What’s Wrong in the Mekong?

Tuesday, March 03, 2009

By Roger Bate and Julian Harris

Enfant moustiqueMalaria is deadly enough already, killing over a million people a year, but now the World Health Organization (WHO) warns it could get worse. In parts of Asia malaria is becoming increasingly resistant to even the most modern drugs–largely because of badly-made or counterfeit medicine.

A recent study in the New England Journal of Medicine demonstrates increasing resistance to the malaria “wonder drug” artemisinin in Western Cambodia. This complements studies into criminal fakes such as those by Dr Paul Newton of Oxford University. In 2006 his team surveyed artemisinin drugs throughout Cambodia, Vietnam, Laos, and Myanmar and found 68 per cent to be sub-standard.

Natural selection alone can cause diseases to mutate, but resistance is greatly exacerbated by growing numbers of counterfeit and sub-standard drugs, especially in poor countries. These often contain some correct active ingredients but not enough to cure, just enough to encourage mutation and resistance.

The fight against malaria has had some success in recent years: in 2007, there were over 75,000 malaria cases in Cambodia and Thailand combined, yet just over 300 deaths. That’s an improvement on the 1990s which often saw 1,000 deaths a year in Thailand alone.

The improvement is largely due to access to new and highly effective drugs containing artemisinin–described as “a breakthrough” by the WHO. But now the miracle may be fading.

This has happened before. "Resistance along the Thai-Cambodia border started with chloroquine, followed by resistance to sulfadoxine-pyrimethamine and mefloquine, drugs used in malaria control several years ago," the WHO statement says.

Malarial resistance to mefloquine and other drugs was overcome by artemisinin combinations but there are no new drugs to replace artemisinin. All the drugs under mid- and late-stage development are combinations using artemisinin alongside another drug. Experts meeting in Phnom Penh in January 2007 gave the newest combination only two years before a change would be required: time is up.

In the city of Pailin in Western Cambodia, near the Thai border, artemisinin efficacy has been declining. The success rate fell from 85.7 per cent in 2002 to 79.3 per cent in 2004, with similar results evident elsewhere along the Thai border. Resistance has also been noted (albeit at lower levels) in China and Vietnam.

WHO assistant director-general Hiroki Nakatani said this week that drug-resistant malaria around the Thai-Cambodian border “could spread rapidly to neighboring countries and threaten our efforts to control this deadly disease."

If the resistant strains reach Africa, which seems inevitable, tens of thousands more children will die every year as a result. Malaria can be fatal within 48 hours and currently kills a child every thirty seconds, mainly in Africa.

Rich nations have committed billions to fighting malaria, HIV / AIDS and tuberculosis but this is futile if the diseases become resistant.

International donors must pay greater attention to quality and not simply the cheapest deal–of which the Global Fund is guilty. They also need to pay for testing programmes that ensure medicines are genuine. It is counterproductive to spend millions of aid dollars on drugs without ensuring that they are real, that they will continue to work in the near future and that they will not increase drug resistance.

Governments in poor countries can also help by reducing (or ideally eliminating) widespread heavy taxes on pharmaceutical imports, so that legitimate suppliers can provide their good-quality drugs at lower prices, challenging the cheap fakes. Political support for local manufacturers that produce sub-standard drugs must also stop.

Political pressure from some members has kept the World Health Organization’s International Medical Products Anti-Counterfeiting Taskforce (IMPACT) from putting the spotlight on sub-standard medicines but this makes no sense:  a sub-standard drug is harmful whether it was made with criminal intent or through negligence.

But the WHO’s latest warning mentions counterfeits only once and does not include them in its multi-million dollar "key objectives."

If we really do care about the health of the poorest on the planet then every government and pressure group must take immediate action to improve global standards of medicines. The diseases, the counterfeiters, the sub-standard manufacturers and the smugglers are way ahead of us.

Roger Bate is a Resident Fellow at the American Enterprise Institute, a US think-tank. Julian Harris is a researcher at the Campaign for Fighting Diseases, London.