Malaria: MSF's constant challenge

© Julie Remy
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"Of the estimated one million people who die from the disease each year, 90 percent are African children under the age of five."

Over the last few decades, MSF doctors, along with other health workers in the developing world, have been dismayed to see the struggle with malaria become more and more difficult. Eradication efforts in the United States and Europe wiped out malaria by the 1950s. But in most parts of Asia, Africa and Latin America, the rapid development of parasite resistance to medicines and growing resistance of the mosquito vector to insecticides have combined with waning Western interest in the former colonial world to defeat eradication efforts.

Today, 300-500 million people develop malaria each year - far more than in the 1970s. Of the estimated one million people who die from the disease each year, 90 percent are African children under the age of five. Malaria continues to be the number one cause of illness addressed by our programs. Last year alone, more than a million people were treated by MSF for the deadly form of the disease, falciparum malaria.

Frustrated by the poor availability of effective medicines and diagnostic tools, MSF began three years ago to draw on its field experience to press the international community to take greater responsibility for increasing access to malaria treatment.

Because many of the older malaria treatments such as chloroquine and fansidar, have become almost completely ineffective, a new line of medicines, known as artemisinin-based combination therapy (ACT), has been developed recently. Treatment with ACT takes just three days and costs as little as US$ 0.60 per child and US$ 2.00 per adult.

MSF has demonstrated the effectiveness of these new treatments: In a high transmission area in Angola, for example, admissions for severe malaria were reduced by 25 percent in the year following the introduction of ACT. Over the same period, mortality was reduced by 75 percent compared to the previous year.

In part because of such evidence, there is now widespread recognition by donors, UN agencies and affected countries that ACTs must be made available as soon as possible to halt malaria deaths, mainly of young children who are not treated adequately. Most countries in sub-Saharan Africa have switched their national treatment policies from use of older, inadequate treatments to ACT-based therapy.

Denied effective treatment

However, the problem is far from solved. Even where new policies are in place, MSF has observed that effective diagnosis and treatment remains available to only a tiny proportion of those who need it. Although 33 African countries have agreed to use ACTs, only 11 have begun to do so, and only a handful have done so nationally.

At the international level, two major issues persist: there is a critical shortage of ACTs and not enough money to allow malaria-burdened countries - among the poorest in the world - to provide treatment for free. In addition, while demand worldwide for ACT has increased, pharmaceutical companies that had promised to increase production to meet the need have failed to do so.

Second, there is not enough money to allow malaria-burdened countries to provide treatment for free. In Burundi, for example, the main problem with treatment is the cost. In the last few years, the government changed its malaria-treatment policy to ACT, funding was procured, training was implemented, and the old, ineffective drugs were removed from clinics. But like many countries, Burundi has been persuaded by the World Bank that it needs to charge a small fee for a medical consultation.

Largely as a consequence of this decision, patients are being denied effective treatment. One MSF survey conducted in the country's Makamba province found that fewer than 30 percent of patients with malaria were treated with ACT.

This payment policy has been promoted in the hope that "cost-sharing" or "cost-recovery" schemes will make health systems in poor countries more sustainable. This is a false hope in these very poor countries: Rather than adding income to the health system, cost-sharing has proven to be a very effective way of keeping the poorest from receiving treatment.

MSF studies have shown that the death rate from malaria goes up with increasing health-service charges. One study, conducted earlier this year in Chad, found that the cost of ACT was a heavy financial burden for most. For half of the people surveyed, the price paid at the health center was equivalent to at least 12 days of income; for the poorest 20 percent it exceeded their monthly revenue. Seventy percent of those who sought medical assistance needed to sell goods or borrow money to pay for it.

These policies also have been found to prevent effective diagnosis. Confirmation of clinically suspected malaria by either microscopy or rapid diagnostic test is a crucial part of tackling malaria effectively. These tests are needed for two important reasons: to confirm that a patient has malaria so that ACTs are not misused, and to encourage correct diagnosis so that other causes of fever can be treated (often all fevers are assumed to be malarial).

MSF teams have found that the availability of microscopy is limited by lack of sufficient numbers of trained technicians, and the use of rapid diagnostic testing is, like ACT, limited by short-sighted policies that deem them too expensive.

A political, not a medical problem

For MSF, it is clear that the major problems involved in tackling malaria are not technical, medical or scientific. It is entirely feasible to produce enough ACTs and to ensure their distribution so that treatment can reach people in need. But that will only happen if there is urgent and sufficient political action. The responsibility for curing malaria cannot lie with a child's poverty-stricken family. The responsibility lies with the international community, which can and must provide the funds to treat every child and adult suffering from this entirely curable disease.