Malaria claims up to a million lives every year. In 2008, 88 lakh children under five died, half of them in Africa. Just three countries – Democratic Republic of the Congo, Nigeria and Uganda – accounted for 43% of these sad deaths in Africa. Malaria alone has killed over 354 thousand children under five in these three countries, 677 thousand in Africa, and 732 thousand worldwide.
These estimates were recently published by the independent Child Health Epidemiology Reference Group, established by the World Health Organisation (WHO). Incorporating these findings with the revision of global child mortality by the UN Inter-agency Group for Child Mortality Estimation, the WHO has published revised estimates in its latest World Malaria Report.
Its broad conclusions are that malaria mortality and incidence rates have remained constant between 2000-2004, but continuously declined from 2005 to 2010 with the mortality rate down by a quarter worldwide, and the incidence rate down by 17%. But is there a reason to celebrate? Not quite. Incidence rate isn't the same as number of cases, and the mortality rate isn't the same as the number of deaths. Although both have gone down, malaria cases and deaths haven't effectively decreased in Africa.
The achievements of the last decade may get negated if we were to lose Artemisinin, the drug that has helped us to win our recent battles against malaria by reducing its mortality rate. Of the five species of Plasmodium known to infect humans, Plasmodium falciparum (Pf) is the deadliest. Pf has developed resistance to all currently used antimalarials. So far, Artemisinin has managed to escape drug resistance because it has been used in combination with older drugs (called ‘Artemisinin-based combination therapies') and seldom on its own (monotherapy), as recommended by the WHO.
However, some countries have not complied with these guidelines. Worryingly, several recent studies have warned of Artemisinin-resistant Pf malaria emerging in Cambodia, Thailand, Myanmar and Vietnam. Malaria cases and deaths have spiked whenever resistance to front-line drugs has spread around the world. If we also lose Artemisinin-based combination therapies to resistance, we will run out of weapons in our war against malaria unless a new miracle drug is found.
In spite of repeated calls for actions recommending a ban on oral Artemisinin-based monotherapies, 28 pharmaceutical companies (most of them in India) market them in 25 countries (mostly in Africa), jeopardising the health of the whole world. In May 2010, at the Eighteenth Roll Back Malaria Board meeting, representatives of 40 ministries of health, including India, committed themselves to “express our governments' engagement to eliminate (ban and enforce) oral Artemisinin-based malaria monotherapies and substandard ACTs from the market through tangible policies, strategies and regulatory measures within the next 12 months”. This resolution was hailed as part of the latest Global Plan for Artemisinin Resistance Containment.
However, the WHO's list still mentions that nine Indian companies have not yet disclosed their intentions to comply with its recommendations. The Indian government must act on a war footing to redress this situation and also put severe diplomatic pressure on Bangladesh, Bhutan and Myanmar so that they ban oral Artemisinin-based monotherapies for the treatment of uncomplicated malaria.
As an emerging power, India should divert significant resources towards this major public health problem, at least for its own sake. We cannot afford to be complacent after winning a few battles. It would indeed be devastating if Artemisinin-resistant Pf malaria spreads to Africa and the Indian subcontinent.
SS Vasan is with the Health Protection Agency, Porton Down, Britain. The views expressed by the author are personal.