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AFRO-NETS> In Ethiopia's Malaria War, Weapons Are the Issue
- Subject: AFRO-NETS> In Ethiopia's Malaria War, Weapons Are the Issue
- From: Dr Rana Jawad Asghar <email@example.com>
- Date: Tue, 9 Dec 2003 06:30:20 -0500 (EST)
In Ethiopia's Malaria War, Weapons Are the Issue
The New York Times
December 9, 2003
By DONALD G. McNEIL Jr.
With a major malaria outbreak sweeping Ethiopia, an international
doctors' group working there contends that outdated drugs are be-
ing used to fight it and may even worsen the epidemic.
Unicef, the United Nations agency providing the drugs, defended
the choices it made in consultation with the Ethiopian govern-
ment. The older drugs are still effective, it said, and changing
policy midepidemic for a health system as battered as Ethiopia's
can be disastrous.
But an internal World Health Organization memo from Dec. 3, ob-
tained by The New York Times, disagrees and "strongly recommends"
that a new but more expensive drug be used.
The struggle illustrates problems confronting the makers of world
health policy. Drug-resistant strains can evolve faster than new
drugs can be discovered, and new cures are inevitably more expen-
sive, forcing choices between costly drugs that work and cheap
ones that may not.
The W.H.O. expects Ethiopia's epidemic to spread to 15 million of
its 65 million population - triple the normal rate.
The aid group arguing for newer drugs, Doctors Without Borders,
says that in the two Ethiopian areas where it runs clinics, up to
60 percent of patients have strains that appear resistant to the
first-line treatment that Unicef and Ethiopia picked, a two-drug
cocktail of chloroquine and sulfadoxine-pyrimethamine, better
known by its initials, SP, or the brand name Fansidar.
The doctors' group said the second-line treatment, hospitaliza-
tion for five days of quinine, was inaccessible for many patients
and hard on malnourished children. Ethiopia is a mountainous
country, where many people live far from clinics or are nomadic.
Doctors Without Borders wants to introduce artemisinin, a chemi-
cal that Chinese herbalists first derived 30 years ago from the
sweet wormwood plant. It has become the latest wonder drug
against malaria. But it is relatively expensive. Even at the
prices drug companies offer to the poorest countries, cocktails
that use it cost $1 to $2.50 an adult treatment. A typical treat-
ment of chloroquine and SP costs about 20 cents.
The artemisinin program also requires taking pills for three days
instead of one.
Nonetheless, the W.H.O., which usually provides treatment guid-
ance, strongly endorses artemisinin cocktails, which are being
used in several African countries, including Burundi, Liberia and
South Africa. Because resistance to chloroquine is widespread,
the W.H.O. discourages its use.
Dr. Kevin Marsh, a malaria expert working in Kenya, called
chloroquine "a failed drug" and said health authorities were
foolish to spend money on it.
Heavy rains this year ended five years of a drought that starved
and weakened people in wide swaths of Ethiopia. The rains were
accompanied by unusually hot weather that let mosquitoes breed at
Malaria surged. United Nations relief agencies are calling the
outbreak the worst since 1998 and the country's "single biggest
But malaria death rates in some villages are five times the nor-
mal rate, said Dr. Pauline Horrill, an emergency coordinator for
Doctors Without Borders.
Across the world, malaria kills three children a minute.
This year, Unicef, the United Nations Children's Fund, tried to
head off the epidemic by ordering hundreds of thousands of mos-
quito nets and $1.2 million worth of drugs.
Several countries have dropped requests for money for chloroquine
and have asked for artemisinin. Nonetheless, the Ethiopian gov-
ernment has refused to let artemisinin be imported.
"The Ministry of Health says the old treatment is still effec-
tive," said Ambassador Teruneh Zenna, Ethiopia's deputy permanent
representative to the United Nations. "They have been using it
for a long time now. They are not against the new treatment, but
they have to make controlled experiments to prove it works."
The health chief at Unicef, Dr. Pascal Villeneuve, defended his
agency's choice as "a pragmatic approach." Drug companies do not
make enough artemisinin to supply all of Ethiopia, the cost is a
barrier, and as a United Nations agency, Unicef has to follow the
lead of the host country, he said.
"National policies are not an issue that should be taken
lightly," he said.
Dr. Kent Campbell, a malaria expert for Unicef, said chloroquine
was still effective against vivax malaria, which is less fatal
than more predominant falciparum malaria, but persists in Ethio-
pia. Artemisinin "wouldn't hurt," Dr. Campbell said. "But it
wouldn't change the number of people dying."
No program, he added, should be changed based on "anecdotal data"
from two sites run by Doctors Without Borders.
Dr. Villeneuve, Dr. Campbell and two other United Nations malaria
specialists declined to say in a joint telephone interview
whether they agreed with Ethiopia's policy or were lobbying to
At the time they were interviewed, they did not know about the
W.H.O. memo disagreeing with them. A Unicef spokesman said late
yesterday that there was "nothing religious" about Unicef's posi-
tion and "we want proper science to guide the decision-making
Dr. Horrill called Ethiopia's position "frustrating and very dif-
ficult to understand."
Also, she argued, using SP in an epidemic may actually speed the
spread of malaria. The drug attacks one phase of the life cycle
of the malaria parasite, but stimulates the production of gameto-
cyte cells that mosquitoes can pick up and spread to others.
By contrast, artemisinin gives "rapid cure and rapid knockdown of
the epidemic," Dr. Horrill said.
Dr. Campbell said the spread of the epidemic could be slowed by
insecticide-impregnated mosquito nets.
If the resistance levels detected by Doctors Without Borders are
widespread, using artemisinin "would be a sensible strategy to
follow," said Dr. Mary Ettling, chief malaria expert at the
United States Agency for International Development.
The United States, which has contributed more than $2 million to
fight the Ethiopian epidemic, now endorses using artemisinin in
many African countries, in the Amazon Basin and in the Mekong
Delta of Vietnam. That is a policy change from 18 months ago,
when the United States generally opposed its use in Africa.
At the time, a Usaid malaria adviser said, artemisinin was too
expensive, came in multiple regimens that were difficult to take
and needed more testing in children.
Regimens are now simpler, and the drug can be given even to dehy-
drated, malnourished children.
Dr Rana Jawad Asghar
Program Manager Child Survival, Mozambique
Provincial Coordinator Sofala Province, Mozambique
Health Alliance International, Seattle, WA, USA
Coordinator South Asian Public Health Forum
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