We're losing the malaria battle
6 March 2004
While the fight to get Aids drugs to people in Africa has been noisy and relatively high-profile, the struggle for effective treatment for an older killer has been going on in a largely subdued fashion in the background. Malaria kills more than a million people every year, most of them children under five. Unlike Aids, there are drugs to cure it. Yet the World Health Organisation's big campaign launched in 1998 to halve malaria deaths by 2010 is not working. More people are dying. Lack of will, shortages of money and logistical difficulties have all played a part in the failures of the campaign, Roll Back Malaria. But the biggest problem of all now is the nature of the parasite that causes the disease when it is transmitted to humans by the bite of the anopheles mosquito. It has shown an unnerving ability to evolve, building resistance to the drugs used against it with alarming rapidity. Chloroquine, the drug that used to be first-line treatment in Africa, looked like the perfect anti-malarial when it was developed in 1934. It is very cheap, easy to administer and has no side-effects, unlike quinine which is truly horrible to take and can cause temporary deafness and tinnitus. But chloroquine is now virtually useless and the second-line drug, sulfadoxine pyrimethamine (known as SP or by its brand name Fansidar) is failing fast. In many parts of Africa resistance to chloroquine has reached 90%. The British National Formulary - the drug bible for healthcare professionals - states unequivocally that in most parts of the world the malaria parasite "is now resistant to chloroquine which should not therefore be given for treatment". Resistance to the newer SP has now reached 60% in parts of Burundi and Uganda. In the past six months there has been a concerted effort by malaria experts and campaigners to speed the introduction of new drug combinations using derivatives of the Chinese plant artemesia, which has long been used in Asia against malaria. They have shown excellent results in trials. The new drugs are 10 times as expensive as the old, but useless drugs cost lives. An article by malaria experts led by Amir Attaran, of the Royal Institute of International Affairs in London, in the Lancet medical journal in January caused uproar when it accused the World Health Organisation and the UN's Global Fund for Aids, tuberculosis and malaria of "medical malpractice" for continuing to pay for chloroquine and SP. But the article appears to have focused minds. Most donor countries and international organisations now accept that the ACTs (artemisinin-based combination therapy) are the only way forward in spite of the price. USAID and Unicef are on board, says the volunteer doctors' organisation Medecins Sans FrontiÃ?â?¦›res, but they accuse one government of dragging its feet: ours. "What we're finding quite difficult with DFID (the department for international development) is that they won't make a policy," says Christa Hook, an Edinburgh-based doctor who works on MSF's malaria programme. "They say that they just respond to what the country asks for. This is very frustrating because we know from what countries tell us that they do not put forward the possibility of better treatment. It is not enough to say somebody asks us for drug X so we give it." She cites Uganda as an example. DFID has been funding programmes there for four years, using chloroquine together with SP, even though there is a resistance problem with chloroquine on its own and in combination. If the Ugandan government is now recognising it needs to switch to ACTs, it is not because of advice from DFID, says MSF. DFID doesn't see a problem in failing to be proactive. "We support countries in making their own decisions on national drug strategies," says a spokeswoman. So far there is no resistance to the artemisinin drugs, and to preserve their efficacy as long as possible the WHO recommends that they should be used in combinations with other drugs. That way they hit different biochemical targets of the parasite. Resistance will eventually build - that is the nature of evolution - but it is not expected to happen fast. "There are some drugs to which resistance grows very slowly," says Dr Hook. "Quinine is a good example. Like quinine, these drugs have a plant-based complexity which may be helpful. And if you have a very short half-life, it stops resistance building. Artemisins have the shortest half-life of any malaria drugs." This means that they are cleared quickly from the body. It also means they need to be taken for seven days, but in combination, the treatment can be effective within three. If ACTs are to be widely used, then farmers need to start planting. Artemesia grows easily in Vietnam, but widespread cultivation won't happen until the farmers are sure of their market, which is another reason why the malaria experts want governments and institutions to make commitments. All those involved are frustrated at the failure even to slow malaria down. Medicines for Malaria, the non-profit foundation that is directing efforts from pharmaceutical companies into artemisinin-derived and other malaria drugs, points out that it is "both a cause and a result of poverty and a major constraint to economic development", costing Africa $12bn a year in lost GDP. Those sort of sums make the amounts needed to pay for ACTs seem like pocket money.