We can't rid the world of malaria & That Fever Won't Go Away:
Huge investment in prevention in recent years has raised hopes that deaths from the disease could be almost eradicated by 2015. But politics, poverty and corruption will always get in the way, says Mark Honigsbaum.
Malaria is one of the oldest diseases known to humanity – and certainly one of the deadliest. DNA from the parasite that transmits malaria has been found in the skeletons of ancient Egyptian mummies. Even today, the disease kills some 850,000 people a year, the majority of them women and children below the age of five.Compared with HIV/Aids, however, malaria is not a particularly complex disease. In theory, all you need to stop mosquitoes from transmitting the malaria parasite are insecticide-treatedbed-nets, and all you need to reduce the reservoir of infectious human carriers is a course of pills costing less than £5.
So why is it that the eradication of malaria, unlike the eradication of smallpox, which was achieved in 1979, remains such a seemingly distant prospect? And how is it that on what should have been a routine holiday to Tanzania last month the singer Cheryl Cole contracted the disease, necessitating her being rushed to hospital last weekend from her Surrey home?Cole is not the first famous casualty of malaria, nor is she likely to be the last. Malaria almost certainly contributed to the death of King Tutankhamun and, in the 17th century, when malarial mosquitoes bred beneath Lambeth Bridge, it carried off the Lord Protector, Oliver Cromwell.Nor, if it is true that Cole was taking a preventive medication, will she be the first person for whom a prophylactic regime has failed. One reason why defeating malaria has been less straightforward than scientists had hoped is that the parasite is co
ntinually evolving resistance to the latest pharmaceuticals. Choloroquine, which used to be the preferred treatment drug, has been steadily losing its efficacy since the 1960s. In the 1980s the same thing happened to sulfadoxine-pyrimethamine (Fansidar) and the prophylactic mefloquine (Larium).Now there are reports from the Thai-Cambodian border of growing resistance to artemisinin, the key ingredient in the combination therapies (ACTs) donated by the West to Asia and elsewhere. This is potentially very bad news: if artemisinin follows the same pattern as chloroquine and Fansidar, then within 30 years that resistance could spread worldwide, undermining the World Health Organisation's efforts to end malaria deaths by 2015.However, to listen to Ray Chambers, the UN special envoy for malaria, there are presently far more reasons for optimism than for gloom. He points out that in malaria-endemic countries such as Ethiopia, Ghana, Rwanda and Zambia, the efficient distribution of ACTs and bed-nets has cut morbidity and mortality from the disease by up to 70 per cent. In Zanzibar, where deaths have been reduced to zero, officials are daring to use the word "elimination" again. Buoyed by such successes, and pledges of $2 billion annually to fund new malaria initiatives, Chambers is confident of meeting the target of universal coverage of nets by the end of 2010, and near-zero deaths from the disease by 2015.These successes are testimony to the financial commitment to fighting malaria, HIV/Aids and tuberculosis shown by G8 leaders at the Gleneagles summit in 2005, and the leverage provided by the Bill and Melinda Gates Foundation, whose support for scientific research has prevented malaria from becoming another "forgotten" tropical disease (it has put $287 million into malarial vaccine research alone). Another key factor is the proliferation of non-profit groups such as Malaria No More, employing high profile celebrities such as David Beckham, Ashton Kutcher and, ironically, Cheryl Cole, who was persuaded to clamber to the top of Mount Kilimanjaro last year on behalf of Comic Relief to raise money for insecticide-treatedbed-nets.But if solving a problem like malaria was simply a question of money, then the parasite and the mosquitoes that transmit it would have been consigned to collectors' trophy cabinets years ago. That they haven't arguably reflects not only the short-sightedness of top-down Western solutions to malaria control but also the fact that, as the Nobel prize-winning economist Jeffrey Sachs puts it, malaria is first and foremost a disease of poverty.What made the elimination of malaria possible in Panama in the early 1900s and in Italy in the 1930s was the imposition of military-style campaigns employing DDT, quinine and the full resources of the modern state. Marxist regimes such as Cuba and Madagascar scored similar successes by making malaria control a political and economic priority. But in post-colonial times it is no longer possible for Western governments to parachute into malarial zones and "solve" the problem for the "natives". Instead, the WHO must cajole and persuade, realising all the while that many developing countries that are in receipt of free drugs and bed-nets may not have the political will, or the means, to ensure they reach populations most in need of help.A good example is Uganda, which used to be the darling of the international aid community. These days, malaria transmission rates in Apac and other war-torn regions in the north of the country are soaring. Far from reducing malaria mortality, as neighbouring Rwanda has, Uganda now suffers a reported 340 deaths every day.One reason for this surge in infections is that many Ugandan farmers refuse to spray their crops with pesticides that might kill the mosquitoes that transmit the disease, citing the concerns of the environmental lobby who have lon
g campaigned against the use of DDT and other chemicals.Another is the countrywide shortage of ACTs supplied by Western donors. The reason? The drugs, which are subsidised to make them affordable to the poorest Africans, are being siphoned off by unscrupulous health officials and sold for a profit on the black market. To compound the predicament of ordinary Ugandans, in 2005 the Global Fund to Fight AIDS, TB and Malaria was forced to suspend grants to the country of some £200 million following allegations of corruption involving three government health ministers. In Kenya and Tanzania, where Cheryl Cole was holidaying, officials are also suspected of diverting drugs donated by international donors, albeit not to the same degree.As Charles Mpagi, the political editor of Kampala's Sunday Monitor, told me when I visited Uganda last year to make a film about the shortage of ACTs, the problem is that Uganda's public health system has been starved of funds and many doctors and provincial health officials feel they are underpaid. He also says the penalties for black marketeering are not harsh enough.The black market trade in ACTs is not only a problem for Uganda but potentially for the whole east African region, as it also fuels a trade in counterfeit ACT medications and monotherapies which are one of the triggers of parasite resistance. Nor should we be overly optimistic about the chances of the containment exercise launched along the Thai-Cambodian border last year by the WHO with the backing of the Gates Foundation. Bill and Melinda Gates have pledged a huge sum – $22 million – to prevent the spread of drug-resistant parasites to other part of Southeast Asia, but negotiations over the distribution of bed-nets and ACTs to Cambodian farmers have been mired in bureaucratic delays and political wrangling between the WHO and Cambodian officials. In the meantime, the black market trade in counterfeits continues to thrive.Better distribution of ACTs is not the only challenge. Thanks to high profile campaigns by Comic Relief and the US TV show American Idol, hundreds of thousands of bed-nets are now on their way to countries like Tanzania and Zambia. This is in addition to the 700 million insecticide-treated bed-nets that UN agencies aim to distribute in Africa by the end of 2010. But as workers on the ground have discovered, all too often these deliveries never make it out of the warehouses, or they lie rotting unused in the corner of people's homes.The complaints are multiple: the nets are difficult to put up, they are too hot to sleep under, or as one Ugandan mother explained to me as she prepared dinner for her three children inside her tiny mud hut, they have a tendency to catch light whenever she sets a fire. The point is that until we find a way to take account of local cultural practices, it would be foolhardy for anyone to predict when and how malaria might be conquered.And suppose, for a moment, that we were to succeed in 100 per cent bed-net coverage. What guarantee do we have that the mosquito would go along with the plan? The Anophelines may, for instance, adapt to bite outside humans' sleeping hours, rendering bed-nets less effective.Of course, a vaccine – the Holy Grail of malaria research – would solve all of these problems, but no one should expect to see that soon. Plasmodium falciparum, the deadliest form of the malaria parasite, has some 5,000 genes. By comparison, the HIV virus, another long-standing target for vaccine development, has just nine.Mark Honigsbaum is the author 'The Fever Trail: In Search of the Cure for Malaria' (Pan Macmillan). His film on malaria, The Killing Season, can be viewed on Aljazeera.net.
ntinually evolving resistance to the latest pharmaceuticals. Choloroquine, which used to be the preferred treatment drug, has been steadily losing its efficacy since the 1960s. In the 1980s the same thing happened to sulfadoxine-pyrimethamine (Fansidar) and the prophylactic mefloquine (Larium).Now there are reports from the Thai-Cambodian border of growing resistance to artemisinin, the key ingredient in the combination therapies (ACTs) donated by the West to Asia and elsewhere. This is potentially very bad news: if artemisinin follows the same pattern as chloroquine and Fansidar, then within 30 years that resistance could spread worldwide, undermining the World Health Organisation's efforts to end malaria deaths by 2015.However, to listen to Ray Chambers, the UN special envoy for malaria, there are presently far more reasons for optimism than for gloom. He points out that in malaria-endemic countries such as Ethiopia, Ghana, Rwanda and Zambia, the efficient distribution of ACTs and bed-nets has cut morbidity and mortality from the disease by up to 70 per cent. In Zanzibar, where deaths have been reduced to zero, officials are daring to use the word "elimination" again. Buoyed by such successes, and pledges of $2 billion annually to fund new malaria initiatives, Chambers is confident of meeting the target of universal coverage of nets by the end of 2010, and near-zero deaths from the disease by 2015.These successes are testimony to the financial commitment to fighting malaria, HIV/Aids and tuberculosis shown by G8 leaders at the Gleneagles summit in 2005, and the leverage provided by the Bill and Melinda Gates Foundation, whose support for scientific research has prevented malaria from becoming another "forgotten" tropical disease (it has put $287 million into malarial vaccine research alone). Another key factor is the proliferation of non-profit groups such as Malaria No More, employing high profile celebrities such as David Beckham, Ashton Kutcher and, ironically, Cheryl Cole, who was persuaded to clamber to the top of Mount Kilimanjaro last year on behalf of Comic Relief to raise money for insecticide-treatedbed-nets.But if solving a problem like malaria was simply a question of money, then the parasite and the mosquitoes that transmit it would have been consigned to collectors' trophy cabinets years ago. That they haven't arguably reflects not only the short-sightedness of top-down Western solutions to malaria control but also the fact that, as the Nobel prize-winning economist Jeffrey Sachs puts it, malaria is first and foremost a disease of poverty.What made the elimination of malaria possible in Panama in the early 1900s and in Italy in the 1930s was the imposition of military-style campaigns employing DDT, quinine and the full resources of the modern state. Marxist regimes such as Cuba and Madagascar scored similar successes by making malaria control a political and economic priority. But in post-colonial times it is no longer possible for Western governments to parachute into malarial zones and "solve" the problem for the "natives". Instead, the WHO must cajole and persuade, realising all the while that many developing countries that are in receipt of free drugs and bed-nets may not have the political will, or the means, to ensure they reach populations most in need of help.A good example is Uganda, which used to be the darling of the international aid community. These days, malaria transmission rates in Apac and other war-torn regions in the north of the country are soaring. Far from reducing malaria mortality, as neighbouring Rwanda has, Uganda now suffers a reported 340 deaths every day.One reason for this surge in infections is that many Ugandan farmers refuse to spray their crops with pesticides that might kill the mosquitoes that transmit the disease, citing the concerns of the environmental lobby who have lon
g campaigned against the use of DDT and other chemicals.Another is the countrywide shortage of ACTs supplied by Western donors. The reason? The drugs, which are subsidised to make them affordable to the poorest Africans, are being siphoned off by unscrupulous health officials and sold for a profit on the black market. To compound the predicament of ordinary Ugandans, in 2005 the Global Fund to Fight AIDS, TB and Malaria was forced to suspend grants to the country of some £200 million following allegations of corruption involving three government health ministers. In Kenya and Tanzania, where Cheryl Cole was holidaying, officials are also suspected of diverting drugs donated by international donors, albeit not to the same degree.As Charles Mpagi, the political editor of Kampala's Sunday Monitor, told me when I visited Uganda last year to make a film about the shortage of ACTs, the problem is that Uganda's public health system has been starved of funds and many doctors and provincial health officials feel they are underpaid. He also says the penalties for black marketeering are not harsh enough.The black market trade in ACTs is not only a problem for Uganda but potentially for the whole east African region, as it also fuels a trade in counterfeit ACT medications and monotherapies which are one of the triggers of parasite resistance. Nor should we be overly optimistic about the chances of the containment exercise launched along the Thai-Cambodian border last year by the WHO with the backing of the Gates Foundation. Bill and Melinda Gates have pledged a huge sum – $22 million – to prevent the spread of drug-resistant parasites to other part of Southeast Asia, but negotiations over the distribution of bed-nets and ACTs to Cambodian farmers have been mired in bureaucratic delays and political wrangling between the WHO and Cambodian officials. In the meantime, the black market trade in counterfeits continues to thrive.Better distribution of ACTs is not the only challenge. Thanks to high profile campaigns by Comic Relief and the US TV show American Idol, hundreds of thousands of bed-nets are now on their way to countries like Tanzania and Zambia. This is in addition to the 700 million insecticide-treated bed-nets that UN agencies aim to distribute in Africa by the end of 2010. But as workers on the ground have discovered, all too often these deliveries never make it out of the warehouses, or they lie rotting unused in the corner of people's homes.The complaints are multiple: the nets are difficult to put up, they are too hot to sleep under, or as one Ugandan mother explained to me as she prepared dinner for her three children inside her tiny mud hut, they have a tendency to catch light whenever she sets a fire. The point is that until we find a way to take account of local cultural practices, it would be foolhardy for anyone to predict when and how malaria might be conquered.And suppose, for a moment, that we were to succeed in 100 per cent bed-net coverage. What guarantee do we have that the mosquito would go along with the plan? The Anophelines may, for instance, adapt to bite outside humans' sleeping hours, rendering bed-nets less effective.Of course, a vaccine – the Holy Grail of malaria research – would solve all of these problems, but no one should expect to see that soon. Plasmodium falciparum, the deadliest form of the malaria parasite, has some 5,000 genes. By comparison, the HIV virus, another long-standing target for vaccine development, has just nine.Mark Honigsbaum is the author 'The Fever Trail: In Search of the Cure for Malaria' (Pan Macmillan). His film on malaria, The Killing Season, can be viewed on Aljazeera.net.Malaria Fever That Won't Go Away :
FIFTEEN years ago when, as a doctor, I treated people in Rwanda, we relied on presumptive diagnosis - anyone with a fever was treated for malaria. A great deal of progress has been made since then on the complex issues of diagnosing malaria, drug resistance and access to care. Nonetheless, in this raw and vivid account, Sonia Shah gives an alarmingly accurate picture of how basic practices like presumptive diagnosis still endure. In too many countries malaria is viewed with little more seriousness than the common cold, not as a public health crisis that kills close to a million people each year.
Malaria has been around for centuries, and Shah presents a fascinating history of how it played a major role in significant historical turning points, from the collapse of the Roman Empire to the Vietnam war, when the disease sometimes put more soldiers out of action than the enemy did. Shah's lucid account of how malaria spreads will give non-experts a fascinating glimpse into parasite biology and what drug resistance means in practice.Sadly, nearly all the challenges that malaria posed in the past are still recognisable today. Malaria leads to poverty and poverty leads to malaria. The logical conclusion, that malaria treatment should be free, is still absent in many countries where the disease i
s endemic. Shah examines the resistance to insecticides and antimalarial drugs that continues to impede progress, including today's horrific situation in which resistance is emerging to the most powerful weapon we have - artemisinin combination therapies. As Shah explains, treatment based on combination therapies can avoid a rapid surge in drug resistance, yet their efficacy is being threatened by profit-driven sales of artemisinin on its own, and by substandard drugs.We do, however, have a number of other resources at our disposal, including insecticide-treated bed nets that retain their efficacy after 30 to 40 washes, and rapid diagnostic kits that remove the need for presumptive diagnosis. What is needed is to raise awareness in regions where malaria is endemic, rather than simply assuming that people will sleep under a bed net because it is dropped on their doorstep. Critically, The Fever exposes the growing threat posed by donors who want to see immediate results. The issue is all too familiar to field workers, who see aid flooding into countries where success is more or less guaranteed, but poor investment in chaotic post-conflict countries where the burden of the disease is often heaviest. Everyone - politicians, donors, research institutes, lobby groups and the pharmaceutical industry - has their own agenda when it comes to malaria. Shah's examination explores them all. The Fever is a mine of information, drawing on diverse accounts from medical experts and field workers. This is an important book on the historical lessons we must not forget and the mistakes we are still making today in the battle against what remains a formidable killer.
s endemic. Shah examines the resistance to insecticides and antimalarial drugs that continues to impede progress, including today's horrific situation in which resistance is emerging to the most powerful weapon we have - artemisinin combination therapies. As Shah explains, treatment based on combination therapies can avoid a rapid surge in drug resistance, yet their efficacy is being threatened by profit-driven sales of artemisinin on its own, and by substandard drugs.We do, however, have a number of other resources at our disposal, including insecticide-treated bed nets that retain their efficacy after 30 to 40 washes, and rapid diagnostic kits that remove the need for presumptive diagnosis. What is needed is to raise awareness in regions where malaria is endemic, rather than simply assuming that people will sleep under a bed net because it is dropped on their doorstep. Critically, The Fever exposes the growing threat posed by donors who want to see immediate results. The issue is all too familiar to field workers, who see aid flooding into countries where success is more or less guaranteed, but poor investment in chaotic post-conflict countries where the burden of the disease is often heaviest. Everyone - politicians, donors, research institutes, lobby groups and the pharmaceutical industry - has their own agenda when it comes to malaria. Shah's examination explores them all. The Fever is a mine of information, drawing on diverse accounts from medical experts and field workers. This is an important book on the historical lessons we must not forget and the mistakes we are still making today in the battle against what remains a formidable killer.
No comments:
Post a Comment