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When Brian Greenwood started work as a British medic in west Africa in the 1960s, he encountered medieval death rates. In Gambia, about 400 children in 1,000 died before their fifth birthday. Perhaps half the victims were killed by malaria.
Professor Greenwood, now 86, a malaria expert at the London School of Hygiene and Tropical Medicine, has just retired after a career that coincided with a transformation: mortality among the under-fives in most of sub-Saharan Africa fell “fivefold or more”. The son of two doctors from Manchester tells me, “It’s extraordinary that it has been achieved in one scientist’s lifetime.” More children survived largely because malaria declined, even before the first vaccines against the disease arrived in 2023. It’s a rare contemporary good-news story, even though Greenwood thinks it should have happened faster.
Malaria is one of history’s worst scourges. Richard Carter and Kamini Mendis of Edinburgh university estimated that the mosquito-borne disease was “a factor in between 2 and 5 per cent of all deaths” last century, killing 150mn to 300mn people. Most deaths in early 20th-century India probably involved malaria.
By the time Greenwood entered the field, many remedies were already known. Antimalarial drugs have been used for centuries. During the second world war, bednets protected British soldiers against mosquitoes. Scientists were then already working on vaccines; a study on attempted immunisation of ducklings appeared in 1945. European countries such as Italy eradicated malaria after the war, mostly through drugs and insecticide.
But until about 2000, few interventions were tried in Africa. African states lacked capacity to fight malaria, partly, precisely because the disease was felling their citizens and overwhelming their health systems. And, until recently, Africa barely trained experts in malaria.
That’s where Greenwood came in. He and his wife, a paediatrician, saw that their children, raised in west Africa, never got the disease because they took antimalarial drugs. Why not distribute those to African children too?
Greenwood also saw some Gambians using bednets. He led a trial proving that bednets treated with insecticide reduced malaria. “A lot of it was common sense,” he says. But the findings initially had little impact: after malaria disappeared from developed countries, it dropped off the international agenda.
That changed with a Multilateral Initiative on Malaria conference in 1997. Greenwood calls it “the most important meeting in my career”. Harold Varmus, Nobel laureate for medicine, was there and helped put malaria back on the agenda.
Donors came in. Western governments, NGOs, and Bill Gates paid for bednets and drugs, and funded Africans to take PhDs in malaria. By 2023, 53mn children received “seasonal malaria chemoprevention” medicines. Foreign aid isn’t fashionable, but Greenwood says it helped quell malaria.
Finally, vaccines arrived. RTS,S, created by British pharmaceutical company GSK in 1987, was approved in 2021, the first vaccine against any parasite in humans. Two years later, a similar vaccine developed at Oxford university was approved. Imperfect though both vaccines are, they work well when combined with drugs and bednets. That combination tells the story of the antimalarial battle. Like leukaemia and measles, malaria was pushed back by various interventions. Greenwood says, “There hasn’t been one dramatic event. It has taken too long. We’ve shown with Covid [vaccines] how fast you can move when there is money and will.”
Still, the success has been epochal. In 2021, Greenwood led a World Health Organization delegation to China, certifying the country’s eradication of malaria. Fourteen countries have reached that landmark since 2015. Climate change is spreading malaria to new areas, but for now the disease has become concentrated in central Africa, where mosquitoes are more efficient than local health systems. Greenwood says, “If you’re a child there sleeping in the rainy season without a bednet, you might be bitten once or twice a night by infected mosquitoes. The infection rate is so high, you have to have an almost perfect intervention.” About 95 per cent of the world’s 748,000 malaria deaths in 2021 were in Africa.
Still, Greenwood has helped make the world healthier. He says, “What I’m most proud of is establishing African scientists who can take the lead. Now it’s their problem.” He isn’t done, though, not even at 86 with long Covid. Better malaria vaccines are coming. His mission is to find out: “How best can we use them?”
Email Simon at [email protected]
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