Inside this issue On FT.comCorporate projectsControl programmes take greatpreparation but the resultsimpress. Charles Batchelorreports Page 2

Disease development CliveCookson on worrying mutationsin the malarial parasite Page 4

Procurement Supplies increasebut distribution stalls, saysAndrew Jack Page 4

South­east Asia Tim Johnstonfinds activists worrying aboutthe ‘black hole’ of funding andcontrol in Burma Page 6

Guest columns●Jakaya Mrisho Kikwete,president of Tanzania, andJoy Phumaphi, interim executivesecretary of the African LeadersMalaria Alliance

●Suzanne Hill andGeorge Jagoe of the WHO andMedicines for Malaria Venture

●Ray Chambers, UN specialenvoy for malaria

●Youssou N’Dour, musician,Unicef and Roll Back Malariaambassador and board memberfor Malaria No More

COMBATING MALARIAFINANCIAL TIMES SPECIAL REPORT | Friday April 23 2010

www.ft.com/combating­malaria­2010 | twitter.com/ftreports

Optimism grows as target is in sight

With just eightmonths to meet hisgoal of distributinghundreds of mil-

lions of mosquito nets aroundthe world to people at high riskof contracting malaria, RayChambers is feeling confident.

The UN special envoy onmalaria believes efforts are ontrack for completion of deliver-ies during 2010, supportingbroader plans to reduce greatly,within five years, the huge bur-den of illness and death fromthis leading killer disease.

“This is the most optimisticWorld Malaria Day to date,” hesays. “Today, we know we canachieve the goal of universalcoverage of nets by the end ofthis year and near zero deathsfrom the disease by 2015.”

His optimism is shared byother top officials who haveobserved a recent resurgence inefforts to tackle the disease,which the latest estimates sug-gest infects 250m people andkills more than 850,000 a year.

Imaginative advocacy hashelped raise awareness, in turnstoking an upsurge in fundingfrom $60m a year at the start ofthe millennium to nearer $2bnannually today.

Some far more effective toolsfor prevention and treatmenthave become available and thepipeline of technologies is grow-ing to include more potent andeasier-to-take medicines, andeven possible vaccines.

There is growing managementinnovation, from “SMS for Life”messages to monitor drugstocks in rural Tanzania, to theAffordable Medicines Facilityfor Malaria, to be launched inup to nine countries nextmonth, where it will subsidisethe best drugs sold in the pri-

vate sector to make them moreaffordable.

Respected personalities – fromSenegalese musician YoussouN’Dour to football players in theUnited Against Malaria cam-paign of the World Cup in SouthAfrica this summer – are stok-ing debate and spreading themessage to those most affectedthat they can and must helptackle malaria themselves.

Community volunteers andreligious organisations – Chris-tian, Muslim and Jewish alike,sometimes working together– are filling gaps in often weakpublic health systems.

Tony Blair, the British formerprime minister, has becomeinvolved through his inter-faith

foundation, adding to a growinglist of corporate chief executivesand public figures who bringclout, profile and funding.

Perhaps most important, thecreation last autumn of the Afri-can Leaders Malaria Alliancesuggests the continent’s ownpoliticians are beginning to takea necessary fresh look at theirpivotal responsibility in improv-ing their citizens’ health.

Awa Coll-Seck, head of theRoll Back Malaria partnershipof public, private and non-gov-ernmental groups, says: “Thingshave moved really very quicklyover the past three years, andyou can see the results.”

Her organisation has helpedtrack progress in a dozen

malaria-endemic African coun-tries, and points to significantimprovements in several. Ethio-pia, Ghana, Rwanda, Zambiaand Zanzibar have cut deathand disease by up to 70 per centin recent years, for instance.

But others – including somewith the greatest burden suchas Nigeria and the DemocraticRepublic of Congo – have per-formed much less well. Stillmore countries have such poor-quality data that attempting tomeasure progress is difficult.

In the tiny Kyekumbra clinicjust two hours’ drive from theUgandan capital of Kampala,nurse Winfred Namudde sayshalf her patients are still pre-senting with malaria. “But we

just had three months withoutdrugs,” she says, leaving herwith none of the recommendedmedicines to offer them.

Her experience highlights howmuch more needs to be donedespite the positive momentum.The big challenges ahead arethree-fold: deepening, broaden-ing and sustaining the response.

The first aspect is to deepenexisting approaches, which haveuntil now focused on large-scale,efforts to bring control andtreatment tools to countries inneed.

That has meant a vastexercise to fund, procure anddeliver drugs and bed nets,

Andrew Jack explainswhy there is a feelingthat 2010 will markthe most hopefulWorld Malaria Dayto date

A boy with malaria waits at a special clinic in Sittwe, Burma. Between 2000 and 2008, the level of cases there increased and activists worry about tolerant strains spreading Getty

Continued on Page 2

2 ★ FINANCIAL TIMES FRIDAY APRIL 23 2010

Combating Malaria

ContributorsAndrew JackPharmaceuticals Correspondent

Clive CooksonScience Editor

Richard LapperSouthern Africa Bureau Chief

Tim JohnstonBangkok Correspondent

Charles Batchelor,Joseph Milton,Sarah Murray,Anna WangFT Contributors

Ursula MiltonCommissioning Editor

Steven BirdDesigner

Andy MearsPicture Editor

For advertising details,contact:Mark Carwardine on:+44 (0) 207 873 4880;e­mail:mark.carwardine@ft.comor your usual FT representative

Optimismgrows astarget isin sight

supplemented by insecticidesand diagnostics.

Yet in the rush to meet uni-versal coverage targets for thesegoods, such programmes haveoften taken scant account oflocal variations.

They have also incurredhigher costs than necessary andresulted in less speed in deliver-ing fast-expiring drugs “thefinal mile” to patients. Moreeffort to ease distribution andeffective use is required.

The focus on freighting in bednets has left many sitting inwarehouses, misused or simplyunused in individuals’ houses.

Without more culturally sensi-tive projects to train people innet use, as well as insecticidere-treatment and replacementplans, scarce resources arebeing poorly deployed and creat-ing a large future environmen-tal burden.

There is a need for closerscrutiny of progress, managerialfine-tuning, and monitoring bet-ter to understand local varia-tions: how malaria transmissionmay vary over time andbetween places and, given this,the need to vary localapproaches.

That issue points to a secondchallenge for the malaria com-munity: to broaden itsapproach. Heavy top-down pres-sure to tackle the disease,backed by international fundinghas often undermined the poli-cies, staff and systems of fragilenational governments. So havethe manifold well-intentionedbut duplicative and, in somecases, counter-productive pri-vate and charitable initiatives.

Rob Newman, director of theWorld Health Organizationmalaria programme, says: “Theissue of under-treatment maynot be as catastrophic as it ismade out to be.” He argues thatmalaria should be a wedge topush for broader “horizontal”programmes.

As diagnosis and treatmentbecomes more reliable, otherdiseases, previously wronglydiagnosed as malaria, are identi-fied and require differentapproaches. That calls for bettertrained, motivated and managedhealthcare workers.

Even within the malaria field,there is a need to expand think-ing and research on elimination;the use of intermittent treat-ment in pregnant women as aprophylaxis; alternativeapproaches to insecticides suchas wall hangings or treatedclothing; and approaches todealing with less lethal buthighly burdensome strains suchas plasmodium vivax.

The final challenge is sustain-ability. History has proven theextraordinary versatility of theparasite in defying elimination.Resistance to the latest drugs –already identified in south-eastAsia – risks undermining thebest drugs available. If mosqui-toes adapt to bite outsidehumans’ sleeping hours, netswill be rendered less effective.

Any effort to reduce, andmaintain at low levels, the bur-den of malaria will require largesums over many years. Yet evencurrent needs are significantlyunder-funded. The financial cri-sis and “donor fatigue” riskdiverting support further. Ste-ven Phillips, medical directorfor global issues at ExxonMobil,says: “Once you get even a 10-30per cent decrease in malaria,how do you persuade people tospend more when the problemappears to be going away?”

Recent progress is impressive,but World Malaria Day will bemarked long into the 21st cen-tury.

Continued from Page 1

Funding and stamina required for the long haul

When AngloGold Ashanti beganspraying anti-malarial chemi-cals in the homes of workers atits Obuasi mine in Ghana, alarge crowd of people gathered.

“There must have been about1,000 people standing aroundwhen we sprayed the firsthouse,” recalls Steve Knowles,director of the malaria controlprogramme at the Johannes-burg-based gold-mining group.

“The lady of the house getsfree pest control because, alongwith the mosquitoes, the chemi-cals kill cockroaches and ants.”

Companies can benefit enor-mously from reducing theimpact of malaria while bur-nishing their image withemployees and increasinglydemanding customers, lobbyists

and governments. What theybring to the fight is their exper-tise in project management,their ability to train and moti-vate staff and a focus on results.

But with malaria, they face anenormous challenge. The dis-ease is very resistant to effortsto control it and will recolonisetreated areas from untreatedregions. Successful programmessometimes make local peoplethink they no longer need totake precautions and the diseasecan return. Sufficient fundingand stamina for a long haul arerequired.

Programmes such as Anglo-Gold Ashanti’s take a lot ofpreparation. There are manymyths about malaria and it maynot seem obvious to local peoplethat draining patches of stag-nant water and clearing blockeddrains can help reduce the inci-dence of the disease.

“There was a six-month build-up to the launch of the pro-gramme that involved walkingaround and shaking hands withpeople,” Mr Knowles explains.“You have to build credibility

with the local community andyou have to have motivated,trained staff to do the work. Wecall our community volunteeractivists our John the Baptists.”

AngloGold Ashanti itself hada strong motivation. It had iden-tified malaria as the most signif-icant public health threat to itsoperations in Ghana, Mali,Guinea and Tanzania.

A map of the globe showsmany of its mines dotted acrossthe malaria belt stretching fromSouth America, through Africaand the Indian subcontinent tosouth-east Asia.

The company’s Obuasi minein southern Ghana lost an aver-age of 6,983 man days a monthbecause of malaria in 2005, withan average of 238 employeesaffected each month.

The cost of treating these peo-ple at the company’s hospitalwas $22,000 a month, rising to$55,000 when family memberswere included. To counter theimpact of malaria, staffing lev-els at the mine increased by 20per cent.

The control programme,

launched in 2006, involvedspraying the insides of build-ings, providing nets and repel-lents, spraying water surfaceswith chemicals to control thegrowth of larvae and providingdrugs to malaria sufferers.

Its impact has been impres-sive. Lost days per month fell to273 in 2009, with some 38employees affected. Medicationcosts fell to $2,000 for employees

and $8,900 including their fami-lies. Eighty per cent of newcases involve people who havecontracted the disease outsidethe control zone.

AngloGold Ashanti is not theonly company with significantactivities in Africa that arethreatened by malaria. Mara-thon Oil’s regional gas process-ing hub on Bioko Island, in

Equatorial Guinea, was affectedby the disease.

Apart from the cost of treat-ment and the impact on produc-tion, expatriates are reluctant towork in Africa because they fearfor the health of their families.Because of the disease, localemployees are difficult to inte-grate into the company’s struc-tures and key growth sectorssuch as manufacturing andtourism will not develop.

Marathon launched a five-year, $15.8m programme withpartners to combat malaria in2003. It reported the results lastyear in terms of the impact onchildren below the age of five.There was a 64 per cent reduc-tion in deaths, a 57 per cent fallin malarial infections in two-to-five year olds and an 86 per centdrop in anaemia in this agegroup. In 2006, the programmewas extended to the mainland.

Companies with large produc-tion centres in malaria zonestake little persuading that fight-ing the disease is a priority. Butothers can need some encour-agement.

United Against Malaria, apartnership of public and pri-vate organisations that seeks touse football, and the 2010 WorldCup in South Africa, to promotethe fight against malaria,encountered early resistance.

“When I started talking tocompanies, they said it was notan issue in Africa,” says Chris-tina Vilupti Barrineau, directorof African operations. Whencompanies did have malaria pro-grammes they were often verylocalised, involving, for exam-ple, support for a hospital.

Since starting the campaign,Ms Barrineau says she hasreceived enthusiastic supportfrom Nando’s, a privately ownedSouth African restaurant chainactive in more than 25 coun-tries, and from MTN, a listedmobile telephone companybased in Johannesburg.

Companies with wide distribu-tion networks – real or virtual –can use them to reach their cus-tomers, suppliers and staff withinformation, fund-raising cam-paigns and help with distribut-ing medicines and bed nets.

Corporate projectsControl programmestake great preparationbut the results impress,says Charles Batchelor

The AngloGoldAshantianti­malariasprayingprogramme atits Obuasi minein Ghana

Focus on nets‘seductive butshort­sighted’

When Susan Lassen travelled toone southern African countryrecently on behalf of the JCFlowers Foundation, which dis-tributes bed nets through Chris-tian groups to help combatmalaria, she was disturbed bywhat she found.

Sacks containing 90,000 netspaid for by donors had beengathering dust in a warehousefor a year, as the governmentstruggled to find ways to distrib-ute them “the final mile” to peo-ple in need.

Her experience highlights theflipside of the prominence givento mosquito nets, which havebecome the focus of a campaignto achieve “universal coverage”by the end of this year, turningnet manufacture, sale and distri-bution into a big business.

Reduced malaria deaths andinfection rates in countrieswhere bed net use is wide-spread, show their importance.They are a low-cost and effec-tive “tool” that also offers apowerful way to raise moneyand awareness.

Peter Chernin, the formerhead of News International,says: “You run into a challenge:in the US, where there is zeroconstituency,” he says. “No oneis calling their congressman tosay ‘Gee, what are you doingabout malaria?’”

He used his influence to helplaunch malaria-related initia-tives, for example through a UStelevision fundraising event,Idol Gives Back, endorsementsby well-known footballers andThe Sun newspaper’s alliancewith Comic Relief in the UK.

“We have never been focusedsolely on nets, but it’s a remark-ably effective tool as a first lineof defence,” he says. “The bigupside is that we have enor-mous results that can help keeppeople engaged.”

The problem is that some ofthe high profile non-profit initia-tives that have emerged – suchas Nothing But Nets – downplaythe importance of otherapproaches that require just asmuch support, including drugs,insecticide spraying and dia-gnostics.

Many organisations employ apowerful but somewhat over-simplified formula that equatesa small donation to a tangibleresult.

The American Red Cross says:“One bed net, five dollars, savea life”. The Foundation of theUS government’s Centers forDisease Control and Prevention,says: “$5 can save a child’s life”.

In fact, analysis suggests thatit takes closer to 20 properlyused nets (costing closer to $10each, including all necessaryoverheads) to save a life andthere is much debate about netreliability and how long theyremain effective.

“We have done a terriblething by putting a price tag onthis,” says Ms Lassen. “It wasvery seductive but also veryshort-sighted. In five years’time, people will say ‘But Ialready gave my $5. Why isn’tthis solved?’”

There is little doubt that larg-er-scale, more consistentprocurement of standardisednets by countries and interna-tional organisations could

undoubtedly help save substan-tial sums.

Adam Flynn from SumitomoChemical, a partner of Africa’slargest manufacturer of nets,says: “We are producing 25-30per cent less than we could bebecause of retooling for differentmarkets.”

Another danger with somefundraisers is an over-emphasison efficiency. The AgainstMalaria Foundation argues thatevery penny it raises goes to thepurchase of nets. But thatleaves others to find theresources to ensure that netsare delivered to those who needthem, and then used consist-ently and effectively.

Susan Mukasa is head inUganda of the non-profit group,Population Services Interna-tional.

The organisation is involvedin distribution campaigns,which are currently beingscaled up, as large numbers ofnets arrive in the country. Shepoints out: “Getting the nets tothe right people is challenging.”

While she dismisses as “anec-dotal” the stories of bed netsbeing misused by people forfishing or as wedding veils, sheworries that during an electionperiod, politics may influencetheir distribution to differentregions.

Just as important, she saysonly about 32-40 per cent of netsthat are successfully distributed

are used consistently all nightby their recipients.

People can be put off by thesmell, the heat, or the inconven-ience, for instance. Her organi-sation has launched “hang yournet” campaigns designed to“make it fun and not like polic-ing”.

Janet Hemingway, head of theLiverpool School of TropicalMedicine, points out: “The prob-lem with bed nets is that theyhave been developed anddesigned by entomologists andwe have tried to force people touse them. I’d love consumerproducts companies to becomeinvolved.”

“Baseline” data against whichto measure the overall reductionin the disease is sparse in manymalaria-endemic countries, andcontrolled studies to judge therelative impact of nets com-pared with other approaches isscant.

Organisations instead haverushed to deliver somethingthat seems effective.

Sarah Staedke, a researcherfrom the London School ofHygiene and Tropical Medicine,says some funders now considerit unethical to conduct malariacontrol research that does notinclude net distribution as a“standard of care”.

While nets play an importantrole, failure to keep studyinghow they should best bedesigned, distributed and usedrisks not taking full advantageof their value.

The current focus on their usealso needs to be balanced with asearch for sustainable, reliableand affordable alternatives.

PreventionAndrew Jack saysother approaches needjust as much support

Hopeful results leadto first large­scale trial

Over the past year, 9,000babies and young chil-dren in seven Africancountries have

received a shot of the firstmalaria vaccine to undergo alarge-scale clinical trial. Eventu-ally as many as 16,000 childrenwill receive the so-called RTS,Svaccine.

“We are very happy with theway enrolment is going,” saysJoe Cohen of GlaxoSmithKlineBiologicals in Belgium, who hasbeen working on RTS,S for morethan 20 years.

The vaccine originated withresearch at the Walter ReedArmy Institute of Research inthe US in the mid 1980s. AfterGSK had taken up RTS,S, testsin adult volunteers started inthe US in 1992 and Africa in1998.

A public-private partnershipbetween GSK and the PathMalaria Vaccine Initiative (MVI)began in 2001 to put RTS,Sthrough more extensive “Phase2” trials with African children.Their encouraging results –showing an efficacy for the vac-cine of about 50 per cent – led tothe current much larger-scale“Phase 3” trial.

Altogether, GSK has alreadyinvested $300m in RTS,S andexpects to invest at least $100mmore before the project is fin-ished. MVI has spent $200m, pro-vided mainly by the Bill &Melinda Gates Foundation.

The long and expensive his-tory of RTS,S illustrates thepatience needed to developmalaria vaccines. And the storyis far from at an end because,

while a vaccine that provides 50per cent protection wouldreduce significantly the toll of800,000 African children underfive who die every year frommalaria, MVI aims to have avaccine with 80 per cent efficacyavailable by 2025.

However Christian Loucq,MVI director, says future vac-cines can be developed morequickly and at somewhat lowercost than RTS,S. Phase 3 vac-cine trials require thousands ofparticipants but the numberbecomes smaller as the vaccinebecomes more effective, asgreater effectiveness shows upmore quickly. And the Africaninfrastructure set up for theRTS,S trial could be used again.

Dozens of potentially moreeffective candidate vaccines arein earlier stages of developmentin academic and industry labsaround the world. For maxi-mum effectiveness they arelikely to be used in combinationrather than individually.

A partnership announced ear-lier this month between GSKand Crucell, the Dutch biotech-nology company, is a pointer tothe way things will go.

The two companies will carryout clinical trials with a combi-nation of RTS,S with Crucell’sAd35-CS vaccine candidate. Ani-mal tests have already shown asignificant enhancement whenthe two are used together.

The immune-stimulating anti-gen in both vaccines is a surfaceprotein from the so-called sporo-zoite stage of the malaria para-site’s complex life cycle – thestage at which it enters thehuman bloodstream after a mos-quito bite, and heads toward theliver where it will mature andmultiply. But the antigen ispackaged in different ways.

In RTS,S the antigen proteinis administered with an “adju-vant” that boosts the immuneresponse. In Ad35-CS the anti-gen is inserted into an adenovi-rus, a type of virus associatedwith mild respiratory infections,which delivers it to the immunesystem (adenoviruses are alsoused as vectors for gene ther-apy).

At an earlier stage of research– and using a very differentantigen – is a “transmission-blocking vaccine” or TBV beingdeveloped by Johns Hopkins

Bloomberg School of PublicHealth and the Sabin VaccineInstitute with support fromMVI. This approach aims to stopthe malaria parasite developingin the mosquito, so it cannotpass the infection on to humans.

The TBV uses a mosquitoantigen called AnANP1, whichplays an important role in theparasite’s establishment withinthe insect. Field research showsthat AnANP1 induces mosquitoantibodies that prevent the par-asite invading the insect’s gut,and the idea is that vaccinatedhumans would pass enhancedlevels of the antigen on to themosquitoes that bite them.

While a TBV would offer noimmediate protection againstmalaria to the vaccinated indi-vidual, the benefits would accu-mulate over time as the numberof infections declines with timein the community.

Another potentially fruitfulfield of research focuses on pre-venting malaria in pregnancy.Women are particularly vulner-able to infection while pregnant,because their immune defencesare lowered and because theparasites accumulate in the pla-centa. Maternal malaria kills10,000 women and 100,000 to200,000 babies every year.

Researchers at the Universityof Copenhagen are developing apotential vaccine based on theVAR2CSA antigen which shouldelicit antibodies that stop theparasite binding to the placenta.

The Danish scientists havethe elegant idea of attachingVAR2CSA to the human papil-loma virus (HPV) vaccines thathave recently been introducedto prevent cervical cancer. IfHPV can indeed act as a carrierfor the placental malaria vac-cine, then it would be possibleto protect girls in Africa againstboth placental malaria and cer-vical cancer with a single shot.

Vaccine developmentClive Cooksonassesses progress andexplains methods

Clinical intervention: a child is vaccinated as part of a trial in Kisumu­West District Hospital in Kenya Benjamin Moldenhauer

‘The problem with bednets is that they havebeen designed byentomologists. I’dlove consumerproducts companiesto become involved’

Estimated global resource requirements for malaria control

Source: WHO

$ billion

2008 15 20 25 30 35 40

6

5

4

3

2

1

0

From Global FundFrom other sources

Estimated funding available

FINANCIAL TIMES FRIDAY APRIL 23 2010 ★ 3

4 ★ FINANCIAL TIMES FRIDAY APRIL 23 2010

Combating Malaria

Vagaries of weather and the market hamper deliveries

Artemisia annua, a weedfound in the foothills ofsouth-west China, is nowthe most effective weaponin killing the malaria para-site. However, securing astable supply of its potentextract, artemisinin, isproving a big challenge.

Relying on the forces ofsupply and demand doesnot seem to be a solution.

The price of a kilo ofartemisinin, the key ingre-dient in the current pre-ferred malaria treatment,Artemisinin CombinationTherapy (ACT), ranged

from $1,200 in 2006 to $150in 2008. Today, the price ishovering at $400, which isexpected to increase withconcerns over a shortage,because of poor weatherand lack of cultivation in2009.

When the price was at itslowest, the panic was overpotential shortages of thedrug because farmers wereleaving the market for morelucrative crops. Whenprices were high, drug man-ufacturers could not affordto purchase the raw mate-rial and the global healthcommunity worried overthe increase in prices of thedrugs for patients.

According to Charles Lu,president of HolleyPharm ofChina, the largest supplierof artemisinin, there willvery likely be a shortage in2010 because of the severedrought in four main prov-

inces of China where it isgrown. “My fear is that lastyear’s drought has hurt thefarmers. It’s not easy forthem to recover their lossesand their confidence,” saysMr Lu.

Most Artemisia cropscome from relatively smallfarms. In addition to theweather, public influencessuch as donor funding, sup-ply chain management anddrug policies, have a bigimpact on the market.

ACTs are a relatively newclass of drug, so farmers,extractors and manufactur-ers are still getting to knowthe business. Aside fromindustry giants, Novartisand Sanofi-Aventis, themajority of manufacturersare generic drug companieswithout experience of pro-ducing drugs with a plantextract as a key ingredient.

Malcolm Cutler, an expert

in the artemisinin supplychain, says: “Generic manu-factures are used to pickingup the phone and orderingchemicals. They are notused to planning ahead,which is what you have todo, since it takes 14 monthsfrom seed to extraction.

“We have to cut down onthis boom-and-bust sce-nario. Long-term contractsare the key to the stabilityof the market.”

Novartis, which supplied84m ACT treatments in2009, has three-year con-tracts with extractors. It isone of the reasons the com-pany is able to deliverorders on time, while othershave had problems meetingdelivery dates.

Attracted by the successof ACTs in treating malariaand various initiatives toensure more patients haveaccess to the drugs, more

people are getting involved,from farmers and extractorsto drug manufacturers.

“Actually, the last thingwe need is new players atthe artemisinin extractionlevel. We have more thanenough capacity to meet

the current demand,” saysPatrick Henfrey, chief exec-utive of Botanical ExtractsEPZ in Kenya, one of thetwo main artemisinin pro-ducers in Africa.

“The international com-munity is involved in ACTsupply; it is necessary to

include the raw materialinto the plan,” says Mr Lu.

“I would like to seemaybe six or 10 qualifiedsuppliers who have thecapacity and can meet qual-ity standards. Then, thereshould be financial support,such as loans, because thisis a cash business and itcan create a high burden.”

At the average price of $1per treatment for the publicsector, ACTs are still tooexpensive without donorsupport, as hundreds of mil-lions of treatments areneeded each year.

One solution to bringdown the price is toincrease crop yield. In theUK, the University of Yorkhas been researching waysto create more robust varie-ties of Artemisia andincrease yields of artemisi-nin, without geneticallymodifying the plant.

Ian Graham, director ofthe Artemisia researchproject at York, says:“Unlike GM, we have notintroduced new DNA.Instead, we have selectedthe most productive DNAfor breeding. Our aim is todouble the artemisininyield, which would have ahuge impact on the price.”

Efforts to improve yield,stabilise the market, andincrease access face a seri-ous problem – drug resist-ance.

Resistance has been con-firmed on the border ofThailand and Cambodia,the same location wherec h l o r o q u i n e - r e s i s t a n tstrains of malaria surfacedand later spread throughoutthe world. There is now anaggressive attempt to con-tain the resistant strain.

Ultimately, the best wayto counter resistance and

curb the volatile artemisi-nin market is a completelynew class of drug that doesnot rely on a plant. Thenon-profit Medicines forMalaria Venture (MMV) hasbeen working on the nextgeneration of drugs for thepast 10 years.

MMV aims to register twonew artemisinin combina-tions by early 2011. Themost awaited drug, how-ever, is a non-artemisininsynthetic compound thatmimics the fast-actingmechanism of artemisininbut does not require theplant. One formulation,known as OZ439, has beguntrials in patients. MMVhopes it can be offered as asingle dose cure.

Tim Wells, chief scientificofficer of MMV, says: “Weare quietly hopeful that wecan have this non-artemisi-nin drug ready by 2015.”

Faith can helpheal bodies aswell as souls

Two months ago I joinedNigerian ex-PresidentOlusegun Obasanjo and anumber of the country’sreligious leaders in Kuje, atownship outside Abuja topromote a multi-faithprogramme to train 300,000Nigerian religious leadersin malaria prevention.

The idea is simple butpotentially very effective.Most communities inAfrica do not havehospitals or clinics, but allhave a church or mosque.

The programme uses thismassive infrastructure withits imams and priests todistribute bed nets andmedicines and facilitateaccess to trained healthworkers to combat malariain Nigeria.

This has been given thebacking of the Sultan ofSukoto, the leading Muslimin the country, and theCatholic Archbishop ofAbuja, John Oneiyekan.There is a full-time,centrally organised team toco-ordinate the programme.If it succeeds, the impactwill be enormous.

My Faith Foundation issupporting this work. Thepurpose of the foundationis to promote interfaithunderstanding.

Involving religiouscommunities is a sensiblepragmatic response to thescourge of malaria and thehealth challenges of theMillennium DevelopmentGoals.

For the simple truth isthat, while accuratestatistics are hard to comeby, the World HealthOrganization (WHO)estimates that in sub-Saharan Africa countries,on average, faithcommunities supply 40 percent of health care.

Faith communities reachinto rural areas wheregovernments find itdifficult to implementnational plans, for lack ofinfrastructure.

Embedded in localcommunities, religiousleaders are trusted and, iftrained, can giveauthoritative healthmessages. They haveprivileged access todynamic and committedwomen, motivated by theirfaith, who are so importantfor health care. They andtheir communities are stillthere when the donors gohome.

So why are very fewmosque and churchcommunities in sub-Saharan Africa fullyinvolved in the drive tohalt and reverse the spreadof malaria?

Several of the mostimportant reasons are: lackof resources andinformation, a degree ofmistrust and, sometimes,because governments areunderstandably anxiousabout proselytism and thedivisive potential ofreligion; and most religiousleaders are overworked andlack resources.

Religious leadersgenerally lackunderstanding of howgovernment ministrieswork, are almost neverinvolved in upstreamhealth planning, andreceive less than 5 per centof the money available for

health care, although theyundertake a large amountof the work. So there areobstacles to overcome.

But the process ofdismantling some of theseis under way. ChristianHealth Associations,drawing in a range ofchurches nationally, havesigned memoranda ofunderstanding withgovernments.

The Kenyan agreementto work together on healthis going well. A multi-faithinitiative in Mozambique,Together Against Malaria,has trained hundreds ofreligious leaders who aretrying to share their newlyacquired health educationwith their communities.

Pastor Rick Warren’schurch is doing good workin Rwanda in primaryhealth care. The NigerianInterfaith ActionAssociation (NIFAA) hasestablished itself as a “one-stop-shop” for governmentto make it easier tocollaborate on healthinitiatives with faithcommunities. The Ministryof Health, with WorldBank aid, is supporting itto the tune of $1m a year.

The Faith Foundationhelps co-ordinate dialoguebetween public healthofficials and faith leaders.

We also promoteresearch into the role offaith communities inhealth care. The key is totrain religious leaders inhealth and public healthofficials in a deeperunderstanding of how thevarious faith communitieswork, their “health worlds”and their potential.

But the campaigning roleof faith communities in thedeveloped world is alsosignificant.

The goal of theFoundation’s “Faiths ActFellows”, 15 interfaithpairs of young adults inCanada, the US and theUK, is to mobilise thepotential of religiouscommunities in haltingand reversing the spread ofmalaria.

We have volunteers in 75countries contributing toan international campaignagainst what one of thebishops in Abuja dubbed“the number one terroristin Nigeria”, the mosquitovector.

An encouraging sign isthat the “malaria sector”is now sometimes oddlydescribed as“overpopulated”. But thisis something I welcome.

Religious leaders,transnational businesses,government developmentagencies, academics, andmultilateral donors are allrequired to create thecritical mass that hasstarted the process oferadicating malaria fromthe African continent –just as it was eradicatedfrom Europe.

The Rt Hon Tony Blair isfounder and patron of theTony Blair FaithFoundation.

Supplies increase but distribution stalls

Sarah Byasi shakes herhead as she runs her fingerdown the stock page. She isin charge of drug suppliesat the Kibogo hospital inUganda and points toblanks showing there wereno modern malaria drugsfor adults for the 3 monthsuntil January; and none forchildren are currently avail-able.

“We give paracetamol ifthere are no ACTs [artem-isinin combination therapy– the current preferredtreatment for malaria],” shesays – a solution that pro-vides only palliative sup-port to patients sufferingthe disease’s symptoms offevers and aches.

Others in local clinicsturn to quinine – a “sal-vage” drug. But its misuse,

like that of ACTs, increasesthe risks of drug resistancethat will render treatmentsstill less effective.

Such “stock-outs” high-light how the developmentof even potent drugs suchas ACTs are only the firststep to ensure that treat-ments reach patients. Fund-ing and medical suppliesare increasing, yet they arestill not saving as manylives as they should.

The frustration is com-pounded by scenes such asthat across the road fromKibogo hospital, where aprivate pharmacy has nosuch supply problems. Itoffers wealthier patients alarge range of ACTs – aswell as many unauthorisedmalaria therapies that areineffective or risk triggeringresistance.

“Uganda loses 300 lives aday to malaria,” says HansRietveld, head of globalmarketing and access forCoartem, the leading ACT,at Novartis. “We have seenmothers harassing health-care workers when afterwalking two hours to aclinic they find there are no

drugs. Perversely, com-pared with one year ago,there are more suppliers,but the availability is worsethan before.”

One issue is poor manage-ment of funds to buy ACTs,which remain relativelyexpensive compared witholder – albeit less effective –malaria drugs. The GlobalFund to Fight HIV, TB andMalaria, which channelsmultilateral donor support,earmarked large sums forUganda for the drugs. Thenit suspended grants afterconcern over the country’sinability to account for howfunds were spent.

In March this year, threeof the principal officialsmanaging the government’smalaria programme werearrested, albeit in an inves-tigation that some observ-ers suggest was politicallyor commercially motivatedand for which the civil serv-ants are scapegoats.

Whatever the specificfacts, Uganda has allowedforeign donors to take fullresponsibility for itsmalaria programme, leav-ing it exposed and unable to

make its own drug pur-chases when externalmoney dries up. It has beenforced to seek help from theUS President’s Malaria Initi-ative to meet the shortfall.

That has sparked internaldebates about whether sucha poor country with a highdisease burden ever shouldhave switched to expensivemodern drugs like ACTs;

and if so, whether it shouldhelp provide domestic fund-ing by charging patients forother essential but non life-saving drugs such as pain-killers and antibiotics.

A second explanation forUganda’s stock-outs is itsprocurement processes. Asin other countries, tendersdo not always go to the low-est bidder, and deliveriesfrom the winning bidder are

not always met. Novartishas lost out in severalrecent tenders, and thenbeen asked in extremis bygovernments to fill gaps incommitments from the win-ning company.

“We are an autonomousbody without autonomy inprocurement,” says MosesKamabare, general managerof the country’s NationalMedical Stores, who saysthe process can take manymonths. “There has beenmore corruption thanbefore. There are so manytechnical reasons to removean offer. You can structureit to knock out all but themost expensive.”

Even when funds areavailable and drugs make itinto the country, they arenot always effectively dis-tributed. Mr Kamabareblames Uganda’s health dis-tricts, which he says do notplace orders on time orauthorise the necessarypayments.

Local clinics retort thatthey often receive incom-plete orders of the wrongdrugs, sometimes close totheir expiry dates, long

after they have beenrequested. Patients contrib-ute to a vicious spiral,feigning malaria when freshsupplies arrive so they canhorde for future infections.“When we have stock-outs,they have stock-ins,” jokesMs Byasi.

One response set tolaunch next month in ninecountries is the AffordableMedicines Facility forMalaria, which uses donorfunds to subsidise the ACTssold by private distributorsto ensure effective drugsare sold more affordably.

Other efforts try toimprove management in thepublic health system. InUganda, the medical charityAmref is helping introducecomputerised informationsystems to monitor diseaselevels. In Tanzania, groupsare experimenting with textmessages to disseminateinformation on stock levels.

But, as Mr Rietveld putsit, for such initiatives towork: “We need more politi-cal accountability, withnon-governmental organisa-tions defending patients’rights.”

ProcurementThe system isplagued by poormanagement andunreliable delivery,says Andrew Jack

New straindevelopsways roundimmunity

Most malaria researchand writing focuseson plasmodium falci-parum, the most

deadly of the four species of para-site that cause human malaria.

But the other three have a bigimpact on public health too, par-ticularly plasmodium vivax,which is the species most widelydistributed around the world.

According to the US ArmyCenter for Health Promotion andPreventive Medicine, p. vivaxaccounts for 70m-80m cases of dis-ease a year – about 20 per cent ofall malaria.

P. vivax, unlike p. falciparum, israrely fatal, but it does cause sig-nificant long-term illness. Symp-toms are similar to other types ofmalaria, including cycles of feverand chills, headache, weakness,vomiting and diarrhoea.

Relapses can occur months oryears after treatment, if the para-sites become dormant in the liver.The most common complication isenlargement of the spleen, accord-ing to the Malaria Vaccine Initia-tive (MVI).

Like the other plasmodium spe-cies, vivax is spread by anophelesmosquitoes. But there are severaldifferences from falciparum. Itpreferentially infects younger,smaller red blood cells and it canhibernate in the human liver forup to five years.

While falciparum is concen-trated in sub-Saharan Africa,vivax occurs widely across Asia,

the Americas, the Middle East,north Africa and the SouthPacific. It can tolerate cooler con-ditions than the heat-loving falci-parum.

Most cases of malaria found intravellers returning to Europeand North America are vivaxinfections. Those who fear areturn of malaria to temperateregions where it has been eradi-cated, as a result of climatechange and increased interna-tional travel, are particularly con-cerned about vivax.

Vivax is the only form ofmalaria endemic to the Koreanpeninsula. Although the WorldHealth Organisation officiallydeclared South Korea to be malar-ia-free in 1979, it reappeared therein the early 1990s and now causeswhat the US Army Center forHealth Promotion and PreventiveMedicine calls “sporadic epidem-ics”, as its carrier, the localanopheles sinensis mosquito,breeds in water in rice paddies.

The country worst affected byvivax is India, where the speciescauses up to 65 per cent ofmalaria cases. As a result, India isa leading centre of research intovivax malaria.

The main reason why Africahas few cases of vivax malaria isthat Africans are usually geneti-cally resistant to infection by theparasite. P. vivax, unlike theother plasmodium species, entersred blood cells through the so-called Duffy receptor – which ismissing in most black Africanpopulations.

But worrying research, pub-lished last month in the Proceed-ings of the National Academy ofSciences, suggests that vivax isevolving new strains that caninfect previously immune peoplewith “Duffy-negative” bloodgroups.

A study in Madagascar foundthat 10 per cent of clinical malariacases were occurring in Duffy-negative patients infected with p.vivax.

“These findings will have amajor impact on efforts to elimi-

nate malaria worldwide, particu-larly in large regions of Duffy-neg-ative west, central and southernAfrica,” says Peter Zimmerman ofCase Western Reserve University,senior author of the study.

“It will be imperative for the

global health community to findways to prevent the spread ofthese new strains of p. vivax tothe continent of Africa.”

The researchers believe the newstrains evolved in Madagascarbecause of population mixingthere, between people with Duffy-negative African ancestors andDuffy-positive Asian ancestors.This gave p. vivax many opportu-nities to attempt infection ofDuffy-negative blood cells, whicheventually succeeded throughmutation into a new strain.

P. vivax has traditionally beentreated successfully with the long-standing antimalarial drugs, chlo-roquine and primaquine. The lat-ter acts particularly against theliver stage of the parasite, reduc-ing the risk of relapse.

But vivax, like p. falciparum, isbecoming resistant to chloroquineand primaquine.

Vaccine development under-standably concentrates on p. falci-parum because it is the mainmalarial killer, though an Asianresearch network is looking forvivax vaccine candidates.

But the MVI says the long-termaim is to create a combined vac-cine that can prevent both typesof malaria – or at least reduce theseverity of symptoms.

Meanwhile, its vivax efforts arefocused on projects with the USWalter Reed Army Institute ofResearch and with the Interna-tional Centre for Genetic Engi-neering and Biotechnology inIndia and its industrial partnerBharat Biotech.

“We know less about p. vivaxthan falciparum, and we are stilllooking for more data to under-stand vivax and the severity ofthe disease it causes,” says Chris-tian Loucq, MVI director.

Disease developmentClive Cookson looks atworrying mutationsin the vivax speciesof the malarial parasite

Anopheles gambiae mosquito: one of the primary vectors of malaria in sub­Saharan Africa Science Photo Library

‘Researchers believethe new strainsevolved in Madagascarbecause of populationmixing there’

Guest ColumnTONY BLAIR

ArtemisininAnna Wang sayssecuring a stablesupply of the plantextract is difficult

‘Long­termcontracts arethe key tothe stabilityof the market’

Patients contributeto a vicious spiral,feigning malaria sothey can horde forfuture infections

Most communitiesdo not have clinicsbut they all have achurch or a mosquethat can be used asa health centre

FINANCIAL TIMES FRIDAY APRIL 23 2010 ★ 5

Combating Malaria

Illegal, immoral and liableto increase drug resistance

Few trades are as callous asthe manufacture and distri-bution of counterfeit medi-cines for curable but life-threatening diseases suchas malaria.

Reliable statistics aboutthe scale of the problem areunavailable, but counterfeitdrugs are thought by theWorld Health Organisation(WHO) to constitutebetween 25 and 50 per centof the medicine supply inless developed countries.

The global trade in boguspharmaceuticals will beworth some £45bn ($75bn)in 2010, according to the US-based Center for Medicinein the Public Interest(CMPI), an industry-backedthink tank.

Fake antimalarial drugsare a particular problem, asthe 500m cases of malariaworldwide every year makeit a large, lucrative market.

Thirty per cent of WHOmember states have ineffec-tive or nonexistent drugregulation, so the manufac-ture and sale of fake anti-malarials is relatively risk-free in many countries.

Paul Newton, head of theWellcome Trust-MahosotUniversity Oxford TropicalMedicine Research Pro-gramme, based in Vien-tiane, Laos, says the humancost of the trade is almostimpossible to estimate.

However, a significantproportion of the 1m deathsfrom malaria annually maybe attributable to counter-feit drugs.

In response to theincreasing sophisticationand global scope of counter-feiting operations, the WHOand Interpol – the interna-tional police organisation –formed the InternationalMedical Products Anti-Counterfeiting Taskforce(Impact) in 2006.

Aline Plançon, an Inter-pol officer at Impact, says:“The idea was to puttogether multidisciplinary

groups and encourage co-ordinated enforcement.”

In January, Interpol wenta step further, creating thededicated Medical ProductsCounterfeiting and Pharma-ceutical Crime (MPCPC)unit, headed by Ms Plançon.Several successful opera-tions have led to arrestsand seizures.

Operation Mamba II,which took place through-out August 2009, involvedraids across Uganda, Tanza-nia and Kenya. The opera-tion resulted in 83 policecases and some convictions– often hard to achieve.

South-east Asia was tar-geted in Operation Storm II,which concluded in Janu-ary. Impact seized about20m pills and made morethan 30 arrests.

However, it is difficult totrack counterfeit drugs totheir origins. Chemical test-ing of tablets and analysisof pollen grains found inthe pills and packaginghave been used to trace thelocation of manufacturers.

“We know there are crim-inal connections betweenAfrica and Asia, and areworking to identify exact

source sites, but there ismore work to be done,”says Ms Plançon. Dr New-ton thinks the majority offakes originate in Asia andare shipped to Africa forsale.

Seized counterfeit antima-larials range from benigntablets composed entirely offlour to dangerous mixturesof toxic substances.

Some samples actuallycontain the correct active

ingredients, probably in anattempt to evade detection.They are, however, oftenpresent in very low quanti-ties. This not only under-mines treatment, but couldcontribute to the develop-ment of resistance, render-ing the medicines useless.

Malaria is now frequentlytreated with derivatives ofartemisinin, a chemical

from wormwood plants.Artesunate, a semi-syn-thetic artemisinin deriva-tive, was the first suchdrug, developed in the 1970sin China.

The WHO now recom-mends administeringartesunate in combinationwith other antimalarials,known as artemisinin-basedcombination therapy (ACT).

These drugs have becomea target for criminals, asdemand is high, and theyare relatively expensive. In2008, counterfeit ACTs wereestimated to account forbetween 33 and 53 per centof samples in mainlandsouth-east Asia.

Although south-east Asiais likely to be the mainmanufacturing base for fakeantimalarials, the problemis global. Counterfeitingoperations have become bigbusiness in Africa, Indiaand Latin America.

Large shipments of coun-terfeited ACTs were seizedrecently in six Africancountries. “Everywhere welooked, we found counter-feit medicines,” says MsPlançon.

Despite Impact’s success-ful operations and ongoingefforts to tackle the trade,George Jagoe, of the Medi-cines for Malaria Venture –a not-for-profit public-pri-vate partnership aiming totackle the disease – says thedearth of reliable datamakes it impossible tojudge whether the situationis improving.

Dr Newton agrees,describing the available sta-tistical evidence as “mea-gre”.

Mr Jagoe suggests thatthe problem could be tack-led by introducing moresophisticated tracking oflegitimate drugs, increasingpublic awareness of theproblem and reducing thecosts of medicines.

There is hope: the ACTConsortium, funded by theBill & Melinda Gates Foun-dation, is working toimprove access to ACTs forall those suffering frommalaria in less developedcountries. If ACTs becomecheap and readily available,the counterfeiters may findthemselves out of business.

Fake medicinesJoseph Miltonlooks at moves tocounter the trade

If ACTs becomecheap and readilyavailable, fakersmay be put outof business

Smuggled and counterfeit medicines on a market stall AFP

Football fever Spreading word about public healthMalaria may wreak greatest damageamong the poor and the young but itis an undiscriminating disease. Evensome of Africa’s most successfulprofessionals – its highly­paid footballstars who have made their names inthe European leagues – have suffered.

So it is perhaps not surprising thatanti­malaria campaigners have seizedon the occasion of Africa’s first everWorld Cup, due to begin in SouthAfrica in June, as an opportunity toget their health care message acrossto larger numbers of people. Nor thatfootballers have been willingcampaigners.

As he juggles a ball for the camerasof the United Against Malaria (UAM)campaign, Kolo Touré, the ManchesterCity and Ivory Coast centre half,delivers a simple message. “In the 90minutes it takes to play a footballmatch, 180 children die from malaria.Yet a simple net prevents malaria.”says Mr Touré, who was hospitalisedby the disease two years ago.

The measures advocated by UAM,formed by groups including ComicRelief, the Roll Back MalariaPartnership and the UN Foundation,are straightforward: more emphasis oneffective primary health care.

That means making sureprogrammes, which are sometimesseen as the poor relations of Aids ortuberculosis efforts, are given a highenough priority by Africangovernments. Mosquito nets arecrucial: lobbying for public funding is apriority and to advertise the effort,UAM has produced an anti­malariabracelet, sales from which are directedtowards their purchase.

It means making sure peopleunderstand how they can avoidcontracting the disease and know whatthey need to do if they become ill.

The innovative thing about UAM isthe way that it is using footballfever to spread the word.

“African footballers are thenew stars of world footballand are the perfectmessengers to individuals inAfrica, and are also highlyinfluential in gettingbusinesses andgovernment onboard,” explainsPru Smith ofUAM.

“If a group of kidsare watching TV andtheir favourite playertells them to sleepunder a net they willlisten,” she says.“Everybody likesfootball. It is away to take the

message to the remotest village.”As well as global stars such as Mr

Touré, local football associations fromGhana, Tanzania and several othercountries have come on board, withadministrators arguing that theprevalence of malaria – especiallyamong young people – is underminingthe game’s potential in Africa.

Ms Smith says that the popularity offootball has made it easier to getpublic health ministers and officials toback public education efforts.

Above all the commercial reach ofthe World Cup has also made itattractive for companies to dedicatesome of their social responsibilitybudget to the campaign.

In South Africa, Standard Bank,MTN – the telecommunications groupthat is a big sponsor of the World Cuptournament – and Nando’s, a fastfood chain, have signed up.

Other heavyweights backing thecampaign include cable channels ESPNand Fox, the Japanese bank,Sumitomo and the pharmaceuticalcompanies Pfizer and Novartis.

For all these groups, fighting malariamakes commercial sense. Standardemployees are potentially vulnerable tothe disease both in a couple ofprovinces of South Africa and in manyof the African countries where thegroup has set up operations, so thereis a broader risk, explains SimTshabalala, the deputy chief executive.

Last year, days lost through malariacost the bank R450m. Mr Tshabalala,however, says that underestimates thereal impact. Endemic diseasesundermine social cohesion and in thelong run represent political risk andmean companies have to pay more fortheir capital. “South Africa ranksamong the world’s biggest 30economies but is 129th in the humandevelopment index. To the extent that

we fail we are increasing countryrisk.”

Standard is buying the publicitybracelets for all its 45,000

staff, equipping anyvulnerable employee

with a mosquito netand workingalongside NGOsin a number of

country­specificanti­malaria initiatives.

It won’t say exactly how muchis being spent, but Mr Tshabalalasays the benefits are much greaterthan the costs.

Richard Lapper

Kolo Touré, Manchester Cityand Ivory Coast centre half andmalaria campaigner

Better tests bring challenges

As the health community con-tinues to make progress inreducing the global incidenceof malaria, the need for accu-

rate and affordable diagnostics isgaining attention, with the WorldHealth Organisation (WHO), whichsees testing as a critical tool in thebattle against the disease, advocatinguniversal testing of all suspectedcases.

Fortunately, microscopy is nolonger the only diagnostic technologyavailable. The recent development ofrapid diagnostic tests (RDTs), whichuse a simple dipstick and a drop ofblood, means testing can done on alarge scale.

Yet developing RDTs for malariahas not been easy. While the tests cannow be produced very cheaply, thechallenge is that they need to remainstable in places where temperatureand humidity levels are high. At thesame time, they need to be sensitiveenough to detect low densities of theparasite in blood samples, withoutproducing false positives.

Companies may use the same rea-gent but the production of accurate,heat-stable tests can be more of an artthan a science, says Neil Mehta, presi-dent and chief executive of PremierMedical Corporation, which has devel-oped point-of-care rapid tests formalaria.

“You can give the same cookbook toeverybody, but the food all comes outdifferently,” he says.

This was the finding of the WHO,after it conducted the first majorreview of RDTs in April last year. Inindependent, laboratory-based evalua-tions of more than 40 commerciallyavailable RDTs, it found some coulddetect malaria in blood samples whereparasite densities were low while oth-ers could only detect the parasite athigh densities.

It also found test performance var-ied between batches, and recom-mended testing batches after they arepurchased and before they are used.

Publishing these results has serveda number of purposes. For a start, theperformance evaluation will be con-ducted on an annual basis – with thenext version publishing this month –providing a benchmark for the compa-nies developing the tests.

“Once people know that there’s aroutine system for assessing theseproducts, it will drive the quality ofthe market overall,” says Robert New-man, director of the global malariaprogramme at the WHO.

Moreover, the data are helpinghealth ministries and others selectfrom the many RDTs on the marketthe test most suited to their local con-ditions.

“It makes it possible to do some-thing that’s not possible for manythings sold into developing coun-tries,” says Mark Perkins, chief scien-tific officer at the Foundation forInnovative New Diagnostics (Find),one of the organisations behind theWHO’s evaluation study.

“And that is to allow ministries ofhealth who don’t have the staff or thecapabilities to do this kind of analysisto decide what to buy.”

Meanwhile, new malaria guidelinespublished by the WHO in Marchstress the importance of using diag-nostic testing where it is available,

rather than delivering treatmentbased on symptoms alone.

By helping inform procurementdecision-makers, the WHO data andguidelines will prove important toolsin the next phase of the battle againstthe disease – and not just for malariasufferers.

When the disease was rampant,health workers could, with reasonablejustification, assume that anyone withsigns of fever had malaria. However,as prevalence drops and the propor-tion of people whose fever is attributa-ble to malaria falls, health expertsstress the need to rule it out, so peo-ple can be treated for the real cause oftheir fever.

“The time for presumptive treat-ment has passed,” says Dr Newman.“We do no one a service by givingthem an ACT [artemisinin-based com-bination therapy – the current pre-ferred treatment] when they havesomething other than malaria.”

Health experts also point to the dan-gers of overusing malaria treatments.

“Indiscriminate use of anti-malarialdrugs fosters resistant strains andlessens the impact of the limitednumber of drugs we have to fight thedisease,” says Daniel Carucci, vice-president for global health at theUnited Nations Foundation, a charityand advocate for the UN.

Of course, the ability to distinguishpeople who have malaria from thosewith fevers caused by other illnessesbrings a fresh challenge – the need forbetter diagnosis of all conditions.

“This pushes the envelope in termsof what is required of healthcareworkers,” says Dr Perkins. “We mustrecognise the real limitations of thesystem and the capacity for them toreact to diagnostics. But it is a seachange we must face.”

At the same time, universal testingremains some way off. “This isn’tgoing to roll out everywhere and noone should be sent away withouttreatment because a test wasn’t avail-able,” says Dr Newman. “But the bot-tom line is we’ve raised the bar.”

DiagnosticsSarah Murray finds moreaccurate diagnosis of allcauses of fever is required

Rapid response: a malaria test is performed on a blood sample at a hospital in Cambodia Bloomberg

6 ★ FINANCIAL TIMES FRIDAY APRIL 23 2010

Combating Malaria

Activists worry about‘black hole’ of Burma

All day the boats chug backand forth across the slug-gish Moei river below theWang Pha clinic in westernThailand, carrying every-thing from timber and teato migrants and malaria.

The Moei forms the bor-der between Thailand andBurma, but if it is a negligi-ble barrier to goods, people,and disease, it is a huge onein the fight against malaria.

South-east Asia does nothave the same kinds ofinfection rates that are seenin Africa: the average per-son around Wang Pha getsan infectious bite about 0.6times a year, comparedwith more than 300 timesfor parts of Tanzania.

However, the Thai-Cam-bodian and Thai-Burmeseborders have the dubiousdistinction of being thesource of resistance to anti-malarial drugs.

Chloroquine and melflo-quine, both huge pharmaco-logical breakthroughs intheir day, met their matchin the jungles of south-eastAsia and surrendered.

And it is in this area thatdoctors such as FrançoisNosten first started tonotice tolerance to the drugartemesinin, the newestand current best hopeagainst malaria.

“I can still get the samenumber of patients cured,but it takes a little bitlonger,” says Prof Nosten,the director of the ShokloMalaria Research Unit, acollaboration between Ox-ford University in the UKand Thailand’s MahidolUniversity.

No one is entirely surewhat is happening withartemesinin tolerance.Around the Cambodiantown of Pailin, where it was

first observed, it now takesartemesinin-based combina-tion therapy (ACT) five toseven days to clear the par-asite from the bloodstream,up from 48 hours when itwas first used.

Prof Nosten says Shoklohas studied the genome ofthe tolerant strain and hasyet to find significant differ-ences. He even suggests itis possible the strain hasalways existed but has onlyrecently become noticeablebecause ACTs have elimi-nated most of the sensitiveparasites, leaving the toler-ant ones.

Shoklo has its offices andmain laboratory in the Thaicity of Mae Sot and runs aseries of clinics up anddown the Burma border.Prof Nosten says the workof the Global Fund andother agencies is having asignificant impact in Thai-

land and Cambodia, butBurma is a “black hole”, asource of disease untouchedby international funding.

He says that, as artemesi-nin tolerance spreads,Burma is a disaster waitingto happen: “You can proba-bly stop it in Cambodia, youcan probably stop it inThailand, but if it reachesBurma you have lost.”

The answer, Prof Nostenbelieves, is to democratisediagnosis and treatment.

Since simple, cheap andreliable diagnosis kits havebecome available, Shoklohas experimented withtraining villagers to diag-nose and treat locals. Thefaster a patient is treated,the less chance of extendingthe cycle of infection.

“You need to get the guyto the clinic within 48hours, and how can you do

that if the clinic is fivehours walk away?” he asks.

The programme has hadan extraordinary effect. In2007, the Shoklo networktreated 60,000 cases of falci-parum malaria; last year ittreated 35,000.

The problem is Burma,but in this case it is notthat the area just across theriver is a war zone, nor is itthe result the legendaryintransigence of the Bur-mese authorities: it is whatthe blue line of the Moeirepresents to the interna-tional authorities fundingthe fight against malaria.

“You have all the moneybeing concentrated on thisside of the border,” saysProf Nosten. “Research isglobal and they see the bor-der as a wall.”

A short walk across theborder from the Wang Phaclinic, lies Koko Hospital,sleepy in the baking heat ofthe late dry season. Dr NawBaw, the hospital director,has tried to set up a similarscheme, but she has nomoney and the terms ofProf Nosten’s funding pro-hibits him from sharing his.

“Different organisationshave different ideas, andsome are frightened tocome here,” is all she willsay of international reluc-tance to fund projects.

It is an attitude that infu-riates Prof Nosten. Heunderstands why Thailandwould be reluctant to givesome of its hard-won GlobalFund money to Burma, andis unsurprised that Burma –which again became eligiblefor Global Fund grants lastyear – has not spared anyfor the remote borderregion opposite Wang Pha.

What he cannot under-stand is why the fundinghas been structured so as tomake it difficult to obtainmoney for cross-border pro-grammes.

“If we stop at the border,we will not be able to stopresistance,” he says. “Wehave the tools, the drugs,even the money. The onlyproblem is the politics.”

South­east AsiaTim Johnston on asource of resistantdisease untouchedby global funding

Systemicproblemsthreatenprogress

It has been anotherbusy morning at thehealth post in Ndala-Mulemba, an hour out-

side Angola’s capital,Luanda, and the woman incharge, Fineza Amualdo,already sounds as if she hashad quite enough work forone day.

“We have had six malariacases already and anotherfive are waiting,” says the32-year-old Ms Amualdo, asa long line of women andchildren takes shelter fromthe sun under the canopyoutside her office.

“We are always tellingthem to use the nets butsometimes they don’t. Thenumber of cases is alwayshigh.”

Angola may be on theroad to recovery from a dev-astating three-decade civilwar, with the economygrowing and social spend-ing rising, but the health-care situation in slum areassuch as Ndala-Mulemba isprecarious.

Despite efforts to fight it,malaria remains thenumber-one killer disease,wreaking particular havocamong young children.

Considering that the local

authorities – with the sup-port of the United NationsChildren’s Fund (Unicef) –have radically stepped upprimary health efforts overthe past three years, thiscontinuing prevalence high-lights the difficulties infighting the disease.

Since 2007, the town ofCacuaco has built thehealth post at Ndala-Mulemba and benefitedfrom a Cuban health mis-sion, which has increasedthe number of public sectordoctors in the town of800,000 from three to seven.

Private sector clinicshave been persuaded tomake some services availa-ble to their public sectorcounterparts and themunicipality has contracted1,000 volunteer communityhealth agents.

The agents, who work intheir spare time, receive $50a month to cover their costsand distribute mosquitonets and chemicals to cleanwater. They persuade fami-lies to register births andvaccinate their children anddispense simple advice.

The effort is paying divi-dends in some areas. Lastyear, for example, 200,000children were vaccinatedagainst polio and whoopingcough, an increase of about20 per cent compared withtwo years ago.

But progress has beenslow. Part of the reason isthat it has been difficult toimprove health standardsamong a badly educatedpopulation that is new tourban living.

Joanna Silva, a doctorand municipal health offi-cial who has been orches-trating the effort, saysabout half the population ofNdala-Mulemba are first-generation rural migrants.Many are illiterate.

“The population growsday by day,” she says,which makes it difficult toplan the delivery of socialand health services.

Karina, a 36-year-old

Cuban doctor workingalongside Angolan nursesas part of a broader Cubanhealthcare mission, saysmany of her patients havebeen slow to put health rec-ommendations into prac-tice.

“They use their mosquitonets even when they haveholes in,” she says.

There are also signs thatlocal bureaucrats and pub-lic health workers have not

been 100 per cent behindthe effort. One of 20 volun-teers attached to the Ndala-Mulemba post, says thatfull-time nurses and admin-istrative staff have beenuncooperative.

“The nurses arrive lateand there are a lot ofdelays,” the volunteer com-plains. “If there is noimprovement in the service,there is really no point inus bothering. We are reallyde-motivated.”

Vaccines and chemicalsused to treat drinking waterhave sometimes been una-vailable. And efforts toencourage people to registerbirths [only about a third ofbabies are currently cata-logued] have run intoinflexible administrativeprocesses.

To cap it all, the provin-cial government has notpaid the volunteers the $50monthly stipend for nearlya year.

Domingo Dinis, a 30-year-old volunteer who alsoworks as a nurse, agrees.“It’s been going on formonths and we still haven’thad a response from theprovincial government. Itreally creates a problem,because when the bureau-

crats don’t respond, peopleblame us.”

Already four of 20 volun-teers have stopped working.

Nkanga Guimerães, adoctor and child healthspecialist at Unicef, saysthat vaccination and anti-malaria programmes arehaving a positive impact,but efforts to revitalisethese programmes are nec-essary.

“It is only the beginning,but it is being threatenedby small things,” he says.

Worse still, the other ele-ments of an ambitious pri-mary health care pilotscheme being developed inthe town are not panningout as hoped.

Few private clinics haveresponded to the municipal-ity’s call to help in the pub-lic sector.

Even the long-sufferingCubans are complaining.Karina says she spendsthree hours a day stuck intraffic, travelling to theclinic where she works.

“You waste a lot of timein traffic. It annoys you alot,” she says.

“We came here to workafter all. It is a rich coun-try, but they don’t knowhow to take advantage.”

Country profileAngolaRichard Lapper citeslack of education,bureaucracy anddemotivated staff

‘If there is noimprovement inthe service thereis really no pointin us bothering’

Patient waiting: locals queue at the Ndala­Mulemba clinic in Angola Fatima Carvalho

‘We have thetools, the drugs,even the money.The only problemis the politics’