TCS Daily

Giving the Poor Drugs That Don't Work

By Roger Bate - December 2, 2003 12:00 AM

It's bad enough that the World Health Organization (WHO), US Agency for International Development, the World Bank and almost every other aid/development agency will not allow DDT to be bought with their funds to combat malarial mosquitoes. Now it appears that its not just political correctness over insecticides that these groups adhere to, but also bad drug practice: the WHO and Global Fund are supplying useless drugs to African nations. This must stop. At a conference this week at the American Enterprise Institute some of the culprits will be put on the spot and they don't have much wriggle room.


To stop malaria one can either kill the mosquito, which carries the disease, or kill the parasite that causes it. Bed nets, DDT and other insecticides perform the first function, drugs the second. But bed nets with holes in them or failed insecticides (those that insects resist) do not protect humans from being bitten by mosquitoes. New nets and better insecticides must be applied. Similarly there are drug-resisting parasites and when resistance becomes significant those drugs must be dropped and alternatives found.


Insecticide and drug resistance is a natural perpetual problem. Like Sisyphus' mythical chore in Hades -- rolling a rock to the top of a hill only to watch it fall down again and repeating the process for eternity -- biological resistance will always be with us.  


There are two ways to overcome it. The easiest is rotating the insecticides or drugs that you already have. DDT is an old insecticide and one that had not been used in some locations for a long time; it therefore had lower resistance than newer insecticides to which mosquitoes had become accustomed. Since it takes genetic effort for a mosquito to maintain resistance to an insecticide, natural selection will de-select that resistance when the mosquito is no longer systematically faced with that threat. Therefore simply rotating insecticides or drugs will help.


The second, and ultimately only long run solution, is to develop new drugs/insecticides, always keeping one step ahead of the bugs and parasites that attack us.


For malarial parasite control that means making new drugs. A recent development has been artemisinin-based drugs, which, so far, have virtually zero parasite resistance. Like all new drugs they are more expensive than older drugs, often due to patents, which allow the developer to recover costs and make profits.


Malaria drug researchers are outraged that the Global Fund for AIDS, Tuberculosis and Malaria ("the fund"), with WHO advice, has been purchasing the old anti-malarial chloroquine, which costs $0.10 per dose, but is largely ineffective in Africa due to widespread resistance. Chloroquine was an amazing drug, used effectively for over 50 years, but its time it was retired, at least for a decade or so since resistance to it is over 80% in some locations. Malaria specialists are dismayed that artemisinin drugs are not being deployed, even though they cost 10 times as much to produce. They claim lives are being lost needlessly. In other words it is better to treat fewer people properly than many badly.


"It is terrible to waste lives and money deploying a useless drug," said Professor Nicholas White, director of the Wellcome Trust's South-East Asia Overseas Unit. And Professor White should know, he is the world's leading researcher on malaria drug resistance, operating out of Thailand, where resistance is the worst in the world.


It appears that the WHO and Global fund are ducking the blame by pointing the fingers at each other and ultimately the health departments of the wretchedly poor countries they're supposed to be helping. Dr. Vinand Nantulya, senior advisor to Global Fund head, Dr Richard Feacham said: "When the fund buys chloroquine it is because a country itself has asked for it. We would like artemisinin-based combination therapies to be made available to all countries....That is the best treatment. But we don't tell countries what to use. We leave it to WHO to guide the process in terms of technical support. We're a financing mechanism."


Dr. Allan Schapira, WHO Roll Back Malaria's coordinator claimed it would be better if countries asked the fund to back artemisinin-based treatments. He went on to say that at least the combination therapies using chloroquine they were asking for were better than chloroquine alone.


In short, WHO RBM should be more strongly advising countries to use artemisinin, and the fund should be providing these drugs, but apparently the poor countries are asking for the wrong drugs and it's mainly their fault. But according to Doctors Without Borders there is widespread confusion about which drugs WHO is recommending in Africa. They originally promoted artemisinin-based drugs in 2001 but given the cost are now back-pedaling.


Ultimately all aid/health agencies are falling down on the job. According to Professor Bob Snow of the Kenyan Medical Research Institute, the fund is doing a poor job at peer reviewing proposals from developing countries like Uganda (which asked for a combination therapy with over 30% failure rate), and the WHO is not providing the technical leadership countries deserve.


Meanwhile in the time it's taken you to read this far at least 5 children in Africa have died from malaria, a preventable and curable disease. Only South Africa, which is using DDT and artemisinin-based drug therapy, has malaria firmly under control, and they don't get any aid agency funds because they are fortunately rich enough to fund their own programs. The rest of Africa had better adopt western democratic institutions and get rich quick because those sent to help them are woefully falling down on the job.


Dr Bate is a visiting fellow at the American Enterprise Institute and a Director of Health advocacy group Africa Fighting Malaria.

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