A tragic delivery failure in Africa

The Baltimore Sun

LOS ANGELES -- To an African woman living in a remote village, everything is precious: a cup, a pencil, a length of twine. But above all, tablets that can save a sick child's life. Most African mothers will trudge miles and wait hours in hopes of obtaining such medicine.

That's why it is so dismaying that Sanofi-Aventis may soon destroy 10 million doses of the world's best malaria medicine - a drug that quickly slays lethal strains that still claim 1 million African children every year. In a letter mailed to malaria experts this summer, the pharmaceutical giant explained its reasons. First, the drug has an inherently short shelf life, for which no one can be blamed. More important, global orders for artesunate simply haven't materialized as expected.

The announcement represents another painful chapter in an ongoing tragedy. Malaria treatment has rapidly lost ground to drug resistance over the last 20 years: Today, in much of the world, once-reliable mainstays behave more like sugar pills. However, effective drugs do exist, and artesunate is a prime example. Combined with a partner drug, it is state-of-the-art therapy, otherwise known as artemisinin-based combination treatment, or ACT. Malaria experts have been touting ACT for more than a decade.

But in that same time period, many malaria-ridden countries have failed to replace obsolete drugs with ACT. Mind you, we're not talking about costly, lifelong treatment here. An ACT for an African child costs $2. In April 2005, Sanofi agreed to produce an even cheaper, faster regimen. For the bargain price of one buck, the new pediatric cocktail - pairing artesunate and a second drug - consists of one daily pill for three days. Period.

Needless to say, now would be a good time to grab up Sanofi's remaining stock of plain artesunate - which, it appears, the drug company is prepared to give away. Sadly, it's not that easy.

The grim truth behind Sanofi's absent orders is an ineffective, fractured system for forecasting global needs for modern malaria drugs, along with subsidizing, packaging and distributing them. Today, if a poor, malarious country wishes to use the Sanofi pills destined for the dump, it must waive import laws barring pharmaceuticals with a waning shelf life, co-package artesunate with a partner drug, and then hustle the lifesaving combo into faraway clinics and roadside stands at a price people living on a dollar a day can actually afford. Without coordinated, external assistance and a long-term plan to sustain the purchase and flow of lifesaving ACT, that's not likely to happen.

So, who's responsible for the gridlock in malaria treatment? There's plenty of blame to go around.

In 1998, with much fanfare, the World Health Organization launched its Roll Back Malaria partnership, aiming to halve malaria deaths by 2010. Unfortunately, WHO's leadership proved weak, and the goal now appears unattainable.

In 2000, the World Bank earmarked $500 million for malaria treatment and drug delivery in Africa over five years. When that clock ran out, no more than $150 million had left its coffers.

Another underwhelming performer has been the U.N. Global Fund to Fight AIDS, Tuberculosis and Malaria. Until 2004, it routinely gave money to African countries to replenish failing malaria drugs instead of championing the switch to ACT.

Last year, in a Senate subcommittee hearing, the U.S. Agency for International Development received blistering criticism for its malaria portfolio. What emerged was a dismal disconnect between its endorsement of ACT and its investment in the treatment.

Finally, at the country level, governments failed to exercise leadership. Without a pipeline of aid, most simply postponed implementing new treatment guidelines year after year - although there have been notable exceptions.

There is a glimmer of hope. In 2004, a panel led by Kenneth J. Arrow, a Nobel laureate economist, recommended a high-level global subsidy for ACT, possibly overseen by UNICEF. Two months ago, the Bill and Melinda Gates Foundation gave the World Bank a substantial grant to explore the subsidy. In another year or two, it could be up and running. Who will pay for ACT in the long run is still an open question, of course.

As is this: How many more children must die because this treatment failed to reach them?

Claire Panosian Dunavan is a professor of medicine and infectious diseases and co-founder of the Program in Global Health at the David Geffen School of Medicine at the University of California, Los Angeles. Her e-mail is cpanosian@mednet.ucla.edu.

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