 Good morning and welcome to CSIS and a welcome to those who are online as well viewing from a distance. I'm Steve Morrison. I'm Senior Vice President here at CSIS and Director of Global Health Policy Program. I want to first thank the many different people who contributed to this conference. It's been an evolution for several months. Many people, many organizations have joined in helping us conceptualize it and have agreed in terms of reviewing papers, moderating and speaking, and traveling great distances. We drew a lot of support from CDC, from the Bill and Melinda Gates Foundation, from the President's Malaria Initiative, the Global Fund. Izaskoong Gaviria has been exceedingly helpful, cannot be with us today, but a shout out to her. WHO, the Department of Defense, Kaiser Family Foundation, Malaria No More. I want to offer a special thanks to those who came quite a long distance to be here today with us. Martin Okigbeto from Benin, Fredros Okumu from Tanzania, Dr. Nipon Chinanon Wait from Thailand, Dr. Antie from Myanmar, Major General Bin from Vietnam along with Major Chien, Pascal Ringwald from WHO, Geneva, Admiral Chin and Colonel Fukuda from Hawaii. Our moderators deserve a special thanks, Regina Rabinovich, Alan McGill, Amy Sturart from CSIS, Patrick Couture, the branch chief from Malaria from CSIS. Katie Peck, my colleague at CSIS, a very special thanks for all her work over the last six months in pulling this together. We've been aided also by other colleagues, Talia Dubovie, Sahil Angelo, Catherine Stryphill, Travis Hopkins, Jesse Swanson, Carolyn Schroek from the staff who put on these events. Our organizing concept for this gathering here today is really elimination. The question of what is it, what is it, what's the rationale, how is it tied to U.S. national interests and to other interests, to what degree is this becoming a shared global goal, how are we to get there, what's it going to take in terms of political will? Financial commitments, institutional capacities, financing science and technology, and how are we to balance hope and aspirations with some of the realities that we'll discuss today. We've made the broad mega-subject of what is it and how do we get there, the opening topic for the first round table with who I'll be introducing and moderating in a moment. We've also broken out three of the critical challenges into special panels, one on resistance, one on financing, one on new technological tools, vaccines, therapies, diagnostics. We've also chosen to highlight both Africa and Southeast Asia and the partnerships that exist in those two critical continents. Today, we're giving special weight during the lunch hour to Mekong Subregion. We're dedicating 90 minutes to a discussion there. We think that merits special attention for all the reasons that will become clear over the course of the discussion. Throughout this conference, we are also drawing attention to the security dimension, both in the rationale, but also programmatically, the imperative for civil military cooperation, the imperative to keep militaries in mind in thinking about the capacities and the partnerships that need to be brought forward on an elimination strategy. We're bringing forward five new papers today. I hope you will get hard copies of those and take those with you. They will be available online and will be posting the links over the course of the day. Mark Fukuda, Colonel Fukuda, and Tom Cullison wrote a paper on the U.S. DOD contributions to malaria elimination in an era of Artemis and resistant malaria. That paper builds on an earlier body of work that I'll mention in a moment that CSIS has undertaken around the contributions of DOD writ large in global health. Charlie Schneider and her colleagues at PATH have produced an excellent paper on the transformative tools for malaria elimination, looking at the different technologies needed and where are we. Christopher Plow, University of Maryland wrote a paper, The Danger of Untreatable Malaria. It's real and present. This is a focus on Artemis and resistant malaria in Mekong and the status of efforts to arrest that resistance. It builds on a paper that Chris Daniel published from CSIS a year ago here at a conference on the Mekong. Bill Brogdon and his colleagues at CDC have produced a paper on insecticide resistance, pyrethroid resistance in malaria. Jennifer Cates and Adam Wexler, close friends at Kaiser Family Foundation, kindly put together an excellent paper on global financing for malaria. So we're very happy and grateful to all of those authors for the work that was invested in bringing forward this new content. All of those papers are meant to be short, concise, and written in plain English and that they will be readable by a very interested non-technical audience, which is the audience we're trying to reach oftentimes here in Washington, both on the Hill, within the administration, among interested advocacy and non-governmental groups. As I said, this work builds on the body of work that we've created over the last several years, starting 2010 and 11, a year-long study of the DOD overseas medical research labs in 2013. Chris Daniel and Admiral, I'm sorry, General Peake led a task force on Southeast Asia why health ties there to U.S. national interests and what an integrated U.S. approach to Southeast Asia focused on health should look like. We've had two major delegations to Myanmar in August of 2013 and August of 2014, followed by major reports, as I mentioned a year ago, November 12th of 2013, major conference on the Mekong in health. We're in this for the long run. This conference fits within that body of work, and we will be continuing in this vein into 2015 and 2016, and we certainly would welcome your suggestions and thoughts about how we might shape our future engagement in this area. We're going to move now into our first panel, so I'd like to welcome our panelists to come on up. This is going to be a round table. We have with us this morning quite a distinguished assembly. I'll start with David Smith, Dr. David Smith, the Deputy Assistant Secretary of Defense responsible for force protection and readiness at the Department of Defense. Welcome, David. Bernard Nailen is the Deputy Coordinator of the President's Malaria Initiative based at USAID. Alan McGill is the Director for Malaria at the Bill and Melinda Gates Foundation, and Petra Ketcher is the Branch Chief at CDC for Malaria. We should pull this back a bit. So Alan, could you kick this off a bit? You've thought a lot and spoken a lot about the rationale, why we should be thinking about elimination as a strategic goal, and what are the roots of that, and where does that carry us? What does that imply? Sure. Thanks, Steve. Happy to. I think we break this out in a couple of points, is where we are today in our global efforts at malaria control and elimination. I think as we think about that, it's really a decade of improvement. So between the end of the 90s, early 2000s and 2012, we actually have seen malaria deaths decrease by 45 percent, and this equates to roughly a little over three million deaths saved by modeling in estimates. We recognize that some of these estimates are a little controversial, but the airbars are wide, and I think all estimates agree there's been marked progress over the last decade. And I think a lot of this progress has been seen in the 10 highest burdened countries. As a result of this, some countries are now looking to set more ambitious goals about national elimination targets, and the Asia Pacific region alone, the number of countries with such ambitions have increased from 10 to 16 countries over the past five years. So I think we're now in a place where how do you make the case for malaria elimination as a strategic objective? And I think since the founding of the Rollback Malaria Program in 1998, significant resources have followed with the Global Fund, the Players in its Malaria Initiative, and that significant increase of resources has directly translated to putting commodities and strategies that work. This is bed nets, insecticide-treated bed nets, IRS where it's appropriate, malaria rapid diagnostic test, and Artemis and incombination treatments out into malaria endemic countries at scale, and this investment has yielded an excellent return. I think there's broad consensus across the board on that. However, I don't think we can assume that those resources will be available forever. They're estimated at $5 billion a year. Right now, it's about $2 billion a year. So there's already a deficit gap. And then I think more importantly, we face the biologic imperative. The urgency that resistance to the drugs we use and resistance to insecticides is a current problem and will continue to be a problem as long as we apply these selective pressures to the natural populations. And so I think when I look at this, you sort of say, well, we had a great start. I like to say there was a humanitarian crisis in the late 1990s, and we responded as a community. And that response was with the tools we had and strategies we knew work, and we've seen a tremendous reduction in disease burden. But now we're in sort of the mid-game, and I think it's time to look at the end-game. Where are we going from this point forward? And I think for me, and I hope for many of us, the sustainable future here is actually eradication is the long-term goal, because that's the end. We move from this to another, to a world without malaria. So what will it take to reach this goal? I think currently there's still a lot of disease burden in countries, and we keep the focus on eliminating or taking deaths to near zero. We all know that with the proper systems in place, one can do that with the currently available tools and current strategies. It is certainly more difficult in some settings than the others. And I think in all settings we can start looking at improved mapping, surveillance, and information tools that we have to go from universal coverage to effective and optimal coverage in areas where it makes sense to do so. And all of this surveillance efforts will really help the health systems in place, and there'll be a general benefit to the health systems. And then I think in the near term, we can take the current tools we have and use them in new strategies, and this is, as I say, it's going from defense to offense. We now basically sit in healthcare facilities and wait for sick people to come to us. We need to go on the offense, which is go into the community and go after the parasite, if you will. So this current tools, new strategies, is where we're going to probably make the biggest gain in the next five years or so. And then there's certainly a number of game changing technologies and interventions that are in the works. Many of you in this room are directly engaged in developing these new tools. And I think whether it's in diagnostics or prevent transmission, vector tools, vaccines that interrupt transmission, and single-dose cures, we're going to see a future hopefully in the five to 10-year time frame where we'll be able to go out in the community with new tools and new strategies. But I think the in-game needs to now clearly focus on the elimination as the target. That's why we're doing what we're doing. And finally, the biggest piece here is the political will and commitment to do the job. We all know that with political commitment and proper management and systems in place, we could eliminate malaria in any place in the world today, probably with the tools we have. But the reality is the political commitment and the systems are not in place to do that. And I think we would like to, I think it's time to raise our collective ambition and to maximize this already big investment in global health and to finish the job. I'll stop there. Thank you. Bernard. Well, unfortunately, Steve Allen's already said everything, so I'll just, not a very good summary. But just adding to that, I mean, the bottom line is, as Allen said, there's been a tremendous amount of progress over the past decade. And those of you who are around a decade ago, and looking in the audience, I know some of you were around a decade ago, that was a time when we actually had some tools we thought would be pretty powerful if they were scaled up, better vector control tools, better medicines, better diagnostics, but there weren't actually any resources to do so. And I wasn't in Washington when the President's Malaria Initiative was conceptualized or watched, but frankly, the U.S. government's commitment to putting significant resources behind this has been a true game changer, not only through their bilateral funding through PMI, but also through the Global Fund and in partnership with some of the other major governments such as the United Kingdom, Australia, previously the World Bank and some other financing groups, and the crucial importance of the Bill and Melinda Gates Foundation providing leadership, particularly around the investments in research and new tools which are coming to the forward. I think, as Allen pointed out, one of the big challenges we have at this point in time, there's a bit of, I think, confusion out there that because some of these countries which have had such great success are also in the process of actually developing, so therefore they may not need the sort of level of outside support that they've had in the past. I think we need to be very wary of that and very careful because just to remind people, malaria not only affects the poorest of the poor in poor countries, but they also, the highest burden countries we're dealing with in Africa still have a long way to go before they're going to have the resources available to scale up simple things like fairly inexpensive drugs and diagnostics and vector control tools. I think the U.S. is indeed in it for the long term. The sort of enthusiasm that's been generated over the past decade is what's given us, I mean, even some of the, those who may have been a little bit skeptical when the call for elimination eradication was initially sort of put forward by Bill and Melinda Gates in October 2007. I think the examples of countries who've been able, through commitment and proper support to do some pretty remarkable things can't be ignored and frankly is one of the biggest successes in global health over the past decade. PMI, the President's Malaria Initiative as you know was launched in 2005 with USAID as the main need agency and CDC as the main implementing agency, but it really is. We work very closely with our Department of Defense, with the FDA and with other parts of the U.S. government, NIH to move forward on this agenda. We have a new strategy which will be released shortly, our next six-year strategy, 2015-2020. And that's very much aligned with what some of you, you probably know that WHO has a global technical strategy which will be going through the World Health Assembly in May of this year. There's some, the Robach Malaria has the Global Malaria Action Plan which is sort of the how to do the global technical strategy which is being prepared and will also be launched together with the GTS later next year. And we also paid very close attention to the Bill and Melinda Gates Malaria strategy. So our new strategy which will be made available shortly is totally aligned with that. Just briefly, our major role at this point in time, in addition to working with other groups that are involved more in the elimination side of things, our major focus will be to continue to scale up today's tools today and to continue to save lives in these high burden countries in Africa while at the same time creating the systems which will allow for introduction of whatever new tools come along. It's not only about having better tools, it's actually about having the systems in place in order to be able to deliver those. And we are on the offense, a lot of our systems where we're working with communities in Africa is really very much at a community level to be able to diagnose and treat febrile illnesses and if it's not malaria then working with communities in the health system to figure out how that's going to be. I think the example of Ebola recently shows, first of all what happens when you don't have good systems in place, but secondly even if you have better systems in place such as we saw in Senegal and Nigeria, and Nigeria is primarily using the polio eradication folks, if you have better systems in place you actually can respond to something like Ebola as it arises. I think it's going to be very important because as we invest in malaria in the future there will need to be more and more folks who are out there at the periphery doing surveillance of febrile illness and hopefully being part of the response to malaria, but to other things which may arise unexpectedly. So again the US government's in here for the long haul, I do, we are committed, we do think that elimination moving towards eradication, well elimination's already occurring in some countries, but the eradication is the right way to go. It won't be easy, but we wouldn't be here if we thought it was going to be easy. Thank you, Patrick. Thanks. On behalf of CDC I'm here to represent Dr. Tom Kenyon, the director of the Center for Global Health, and in addition to the points that Alan made about malaria elimination and a global aspiration for eradication and the points Bernard made about PMI and the developing new strategy, new US government strategy for malaria. Dr. Kenyon wanted to draw the group's attention to the Global Health Security Agenda as a key point in CDC's strategy going forward, as well as that of other US government partners and international partners. The goal of the Global Health Security Agenda is three fold to prevent avoidable outbreaks of new diseases to detect and respond to epidemics and global health threats as they emerge and as efficiently as possible. And the Global Health Security Agenda articulates 11 general sets of activities. Key among these are several that relate to malaria. What I'd like to mention is antimicrobial resistance, and we'll have a session later this afternoon where we can go into more depth about the issues of drug-resistant parasites and insecticide-resistant mosquitoes, how those affect our approach to malaria today, how they might shape the directions we move as we move towards elimination and eradication. And I hope we'll have a chance to discuss how those very real phenomena, just as Alan pointed out, those inevitable biological processes actually put us in a position to prioritize elimination and eradication at this point in time. In addition to antimicrobial resistance, among those 11 activities are about five that relate to general capacity strengthening. That will be very important for finishing the job of scaling up current malaria control interventions and moving towards elimination. And those include strengthening information systems, laboratory systems, emergency operation centers or epidemic response centers. Bernard's already pointed out the importance of information systems and human capacity to respond to public health threats. And it'll be important to build these not only for emergency responses but for common endemic diseases like malaria in order to achieve the goals of the global health security agenda. And then a final item on the GHSA that might not immediately cry out malaria calls for better coordination between public health and law enforcement. And this really does have relevance to the issues around drug-resistant malaria and insecticide-resistant vectors. Very often we've found that the regulatory authorities that are responsible for managing deployment of approved drugs and insecticides for public health use lack the capacity to fully investigate and enforce the regulations that they have at their disposal to help manage and mitigate practices that encourage resistance. And so I think those elements of the global health security agenda are all areas where we feel malaria control finishing the job that's still outstanding to scale up the current interventions and moving toward elimination will be important. CDC's particular role in all of this, I like to remind people that we started as a malaria elimination effort in the Southern United States before and during World War II and elimination of malaria still remains a goal that we enthusiastically support. It's enshrined in the U.S. government PMI strategy for malaria control, both the one that expired this year under the Lantos Hyde Act, as well as the one that Bernard mentioned in development. It's also a key element in the evolving global technical strategy and global malaria action plan at the international level. And I think elimination may be not only an aspiration, but it may be one of the most effective ways for us to be able to bring retractable problems like drug-resistant malaria in the Mekong under control, but maybe the most feasible way to deal with drug resistance in places where it can still be found to be focal and isolated would be to eliminate transmission in that area. Thank you. Thank you, David. Well, good morning. And I first want to thank Steve and CSIS for having DOD as part of the panel because we recognize the clear need, the national security effect of malaria and infectious disease and really appreciate being part of the panel. And DOD obviously has been very involved in this. If you recognize from an infection point of view, since we have to be deployed around the world from a force health protection point of view, we clearly have a keen interest. Additionally, recognizing the importance of global health engagement, global health security. We're involved around the world in stability ops, think Iraq and Afghanistan, partnership, kinds of engagements, and also in disaster and humanitarian relief exercises. And in all of those, it requires the knowledge of the risks for the local population, the local militaries, and of course, going back to the force health protection from our side. And we also recognize that malaria burden in endemic regions is responsible for significant social and financial drain on local resources, which can cause instability in countries that we're particularly interested in. I wanted to point out that deployed military populations are a unique sub-population. And when, with long travel durations, sub-standard housing think tents and constantly migrating and moving like other populations under a particular amount of stress, they're clearly going to have issues with higher morbidity associated with malaria. And often, malaria and other infectious disease create more morbidity and mortality in conflicts than the conflicts themselves. And the plasmodium parasite, as I think most of this audience knows, has the ability to cause sudden outbreaks, which can also be a great concern to militaries and halt their progress. And malaria has often been cited as one of the highest disease burdens around militaries and even within the U.S. military. And we know that individuals who are coming from non-endemic areas, going to endemic areas, tend to have a higher rate of acquiring malaria and also suffering the more severe aspects of the disease. And so during peacekeeping operations, that can be a particular problem. And the reverse is also true, where you have a number of militaries that come from endemic areas that now are being exposed to strains that they aren't necessarily immune to and are underestimating their immunity, not taking the proper precautions. And the African Union has clearly pointed out that this is one of the major issues they have in peacekeeping operations with the forces that they deploy. And so clearly it goes back to the basics of sort of understanding what the risks are, making sure the population is educated, that we have the right proper personal protective equipment along with chemoprophylaxis and, of course, great surveillance. Now the U.S. DOD has had a long history of involvement in malaria because of the issues that I just discussed. And most of the modern drugs, if you think mephlequin and malarone, were developed by the Walter Reed Army Institute of Research. Very early on, quinine in its application was actually popularized within the Army. But also they've been very involved in some cutting-edge malarial vaccine work, which we hope will be a real game changer, along with validation of many of the malaria rapid diagnostic tests and developing PCR primers for malarial diagnostics. We also have the Armed Forces Health Surveillance Center that is actively engaged supporting accredited malaria diagnostic training centers both in Kenya and Peru. And those centers do a tremendous amount of training of locals from both of those continents in critical diagnostic, microscopic kinds of training for malaria diagnosis. Armed Forces Health Surveillance Center and GAIS, the global emerging infectious surveillance and response network that we have, also supports malaria efforts in characterizing the burden, the transmission, the drug resistance of malaria strains through enhancing human reservoir and vector capabilities, both through in vivo and in vitro studies for the resistance to art of medicines and other malarial drugs, along with trying to find genetic markers for that resistance. And then we have the Armed Forces Pest Management Board that recommends, sort of from an entomologic point of view, various controls, such as introducing permethrine-treated uniforms, permethrine-treated bed nets, and also do a fair amount of training around the world in pesticide and repellent application, aerial spraying, and operational entomology. But military members can acquire and transmit malaria to their home countries of origin and therefore pose a risk for introduction of novel and drug-resistant parasite strains. And militaries play an important role in the malaria elimination efforts. But they also serve as an important bio-reservoir that we need to keep in mind. So I think the main point is that militaries must be included with country, regional, and global plans because they're a significantly highly mobile bio-reservoir that needs to be considered, and particularly in countries that have some in in diminicity in some areas and not in others. The militaries typically are going back and forth, and if we don't take the militaries into account, so that's an important message I think to take home. And then the final point I wanted to bring up is drug resistance, and that's a daunting barrier to this elimination goal, because we know in the new era of malaria elimination it will challenge drug effectiveness. And malaria eradication will require more chemicals and methods from mosquito avoidance and certainly more effective drugs for treatment, diagnostics, all the things that have already been talked about are in the pipeline, but we need to make sure with the elimination efforts that those are important parts of the equation. And a good example, we know that art menacing resistance is a particular global concern and our Armed Forces Health Surveillance Center is sponsoring a study that allows in Peru, in Kenya, and in Thailand to look at the issue of parasite clearance rates. And it will be quite interesting for us to look at the difference in Thailand where we know we have the issue with art menacing resistance, those clearance rates compared to what is in Kenya and in Peru. So in conclusion, given the global nature of malaria and its impact on military operations, peacekeeping operations, regional stability, the U.S. DOD is well-served to focus on both our resources on malaria control, but also on elimination. And we're all in. We were founding a partner in the Global Health Security Gena in Koli supporting that and we're very closely with the President's Malaria Initiative on these issues. And I just want to re-emphasize the fact that we need to include militaries in our elimination efforts because of that bio reservoir and that we need to make sure that it's not simply the elimination piece, but all of those additional research and development and other pieces to help support the effort. Thank you. Thank you very much. I'm struck by a couple of things here. When we're talking about elimination, we're talking about a somewhat mixed picture and a bit of an anxious set of transitions that are underway. We're coming off of a period of dramatic success, of a scale-up, a tripling of resources, but I think as Alan, as you put it, we're in midstream, we're changing out of crisis into more normal circumstances. Success can demotivate people. Success, the last, you know, making that transition can be something that becomes more difficult than earlier to mobilize and to motivate people. And the advantageous factors, it seems to me, that enter this is you have the GMAP coming forward in the technical study. There seems to be a pretty strong alignment of strategies across PMI, WHO, Rollback Malaria, Gates Foundation, that there seems to be a convergence. There's an alignment along the strategic side with elimination as a core element. There's a concentration in this field, a concentration of spending power. And the Global Fund, the U.S. government, the Gates Foundation. This is not a heavily distributed system in the sense that if decision power and strategy are matched together, it should be possible to move much more effectively in this way. We also know that there are some important voices that are out there on this agenda. Bill Gates' speech in New Orleans to the ASTMH conference, the TrotMed conference just a short while ago. Senator Leahy, Senator Graham at the Malaria, you know, more breakfast just recently, statements by Senator Kuhn and Representative Crenshaw. These are all very important indicators that on a bipartisan basis, there are political leaders that are migrating in this direction as well. But there has to be more, it seems to me, as a political, I'm getting back to Alan's point. The political will and the mobilization of high-level political will, there needs to be much more in order to move this forward, it seemed to me. And in terms of embrace and enshrinement of this goal by countries, by institutional leaders, by key donors. And that will be critical to mobilizing additional resources as well, which we'll be talking about in the next panel in terms of the resource gap. Perhaps you could say a bit more about what is your thinking on how to take that step, to be successful in the future in building on the alignment of strategies, the successes of the day, make reference to the threats that we see in resistance, which can motivate people. How is the political side going to be met, Alan? Well, that's an easy question. So first of all, I think I made a couple of very key points. One of those, I think, is this concept of partnership. And there's a couple of key issues there. One is it's 2014, it's not 1955. And the global health architecture and this maze of people with resources, countries, policies, implementing groups, there are hundreds and hundreds of players out there in the community. And as we say in the partnership issue, it's all about a shared goal, which is ultimately eradication. It's not an easy goal, it's not a five-year goal, but it is the goal, nevertheless. And a part of that is that once you have that shared goal, it's a lot about trust. And it's the partners working together and as we say play to your strength and play your position. So most organizations, most agendas, they have their core strengths and the other areas, they don't do so well. And I think the matching that across the board to achieve that goal is very key. From a political perspective, one of the challenges is since eradication is not a three- or a five-year goal, well, most politicians don't hang around much longer than three or five years, right? So they can't see the ultimate, you know, if they make this investment today, are they going to see that result before they leave office? And they can't. So really convincing them that, again, being part of that partnership and investing for the future for the next group. And also I make the case certainly of what I call malaria exceptionalism. And I say that because malaria can be eradicated, right? We biologically and ecologically, it is an eradicable disease. And we have already the tools to do that. What we're looking for is tools to make this much more operationally efficient. As Bernard was saying, the systems needed to do this today are hard with the tools we have. So a vaccine, a single-dose cure, those things just make our strategies much more operationally efficient. So that leads to the ultimate questions from politicians is when, how, and particularly how much is this going to cost? And I think we just need to be very realistic going forward as we talk to folks and not try to give them a figure, a dollar figure now and a date which is really fanciful thinking. We have to really think of this in incremental blocks moving forward. So I think being very candid with politicians but engaging them in this larger goal. And as we've seen, that actually works. People really do respond to the concept that this can be done. It is something they'd like to be a part of going forward. And I think the malaria exceptionalism argument is one that malaria can and should make. That's not to say that HIV and TB or other diseases are any less important. It's just because of the nature of those pathogens and the biology, they are not amenable today to eradication in any shape of the word with pathogens. So I think a good continued dialogue elevating at the highest levels and for example within the U.S. federal government, there's enormous resources in terms of dollars but in terms of capability with the agencies here with CDC, with PMI, NIH and DOD. There's enormous talent and resources coordinating and focusing on going forward. As former military myself, I will say that the ultimate protection for the warfighter is eradication. It's just that simple. If there is no malaria then there's no, that's just one less thing you have to deal with in force health protection. So the military should be the actually, I think the leader in standing up and saying, you betcha we want eradication. And we'll do everything we do now, the tools and strategies and all the things we have. And we'll also extend our reach to actually eliminating in the greater Mekong and others because that really is in the military's best interest long-term. So how do you see the debate unfolding around the post-MDGs and the sustainable development goals? Is this going to help? Is this going to obscure? Is it going to leave malaria in a weaker position or is it an opportunity to elevate and make eradication and elimination a top-line, visible and conspicuous goal? Bernard, what do you think? Well, first of all, having an MDG, I've been living development ago, that actually mentioned the word malaria was very important for where we are now because it did coalesce a lot of activities at different levels which may not have occurred in the absence of that. I should point out, however, that malaria also contributes to some of the other MDGs. MDG 1, which is poverty reduction, and I think this is very important because there are different audiences we speak to about malaria. Those of us who are global health people, physicians, medical epidemiologists or whatever, we look at the health burden, but there are others who actually look at this as a development agenda. And there's lots of data showing that, for example, in Malawi, a third of a family's household income spent seeking treatment for malaria. If they didn't have to do that, they would have a third more income that they could do other things with. Throughout Africa, the average number of days of productive life a woman loses for each episode of malaria in a child is three days. So if you have one child who may have three or four episodes a year, that's one thing. But many children, you can see the economic impact on families, on societies, school attendance, et cetera, et cetera, et cetera. The private sector has recognized this. Many of you are probably aware of investments that, for example, Shanti Gold and Ghana or the sugar industry in Malawi have made in their own populations where they get an incredible return on investment by the company itself investing in keeping their workers free from malaria. I only mention this because, you know, as a poverty, one of the SDGs will have a big focus as it should on poverty reduction. So ending a streamed poverty is one of the primary foci of the President administration along with ending preventable maternal and child deaths. And of course, malaria does end preventable maternal and child deaths in high burdened countries in Africa. The SDGs are still a bit of a work in progress. It's a bit of a prism. You can look at any of those. And frankly, not only malaria, but others will be doing this, trying to figure out how they fit in there. I actually just saw a report from the Secretary General Ban Ki-moon on the SDGs, which is going forward. And believe it or not, in that report there is a paragraph which lays out several different health goals. But in the middle of that report is eradicate malaria. So I was a bit taken aback, but it is there. So presumably if the Secretary General of the UN has that there putting forward to the UN, that again will be very important when it comes to helping all of us keep the political will and traction that we're actually going to need in order to be able to push forward. Some of the biggest supporters of malaria, if you speak to President Kikwete in Tanzania, who has seen benefit to his people in the past few years and the incredible reduction in diseases and deaths in large parts of Tanzania. Many other presidents around the world are probably aware that in the Asia Pacific region there's now the Asia Pacific Leaders Malaria Alliance, which is chaired by Australia and Vietnam, if I remember correctly. And that's a very important thing, working with the Asia Development Bank to try to look at creating a funding platform in addition to the Global Fund and other donor resources so that the region itself can generate resources. There's basically some fairly wealthy countries in that region, such as China. So I think the hope is that some of these other countries will see the benefit of investing in malaria elimination eradication in their own backyard in order to be able to contribute to this. Lastly, some countries such as Zambia are already putting more of their own national resources into malaria control. We talk about countries developing and having more money in their national coffers in order to be able to make decisions on how they're going to spend it. And Zambia is an example, I can give other examples of where national leaders themselves are starting to put more of the national budget into this. It still is, again I just want to emphasize, there's still going to be a need for quite a while for some pretty significant external resources in order to help support that in addition. But I think it's possible. And there is this issue of absorptive capacity also. We do need to work to create the systems in place so when there is a vaccine, when there is a new drug or diagnostic test ready to roll, countries not only have the resources to do that, they're actually able to do that going forward. And let's face it, most of the countries where we're working would do well to put more of their national budgets into building up their own health systems. Bernard, I'm glad you raised that. I mean the East Asia Summit that just occurred in Yangon, the chairman's statement had a pretty ambitious target there in terms of malaria eradication. And that sort of leadership rallying around that is the sort of political mobilization that I think is what we're talking about requiring here. On the global health security agenda that you've talked about, Patrick, this is at the core of the president's request for $6.2 billion that is now, before the Congress and is going to be acted on, we expect this week as the December 11 date approaches. We don't know what the final resolution will be, but most indications are that it's going to be a very substantial portion of that that will be dedicated overwhelmingly towards CDC and AID operating within the region in building up durable health capacities along the lines that you've spoken about. Our malaria programs, our PMI programs have taken a hit in the country's most devastated by Ebola. Is this going to be potentially an opportunity if four or five billion dollars of that request come through? This is a big moment, a big change in CDC and AID's posture within that region, an opportunity to put into force what's been discussed up to this point around the global health security agenda. What do you think of that? I'm very hopeful that it will be, and I think it's important to think about these USG or global initiatives as being integrated and being able to find a role for malaria in all of them. I guess my naive understanding of how political will works is that a key driver will be progress and success, and if we can build an infrastructure that allows us to make sure we're tracking progress towards elimination. Right now we're tracking implementation and delivery of treatment and prevention commodities. But if we move ourselves towards being able to track progress towards elimination, I think will be better situated to spark and sustain the political will towards a generational goal of elimination and eradication. I think demonstrating some successes, we've talked and we'll talk more I'm sure about the importance of elimination in the Mekong subregion where drug resistance is a threat but also a great motivator. I'm very excited about an effort that the Bill and Melinda Gates Foundation is supporting us along with partners at the Carter Center, PSI, PAHO, WHO, the Clinton Health Access Initiative and the Haitian and DR ministries to seriously undertake elimination of malaria on the island of Hispaniola, the last place in the Caribbean where it's a problem and a place where elimination would be transformative. It would really make a noticeable difference in the global map of malaria. So I think some early successes in places that aren't simple like Hispaniola, but where we can achieve elimination in a 15 to 20 year time frame, I think will be critical to developing and sustaining political motivation to move forward. David, when we did the study a few years ago of the overseas labs, the DOD overseas medical research labs, both the Army and Navy and their parent organizations back here in the Washington area, one of the really strong impressions from that study was what remarkable capacity exists and how weakly understood here in town those capacities are and how chronically vulnerable they are budgetarily, how critically important they are to the tasks that we're talking about here in both Africa, the Mekong and other areas. And their record of achievement is very impressive. They are essential tools, but they need a higher profile, a stronger base of understanding and a better, firmer, more reliable budgetary basis as we move forward. So can you speak to that at all in terms of how this moment in time, this middle moment that Alan has described where we need to convert and move forward? How does that issue about the critical tools that exist within DOD and how do we strengthen them and bring them forward? As you've already articulated, we recognize the labs are a great national asset actually, not just DOD's asset and their geographic distribution, their capability. And I think going back to the global health security agenda that has helped sort of position them as one of the key players in moving forward on these important public health initiatives to build capacity and compliance with international health regulations. And all the labs now partner with the interagency and clearly with regional partners in that area to be able to get the work done. They have gotten, and we've got one of the commanders here, they do do a fair amount of soft money work rather than hard money work, but that has been part of the way that we've been able to sustain it in declining DOD budgets. And I think that there's strong support within the department and they understand what crown jewels these actually are in the effort. But going back to the, I think the global health security agenda, which is truly a world effort, the world health organization now led with over 40 countries involved in it is one of the key pieces to this, because it's going to give that overarching public health structure that is critical to be able to do the elimination effort. I'm not sure we can do it without that, and so building that capacity to be able to drive that to countries that don't have the infrastructure will be very important to malaria elimination, but also to preventing future Ebola outbreaks and other, or actually outbreaks that are uncons, that are to the extent we presently have, because we know that we wouldn't have had this outbreak if we had had better public health infrastructure to prevent it. Thank you. We're going to turn to the audience in a moment and collect some thoughts. Bernard, can you just say a quick word about the PMI programs West Africa, Ebola, status of this, and as we move towards the post-Ebola reconstruction, if there's ample resources, what might that mean for moving towards elimination in West Africa? Sure. Well, PMI, you know, Liberia and Guinea, two of the most affected countries by Ebola are two PMI-focused countries. Our staff on the ground, along with other CDC staff who are there involved in the Ebola response, are sort of boosting the ground, trying to make sure that in the midst of all this, malaria doesn't fall off the cliff, because let's face it, there's going to be more people dying from malaria in the midst of all this than from Ebola. There are some challenges. I mean, Liberia, for example, had not yet scaled up bed nets, so there is a plan now to help them go forward with that. Guinea has already had a big bed net campaign, but certainly making sure, and now with the, you're probably aware there's now a no-touch policy, so we've moved away from diagnostic testing in these environments, and frankly, rolled things back a decade, so we're now going back to presumptive treatment, which, and our PMI teams are working to make sure now that we are cost-shifting to making sure that adequate supplies of ACTs are available, and are actually out there in the periphery, as we wait post-Ebola to start reintroducing diagnostics. So it has created some challenges, which are ongoing, but we are doing everything we can to make sure that doesn't fall by the wayside. The more and the better systems we have in the future in order to be able to detect and respond to these Ebola or whatever other things are going to be thrown at us in a more timely fashion will obviously benefit not only malaria, but the countries themselves and these communities, and there are these, like I said, if you actually look at what happened in Nigeria, you can imagine what would have happened if Ebola had actually taken foothold in Nigeria in a place like Lagos. It would have been mind-boggling, but frankly, still not that there's not a possibility of that happening, but frankly, the ability of the Nigerians to rally the polio surveillance people and others on the ground in order to do contact tracing and move forward on this without waiting solely for outside help was pretty impressive. And similarly in Senegal, we need to create that capacity in Liberia and Sierra Leone and Guinea and other countries in the region, Mali, which are threatened by Ebola. Thank you. Let's get a few questions right here. We'll bundle three or four together and then come back to our speakers. Please identify yourself. You need a microphone, please. Please identify yourself and be very brief. I'm Steve Hoffman from Scenario. I appreciate the reference to new tools by a number of the speakers, but these are technical tools. So if I look at what I've heard in this discussion, almost all of what I've heard is about more investment and political will, but not looking at actually what has come. So we're now investing, if you do the numbers, in about $80 to $100 per infant born in sub-Saharan Africa where there's malaria transmitted. There are places in sub-Saharan Africa where we're investing over $1,000 per infant born, per year over the last 10 years, and we still have lots of malaria. We had an illusion to the fact that, hey, we're going to get together now and eliminate malaria from Hispaniola, an island of 20 million people that's a few hours from the United States. And then we're talking about eradicating malaria from the world when we've got it two hours from here in an island of only 20 million people. And so if we go back and we say, okay, Fred Soper did this, eliminated eradicated anopheles in Brazil in the 1930s. And many of the countries in sub-Saharan Africa where we're celebrating our success we did very well in colonial times and in the 50s and 60s, and we're not much better or we may even worse in some of those places than we were then. So I'd like to hear something about the strategies that are being, you know, the approach that's trying to look at even with our, how are we doing anything different than we've done for 60 years other than we're saying we need more political will and we need more money. And applying the fact that we have computers now and GIS and RDTs and ACTs, but it's really not different than what we had with chloroquine and DDT in the 50s and 60s. Thank you. Other comments, questions? Right, Martin? Thank you. Just a comment for... Please identify yourself, Martin. Please identify yourself. My name is Martin Acapito. I come from Benin, West Africa. I have a general comment for those who are hesitating about malaria elimination, particularly in Africa. Some researchers are hesitating when they refer to the last program of malaria eradication, but I think we don't hesitate. There is no comparison between the last program and the current program. Now the context is good. It's very good. Many tools are available, ACT, RDT, ITPI, non-lacing net, indoor resource spray. But these tools need serious use, use against malaria parasites and malaria vectors. Malaria elimination is not utopia. Everywhere in Africa, malaria is decreasing. But these tools will... Malaria elimination will require a lot of sacrifice, a lot of investment. This is why I support this meeting. Thank you. Thank you. Do we have another comment or question? Yes, Rima? Hi, I'm Rima Shredder from UCSF, the Global Health Group. There's just two issues I wanted to highlight. The World Malaria Report that comes out tomorrow still says that about 9 to 26% of children under 5 receive ACTs, which is really the progress we've made over the last decade has been phenomenal. But that's one area that we're still lacking in. The other issue that I want to highlight is a role of the private sector. The panellists didn't actually address that. We know that over 60% of treatment for malaria occurs in the private sector. So how can we then mobilize a private sector to ensure that we can actually carry through those goals from control to elimination? And what would be that role of the private sector? Again, when we're talking about putting in resources in the public sector, even when we're talking about community health workers at the dinner yesterday, those are all quasi-public sectors. So how can we mobilize a private sector to achieve our goals? Thanks. Thank you. Why don't we come back to you, Alan. Would you like to start off on the first question? Sure. So I'll interpret a couple of things on Steve's question about one is in certain areas there seems to be some sort of a barrier. We get to 30% prevalence by some measure, and it seems to get stuck there. And I think there's a couple of things there. And this is one is when in a couple of settings, and for example, East Africa and a couple of other places where we've actually gone and looked directly, we find that, well, it's not quite what you think. And you really have to go on boots on the ground and actually look. It turns out that, well, I'll say it's 30% prevalent despite all these interventions. Turns out there's actually no interventions. There hasn't been any spraying in 10 years or something like that. So I think one of the things is it's about getting accurate intelligence about what exactly is going on in the ground. Because sometimes what you hear is not what's actually happening. So that's, you know, in any good campaign, good intelligence is what you need in order to move forward. I think secondly, this is kind of a, I would say, a personal key point for me is an understanding from a more of a historical context, the transition in the late 50s and early 1960s, the definition of eradication was very clear. It came from the World Health Organization, Emilio Pompana in his book, a textbook of eradication. The definition of eradication was the elimination of the parasite from the human reservoir. Somewhere over the 70s or 80s, that definition got changed to a transmission interruption definition. And I think that's been really not correct going forward. We really need to get back to the primary definition, which is parasites out of people. Transmission is a verb. It's an event. And you can interrupt transmission for a week, a month, or four or five years. And the reality is you're still going to get parasites in people because of the really prolonged duration of falciparin parasitemia for years in people. And again, history repeats itself. You go back to the 20s and 30s, as we say, a combined operation of transmission interruption and getting parasites out of people with drugs has a remarkable effect at dropping the parasite prevalence, crashing it absolutely within months, actually. So where are the parasites there in people? Well, where are the people? It's the asymptomatic reservoir. In many of these places, 80, 90% of the reservoir is in asymptomatic people. Today, we do absolutely nothing about those. We don't target them. We don't do nothing. And that's part of, as we say, learning from the neglected tropical disease community about community engagement, mass drug administration, using albendazol, ivermectin, other safe drugs. We can do targeted areas like that in malaria to achieve this rapid decline. And then I think one point we do have to remember is as much as we would love a vaccine or a drug to do this, they actually don't leap off the shelf, run across the floor, and jump into someone's arm or their mouth. They do have to be delivered by people and systems. And in areas where the systems are marginal, we can build them up. In other places where they're strong, we can encourage them to go to current tools, new strategies. We'll always have fragile and indeed failed states. And part of our transformative tool development is to think ahead to, in 15 or 20 years, when we may be approaching the end game in malaria and we'll be looking, as we are in polio today in northern Nigeria or in Pakistan, where we have very difficult environments to work in. These aren't biological or technical environments. This is political. And how do we work in failed states? With smallpox and rendered pest, we eliminated in very difficult settings in failed states with a single dose vaccine that you could actually work in those areas. So the transformative tools, whether they're genetically modified mosquitoes or vaccines could prove to be that next step going forward in those areas where delivery is never going to reach the levels that we need them to reach for these more complex interventions. Patrick and Bernard, would you like to add any comments on private sector issues? I'll let Bernard make some comments. I think he did invoke the private sector in terms of the role that private sector development partners, extraction companies, and others are involved in protecting their workforce or the communities in which they're situated. I think your question probably also reflects your interest in what I shared, and that is engaging the private sector as a resource for care and treatment of people when they develop malaria. And I think that's still an area that is underutilized in terms of it's not underutilized by the population. It's underutilized by those of us who organize around trying to deliver services to treat and prevent malaria. I think more can be done. I think we've had some interesting experiences with expanding and being able to look at tools to ensure better quality of care in the private sector or access to drugs like the ACTs that might otherwise not have reached the private sector. We're at a critical point where we have to decide whether or not a diagnostic is going to work in that, in the arithmetic around delivering treatment drugs in the private sector. I think we still are going to need to learn more about how to do that well. But it is definitely an issue that countries, malaria control programs in endemic countries are increasingly aware of and interested in engaging in. And I think there's a much more vocal advocacy community out there helping to bring this issue to the front of global discussions around the availability and the affordability of medicines and diagnostics. Bernard, did you have a thought? Sure. Well, first of all, I think we need to be clear what we mean by the private sector because it tends to be sort of a garbage can term for everything. So we just unpack the term private sector when it comes to drug delivery, for example. You have licensed shops in countries that are under some sort of a regulatory authority for the national government itself. Then you have unlicensed shops where people go to buy their cooking oil and their drugs. Then you have itinerant drug salesmen, which is a totally different sort of problem. So at least when it comes to licensed shops, we should be able to do a better job of making sure they have access to good quality anti-malarial. I should also point out that the reason there's such a high proportion of drug seeking behavior in private shops is because there aren't any drugs in the public sector, or previously there were none. I mean, poor people don't necessarily decide, I prefer to go and pay in a private shop because I don't like the drugs in the public sector. There were no drugs in the public sector. So that dynamic is already changing. If you look in Zambia, people going to private shops is not high at this point in time because the public sector has done such a good job. Having said that, there are countries like Nigeria where the private sector is huge, huge challenges. And we are working with piloting some different approaches to try to be able to look at how we can make subsidized ACTs and diagnostic tests available to see if that will actually work. So it's a work in progress. Lastly, when we talk about private sector health care delivery beyond just drugs, within that term private sector health facilities, that includes NGOs and faith-based organizations who frankly tend to do a better job in many countries than the weak national systems at this point in time. So my only point is, let's not use the term private sector without actually clarifying what we're actually talking about here. Thank you. We're getting to the end of our hour and we're going to need to break each of you. If we regroup in three years' time, what's the realistic and hopeful milestone of change on this elimination agenda that we're talking about? What would you look for as the concrete evidence of major gain on the elimination strategy? What should we be setting our sights on in the next three years? Alan, what would you say? What should we be looking for? Well, I think in a couple of areas, one is a clear commitment at the highest levels in the global community of eradication as an end goal. Not as an approximate goal, but as that's the target that we're all shaping for. I think also significant progress in the greater Mekong in terms of falciparum elimination as the answer to Artemisinin resistance. Thank you. David. I agree with both. And I think also a wider range of tools within three years, along with greater cooperation with the various militaries and the private sector. Thank you. I agree with both of those. I think as CDC, my focus might be more on pivoting from tracking the delivery of commodities to actually tracking the impact, tracking real numbers of cases and expanding the areas of the malaria endemic world where we can rely on actual reported cases and don't have to model the impact of malaria. Bernard, how did you get the last word today? Well, obviously I agree with all of that. Sustained political commitment at all levels is crucial. The multilateral UN system, donor governments including, frankly I have to say I continue to be surprised, impressed, gratified by the commitment of people up on Capitol Hill. Because malaria is a disease which most Americans don't need to think about or worry about on a day-to-day basis. But the fact that it's not a political issue, there's such a high level of bipartisan support throughout all aspects of the administration. And hopefully going forward that will be sustained because that's crucial. And the ability to do that, again we talk about the U.S. leadership not only in the technical aspects and ability to work with countries to do that, but also making sure that the U.S. is able to influence our bilateral relationships with malaria endemic countries and other donor countries to make sure there's adequate funding available to be able to continue to push forward. Please join me in thanking our panelists. In getting us going this morning, I skipped right past Margaret Chan's three-minute video. We'll bring that forward perhaps at the opening of the lunch hour so you can see that. It's a short piece.