Optimism grows as target is in sight Financial Times

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                                                                                                                                                                                   ­malaria­2010 |

Optimism grows as target is in sight
Andrew Jack explains
why there is a feeling
that 2010 will mark
the most hopeful
World Malaria Day
to date

              ith    just    eight
              months to meet his
              goal of distributing
              hundreds of mil-
lions of mosquito nets around
the world to people at high risk
of contracting malaria, Ray
Chambers is feeling confident.
   The UN special envoy on
malaria believes efforts are on
track for completion of deliver-
ies during 2010, supporting
broader plans to reduce greatly,
within five years, the huge bur-
den of illness and death from
this leading killer disease.
   “This is the most optimistic
World Malaria Day to date,” he
says. “Today, we know we can
achieve the goal of universal
coverage of nets by the end of
this year and near zero deaths
from the disease by 2015.”
   His optimism is shared by
other top officials who have
observed a recent resurgence in
efforts to tackle the disease,
which the latest estimates sug-
gest infects 250m people and
kills more than 850,000 a year.      A boy with malaria waits at a special clinic in Sittwe, Burma. Between 2000 and 2008, the level of cases there increased and activists worry about tolerant strains spreading                                       Getty
   Imaginative advocacy has
helped raise awareness, in turn      vate sector to make them more       foundation, adding to a growing      malaria-endemic African coun-       just had three months without
stoking an upsurge in funding        affordable.                         list of corporate chief executives   tries, and points to significant    drugs,” she says, leaving her         Inside this issue                 On
from $60m a year at the start of       Respected personalities – from    and public figures who bring         improvements in several. Ethio-     with none of the recommended          Corporate projects                Guest columns
the millennium to nearer $2bn        Senegalese musician Youssou         clout, profile and funding.          pia, Ghana, Rwanda, Zambia          medicines to offer them.              Control programmes take great     ●Jakaya Mrisho Kikwete,
annually today.                      N’Dour to football players in the      Perhaps most important, the       and Zanzibar have cut death           Her experience highlights how       preparation but the results       president of Tanzania, and
   Some far more effective tools     United Against Malaria cam-         creation last autumn of the Afri-    and disease by up to 70 per cent    much more needs to be done            impress. Charles Batchelor        Joy Phumaphi, interim executive
for prevention and treatment         paign of the World Cup in South     can Leaders Malaria Alliance         in recent years, for instance.      despite the positive momentum.        reports Page 2                    secretary of the African Leaders
have become available and the        Africa this summer – are stok-      suggests the continent’s own           But others – including some       The big challenges ahead are                                            Malaria Alliance
pipeline of technologies is grow-    ing debate and spreading the        politicians are beginning to take    with the greatest burden such       three-fold: deepening, broaden-       Disease development Clive
ing to include more potent and       message to those most affected      a necessary fresh look at their      as Nigeria and the Democratic       ing and sustaining the response.      Cookson on worrying mutations     ●Suzanne Hill and
easier-to-take medicines, and        that they can and must help         pivotal responsibility in improv-    Republic of Congo – have per-         The first aspect is to deepen       in the malarial parasite Page 4   George Jagoe of the WHO and
even possible vaccines.              tackle malaria themselves.          ing their citizens’ health.          formed much less well. Still        existing approaches, which have                                         Medicines for Malaria Venture
   There is growing management         Community volunteers and             Awa Coll-Seck, head of the        more countries have such poor-      until now focused on large-scale,     Procurement Supplies increase
innovation, from “SMS for Life”      religious organisations – Chris-    Roll Back Malaria partnership        quality data that attempting to     efforts to bring control and          but distribution stalls, says     ●Ray Chambers, UN special
messages to monitor drug             tian, Muslim and Jewish alike,      of public, private and non-gov-      measure progress is difficult.      treatment tools to countries in       Andrew Jack Page 4                envoy for malaria
stocks in rural Tanzania, to the     sometimes working together          ernmental groups, says: “Things        In the tiny Kyekumbra clinic      need.
Affordable Medicines Facility        – are filling gaps in often weak    have moved really very quickly       just two hours’ drive from the        That has meant a vast               South­east Asia Tim Johnston      ●Youssou N’Dour, musician,
for Malaria, to be launched in       public health systems.              over the past three years, and       Ugandan capital of Kampala,         exercise to fund, procure and         finds activists worrying about    Unicef and Roll Back Malaria
up to nine countries next              Tony Blair, the British former    you can see the results.”            nurse Winfred Namudde says          deliver drugs and bed nets,           the ‘black hole’ of funding and   ambassador and board member
                                                                                                                                                                                        control in Burma Page 6           for Malaria No More
month, where it will subsidise       prime minister, has become             Her organisation has helped       half her patients are still pre-
the best drugs sold in the pri-      involved through his inter-faith    track progress in a dozen            senting with malaria. “But we                   Continued on Page 2
2                                                                                                  ★                                                                                                                           FINANCIAL TIMES FRIDAY APRIL 23 2010

Combating Malaria
Optimism                              Funding and stamina required for the long haul
grows as                                                                    and governments. What they           with the local community and            launched in 2006, involved              Equatorial Guinea, was affected         United Against Malaria, a

target is                             Corporate projects
                                      Control programmes
                                                                            bring to the fight is their exper-
                                                                            tise in project management,
                                                                            their ability to train and moti-
                                                                                                                 you have to have motivated,
                                                                                                                 trained staff to do the work. We
                                                                                                                 call our community volunteer
                                                                                                                                                         spraying the insides of build-
                                                                                                                                                         ings, providing nets and repel-
                                                                                                                                                         lents, spraying water surfaces
                                                                                                                                                                                                 by the disease.
                                                                                                                                                                                                   Apart from the cost of treat-
                                                                                                                                                                                                 ment and the impact on produc-
                                                                                                                                                                                                                                       partnership of public and pri-
                                                                                                                                                                                                                                       vate organisations that seeks to
                                                                                                                                                                                                                                       use football, and the 2010 World

in sight                              take great preparation
                                      but the results impress,
                                                                            vate staff and a focus on results.
                                                                              But with malaria, they face an
                                                                            enormous challenge. The dis-
                                                                                                                 activists our John the Baptists.”
                                                                                                                    AngloGold Ashanti itself had
                                                                                                                 a strong motivation. It had iden-
                                                                                                                                                         with chemicals to control the
                                                                                                                                                         growth of larvae and providing
                                                                                                                                                         drugs to malaria sufferers.
                                                                                                                                                                                                 tion, expatriates are reluctant to
                                                                                                                                                                                                 work in Africa because they fear
                                                                                                                                                                                                 for the health of their families.
                                                                                                                                                                                                                                       Cup in South Africa, to promote
                                                                                                                                                                                                                                       the fight against malaria,
                                                                                                                                                                                                                                       encountered early resistance.
                                      says Charles Batchelor                ease is very resistant to efforts    tified malaria as the most signif-        Its impact has been impres-           Because of the disease, local           “When I started talking to
Continued from Page 1                                                       to control it and will recolonise    icant public health threat to its       sive. Lost days per month fell to       employees are difficult to inte-      companies, they said it was not
                                                                            treated areas from untreated         operations in Ghana, Mali,              273 in 2009, with some 38               grate into the company’s struc-       an issue in Africa,” says Chris-
supplemented by insecticides          When AngloGold Ashanti began          regions. Successful programmes       Guinea and Tanzania.                    employees affected. Medication          tures and key growth sectors          tina Vilupti Barrineau, director
and diagnostics.                      spraying anti-malarial chemi-         sometimes make local people             A map of the globe shows             costs fell to $2,000 for employees      such as manufacturing and             of African operations. When
  Yet in the rush to meet uni-        cals in the homes of workers at       think they no longer need to         many of its mines dotted across                                                 tourism will not develop.             companies did have malaria pro-
versal coverage targets for these     its Obuasi mine in Ghana, a           take precautions and the disease     the malaria belt stretching from                         The AngloGold            Marathon launched a five-           grammes they were often very
goods, such programmes have           large crowd of people gathered.       can return. Sufficient funding       South America, through Africa                            Ashanti                year, $15.8m programme with           localised, involving, for exam-
often taken scant account of            “There must have been about         and stamina for a long haul are      and the Indian subcontinent to                           anti­malaria           partners to combat malaria in         ple, support for a hospital.
local variations.                     1,000 people standing around          required.                            south-east Asia.                                         spraying               2003. It reported the results last      Since starting the campaign,
  They have also incurred             when we sprayed the first               Programmes such as Anglo-             The company’s Obuasi mine                             programme at           year in terms of the impact on        Ms Barrineau says she has
higher costs than necessary and       house,” recalls Steve Knowles,        Gold Ashanti’s take a lot of         in southern Ghana lost an aver-                          its Obuasi mine        children below the age of five.       received enthusiastic support
resulted in less speed in deliver-    director of the malaria control       preparation. There are many          age of 6,983 man days a month                            in Ghana               There was a 64 per cent reduc-        from Nando’s, a privately owned
ing fast-expiring drugs “the          programme at the Johannes-            myths about malaria and it may       because of malaria in 2005, with                                                tion in deaths, a 57 per cent fall    South African restaurant chain
final mile” to patients. More         burg-based gold-mining group.         not seem obvious to local people     an average of 238 employees             and $8,900 including their fami-        in malarial infections in two-to-     active in more than 25 coun-
effort to ease distribution and         “The lady of the house gets         that draining patches of stag-       affected each month.                    lies. Eighty per cent of new            five year olds and an 86 per cent     tries, and from MTN, a listed
effective use is required.            free pest control because, along      nant water and clearing blocked         The cost of treating these peo-      cases involve people who have           drop in anaemia in this age           mobile     telephone    company
  The focus on freighting in bed      with the mosquitoes, the chemi-       drains can help reduce the inci-     ple at the company’s hospital           contracted the disease outside          group. In 2006, the programme         based in Johannesburg.
nets has left many sitting in         cals kill cockroaches and ants.”      dence of the disease.                was $22,000 a month, rising to          the control zone.                       was extended to the mainland.           Companies with wide distribu-
warehouses, misused or simply           Companies can benefit enor-           “There was a six-month build-      $55,000 when family members                AngloGold Ashanti is not the           Companies with large produc-        tion networks – real or virtual –
unused in individuals’ houses.        mously from reducing the              up to the launch of the pro-         were included. To counter the           only company with significant           tion centres in malaria zones         can use them to reach their cus-
  Without more culturally sensi-      impact of malaria while bur-          gramme that involved walking         impact of malaria, staffing lev-        activities in Africa that are           take little persuading that fight-    tomers, suppliers and staff with
tive projects to train people in      nishing their image with              around and shaking hands with        els at the mine increased by 20         threatened by malaria. Mara-            ing the disease is a priority. But    information, fund-raising cam-
net use, as well as insecticide       employees and increasingly            people,” Mr Knowles explains.        per cent.                               thon Oil’s regional gas process-        others can need some encour-          paigns and help with distribut-
re-treatment and replacement          demanding customers, lobbyists        “You have to build credibility          The    control     programme,        ing hub on Bioko Island, in             agement.                              ing medicines and bed nets.
plans, scarce resources are
being poorly deployed and creat-
ing a large future environmen-
tal burden.

                                                                                                                                                                                                 Focus on nets
  There is a need for closer
scrutiny of progress, managerial
fine-tuning, and monitoring bet-
ter to understand local varia-
tions: how malaria transmission
may vary over time and
between places and, given this,
the    need
                to   vary    local                                                                                                                                                               ‘seductive but
  That issue points to a second
challenge for the malaria com-
munity:      to    broaden     its
approach. Heavy top-down pres-
sure to tackle the disease,
backed by international funding
has often undermined the poli-                                                                                                                                                                                                         undoubtedly help save substan-
cies, staff and systems of fragile                                                                                                                                                               Prevention                            tial sums.
national governments. So have                                                                                                                                                                                                             Adam Flynn from Sumitomo
the manifold well-intentioned                                                                                                                                                                    Andrew Jack says                      Chemical, a partner of Africa’s
but duplicative and, in some
cases, counter-productive pri-
                                                                                                                                                                                                 other approaches need                 largest manufacturer of nets,
                                                                                                                                                                                                                                       says: “We are producing 25-30
vate and charitable initiatives.                                                                                                                                                                 just as much support                  per cent less than we could be
  Rob Newman, director of the                                                                                                                                                                                                          because of retooling for different
World      Health   Organization                                                                                                                                                                                                       markets.”
malaria programme, says: “The                                                                                                                                                                    When Susan Lassen travelled to           Another danger with some
issue of under-treatment may                                                                                                                                                                     one southern African country          fundraisers is an over-emphasis
not be as catastrophic as it is                                                                                                                                                                  recently on behalf of the JC          on efficiency. The Against
made out to be.” He argues that                                                                                                                                                                  Flowers Foundation, which dis-        Malaria Foundation argues that
malaria should be a wedge to                                                                                                                                                                     tributes bed nets through Chris-      every penny it raises goes to the
push for broader “horizontal”                                                                                                                                                                    tian groups to help combat            purchase of nets. But that
programmes.                                                                                                                                                                                      malaria, she was disturbed by         leaves others to find the
  As diagnosis and treatment                                                                                                                                                                     what she found.                       resources to ensure that nets
becomes more reliable, other                                                                                                                                                                        Sacks containing 90,000 nets       are delivered to those who need
diseases, previously wrongly                                                                                                                                                                     paid for by donors had been           them, and then used consist-
diagnosed as malaria, are identi-                                                                                                                                                                gathering dust in a warehouse         ently and effectively.
fied and require different                                                                                                                                                                       for a year, as the government            Susan Mukasa is head in
approaches. That calls for better                                                                                                                                                                struggled to find ways to distrib-    Uganda of the non-profit group,
trained, motivated and managed                                                                                                                                                                   ute them “the final mile” to peo-     Population Services Interna-
healthcare workers.                                                                                                                                                                              ple in need.                          tional.
  Even within the malaria field,                                                                                                                                                                    Her experience highlights the         The organisation is involved
there is a need to expand think-                                                                                                                                                                 flipside of the prominence given      in    distribution    campaigns,
ing and research on elimination;                                                                                                                                                                 to mosquito nets, which have          which are currently being
the use of intermittent treat-                                                                                                                                                                   become the focus of a campaign        scaled up, as large numbers of
ment in pregnant women as a                                                                                                                                                                      to achieve “universal coverage”       nets arrive in the country. She
prophylaxis;          alternative                                                                                                                                                                by the end of this year, turning      points out: “Getting the nets to
approaches to insecticides such                                                                                                                                                                  net manufacture, sale and distri-     the right people is challenging.”
as wall hangings or treated                                                                                                                                                                      bution into a big business.              While she dismisses as “anec-
clothing; and approaches to                                                                                                                                                                         Reduced malaria deaths and         dotal” the stories of bed nets
dealing with less lethal but                                                                                                                                                                     infection rates in countries          being misused by people for
highly burdensome strains such                                                                                                                                                                   where      bed net use is wide-       fishing or as wedding veils, she
as plasmodium vivax.                  Clinical intervention: a child is vaccinated as part of a trial in Kisumu­West District Hospital in Kenya                           Benjamin Moldenhauer
                                                                                                                                                                                                 spread, show their importance.        worries that during an election
  The final challenge is sustain-                                                                                                                                                                They are a low-cost and effec-        period, politics may influence

                                      Hopeful results lead
ability. History has proven the                                                                                                                                                                  tive “tool” that also offers a        their distribution to different
extraordinary versatility of the                                                                                                                                                                 powerful way to raise money           regions.
parasite in defying elimination.                                                                                                                                                                 and awareness.                           Just as important, she says
Resistance to the latest drugs –                                                                                                                                                                    Peter Chernin, the former          only about 32-40 per cent of nets
already identified in south-east                                                                                                                                                                 head of News International,           that are successfully distributed
Asia – risks undermining the                                                                                                                                                                     says: “You run into a challenge:
best drugs available. If mosqui-
toes adapt to bite outside
humans’ sleeping hours, nets
will be rendered less effective.
  Any effort to reduce, and
                                      to first large­scale trial                                                                                                                                 in the US, where there is zero
                                                                                                                                                                                                 constituency,” he says. “No one
                                                                                                                                                                                                 is calling their congressman to
                                                                                                                                                                                                 say ‘Gee, what are you doing
                                                                                                                                                                                                 about malaria?’”
                                                                                                                                                                                                                                       ‘The problem with bed
                                                                                                                                                                                                                                       nets is that they have
                                                                                                                                                                                                                                       been designed by
maintain at low levels, the bur-
den of malaria will require large                                           while a vaccine that provides 50        The two companies will carry         Bloomberg School of Public
                                                                                                                                                                                                    He used his influence to help
                                                                                                                                                                                                 launch malaria-related initia-
                                                                                                                                                                                                                                       entomologists. I’d
sums over many years. Yet even        Vaccine development                   per cent protection would            out clinical trials with a combi-       Health and the Sabin Vaccine            tives, for example through a US       love consumer
current needs are significantly                                             reduce significantly the toll of     nation of RTS,S with Crucell’s          Institute with support from             television fundraising event,
under-funded. The financial cri-      Clive Cookson                         800,000 African children under       Ad35-CS vaccine candidate. Ani-         MVI. This approach aims to stop         Idol Gives Back, endorsements
                                                                                                                                                                                                                                       products companies
sis and “donor fatigue” risk          assesses progress and                 five who die every year from         mal tests have already shown a          the malaria parasite developing         by well-known footballers and         to become involved’
diverting support further. Ste-                                             malaria, MVI aims to have a          significant enhancement when            in the mosquito, so it cannot           The Sun newspaper’s alliance
ven Phillips, medical director        explains methods                      vaccine with 80 per cent efficacy    the two are used together.              pass the infection on to humans.        with Comic Relief in the UK.
for global issues at ExxonMobil,                                            available by 2025.                      The immune-stimulating anti-            The TBV uses a mosquito                 “We have never been focused        are used consistently all night

says: “Once you get even a 10-30                ver the past year, 9,000       However Christian Loucq,          gen in both vaccines is a surface       antigen called AnANP1, which            solely on nets, but it’s a remark-    by their recipients.
per cent decrease in malaria,                   babies and young chil-      MVI director, says future vac-       protein from the so-called sporo-       plays an important role in the          ably effective tool as a first line     People can be put off by the
how do you persuade people to                   dren in seven African       cines can be developed more          zoite stage of the malaria para-        parasite’s establishment within         of defence,” he says. “The big        smell, the heat, or the inconven-
spend more when the problem                     countries           have    quickly and at somewhat lower        site’s complex life cycle – the         the insect. Field research shows        upside is that we have enor-          ience, for instance. Her organi-
appears to be going away?”            received a shot of the first          cost than RTS,S. Phase 3 vac-        stage at which it enters the            that AnANP1 induces mosquito            mous results that can help keep       sation has launched “hang your
  Recent progress is impressive,      malaria vaccine to undergo a          cine trials require thousands of     human bloodstream after a mos-          antibodies that prevent the par-        people engaged.”                      net” campaigns designed to
but World Malaria Day will be         large-scale clinical trial. Eventu-   participants but the number          quito bite, and heads toward the        asite invading the insect’s gut,           The problem is that some of        “make it fun and not like polic-
marked long into the 21st cen-        ally as many as 16,000 children       becomes smaller as the vaccine       liver where it will mature and          and the idea is that vaccinated         the high profile non-profit initia-   ing”.
tury.                                 will receive the so-called RTS,S      becomes more effective, as           multiply. But the antigen is            humans would pass enhanced              tives that have emerged – such          Janet Hemingway, head of the
                                      vaccine.                              greater effectiveness shows up       packaged in different ways.             levels of the antigen on to the         as Nothing But Nets – downplay        Liverpool School of Tropical
                                        “We are very happy with the         more quickly. And the African           In RTS,S the antigen protein         mosquitoes that bite them.              the     importance      of   other    Medicine, points out: “The prob-
                                      way enrolment is going,” says         infrastructure set up for the        is administered with an “adju-             While a TBV would offer no           approaches that require just as       lem with bed nets is that they
    Contributors                      Joe Cohen of GlaxoSmithKline          RTS,S trial could be used again.     vant” that boosts the immune            immediate protection against            much support, including drugs,        have been developed and
    Andrew Jack                       Biologicals in Belgium, who has          Dozens of potentially more        response. In Ad35-CS the anti-          malaria to the vaccinated indi-         insecticide spraying and dia-         designed by entomologists and
    Pharmaceuticals Correspondent     been working on RTS,S for more        effective candidate vaccines are     gen is inserted into an adenovi-        vidual, the benefits would accu-        gnostics.                             we have tried to force people to
                                      than 20 years.                        in earlier stages of development     rus, a type of virus associated         mulate over time as the number             Many organisations employ a        use them. I’d love consumer
    Clive Cookson                       The vaccine originated with         in academic and industry labs        with mild respiratory infections,       of infections declines with time        powerful but somewhat over-           products companies to become
    Science Editor                    research at the Walter Reed           around the world. For maxi-          which delivers it to the immune         in the community.                       simplified formula that equates       involved.”
                                      Army Institute of Research in         mum effectiveness they are           system (adenoviruses are also              Another potentially fruitful         a small donation to a tangible          “Baseline” data against which
    Richard Lapper                    the US in the mid 1980s. After        likely to be used in combination     used as vectors for gene ther-          field of research focuses on pre-       result.                               to measure the overall reduction
    Southern Africa Bureau Chief      GSK had taken up RTS,S, tests         rather than individually.            apy).                                   venting malaria in pregnancy.              The American Red Cross says:       in the disease is sparse in many
                                      in adult volunteers started in           A partnership announced ear-         At an earlier stage of research      Women are particularly vulner-          “One bed net, five dollars, save      malaria-endemic countries, and
    Tim Johnston
    Bangkok Correspondent             the US in 1992 and Africa in          lier this month between GSK          – and using a very different            able to infection while pregnant,       a life”. The Foundation of the        controlled studies to judge the
                                      1998.                                 and Crucell, the Dutch biotech-      antigen – is a “transmission-           because their immune defences           US government’s Centers for           relative impact of nets com-
    Charles Batchelor,                  A public-private partnership        nology company, is a pointer to      blocking vaccine” or TBV being          are lowered and because the             Disease Control and Prevention,       pared with other approaches is
    Joseph Milton,                    between GSK and the Path              the way things will go.              developed by Johns Hopkins              parasites accumulate in the pla-        says: “$5 can save a child’s life”.   scant.
    Sarah Murray,                     Malaria Vaccine Initiative (MVI)                                                                                   centa. Maternal malaria kills              In fact, analysis suggests that      Organisations instead have
    Anna Wang                         began in 2001 to put RTS,S            Estimated global resource requirements for malaria control                   10,000 women and 100,000 to             it takes closer to 20 properly        rushed to deliver something
    FT Contributors                   through more extensive “Phase         $ billion                                                                    200,000 babies every year.              used nets (costing closer to $10      that seems effective.
                                      2” trials with African children.                                                                                      Researchers at the University        each, including all necessary           Sarah Staedke, a researcher
    Ursula Milton                     Their encouraging results –                                                                                        of Copenhagen are developing a          overheads) to save a life and         from the London School of
    Commissioning Editor              showing an efficacy for the vac-      6                                                                            potential vaccine based on the          there is much debate about net        Hygiene and Tropical Medicine,
                                      cine of about 50 per cent – led to                                                                                 VAR2CSA antigen which should            reliability and how long they         says some funders now consider
    Steven Bird                                                                                                            Estimated funding available
                                      the current much larger-scale         5                                                                            elicit antibodies that stop the         remain effective.                     it unethical to conduct malaria
    Designer                          “Phase 3” trial.                                                                       From Global Fund            parasite binding to the placenta.            “We have done a terrible         control research that does not
                                        Altogether, GSK has already         4                                                From other sources             The Danish scientists have           thing by putting a price tag on       include net distribution as a
    Andy Mears                        invested $300m in RTS,S and                                                                                        the elegant idea of attaching           this,” says Ms Lassen. “It was        “standard of care”.
    Picture Editor                    expects to invest at least $100m                                                                                   VAR2CSA to the human papil-             very seductive but also very            While nets play an important
                                      more before the project is fin-                                                                                    loma virus (HPV) vaccines that          short-sighted. In five years’         role, failure to keep studying
    For advertising details,
                                      ished. MVI has spent $200m, pro-      2                                                                            have recently been introduced           time, people will say ‘But I          how they should best be
    Mark Carwardine on:               vided mainly by the Bill &                                                                                         to prevent cervical cancer. If          already gave my $5. Why isn’t         designed, distributed and used
                                      Melinda Gates Foundation.             1                                                                            HPV can indeed act as a carrier         this solved?’”                        risks not taking full advantage
    +44 (0) 207 873 4880;
    e­mail:                             The long and expensive his-                                                                                      for the placental malaria vac-             There is little doubt that larg-   of their value.
                                      tory of RTS,S illustrates the         0                                                                            cine, then it would be possible         er-scale,     more      consistent      The current focus on their use
                                      patience needed to develop                2008          15         20        25         30          35        40   to protect girls in Africa against      procurement of standardised           also needs to be balanced with a
    or your usual FT representative
                                      malaria vaccines. And the story                                                                                    both placental malaria and cer-         nets by countries and interna-        search for sustainable, reliable
                                                                            Source: WHO
                                      is far from at an end because,                                                                                     vical cancer with a single shot.        tional     organisations     could    and affordable alternatives.
4                                                                                                  ★                                                                                                                       FINANCIAL TIMES FRIDAY APRIL 23 2010

Combating Malaria

Supplies increase but distribution stalls                                                                                                                                                              Faith can help
                                like that of ACTs, increases
                                the risks of drug resistance
                                                                 drugs. Perversely, com-
                                                                 pared with one year ago,
                                                                                                   make its own drug pur-
                                                                                                   chases     when     external
                                                                                                                                   not always met. Novartis
                                                                                                                                   has lost out in several
                                                                                                                                                                  after they have been
                                                                                                                                                                  requested. Patients contrib-
                                                                                                                                                                                                       heal bodies as
                                                                                                                                                                                                       well as souls
                                that will render treatments      there are more suppliers,         money dries up. It has been     recent tenders, and then       ute to a vicious spiral,
The system is                   still less effective.            but the availability is worse     forced to seek help from the    been asked in extremis by      feigning malaria when fresh
plagued by poor                    Such “stock-outs” high-
                                light how the development
                                                                 than before.”
                                                                   One issue is poor manage-
                                                                                                   US President’s Malaria Initi-
                                                                                                   ative to meet the shortfall.
                                                                                                                                   governments to fill gaps in
                                                                                                                                   commitments from the win-
                                                                                                                                                                  supplies arrive so they can
                                                                                                                                                                  horde for future infections.
management and                  of even potent drugs such        ment of funds to buy ACTs,          That has sparked internal     ning company.                  “When we have stock-outs,
unreliable delivery,            as ACTs are only the first
                                step to ensure that treat-
                                                                 which remain relatively
                                                                 expensive compared with
                                                                                                   debates about whether such
                                                                                                   a poor country with a high
                                                                                                                                     “We are an autonomous
                                                                                                                                   body without autonomy in
                                                                                                                                                                  they have stock-ins,” jokes
                                                                                                                                                                  Ms Byasi.                            Guest Column
                                                                                                                                                                                                                                       health care, although they
                                                                                                                                                                                                                                       undertake a large amount
says Andrew Jack                ments reach patients. Fund-      older – albeit less effective –   disease burden ever should      procurement,” says Moses          One response set to               TONY BLAIR                      of the work. So there are
                                ing and medical supplies         malaria drugs. The Global         have switched to expensive      Kamabare, general manager      launch next month in nine                                            obstacles to overcome.
Sarah Byasi shakes her          are increasing, yet they are     Fund to Fight HIV, TB and         modern drugs like ACTs;         of the country’s National      countries is the Affordable                                            But the process of
head as she runs her finger     still not saving as many         Malaria, which channels                                           Medical Stores, who says       Medicines     Facility   for         Two months ago I joined         dismantling some of these
down the stock page. She is     lives as they should.            multilateral donor support,                                       the process can take many      Malaria, which uses donor            Nigerian ex-President           is under way. Christian
in charge of drug supplies         The frustration is com-       earmarked large sums for          Patients contribute             months. “There has been        funds to subsidise the ACTs          Olusegun Obasanjo and a         Health Associations,
at the Kibogo hospital in       pounded by scenes such as        Uganda for the drugs. Then        to a vicious spiral,            more     corruption    than    sold by private distributors         number of the country’s         drawing in a range of
Uganda and points to            that across the road from        it suspended grants after                                         before. There are so many      to ensure effective drugs            religious leaders in Kuje, a    churches nationally, have
blanks showing there were       Kibogo hospital, where a         concern over the country’s        feigning malaria so             technical reasons to remove    are sold more affordably.            township outside Abuja to       signed memoranda of
no modern malaria drugs
for adults for the 3 months
                                private pharmacy has no
                                such supply problems. It
                                                                 inability to account for how
                                                                 funds were spent.
                                                                                                   they can horde for              an offer. You can structure
                                                                                                                                   it to knock out all but the
                                                                                                                                                                     Other efforts try to
                                                                                                                                                                  improve management in the
                                                                                                                                                                                                       promote a multi-faith
                                                                                                                                                                                                       programme to train 300,000
                                                                                                                                                                                                                                       understanding with
until January; and none for     offers wealthier patients a        In March this year, three       future infections               most expensive.”               public health system. In             Nigerian religious leaders        The Kenyan agreement
children are currently avail-   large range of ACTs – as         of the principal officials                                          Even when funds are          Uganda, the medical charity          in malaria prevention.          to work together on health
able.                           well as many unauthorised        managing the government’s                                         available and drugs make it    Amref is helping introduce              The idea is simple but       is going well. A multi-faith
  “We give paracetamol if       malaria therapies that are       malaria programme were            and if so, whether it should    into the country, they are     computerised information             potentially very effective.     initiative in Mozambique,
there are no ACTs [artem-       ineffective or risk triggering   arrested, albeit in an inves-     help provide domestic fund-     not always effectively dis-    systems to monitor disease           Most communities in             Together Against Malaria,
isinin combination therapy      resistance.                      tigation that some observ-        ing by charging patients for    tributed. Mr Kamabare          levels. In Tanzania, groups          Africa do not have              has trained hundreds of
– the current preferred            “Uganda loses 300 lives a     ers suggest was politically       other essential but non life-   blames Uganda’s health dis-    are experimenting with text          hospitals or clinics, but all   religious leaders who are
treatment for malaria],” she    day to malaria,” says Hans       or commercially motivated         saving drugs such as pain-      tricts, which he says do not   messages to disseminate              have a church or mosque.        trying to share their newly
says – a solution that pro-     Rietveld, head of global         and for which the civil serv-     killers and antibiotics.        place orders on time or        information on stock levels.            The programme uses this      acquired health education
vides only palliative sup-      marketing and access for         ants are scapegoats.                A second explanation for      authorise the necessary           But, as Mr Rietveld puts          massive infrastructure with     with their communities.
port to patients suffering      Coartem, the leading ACT,          Whatever the specific           Uganda’s stock-outs is its      payments.                      it, for such initiatives to          its imams and priests to          Pastor Rick Warren’s
the disease’s symptoms of       at Novartis. “We have seen       facts, Uganda has allowed         procurement processes. As         Local clinics retort that    work: “We need more politi-          distribute bed nets and         church is doing good work
fevers and aches.               mothers harassing health-        foreign donors to take full       in other countries, tenders     they often receive incom-      cal accountability, with             medicines and facilitate        in Rwanda in primary
  Others in local clinics       care workers when after          responsibility      for     its   do not always go to the low-    plete orders of the wrong      non-governmental organisa-           access to trained health        health care. The Nigerian
turn to quinine – a “sal-       walking two hours to a           malaria programme, leav-          est bidder, and deliveries      drugs, sometimes close to      tions defending patients’            workers to combat malaria       Interfaith Action
vage” drug. But its misuse,     clinic they find there are no    ing it exposed and unable to      from the winning bidder are     their expiry dates, long       rights.”                             in Nigeria.                     Association (NIFAA) has
                                                                                                                                                                                                          This has been given the      established itself as a “one-
                                                                                                                                                                                                       backing of the Sultan of        stop-shop” for government
                                                                                                                                                                                                       Sukoto, the leading Muslim      to make it easier to
                                                                                                                                                                                                       in the country, and the         collaborate on health

New strain
                                                                                                                                                                                                       Catholic Archbishop of          initiatives with faith
                                                                                                                                                                                                       Abuja, John Oneiyekan.          communities. The Ministry
                                                                                                                                                                                                       There is a full-time,           of Health, with World
                                                                                                                                                                                                       centrally organised team to     Bank aid, is supporting it
                                                                                                                                                                                                       co-ordinate the programme.      to the tune of $1m a year.
                                                                                                                                                                                                       If it succeeds, the impact        The Faith Foundation

                                                                                                                                                                                                       will be enormous.               helps co-ordinate dialogue
                                                                                                                                                                                                          My Faith Foundation is       between public health
                                                                                                                                                                                                       supporting this work. The       officials and faith leaders.
                                                                                                                                                                                                       purpose of the foundation         We also promote
                                                                                                                                                                                                       is to promote interfaith        research into the role of
                                                                                                                                                                                                       understanding.                  faith communities in

ways round
                                                                                                                                                                                                          Involving religious          health care. The key is to
                                                                                                                                                                                                       communities is a sensible       train religious leaders in
                                                                                                                                                                                                       pragmatic response to the       health and public health
                                                                                                                                                                                                       scourge of malaria and the      officials in a deeper
                                                                                                                                                                                                       health challenges of the        understanding of how the
                                                                                                                                                                                                       Millennium Development          various faith communities

                                                                                                                                                                                                       Goals.                          work, their “health worlds”
                                                                                                                                                                                                          For the simple truth is      and their potential.
                                                                                                                                                                                                       that, while accurate              But the campaigning role
                                                                                                                                                                                                       statistics are hard to come     of faith communities in the
                                                                                                                                                                                                       by, the World Health            developed world is also
                                                                                                                                                                                                       Organization (WHO)              significant.
                                                                                                                                                                                                       estimates that in sub-
                                       the Americas, the Middle East,                                                                                                                                  Saharan Africa countries,
Disease development                    north Africa and the South                                                                                                                                      on average, faith               Most communities
Clive Cookson looks at                 Pacific. It can tolerate cooler con-                                                                                                                            communities supply 40 per       do not have clinics
                                       ditions than the heat-loving falci-                                                                                                                             cent of health care.
worrying mutations                     parum.                                                                                                                                                             Faith communities reach      but they all have a
in the vivax species                      Most cases of malaria found in
                                       travellers returning to Europe
                                                                                                                                                                                                       into rural areas where
                                                                                                                                                                                                       governments find it
                                                                                                                                                                                                                                       church or a mosque
of the malarial parasite               and North America are vivax                                                                                                                                     difficult to implement          that can be used as
                                       infections. Those who fear a                                                                                                                                    national plans, for lack of
                                       return of malaria to temperate                                                                                                                                  infrastructure.
                                                                                                                                                                                                                                       a health centre

             ost malaria research      regions where it has been eradi-                                                                                                                                   Embedded in local
             and writing focuses       cated, as a result of climate                                                                                                                                   communities, religious            The goal of the
             on plasmodium falci-      change and increased interna-                                                                                                                                   leaders are trusted and, if     Foundation’s “Faiths Act
             parum,     the    most    tional travel, are particularly con-                                                                                                                            trained, can give               Fellows”, 15 interfaith
deadly of the four species of para-    cerned about vivax.                                                                                                                                             authoritative health            pairs of young adults in
site that cause human malaria.            Vivax is the only form of                                                                                                                                    messages. They have             Canada, the US and the
  But the other three have a big       malaria endemic to the Korean                                                                                                                                   privileged access to            UK, is to mobilise the
impact on public health too, par-      peninsula. Although the World                                                                                                                                   dynamic and committed           potential of religious
ticularly    plasmodium       vivax,   Health Organisation officially                                                                                                                                  women, motivated by their       communities in halting
which is the species most widely       declared South Korea to be malar-                                                                                                                               faith, who are so important     and reversing the spread of
distributed around the world.          ia-free in 1979, it reappeared there                                                                                                                            for health care. They and       malaria.
  According to the US Army             in the early 1990s and now causes                                                                                                                               their communities are still       We have volunteers in 75
Center for Health Promotion and        what the US Army Center for                                                                                                                                     there when the donors go        countries contributing to
Preventive Medicine, p. vivax          Health Promotion and Preventive                                                                                                                                 home.                           an international campaign
accounts for 70m-80m cases of dis-     Medicine calls “sporadic epidem-                                                                                                                                   So why are very few          against what one of the
ease a year – about 20 per cent of     ics”, as its carrier, the local        Anopheles gambiae mosquito: one of the primary vectors of malaria in sub­Saharan Africa          Science Photo Library   mosque and church               bishops in Abuja dubbed
all malaria.                           anopheles     sinensis    mosquito,                                                                                                                             communities in sub-             “the number one terrorist
  P. vivax, unlike p. falciparum, is   breeds in water in rice paddies.         A study in Madagascar found          global health community to find          Vaccine development under-               Saharan Africa fully            in Nigeria”, the mosquito
rarely fatal, but it does cause sig-      The country worst affected by       that 10 per cent of clinical malaria   ways to prevent the spread of          standably concentrates on p. falci-        involved in the drive to        vector.
nificant long-term illness. Symp-      vivax is India, where the species      cases were occurring in Duffy-         these new strains of p. vivax to       parum because it is the main               halt and reverse the spread       An encouraging sign is
toms are similar to other types of     causes up to 65 per cent of            negative patients infected with p.     the continent of Africa.”              malarial killer, though an Asian           of malaria?                     that the “malaria sector”
malaria, including cycles of fever     malaria cases. As a result, India is   vivax.                                    The researchers believe the new     research network is looking for               Several of the most          is now sometimes oddly
and chills, headache, weakness,        a leading centre of research into        “These findings will have a          strains evolved in Madagascar          vivax vaccine candidates.                  important reasons are: lack     described as
vomiting and diarrhoea.                vivax malaria.                         major impact on efforts to elimi-      because of population mixing             But the MVI says the long-term           of resources and                “overpopulated”. But this
  Relapses can occur months or            The main reason why Africa                                                 there, between people with Duffy-      aim is to create a combined vac-           information, a degree of        is something I welcome.
years after treatment, if the para-    has few cases of vivax malaria is                                             negative African ancestors and         cine that can prevent both types           mistrust and, sometimes,          Religious leaders,
sites become dormant in the liver.     that Africans are usually geneti-      ‘Researchers believe                   Duffy-positive Asian ancestors.        of malaria – or at least reduce the        because governments are         transnational businesses,
The most common complication is        cally resistant to infection by the    the new strains                        This gave p. vivax many opportu-       severity of symptoms.                      understandably anxious          government development
enlargement of the spleen, accord-     parasite. P. vivax, unlike the                                                nities to attempt infection of           Meanwhile, its vivax efforts are         about proselytism and the       agencies, academics, and
ing to the Malaria Vaccine Initia-     other plasmodium species, enters       evolved in Madagascar                  Duffy-negative blood cells, which      focused on projects with the US            divisive potential of           multilateral donors are all
tive (MVI).
  Like the other plasmodium spe-
                                       red blood cells through the so-
                                       called Duffy receptor – which is
                                                                              because of population                  eventually succeeded through
                                                                                                                     mutation into a new strain.
                                                                                                                                                            Walter Reed Army Institute of
                                                                                                                                                            Research and with the Interna-
                                                                                                                                                                                                       religion; and most religious
                                                                                                                                                                                                       leaders are overworked and
                                                                                                                                                                                                                                       required to create the
                                                                                                                                                                                                                                       critical mass that has
cies, vivax is spread by anopheles     missing in most black African          mixing there’                             P. vivax has traditionally been     tional Centre for Genetic Engi-            lack resources.                 started the process of
mosquitoes. But there are several      populations.                                                                  treated successfully with the long-    neering and Biotechnology in                  Religious leaders            eradicating malaria from
differences from falciparum. It           But worrying research, pub-                                                standing antimalarial drugs, chlo-     India and its industrial partner           generally lack                  the African continent –
preferentially infects younger,        lished last month in the Proceed-      nate malaria worldwide, particu-       roquine and primaquine. The lat-       Bharat Biotech.                            understanding of how            just as it was eradicated
smaller red blood cells and it can     ings of the National Academy of        larly in large regions of Duffy-neg-   ter acts particularly against the        “We know less about p. vivax             government ministries           from Europe.
hibernate in the human liver for       Sciences, suggests that vivax is       ative west, central and southern       liver stage of the parasite, reduc-    than falciparum, and we are still          work, are almost never
up to five years.                      evolving new strains that can          Africa,” says Peter Zimmerman of       ing the risk of relapse.               looking for more data to under-            involved in upstream            The Rt Hon Tony Blair is
  While falciparum is concen-          infect previously immune people        Case Western Reserve University,          But vivax, like p. falciparum, is   stand vivax and the severity of            health planning, and            founder and patron of the
trated in sub-Saharan Africa,          with     “Duffy-negative”     blood    senior author of the study.            becoming resistant to chloroquine      the disease it causes,” says Chris-        receive less than 5 per cent    Tony Blair Faith
vivax occurs widely across Asia,       groups.                                  “It will be imperative for the       and primaquine.                        tian Loucq, MVI director.                  of the money available for      Foundation.

Vagaries of weather and the market hamper deliveries
                                from $1,200 in 2006 to $150      inces of China where it is        in the artemisinin supply       people are getting involved,   include the raw material                Ian Graham, director of      curb the volatile artemisi-
Artemisinin                     in 2008. Today, the price is     grown. “My fear is that last      chain, says: “Generic manu-     from farmers and extractors    into the plan,” says Mr Lu.          the Artemisia research          nin market is a completely
                                hovering at $400, which is       year’s drought has hurt the       factures are used to picking    to drug manufacturers.           “I would like to see               project at York, says:          new class of drug that does
Anna Wang says                  expected to increase with        farmers. It’s not easy for        up the phone and ordering         “Actually, the last thing    maybe six or 10 qualified            “Unlike GM, we have not         not rely on a plant. The
securing a stable               concerns over a shortage,        them to recover their losses      chemicals. They are not         we need is new players at      suppliers who have the               introduced      new    DNA.     non-profit Medicines for
                                because of poor weather          and their confidence,” says       used to planning ahead,         the artemisinin extraction     capacity and can meet qual-          Instead, we have selected       Malaria Venture (MMV) has
supply of the plant             and lack of cultivation in       Mr Lu.                            which is what you have to       level. We have more than       ity standards. Then, there           the most productive DNA         been working on the next
extract is difficult            2009.                              Most Artemisia crops            do, since it takes 14 months    enough capacity to meet        should be financial support,         for breeding. Our aim is to     generation of drugs for the
                                  When the price was at its      come from relatively small        from seed to extraction.                                       such as loans, because this          double     the   artemisinin    past 10 years.
                                lowest, the panic was over       farms. In addition to the           “We have to cut down on                                      is a cash business and it            yield, which would have a         MMV aims to register two
Artemisia annua, a weed         potential shortages of the       weather, public influences        this boom-and-bust sce-         ‘Long­term                     can create a high burden.”           huge impact on the price.”      new artemisinin combina-
found in the foothills of       drug because farmers were        such as donor funding, sup-       nario. Long-term contracts      contracts are                    At the average price of $1            Efforts to improve yield,    tions by early 2011. The
south-west China, is now        leaving the market for more      ply chain management and          are the key to the stability                                   per treatment for the public         stabilise the market, and       most awaited drug, how-
the most effective weapon       lucrative    crops.    When      drug policies, have a big         of the market.”                 the key to                     sector, ACTs are still too           increase access face a seri-    ever, is a non-artemisinin
in killing the malaria para-
site. However, securing a
                                prices were high, drug man-
                                ufacturers could not afford
                                                                 impact on the market.
                                                                   ACTs are a relatively new
                                                                                                     Novartis, which supplied
                                                                                                   84m ACT treatments in
                                                                                                                                   the stability                  expensive without donor
                                                                                                                                                                  support, as hundreds of mil-
                                                                                                                                                                                                       ous problem – drug resist-
                                                                                                                                                                                                                                       synthetic compound that
                                                                                                                                                                                                                                       mimics     the    fast-acting
stable supply of its potent     to purchase the raw mate-        class of drug, so farmers,        2009, has three-year con-       of the market’                 lions of treatments are                 Resistance has been con-     mechanism of artemisinin
extract,    artemisinin,  is    rial and the global health       extractors and manufactur-        tracts with extractors. It is                                  needed each year.                    firmed on the border of         but does not require the
proving a big challenge.        community worried over           ers are still getting to know     one of the reasons the com-                                      One solution to bring              Thailand and Cambodia,          plant. One formulation,
  Relying on the forces of      the increase in prices of the    the business. Aside from          pany is able to deliver         the current demand,” says      down the price is to                 the same location where         known as OZ439, has begun
supply and demand does          drugs for patients.              industry giants, Novartis         orders on time, while others    Patrick Henfrey, chief exec-   increase crop yield. In the          chloroquine-resistant           trials in patients. MMV
not seem to be a solution.        According to Charles Lu,       and Sanofi-Aventis, the           have had problems meeting       utive of Botanical Extracts    UK, the University of York           strains of malaria surfaced     hopes it can be offered as a
  The price of a kilo of        president of HolleyPharm of      majority of manufacturers         delivery dates.                 EPZ in Kenya, one of the       has been researching ways            and later spread throughout     single dose cure.
artemisinin, the key ingre-     China, the largest supplier      are generic drug companies          Attracted by the success      two main artemisinin pro-      to create more robust varie-         the world. There is now an        Tim Wells, chief scientific
dient in the current pre-       of artemisinin, there will       without experience of pro-        of ACTs in treating malaria     ducers in Africa.              ties of Artemisia and                aggressive attempt to con-      officer of MMV, says: “We
ferred malaria treatment,       very likely be a shortage in     ducing drugs with a plant         and various initiatives to        “The international com-      increase yields of artemisi-         tain the resistant strain.      are quietly hopeful that we
Artemisinin Combination         2010 because of the severe       extract as a key ingredient.      ensure more patients have       munity is involved in ACT      nin, without genetically                Ultimately, the best way     can have this non-artemisi-
Therapy (ACT), ranged           drought in four main prov-         Malcolm Cutler, an expert       access to the drugs, more       supply; it is necessary to     modifying the plant.                 to counter resistance and       nin drug ready by 2015.”
FINANCIAL TIMES FRIDAY APRIL 23 2010                                                              ★                                                                                                                                                                   5

                                                                                                                                                                                                  Combating Malaria

Better tests bring challenges                                                                                                                                                Football fever Spreading word about public health
                                                                                                                                                                             Malaria may wreak greatest damage
                                                                                                                                                                             among the poor and the young but it
                                                                                                                                                                             is an undiscriminating disease. Even
                                                                                                                                                                                                                         message to the remotest village.”
                                                                                                                                                                                                                            As well as global stars such as Mr
                                                                                                                                                                                                                         Touré, local football associations from
                                                                                                                                                                             some of Africa’s most successful            Ghana, Tanzania and several other
Diagnostics                                                                                                                                                                  professionals – its highly­paid football    countries have come on board, with
                                                                                                                                                                             stars who have made their names in          administrators arguing that the
Sarah Murray finds more                                                                                                                                                      the European leagues – have suffered.       prevalence of malaria – especially
accurate diagnosis of all                                                                                                                                                       So it is perhaps not surprising that
                                                                                                                                                                             anti­malaria campaigners have seized
                                                                                                                                                                                                                         among young people – is undermining
                                                                                                                                                                                                                         the game’s potential in Africa.
causes of fever is required                                                                                                                                                  on the occasion of Africa’s first ever         Ms Smith says that the popularity of
                                                                                                                                                                             World Cup, due to begin in South            football has made it easier to get
                                                                                                                                                                             Africa in June, as an opportunity to        public health ministers and officials to

         s the health community con-                                                                                                                                         get their health care message across        back public education efforts.
         tinues to make progress in                                                                                                                                          to larger numbers of people. Nor that          Above all the commercial reach of
         reducing the global incidence                                                                                                                                       footballers have been willing               the World Cup has also made it
         of malaria, the need for accu-                                                                                                                                      campaigners.                                attractive for companies to dedicate
rate and affordable diagnostics is                                                                                                                                              As he juggles a ball for the cameras     some of their social responsibility
gaining attention, with the World                                                                                                                                            of the United Against Malaria (UAM)         budget to the campaign.
Health Organisation (WHO), which                                                                                                                                             campaign, Kolo Touré, the Manchester           In South Africa, Standard Bank,
sees testing as a critical tool in the                                                                                                                                       City and Ivory Coast centre half,           MTN – the telecommunications group
battle against the disease, advocating                                                                                                                                       delivers a simple message. “In the 90       that is a big sponsor of the World Cup
universal testing of all suspected                                                                                                                                           minutes it takes to play a football         tournament – and Nando’s, a fast
cases.                                                                                                                                                                       match, 180 children die from malaria.       food chain, have signed up.
  Fortunately, microscopy is no                                                                                                                                              Yet a simple net prevents malaria.”            Other heavyweights backing the
longer the only diagnostic technology                                                                                                                                        says Mr Touré, who was hospitalised         campaign include cable channels ESPN
available. The recent development of                                                                                                                                         by the disease two years ago.               and Fox, the Japanese bank,
rapid diagnostic tests (RDTs), which                                                                                                                                            The measures advocated by UAM,           Sumitomo and the pharmaceutical
use a simple dipstick and a drop of                                                                                                                                          formed by groups including Comic            companies Pfizer and Novartis.
blood, means testing can done on a                                                                                                                                           Relief, the Roll Back Malaria                  For all these groups, fighting malaria
large scale.                                                                                                                                                                 Partnership and the UN Foundation,          makes commercial sense. Standard
  Yet developing RDTs for malaria                                                                                                                                            are straightforward: more emphasis on       employees are potentially vulnerable to
has not been easy. While the tests can                                                                                                                                       effective primary health care.              the disease both in a couple of
now be produced very cheaply, the                                                                                                                                               That means making sure                   provinces of South Africa and in many
challenge is that they need to remain                                                                                                                                        programmes, which are sometimes             of the African countries where the
stable in places where temperature                                                                                                                                           seen as the poor relations of Aids or       group has set up operations, so there
and humidity levels are high. At the                                                                                                                                         tuberculosis efforts, are given a high      is a broader risk, explains Sim
same time, they need to be sensitive                                                                                                                                         enough priority by African                  Tshabalala, the deputy chief executive.
enough to detect low densities of the                                                                                                                                        governments. Mosquito nets are                 Last year, days lost through malaria
parasite in blood samples, without                                                                                                                                           crucial: lobbying for public funding is a   cost the bank R450m. Mr Tshabalala,
producing false positives.                                                                                                                                                   priority and to advertise the effort,       however, says that underestimates the
  Companies may use the same rea-                                                                                                                                            UAM has produced an anti­malaria            real impact. Endemic diseases
gent but the production of accurate,                                                                                                                                         bracelet, sales from which are directed     undermine social cohesion and in the
heat-stable tests can be more of an art                                                                                                                                      towards their purchase.                     long run represent political risk and
than a science, says Neil Mehta, presi-    Rapid response: a malaria test is performed on a blood sample at a hospital in Cambodia                               Bloomberg      It means making sure people              mean companies have to pay more for
dent and chief executive of Premier                                                                                                                                          understand how they can avoid               their capital. “South Africa ranks
Medical Corporation, which has devel-         “Once people know that there’s a         rather than delivering treatment           “Indiscriminate use of anti-malarial       contracting the disease and know what       among the world’s biggest 30
oped point-of-care rapid tests for         routine system for assessing these          based on symptoms alone.                   drugs fosters resistant strains and        they need to do if they become ill.         economies but is 129th in the human
malaria.                                   products, it will drive the quality of        By helping inform procurement            lessens the impact of the limited             The innovative thing about UAM is        development index. To the extent that
  “You can give the same cookbook to       the market overall,” says Robert New-       decision-makers, the WHO data and          number of drugs we have to fight the       the way that it is using football              we fail we are increasing country
everybody, but the food all comes out      man, director of the global malaria         guidelines will prove important tools      disease,” says Daniel Carucci, vice-       fever to spread the word.                       risk.”
differently,” he says.                     programme at the WHO.                       in the next phase of the battle against    president for global health at the            “African footballers are the                    Standard is buying the publicity
  This was the finding of the WHO,            Moreover, the data are helping           the disease – and not just for malaria     United Nations Foundation, a charity       new stars of world football                            bracelets for all its 45,000
after it conducted the first major         health ministries and others select         sufferers.                                 and advocate for the UN.                   and are the perfect                                       staff, equipping any
review of RDTs in April last year. In      from the many RDTs on the market              When the disease was rampant,              Of course, the ability to distinguish    messengers to individuals in                                   vulnerable employee
independent, laboratory-based evalua-      the test most suited to their local con-    health workers could, with reasonable      people who have malaria from those         Africa, and are also highly                                        with a mosquito net
tions of more than 40 commercially         ditions.                                    justification, assume that anyone with     with fevers caused by other illnesses      influential in getting                                               and working
available RDTs, it found some could           “It makes it possible to do some-        signs of fever had malaria. However,       brings a fresh challenge – the need for    businesses and                                                        alongside NGOs
detect malaria in blood samples where      thing that’s not possible for many          as prevalence drops and the propor-        better diagnosis of all conditions.        government on                                                         in a number of
parasite densities were low while oth-     things sold into developing coun-           tion of people whose fever is attributa-     “This pushes the envelope in terms       board,” explains                                                    country­specific
ers could only detect the parasite at      tries,” says Mark Perkins, chief scien-     ble to malaria falls, health experts       of what is required of healthcare          Pru Smith of                                      anti­malaria initiatives.
high densities.                            tific officer at the Foundation for         stress the need to rule it out, so peo-    workers,” says Dr Perkins. “We must        UAM.                                                It won’t say exactly how much
  It also found test performance var-      Innovative New Diagnostics (Find),          ple can be treated for the real cause of   recognise the real limitations of the         “If a group of kids                           is being spent, but Mr Tshabalala
ied between batches, and recom-            one of the organisations behind the         their fever.                               system and the capacity for them to        are watching TV and                              says the benefits are much greater
mended testing batches after they are      WHO’s evaluation study.                       “The time for presumptive treat-         react to diagnostics. But it is a sea      their favourite player                           than the costs.
purchased and before they are used.           “And that is to allow ministries of      ment has passed,” says Dr Newman.          change we must face.”                      tells them to sleep
  Publishing these results has served      health who don’t have the staff or the      “We do no one a service by giving            At the same time, universal testing      under a net they will                                           Richard Lapper
a number of purposes. For a start, the     capabilities to do this kind of analysis    them an ACT [artemisinin-based com-        remains some way off. “This isn’t          listen,” she says.
performance evaluation will be con-        to decide what to buy.”                     bination therapy – the current pre-        going to roll out everywhere and no        “Everybody likes                            Kolo Touré, Manchester City
ducted on an annual basis – with the          Meanwhile, new malaria guidelines        ferred treatment] when they have           one should be sent away without            football. It is a                           and Ivory Coast centre half and
next version publishing this month –       published by the WHO in March               something other than malaria.”             treatment because a test wasn’t avail-     way to take the                             malaria campaigner
providing a benchmark for the compa-       stress the importance of using diag-          Health experts also point to the dan-    able,” says Dr Newman. “But the bot-
nies developing the tests.                 nostic testing where it is available,       gers of overusing malaria treatments.      tom line is we’ve raised the bar.”

Illegal, immoral and liable
to increase drug resistance
                                 groups and encourage co-         source sites, but there is      from wormwood plants.
Fake medicines                   ordinated enforcement.”          more work to be done,”          Artesunate, a semi-syn-
                                   In January, Interpol went      says Ms Plançon. Dr New-        thetic artemisinin deriva-
Joseph Milton                    a step further, creating the     ton thinks the majority of      tive, was the first such
looks at moves to                dedicated Medical Products
                                 Counterfeiting and Pharma-
                                                                  fakes originate in Asia and
                                                                  are shipped to Africa for
                                                                                                  drug, developed in the 1970s
                                                                                                  in China.
counter the trade                ceutical Crime (MPCPC)           sale.                             The WHO now recom-
                                 unit, headed by Ms Plançon.         Seized counterfeit antima-   mends         administering
                                 Several successful opera-        larials range from benign       artesunate in combination
Few trades are as callous as     tions have led to arrests        tablets composed entirely of    with other antimalarials,
the manufacture and distri-      and seizures.                    flour to dangerous mixtures     known as artemisinin-based
bution of counterfeit medi-        Operation     Mamba      II,   of toxic substances.            combination therapy (ACT).
cines for curable but life-      which took place through-           Some samples actually          These drugs have become
threatening diseases such        out August 2009, involved        contain the correct active      a target for criminals, as
as malaria.                      raids across Uganda, Tanza-                                      demand is high, and they
   Reliable statistics about     nia and Kenya. The opera-                                        are relatively expensive. In
the scale of the problem are     tion resulted in 83 police       If ACTs become                  2008, counterfeit ACTs were
unavailable, but counterfeit     cases and some convictions       cheap and readily               estimated to account for
drugs are thought by the         – often hard to achieve.                                         between 33 and 53 per cent
World Health Organisation          South-east Asia was tar-       available, fakers               of samples in mainland
(WHO)        to    constitute
between 25 and 50 per cent
                                 geted in Operation Storm II,
                                 which concluded in Janu-
                                                                  may be put out                  south-east Asia.
                                                                                                    Although south-east Asia
of the medicine supply in        ary. Impact seized about         of business                     is likely to be the main
less developed countries.        20m pills and made more                                          manufacturing base for fake
   The global trade in bogus     than 30 arrests.                                                 antimalarials, the problem
pharmaceuticals will be            However, it is difficult to    ingredients, probably in an     is global. Counterfeiting
worth some £45bn ($75bn)         track counterfeit drugs to       attempt to evade detection.     operations have become big
in 2010, according to the US-    their origins. Chemical test-    They are, however, often        business in Africa, India
based Center for Medicine        ing of tablets and analysis      present in very low quanti-     and Latin America.
in the Public Interest           of pollen grains found in        ties. This not only under-        Large shipments of coun-
(CMPI), an industry-backed       the pills and packaging          mines treatment, but could      terfeited ACTs were seized
think tank.                      have been used to trace the      contribute to the develop-      recently in six African
   Fake antimalarial drugs       location of manufacturers.       ment of resistance, render-     countries. “Everywhere we
are a particular problem, as       “We know there are crim-       ing the medicines useless.      looked, we found counter-
the 500m cases of malaria        inal connections between           Malaria is now frequently     feit medicines,” says Ms
worldwide every year make        Africa and Asia, and are         treated with derivatives of     Plançon.
it a large, lucrative market.    working to identify exact        artemisinin, a chemical           Despite Impact’s success-
   Thirty per cent of WHO                                                                         ful operations and ongoing
member states have ineffec-                                                                       efforts to tackle the trade,
tive or nonexistent drug                                                                          George Jagoe, of the Medi-
regulation, so the manufac-                                                                       cines for Malaria Venture –
ture and sale of fake anti-                                                                       a not-for-profit public-pri-
malarials is relatively risk-                                                                     vate partnership aiming to
free in many countries.                                                                           tackle the disease – says the
   Paul Newton, head of the                                                                       dearth of reliable data
Wellcome        Trust-Mahosot                                                                     makes it impossible to
University Oxford Tropical                                                                        judge whether the situation
Medicine Research Pro-                                                                            is improving.
gramme, based in Vien-                                                                              Dr     Newton       agrees,
tiane, Laos, says the human                                                                       describing the available sta-
cost of the trade is almost                                                                       tistical evidence as “mea-
impossible to estimate.                                                                           gre”.
   However, a significant                                                                           Mr Jagoe suggests that
proportion of the 1m deaths                                                                       the problem could be tack-
from malaria annually may                                                                         led by introducing more
be attributable to counter-                                                                       sophisticated tracking of
feit drugs.                                                                                       legitimate drugs, increasing
   In   response      to   the                                                                    public awareness of the
increasing      sophistication                                                                    problem and reducing the
and global scope of counter-                                                                      costs of medicines.
feiting operations, the WHO                                                                         There is hope: the ACT
and Interpol – the interna-                                                                       Consortium, funded by the
tional police organisation –                                                                      Bill & Melinda Gates Foun-
formed the International                                                                          dation, is working to
Medical Products Anti-                                                                            improve access to ACTs for
Counterfeiting      Taskforce                                                                     all those suffering from
(Impact) in 2006.                                                                                 malaria in less developed
   Aline Plançon, an Inter-                                                                       countries. If ACTs become
pol officer at Impact, says:                                                                      cheap and readily available,
“The idea was to put                                                                              the counterfeiters may find
together multidisciplinary       Smuggled and counterfeit medicines on a market stall       AFP   themselves out of business.
6                                                                                               ★                                                                                                                         FINANCIAL TIMES FRIDAY APRIL 23 2010

Combating Malaria

Systemic                                                                                                                                                            Activists worry about
                                                                                                                                                                    ‘black hole’ of Burma
problems                                                                                                                                                            South­east Asia
                                                                                                                                                                    Tim Johnston on a
                                                                                                                                                                                                     first observed, it now takes
                                                                                                                                                                                                     artemesinin-based combina-
                                                                                                                                                                                                     tion therapy (ACT) five to
                                                                                                                                                                                                                                       that if the clinic is five
                                                                                                                                                                                                                                       hours walk away?” he asks.
                                                                                                                                                                                                                                         The programme has had

                                                                                                                                                                                                     seven days to clear the par-      an extraordinary effect. In
                                                                                                                                                                    source of resistant              asite from the bloodstream,
                                                                                                                                                                                                     up from 48 hours when it
                                                                                                                                                                                                                                       2007, the Shoklo network
                                                                                                                                                                                                                                       treated 60,000 cases of falci-
                                                                                                                                                                    disease untouched                was first used.                   parum malaria; last year it
                                                                                                                                                                    by global funding                   Prof Nosten says Shoklo
                                                                                                                                                                                                     has studied the genome of
                                                                                                                                                                                                                                       treated 35,000.
                                                                                                                                                                                                                                         The problem is Burma,

                                                                                                                                                                                                     the tolerant strain and has       but in this case it is not
                                                                                                                                                                    All day the boats chug back      yet to find significant differ-   that the area just across the
                                                                                                                                                                    and forth across the slug-       ences. He even suggests it        river is a war zone, nor is it
                                                                                                                                                                    gish Moei river below the        is possible the strain has        the result the legendary
                                                                                                                                                                    Wang Pha clinic in western       always existed but has only       intransigence of the Bur-
                                                                                                                                                                    Thailand, carrying every-        recently become noticeable        mese authorities: it is what
                                                                                                                                                                    thing from timber and tea        because ACTs have elimi-          the blue line of the Moei
                                 authorities – with the sup-                                                                                                        to migrants and malaria.         nated most of the sensitive       represents to the interna-
Country profile                  port of the United Nations                                                                                                           The Moei forms the bor-        parasites, leaving the toler-     tional authorities funding
Angola                           Children’s Fund (Unicef) –
                                 have radically stepped up
                                                                                                                                                                    der between Thailand and
                                                                                                                                                                    Burma, but if it is a negligi-
                                                                                                                                                                                                     ant ones.
                                                                                                                                                                                                        Shoklo has its offices and
                                                                                                                                                                                                                                       the fight against malaria.
                                                                                                                                                                                                                                         “You have all the money
Richard Lapper cites             primary health efforts over
                                 the past three years, this
                                                                                                                                                                    ble barrier to goods, people,
                                                                                                                                                                    and disease, it is a huge one
                                                                                                                                                                                                     main laboratory in the Thai
                                                                                                                                                                                                     city of Mae Sot and runs a
                                                                                                                                                                                                                                       being concentrated on this
                                                                                                                                                                                                                                       side of the border,” says
lack of education,               continuing prevalence high-                                                                                                        in the fight against malaria.    series of clinics up and          Prof Nosten. “Research is
bureaucracy and                  lights the difficulties in                                                                                                           South-east Asia does not       down the Burma border.            global and they see the bor-
                                 fighting the disease.                                                                                                              have the same kinds of           Prof Nosten says the work         der as a wall.”
demotivated staff                   Since 2007, the town of      Patient waiting: locals queue at the Ndala­Mulemba clinic in Angola              Fatima Carvalho   infection rates that are seen    of the Global Fund and              A short walk across the
                                 Cacuaco has built the                                                                                                              in Africa: the average per-      other agencies is having a        border from the Wang Pha
                                 health post at Ndala-             Joanna Silva, a doctor       been 100 per cent behind        crats don’t respond, people         son around Wang Pha gets         significant impact in Thai-       clinic, lies Koko Hospital,

     t has been another          Mulemba and benefited           and municipal health offi-     the effort. One of 20 volun-    blame us.”                          an infectious bite about 0.6                                       sleepy in the baking heat of
     busy morning at the         from a Cuban health mis-        cial who has been orches-      teers attached to the Ndala-       Already four of 20 volun-        times a year, compared                                             the late dry season. Dr Naw
     health post in Ndala-       sion, which has increased       trating the effort, says       Mulemba post, says that         teers have stopped working.         with more than 300 times         ‘We have the                      Baw, the hospital director,
     Mulemba, an hour out-       the number of public sector     about half the population of   full-time nurses and admin-        Nkanga Guimerães, a              for parts of Tanzania.           tools, the drugs,                 has tried to set up a similar
side    Angola’s     capital,    doctors in the town of          Ndala-Mulemba are first-       istrative staff have been       doctor and child health               However, the Thai-Cam-                                           scheme, but she has no
Luanda, and the woman in         800,000 from three to seven.    generation rural migrants.     uncooperative.                  specialist at Unicef, says          bodian and Thai-Burmese          even the money.                   money and the terms of
charge, Fineza Amualdo,
already sounds as if she has
                                    Private sector clinics
                                 have been persuaded to
                                                                 Many are illiterate.
                                                                   “The population grows
                                                                                                  “The nurses arrive late
                                                                                                and there are a lot of
                                                                                                                                that vaccination and anti-
                                                                                                                                malaria programmes are
                                                                                                                                                                    borders have the dubious
                                                                                                                                                                    distinction of being the
                                                                                                                                                                                                     The only problem                  Prof Nosten’s funding pro-
                                                                                                                                                                                                                                       hibits him from sharing his.
had quite enough work for        make some services availa-      day by day,” she says,         delays,” the volunteer com-     having a positive impact,           source of resistance to anti-    is the politics’                    “Different organisations
one day.                         ble to their public sector      which makes it difficult to    plains. “If there is no         but efforts to revitalise           malarial drugs.                                                    have different ideas, and
  “We have had six malaria       counterparts      and     the   plan the delivery of social    improvement in the service,     these programmes are nec-             Chloroquine and melflo-                                          some are frightened to
cases already and another        municipality has contracted     and health services.           there is really no point in     essary.                             quine, both huge pharmaco-       land and Cambodia, but            come here,” is all she will
five are waiting,” says the      1,000 volunteer community         Karina,    a   36-year-old   us bothering. We are really        “It is only the beginning,       logical breakthroughs in         Burma is a “black hole”, a        say of international reluc-
32-year-old Ms Amualdo, as       health agents.                                                 de-motivated.”                  but it is being threatened          their day, met their match       source of disease untouched       tance to fund projects.
a long line of women and            The agents, who work in                                       Vaccines and chemicals        by small things,” he says.          in the jungles of south-east     by international funding.           It is an attitude that infu-
children takes shelter from      their spare time, receive $50   ‘If there is no                used to treat drinking water       Worse still, the other ele-      Asia and surrendered.              He says that, as artemesi-      riates Prof Nosten. He
the sun under the canopy         a month to cover their costs    improvement in                 have sometimes been una-        ments of an ambitious pri-            And it is in this area that    nin    tolerance     spreads,     understands why Thailand
outside her office.              and distribute mosquito                                        vailable. And efforts to        mary health care pilot              doctors such as François         Burma is a disaster waiting       would be reluctant to give
  “We are always telling         nets and chemicals to clean     the service there              encourage people to register    scheme being developed in           Nosten first started to          to happen: “You can proba-        some of its hard-won Global
them to use the nets but
sometimes they don’t. The
                                 water. They persuade fami-
                                 lies to register births and
                                                                 is really no point             births [only about a third of
                                                                                                babies are currently cata-
                                                                                                                                the town are not panning
                                                                                                                                out as hoped.
                                                                                                                                                                    notice tolerance to the drug
                                                                                                                                                                    artemesinin, the newest
                                                                                                                                                                                                     bly stop it in Cambodia, you
                                                                                                                                                                                                     can probably stop it in
                                                                                                                                                                                                                                       Fund money to Burma, and
                                                                                                                                                                                                                                       is unsurprised that Burma –
number of cases is always        vaccinate their children and    in us bothering’               logued] have run into              Few private clinics have         and current best hope            Thailand, but if it reaches       which again became eligible
high.”                           dispense simple advice.                                        inflexible    administrative    responded to the municipal-         against malaria.                 Burma you have lost.”             for Global Fund grants last
  Angola may be on the              The effort is paying divi-                                  processes.                      ity’s call to help in the pub-        “I can still get the same        The answer, Prof Nosten         year – has not spared any
road to recovery from a dev-     dends in some areas. Last       Cuban     doctor     working     To cap it all, the provin-    lic sector.                         number of patients cured,        believes, is to democratise       for the remote border
astating three-decade civil      year, for example, 200,000      alongside Angolan nurses       cial government has not            Even the long-suffering          but it takes a little bit        diagnosis and treatment.          region opposite Wang Pha.
war, with the economy            children were vaccinated        as part of a broader Cuban     paid the volunteers the $50     Cubans are complaining.             longer,” says Prof Nosten,         Since simple, cheap and           What he cannot under-
growing and social spend-        against polio and whooping      healthcare mission, says       monthly stipend for nearly      Karina says she spends              the director of the Shoklo       reliable diagnosis kits have      stand is why the funding
ing rising, but the health-      cough, an increase of about     many of her patients have      a year.                         three hours a day stuck in          Malaria Research Unit, a         become available, Shoklo          has been structured so as to
care situation in slum areas     20 per cent compared with       been slow to put health rec-     Domingo Dinis, a 30-year-     traffic, travelling to the          collaboration between Ox-        has experimented with             make it difficult to obtain
such as Ndala-Mulemba is         two years ago.                  ommendations into prac-        old volunteer who also          clinic where she works.             ford University in the UK        training villagers to diag-       money for cross-border pro-
precarious.                         But progress has been        tice.                          works as a nurse, agrees.          “You waste a lot of time         and Thailand’s Mahidol           nose and treat locals. The        grammes.
  Despite efforts to fight it,   slow. Part of the reason is        “They use their mosquito    “It’s been going on for         in traffic. It annoys you a         University.                      faster a patient is treated,        “If we stop at the border,
malaria      remains      the    that it has been difficult to   nets even when they have       months and we still haven’t     lot,” she says.                       No one is entirely sure        the less chance of extending      we will not be able to stop
number-one killer disease,       improve health standards        holes in,” she says.           had a response from the            “We came here to work            what is happening with           the cycle of infection.           resistance,” he says. “We
wreaking particular havoc        among a badly educated             There are also signs that   provincial government. It       after all. It is a rich coun-       artemesinin         tolerance.     “You need to get the guy        have the tools, the drugs,
among young children.            population that is new to       local bureaucrats and pub-     really creates a problem,       try, but they don’t know            Around the Cambodian             to the clinic within 48           even the money. The only
  Considering that the local     urban living.                   lic health workers have not    because when the bureau-        how to take advantage.”             town of Pailin, where it was     hours, and how can you do         problem is the politics.”

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