United to Beat Malaria is thrilled with the Biden Administration’s appointment last fall of Dr. David Walton, MD MPH, as the U.S. Global Malaria Coordinator and head of the US President’s Malaria Initiative (PMI).
Dr. Walton, who was appointed in September, is a longtime physician who brings over two decades of experience working in global health – specifically in highly vulnerable countries and communities, working to strengthen health systems, improve and expand access to medical care, and coordinate new medical infrastructure.
I sat down with Dr. Walton last November during ASTMH’s Annual Meeting in Seattle, to discuss a range of topics – malaria’s multi-level impact, PMI’s strategy to ‘reach the unreached,’ efforts to decolonize global health and invest in communities, and more! Read the full transcript below.
Margaret McDonnell: So for those people who have not had the opportunity like you’ve had to live and work in communities affected by malaria, could you sort of help to explain, paint a picture, what that means? Like, how does malaria affect people in communities – from the health system, the economy?
David Walton: So I think it’s important to step back and to say, what is the state of malaria today? Where are we as a global community? And it’s still quite profound in terms of the impacts. In 2020, there were over 600,000 deaths caused by malaria. And there were over 240 million cases globally.
And so, we take a look at present day. But then we’re sitting here in Seattle. Malaria was very, very present in the United States. In fact, fun fact, the [Centers for Disease Control and Prevention] was founded in the 1940’s to eradicate malaria. And interestingly, by the 1950s, it had been largely eradicated in the US. So we know it’s possible. We know that it was here, not necessarily in Seattle, but certainly in the US.
And so, understanding that when you look at who malaria affects, it’s really the most vulnerable among us. It most profoundly affects children and women – children who are our future, and women who are in so many of the malaria-endemic countries the pillars of their community, the pillars of their family, engines by which their families are able to move forward. And so, it’s quite devastating for communities.
And from an economic standpoint, there’s been a lot of scholarship and data that’s been written about this. But I was just looking at an article recently that, if you look at the effect of malaria in some of the hardest hit countries, it reduces GDP by 5 to 10% – with a single disease. It is one of our oldest pandemics.
And so, again, sitting in Seattle, we don’t see it. Most of the cases, all the cases I should say, that we see here in the U.S. are contracted from abroad. But it’s still just a profoundly devastating disease for so many folks, particularly in Africa, because of those 240 million cases and over 600,000 deaths [in 2020], 96% of those are on the continent of Africa.
Ms. McDonnell: And it’s amazing to me how malaria really affects at the individual level, the family level, the community level, the country level. So thanks for illuminating that for us.
So most of your career has focused on equity and increasing access. So could you talk a little bit about how – I know PMI recently came out with this strategy 2021-2026, End Malaria Faster, right? Which I love. So could you talk about that strategy and how it’s specifically working to address historic inequities in terms of health access?
Dr. Walton talks about PMI’s strategy to ‘reach the unreached’ in this film:
Dr. Walton: So it’s a brilliant strategy. I inherited the strategy. The team and my predecessor, the former coordinator, put that strategy together. And I just think for me it is the right strategy for this particular time. And I think what the entire strategy really does speak to in a profound way is equity and decolonizing global health as it pertains to PMI and the way in which we’re interacting with malaria, the community, the continent of Africa, but also globally.
And I think for that question in particular, I think one of the most important aspects of the strategy is reaching the unreached. Now reaching the unreached is a little bit more nuanced. Because I think at first blush you may say, well, reaching the unreached, just finding the folks that haven’t found care.
That’s one bucket. So if you think about it in buckets. So one bucket would be there’s a whole cohort of folks out there who just don’t have access to services. And there’s a second bucket. Those folks may have access to some, but not all of the really effective business- and data-driven tools that we have to prevent malaria or treat malaria.
And then the third is that there’s a cohort of folks who might be getting everything, the entire suite of tools – the nets, they have access to diagnostics or therapeutics. But you and I just sat together in a lecture here at ASTMH about resistance to the most effective drug we have in Africa for malaria: artemisinin and artemisinin-based compounds. And so imagine this last cohort I mentioned, they have access to everything, but they’re still unreached because the tools aren’t effective, certainly not as effective as they used to be. And so you’re having someone you think you’re doing all the things you can, they have the entire suite of set of tools, and yet they’re still dying. The morbidity, the mortality is still there.
So reaching the unreached – these are the categories that I think of. And there’s different strategies for each of those categories, right? For this first category of folks who don’t have access at all, what is our strategy of trying to reach them? And it really centers around community-based care, partnering with communities in a more robust way than I think we have in the past, empowering community health workers, making sure they’re trained, making sure that – they’re predominantly women as you know – making sure they’re paid, making sure they’re well equipped and making sure they have the tools or resources to get to those folks who haven’t historically had access in the past.
And they also play another important role in the second group of folks who I said may not be getting some of the things. They may be getting nets or maybe the nets they’re getting, they get them every three years, but the nets are only durable for two years. So how do we make sure that the folks who get intermittent access to effective tools can get steady access to all the tools we have – spraying of insecticides and things of that nature – when they need it, where they need it. And so, tightening, shoring these things up – again, that’s heavy investment into commodities procurement, but also making sure that the community based care, the primary care is there, delivering that care.
And then the last category, this is the session we just got out of, it’s PMI’s involvement in the engagement in the science. How are we engaging the science and supporting the scientists and the folks who are really doing this cutting-edge work to identify where the tools aren’t working, both the diagnostics and the therapeutics and the nets even, to make sure that we can take that science, do the operational research, and then take it and help folks in the private sector, as I mentioned, really develop new tools, which we’re also doing, to then be able to bring to bear on some of these challenges.
Ms. McDonnell: So interesting because when I usually think about access, I think about, literally, how for some communities people have to walk miles to get [services]. But I think it’s interesting and a very positive development over the last few years – in part it’s been necessary – is to really think about the need for tailored approaches and to have tools that meet the people where they are and to make sure that [the tools] are the most effective as possible. So I think that’s really it’s more complicated and a lot more planning is involved from your team and others.
But I also think that investment in community health workers, I do feel like especially with COVID, it’s just shown us the importance of investing in people who are on the frontlines. And I know PMI recently adopted a new strategy, a commitment around paying health workers, which is huge. And like you said, the majority are women doing this work, underpaid, volunteer, which again – bless their hearts. But this is important lifesaving work.
Dr. Walton: I think that this is the issue or one of the issues where, they’re the most important frontline workers that we have. And so, we can never reach full eradication of malaria if we’re not focused on those folks and focusing on those folks who are at the frontline, doing the work, making sure that they have a living wage so they can actually do the work that we’re asking them to do or their countries are asking them to do, partnering with them in an effective way. Otherwise, again, we really have to think differently about how we are functioning as a US agency and working in solidarity with those communities and continuing to decolonize the ways in which and evolve the ways in which we are working with those communities at both the community level but also alongside our national malaria control counterparts as well.
Ms. McDonnell: That’s great. I think that kind of speaks to this next question about – and we know you’ve also made it a priority to really invest locally. And I know you’ve always been about working in close partnership with the country and community leaders. But could you talk about why that’s important to PMI and sort of what shifts or other adjustments that PMI is making to ensure commitment around that?
Dr. Walton talks about PMI’s commitment to collaborating with communities in this film:
Dr. Walton: Absolutely. And I think, again, that represents an evolution of how we think about – malaria’s continuing to evolve. Malaria, the parasite is evolving. It’s developing resistance, the mosquito is developing resistance. And so, you have that going on. And so that’s always a challenge. And then you have what we’re trying to do as [PMI] and where we are in time.
And as we chase this biological threat, we’re also trying to figure out what are the ways in which we’ve worked in solidarity with communities and PMI countries in the past and what is needed as we move forward. And when we think about, again, eradication and improved malaria control, it can fundamentally not fully depend on us or the other large funders. The work has to be done on the continent and, say, in Africa, or, let me put it this way, in malaria endemic countries. And so the work has to be done there, both the science, but also, the production of medication, the production of nets, the tools that we’re using in addition to vaccines.
Case in point: so during the early parts of the COVID-19 pandemic, I was working as a clinician at Brigham and Women’s Hospital in Boston. We didn’t have enough N95 [masks]. Why? Because N95’s were made in China. And so globalization affects all of us. You know, when there was a big push for broadening vaccine access, India – one of the largest producers of vaccines globally – really decided to focus on vaccinating their population in India first, which then delayed creating access to vaccines across the world.
How do we empower folks on the continent to not be subject to the whims of globalization and be able to access the tools and treatments that are required and necessary for them by them, for their communities, for the population that lives in those countries.
And so as we think about that need, we think about our role as [PMI], and we think about the Administration’s priorities. And so not only is this a [PMI] priority, it’s an agency priority, and it’s also an Administration priority for President Biden. And so then we think about what are the ways in which we do this, right? So, yes, we’re, as we noted, already investing in community health workers. We’re trying to procure more commodities on the continent, because most of our work, 24 of our 27 countries, are in Africa. We’re trying to procure locally. We’re trying to encourage vaccine manufacturing on the continent. We’re partnering with private sector partners in these countries as well.
But I would also say, part of how we look at localization is capacity building, right? I mentioned like the science has to be done on the continent. So from our perspective, localization also means our ability to strengthen the capacity of the scientists, strengthen capacity of the local epidemiologists so that, over time, the fundamental shift is that they are in control of their destiny. The work is done by them. And we will always continue to support them. But they’re driving the agenda, not us. It’s a subtle point, but an important one. The locus of control, of agency, of decision-making, shifts – from a funder to those for whom we are working in solidarity.
Margaret: And that is really exciting. I mean, that is revolutionary. We’re doing that more and more. And it feels like especially during COVID, I know there was initially a lot of concern about, well, the staff aren’t going to be able to travel in-country. And I think community and country leaders rose to the challenge in such incredible ways. And not that that should have been a surprise, but just it just shows you, when you have that level of commitment, I mean, people were affected by this disease in and out, their families and colleagues. So it’s awesome to hear that the US government is just doubling down on that commitment.
Dr. Walton: I would also say two things on that score. Number one is, I think it reflects the investments that the US government made previously. So the investment in diagnostics, investments in, really again, trying to buttress health systems that we’ve been engaged in for years. But, certainly, I would say in West Africa after Ebola, really trying to understand where were the opportunities, where we could have done better and really trying to identify that.
But most importantly, we underestimated our colleagues. Not unusual, but we did it. And I think they proved to us that we have traditionally, historically underestimated them. It’s an important lesson for us, that, again, I’ll go back to the theme of decolonization and sort of how do we shift the mindset there? The achievements they were able to demonstrate during COVID were not surprising to them. They weren’t surprised. We were surprised as a community and that’s, we need to reflect on – that’s on us. How do we take that information and understand how we have not yet evolved to where we need to be in terms of where we are today, where they are today, and how we shift that dynamic.
Margaret: Well, thank you. Well, now we’re going to shift to the part of the program where we do some rapid fire questions. So, okay, number one. So if you didn’t go to medical school, what would you be doing right now? What would be your next dream career?
Dr. Walton: It’s a great question, but I think when I was younger and had more time and more hair, I used to be very into photography, so probably for photographer.
Margaret: Very cool, like nature, fashion people, places?
Dr. Walton: People. So when I was living and working in Haiti, with permission of course from my patients, I did a lot of photography with them. For them. In their homes. It was just such a privilege to be in proximity, to be in communion with them and to be able to be in their homes, to be able to photograph them. And some of the images still bring me to tears, not because I’m that talented, but rather those poignant moments that they allowed me to witness.
Margaret: Amazing. You should have an exhibit! Okay, so I know you’re very busy, but if you were to have time to read or watch TV or listen, what would it be?
Dr. Walton: Yeah, the past few months have been filled with lots of malaria all the time, in terms of what I’ve been reading and thinking about. I will say the best book that I’ve read in the last five years that I read recently was a book called Caste: The Origins of Our Discontents by Isabel Wilkerson, around the caste system in the U.S. and that we don’t really think about it as a system. But she really just beautifully lays out the fact that we do have a caste system here. It’s ever-present. And then she looks at other caste systems – Germany, pre-war, and India. It really looks at the common themes of caste systems in general, but it really focuses her time on the caste system in the US. It’s a poignant, poignant analysis of where we are and really a really fresh look at some of these issues.
Margaret: That’s fascinating. I’ll have to check it out. Thank you for the recommendation. Okay, it’s always hard to say your favorite, but what is the most beautiful or special place you’ve been?
Dr. Walton: I love Cape Town, South Africa, because it combines some of the things that I really love, which is like nature and wine and food and proximity to the beach. And it’s just a stunning vista. I mean, like many places, it’s rife with inequality and challenges. So the beauty is always tempered by reality, right? It doesn’t live in a bubble. It lives in the reality of the legacy of apartheid that is visible and apparent in every interaction everywhere. And I can’t even fully appreciate it as an American and not a South African. So it’s beauty. But the beauty is tempered by that legacy.
Margaret: Wow. Oh, I’d love to go. I’ve never been. I lived in Botswana and worked there, but I never got to South Africa because I was broke at the time. Yes, but one day I will get there. Well, thanks so much for taking the time to share and really enjoy the conversation and more to come.
Dr. Walton: Yes, thank you and thank you for all the work that you all do. I know it’s so critically important, it’s underappreciated. So I want to make sure that I can highlight it, for what you’re doing in particular. Really, with partners like you, we’re able to do the work that we do. And so just incredibly grateful for you, for the United Nations Foundation and for just highlighting malaria, because it’s not often thought about, it’s sort of fallen out of favor. But I think it’s an underappreciated global, an actual current global pandemic that we’re dealing with, that is one of our oldest pandemics. And we’re grateful to you for your solidarity, your support and all the work that you do to highlight this pandemic in the places and the communities that it affects the most.
Margaret: Wel thank you. And you know, it’s one of the things that makes me really proud to be an American, honestly, is U.S. leadership – bipartisan, bicameral, across administrations – thanks to strong programs that have great track records and effective advocacy. So I’m really proud of the role that the U.S. has played, and [PMI] is obviously a huge part of that, along with support for the Global Fund and R&D and all the things. So, I’m hopeful that while we have challenges, while there’s been some setbacks, that there’s positive momentum and it’s exciting to see it’s headed by you and the energy that you bring to it. So thanks so much for taking the time.
Dr. Walton: Thank you. Really, really a pleasure, thanks.