In Ethiopia's Malaria War, High Prices Are the Real Killer

December 11, 2003
By Donald McNeil Jr
The New York times

With a major malaria outbreak sweeping Ethiopia, an international doctors' group working there contends that outdated drugs are being used to fight it and may even worsen the epidemic.

The UN Children's Fund, the agency providing the drugs, de-fended the choices it made in consultation with the Ethiopian governmet. The older drugs are still effective, it said, and changing policy mid epidemic can be disastrous.

But an internal World Health Organization memo from Dec 3, obtained by The New York Times, disagrees and "strongly recommends" that a new but more expensive drug be used.

The struggle illustrates problems confronting the makers of world health policy. Drug-resistant strains can evolve faster than new drugs can be discovered, and new cures are inevitably more expensive, forcing choices between costly drugs that work and cheap ones that may not.

The WHO expects Ethiopia's epidemic to spread to 15 million of its 65 million population—triple the normal rate.

The aid group arguing for newer drugs, Medecins sans Frontieres, says that in the two Ethiopian areas where it runs clinics, up to 60 percent of patients have strains that appear resistant to the first-line treatment that Unicef and Ethiopia picked, a two-drug cocktail of chloroquine and sulfadoxine-pyrimethamine, better known as, SP, or the brand name Fansidar.

The group said the second-line treatment, hospitalization for five days of quinine, was inaccessible for many patients and hard on malnourished children.

Medecins sans Frontieres wants to introduce artemisinin, the latest wonder drug against malaria. But it is relatively expensive. Even at the prices drug companies offer to the poorest countries, cocktails that use it cost from $1 to $2.50 per adult treatment. A typical treatment of chloroquine and SP costs about $0.20.

The artemisinin program requires taking pills for three days, not one.

Nonetheless, the WHO, which usually provides treatment guidance, strongly endorses artemisinin cocktails, which are being used in several African countries, including Burundi, Liberia and South Africa. Because resistance to chloroquine is widespread, the WHO discourages its use.

Dr Kevin Marsh, a malaria expert working in Kenya, called chloroquine "a failed drug" and said health authorities were foolish to spend money on it.

Several countries have dropped requests for money for chloroquine and have asked for artemisinin.

Nonetheless, the Ethiopian government has refused to let artemisinin be imported.

The US, which has contributed more than $2 million to fight Ethiopia's epidemic, now endorses using artemisinin in many African countries, in the Amazon Basin and in Vietnam's Mekong Delta. That is a policy change from 18 months ago, when the US generally opposed its use in Africa.