The total number of malaria infections worldwide are greater and more widespread than what epidemiologists predicted when they took stock of the situation few years ago. Malaria continues to decimate populations of Africa. The persistent morbidity and mortality from malaria presents a multi-faceted challenge with far reaching problems such as increased drug resistance in the parasite Plasmodium falciparum, poverty that exacerbates health problems, and inconsistent and politicized efforts to eradicate the disease. With global temperature change threatening to increase the number of mosquitoes, the urgency for malaria vector control and disease treatment only increases.
In some ways, progress has been good. Efforts to treat and prevent infection and death show multiple progress in reduced incidence of disease and death. Scientists sequenced P. falciparum in 2002 and funding for better drugs, prevention, and vaccine development is increasing. But despite the excellent array of promising technologies, scientists and public health doctors disagree about how to use existing technologies. Available methods for mosquito control are not deployed to their full potential because of politics, economics and research funding quagmires. Competing agendas of researchers, pharmaceutical companies, government agencies and public health experts complicate this. On one hand the competition between various parties is helpful for advancing multiple approaches with uncertain efficacy, but it also interferes with actual treatments for people who live in the malaria infected areas.
Various players all sincerely want to see malaria eradicated but can't stop bickering about the solutions. For example, bed nets have long offered a promising low tech method of malaria control. Permethrin impregnated bed nets are cheap and easy to distribute and studies show they decrease deaths. However, only one in 20 children use the nets. Typical to many efforts, funding is often scarce or erratic. Political stalling in distributing available funds is typical when aid is tied to policies that recipient countries don't agree with.
As if these problems weren't challenge enough, the bed net advocates seem to be directly at odds with the DDT advocates. The DDT contingent argues that spraying will eradicate mosquitoes. DDT is endorsed by the the military. But in order to promote their agenda, the defenders of DDT try to poke holes in studies about bed nets. Reason magazine disparaged bed nets in a recent article, saying "bed nets protect only at night". The truth is that mosquitoes that carry the malaria vector are actually only a threat at night. Wrong, politically motivated assertions like this interfere with the goal of decreasing deaths and illness from malaria.
Another example of complications with available technologies involves the artemisinin derived drug Coartem. In 2001, the WHO approved use of this drug from Novartis. The drug combines an artemisinin derivative harvested from the qinghao plant indigenous to China, with a second drug - lumefantrine. The artemisinin combination therapies (ACT) have proven to be the most effective treatment, as older treatments are increasingly ineffective against drug resistant strains. As a result reliable artemisinin sources are high in demand.
Today, for the second year in a row, Novartis, the sole producer of the drug, reported that its supply of Coartem will not meet its production goals. This year the company will only supply 13 million doses, instead of an estimated 30 million needed. Novartis says it received too few orders in time to produce the quantity needed, and also that it can't make the drug because Tonhe, a Chinese company contracted to supply the qinghao, can't get the plants it promised because farmers are selling their harvested crops to better paying local Chinese companies.
Unfortunately Novartis ran into the same shortages last year. At the time, the World Health Organization (WHO), which chided the company for the mishap. In a letter to the editor in response to an article about the dispute a Novartis VP and General Manager of Malaria Initiatives defended their effort in the Financial Times.:
"Sir, Contrary to the headline on your recent report "Finance Dispute Halts New Malaria Treatment Project (February 19), our partnership with the [WHO]...continues to move forward rapidly...In response to recent exponential increases in demand, Novartis has rapidly scaled up production capacity and expects to be able to produce 30m Coartem treatments this year...." (March 3, 2005)
But when the time came, Novartis again failed to deliver for unknown reasons.
Sanofi-Aventis has recently announced plans to produce a artemisinin based treatment next year in a joint research and development agreement with the Drugs for Neglected Diseases Initiative (DNDi), a research group based in Geneva. Hopefully the added competition will change the dynamics of production, although if there is a shortage of the plant, arguably more competition won't solve the problem.
Almost everyone agrees that infection by Plasmodium falciparum will be easiest to prevent with a vaccination, yet this too remains an elusive goal. A study last year in Mozambique done by University of Barcelona and GlaxoSmithKline showed good initial results. Another study done by Oxford looked promising but fell through last year -- to their credit Oxford group has published a follow-up study about the failure.
While vaccines are the ultimate solution, we are a world of limited resources and ever burgeoning populations of people and infectious diseases. Are we attached to the idea that no disease can be controlled without a vaccine, even as malaria and other diseases could be controlled with other available technology? Vaccines attempt to circumvent politics and competing ideologies. This works as long as vaccine development doesn't get stuck in the very same political quagmires.
Acronym Required previously wrote about new schemes for vaccine funding here, and writes frequently about public health.