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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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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.
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