New Drug for Malaria Pits U.S. Against Africa

By DONALD G. McNEIL Jr.
The New York Times
May 28, 2002 

ENEVA - With resistance to old malaria drugs spreading, African officials want to start using a relatively new Chinese remedy so powerful that some experts consider it a miracle drug. Because more than 2,000 African children die of malaria each day, doctors there are clamoring for the drug, and the World Health Organization recommends it.

But the United States generally opposes using it in Africa yet.

An adviser to the Agency for International Development in Washington, Dennis Carroll, said the medicine, artemisinin, probably represented "the best long-term option." But, he added, the drug is expensive and hard for poorly educated people to take correctly. It needs, he said, more testing in infants and is "not ready for prime time."

Other experts say delays will cost too many lives because the drugs now in use are rapidly losing their effectiveness.

Artemisinin was first refined 30 years ago in China from the qinghaosu plant, used in fever remedies for 2,000 years. The raw material comes from China and Vietnam, although the source plant, Artemisia annua, known as sweet wormwood or Chinese wormwood, grows wild even in the United States.

In Vietnam, according to W.H.O., the death toll from an epidemic was reduced 97 percent from 1992 to 1997 using bed nets, indoor DDT spraying and artemisinin. In a study under way in rural South Africa, malaria deaths dropped 87 percent in a year.

"It really is a marvelous drug," said Dr. David Nabarro, executive director in the director general's office at W.H.O. "It's not only a treatment, but the treated person then contains a sterile form of the malaria. So it reduces the intensity of the epidemic."

Many African countries want to switch to it now, arguing that resistance to chloroquine and sulfadoxine-pyrimethamine, the usual front-line drugs, is rapidly spreading.

Most of those countries cannot buy drugs without help from donors or World Bank loans. Some public health officers complain that A.I.D. quietly pressures them not to even request artemisinin.

Mr. Carroll denied the pressure but said the agency believed that artemisinin had not been tested enough on infants and that sulfadoxine/pyrimethamine, or S/P, had some years of usefulness left. For that reason, the agency officially suggests saving artemisinin for cases not helped by first-line drugs.

That infuriates malaria specialists like Dr. Fred Binka, a professor of epidemiology at the University of Ghana. "I couldn't believe my ears," Dr. Binka said after American officials defended that view at a conference here in February. "In poor countries like ours, children have only one chance. They struggle just to visit a health service, and if they get the wrong drug the first time, they are then found dead."

Dr. Bernard Pecoul, director of the Doctors Without Borders campaign for cheaper medicines, called the American position "frankly, very difficult to understand."

Senior W.H.O. officials are careful to say just that the United States is "sounding useful notes of caution," in the words of Dr. David J. Alnwick, manager of the Roll Back Malaria project in the agency.

"It's wrong to polarize it and say the U.S. is anti-artemisinin," he said.

But Dr. Kamini Mendis, another official at Roll Back Malaria, said applying pressure not to seek the best treatment would be disturbing.

"It's not logical," Dr. Mendis said. "Resistance is a huge problem, and there are not many drugs in the pipeline because it's not a rich man's disease."

A study in 1996, underwritten by the Wellcome Trust, a British foundation that researches medical issues, found that $42 per malaria death was spent on research, compared with $840 per death on asthma research and $3,360 per death on AIDS research.

Malaria is in 90 countries, with more than 300 million cases a year, more than a million of them fatal.

Rural African children suffer up to six bouts a year. The disease is often poorly treated, meaning that the children die slowly of anemia. Survivors may be mentally stunted.

The disease also drains national economies. W.H.O. studies show that families affected by malaria clear 40 percent of the land for planting that healthy people do. The disease also scares off tourists and foreign investors. Most African countries have used chloroquine as their first-line drug since 1970. But resistance is up to 90 percent in some areas.

Sulfadoxine-pyrimethamine, under brand names like Fansidar, succeeded it. But pockets of resistance have been found from South Africa to Burundi, sometimes running as high as 60 percent of the cases.

"If you had such resistance levels to a drug in the West," Dr. Binka of of Ghana said, "you know there would be an outcry."

Experts now agree that treatment has to be mixtures of drugs, or cocktails, like those used for AIDS, to fight resistant strains.

Chloroquine and S/P are extremely cheap, as little as 20 cents for an adult treatment. Chloroquine usually has to be taken three times over three days. S/P is a one-time dose.

Artemisinin compounds, by contrast, can be 100 times as expensive. Novartis, the Swiss multinational, sells its cocktail of an artemisinin drug and lumefantrine as Riamet for $20 in rich countries and as Coartem to W.H.O. for poor countries for $2. Using Chinese or Vietnamese suppliers, Doctors Without Borders says it believes that it can obtain a similar combination for $1.30 a dose.

But price is not the sole factor. Africans obtain virtually all AIDS and tuberculosis medicines by prescription. But 80 percent buy malaria pills where they buy detergent, matches or aspirin.

Those small stores and peddlers are de facto pharmacists and, Dr. Binka said, have to be retrained somehow to give sound advice.

Artemisinin drugs have drawbacks. Up to 12 pills have to be taken over three days, preferably with milk. They rapidly stop the aches and fever, so patients who cannot afford 12 pills or milk may stop. That lets the most resistant parasites survive, to be transferred by mosquito to the next victim. Nonetheless, many doctors in Africa are worried enough to want the drugs now.

The public health director in Zambia, Dr. Rosemary Sunkutu, said malaria was the No. 1 killer there. Chloroquine is nearly useless, Dr. Sunkutu said, and S/P resistance is reported at 16 percent. With an additional $8 million, she said, Zambia could switch to Coartem "and substantially reduce the number of children who would die." The American Embassy's aid representative in Lusaka asked her to keep using the cheaper drugs, she said.

Mr. Carroll of A.I.D. and Dr. Richard W. Steketee, chief of the malaria epidemiology branch of the Centers for Disease Control and Prevention, defended the reluctance to endorse artemisinin for Africa.

"In the vast majority of Africa, S/P remains effective," Mr. Carroll said, although he acknowledged that it would not be for long.