The Three-legged Stool of Successful Disease Prevention

When not focused on the forthcoming royal wedding in London, much of the world on April 25 directed its attention to World Malaria Day. In the U.S., we heard from the President's Malaria Initiative (PMI) that child death rates in focus countries have declined by 23-36 percent and that globally 150,000 fewer children have died from malaria since 2006, when the initiative began. Independent reports from the World Health Organization (WHO) and UNICEF also demonstrate declines over the last decade.

2011-05-09-Stool.png These successes with malaria are promising, but fragile -- and largely dependent on existing technologies and the ability to scale up delivery systems to deliver them. A closer look provides a valuable reminder that sustained gains against malaria must be built upon a three-legged 'stool' that that includes 1) delivery of existing interventions, 2) operational research to improve delivery systems, and 3) research and development of new tools for control, prevention, and treatment.

Old-fashioned, community-based public health programs deserve the bulk of the credit for the reductions in malaria being observed right now. According to the latest report of the President's Malaria Initiative, the $464 million U.S. effort will focus on scaling up four proven malaria prevention and treatment measures: insecticide-treated mosquito nets (ITNs); indoor residual spraying with insecticides (IRS); intermittent preventive treatment for pregnant women (IPTP) and improved laboratory diagnosis and appropriate treatment, including artemisinin-based combination therapies (ACTs).

This list doesn't include any particularly cutting-edge technologies. Instead it features insecticides that have been around for decades, simple mesh nets that cover your sleeping area, and a new malaria drug that comes from the bark of a tree and has been used for hundreds of years in traditional Chinese medicine. The PMI maximizes progress against malaria by improving logistics and delivery efforts that expand coverage of these interventions to everyone who needs them.

These investments are tremendously important, and the success of the effort so far reinforces the need to do everything possible with existing technologies. We must keep in mind, however, that existing technologies and scale-up approaches alone will not be enough to tackle a disease responsible for nearly 250 million cases and one million deaths every year or to stay ahead of a parasite and an insect that are constantly evolving new ways to outsmart our treatments and insecticides. To be sure, there is a wide recognition of the need to continue research into new and improved ways to combat malaria. Reports of resistance by mosquitoes to insecticides and of plasmodium, the malaria parasite, to available drugs both underscore the need for research to develop new insecticides, better drugs, and ultimately, a safe, effective vaccine that can prevent this terrible disease, for which more than 3 billion people are at risk each year.

Focused health days like World Malaria Day, World Pneumonia Day and World Meningitis Day provide a useful opportunity to call for more efforts to combat devastating diseases. Most often, these days are used to urge people to take action and increase their use of existing treatments or vaccines. Indeed the compelling humanitarian call to "do more today" with existing tools must be answered -- but we must not become complacent or miss the opportunity to remind everyone of the need for a robust research enterprise to fill the pipeline with new drugs, vaccines and other tools. By ensuring that we build a foundation for the future that gives weight to all legs of the prevention 'stool,' we can both save lives today and help sustain that success for the next generation.