Vaccines vs. bednets: the malaria dilemma

There are few clearer examples of the need to combine high-tech solutions to development issues with the reality of problems as experienced and perceived on the ground than the challenge of designing an international strategy to combat malaria.

One of the major difficulties facing those who promote the greater use of science and technology in development is the management of expectations. Promise too little — or wait for a demand that may fail to materialise — and you are unlikely to generate the enthusiasm and imagination needed to persuade sponsors to invest in the necessary long-term research and development.

Bednets treated with insecticide are invaluable in the fight against malaria

But promise too much, and you risk generating a backlash against science-based interventions. This can happen either when the promised technological miracle fails to materialise, or when their implementation creates further, unanticipated problems (remember the promise that nuclear power would eventually become ‘too cheap to meter’).

The solution lies in promoting and pursuing strategies that, on the one hand, acknowledge the central role of science in meeting social needs, but on the other, simultaneously accept the potential limitations of science-based solutions to problems that may have deep and complex social roots.

In other words, strategies are needed that combine the dynamics of science-led innovation with a practical assessment of both the needs that such innovation is seeking to address, and the constraints that social factors — which can be cultural, ethical, political, or even environmental — place on any attempts to resolve them.

The challenge of malaria control

Nowhere is the challenge more evident than in designing a global strategy for combating malaria. Over the past few weeks, Britain’s Chancellor of the Exchequer, Gordon Brown, has been sketching out the details of a potential multi-billion dollar programme to address such a goal. He is proposing to do this primarily by creating incentives (such as advance purchase guarantees and revised policies on issues like intellectual property) to persuade the private sector to invest in the development of new drugs and vaccines.

The leaders of the world’s industrialised nations are likely to be asked to endorse this strategy when they gather for their annual G8 summit meeting in Scotland in July. Central to it is a belief that modern science (and particularly recent advances in genomics and biotechnology) offers an unprecedented promise to solve the world’s health problems.

In a speech last week to the Catholic aid agency CAFOD, for example, Brown heaped praise on the success of child health campaigns led by the Global Alliance for Vaccines and Immunization. “If we could do the same for … research and advance purchasing of drugs to cure malaria and HIV/AIDS, think of the better world we can achieve,” he said.

There is, of course, a strong and important element of truth in this belief. As has been frequently argued on this website, one of the weaknesses of many current aid policies is that they underplay the potential contributions of modern science. They also pay insufficient attention to the need for the scientific capacity within developing countries that can enable them to tap into this potential.

In that context, Brown’s proposals have, rightly, been widely welcomed, particularly by those in the research community who see them as signalling a significant new commitment to building effective bridges between biomedical research and its application to relatively neglected health problems in the developing world.

The dangers of tunnel vision

But there is a danger in taking this belief too far. Namely that, by focussing excessively on the implementation of ‘high-tech’ solutions to the problems of malaria, insufficient attention may be paid to less glamorous, but equally important, strategies.

Similarly an enthusiasm for what might be described as ‘top-down’ approaches — typified, for example, by the search for an effective vaccine — can, unless carefully handled, undermine equally important ‘bottom-up’ strategies that emphasise the need for better education and information dissemination, improved health delivery systems, and greater public participation in designing implementation strategies.

The dangers are highlighted in an open letter sent to Brown by two prominent health researchers Bob Snow and Nick White (see New vaccines are not the only answer to malaria). They point out that two other approaches could be just as important as novel vaccines in combating malaria.

One is the active promotion of accordable access to promising new anti-malarial drugs such as artemisinin-based combination therapy (a strategy endorsed last year in an important report from the US Institute of Medicine: Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance). The second is use of insecticide-impregnated bednets that have been shown to reduce the incidence of malaria in some villages by up to 90 per cent.

In each case, argue Snow and White, the technology itself is only half of the answer. The other half lies in the way it is applied. Drugs will only be effective if they can be afforded; the cost of the most widely-available anti-malarial drugs currently on the market is more than many poor families can afford, even where these drugs are being made available at subsidised rates. Similarly the US$3 cost of a bednet may sound low to economists (and even donor agencies); but it still places them outside the reach of many families that need them most.

Conflicting world-views

It is easy enough to say that the solution lies in a balanced portfolio of technical options. This is, indeed, one of the conclusions of Snow and White’s arguments. “It is not a question of whether we spend money on vaccine R&D or expanding coverage of bednets and effective drugs — we must spend money on both, but spend it wisely,” they write. To which UK Treasury minister Paul Boateng has responded: “we couldn’t agree more”.

But addressing the issue requires much more than a technologically balanced strategy. Equally important, and far more elusive, is an approach that successfully combines the promise of the natural sciences with the insights of the social sciences. Given adequate support, the natural sciences can set out the exciting technical possibilities ahead, whether for vaccines, for new drugs, or even for improved bednets (scientists have, after all, been described as having “the future in their bones”).

And given adequate acknowledgement, the social sciences can map out the most effective strategies for ensuring that these possibilities are put into effect, drawing not only on the work of health and development economists, but those who have, for several decades, been studying the structure of public responses to technological innovations. The challenge lies in combining the two.

Cultural roots

The dilemma here is a cultural one — particularly within developed countries — that tends to permeate both scientific communities and aid agencies. Those advocating more science in development strategies are, too frequently, distrustful of social scientists (particularly those whom they see as attempting to legitimise strategies for greater public participation in science-related decisions).

Conversely, advocates for the social sciences can be equally dismissive in their analysis of the potentially beneficial effects of advanced science and the new technologies arising from it. Frequently such individuals place excessive weight on the potentially negative implications of new technologies, and underplay their positive contributions to developing country needs (witness, for example, recent critiques of genetically-modified crops).

The urgency of problems such as malaria, which kills one child in Africa every 20 seconds and currently consumes 40 per cent of the health budget of many developing countries, make it even more important than ever that some way is found of reconciling these two opposing world-views. But it will not be achieved through academic conferences, study groups or research projects; the differences are too deeply entrenched, both socially and intellectually.

Rather it requires engagement by both sides in informed public debate all levels (such as that which can, for example, be provided by the media). And eventually it needs the political imagination to distil this debate into a programme of action that is simultaneously scientifically and socially realistic. That is the challenge that Brown and his colleagues face as they prepare for the G8 meeting in July. And that is the goal by which the outcome of the meeting will be judged.