The Root Of The Science Podcast
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The Root Of The Science Podcast
EP 150: The Race Against Time: Progress, Challenges and the Road Ahead in the Fight against Malaria
In our final episode this year, we spoke with Jenn Gardy (Deputy Director, Malaria Surveillance, Data & Epidemiology, Gates Foundation) and Susan Rumisha (Principal Research Scientist and Lead, Malaria Atlas Project, Dar Node), to unlock the secrets to eradicating malaria by 2030.
They discuss the innovative approaches and daunting challenges in the ongoing battle against malaria. From preventive strategies like environmental modifications and dual active-ingredient (AI) insecticide-treated bed nets to addressing cultural and healthcare access gaps, our discussion paints a comprehensive picture of the current landscape and future directions.
We also reflect on the insights from the 2024 World Malaria Report, emphasizing the pressing need for increased funding to drive these global efforts forward.
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prevent mosquitoes from being around and biting people, period, that is that nobody would be sad if the world's mosquito population suddenly decreased dramatically. We get wonderful knock-on effects in other diseases too. So here we're talking about things like can you prevent mosquitoes from breeding and growing up in the first place? You can do things like environmental modifications, so doing drainage, get rid of their breeding sites, even simple things like kind of urbanization and you know, building sidewalks, roads, improved housing those are all things that can keep mosquitoes from being born and growing up and entering homes and biting people. We can use things like bed nets. A lot of mosquitoes like to bite indoors, not outdoors, and they like to bite at nighttime when people are sleeping. So if we can put people under an insecticide-treated bed net, first of all it's creating a physical barrier so the mosquito can't get in and bite them. But those bed nets also are treated with insecticides that can last for many years.
Speaker 2:But also we have people that they are actually just it's about an understanding of like I need to act this way and the action to go and seek care. We are seeing this gap in care seeking in the modeling that we do is not small. We have countries that maybe just half of the population is able to be able to act when they're getting there. So we have put a lot of effort in making sure they're there, but the access for them is coming from them, it's not about the distributor when they are getting there. So we have put a lot of effort in making sure they are there, but the access for them is coming from them, it's not about the distributor. So it's actually so. It means there is also another group that they won't just go there because they think they don't need to go there. So there is another gap of how the system has to make sure that they are pushing people to access care.
Speaker 2:But, another thing is also there is this age difference because some things are cultural.
Speaker 3:So people in the communities, in the household, Hello everyone and welcome back to another episode of the Root for the Suns podcast with your girl and with Ani. If you are new here, thank you so much for tuning in and if you're returning, welcome back. It's always such a pleasure to have new people onto the show. So this is our last episode of the year, which is really exciting. I think I want to take this moment to just say thank you to every single person who's been on the show. Also, a big thank you to all of our past guests. If you are unaware, we've been running the Rooted in Health series in partnership with Global Health Strategies for the last couple of months, and we told you that this would be a four-episode series, but we thought you know what. Let's add a last one. Think of it as a little Christmas present from us to you.
Speaker 3:Today we are going to chat on a topic which we're titling the race against time, progress, challenges and the road ahead, and the fight against malaria. This is against the backdrop of the World Health Organization's report that came out on the 11th of December. So you are listening to this a couple of days later, on the 11th of December 2024, in case you're listening to this a couple of years later. So my guest today is Jennifer Gaudi is Jennifer Goddy. She is the Deputy Director of Malaria Surveillance Data and Epidemiology at the Bill and Melinda Gates Foundation. She brings in her experience on malaria eradication strategies and the innovative tools in research and development pipeline. I'll be also joined by Susan Ramesha, who is the principal research scientist and the lead for the Malaria Atlas Project, who will bring in her experience in leveraging cutting-edge data modeling techniques that are able to inform targeted interventions and fighting against malaria.
Speaker 3:So, in this particular topic, we'll discuss some of the findings from the 2024 World Malaria Report, the impact of climate change on malaria, some of the gender-sensitive approaches to these interventions and the innovative tools that could help eradicate malaria by 2030. We also talk on the urgent need for increased funding, and this was a very rich conversation. I hope that you enjoy it, so tune in for all of this and so much more. Hello Susan, hello Jen and welcome to the show. Hi and thank you, it is such a pleasure.
Speaker 2:Nice having me here. Thanks so much, it's going to be fun.
Speaker 3:It is, it is, it is. It's such a pleasure to chat to you both today, on the day that the World Health Organization report is actually going live, even though this is coming out a bit later, so this is a conversation that is very on time. So, first things first. Before we go on to the World Health Report that we started, there was also a report that was done by you know, the Malaria Atlas Project, which you lead, susan, as well as the Boston Consultants Group, and it tells us a lot that climate change has seen an increase in malaria burden, particularly in sub-Saharan Africa. In fact, it could actually lead to over 550,000 additional malaria deaths. So I'm going gonna start, maybe with you, jen, with this backdrop how is climate change affecting the geographic spread of malaria? And when you answer that, like, how can we minimize these things?
Speaker 1:Excellent questions and big questions both of them. So for folks that may not be as familiar with malaria as perhaps some listeners are, this is a disease that is very intimately tied to our environment. Malaria is, of course, spread by mosquitoes that are carrying a parasite Mosquitoes. We know that they thrive in certain areas. They love places where it's warm, where it's temperate, where there's a lot of rainfall. It creates the puddles and the standing water that mosquitoes lay their eggs in. They love forested areas, thick, dense with vegetation. So when you think about where those areas are around the world, if you look at sub-Saharan Africa, for instance, we sort of have a belt really going from kind of the upper left to the lower right of the continent, where you do have a lot of that forested region, where you do have a lot of rainfall and where you, of course, have really temperate conditions, all of which really makes that perfect ecosystem for malaria.
Speaker 1:Now, the issue with climate change is that it is changing both temperature and general climatic conditions in many different places in many different ways. So areas that might have once been quite dry suddenly are seeing increased rainfall, increased rainfall, more mosquito breeding sites, areas that are, say, quite high elevations and have been really cold in the past. Those start to get warmer over time with climate change, warmer, more hospitable to mosquitoes. So you're seeing the potential for malaria to come back in places where environmental conditions in the past maybe sort of worked in our favor against preventing transmission, in our favor against preventing transmission. You see malaria get into areas where changing rainfall is meaning there's completely different mosquito habitats. And on top of this sort of consistent change in climate, we also see climate changes bring with us climate emergencies. So things like cyclones, flooding, hurricane events Anytime you have a health emergency like this that's disrupting health care systems. Imagine you have a flood. It destroys people's houses, it destroys health care facilities. Malaria loves opportunities like that, it loves emergencies, and it will surge in the wake of those events. So you've kind of got this double-edged sword where there's this continuous, you know the temperature is always being turned up, the water is increasingly boiling, and then you get these big, acute emergency events. On the other hand, there are opportunities associated with changing climate.
Speaker 1:I think people are paying a lot more attention to the climate crisis than they might be to malaria, which is arguably a crisis, an emergency, but because it's been with us for so long. It's something that people have almost become complacent to to a certain degree. But climate emergencies these are affecting everybody. Everybody is caring about these things. So it gives us an angle that we can actually approach malaria control with. We can say malaria is so tied to climate. This is an area that you are extremely concerned about. If you start addressing climate issues, you get this wonderful knock-on benefit of, you know, uplifting the malaria ecosystem as well. So it kind of gives us another impetus to get ahead of malaria eradication, you know, take it off the page as something that's going to come along with the climate emergency and really turn the world's attention to it in a way that we might not have had the opportunity to do recently. But Susan's a real expert in this space, so I think she's probably got some really fantastic things to say on this.
Speaker 3:Yeah, no, thank you so much for that overview, Jen, and it's quite interesting that you know there's that interplay of climate change and in health, and I think that conversation was brought up a lot last year, even at COP, where they had the health day. So, susan, over to you. You are working, you know firsthand with the project that you are leading. So how can data modeling initiatives actually, like the Malaria Atlas Project, help us have more targeted interventions to this crisis that we're currently facing?
Speaker 2:Yeah, Thank you so much, annie, and I think this is a best opportunity to speak about some of this stuff Before even responding to that. The modeling initiatives you are asking I think it's a time now we start to look at that as a nested intervention, as if on its own. So, taking an example of the group that we are, what these initiatives can contribute to, this informing intervention, that they are targeted against these threats first is to give the insights. It's like what is actually happening, the analytics, which are very advanced and more sophisticated. They tell you what is happening so they are able to help you to quantify the magnitude of this problem that Jane has been speaking about. Which places are mostly affected? What time do we see these events? Is there a seasonal pattern? Is there a very specific pattern that we can track over time? Is it moving? Is it changing? Is it different by different places? So once you know the magnitude of the problem and you know where and how it's happening, then immediately you can now start looking deeper into type of of intervention that we do. For example, malaria Among the interventions, let's say, use of nets, iris, access to these effective drugs. What among these interventions is affected the most? Because all of these have different logistical strategies, how to be deployed into these different countries. So we have to look like what is actually affected and where and what is the contribution of this disruption that you see into the destructions of these innovations. So when you gather that information, you can do that, you can predict in everywhere that you are able to able to collect that information. Then now you give that to those who are making decisions. So once they know this, now, with the limited resources they have, or the amount of resources they have, let's say it could be money, it could be human capital, it could be all the mechanisms that they have into their countries or their states, now they know how to tailor these interventions and they know how to prioritize. They know how to pre-position themselves, because now we have given now what is going to happen in the next 5 or 10 or 50 years, so they can pre-position themselves for the commodities, like what they need to be prepared, so that they can act on much more efficiently way.
Speaker 2:But another thing that the modeling can do. These are, I've been mentioning, like interventions that are already there, they are being deployed. But there is again another set of interventions that are not yet fully covered everywhere, things like vaccines. So these are the ones that are coming in, like chemo preventions. But we have these new tools that we know. They have a different kind of like how they act, but the modeling can tell you now, like how are these new tools can now contribute into the effect of these threats?
Speaker 2:For example, take an example of vaccines. Vaccines, when you vaccinate kids or population, the protection is not just a one-off, it goes. It can go maybe a couple of years. So even if there are threats here, people are displaced, they are moving, they are more protected. So actually it's giving you a time to act because you have now put a good intervention than just a net which, once the house is gone, the net is gone. When the bridge is gone, they cannot access the health facilities. So modeling is able to tell you that this contribution of that, those insights, so the cumulative of that is what I think gives the modeling as a very strong tool and not only tool. I repeat, it's an intervention on its own. We need to invest into that.
Speaker 3:Absolutely. I think I like what you said about it, that it is an intervention on its own, because it gives us real insight that maybe in the past we weren't able to see how to effectively you know manage this crisis. And you spoke a lot on interventions, and this will then really dive nicely into the interventions and the innovations and I want to bring you in here, jen, what are some of these interventions and innovations that are actually promising in helping deal with this crisis? Because Susan has told us we have the data, it's telling us all of this stuff, but what exactly is there in the pipeline or it's already there?
Speaker 1:There's a lot. Malaria is frustrating and exciting because it's a complicated disease. As I said earlier, you've got parasite. It's transmitted by a mosquito. That mosquito has to bite a human. It's going to be exposed to it in varying degrees. That human might have, you know, pre-existing immunity. And then there's a big environmental angle. We talked about temperature, climate, but also things like housing and in the environment. But all of that complexity, the fact that you have a parasite, that you can intervene on a mosquito, a human, a built environment that gives you a huge array of intervention opportunities.
Speaker 1:So, unlike other diseases where you might have a single silver bullet, you know one vaccine or one therapeutic, in malaria we have a menu, a buffet of interventions that we can choose from, and we've got things that are here and ready and proven now and we've got some really exciting stuff that's coming down the pipeline too. So you can think about it in a few different categories. So one of the things the best thing we can do is just prevent mosquitoes from being around and biting people, period. Nobody would be sad if the world's mosquito population suddenly decreased dramatically. We get wonderful knock-on effects in other diseases too. So here we're talking about things like can you prevent mosquitoes from breeding and growing up in the first place. You can do things like environmental modifications so doing drainage, get rid of their breeding sites. Even simple things like urbanization so doing drainage, get rid of their breeding sites even simple things like kind of urbanization, and you know, building sidewalks, roads, improved housing, those are all things that can keep mosquitoes from you know, being born and growing up and entering homes and biting people.
Speaker 1:We can use things like bed nets. A lot of mosquitoes like to bite indoors, not outdoors, and they like to bite at nighttime when people are sleeping. So if we can put people under an insecticide treated bed net, first of all it's creating a physical barrier so the mosquito can't get in and bite them. But those bed nets also are treated with insecticides that can last for many years, and so what will happen is, when a mosquito lands on the surface of the net, the insecticide travels through the mosquito's feet, ultimately will kill it, and that mosquito hasn't gotten into the net to physically bite somebody and it's died. So you've got this wonderful bed net will offer both this personal protection but community protection as well. So it's knocking down the mosquito population. So we're always looking. Can we develop new and better bed nets, and something that's been really exciting recently has been the rollout of what we call dual AI nets, and so these are nets that contain not one but two different types of insecticides, and so they're much more powerful than existing nets, to which mosquitoes have already started to develop insecticide resistance. So it's a great example of a simple twist on a new and existing and very or an old and existing and very effective tool that just makes a lot more effective.
Speaker 1:You can also think about other vector control methods. At the Foundation, we are really interested in the prospect of what we call genetically-based vector control. Or can you go in and, using genetic techniques, knock just a single mosquito species out of a local ecosystem? In a given area there's probably 10s, 20, 30 different mosquito species. Maybe only one of those is responsible for transmitting malaria. If you've got an exquisitely sensitive insecticide, but in a genetically based form, you can go in and knock out just that one mosquito species. You can preserve the rest of them. It can be food for bugs and frogs and things, but you got rid of that one that is likely to cause malaria. So lots of cool stuff on the vector control side In terms of what do we do in preventing a mosquito bite from actually turning into a malaria infection?
Speaker 1:Susan mentioned vaccines earlier. This is a new intervention. Just in the last couple of years we have the first two malaria vaccines that are starting to be rolled out across sub-Saharan Africa Huge scientific achievement in creating these. I think there's still plenty of room to go in making an even better vaccine, but I have no doubt that in the coming years we're going to see new and improved vaccines that give us more tools for preventing a mosquito bite from turning into a malaria infection. And then, if you do get an infection, we're also seeing better and better drugs coming down the pipeline. We would love it if you could get rid of malaria with a single dose of one pill Easy, affordable, accessible, super, super simple. So some really exciting developments there. I think we're also looking at some neat developments in what we would describe as the chemoprevention space or the chemoprophylaxis space. Is the chemoprevention space or the chemoprophylaxis space?
Speaker 1:Any of your listeners that have traveled to malaria endemic areas around the world might have taken malaria prophylaxis while they're there, taking your malaria pills so you don't get an infection and the epidemiologically minded amongst them might have gone.
Speaker 1:Oh so if I could take these pills to keep myself safe for a week or two while I'm traveling, why can't people in malaria endemic countries, you know, take them all the time to keep themselves safe? And we're working towards alternatives to those malaria pills that would make it actually effective and feasible to do that, say, at the beginning of a malaria transmission season. If you could get a single dose of a medicine or a single dose of an injectable perhaps you know monoclonal antibody, a vaccine, some other type of malaria medicine, if you could get something that would keep you safe for months at a time with just one single encounter with the health care system, huge, huge, huge win. So plenty of effective tools right now, a really exciting array of both tweaks to existing tools and totally new tools coming down the pipeline. So it's actually, from an R&D, research and development perspective, it's really exciting and good time for malaria.
Speaker 3:It is. It is so many exciting and innovative tools that are on the way and I'm sure even our listeners are like, hey, I know this tool, but the fact that it can be improved, that's even more exciting. Susan, over to you now, I want. Jen has painted us a picture of all these tools that are available for us, but in reality, how accessible, how available are they for the people on the ground who are affected by this problem?
Speaker 2:Wow. So, coming to that, we can talk a few tools. Well, that I think is different based on which tool is actually provided or deployed into these countries. And so we have a big percent of the community that is able to access the nets, is able to access the medicine, because they are a good network of health facilities, point of care. And countries have initiated other strategies like to access people using like community health workers, so that they can reach some of the populations that are actually were hard to get to these facilities on themselves. But they can be managed now with these drugs. But people are also able to access testing. So people they are actually following a very good case management process because they can be able to the country they are able to purchase and distribute testing. These are rapid tests, so we have a good proportion that they are accessing that.
Speaker 2:But we still have a couple of gaps into that. We have still a significant proportion of people and this is varying by country by country of people that they don't really have this access to these tools and multiple reasons for that. So some of them is still the infrastructure component that they cannot really get there and we have not managed as a health system because there is not. There is an investment in health system but it's not substantial. So the countries are struggling there to make sure that everybody is able to access care. So there is kind of a group that is not yet accessing these ones, but so many people they may get sick and they may not be able to be treated because they could not get into the facility.
Speaker 2:Even if they get into the facility, maybe this facility they have been kind of a gap into the distribution so there are no drugs into these facilities. So they'll get there but they won't be able to be treated or they will get treated but there's another gap of like who is actually being able to get there. But there is also indirect cost of them accessing this course. But also we have people that they are actually just. It's about an understanding of like I need to act this way and the action to go and seek care.
Speaker 2:We are seeing this gap in care seeking in the modeling that we do is not small. We have countries that maybe just half of the population is able to be able to act when they are getting there. So we have put a lot of effort in making sure they are there but the access for them is coming from them, it's not about the distributor. So it means there is also another group that they won't just go there because they think they don't need to go there. So there is another gap of how the system has to make sure that we are pushing people to access care.
Speaker 2:But another thing is also there is this age difference, because some things are cultural. So people in the communities, in the household, these decisions, they vary and they could be minimal. We could think that they are not significant but they are accumulative Because people they act different. If we say under one sick, under five sick, an adult sick, but all these people, if they are in the community and they think I don't need to prioritize a school kid, for example, to go to a facility, it's creating an access problem because of those decisions. So when you talk about access, so we have these pockets of things that are happening and they are all controlling the same basket of access but they are causing now an equitable kind of distribution of who can get. But we are getting there because we are pushing now Countries are trying to push a lot of initiatives to make sure that there are some initiatives that are going to focus on school kids, on underprivileged, on adults, to make sure the entire population is able to access the intervention that we have.
Speaker 2:Jenny spoke about vaccine. Vaccine is coming and of course everybody would like to be vaccinated if they could be understanding why they need to be vaccinated. But we know we are talking about Africa People. They have a lot of this lack of knowledge. So intervention will be there.
Speaker 2:Maybe there will be other groups that will support it to subsidize the cost of this. But there is a bigger fish to fry to make them get to this, to get to use the vaccine that we are developing and that is going to them, because people they have come from different backgrounds, different understanding of why this is happening and we have been there maybe for maybe over a decade with malaria and there was no vaccine in the people. There's a lot of R&D behind that vaccine is being pushed and developed. You look at the history of people struggling to get a vaccine for malaria. It's a long journey, but those that we are targeting they don't really know that people are struggling, so suddenly for them it's become like a boom. Now we are vaccinated for malaria. Immediately. There is kind of this push between us and those that we are intending actually to support.
Speaker 2:So I'm just saying that there are little pockets of access of this intervention. It's varying a lot in terms of what we're actually looking at.
Speaker 3:It's quite interesting. I mean, with these insights, the fact that it's different from country to country and the aspect of the cultural aspect. This is something I didn't even think of, but I think it's very important and I think this is clear because it comes in from the insights that you've been getting from the data from the Malaria Atlas Project, right? So maybe can we talk more about that. Can you explain some of these sophisticated systems that you have that you are able to track this kind of information and why it's so important to use that in answering these questions?
Speaker 2:Oh, beautiful. So with Malaria Atlas project we have two layers. We have the first layer, which this is the global level, and that's where we are building sophisticated tools, analytical architectures. First, to estimate the burden of disease means cases and death. So by estimating that. So we are using a lot of data that is coming from mainly primary, secondary sources like national surveys. We are using data from routine systems. We are using data from all that published literature of how malaria prevalence is happening. So there's a big team behind collecting this data. So we use that.
Speaker 2:And then, at that level, now we are able to monitor the burden itself and that is kind of like it's annual. But it's a monitoring system that is very sensitive, very high quality, very scrutinized. Actually, we really challenge our models to make sure that they are sensitive and they are developing a product that is trusted and is of good quality when it goes out. So at that level, at the global level, we can see the budding, how it's going, we can see the coverage of the interventions, the key ones talking about ITN, iris, the drugs itself. Those are the core ones that we monitor at that level. But also we are doing attribution. It's like if you have a different level, different type of interventions, what's the contribution of each. And that information is critical because now people they know what they should think to focus more, because you see which one is actually contributing more to the burden that you see or is much more impactful. But that's the first part, so you can see the global picture.
Speaker 2:But with the model that we have now, we have decentralized the group and that's the group I'm leading in Dar es Salaam. So since 2018, we started the initiative which is called High Blood and High Impact Initiative. So actually we are zooming in. So imagine that you have like 10 countries in Africa in particular, or maybe 10, or maybe now I think there are like 12 countries. They are contributing maybe almost 60% of. I think they are like 12 countries. They are contributing maybe almost 60% of the disease. So all the countries that you have, like Fortisanda, you have this small set that they're contributing almost everything. So this HBHRI initiative was now. Can we, instead of like standing at the global analytics, can we zoom into these specific countries?
Speaker 2:and do analytics which are very bespoke, they are very tailored to these countries. So now, instead of looking at the picture of the country, you are going another layer down. But it's not only that. So you go sub-nation. So when you go sub-nation, because even the decisions now, because the countries now they are moving, they are doing decisions sub-nation. So it means we have to follow them as well. So give them a product, an insight that is in that area that they are looking at, where they are making the decision. So with that we don't only do the sub-national, but also we are using more data, because in the global models there is data that you cannot plug in into those models, because the models they need data, maybe for at least a certain amount of places, so that you can be able to fit these models or these analytics. So the monitoring system now has gone down to subnational. So now you're going back to the tailored systems which are much more closer to what is happening. So we are zooming into the hotspots, you are zooming in to give them more insight that they can actually point, and now even resource allocation becomes even better.
Speaker 2:So what we are doing also with the direct group, which that is going to be. Our now journey is also to go find places that you can even do below this, maybe districts or admin tool levels. So there you can start plugging in not only maybe monthly data, for these are the common data we use for maybe for incidents, you can use maybe weekly data, because there are systems that they are collecting this data weekly. So can you also know innovative architectures that they are monitoring these systems in much closer times. So you don't have just a space, you have the space in closer terms of time. So look at that. So that is where we think our group is contributing to In the next five, 10 years. It's going to be so different. We'll be able to pinpoint areas that they are really troublesome. They are really persisting because the data sometimes is there With the global area.
Speaker 2:If you are going to this level you don't access because most of the electronic systems they don't have this data.
Speaker 2:At that level the data when it's collected, the paper base, is very granular.
Speaker 2:It's very like you can have the data by person, but the system that they are gathering this data are aggregated. So the group that we, this malaria address group, with the new mode of decentralized, will go and really dig deep into these countries and you can see some data that have never been actually digged up. We're going to get all this data and make sure that whatever we produce is robust. It's actually like putting the mirror multifaceted so that whatever they see, they see all the connection of how they can monitor their systems. And we believe with this system, with this project that we are now doing, at this much more zoomed-in strategy, we can even inform back the system of information. It's like maybe some indicators you don't need to collect and that goes to the money, so maybe you don't need to invest here because these parameters, these five, are enough. So it's like having an optimal need. So it's very exciting actually what we are doing in Dar es Salaam. I mean the team, of course we are really going to chase the continent malaria out of the continent.
Speaker 3:Yes, I love it. I love your passion. It comes through so much when you're speaking about this work and it's so, so fascinating, jen. You can hear this type of excitement that's happening. You've spoken about the wonderful innovations that are coming through, but I mean, we're always going to come back to the money issue, which is investment right, so it's always going to lead back to that. In this case, investing more will really help us, you know, fight this problem and find more solutions that you know, access, et cetera, et cetera, et cetera. So, to people who are unfamiliar, what is the estimated return on investments for malaria control and the elimination efforts? Like you know, just now, let's we need to start having that money conversation always yeah, it always does come back to money.
Speaker 1:I think that's true of almost anything in life, but, yeah, it very true of malaria as well. So there have been some estimates out there really good estimates that say that essentially, for about every dollar you invest in malaria control, elimination and ultimately eradication, getting to zero malaria worldwide, for every dollar you can expect about $40 in return, a 40-fold return. And that's amazing. I mean, if I could get 40-fold return on my investments, amazing, I mean, if I could get 40-fold return on my investments, I'd be in a pretty happy life, I'd say. And the reason for that I mean some of it is direct benefits. Obviously, when we're able to prevent malaria cases, we're able to keep people from becoming sick, they are able to attend school, they're able to stay in the workforce, they're not taking days off, they're not losing days to caregiving, but all of those things then have all these knock on effects as well. So, you know, when a child is able to stay in school longer because they're not going out, you know, every couple of months with a malaria episode, that's an investment in their education and that education leads to economic empowerment and independence later on, and so they become somebody that is, you know, well-educated, has a great job, is giving back to society, is earning, has earning power for their family. It just is something as simple as early interventions, and keeping kids safe and healthy has this lifetime knock on benefit. Similarly, malaria and gender are very, very intimately intertwined, and we know that when you invest in malaria control, you see returns in women's health and economic empowerment as well. We know that, you know, pregnant women are at increased risk for malaria, so we're directly keeping them safe. But because women are such a big part of the caregiving world, both for family members, they're oftentimes the majority of the community healthcare workforce. In rural communities it's women, and often unpaid or underpaid women when you invest in malaria control, you have these benefits for that caregiving portion of society as well, so we have to think about it both in those kind of direct and indirect terms.
Speaker 1:The scale of investment that we need, though, is pretty dramatic as well. You know, a 40-time return on investment is amazing, but the size of the problem we're facing is also amazing. So it's estimated that around three and a half to four billion dollars a year is being spent on malaria directly, but we know from modeling results and work that groups like Malaria Atlas Project, have done that that globally, what we actually need in terms of financial resources to truly get ahead of malaria and get to eradication, we're going to need about $8 billion a year, and this is all in US dollar figures. So there's this gulf. We're only investing about half of what we need into the system in order to generate those returns that will have those wonderful direct and indirect benefits.
Speaker 1:So there is a very strong investment case that you know. We need more resources in malaria. Those resources will give you a return on investment, an incredibly big return on investment. But we are far, far shy of where we need to be right now. So it really does call attention to the importance of countries around the world not just malaria endemic countries, but countries around the world saying, when we invest in this, we all, as a global community, derive benefit. So making sure that institutions like the Global Fund, where a lot of malaria communities commodities come from, making sure that institutions like the Global Fund, where a lot of malaria communities commodities come from, making sure that those are well funded, making sure that countries around the world have a strong foreign aid budget, making sure that malaria endemic countries are able to deploy their resources effectively and start using domestic funding for malaria as well. It's really a global issue and, as I said, an issue of substantial scale but substantial potential return as well.
Speaker 3:Definitely, definitely. And I want to touch on something that you mentioned the issue of women in malaria, and I think the gender issue is an issue that it's great that it's getting a lot of attention. I think for the longest time that wasn't the case and, like I said, that the World Health Report has gone live today is that women and adolescent girls are uniquely, disproportionately impacted by malaria. But there is a gender intentional approach has been missing, and they've recommended interventions such as primary health care, adopt gender transformative strategies, embedded equity as a guiding principle in investing, you know, in this approach. So, susan, I wanted to ask you, maybe with your own experience as a woman working in this type of field, why do you think the gender intentional approach to the malaria response has been overlooked for so long?
Speaker 2:Thank you. That's a huge, that's a big, it's a very big question and from where I'm sitting, it's very true that gender is not in the guiding principle of a lot of initiatives and that's sad to speak. And if I speak from the context of the continent that I am coming from, africa, and I think there are multiple layers of that why we are where we are. And it starts very far. It starts from the culture and norms and it starts very far. It starts from the culture and norms. Women, adolescent girls or girls, the way the culture looks at them speak volume about that. And for that specific one, I'll just end there, this culture part, but also, because of that, now the entire system. There is a domino effect of that.
Speaker 2:People are not aware that there is a problem that focuses on this specific group. It is not about the initiative targeting pregnant mothers, pregnant women. I tell you, up to date we have no very strong strategies focusing to this category. Those women are because they are carrying a baby and people they care about having a safe baby. That's why you can see initiative like antenatal care, testing and everything they are happening. But just women, no more in the community, you're just a woman. So that knowledge, that awareness because it's not there is creating that gap into those approaches not to be looked at. But then come to my lovely place data. We have data and we try our best to have data that could categorize. You can see. See, if you go back like 10 years ago and you look at the health information or health management information systems, the age categories have been moving and changing and coming where we are trying them to go.
Speaker 1:As I've said before, the collected data is everything.
Speaker 2:You have information about every person. You can get out the adolescents, you can get out the school kids. You can get out the women everything. You have every information about every person. You can get out the adolescents, you can get out the school kids, you can get out the women everything, but the system it doesn't get. Give you an example of Tanzania. The data that we collect you have zero less than one month. So we can capture the neonates. We can capture the infants. We can capture under fives. After that that we jump five years to 60. So these kids, they are in the middle there. You can't find them. So the data is broken down by sex. You can have female gays, but you can't capture these age categories that are very sensitive. And that is aggregated data. So if you want to act on that specific space, you need to go further down to the raw data, because Because it's there, but in the system and because that is also explained, because of the cost. So we are lacking good data to be able to do this gender intentional analytics so that we can understand what is happening. But now around that they rappel about. You need a lot of qualitative work around malaria to understand that they are the problem.
Speaker 2:These are the kids that wake up in the morning, these girls to fetch fire, water and fire before they go to school. The boys will be like enjoying their sleep. The most tutors that Jane has spoken about. Change of behavior and how they bite. Who is going to affect it most? A woman or a mother? And the girls. That is a quality part. So if we are not pushing this, we won't be able to see that, because if that is like another, somebody has to do that. So, being on STEM, because I've been a woman, I've been a girl in the past, it's like I have all the recipes. I think we need first to remove that gender stereotype, that boys. Put them somewhere similar so that we can look at them and we can focus because there is a problem there. So that culture, trying to break down those blocks of the grouping, this so that we can get them out and get to understand what is actually happening, to be able even to initiate something.
Speaker 2:But push a lot of this gender stuff as a guiding principle. We need to say it over and over and over and over and over and over so that we can be able. Even this WHO? I was very happy. Actually, we were with another lady from Ghana who has been part of this WHO report putting those genders in there, and I'm very happy it came out now, because if you go back and google those other reports and find gender, you'll cry. You won't find that terminology, it's not even there. So this is a good step. Now we are pushing, pushing so that by the time it's starting coming out you start to see it like changing the data. We try to push the initiative because somebody is pushing from from the top who is making decisions for us. So maybe I should probably. Otherwise we're speaking a lot about gender gender and data.
Speaker 3:It all comes back down to that. So you're absolutely right. I was also quite interested when I came through that part. I was like, yes, we're having this conversation, it's coming up and now we can start thinking of how to get our data to speak to these gaps that we've seen. And, jen, maybe this is where you can come in, like, how do we integrate the agenda into programs so that we can have data that allows for equitable access and prevention as well?
Speaker 1:Start collecting it and start routinely using it, like we have the playbook. We know what to do, we just have to start doing it. And I think a little bit of it may be an issue of scale. So, for example, say you're one of the highest burden malaria countries out there. You, how much malaria you are dealing with generally, sort of where is it following temporal trends? You're like, okay, how much, how big, where.
Speaker 1:Once you've got a handle on that and you've got a good functioning surveillance system that can reliably kind of count and track cases, that's the point where you're like all right, let's drill down a layer further and start getting data that are what we call gender disaggregated. So it says this is a number of cases we see in males, these are the number of cases we see in females. And you can collect age disaggregated data as well, because we know that malaria disproportionately affects young folks and we know that that's different across different age bands. So in the zero to five age group, maybe the five to 15 year olds, maybe kids that are 10 to 18, there's going to be sort of different age distribution patterns in different places. So once a country's got a handle on that basic being able to count kind of everything that's happening. That's when you want to go that layer deeper and say, okay, what ages is this in, what gender is this in? Because that gives you, as Susan alluded to earlier, that more bespoke, precise, subnational look. And again you know, once you've got a handle on the big picture and you know how big the problem is, when you start to be able to look at, okay, exactly where is that happening and amongst who is it happening, where are our most vulnerable populations, that's when you can start to go in and do those very kind of bespoke, exquisite, right combination of interventions for the right communities in the right places.
Speaker 1:And if you look at other places in the world where malaria has either been eliminated from within the country or reduced substantially, you see that that very detailed, granular data just becomes more and more and more important over time in helping you to plan your interventions.
Speaker 1:And I'm thinking specifically of, if you look at the greater Mekong sub-region area, so countries like Cambodia, vietnam, laos, thailand.
Speaker 1:They have made incredible progress in malaria, especially just over the last five years or so, and they've done so in the face of some of the threats that Africa is facing now, like drug resistance, like insecticide resistance, but by having really exquisitely sensitive data systems that were getting gender data, getting age data, they were finding that, as their cases were going down in certain countries, they were concentrating amongst adult males, and they were concentrating in adult males in very particular parts of the country as well, and they started to realize that men that were regularly going into the forest for work so they were doing logging activities, mining activities those were the ones, those were the individuals that were picking up malaria and they were getting infected in these last little hot spots.
Speaker 1:So, as a country gets closer and closer to its elimination journey, that very fine grain data helps you to pinpoint with exquisite accuracy this is the population that the malaria is still hanging on in and this is where they are, this is who they are and that tells you what's going to be the best intervention there. So, if you're talking about men that are going into the forest for seasonal work, if we have one of those seasonal protection tools I talked about earlier, where one single shot might keep you safe for six months, give it to those folks. That's how you'll mop up that little hotspot. So really, you know, as countries get closer and closer to that elimination journey, where they're moving from just control into truly eliminating that high grade, high resolution data becomes just an invaluable tool for planning and service delivery.
Speaker 3:Lovely. We are running out of time, unfortunately, and it's been such a rich conversation about so many aspects of the complexity of malaria, so I want just the final note from the both of you. The first one is to Susan. You are working um with this work and I'm sure you've been doing it for a really long time. So to you both, what makes you hopeful, um that of a malaria free world possible? What makes you helpful? I have an idea. I think I know what you're gonna say, say, but what makes you hopeful?
Speaker 2:Oh, okay, so I will start with our climate analysis. We are getting there. We are getting to unpack things that we were forgetting in the past, and now we start to get these insights. The climate analysis was wonderful, so now we are trying to tell the people who they are giving us money. There is a problem and that's where we should focus, and last few weeks the Global Fund Board were meeting and there are new commitments, there are new changes of policies. So there are things that were okay. The routine ones will still get the money. The replacement is coming, so there will be money at least to sustain the gains that we have.
Speaker 2:But now we may have opportunities to get funding for this new stuff. We can push resilient systems. Climate is there. Then you can apply for that. So it means maybe they are trying to accommodate our issues, this gender stuff that you're talking. I was mentioning that we can translate the pillar three of the global strategy as an intervention. So if we can put this one in a way, just a way, the Global Fund maybe gets foundation fund these initiatives, and that itself is going to push us really, really far.
Speaker 2:So those changes and Jenny can speak of the new tools because she's good into that. But the hope is there because we are touching the problems, the really the problems. We have areas that were not able to be looked at. Now we're talking about Nigeria. We're going to really slice Nigeria, which is causing a lot of this. We're going to really go deep into that. We have money somewhere to deep go down, connecting environmental change, climate, health systems. Look at the urban systems, people, livelihood and see like unpacking all those little pieces and that is going to take us a milestone. Malaria is going to go out faster than before.
Speaker 3:I'm going to finish all the time.
Speaker 2:Thanks so much.
Speaker 1:I would say from my end, I'm excited by the people, the people that are going to get across the finish line and I think both Susan and Anne, you are excellent examples of those people. So Susan has shown us today the transformative power of you know data innovation, thinking about problems from a scientific lens. She's talked about how the type of work that she's doing will help all those cool new transformative tools that we have be deployed in the right spaces. So we've got this wonderful collective of you know, individually brilliant people working on malaria, and that gives me a ton of hope. And then, anne, you're an amazing example of somebody that is making issues, including malaria with this episode, matter to the community and putting it on the radar of policymakers, politicians, celebrities, people that have influence in society.
Speaker 1:And it's not going to take, you know, just the bright malariologists and their new interventions and their new tools. It's going to take a whole of society approach. It's going to take governments at every level of the system, whether it's a ministry of health, whether it's a ministry of women's economic empowerment or the ministry of finance. Everybody has a stake in the malaria game. So when we're all aware of the issue, when we all appreciate how much it is touching society and when we all appreciate that this is a preventable and treatable disease that with enough concerted effort together we can and will eradicate. There's tremendous power around that.
Speaker 3:So, whether it's bright spot, individuals or the entirety of the malaria and malaria related ecosystem, I'm really excited about the amazing contribution that people are going to make over the next few years, and I'm sure even our listeners learn so much from this conversation and I'm excited to see what will come out and hopefully one day we can have a follow-up conversations of where things are since this conversation. Thank you both for taking the time out to chat with me and thank you to our listeners who are tuning in for this episode. Until next time, goodbye.
