ONE rare piece of good news about malaria is that we have a very successful drug for treating it. Artemisinin, an extract of the sweet wormwood plant, has been used in traditional Chinese medicine for centuries to treat fever. Derivatives of it, taken for about three days, make very effective anti-malarials.
That these compounds work is no longer in doubt, nor is the futility of sticking with chloroquine, the traditional treatment. Over the past 15 years the malaria parasites鈥� resistance to chloroquine has rendered the drug impotent in many parts of the world, especially Africa. To prevent similar resistance developing to artemisinin, it is best given together with other anti-malarials, and these combination therapies (ACTs) are now the treatment of choice for the World Health Organization and the Global Fund to Fight AIDS, Tuberculosis and Malaria.
But there is a catch. ACTs cost about 20 times as much as chloroquine, and many countries cannot afford them. So chloroquine is still widely used, even where it is known to be useless. That means countless lives are being lost, and countless more people are left with malaria鈥檚 lingering legacies of neurological damage, learning difficulties, financial insecurity and increased susceptibility to malnutrition and disease.
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Now three studies, part of a series of papers under the heading the 鈥淚ntolerable burden of Malaria鈥� in a supplement of the American Journal of Tropical Medicine and Hygiene, have calculated that the economic burden of malaria is such that countries simply cannot afford not to switch to ACTs. Add the cost of lost lives and productivity, future costs as drug-resistance increases and treatments fail, and the case for switching is irrefutable, even in areas where resistance levels today are quite low (see 鈥淢alarial onslaught sparks call to arms鈥�). In some countries, especially in Asia, artemisinin is being given alone 鈥� a very bad idea as it increases the chances of malarial parasites becoming resistant. To stop that happening, the studies recommend an immediate switch to combination therapies.
But many poor countries need more than just economic arguments to persuade them. They need money. And maybe that will come. A report published in July by the US Institute of Medicine recommends priming the market for ACTs by offering a global subsidy on the drugs to bring down their price to that of chloroquine. Guaranteeing incomes from artemisinin for five years would encourage farmers to grow sweet wormwood and drug manufacturers to invest in producing artemisinin combinations. Over that time, economies of scale would cut production costs so the subsidy would no longer be needed.
The institute also suggests a novel way of distributing the subsidy. Normally, governments get grants to buy costly drugs. But many people, especially in rural Africa, obtain malaria drugs not from the public sector, but from small pharmacies, general stores and street traders. Because early treatment is essential to save lives, the institute argues that this access must not be lost. So the subsidy should be spent by a 鈥済lobal wholesaler鈥� which would channel cheap pills to all markets, private and public alike.
All this will cost an additional $500 million a year, the bulk of which will have to come from existing sources of aid. The money is there, says the institute. The World Bank鈥檚 International Development Association has unspent funds, and there is money available from bilateral aid programmes from the US to other countries. The Global Fund is also in a good position to solicit contributions from both public and private sources and earmark them for ACTs.
But money by itself is not enough. Distributing the subsidy as suggested will need some creative thinking from global health agencies. Most of all, one organisation would need to take charge. Without central leadership, there would be too much waste and duplication to make a real impact on the disease. There is widespread doubt about the WHO鈥檚 capacity to do this, so perhaps the Global Fund, or a new body entirely should step into the breach.
Admittedly, $500 million sounds like a lot of money, but it is much less than is planned for treating HIV with anti-retroviral drugs. And the demand should not rise year on year, but at worst remain constant. At between $1 and $2 to save a life, we cannot afford not to act.