WHO, the Global Fund, and medical malpractice in malaria treatment

Sir

Amir Attaran and colleagues (Jan17, p 237)¹ highlight a very serious public-health issue. Provision of ineffective drugs for a life-threatening disease is indefensible. There is no doubt that chloroquine is now ineffective for the treatment of falciparum malaria in nearly all tropical countries, and that its usual successor, sulfadoxine-pyrimethamine, is falling fast to resistance. As a result, malaria mortality in eastern and southern Africa, where hundreds of thousands of children die each year from the infection, has doubled in the past decade.² We have failed to roll back malaria, and we in the developed world bear the responsibility for this humanitarian disaster.

Malaria is not an insoluble problem. We already have the tools (insecticides, bednets, highly effective drugs) to reduce substantially the terrible death toll. But we are not providing them to the people who need them desperately, but who cannot pay for them. Only a tiny fraction of the millions with malaria today receive highly effective treatments. The donors must take some responsibility for this failure. Given the choice between receiving donor support for ineffective chloro-quine or sulfadoxine-pyrimethamine and receiving nothing, most countries have naturally opted for the former. It is not easy to protest, particularly when the main donors, and the representatives of international organisations, both claim these drugs are still “programmatically effective”. It is an uncomfortable but inescapable fact that, despite much anodyne rhetoric, the rich world does not wish to provide the required funds to drive back this eminently treatable killer.

To tackle malaria seriously, we hope that the WHO can recapture the singularity of purpose, scientific rigour, courage, cohesion, and determination that characterised the successful smallpox eradication campaign and more recently its response to the epidemic of severe acute respiratory syndrome (SARS). For this to be achieved, WHO will need to be better supported financially, and regain its independence from the political influence of powerful donors. The Global Fund is a beacon of hope, but it too needs a much greater injection of funds from the wealthier countries, and for malaria it needs better advice and technical review—hopefully led by a revitalised and independent WHO.

Success in controlling malaria is possible, and would provide a tremendous humanitarian and economic benefit to the less developed world, but it will not come if we continue to underinvest in public-health systems in poor countries, and to provide ineffective antimalarial drugs. The international medical and scientific community must do more to present a convincing case to obtain increased appropriate funding. If we could all admit the problems, agree on evidence-based intervention strategies, ban empty and confusing politically driven rhetoric, and show that success can be achieved, then it might be easier to persuade those who control the purse strings that malaria control is both achievable and a humanitarian bargain.