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Funding and distribution of inappropriate drugs contributing to increasing global childhood death from malaria (p 237)

January 14, 2004

'Institutional inadequacies' of the World Health Organization (WHO) and the Global Fund for Aids, tuberculosis, and Malaria (GFATM) have created a crisis which is leading to increased malarial deaths in children and will contribute to the failure of WHO's 1998 'Roll Back Malaria' campaign to halve deaths from malaria by 2010, conclude authors of an article in this week's issue of THE LANCET.

At least a million deaths are caused by malaria every year, principally among children, all of which could be saved by effective treatment. The ability to do this is undermined by drug resistance in Plasmodium falciparum (the deadly species of the disease) to conventional treatments such as chloroquine, sulfadoxine-pyrimethamine, or the combination of these drugs. The rise of drug resistance is the leading cause of the global increase in childhood malarial deaths. Recent evidence suggests that a new, highly effective treatment known as artemisinin-class combination therapy (ACT) offers more hope for treating malaria in countries where drug resistance to conventional drugs has become widespread. For that reason, ACT is now officially the global policy for treating drug resistant malaria according to WHO.

However, international health scholar Amir Attaran from the Royal Institute of International Affairs and colleagues from Africa, Asia, and Europe, document numerous cases where WHO is violating its own policy. The article states: 'Most African countries reluctantly cling to chloroquine, sulfadoxine-pyrimethamine, or the insignificantly better combination of chloroquine and sulfadoxine-pyrimethamine, because ACT is ten times more expensive and, therefore, unaffordable to them. When those same countries seek financial aid from 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 and "not ready for prime time". WHO acquiesces to this pressure to cut costs, and 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.' According to data presented by the authors, GFATM is spending more money to purchase chloroquine and sulfadoxine-pyrimethamine in Africa than ACT.

Amir Attaran and colleagues conclude this is "indefensible", and accuse WHO and GFATM of conduct ethically and legally tantamount to "medical malpractice" in supplying inappropriate drugs to Africans with malaria. They write: "For WHO and GFATM to provide chloroquine and sulfadoxine-pyrimethamine treatmentsat least wastes precious international aid money, and at most, kills patients who have malaria. If one takes the measured increase in childhood malaria mortality that follows P falciparum drug resistance (two-fold to 11-fold) and extrapolates it to populations in which GFATM is funding chloroquine or sulfadoxine-pyrimethamine despite resistanceat least tens of thousands of children die every year as a direct result."

The authors offer several recommendations for improvement that to date have been ignored by WHO and GFATM. They warn that "a risk exists that if WHO and GFATM do not act with celerity, the reputations of both will be tainted to a degree that rich governments lose confidence and cease funding them". Amir Attaran comments: "The fact both agencies are violating their own policies, with knowledge that this will cause the 1998 promise to Roll Back Malaria to be broken, appears highly relevant to their new promise to treat 3 million AIDS patients by 2005.

Lancet