How Close Are We to Eradicating Malaria? 25th April 2015

The scientific community is divided on whether or not we have a chance to achieve malaria eradication. Some argue that the task is too enormous. That lack of products, lack of access, lack of political drive or lack of funds will stop the downward trend of malaria. Some even predict a darker future with a potential resurgence of the disease.

On the other hand some, like Bill Gates, believe that it can be achieved within 15 years with the right resources allocated to the task.

In the end nobody is absolutely right or wrong. Nevertheless there are a few things that are certain:

The IVCC team is on the side of those who believe eradication can be achieved. We also have an acute understanding that it will not be a ‘walk in the park’. All our efforts are directed toward releasing new vector control products and ensuring access to them. This is important, because vector control is already identified as one of the most cost effective solutions to controlling malaria by preventing transmission. The downside is the rapid spread of resistance against most of the insecticides currently in use.

That’s why IVCC is working hard with a wide and diverse group of partners to find new solutions, either by re-purposing insecticides already available in other markets, or by engineering brand new insecticides dedicated to public health.

We are not complacent, but we do have solid reasons to be proud:

So, do I believe we can achieve eradication? I do, but only if all the stakeholders in the battle against malaria work together to make it happen. No-one can do it alone. But together we can turn the vision of eradication into a reality.

Accelerating Development of New Insecticides 3rd February 2015

Sitting snugly in the shadow of Mount Kilimanjaro in Tanzania sits the Kilimanjaro Christian Medical University College. Based at the college is PAMVERC, where a team of scientists works collaboratively across a number of organisations, such as London School of Hygiene and Tropical Medicine and IVCC, to test new innovations in vector control, mostly malaria-focussed.

Even though we know how to prevent malaria, it still kills over 600,000 people each year. The vast majority of these are children under the age of five, and pregnant women.  Insecticide treated bed nets and indoor residual spraying of insecticides have and will continue to save thousands of lives every year; however, as with any monotherapy (only one class of chemistry is available for use in bed nets), resistance is starting to seriously take its toll.  We are seeing resistance to pyrethroid insecticides and other classes of chemistry almost everywhere we look for it, and in some locations in Africa complete failure has been observed. This is not a new story but it is an increasingly frightening one. Insecticide resistance is now reaching the tipping point. (Watch the IVCC video here for more information)

The good news, however, is that even when insecticides fail, the physical barrier of a net continues to provide some level of protection from malaria transmission, so continued net use is important.  IVCC’s mission and focus since its inception in 2005 has been to work across multiple stakeholders, especially industry, to catalyse innovation in vector control and bring new classes of insecticides to market.  New products are starting to become available or are in the product development pipeline at a well-advanced stage. Watch this space!

However, our focus is beginning to shift from managing innovation to managing time from discovery to impact.  I recently asked two different highly respected scientists in the field of malaria and neglected tropical disease research what a complete failure of pyrethroids in bed nets would represent in terms of lives lost and the estimates were staggering—somewhere between 70,000 and 150,000 per year.  Any number of preventable deaths is completely unacceptable, but these types of numbers defy belief and really raise the level of urgency and responsibility.  Today, from discovery to impact for a new insecticide takes about 12 years.  We have a number of new chemistries just entering the development phase, which means that, if we take a normal course to market we will not see an impact until 2024/2025.

What if all the different players in the value chain agreed to do something creative and disruptive so that we can make new life-saving public health insecticides available by 2020—just five years?  This is feasible, and could save many thousands of lives.

We know how to accelerate the development of experimental products when lives are at stake—the Ebola crisis has demonstrated this.  So, we in the malaria community need to take full responsibility and apply the same principles and urgency to solving the malaria problem.

Novel drugs and vaccines are in the research pipeline, but vector control is and will continue to be the foundation of malaria management for the foreseeable future. Can we rise to the challenge of maintaining or improving on the performance of long-lasting insecticide treated nets and indoor residual sprays and getting them into the hands of those that desperately need them in five years or less?

Just Around the Corner May Be In Sight 26th April 2015

As I discovered recently, while visiting Forde Abbey, a 12th century monastery in Dorset, the word about malaria seems to be getting out.

When asked about what I do for a living, I used to expect to start every response with a short explanation of malaria, mosquitoes, insecticides, bed nets and vector control. But this is happening less frequently these days. The general public often knows the basics about malaria and there is an expectation that the challenge of malaria is being managed and a solution is just around the corner.

Just around the corner may be a little optimistic but it certainly it is in sight.  In 2000, <3% of the population at risk from malaria had access to an insecticide treated net; today that number is about 50%.  In the last fourteen years, there has been an estimated 50% global decline of mortality rates. This is something to celebrate, of course, but a staggering 580,000 people still died of malaria in 2013.

The World Health Organization’s new malaria targets are ambitious—to reduce malaria mortality rates and case incidence by ≥90% by 2030, to eliminate malaria from ≥ 35 countries by 2030, and to bring us ‘as close as possible to global eradication.

To achieve this, novel insecticides, drugs and vaccines are essential. IVCC’s mission is to build a toolbox of vector control solutions that can combat insecticide resistance. When IVCC was formed ten years ago, our biggest hurdle was to build partnerships with the major agrochemical industry companies and work with them to identify novel chemistry for public heath use.

Four and a half million compounds and 27 chemical classes later, that challenge has now been replaced with the need to find significant funding to take three new interventions ‘across the finish line’.

In 2013, $2.7 billion was spent on malaria through international and domestic funds. But an estimated $5.1 billion will be needed annually if we are to ensure that malaria ceases to have a devastating impact on people’s health and livelihoods around the world.

So what funding does IVCC need over the next ten years to complete its mission?

It takes much the same process to get a novel insecticide registered and into the right hands as a new drug; chemistry, efficacy, formulations, toxicology, environmental impact and chemistry, registration fees etc. are all needed to provide safe and effective products.

I am very optimistic about the life-saving potential of the IVCC product pipeline, thanks to the incredible support of funders such as the Bill and Melinda Gates Foundation, UKAID, USAID, Swiss Agency for Development and Cooperation, as well as our industry partners such as Syngenta, Bayer, Sumitomo and BASF.

If our current funders ‘stay the course’ until 2025, we need to find an additional $100m, 70% of this in the next four years. I think we can do this, but it will not be easy.

Today we work closely with committed and motivated funders, but there are other sources of funding that could play a part in eradicating malaria.  What about the private sector?   Companies with long-term growth strategies for sub-Saharan Africa, could make a contribution to saving lives and growing the African economy, and at the same time building their brands and repetitional capital.

Are there any senior industry executives out there with the vision to see the value of being a partner in this incredible and winnable fight to eradicate malaria?

Why the Words We Use Matters 23rd April 2015

Why the words we use and the way we understand them matters

What do you understand by the term “commodity”?  To most people in the global health world it means a consumable product essential to delivering health care, like a drug or diagnostic kit.  And when we read reports or grant applications we see the word commodity used all the time in this way.

But in the world of economics or business, or in our everyday lives, “commodity” has another meaning.  It refers to products that are not distinguished from one supplier to another, for example electricity or petrol.  When you buy electricity you don’t expect the electricity from one supplier to be better than another and there is no such thing as a premium quality option.

So, we get tricked by the language into a false conclusion.  Because we call all our consumables in public health commodities, we get misled into thinking that there is no differentiation between them.  Nowhere has this been more apparent than in the market for long lasting insecticide treated nets.  They are treated as pretty much pure commodities, and this has an alarming consequence.

For a true commodity there is no differentiation between one product and another, so there is no reason to look for anything other than the lowest price.  There is no need for product innovation and the simple economics of supply and demand determine the price.    There is a process called commoditisation which is what happens when a product that used to be new and innovative becomes widely manufactured to similar performance.  Think of flat screen TVs and we are all familiar with the key outcome of that; the price falls dramatically!   So if you want products to get cheaper and more uniform then commoditisation is a good thing.

But what if it turns out that having all the products be the same is a bad thing ?  There is an inherent danger in commoditisation that we create monocultures at risk of catastrophic failure. Well that is exactly where we are with insecticide resistance today.  Because they are so effective, safe and cheap, we have become totally reliant on one kind of insecticide, the pyrethroids, and, in our drive to push down costs, we have commoditised the market for products based on that insecticide.   And guess what; we ended up with resistance.  We should not be surprised.

Others elsewhere will talk about the heroic struggle to create new chemistry that will dig us out of the hole of insecticide resistance, but I want to talk about the economics of those new products.

First of all they will become the differentiated non-commodity par excellence.  Not only will they differ from pyrethroid based products and each other but those differences will not be the same for every situation.  Some people will see dramatic differences as they move away from pyrethroids whilst others may barely notice.  Worse still these differentials will vary with time as resistance waxes and wains under varying ecological pressure.

So the day of the vector control product as commodity is soon reaching an end and that calls for a whole new way of thinking about those products and their performance and price.  We are all quite happy with the concept of paying a higher price for a high performance product (let us not touch on that other abused word “quality”) ,  but that’s because we have a view about what high performance means.  We are just going to have to get used to deciding what high performance resistance breaking insecticides are worth and get used to paying it.

Perhaps we could start by calling them something other than commodities. How about differentiated goods?

(Next time I will put the record straight on the difference between quality and performance)

Regulation Must Protect but Not Stifle Innovation 22nd April 2015

Pesticide regulation.  Two words, separately or together, that send shivers down the spines of those on the left and right of the political spectrum.  The words conjure up lengthy risk assessments, decisions written in the language of regulation, and long product labels with lots of small print.

Who grows up wanting to be a pesticide regulator?  It’s unlikely to be a career competing for the top slot among school children.  I have been a government pesticide regulator for my entire career.  Completing a 30 plus year career with the United States Environmental Protection Agency (EPA) in September 2014.

What kept me interested for so long? It was a perfect fit for an academically trained zoologist and biostatistician/epidemiologist with a desire to change the world.

Protecting public health and the environment was the criteria for every single pesticide product decision. At the same time, recognizing the value of pesticide products that allow farmers to produce a diverse, plentiful, affordable food supply, protect houses from being destroying by termites, and protect people from vector borne diseases.

Every single decision made on a pesticide product had an immediate impact on society in some way, nationally and sometimes globally. Every decision made a difference.

The bar is high. To gain and maintain trust and confidence regulation must protect, but not stifle innovation.  In the case of pesticides, a sound regulatory process must also encourage the innovation of safe, effective pesticides to deal with constantly changing pest problems.

Immediately upon retiring from EPA I accepted a position with IVCC to manage the regulatory process for three new insecticide active ingredients with different modes of action.  The goal of the work is to help eradicate malaria!  Pretty much a dream job—to move directly into managing the approval process for insecticides targeted at controlling this global vector borne disease. What better way to put my experience to use—helping to save lives, and really making a difference to the lives of millions of people.

At IVCC I will be working with companies developing new insecticides, to get products available for use in the shortest time possible without sacrificing the quality and thoroughness of the regulatory review. I will help with the development of high quality, complete data packages supporting the safe, effective use of the new products for submission to national regulatory authorities and international review bodies.

Regulation of insecticides is absolutely necessary. It protects people and the environment from unintended adverse effects from their use.  At the same, because public health insecticides play such a vital role in saving lives and improving life chances for millions, regulation must also facilitate development of these essential new chemistries that protect people from vector borne diseases. It’s all an integral part of this great mission to eradicate malaria and change the world.

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