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Africa: Malaria Action at Issue

AfricaFocus Bulletin
Apr 19, 2004 (040419)
(Reposted from sources cited below)

Editor's Note

Malaria kills approximately two million people a year, some 90 percent of them in Africa. These numbers come close to the estimated three million worldwide dying of AIDS. The two diseases differ in many ways, but there are deadly similarities. In both cases, action falls far behind promises, while debates about strategy are used as excuses for failure to provide resources.

In the case of malaria, at stake are both availability of resources and willingness to adopt new, more effective drugs to replace ones that are now ineffective. Both concerns raise issues of political will.

This AfricaFocus Bulletin includes, first of all, a call by the coalition Massive Effort Campaign for organizations and individuals to sign on to letters to decison-makers calling for action on malaria. These will be delivered next week on the fourth anniversary of the Abuja Declaration in which African leaders committed themselves to such action. For more information see the note below and the Massive Effort website at
http://www.massiveeffort.org/Malaria.

Also included are
(1) excerpts from a 2003 background paper by Medecins sans Frontieres (international), as well as links to an updated paper in French from Medecins sans Frontieres (France);
(2) notes on a controversy raised earlier this year which has caused some confusion about responsibility for delays in introducing new drugs; and
(3) reference to an article calling attention to the need for malaria prevention campaigns to follow South Africa's lead in making appropriate use of indoor spraying with DDT, rather than relying only on insecticide-treated bednets.

For earlier background and links on international action on malaria, see:
http://www.africaaction.org/docs02/mal0212.htm,
http://www.africaaction.org/docs02/mal0212.htm,
and http://www.africaaction.org/docs98/mal9811.htm.

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Many thanks to those of you who have already sent in your voluntary subscription payment to support AfricaFocus Bulletin. If you have not yet made such a payment and would like to do so, please visit http://www.africafocus.org/support.php for details.

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ACT Now! To Stop Malaria

http://www.massiveeffort.org/Malaria

April 15, 2004

I write from the Massive Effort Campaign (MEC) - an international NGO dedicated to ending HIV/AIDS, tuberculosis and malaria. As you may know, April 25 is Africa Malaria Day. On this date four years ago in Abuja, Nigeria, African leaders came together with donor and development agencies to issue a series of pledges to roll back malaria.

By 2005, 60% of people infected with malaria would have access to "appropriate" treatment and 60% of "at-risk" people would have access to insecticide treated nets. With only a year left to realize these goals, only 4 African countries are implementing the most effective treatment (ACTs) and only 2% of African children are sleeping under insecticide treated mosquito nets.

This week, MEC launched a major campaign to re-focus the agendas of donor countries, pharmaceutical associations and African countries to live up to the Abuja pledges. On Africa Malaria Day, with the media watching, we will deliver a series of letters to the decision-makers involved. Please add your name to these letters and your voice to this fight by visiting
http://www.MassiveEffort.org/Malaria.

MOST IMPORTANTLY, please forward this note as widely as possibly to your friends, family, co-workers and other associates. If your organization has a listserv, please forward this note to it. Millions have died because world leaders choose NOT to make the fight against malaria a priority. Help us change their minds.

Thank you for your time and help in this important campaign.

Best regards,

Jove Oliver
Senior Communications Manager
Massive Effort Campaign
joliver@massiveeffort.org
+380 505 948 616


ACT NOW - Malaria Report


Medecins sans Frontiers (MSF) April, 2003

[full report available in HTML format on http://www.msf.org (use the search)
or in PDF format (over 1M) on MSF/USA website: http://www.doctorswithoutborders.org/publications/reports/2003/act_now_report.pdf

An updated dossier, in French, with detailed country cases and protocols for ACT treatment, is available on the website of Medecins sans Frontiers / France at:
http://www.msf.fr/documents/paludisme/palu2004.pdf]

Executive Summary

"Malaria is like the common cold, except that it's a killer" - MSF doctor, Kajo Keji, southern Sudan

ACT Now. This is an urgent call to international donors to join African countries in implementing World Health Organization (WHO) treatment guidelines for malaria. On the advice of international experts, WHO recommends that African countries facing resistance to classical antimalarials introduce drug combinations containing artemisinin derivatives - artemisinin-based combination therapy, or ACT for short.

Artemisinin derivatives have attributes that make them especially effective: they are highly potent, fast-acting (parasite clearance is fast and people recover quickly), very well tolerated and complementary to other classes of treatment.

Implementation of new malaria recommendations is a matter of life and death in Africa, where malaria kills between 1 and 2 million people each year. Sickness and death from malaria account for 30-50% of hospital admissions and a yearly loss of US$12 billion on the African continent.

The WHO-led global malaria eradication programme launched in the 1950s sought to eliminate the disease via vector control and effective treatment. The eradication programme was successful in some parts of Asia, North America and Europe, but bypassed sub-Saharan Africa. In 1969, the focus switched to the less ambitious goal of control through treatment. At the time, the treatment of choice was chloroquine, dispensed in a three-day course. This effective treatment campaign led to falling death rates until the early 1980s.

However, since the early eighties, the situation has stopped improving, and has in fact been getting dramatically worse. Average annual cases were four times higher between 1982 and 1997 compared to the period 1962-1981. Death rates have also jumped: hospital studies in various African countries have documented a two- to three-fold increase in malaria deaths. The continuing use of ineffective drugs despite spectacular levels of resistance is leading to increased treatment failure.

While African countries are heeding the advice of world experts to switch from old failing single-drug treatments to combination treatments, they are being forced to switch to stop-gap, less expensive combinations because of a lack of resources.

Why is MSF so focused on treatment?

Effective malaria control requires strong political will from endemic country governments that translates into implementation of comprehensive prevention and treatment programmes. But while the international community has been willing to do everything possible to augment prevention, there has so far been no concerted drive to support improved treatment.

In its projects M‚decins Sans FrontiŠres (MSF) supports prevention as an integral part of effective malaria control. There is no controversy there. The debate that we think needs to be stimulated is on treatment. After extensively documenting resistance to current treatments in MSF projects and carefully considering data gathered by ministries of health in endemic countries, MSF decided to switch to ACT in all its programmes. The decision was articulated in an October 2002 internal MSF malaria policy paper:

To ensure good patient care now and in the future, and to prevent the further spread of the disease in intensity and into new populations, MSF believes it is essential to use artemisinin-based combination therapy (ACT) in all our programmes where there are patients with falciparum malaria, and to explore all avenues open to MSF to assist governments to do the same in affected countries.

Since October 2002, implementation of this policy has focused simultaneously on switching to ACT in all MSF projects, and on advocating for and giving technical support towards increasing the availability of quality ACT drugs.

MSF is seeking to change the current dynamic in which some international donor countries, such as the US and UK, are supporting a "go slow" approach while other countries have no publicly articulated policy. This report debunks detractors' arguments by demonstrating that ACT is safe and effective.

The lack of political and financial support on the part of donors means that endemic countries are often encouraged to "leave alone" failing malaria treatment and are not given financial and technical help to implement more effective strategies.

Without successful implementation of ACT in the next decade, significant progress in controlling malaria will be impossible. This is because there are no miracle non-ACT combinations waiting in the wings, and because malaria control using prevention without effective treatment is doomed to failure.

How can we "go slow" on malaria treatment when one African child dies of malaria every thirty seconds?

This report defines The Malaria Problem, looks at What Works in malaria treatment and outlines what needs to be done to Make ACT a Reality. Our recommendations convey what MSF thinks needs to be done to stem the tide of unnecessary malaria deaths in Africa.

The idea is a simple one. Restock Africa with a malaria medicine that works.

  • The World Health Organization must push for implementation of its own recommendation to switch to ACT
  • Donors must stop wasting their money funding drugs that don't work and help fund efforts of endemic countries to make the switch to ACT
  • Endemic countries need to back up their will to improve malaria control with increased budget allocations
  • ACT must be provided to individuals free of charge, or at an affordable price
  • International agencies and donors must provide technical support to facilitate both treatment implementation and upgrading international and domestic drug suppliers (with technology transfer and technical assistance to enhance production standards)
  • UNICEF, WHO procurement and the Global Fund for AIDS, Tuberculosis and Malaria must pool needs and make large orders to prime the drug production pump and bring down prices
  • International and/or regional pre-qualification needs to be augmented to assist countries in identifying quality drug sources
  • Concerned parties must undertake operational research to improve use of current tools
  • Research & development for new drugs, new formulations and improved diagnostic tools must be placed high on the agenda and implemented through government-supported research and non-profit initiatives such as the Medicines for Malaria Venture.


KwaZulu Natal province-wide implementation of ACT

Early results from KwaZulu Natal are very encouraging. The same malaria control approach will soon be implemented in the Namaacha district of southern Mozambique which will enable the gathering of data in a higher intensity transmission area. The right question is not "if" ACT can be effectively implemented in Africa, but "how" it can be best implemented The introduction of artemisinin-based combination therapy (ACT) in South Africa's KwaZulu Natal province has already had a dramatic affect on public health in the region.

The implementation of artemether/lumefantrine (Coartem ) in February 2001, together with improved vector control measures, resulted in a dramatic reduction in malaria in the province: the number of malaria cases dropped from 41,786 in 2000 to 9,443 in 2001 (78% reduction). Between 2000 and 2001, admissions to Manguzi hospital in KwaZulu Natal for malaria were cut by 82% and the number of reported malaria deaths decreased by 87%.

These remarkable improvements in malaria control and public health reflect the combined effect of residual household spraying with an effective insecticide in both KwaZulu Natal and southern Mozambique, and the replacement of sulphadoxine-pyrimethamine (SP), a drug that had become ineffective because of parasite resistance, with an effective ACT as the first-line treatment of uncomplicated malaria.

These early results from KwaZulu Natal are very encouraging. The same malaria control approach will soon be implemented in the Namaacha district of southern Mozambique which will enable the gathering of data in a higher intensity transmission area.

The South East African Combination Antimalarial Therapy (SEACAT) evaluation is working with national malaria control programmes to assess where and how best to implements ACT as first-line treatment.

They are working in South Africa, Mozambique, and potentially Swaziland. The evaluation involves monitoring therapeutic efficacy, resistance, gametocyte carriage, drug safety, treatment seeking, drug use (especially drug availability and patient adherence), distribution and intensity of malaria transmission, and the costs and cost-effectiveness of implementing ACT.


Whose Malpractice?

Background note (AfricaFocus)

A viewpoint article in The Lancet for 17 January, 2004, raised the issue of ACT treatment, with an extra twist. The authors accused the Global Fund and the World Health Organization of "medical malpractice" for failure to support use of ACT drugs. The principal author, Amir Attaran, has often been identified with drug company positions. His argument was then taken up in an editorial in the Wall Street Journal (available at http://www.aegis.com/news/wsj/2004/WJ040108.html), which accused the international agencies for being opposed to patented drugs.

In the replies below, MSF joins the WHO and Global Fund in rejecting the Lancet and Wall Street Journal's charge as a case of mistaken identity. The failure to move more quickly to ACT is real, and the need urgent. But it is donors rather than international agencies that are the primary obstacles.

For additional documentation on this controversy, see http://www.theglobalfund.org/en/media_center/lancet/default.asp

- - - -

Response to The Wall Street Journal Editorial

(1) From WHO, Global Fund

WHO, Global Fund Get Best Medicine Available

January 26, 2004

In your Jan. 21 editorial "WHO's Bad Medicine," you refer to a Lancet article that claims the World Health Organization and the Global Fund to Fight AIDS, Tuberculosis and Malaria waste money and let children die by recommending and then financing the purchase of medicines that don't work. In detailed responses to The Lancet, WHO and the Global Fund have pointed out numerous errors in the article.

The Global Fund, based on WHO guidance, is financing one of the fastest shifts to new and better treatment regimens ever implemented in the developing world. Changes in the use of first-line medicines often take five to 15 years. Propelled by the dual impact of Global Fund financing that started less than two years ago, and WHO assistance in providing clear and up-to-the minute treatment policies, countries in Africa are already changing to the new, more effective artemisinin-based combination therapy (ACT). So far, Global Fund has financed programs to purchase 19 million ACT treatments in Africa, compared with ACT coverage of 10,000-20,000 treatments per year in 2001. By the end of this year, it is anticipated that 16 African countries will have adopted ACTs as first-line malaria treatment.

The assertion that WHO and Global Fund's treatment guidelines and policies are linked to patents is wrong. WHO, governed by rules collectively agreed upon by its 192 member states, has a straightforward policy regarding its recommendations on which medicines to use: It matters most that medicines are safe, effective and affordable, rather than who manufactures them. It should also be noted that the research-based pharmaceutical industry participates on the Global Fund board through the private sector representative, and that the board is chaired by U.S. Health Secretary Tommy Thompson, a strong supporter of public-private partnerships in global health.

Jack C. Chow
Assistant Director-General
AIDS-Tuberculosis-Malaria
World Health Organization

Richard Feachem
Executive Director
The Global Fund to fight AIDS, Tuberculosis and Malaria
Geneva


(2) From MSF

Lack of Political Will Obstructs Malaria Battle

January 28, 2004

In response to the Jan. 21 editorial "WHO's Bad Medicine" and the Jan. 26 Letter to the Editor "WHO, Global Fund, Get Best Medicine Available":

In editorial writing, as in medicine, it seems that being partially right never leads to proper treatment. Of course it is inexcusable to treat malaria patients with old, ineffective medicines rather than the more effective yet more expensive artemisinin-based combination therapy (ACT). But suggesting that international health institutions have done so out of a preference for off-patent medicines borders on the absurd.

The major obstacle to ACTs has been the lack of political will from international donors, particularly the U.S. government, and malaria-endemic countries to support the treatment. The U.S. has often refused to recommend and fund ACTs, largely because of their cost, and has influenced some countries not to switch to ACTs. In response to a recent epidemic in Ethiopia, the U.S. squandered nearly $1 million financing inadequate drugs, including chloroquine. ACTs are available from multiple sources, not just companies like Novartis, so in this sense patents are not the most important issue here. What malaria patients need is an explicit commitment to ACTs in word and deed, and both the U.S. government and Global Fund can play a pivotal role by stating a clear policy and supplying adequate funds.

Nicolas de Torrente
Executive Director
Doctors Without Borders/Medecins Sans Frontieres (MSF)-USA
New York


Tina Rosenberg, "What the World Needs Now Is DDT"

New York Times, April 11, 2004
http://www.nytimes.com/2004/04/11/magazine/11DDT.html

[summary by AfricaFocus Bulletin. For original article visit link on New York Times website]

Writing in The New York Times Magazine, journalist Tina Rosenberg argues that resistance to using DDT, because of fears of environmental contamination, is blocking one of the most effective remedies to combating the resurgence of malaria in Africa and around the world. The quantities recommended by the World Health Organization for regular indoor spraying against malaria-bearing mosquitoes by the World Health Organization are far below the environmental danger limits for DDT use, which are associated with the use of the powerful chemical as an agricultural pesticide. Targetted spraying is more effective and easier to implement than prevention by insecticide-treated bednets. Yet the negative image of DDT means that both global and national health authorities are reluctant to advocate strongly or to fund spraying with DDT.

Nevertheless, current programs in KwaZulu Natal in South Africa and in southern Mozambique have demonstrated the effectivess of indoor spraying, in association with treatment with newer more effective ACT anti-malaria drugs. These programs are documented on the website of the South East African Combination Anti-malarial Therapy (SEACAT) Evaluation at
http://www.malaria.org.za/Seacat/seacat.html.

Rosenberg argues that the failure of most African countries - and donors - to include DDT in the arsenal of tools against malaria is an "outrage." South Africa, she contends, has taken the right course: "South Africa is beating the disease with a simple remedy: spraying the inside walls of houses n affected regions once a year. Severl insecticides can be used, but South Africa has chosen the most effective one. It lasts twice as long as the alternatives. It repels mosquitoes instead of killing them, which delays the onset of pesticide resistance. It costs a quarter as much as the next cheapest insecticide. It is DDT."


AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

AfricaFocus Bulletin can be reached at africafocus@igc.org. Please write to this address to subscribe or unsubscribe to the bulletin, or to suggest material for inclusion. For more information about reposted material, please contact directly the original source mentioned. For a full archive and other resources, see http://www.africafocus.org


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