Q&A with PATH: An update on malaria

Dr. Kent Campbell is the director of the Malaria Control Program at PATH, which is focused on developing evidence-based national malaria control programs in Africa. From 2004 through 2008, he served as the program director for the MACEPA (Malaria Control and Evaluation Partnership in Africa) program at PATH. He has more than 30 years of leadership experience in malaria control and international public health, and he was recently awarded the Le Prince Medal from the American Society of Tropical Medicine and Hygiene. He spoke with GlobalPost about achievements in the fight against malaria and what is needed to bring transmission to zero.

Q: How long have you been working with malaria in global health?

A: I’ve been working in global health since I was in my residency at Harvard in 1972, so that makes it almost 40 years. I began working at the Center for Disease Control when I was serving as a public health service officer. I had an opportunity in that two-year fellowship program at the CDC to work in West Africa on a disease called Lassa fever. That was quite an experience— in fact, I got very sick and it looked like I had Lassa fever. But, as they say, I did survive.

Then an opportunity became available after I had been there for a year to take a position at a malaria research center in El Salvador, where of course there was a tremendous amount of malaria. Here they were doing fieldwork research on ways to control malaria, particularly the use of indoor residual spray and things of that sort. And it was a fantastic experience for me professionally, right in the middle of my pediatric training. What was going to be a two-year stay ended up being a four-year stay and one thing led to another.

Q: Why did you decide to focus on Africa as your primary region for malaria control?

A: I began my experience in Central America. We were many times asked about working Asia and other places. The focus on Africa is because approximately 90 percent of the deaths caused by malaria occur in sub-Saharan Africa. Malaria is so much more intense of a problem in sub-Saharan Africa than it is in any other place in the world. So my position has been that progress toward malaria must begin in Africa.

Q: How has the approach to malaria treatment changed since you first started working?

A: Following the demise of the global eradication program in the 1960s, the only thing that was being done program-wise was to try and identify the malaria illness and then provide drugs as treatment. That had huge problems with it.

First, the vast majority of malaria cases, which were occurring in children, were indistinguishable from a variety of other illnesses. The hallmark symptom of malaria is a fever and there are many causes of fever. There were no specific diagnoses, and laboratory services were really not available.

The second thing was that during the late 1970s and ‘80s … there was that there was extension of resistance to the primary drug that was being used to treat malaria. This meant that the strategy had a problem, in that the coverage of the intervention—prompt recognition and drug treatment of malaria illness—was not occurring in any systematic way. Particularly in rural areas, where the malaria is most transmitted, there was resistance to the primary drugs being used.

So what began to occur in the mid ‘90s within our group and others was a systematic look as to what would constitute an effective program about controlling malaria. A couple of positions that we took—one, that we really needed to prevent malaria. The strategy of dealing with malaria after a person got infected was never going to be a way of decreasing the risk of getting malaria. A number of groups conducted trials involving insecticide-treated bed nets, which sounds like a really simple technology and indeed it is. But that became available in the 1990s. The power of insecticide treated bed nets was actually almost unbelievable in its impact of reducing transmission.

In addition to that, a new anti-malarial drug based upon a Chinese herbal remedy called artemisinin became available. That was such a powerful anti-malarial and was much more powerful than any other drug that was being used. So all of these things became available through research that was being done and examining how they could be put together in a program. So what have been happening over eight years are efforts to put these things into a whole new program strategy.

Q: How has the President's Malaria Initiative stacked up? How effective has it been and what needs to change?

A: We have worked closely with the President’s Malaria Initiative and I think that the main point about the Initiative is that it is one of the most effective programs of essentially any healthcare initiative of the US government. The director of the program has done an outstanding job in striking the balance in partnerships with countries that they are working with. It has been extremely effective in getting commodities and interventions available to the partner countries.

And they, like our program, have done a great job in terms of evaluating the impact of their program. I think it’s safe to say that the US Congress has been extremely positive about the program because it has clearly demonstrated value for money and return on investment in ways that few other programs can actually do. I think the program has produced enormous results in terms of lives saved.

Q: What do you see as the next step forward in terms of one day reaching the goal of eliminating malaria in sub-Saharan Africa?

A: The big step right now is that there are a number of countries in Africa that have made great progress in terms of bringing down the burden of malaria in their country. But no countries in continental Africa have eliminated malaria. The transmission is still there and the threat of a lapse in bed net coverage and replenishment of bed nets every three years could mean the return of malaria. So the challenge now is what are the strategies that countries could use toward elimination.

Our group, in particular, is focusing on working with several countries to develop program strategies for moving toward elimination and shutting down transmission. This has never been done before, and this is going to take some intense work with a limited number of countries to figure out exactly how this is going to be done. The belief is that this is possible in many parts Africa with currently available forms of intervention: nets, drug use, and indoor residual spraying. This can be done without the need for a malaria vaccine or anything of that sort.

So this is the big challenge in front of us: bringing malaria under control to bringing transmission to zero.

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