with the Kenyan government to
try and help it identify areas where you will increase the amount of intervention coverage,
and areas where you might do things differently, and we've shaped the Kenyan policy in that sense,
beginning with work in 2009 by Dr Abdisalan Mohamed Noor, and that was very influential.
I think we've extended that beyond Kenya's borders, we work now in Somalia,
Sudan, Djibouti, Tanzania, Uganda, many other countries where we provide government support
for epidemiological intelligence, it's trying to understand the landscape of malaria in a country,
so they can design their national strategies effectively, they can invest in a clever way,
and it's again using the science of malaria cartography
and understanding the epidemiology of the disease to shape that.
That's been driven by us here in Kenya, it's now grown into an initiative called the High burden to
high impact initiative run by the WHO but it really actually began here in the programme.