International Order & Conflict

Containing Drug Resistant Malaria: the Risks of Weak Health Systems

in Program

By Karen Masterson – For decades, the global health community has sought
affordable drugs to obliterate malaria-causing microbes – which include strains
so virulent and fast acting they can kill a child the same day symptoms appear.
Africans are the most in need of effective drug therapies because they are the
hardest hit, absorbing 90 percent of the world’s nearly one million
malaria-related deaths each year, and over 80 percent of the roughly 300
million annual cases. For the people of Africa, one recently available class of
drugs has been a game changer. It comes from an herb called artemisia and, with
the support of donor programs, has helped halve malaria-related child mortality
in many communities.

But artemisinin-based drugs are like all other
anti-malarials; they’re extremely vulnerable to drug resistance. This is
because the parasites that cause malaria quickly evolve biological strategies
to survive treatments. These microbes have neutralized the effectiveness of
every drug put to use in global health programs – from the oldest one, quinine,
to the gold standard developed during World War II, chloroquine, and everything
since. The World Health Organization’s investigation into the artemisinins in
the 1990s (which the Chinese had discovered in the 1970s) was a major
breakthrough. Because of unprecedented efforts in the last few years to make
them affordable for use in health assistance programs, they are now the
frontline defense against malaria in 42 African countries. Their importance to
global health assistance programs, recipient governments, NGOs, and the sick
cannot be overstated.

For these reasons, global health experts lost sleep last
month when Cambodian and Thai troops exchanged fire over a land dispute in a
forested border region that is home to the world’s only confirmed
artemisinin-resistant strains of malaria. A tentative ceasefire has been worked
out. But troop movements continue and an estimated 30,000 residents had fled
for safer ground. International interventions seem unlikely to resolve the
dispute, which involves ownership of an 11th-century temple. And
soldiers and civilians continue to move in and out of the area, exposing themselves
to these unique strains of malaria and running the risk of carrying the
microbes to new regions.

Robert Newman, director of the Global Malaria Programme for
the World Health Organization, told the United Nations humanitarian news
service IRIN that concerns about the Cambodian-Thai border dispute potentially
unleashing these strains on Africa “wake me up
at night” and would amount to a “public health disaster.”

In Asia, drug resistant
strains of malaria are slow moving, like a brushfire – moving toward ecosystems
and economic conditions capable of supporting transmission. Malaria-carrying
mosquitoes, called anophelines, thrive throughout the world but contribute to
malaria transmission only where governments fail to maintain adequate health
systems and impoverished people live in mosquito-porous dwellings, often made
of mud and sticks. The most intense transmission zones in the world are found
in sub-Saharan Africa because of crushing
poverty and the presence of the world’s most efficient malaria-carrying
anopheline mosquitoes. In some parts of Kenya and Tanzania exposure rates have
been measured at 1,000 to 2,000 infectious bites per person per year – or 3 to
5 per day! Artemisinin-resistant strains in these areas would spread rapidly,
like wildfire.

Artemisinin-resistance first cropped up in Cambodia in 2009.
Since then, the global community has closely watched a pattern of resistance
growing along Cambodia’s
malarious borders then transiently appearing in other impoverished areas,
including Vietnam
and along the Myanmar-China border. Countries with stronger health systems,
like Thailand, are not as worrisome because they are able to detect, quickly
treat and contain their malaria outbreaks. These other countries, with fragmented
public health systems, are the real threat.

Artemisinin-based drugs are distinct and valuable because
they act so rapidly against infections. This allows them to be combined with
older, slower-acting drugs in a way that sustains therapeutic levels of
treatment in the blood long enough to kill off an infection. But artemisinins
are also politically important; they are needed to keep anti-malaria programs
viable while health assistance programs await a workable malaria vaccine. That
could take another 10 years, which means international stakeholders will have
to do a better job of containing resistance than any other generation before

In January, WHO and Roll Back Malaria announced the creation
of a $175 million fund to help pay for containment plans wherever
artemisinin-resistant strains crop up, with a specific goal of preventing them
from moving into Africa. The cost is estimated at US$10-20 per person along the
Cambodian-Thai border and US$8-10 per head in the at-risk areas of the Greater
Mekong region. When the plan was announced, Margaret Chan, WHO
director-general, warned that the “usefulness of our most potent weapon in
treating malaria is now under threat” and that the consequences are too great
to not act.

The sad truth, however, is that resistant strains might
currently be evolving somewhere on the African continent. As in Cambodia, many
African governments lack the resources or political will to build tight health
systems capable of delivering treatments directly to people. They also lack
adequate controls to ensure drugs are used properly and are protected from
corruption, like theft and counterfeit. Counterfeit anti-malarials are
especially troubling because a severe scarcity of health professionals has
forced donor programs to make these drugs available over the counter at barely
regulated kiosks whose owners operate under little or no oversight. Too often
medicines are diluted or falsified to maximize profits. The sick receive
inadequate doses that fail to clear the infection, creating conditions for

Over time, long-term solutions must target the root causes
of drug resistance. This will require a retooling of all global health spending
so that more money and political might are put toward building stronger health
systems and health-based infrastructures; reversing the severe scarcity of
health professionals in rural areas; securing drug supplies against corrupt
practices; and boosting woefully inadequate healthcare services for
impoverished people in malaria-prone places. 


Photo Credit: female Anopheles albimanus mosquito while
she was feeding on a human host, (CDC 
photo: #7861)




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