23 January 2004
London — Malaria kills up to three million people every year, most of whom are children under the age of five living in sub-Saharan Africa. Child deaths from malaria have increased dramatically over the last few years, and this is often blamed on growing drug resistance.
In response to this, in 1998 the World Health Organisation (WHO), the United Nations Development Programme (UNDP), the United Nations Children's Fund (UNICEF), and the World Bank launched their Roll Back Malaria campaign, which aims to halve the deaths caused by malaria by 2010.
But the work of WHO and the Global Fund for AIDS, Tuberculosis, and Malaria has come under criticism for failing to support the use of the best treatment available. The respected British medical journal, "The Lancet", reports in its latest issue that "The current practices of WHO and the Global Fund are not adequate to safeguard the best interests of patients with malaria".
Dr Amir Attaran states in the article that, although meeting the goal of halving deaths requires prevention such as insecticide-treated mosquito nets and household insecticide spraying, the main difference between life and death hinges on treatment with an effective malaria drug. However, with half the time to the 2010 deadline now past, malaria is still on the increase.
Dr Attaran warns of drug resistance in the deadly species of the malaria parasite, Plasmodium falciparum, and points to the continued use of outdated drugs such as chloroquine, allegedly ineffective in most parts of Africa, and sulfadoxine-pyrimethamine.
There are alternatives. Dr Attaran states that artemisinin-class combination therapies (ACT) are the best treatment option, and expects that the "level of success can probably be maintained for a very long time, since artemisinins have been used as Chinese traditional medicines for 2000 years, with no observed resistance". ACT is now the preferred policy for WHO and the Roll Back Malaria campaign as a whole. But since ACT costs ten times more than the old drugs, many African countries cannot afford to adopt it.
Dr Attaran states "When those same countries seek financial aid from the Global Fund for AIDS, Tuberculosis, and Malaria (GFATM) to purchase ACT, they are forcefully pressured out of it by governments such as the USA, whose aid officials say that ACT is too expensive".
Dr Attaran accuses WHO of acquiescing "to this pressure to cut costs. Despite a policy that names ACT as the gold standard of treatment, WHO signs its approval when GFATM funds cheap but ineffective chloroquine or sulfadoxine-pyrimethamine to treat P falciparum malaria".
To back this claim, it is shown that in Africa in 2003 GFATM spent more on chloroquine and sulfadoxine-pyrimethamine than ACT.
As a result, many patients with malaria will fail treatment - and sometimes die.
Dr Attaran points out that in Kenya, Ethiopia, and Uganda, WHO's country representatives reviewed and supported the funding of inappropriate drugs. "These decisions are indefensible", he writes. "For WHO and GFATM to provide chloroquine and sulfadoxine-pyrimethamine treatments in the countries we cite as examples at least wastes precious international aid money, and at most, kills patients who have malaria." Dr Attaran argues that worldwide at least tens of thousands of children die every year as a direct result of this policy failure. Furthermore, "those patients who survive will often become much sicker and require retreatment, at some further expense of time and money. We do not exaggerate to state that, based on the outcomes, there is no ethical or legal difference that separates them from conduct otherwise condemned as medical malpractice".
Both WHO and GFATM emphasise their roles as mere advisers or funders, but the article claims that using ineffective drugs is a waste of money and inappropriate.
"The weight of evidence", the article declares, "leads us to conclude that a crisis exists, characterised by institutional inadequacies that result in good policies for malaria control not being fulfilled".
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