As I was watching the Gates Malaria Forum's "Town Hall" yesterday evening (entire day's webcast), I was struck by an anecdote told by Brian Greenwood, Professor at London School of Hygiene & Tropical Medicine:

When Sir Ian McGregor was working in the Gambia, of the children who came to the clinic there with malaria, 80% had a positive blood film; 10 years ago it was 40% of those that had clinical malaria had a positive blood film; last year it was 4 percent.

Unless I'm misunderstanding him, Greenwood means that, out of diagnosed purely by their symptoms as having malaria ("clinical") , only 4 percent actually had malaria and that this number has dramatically decreased over time. This anecdote drives home the difficulty of dealing with this pervasive disease ($12.5 billion in productivity is lost in African every year due to malaria).

Blanketing all of those with malaria symptoms with malaria drugs, or performing "presumptive treatment," results in "additional expenses and increases the risk of selecting for drug-resistant parasites" (i.e. strengthens the disease). On the other hand, to borrow an anecdote from the moderator, when faced with a sick child "up-country" and imperfect diagnostic methods, how do you not give that child all available treatments? And how do we get better diagnostics "up-country"? (Greenwood's anecdote was used in response to a question about Rapid Diagnostic Tests.)

The anecdote also informs later discussion in the town hall on the practical and political aspects of setting the "E word" (eradication) as the stated goal (start watching at around the 2-hour mark).

Those arguing for restraint suggested that there is "great honor in disease control" (certainly) and that aiming high and falling short runs the risk of curbing the currently strong public support for malaria efforts.

Several brought up the WHO's Global Malaria Eradication Campaign, launched in 1955. Malcolm Gladwell's superb "The Mosquito Killer," published in The New Yorker in 2001 provides a thorough analysis.

The short story: the campaign, based on spraying 80 percent on the houses in an affected area with DDT, eliminated malaria in Europe, Australia, and other parts of the developed world as well as significantly reduced the number of cases in developing countries like India. Millions of lives were saved. However, due to logistical and cultural difficulties, 80 percent coverage didn't happen everywhere, particularly in sub-Saharan Africa, and a DDT-resistant mosquito quickly began reproducing. "In 1963, the money from Congress ran out" -- in 1958, the U.S. had dedicated the equivalent of billions of 2007 dollars for the effort. "Countries that had been told they could wipe out malaria in four years -- and had diverted much of their health budgets to that effort -- grew disillusioned as the years dragged on and eradication never materialized." And, finally, "[i]n 1969, the World Health Organization formally abandoned global eradication, and in the ensuing years it proved impossible to muster any great enthusiasm from donors to fund antimalaria efforts."

Regardless of where they came down on the "E" discussion, all participants seemed to agree that sustained political will is critical. In the fight against a disease that continues to kill a million people a year and has paralyzed an entire continent, let's hope we can achieve it.