Reflections on 40+ years of fighting malaria

On the eve of his retirement, Deputy U.S. Global Malaria Coordinator Dr. Rick Steketee looks back on his long career

I have been blessed with a life of learning, and often revisiting and relearning.

I saw my first patient with malaria in 1974 when I was a third-year medical student doing my first clinical rotation at the Veterans Administration Hospital in Cincinnati, Ohio. Our team’s lead resident was an efficient clinician and a teacher by doing. He admitted the patient, a soldier returning from Vietnam, and assigned him to me, asking that I take his history and complete a physical exam. He then showed me how to do thick and thin finger-stick blood smears. We took the slide to the laboratory, requested a technician’s help with staining, and put it under a high-power microscope. We easily identified the numerous  Plasmodium vivax parasites. That evening, we started him on a medicine called chloroquine and took another blood sample to  confirm that he would be able to tolerate the medication needed to clear the parasite from his system. The test showed the medication could safely be administered and at discharge we began him on a 14-day course of primaquine.

Nearly a decade later I repeated that event, but this time the patient was me.  I had returned from working in refugee camps, most recently from Somalia. I had taken my malaria prophylaxis religiously and stayed malaria-free, or so I thought. On returning to the U.S. in 1982 for a master’s in public health, I failed to complete a 14-day course of primaquine to clear my liver of the parasites that might be resting there. Indeed, the parasites re-emerged into my bloodstream with a vengeance—fever, chills, and chattering teeth. I recognized my mistake, sought to confirm my suspicion via a blood smear, started chloroquine and then took  the primaquine tablets – every pill for the next 14 days.  That clinical approach to treat malaria is identical to what we do today, almost 50 years later.

I was not yet on a clear path to work on malaria for the remainder of my 40+ year career in public health, but I certainly appreciated the diversity and power of the disease. Upon completing my MPH program, I embarked on the Epidemic Intelligence Service (EIS) and Preventative Medicine Fellowship at the U.S. Centers for Disease Control and Prevention (CDC). I spent two years in the Wisconsin State Health Department, and then did my third year in the Malaria Branch at CDC – a group with a slightly irreverent reputation of doing excellent work in hard places – mostly but not always in Africa, but especially in places with lots of malaria.

The work continued with great opportunities in many different countries, collaborating with many different and dynamic scientists in Kenya, Malawi, the Democratic Republic of the Congo, Zambia, Senegal, Ethiopia, and traveling to many, many other countries for meetings and consultations. The experience was one of constant learning from many, many talented and thoughtful people who face the threat of malaria every day. The parasite, the mosquitoes that carry it, and the people affected by it  taught me to be humble, to question what I think I know, and to be ready to try something new and different while holding onto what is working.

While the treatment for P. vivax may still be the same, many aspects of the work in the fight against malaria have evolved or changed entirely.

Long ago, people slept under mosquito nets, but it was only about 25 years ago that we began systematically putting insecticide on those nets – dramatically increasing their efficacy.  Long ago, we sought to clear mosquito larval habitats and spray inside houses with insecticides; today we tailor those interventions to places where they will work best and have developed many different insecticides to help combat the mosquito’s ability to adapt and resist the chemicals.

We used to rely on fever for a clinical malaria diagnosis and we now have reliable point-of-care rapid diagnostic tests that confirm infections and allow us to treat,count, and report cases with confidence. We have moved through several different drugs to treat our most deadly malaria parasite – Plasmodium falciparum – and no longer rely on single drugs, but rather opt for combination therapies to protect against resistance.  And with a new vaccine approved,and advances in parasite and mosquito genetics and human immunotherapy and next vaccines, perhaps we will soon have the tools needed to stop transmission from mosquitoes-to-humans and from humans-to-mosquitoes.  When you are still learning, there is no such thing as “retirement” – except perhaps that we are putting new tires onto old vehicles and asking others to drive.

 

I started my career in malaria  with CDC, moved to work for a number of years with the Bill and Melinda Gates Foundation, supported theMalaria Control and Elimination Partnership in Africa project (MACEPA) at PATH, and worked most often in three countries:  Zambia, Senegal, and Ethiopia. For the past five years, I returned to work with CDC and USAID as Deputy Coordinator for the U.S. President’s Malaria Initiative (PMI), which partners now with 30 countries – mostly those in Africa experiencing the worst malaria in the world.

These five years have allowed me to work with a great group of people and I am stepping aside at a good but complex time. The leadership and the U.S. government’s efforts in malaria are very strong and well poised to bring new vigor and new people into the work ahead. But it is the skills and capacity of malaria-endemic country leaders and their staff and colleagues at all levels that has expanded in the most remarkable ways, especially during the broad investments in this 21^st century.  The supportive relationships between malaria-fighting colleagues have never been better and with new tools available,others coming onboard, and systems increasingly able to support their delivery and use, the future holds great promise .

I look forward to hearing of (and learning from) the next great advances as we all seek to rid ourselves locally and globally of malaria infection and disease and win the fight against malaria.  I’ll be cheering!