Back to the future

29/09/1997

Back to the future the mood of the Secunderabad conference, which was attended by over 700 researchers, scientists, doctors, health workers and officials, including some 200 from outside India, was of cautious optimism. There was concern over implementation of the new global strategy to control malaria and the need for more funds for research.

The declaration at the end of the conference said that an "increase in the national political and budgetary commitment is needed". It emphasised the need for an intersectoral approach, involvement of the private sector and community involvement. Strong communication networks that allow international coordination of research and control should be a priority, it said. The mim initiated by the World Bank, who and other un agencies, and the Harare declaration on malaria prevention and control by the Organisation of African Unity are evidence of a global team spirit in this direction, it added.

The Malaria Foundation, usa , has a site on the World Wide Web ( www.malaria.org ) dedicated to information on research in malaria control . According to Mary Galinski, who set up the foundation in 1992 to fund research on the disease, "People are not aware that malaria still prevails and just how big the problem is. As soon as they are aware, they want to help." The foundation was set up with funds from pharmaceutical companies. In 1994, the un endorsed a Global Malaria Control Strategy ( gmcs ) proposed by the who in 1992. Under the gmcs , the who formulated an Action Plan for Malaria Control for 1995-2000.

The aim of the gmcs is to provide early diagnosis and prompt treatment of individual cases and epidemics of malaria, and to select and implement preventive measures, including vector control, which can be sustained. It also aims to strengthen capacities of nations and regions in basic and applied research to promote regular assessment of the malaria situation.

The strategy is based on the primary health care ( phc) approach and calls for community participation and decentralisation of decision-making. The aim is to integrate malaria control activities with programmes on related diseases. It seeks to involve other sectors, especially those concerned with education, agriculture, social development and the environment. The emphasis is on international teamwork in research and control of malaria. But implementation of this strategy depends on a change from highly centralised programmes to flexible and cost-effective ones that are adapted to local conditions and responsive to local needs.

The Action Plan for Malaria Control (1995-2000) gives priority to country support by strengthening services at all levels of the health care system, promotion of rational drug use, provision of health information, and selective use of disease prevention methods. The plan has two objectives: to implement appropriate control programmes in at least 90 per cent of the malaria affected countries by 1997; and to ensure that malaria mortality is reduced by at least 20 per cent in 75 per cent of the affected countries by 2000, taking 1995 as the base. At the rate at which revised national malaria control strategies have been implemented in the past two years, the first objective may be met, but the second is unlikely to be achieved.

Louis Miller of the London School of Hygiene and Tropical Medicine said at the conference that participation by all countries is required to overcome malaria. "Australia contributes more per capita to malaria research than any other country.... More countries need to do their part (since malaria is a worldwide problem)," he said.

John LaMontagne, Director of the us National Institute of Allergy and Infectious Diseases, under the National Institutes of Health ( nih ), Bethesda, usa , also felt the need for concerted action and collaborative research. "Malaria research is the fastest growing area. Between 1991 and 1996, nih support for malaria has increased 192 per cent. No other area has seen such enormous funding. The current level of support stands above us $20 million annually. By the end of this fiscal year, it will be significantly higher."

Paul Hagan from the European Commission ( ec ), Brussels, was optimistic about the future. Hagan said that malaria research still faces technical and operational problems. While there is satisfactory progress on the technical front, operational problems remain. "If not today, a vaccine for malaria will be ready tomorrow. The pressing problem is: how do we make sure that we apply our research findings?" he said. "The ec thinks that one way of tackling this issue is coordinated investment."

Hagan feels strongly about the artificial divide between traditional research and development-orientated research. "The two talk different languages. This has to stop. The ec ministers have adopted a resolution outlining just how important research is for development," said Hagan, adding that more collaboration was required in future. If industrial and research organisations collaborate, he predicted, research would soon be translated into useful products.

The World Bank is supporting the health sector in 85 countries, providing us $2 billion annually for supporting malaria research in developing countries. Low income countries can avail of large loans at concessional interest rates from the International Development Association.

An international consortium of scientists and funding agencies has been set up to complete the sequencing of the genome (complete set of genes) of P falciparum . The project will guide malaria research into the next century.

Despite these developments, the scenario in the immediate future is not bright. Said LaMontagne, "In the short term, let's say in the next 10 years, I think prospects are rather grim because of increasing evidence of drug resistance." Greenwood cautioned that even if a vaccine is developed, "it will not be a perfect vaccine". "There are no magic bullets," added Miller.

Progress in India
Indian scientists have made some significant contributions to malaria research. Chetna Chitnis and others at the International Centre for Genetic Engineering and Biotechnology ( icgeb) , New Delhi, have been able to identify that Duffy (one of the well-known blood group types) antigen is indispensable for P vivax to invade rell blood cells ( rbc s), while other chemicals found on the rbc surface, like glycophorin a, are needed by P falciparum .

The proteins of the two parasite species that 'bind' to these chemicals are, however, of the same family. While vivax is able to invade human rbc s, a similar species, P knowlesi - which infects monkeys and apes, and also uses the Duffy antigen for binding - cannot. This is because some chemicals found in human blood block its action. Research is being carried out at icgeb to discover chemicals which can block the binding proteins of vivax and falciparum , thus breaking the life-cycle of the human malarial parasite and preventing disease.

Innovative ways to deliver antimalaria drugs using liposomes (microscopic vessels of lipids or fats) are being tried at the Liposome Research Centre at Delhi University.

Preventing epidemics
Several field trials and experiments with bioenvironmental control have been made in various parts of India by the Malaria Research Centre ( mrc) . The results are very encouraging. But director of mrc , New Delhi, V P Sharma points out that bioenvironmental control methods alone are not enough to counter the threat. They have to be combined with other methods to be successful in different ecological niches.

The use of remote sensing through satellites and geographical information systems ( gis ) has provided some hope in preventing epidemics. Of the 58 anopheline species reported in India, only 10 are known to be vectors. The breeding and longevity of vectors depend on ecological conditions. Remote sensing, combined with analysis of agroclimatic factors, has been used to assess potential areas of major vector distribution using a software called arc/inro 3.1. This, say scientists, will prove invaluable in epidemiology and control of malaria in India.

Bleak scenario
Despite the progress made in India in recent years, the situation is grim. Deputy director of the mrc , Sarla Subbarao, says that field and clinical diagnoses are inadequate in India. "Most private doctors treat malaria chemically without knowing whether it is a vivax or falciparum infection," she says. Kits which allow fast diagnosis, though available, are expensive. Without these, however, the risk of epidemics looms large. Dealing with malaria, she says, "is more of careful planning, careful diagnosis and careful treatment." Spreading awareness among doctors of the importance of identifying Plasmodium species is of utmost importance, according to Subbarao. As far as resurgence of malaria in the country is concerned, she says that epidemics and cases of malaria "are very much there... and will spread."

According to Brian Greenwood, controlling malaria in areas with high intensity transmission is not likely in the near future, even if resources are available. In European countries like Italy and Spain, which are on the edge of the malaria belt, malaria was eradicated. "But it costs a lot of money to do that," he says, adding that malaria "needs to be tackled with several hammers, not one."

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