As someone within the research confines, Dr Knol’s comments ring true. Even in malaria research institutions in endemic countries, where  presumably there is greater pressure to focus on applied and operational questions, most new young scientists are taken by the latest molecular method.

These topics reminds me of a letter to the editor I came across a few years back:

Maintaining health in the tropics requires more than medical intervention after disease strikes. It requires more than drugs and vaccines to prevent disease. It requires something else, hygiene. Next year will be the 100th anniversary of the commencement of the work of Dr. William Gorgas in Panama. That 10-year effort was not accomplished with medicine or global health, it was hygiene: spraying insecticides, eliminating breeding sites, creating efficient drainage, building homes that keep mosquitoes at bay, and many other measures unrelated to clinical or laboratory medicine. Today many of the tropical infectious agents our Society investigates creep out of the conditions created by ignorance of hygiene.

The neglect of hygiene as a tool of disease prevention is lamentable. A simple hygienic practice that could prevent endemic disease often doesn’t happen because no one thought of it. We fly into areas of endemic disease bearing rapid diagnostics and effective therapies, but we neglect to bring the idea for a simple measure of hygiene that could prevent most of the infections being diagnosed and treated. Hygiene has no cache. No one funds research aimed at improving hygiene, and that’s too bad. Hygiene comes with no microsatellite arrays, ELISA wells, or dramatic recoveries in the clinic. Sound hygiene quietly creates communities of healthy people.

Recently, I browsed through a malaria journal article (open access!) whose potential I have difficulty understanding. Can someone explain to me how research on variation in chromosomal inversions and their relationship with stress responses will improve malaria control? Looking carefully through the manuscript, the sole rationale that I could find was:

Polymorphism for the 2La inversion creates heterogeneity in the stress response within A.gambiae, which could directly or indirectly reduce the efficacy of vector control measures, and influence the reaction of vector populations to environmental variation including climate change.

I find this single sentence advanced by the authors both incomplete and unsatisfying. It tells you very little. So let’s think through the rationale ourselves. Understanding the ability of a vector to exploit different habitats is certainly useful – we could predict how mosquito ranges and other characteristics may change with the climate. Understanding the molecular basis of that ability might further help – if the molecular changes had a clear association with a phenotype of interest (i.e. real world characteristics of the mosquito) and were such that they could easily be monitored. Understanding polymorphisms in those molecular mechanisms and their relationship to stress response variation however is not intuitively valuable (perhaps for modelling purposes?). To be clear, my aim is not cast the research as meaningless (though it may be). Sometimes the impact of basic science take years or decades to be realized. Rather, I’m surprised the authors, and especially the reviewers, did not seek to clearly convey the value of the work. If the purpose of public health research is to improve health, then the communication of such research should describe its relevance in explicit and detailed language.

In 2007 the Millennium Village Project published early results related to agriculture, health, and economic development in their three research villages in Kenya, Ethiopia, and Malawi. I am not commenting on their work as a whole but their malaria claims were disproportionate to the evidence (especially given the bias of self-evaluation). The group does note some of their limitations but they also unequivocally state to “have reduced malaria prevalence”. It is an interesting use of the term prevalence, which usually refers to the proportion of parasitemic people in a survey, whereas they used facility based data and measured changes in the proportion of clinical malaria cases against total clinic visits. Regardless, even if prevalence or incidence decreased any credit due is unsubstantiated. Some of the obstacles in interpreting their data include the use of clinical malaria cases (which is problematic as discussed here), no demographic comparisons of facility controls, displaying a reduction in diagnostically confirmed cases without any context of testing trends, and only one year of follow up in the absence of any discussion of pre-intervention trends. To be frank the malaria portion of the paper is rather bad science. I am surprised the Proceedings of the National Academy of Sciences endorsed it.

1. “Flying syringes” – the efforts of Dr Matsuoka from Jichi Medical University in Japan to produce a transgenic mosquito, as a flying syringe, to deliver protective vaccine via saliva.
2. “Microwave therapies” – Dr Spadafora from the Institute for Advanced Scientific Research in Panama wishes to use microwave frequency as a treatment for malaria

New interventions designed to target human and vector populations that are hardest to reach

New interventions that will be valued and used by individuals and communities even after malaria rates fall and the perceived threat of the disease is low

New tools and technologies for monitoring and surveillance of the pathogen, including methods to detect latent and subclinical infection in both human and non-human reservoirs and vectors

New tools and approaches for reducing malaria transmission, especially from low levels to zero

New strategies to apply interventions to populations, such as those considering the underlying heterogeneity of human, mosquito, and parasite populations in space and time

Political and financial commitments will be first and foremost towards embarking on any major effort. Obtaining these (with some level of confidence) is a perilous proposition in itself but will not be sufficient for many parts of the world which have high vectorial capacity (in plain English – really efficient mosquitoes). Data from a number of long term field trials and mathematical models along indicate our inability to eliminate parasite reservoirs in these areas even with near universal application of current interventions. Whether eradication should be on the table is another question altogether, but if Gates is serious about eradicating malaria then finding new tools is a solid move.