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No Time to Waste in the Fight Against Malaria

CHP/PCOR Fellow Kenneth Arrow argues that with a modest global investment, new drugs could start to loosen the disease's stranglehold on mnay impoverished countries.

Not long ago, an experimental malaria vaccine made newspaper headlines. Over six months, it more than halved serious episodes of malaria in 2,000 children in rural Mozambique. The only trouble is that it will take at least 10 years to come to market.

Fortunately, there are new, effective drugs already available that could start to loosen malaria's stranglehold on many impoverished countries. With a modest global investment, these drugs could be mobilised today.

Malaria is one of the world's greatest threats to life and human performance. Each year, it kills more than 1m people, mainly children in sub-Saharan Africa, and triggers some 500m debilitating attacks in people of all ages throughout the tropics. The toll in lost productivity is a big contributor to Africa's poor economic performance.

All concerned with malaria know that new drugs are needed. After the second world war, a drug called chloroquine became standard. Until about 20 years ago, it worked well in Africa. In addition, it was cheap, averaging 10 cents per treatment. However, chloroquine-resistant strains, which first emerged in south-east Asia, are now rife throughout Africa. The death toll from malaria is rising once again.

What makes this situation more distressing is the existence of an effective alternative. When the first signs of drug-resistant malaria appeared in Asia during the Vietnam war, Chinese scientists developed a family of drugs from sweet wormwood, a common shrub that had been used for centuries in traditional medicine. These "artemisinin compounds" are now standard components of malaria treatment in Asia, where they have proved to be the best ever anti-malarial drugs. To circumvent future drug resistance, however, the time has come to partner artemisinins with other anti-malarial drugs, creating artemisinin combination therapies (ACTs) - the same strategy that underlies the treatment of HIV and tuberculosis. In 2002, the World Health Organisation went on record urging governments to adopt such therapies rapidly in order to provide more effective malaria treatment and slow the spread of drug resistance.

Now the only remaining obstacles to these treatments in Africa are economic. At present, ACTs cost about $2 a treatment, not 10 cents. Subsidies are needed - probably in the region of $500m a year, a small amount on any global scale. The other challenge is how this money enters the drug supply chain.

To overcome the need for a new system of delivery, a recent report from the Institute of Medicine, the US-based health advisory organisation, recommended that ACTs be bought at competitive prices by an international organisation such as Unicef, then resold at a deep discount to governments and private wholesalers in countries where malaria is endemic. The main condition underlying access to subsidised ACTs would be that they flow freely through public and private channels - just as chloroquine does now. This approach would accomplish two objectives: it would allow the existing private market to support the switch to ACTs and it would keep the treatment's cost to consumers down to about the price of chloroquine.

Centralised purchasing has other advantages. It would assure a market for producers, and in particular would encourage the planting of sweet wormwood to overcome the existing reported shortage of artemisinin. It would also facilitate quality control. Moreover, the scale of any international subsidy of combination therapy would discourage the distribution of any solo drug whose use might encourage new resistance down the line.

Above all, in the case of anti-malarial drugs, centralised purchasing would provide the impetus for a swift change in the way the world treats malaria. Without a co-ordinated programme, the change is far more likely to be gradual and incomplete, the scenario most likely to jeopardise the effectiveness of artemisinins over the next few years.

There can be no excuse for delay. Resistance is overwhelming the usefulness of existing drugs, and deaths due to drug-resistant malaria are accelerating daily, especially among the poor of Africa. The IOM has proposed a feasible plan to introduce ACTs quickly. All that remains is for the international donor and finance communities to embrace the logic, allocate funds and take action once and for all against malaria.