[Ip-health] NYT-In Ethiopia's Malaria War, Weapons Are the Issue

[Rachel COHEN]

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http://www.nytimes.com/2003/12/09/health/09MALA.html=0D
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The New York Times=0D
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December 9, 2003=0D
In Ethiopia's Malaria War, Weapons Are the Issue=0D
By DONALD G. McNEIL Jr.=0D
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ith a major malaria outbreak sweeping Ethiopia, an international doctors'=
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group working there contends that outdated drugs are being used to fight it=
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and may even worsen the epidemic.=0D
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Unicef, the United Nations agency providing the drugs, defended the choices=
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it made in consultation with the Ethiopian government. The older drugs are=
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still effective, it said, and changing policy midepidemic for a health=0D
system as battered as Ethiopia's can be disastrous.=0D
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But an internal World Health Organization memo from Dec. 3, obtained by The=
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New York Times, disagrees and "strongly recommends" that a new but more=0D
expensive drug be used.=0D
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The struggle illustrates problems confronting the makers of world health=0D
policy. Drug-resistant strains can evolve faster than new drugs can be=0D
discovered, and new cures are inevitably more expensive, forcing choices=0D
between costly drugs that work and cheap ones that may not.=0D
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The W.H.O. expects Ethiopia's epidemic to spread to 15 million of its 65=0D
million population =E2=80=94 triple the normal rate.=0D
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The aid group arguing for newer drugs, Doctors Without Borders, says that=
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in the two Ethiopian areas where it runs clinics, up to 60 percent of=0D
patients have strains that appear resistant to the first-line treatment=0D
that Unicef and Ethiopia picked, a two-drug cocktail of chloroquine and=0D
sulfadoxine-pyrimethamine, better known by its initials, SP, or the brand=
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name Fansidar.=0D
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The doctors' group said the second-line treatment, hospitalization for five=
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days of quinine, was inaccessible for many patients and hard on=0D
malnourished children. Ethiopia is a mountainous country, where many people=
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live far from clinics or are nomadic.=0D
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Doctors Without Borders wants to introduce artemisinin, a chemical that=0D
Chinese herbalists first derived 30 years ago from the sweet wormwood=0D
plant. It has become the latest wonder drug against malaria. But it is=0D
relatively expensive. Even at the prices drug companies offer to the=0D
poorest countries, cocktails that use it cost $1 to $2.50 an adult=0D
treatment. A typical treatment of chloroquine and SP costs about 20 cents.=
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The artemisinin program also requires taking pills for three days instead=
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of one.=0D
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Nonetheless, the W.H.O., which usually provides treatment guidance,=0D
strongly endorses artemisinin cocktails, which are being used in several=0D
African countries, including Burundi, Liberia and South Africa. Because=0D
resistance to chloroquine is widespread, the W.H.O. discourages its use.=0D
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Dr. Kevin Marsh, a malaria expert working in Kenya, called chloroquine "a=
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failed drug" and said health authorities were foolish to spend money on it.=
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Heavy rains this year ended five years of a drought that starved and=0D
weakened people in wide swaths of Ethiopia. The rains were accompanied by=
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unusually hot weather that let mosquitoes breed at higher altitudes.=0D
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Malaria surged. United Nations relief agencies are calling the outbreak the=
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worst since 1998 and the country's "single biggest health problem."=0D
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But malaria death rates in some villages are five times the normal rate,=0D
said Dr. Pauline Horrill, an emergency coordinator for Doctors Without=0D
Borders.=0D
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Across the world, malaria kills three children a minute.=0D
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This year, Unicef, the United Nations Children's Fund, tried to head off=0D
the epidemic by ordering hundreds of thousands of mosquito nets and $1.2=0D
million worth of drugs.=0D
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Several countries have dropped requests for money for chloroquine and have=
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asked for artemisinin. Nonetheless, the Ethiopian government has refused to=
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let artemisinin be imported.=0D
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"The Ministry of Health says the old treatment is still effective," said=0D
Ambassador Teruneh Zenna, Ethiopia's deputy permanent representative to the=
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United Nations. "They have been using it for a long time now. They are not=
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against the new treatment, but they have to make controlled experiments to=
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prove it works."=0D
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The health chief at Unicef, Dr. Pascal Villeneuve, defended his agency's=0D
choice as "a pragmatic approach." Drug companies do not make enough=0D
artemisinin to supply all of Ethiopia, the cost is a barrier, and as a=0D
United Nations agency, Unicef has to follow the lead of the host country,=
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he said.=0D
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"National policies are not an issue that should be taken lightly," he said.=
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Dr. Kent Campbell, a malaria expert for Unicef, said chloroquine was still=
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effective against vivax malaria, which is less fatal than more predominant=
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falciparum malaria, but persists in Ethiopia. Artemisinin "wouldn't hurt,"=
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Dr. Campbell said. "But it wouldn't change the number of people dying."=0D
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No program, he added, should be changed based on "anecdotal data" from two=
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sites run by Doctors Without Borders.=0D
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Dr. Villeneuve, Dr. Campbell and two other United Nations malaria=0D
specialists declined to say in a joint telephone interview whether they=0D
agreed with Ethiopia's policy or were lobbying to change it.=0D
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At the time they were interviewed, they did not know about the W.H.O. memo=
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disagreeing with them. A Unicef spokesman said late yesterday that there=0D
was "nothing religious" about Unicef's position and "we want proper science=
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to guide the decision-making here."=0D
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Dr. Horrill called Ethiopia's position "frustrating and very difficult to=
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understand."=0D
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Also, she argued, using SP in an epidemic may actually speed the spread of=
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malaria. The drug attacks one phase of the life cycle of the malaria=0D
parasite, but stimulates the production of gametocyte cells that mosquitoes=
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can pick up and spread to others.=0D
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By contrast, artemisinin gives "rapid cure and rapid knockdown of the=0D
epidemic," Dr. Horrill said.=0D
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Dr. Campbell said the spread of the epidemic could be slowed by=0D
insecticide-impregnated mosquito nets.=0D
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If the resistance levels detected by Doctors Without Borders are=0D
widespread, using artemisinin "would be a sensible strategy to follow,"=0D
said Dr. Mary Ettling, chief malaria expert at the United States Agency for=
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International Development.=0D
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The United States, which has contributed more than $2 million to fight the=
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Ethiopian epidemic, now endorses using artemisinin in many African=0D
countries, in the Amazon Basin and in the Mekong Delta of Vietnam. That is=
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a policy change from 18 months ago, when the United States generally=0D
opposed its use in Africa.=0D
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At the time, a Usaid malaria adviser said, artemisinin was too expensive,=
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came in multiple regimens that were difficult to take and needed more=0D
testing in children.=0D
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Regimens are now simpler, and the drug can be given even to dehydrated,=0D
malnourished children.=0D
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___________________________________=0D
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Rachel M. Cohen=0D
U.S. Director, Campaign for Access to Essential Medicines=0D
Doctors Without Borders/M=C3=A9decins Sans Fronti=C3=A8res (MSF)=0D
333 Seventh Avenue, 2nd Floor * New York, NY * 10001-5004 * USA=0D
Tel: +1-212-655-3762=0D
Mobile: +1-917-331-9077=0D
Fax: +1-212-679-7016=0D
E-mail: rachel.cohen@newyork.msf.org=0D
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http://www.doctorswithoutborders.org/=0D
http://www.accessmed-msf.org/