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3 January 2008

The one to watch in 2008

Malaria kills thousands each day, mainly in the world's poorest countries. At a research centre in M

By Sholto Byrnes

Westerners travelling to work in malarial regions used to be told that there was only one way to avoid catching the mosquito-borne disease: don’t get bitten. It was by no means a foolproof method, but at least wealthy expats could afford preventative medicine and proper treatment if infected by the parasite. These, however, are not easily available options for many of the 500 million people in developing countries who catch malaria every year. Estimates vary, but somewhere between one and two and a half million of those die.

The statistics make a ghastly roll-call: more than 90 per cent of fatal cases are children under five. Most of these are in Africa, where roughly 2,000 children die from the disease every day. No wonder that ten years ago the World Health Organisation declared the mosquito “public health enemy number one”.

If there is one man who provides hope in the long fight against malaria, which is spreading out of the tropics through a combination of increased travel and trade and, possibly, global warming, it is Pedro Alonso. The director of the Bar celona Centre for International Health Research is a modest man. He insists that he has “just been one of many”. Nevertheless, he is the public face of a project in Mozambique that has made the prospect of eliminating malaria appear tantalisingly within our grasp.

Trial results from Alonso’s Manhiça Health Research Centre have just been published in the Lancet. After testing of an advanced vaccine on infants, new infections were reduced by 65 per cent over a three-month period, and 35 per cent over six months. “It is hard to overstate what a major step forward this is,” said Ripley Ballou of GlaxoSmithKline (GSK), partner in the vaccine’s development. The next phase of testing begins late this year, and will involve 16,000 children at ten different sites in Africa. Crucially, it has the backing of Bill Gates, who is stepping down from his day-to-day role at Microsoft in July to concentrate on his charitable foundation, which has already committed $258.3m to malaria research and development.

“More than a decade ago, Pedro Alonso set up Manhiça in one of the most malaria-infested parts of Mozambique,” Gates told a forum in Seattle in October. “It has the health research facilities of a university in a poor, rural setting – and the value to public health is priceless.” He concluded: “We’re not done, and we will not stop working, until malaria is eradicated.” It’s a bold target, but the results from Alonso’s centre allow researchers to believe that it could, just, be achieved. It is hoped that a vaccine suitable for mass distribution could be available within the next four or five years.

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Alonso, 48, was educated in Madrid and at the London School of Hygiene and Tropical Medicine. After internships in Madrid and Boston, Massachusetts, he spent six years with the UK Medical Research Council in Gambia. “When you arrive as a young doctor in Africa,” he told Time magazine, “and you walk into a hospital, you’re basically confronted with this massive disease that causes so much suffering and death. It is impossible not to become passionate about fighting it.” At the time, in the 1980s, he thought a vaccine was imminent, as had many scientists in the previous 50 years, during which numerous attempts to discover one had been made.

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The parasite that causes malaria is a complex organism, however, and drug companies had too little incentive to undertake extensive trials in the field for a product most needed by those least able to pay for medicine. It was the combination of the Bill and Melinda Gates Foundation, which started the Malaria Vaccine Initiative in 1999, GSK and Alonso’s Manhiça centre that made this breakthrough possible.

“Our group has been researching epidemiology and malaria control for more than 20 years,” says Alonso, referring to the University of Barcelona, of which the Centre for International Health is a part and which he joined in 1992 before setting up Manhiça in 1996 with aid from the Spanish government. “For this reason they thought of us.”

Alonso’s vaccine is manufactured from proteins from the parasite’s surface, and works by provoking an immune response that can combat instances of real infection. “The antigen which is the basis of the vaccine has been known for more than 20 years and has been tested repeatedly, but always unsuccessfully,” Alonso explained in an interview with the Spanish newspaper El País. “Perseverance, international co-operation and technological development have converted an antigen that didn’t work into one that protects.”

It is not the only weapon against malaria: insecticide- impregnated bed nets and spraying homes with DDT can also be effective. But those three initials have a historic infamy from the chemical’s overuse as a pesticide in the 1940s and 1950s, which led to such a decline in wildlife that the pheno menon of the “silent spring” was observed. Yet, given the parasite’s growing resistance to other drugs, such as chloroquine, and with even this new vaccine only partially successful, there is nothing flippant about the advice not to get bitten. Only when a completely effective vaccine has been developed will products such as DDT be rendered unnecessary.

Forgotten problem

If the tools for treating and preventing malaria are not yet entirely satisfactory, neither are conditions in Mozambique. The centre has to deal with occasional power cuts and supply its own drinking water. The staff, who include Alonso’s wife, Clara (they have three children), work 12-hour days. A “die hard” supporter of Real Madrid, Alonso misses attending football matches and yearns for Spanish cuisine. Life could be easier if the centre was in a city – but because more than 70 per cent of Mozambicans live in rural areas, and suffer from different health problems from the urban population, he decided that it should also be in the countryside. The long-term aim is for local doctors to complete training, both at the centre and abroad, and take over the running of Manhiça.

Although he has received honours and medals for his work, Alonso toils in a field of research that receives far less attention in the west than do potential cures for epidemics such as Aids. “Our society has managed completely to forget that the problem exists,” he says, pointing out that 60 years ago malaria caused thousands of deaths every year in Spain and that it was endemic in the United States in the 19th century.

So, for all the excitement the new vaccine has aroused among scientists, Alonso’s is a name little known in the wider world. Yet fame or riches do not interest him. “I feel especially fortunate to live in anonymity, working in what I want to work in, and to be able to contribute to a global effort to improve health in the countries that need it most,” he says. “I don’t envy [the wealth and celebrity of] people who take their clothes off, or footballers.”

With the support of the Gates Foundation and countless other organisations, he could be close to a prize that would mean far more to him. “What I don’t forget,” Alonso says, “is that I have the best job in the world.”

Malaria: the facts

40% of the world’s population is at risk from the disease

500 million people a year become ill with malaria

Between one and two and a half million people a year die from it, mostly babies, children and pregnant women

£2 is the cost of a daily dose of the most effective anti-malarial drugs

£1.50 is the cost of a mosquito net treated with insecticide. This needs to be replaced every six months

Less than 5% of children in sub-Saharan Africa sleep under a bed net

Malaria was eradicated in the United States by 1951 with a programme of wetland drainage and pesticide spraying

Research by Jastinder Khera and Craig Burnett