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WHO refutes malaria malpractice allegations
WHO's Roll Back Malaria department has refuted allegations by an international group of 13 malaria researchers accusing WHO and the Global Fund to Fight, AIDS, Turberculosis and Malaria (GFATM) of failing to promote available and effective malaria treatment in favour of ineffective but less-expensive drugs.
In a commentary published in the UK-based medical journal, the Lancet (2004;363:23740), the critics led by Amir Attaran from London's Royal Institute of International Affairs, accuse the two agencies of blocking the introduction of highly effective artemisinin-based combination therapy (ACT) whilst continuing to approve grants for the conventional chloroquine and sulfadoxine-pyrimethamine in countries where these treatments are failing.
"For WHO and GFATM to provide chloroquine and sulfadoxine-pyrimethamine treatments ... at least wastes precious international aid money and at most, kills patients who have malaria .... at least tens of thousands of children die every year as a direct result," say the authors who compare the agencies with a "doctor who knowingly furnished treatments that failed perhaps 80% of the time, while withholding the alternatives as "too expensive"."
In a letter published in the Lancet (2004;363:397), Fatoumata Nafo-Traoré, Director of WHO's Roll Back Malaria Department, counters the accusations pointing out that "WHO has been making many of the same arguments for the past 3 years and fully supports the use of ACT."
Chloroquine and sulfadoxine-pyrimethamine have become increasingly ineffective due to the development of resistance in the deadly species of malaria, Plasmodium falciparum. Surveillance and clinical trial data in East Africa, for example, show that up to 64% of patients given chloroquine and 45% given sulfadoxine-pyrimethamine will fail treatment, and those figures are climbing, say the critics, Attaran et al.
They point out that artemisins, on the other hand, which form the basis of ACT treatments, have been used in Chinese traditional medicine for 2000 years, with no observed resistance. "In studies done on nearly every continent, ACT successfully treats 90% or more of patients," say Attaran et al.
The problem is cost: ACT is around ten times more expensive forcing most African countries to stick with conventional but increasingly useless malaria treatments. At the centre of the criticisms voiced in the Lancet is the continued approval by GFATM and WHO of funding for chloroquine and sufladoxine-pyrimethamine for those countries which should be switching to ACT. "When those same countries seek financial aid from [GFATM] to purchase ACT, they are forcefully pressured out of it by governments such as the USA, whose aid officials say that ACT is too expensive ... and WHO signs its approval," say Attaran et al.
According to WHO, one reason for poor countries' continuing applications to GFATM for the cheaper but less-effective anti-malaria drugs has been their uncertainty about GFATM which has only been in existence for two years as a source of long-term support. In other words, countries did not wish to switch to a more expensive drug only to see this income cut off a few years later. "Governments need to trust that sustainable funding from the Global Fund [GFATM] and other sources will be available before they can make the commitment of up to US$ 2 per head per year of switching to ACTs," said Nafo-Traoré.
Both agencies have also emphasized their roles as advisers or funders, insisting that antimalarial drug policy decisions must be led by national governments. However, as Nafo-Traoré points out, since 2001 "WHO has been actively promoting the use of ACT in countries before resistance to currently used monotherapies reaches an unacceptable level." Since 2001, South Africa (KwaZulu Natal), Zambia, Zanzibar and Burundi have switched to ACTs as first-line treatment. By 2004 WHO expects at least 16 African countries to have adopted ACTs as first-line treatment. According to WHO, this timeframe is exceptionally short for such a far-reaching policy change. In addition, the threshold for the unacceptable level of therapeutic failures has been lowered from 25% to 15% and "countries will be strongly encouraged to modify their treatment policies accordingly," says Nafo-Traoré.
Rather than refusing requests for suboptimal drugs which are based on current national policy, says Nafo-Traoré, GFATM has generally stipulated a policy review within a short period of time as a condition of funding. "As a result, WHO is able to work more effectively with decision-makers in countries to accelerate rational and feasible policy change."
Malaria causes more than one million deaths worldwide every year, 90% of which occur in Africa, costing the continent more than US$ 12 billion every year. 