Nine months ago, when little Poko had to cry because she suddenly had a fever, her mother Alimata began to smile inwardly. “I immediately thought: That must be the side effect,” says the 47-year-old, stroking her daughter’s forehead. In the hot morning sun, 18-month-old Poko wrestles with her twin sister Pogbi for her mother’s breast. They both tug at Alimata’s baggy t-shirt before younger Pogbi asserts herself and starts sucking. “The day made me happy,” the mother remembers. “Possibly Poko’s immune now.”
In any case, she survived the last malaria season from July to December without getting sick. In Nanoro, a rural district in Burkina Faso, 90 kilometers northwest of the capital Ouagadougou, that is already a success. Here, not only Alimata and her children are prepared to contract malaria at regular intervals. It’s the same for the whole region. “I don’t even know how many times I’ve had it,” says the mother, pointing to the dusty yard in front of her small, light-colored concrete house. »In the rainy season the mosquitoes are everywhere here. You can hardly save yourself from that.«
The five older of the seven children that Alimata has given birth to so far are all already suffering from malaria, one of whom was in mortal danger. And when the mother herself was bitten by a mosquito at the beginning of the year, another parasite settled in her body. She spent a week in the hospital. “I couldn’t get my kids ready for school, cook food or take care of our chickens,” she says in a despairing voice.
The poorest countries in the world in particular are nowhere near as badly affected as malaria. In 2020 alone, 241 million cases and 627,000 deaths were counted worldwide. More than 95 percent of these are in sub-Saharan Africa, where 80 percent of children under the age of five not only become ill but also die from the infections. In Burkina Faso, where the mortality rate is among the highest in the world, one in five infant deaths is due to malaria.
Because the parasites that cause malaria have been reproducing for thousands of years, they are consistently cited as the greatest killers in human history. In Africa, Covid-19 therefore seems like a small thing in comparison. Around five times as many people died from malaria there in the same period.
But if Alimata’s renewed optimism is justified, the dangers could soon be history. Alimata’s two youngest daughters are taking part in a study to determine whether an effective vaccine against malaria has just become available. Since the tests are anonymous, the mother didn’t just come up with her and her children’s names for this article. The family also does not know whether the twins were injected with a placebo or the vaccine. The outbreak of fever leads Alimata to suspect that at least Poko is now vaccinated.
“And how was your sister afterwards?” Magloire asks Natama as he sits down on a folding chair in front of the small terrace. The microbiologist overseeing the study stopped by for one of his regular rounds. “She was fine, quite normal,” replies the mother. “You mean she just got a placebo and has yet to get the real vaccine?” Natama, a tall guy with a big smile and thin glasses, shrugs. “We do not know it. The tests are anonymous for us, too,” he explains. ‘But as soon as we know in a few months we’ll let you know. Promised!”
Nanoro is an inconspicuous area with 33,000 inhabitants, characterized by the yellow-orange dust from the Sahel zone, bumpy roads and isolated houses without electricity. There are few places in the world where the average standard of living is lower. “It’s possible,” says Magloire Natama to Alimata and her children, “that Nanoro will become world-famous.” He doesn’t want to make any promises, but he can say this much: “So far the results are looking good. You and your children are helping to find out even more.” The scientist touches his heart, a typical gesture of respect in Burkina Faso.
In addition to a handful of other regions in Africa, the phase 3 study of the vaccine candidate has recently started in Nanoro. The vaccine called R21 marks only the second development project that has ever advanced to this final test phase. And the breakthrough could be near. Last spring, the second phase of the study conducted here showed that vaccinated subjects were still 77 percent protected against malaria a year later. The twins Poko and Pogbi are now among almost 5,000 children on whom R21 is being tested again in a large-scale study.
Less than an hour’s drive from the settlement where Alimata lives with her children, Magloire Natama slumps into the upholstered armchair in his office in the afternoon. Opposite the district hospital, around which a few small sales stands have settled, a science campus was built here with international research funds, which is dedicated to the topic of malaria from various angles. 40 researchers from Burkina Faso investigate everything possible here – from the immunity that pregnant women transmit to their children to the social use of protective equipment such as mosquito nets.
“Of course, the potential is huge,” says Natama and exhales. “Not just for Nanoro or Burkina Faso. It would be huge for all of Africa if this vaccine were approved.” The 42-year-old scientist from Ouagadougou came to the province a good decade ago to help set up the research center. He has rejected offers from Belgium and the USA. Working in the sweltering, dry heat exhausts him, he says. But she also drives him.
“I was a little kid when I first got malaria myself,” says Natama, turning on the fan. ‘It was as it is for everyone here. My mother had to take care of me all the time and therefore could not do anything for my big sister and the household. That’s why my father had to stay at home and help. That meant that he didn’t earn any money then.« The lesson that little Magloire learned from this: malaria is not only unpleasant for the sick, maybe life-threatening; the disease also creates an economic domino effect.
Malaria has been identified as one of the major obstacles to development in southern African countries. The US Department of Health estimates the direct costs for the affected countries alone at at least twelve billion US dollars per year. A study from southern India found that malaria diseases in agriculture often mean that only 40 percent of the possible yields can be harvested. And in Burkina Faso, malaria is held partly responsible for the fact that Islamist terrorists have been able to conquer parts of the country without much resistance for years. “If we don’t get malaria under control,” says Magloire Natama, “we will never make it out of poverty.”
Why hasn’t a global vaccine against malaria been developed yet? This question has arisen especially since the corona pandemic, in which a global alliance of leading research institutes, pharmaceutical companies and states only needed a year to develop several vaccines against Covid-19.
Called Adrian Hill in Oxford, who played a key role in developing the now promising vaccine candidate. Hill is one of the world’s leading scientists in vaccinology. “Malaria is a parasite and not a virus like Covid-19,” he explains. “That makes it much more complex to develop a vaccine, since parasites develop more efficiently than viruses.” While the corona vaccines each target one spike protein so that the body becomes immune to it, thousands of antigens are possible for malaria parasites.
There have been dozens of attempts over the past few decades to develop a vaccine against malaria, including at Oxford University’s renowned Jenner Institute, which Hill directs. Most never left the lab. Last year, after around 30 years of research, the World Health Organization (WHO) finally recommended a vaccine for the first time with the »RTS,S« vaccine. It is already being used in several African countries, but has one problem: after a year, its effectiveness falls below 40 percent.
“The high level of complexity is also one of the reasons why it takes so long to develop a vaccine,” adds Adrian Hill himself. »A similarly important reason is the financial resources. Between 2007 and 2018, the entire world invested around US$7.3 billion in research and development related to the fight against malaria. The USA alone spent nine billion US dollars working on vaccines against Covid-19 – in about 18 months.«
Are lives worth less in Africa? No one would say so, although this impression has been confirmed since the beginning of the pandemic. “What is certain is that in the case of malaria, the countries that are hit hardest do not have the money to develop the vaccine. We rely on third party funding,” says Hill.
That is why he would like the WHO to make a recommendation as soon as possible with regard to the R21 vaccine candidate. Because only then is it to be expected that large pots of money can be tapped again to make further work possible. “We expect the next interim results of the study in Nanoro in May,” says Hill. “As things stand now, the side effects are much milder than with the previous vaccine. And logistically, the fabric would also be easy to transport. The Serum Institute in India has already prepared for a possible mass production.«
The United Nations aims to have a malaria vaccine available by 2030 that is at least 75 percent effective. So the world seems to be on the verge of the mark. But how long is the remaining way? The phase 3 study has only just begun and, like its predecessor »RTS,S«, could drag on for years.
And a lot of time costs a lot of lives. If around 627,000 people die from malaria in a year so far, the global availability of a vaccine with 77 percent efficacy could in principle save more than 480,000 lives a year. “We definitely want to speed up the process at the WHO,” says Magloire Natama in his office.
And what does the WHO say? David Schellenberg, who heads the World Health Organization’s malaria program in Geneva, connected via video call. “We all want to have a vaccine available as soon as possible.” However, one still has to examine, for example, to what extent R21 remains compatible in combination with other diseases and medications. Couldn’t the process be speeded up, as authorities have done in the case of Covid-19?
Schellenberg says they will hurry, but is also skeptical. “When the expectations of a vaccine are very high,” he points out, “the possible benefits sometimes seem to outweigh the possible dangers.” have to endure two seasons of infection before his organization dares to judge.
In rural Burkina Faso, that’s not fast enough for everyone. “It’s about human lives,” people say to themselves in the corridors of the research campus in Nanoro. “If necessary, we’ll just have to hand out the vaccines without WHO recommendation,” complains a leading employee. When David Schellenberg is asked whether he can understand the current rush, he nods into the camera. “Yes,” he could do that. And the frenzied approvals in the midst of the corona pandemic now, of course, also put increased pressure on malaria.
The research costs for this report were funded by the European Journalism Center as part of the Global Health Security Call, which is supported by the Bill & Melinda Gates Foundation. The authors were not influenced in terms of content.