The troubling fight against old killer

Public health experts agree that artemisinen, when given with other drugs, can cure malaria in three days. And they're meeting in New York today to examine ways to make it the mainstay of a new assault on the mosquito-borne disease, still the leading killer of African children. Malaria parasites have become resistant to older drugs. But doctors say that artemisinen-combination therapy, or ACT, is more expensive, and cost has proven to be a major obstacle to widespread use. A complete three-day course of therapy costs $1.50, at a minumum, vs. a dime per dose for chloroqine or the widely used drug trade-named Fansidar. Many African governments can only devote $5 or $6 per person per year to public health. "There's no denying that this will cost more, probably a lot more," says Ron Waldman of Columbia University's Mailman School of Public Health, which is sponsoring the conference with the World Health Organization, UNICEF and Doctors without Borders. "But people now are spending a lot of money on treatments that don't work." The WHO pegs the annual cost of treating everyone in sub-Saharan Africa at approximately $1 billion for drugs alone, says Allan Schapira, of WHO's Roll Back Malaria program, begun in 1998. Once a global scourge, malaria was endemic in the Southeast USA and killed more American troops in the South Pacific during World War II than the Japanese. The WHO's global eradication effort, begun in the 1950s, wiped out malaria in the USA by 1951 and in Europe by 1979. Doomed by surging drug resistance and a global phase-out of the pesticide DDT, the campaign faltered. Now malaria has come roaring back, especially in Africa, home to the deadliest of the four malaria parasites, Plasmodium falciparum. Research indicates that the number of cases reported in the last two decades is four times that of the previous 20 years. The toll: 300 million to 500 million each year, 90% of them in Africa, according to WHO. Many victims are infants. The disease costs Africa's economy an estimated $12 billion. Epidemics have surged, too, including one in Burundi three years ago that affected half of the country's 6.5 million people and killed 13,000 of them. An outbreak in Ethiopia last year caused some 15 million cases, triple the usual number, unchecked by outdated drugs. "The response to the epidemic was so ineffectual, you might not have bothered," said Christa Hook of Doctors without Borders. Those failures, and the likelihood that the WHO's Roll Back Malaria campaign would fail to meet its goal of cutting cases in half by 2010, prompted a group of angry doctors to accuse WHO, the Global Fund for AIDS, Tuberculosis and Malaria and the U.S. Agency for International Development of "medical malpractice," for failing to aggressively attack malaria with effective drugs. "Those of us in the scientific community know this shift has to happen, but when it comes to get support from the world's donor community, what you get is a great sucking sound," says Amir Attaran, of London's Royal Institute of International Affairs, an author of a salvo in the January issue of the British medical journal Lancet. Attaran is especially critical of USAID for focusing more on pesticide-coated bed nets than medicines, though the bed nets and DDT are believed to be critical to any malaria-control program. Anne Peterson, USAID's assistant administrator for Global Health, concedes that the agency doesn't buy drugs directly and supply them to countries in need. Rather, she says, it will provide funding, technical assistance and prod manufacturers to increase production. "Our business is to get global production from 20 million doses, half of which go to Asia, to 100 million doses for Africa," she says. Burundi, Zambia, Kenya, Sierra Leone and Zanzibar are shifting to ACT as first-line treatment. The best evidence that the new drugs work comes from South Africa's KwaZulu Natal province, parts of which border the malaria belt in Mozambique. In 2001, doctors introduced Novartis's ACT therapy trade-named Coartem, as part of an aggressive malaria control campaign that also relied on careful use of DDT. Malaria cases plummetted by about 77%, and deaths dropped by nearly 90%. By killing the infectious form of the parasite in human blood, the drug also reduced mosquito transmission from one person to another. Each cure cost $11, compared with $146 for the ineffective drugs — because patients taking them needed more medical care, says author, Charlotte Muheki, a health economist at the University of Cape Town. Coartem is the only one of the ACTs now available that comes in a fixed-dose form, but it is slightly more expensive than the other ACTs available. Novartis does not profit from the sale of the drug. The KwaZulu Natal experience revealed a challenge to successful use of the new drugs — making sure patients take all their medicine so parasites don't become resistant to this therapy, too. "Because this drug is like a wonder drug, you take the first dose and feel brilliant," Muheki says. "You forget to take it for the rest of the day."