The scene is all too common. On average, a child dies of malaria every 30 seconds in Africa. Worse, 8-year-old Irene needn’t have suffered so much. A handful of tablets derived from an ancient Chinese herb can cure 95 percent of malaria victims within three days. Patients usually start feeling better within hours. A modern cure based on the herb has been widely available for two decades. And yet U.N. officials have only just begun to trumpet the need for Africa to embrace this cure in the fight against resurgent malaria. Kenya endorsed the medicine last month, and many more months will pass before public hospitals stock it. Activists are calling this delay a scandal–a case of malpractice on a global scale. Washington-based aid specialists, who wield the most influence on agencies like the World Health Organization and stand to shoulder most of the blame, argue that they were exercising caution appropriate for any new drug. What’s certain is that because of the delay, Africa now faces yet another health emergency.
The WHO and other organizations have been following a policy of treating malaria with prevention since 1998. That’s when the Roll Back Malaria campaign began promoting the use of bed nets soaked in insecticides. Scientists also looked for new drugs to replace chloroquine and sulfadoxine-pyrimethamine (SP, formerly Fansidar), to which the malaria parasite is increasingly resistant. Six years on, it’s now clear that the initiative is failing, say critics. By 2002 the death rate from malaria had increased by 10 percent, and it continues to climb 3 percent a year, they say. Malaria now kills more than 1 million people a year–90 percent of them in Africa. The prevention strategy has also failed: only 2 percent of African children sleep under a treated net, says the WHO, in part because 27 African governments still tax the purchase of the nets.
The Roll Back initiative ignored Asia’s success with a traditional Chinese cure for fever–an extract from the leaves of the sweet-wormwood weed called qinghao. Chinese chemists extracted the active ingredient, artemisinin, in the 1970s, and it has proved remarkably effective. Li Guoqiao, a professor of Chinese traditional medicine at the University of Guangzhou, helped administer treatment in Vietnam in the 1990s, virtually ridding the country of the disease. “It is the best medicine in the world to treat malaria,” he says.
When a malaria epidemic hit steamy KwaZulu-Natal province in 1999, the South African government had the budget to break with WHO guidelines. Health workers sprayed DDT on the interior walls of homes, and clinics treated malaria victims with artemisinin compounds. In 15 months the infection rate fell by 75 percent; today it amounts to only a few hundred cases a year. But, says Richard Tren, head of the Johannesburg-based lobbying group Africa Fighting Malaria, “the donors have decided that because it requires funding, it’s unsustainable, so they refuse to pay for it.”
Despite research in Europe and the United States confirming the effectiveness of artemisinin, the WHO and other organizations continued to push prevention and cheaper drugs. The WHO approved artemisinin in 2001, but U.S. officials were actively discouraging its use as recently as 2002, says Amir Attaran of the Royal Institute of International Affairs in London. “If the donors say, ‘We really don’t favor it, don’t ask for it,’ they won’t ask,” says Attaran. Only two African countries, Burundi and Zambia, have begun using the drug as the first-line defense against malaria. Says Dr. Jean-Herve Bradol, president of Medecins Sans Frontieres: “We started discussing this change years ago,” but U.S. officials lobbied the WHO “not to participate in any promotion for [artemisinin].”
The issue came to a boil early this year when a dozen malaria specialists, writing in the British journal The Lancet, accused the WHO and other funders of malpractice. “You cannot countenance a situation where a medicine that fails to work 30 or 50 or even 80 percent of the time continues to be prescribed,” says Attaran, principal author of the article.
The big donors have fought back. “There’s always a lag time for these kinds of things,” says Allan Schapira, coordinator of the WHO’s Roll Back project. He and others say it has taken time to reassure African health ministers that long-term funding would be available for expensive artemisinin treatment. Dennis Carroll, senior infectious-diseases adviser for the U.S. Agency for International Development, says “children were the stumbling block,” because large-scale studies proving the drug safe for the youngest victims weren’t finished until 2002. “We strongly support the rollout,” says Irene Koek, chief of USAID’s Infectious Diseases Division.
Since the public finger-pointing, though, things have been moving quickly. On World Malaria Day last month, the WHO appealed for a course correction. “Better treatment is available and must be delivered urgently to the people who need it most,” said WHO director-general Lee Jong-wook. There’s no longer much doubt that most African governments will quickly switch over to the more expensive treatment strategy. The Global Fund to Fight AIDS, Tuberculosis and Malaria already has helped six countries to introduce artemisinin treatments, and nine others have begun to do so in the last year. Most African countries are expected to follow suit within two years.
Now the main question is logistical–where the money and all that extra sweet-wormwood weed will come from. Synthesizing artemisinin isn’t practical, and growing it is time-consuming. Demand for artemisinin-based compounds will grow from about 20 million adult doses this year to between 130 million and 220 million next year, the WHO estimates. That will cost an extra $1 billion per year, more than the global fund has available. Growers, mainly in the highlands of China, must start putting in extra crops now to avoid a supply squeeze. WHO officials also worry about counterfeiters and quality control. “It’s important that China sees this as really a major contribution to world health,” says Schapira. The change can’t come fast enough for Africa’s suffering children.
