Deputy Commander Walter Reed Army Institute of Research
On April 25, World Malaria Day 2013 will be celebrated around the world with activities that highlight advances in the field of malaria research, but with a focus on how far we have left to go. The day will be an opportunity to reflect on past accomplishments and reinvigorate ourselves for the monumental task yet ahead of us.Malaria, it seems, has been with us forever. Chinese writing on malaria goes back to 2700 B.C., and Eber’s papyrus describes it in 1550 B.C.
Malaria appears a global ancient scourge that has haunted mankind for much of our history, and yet it still impacts our lives and our society today. Despite plans in the 1950s to eradicate malaria worldwide with powerful tools like chloroquine (a powerful drug for treatment) and DDT (dichlorodiphenyltrichloroethane, a remarkably effective mosquito control compound), the emergence of widespread chloroquine-resistant malaria parasites, along with concern regarding the environmental effects of DDT resulted in the declaration of the eradication effort’s failure and eventual demise in 1972.
Still, not to be completely defeated, ‘Roll Back Malaria’ was launched in 1998 with a goal to halve the number of malaria cases by 2010, and eliminate malaria in 8-10 countries by 2015.Fortunately, we are making progress. In Africa, where the majority of the malaria mortality burden is borne, we have seen malaria death cut by one-third in the last decade alone.
Outside of Africa, of the over 50 countries affected by malaria, total numbers of cases have been reduced by 50 percent in the last decade. The progress has been so dramatic that in 2008, the Bill and Melinda Gates Foundation even dared to utter the dreaded “e” word - eradication, as a possible goal once again.With regard to the U.S. military, we know that as far back as 1775, George Washington had to expend his very limited monetary resources to purchase quinine for the treatment of malaria in the Revolutionary Army.
In the 1860s, the Civil War saw 50 percent of Caucasian troops and a staggering 80 percent of Black troops contracting malaria annually.Our military history continued with World War II, Vietnam, and even recently in Afghanistan, where we still see approximately 100 cases annually, despite the resources we have to protect our troops.
While the days of massive debilitating impact on military operations as seen in the Civil War and WWII are behind us, we only have to look back to 2003, when a military peacekeeping operation in Liberia failed due to 80 cases of malaria in 220 Marines, after only a few weeks. Obviously, we still have a long way to go.In 1893, the Walter Reed Army Institute of Research was established as the Army Medical School by War Department General Orders No. 51, dated January 24 of that year. Virtually since the beginning of its existence, the WRAIR has been engaged in the battle against malaria.
Assigned to the newly opened Army Medical School in 1893, Maj. Walter Reed was instrumental in defining the concept of mosquitoes transmitting disease. In Reed’s case, it was the disease yellow fever, but this idea allowed William C. Gorgas to abate the transmission of yellow fever and malaria in the construction of the Panama Canal.
The first synthetic antimalarial, Atabrine, was developed through the coordinated activities of the Allied medical forces, and this set the stage for WRAIR’s later involvement in antimalarial drug development. The Experimental Therapeutics branch of WRAIR remains the only sustained drug development program in the Department of Defense, and this group has the distinct honor of initiating or being involved in virtually every antimalarial drug available for fighting malaria since WWII.
The Malaria Vaccine branch of WRAIR, along with colleagues at GlaxoSmithKline, Inc., developed what is currently the world’s leading malaria vaccine. Known as RTS,S, it is the first candidate malaria vaccine able to demonstrate that protection is even possible. While its 50 percent efficacy rate is insufficient for use among troops to completely protect them from malaria, this vaccine does have the ability to protect some children from death, and therefore is being tested as a possible important adjunct to currently available control measures.
The Entomology branch of WRAIR has worked quietly and diligently on personal protective measures to prevent not only malaria, but several other insect-borne diseases.Finally, WRAIR leadership in the role of education cannot be ignored. When the WRAIR began as the Army Medical School in 1893, tropical medicine subjects such as malaria were a core part of the curriculum. As the mission of the Army Medical School turned more and more away from a traditional educational role, Brig. Gen. George Russell Callendar began the Tropical Medicine Course in July 1941.
This course continued at the WRAIR, providing key and up-to-date information on malaria for the next 52 years, until it was moved to the Uniformed Services University of the Health Sciences.In 2010, it was decided that education on subjects such as malaria needed to reach a broader audience, and the course was once again offered at the WRAIR in September 2010.
Today, this course provides malaria lectures and hands-on training for over 120 military personnel from all services who are at the “tip of the spear,” providing malaria prevention, diagnosis, and treatment worldwide to both military and civilian populations.
Despite all of this exceptional work, which not only benefits the military but also those suffering from malaria worldwide, there is much to be done. Conservative estimates suggest that over 3.3 billion people remain at risk for the disease worldwide, over 200 million cases of the disease appear every year along with over 650,000 deaths (of which over 85 percent are children).
While we optimistically consider eradication, new threats emerge such as monkey malaria, which has established a home in humans and has now become the 5th human malaria. Unfortunately, more strains remain out there that could threaten future generations.Despite being powerful, our current drugs are being used to treat organisms that have consistently found a way to defeat most every one of our older drugs, and these organisms will likely find a way to defeat any new medications discovered for malaria treatment.
While our vaccines show promise, it will likely be years, if not decades, before we have anything that can really make a global difference. As new pesticides to control mosquitoes often suffer from the same resistance problems seen in drugs to control the parasite, we need to continue working on the next generation. And, like most tropical parasitic diseases, malaria is a disease that is tied to poverty and social disruption.It will be a long time before we correct these problems globally.
As this World Malaria Day is celebrated, we have many reasons to be proud. For hundreds of years, military medicine has made many, if not most, of the real advances in malaria prevention, control, diagnosis, and treatment, and over the last 100 years, the U.S. military has been a global leader in this fight.
However, as evidenced by the world’s long association with this disease, this is a fight that must be sustained and constantly addressed.Neither magic nor miracle will suddenly remove this plague from the world.
On this World Malaria Day 2013, we are reminded of the long fight ahead of us, and reinvigorated in resolve to make a difference.