The Challenges Posed by Malaria
By Christa Hook and Nathan Ford
April 23, 2005

In the last few weeks a new disease made the media spotlight. The Marburg virus, which has killed over 200 people in Angola, has all the drama of a Hollywood film. Meanwhile, out of the media spotlight, another disease continues, silently, to kill up to two million people every year. Malaria remains the biggest source of the illnesses faced by MSF, and is one of our most frustrating challenges.

The shock of the old

Over the last few decades, MSF doctors along with other health workers in the developing world have been dismayed to see the struggle with malaria get more and more difficult. While eradication efforts in the US and Europe wiped out malaria by the 1950s, the rapid development of parasite resistance to medicines and insecticides, together with waning Western interest in the ex-colonial world, meant that these eradication efforts have failed in most parts of Asia, Africa and Latin America.

Today, up to 500 million people annually develop malaria – far more than in the 1970s. Of the estimated two million people who die of malaria each year, 90% are African children under the age of five. Malaria continues to be the number one cause of illness addressed by MSF programs. Last year alone, over a million people were treated by MSF for the deadly form of the disease, falciparum malaria.

Frustrated by the poor availability of effective medicines and diagnostic tools, MSF began three years ago to use its field experience to press the international community take greater responsibility for increasing access to care for malaria treatment. The bottom line is this: millions continue to die of a disease that is cheap and easy to cure. For MSF, this is completely unacceptable.

Replacing old medicines that don't work with new ones that do

The situation is not hopeless. While many of the older medicines such as chloroquine and sulfadoxine-pyrimethamine (or Fansidar) are almost completely ineffective, new medicines that do work - artemisinin-based combinations (ACT) - have recently been developed. Treatment with ACT takes just three days and costs as little as 60 cents for a child and $2 for an adult.

MSF has shown the effectiveness of these new treatments - for example in a high transmission area in Angola, admissions for severe malaria were reduced by 25% in the year following the introduction of ACT. Over the same period, mortality reduced by 75%, compared to the previous year.

Partly thanks to evidence such as this, there is now a widespread recognition by donors, UN agencies and affected countries that ACTs must be provided as soon as possible to stop the increasing death rate, mainly of young children who are not treated adequately. Most countries in sub-Saharan Africa have switched their national treatment policies from the older, inadequate treatments to ACT-based therapy.

Putting policy into practice

But the problem is far from solved. Even where the new policy is in place, MSF sees that effective diagnosis and treatment remains available to only a tiny proportion of those who need it.

Not enough medicines, not enough money

At the international level, two major issues persist: there is a critical shortage of ACTs, and there is not enough money to allow malaria-burdened countries – among the poorest in the world – to provide treatment for free.

While demand worldwide for ACT has increased, companies which had promised to increase production to meet the need failed to do so. This has for example left Ethiopia, a country with a heavy malaria burden, with an acute shortage of drugs. It is holding what drugs it has in reserve for epidemics. Children continue to die of inadequately treated malaria.

A year ago MSF sounded a general alarm, calling for extra donor money to prime the pump of supply and production, so that enough of the plant that gives artemisinin would be available. Now at last, there are some large-scale international solutions being put forward. There is hope that the shortages will be over during 2006.

In Burundi, the main problem today remains the cost of treatment. In the last few years the government has changed its malaria treatment policy to ACT, funding was procured, training was implemented, and the old ineffective drugs removed from all the clinics. But like many countries, Burundi has been persuaded that it is necessary to charge a small fee for a consultation.

This policy was promoted by the World Bank, in the hope that “cost-sharing” or “cost-recovery” schemes would make health systems in poor countries more sustainable. In these very poor countries this is a false hope: rather than adding income to the health system, cost-sharing has proven to be a very effective way of keeping the poorest from receiving treatment. Studies done by MSF have shown that the death rate from malaria increases with increasing health service charges.

Rolling back malaria is a political, not a medical problem

For MSF, it is clear that the major problems in tackling malaria are not technical, medical or scientific. It is entirely feasible to produce enough ACTs and get them distributed so that treatment can reach people in need. But that will only happen if there is urgent and sufficient political action.

The responsibility for curing malaria cannot lie with the child's poverty-stricken family; the responsibility lies with the international community, which can and must provide the funds to treat every child and adult suffering from this entirely curable disease.

Christa Hook is head of MSF's international working group on Malaria. Nathan Ford is head of MSF’s Manson unit, which provides support to malaria field programs, located in the United Kingdom.