Dr Frank Smithuis

GOVERNMENTS and aid agencies the world over are clamoring to obtain a highly effective drug that has been used in Myanmar to fight malaria for nearly 10 years, fuelling speculation that a global shortage may be imminent.

The drug, artemisinin, is based on a 200-year-old Chinese herbal treatment.

Doctors say a widely-used drug, chloroquine, is no longer effective against the disease, and artemisinin in combination with other drugs has become the preferred treatment.

Resistance to chloroquine treatment has been growing for decades.

“Chloroquine became useless 25 years ago,” said Dr Frank Smithuis, the country manager for Artsen Zonder Grenzen (Medicins Sans Frontieres-Holland).

Dr Smithuis, a passionate supporter of artemisinin combination therapy, or ACT, was involved with other health professionals in contributing to a change in Myanmar’s malaria policy in 2002 under which the Health Ministry chose artemisinin to treat the disease.

“In the last study we did with artemisinin, we treated 320 patients and 319 got cured. There is no other drug on planet earth where you can see that,” said Dr Smithuis.

Governments and aid agencies have been reluctant to make the switch from artemisinin to chloroquine for one major reason – cost. The price of artemisinin varies according to which drugs it is combined with and how it is packaged, but the mean price is around US$3 a treatment. Chloroquine can cost as little as 20 cents a treatment.

Dr Smithuis says the price of ACT should be considered in the context of a broader treatment strategy.

“That’s very little for a disease that you can die of, but it’s still a lot for a national health project,” said Dr Smithuis.

Representatives in Myanmar of the United Nations Children’s Fund, UNICEF, say it provides treatments for 80,000 malaria patients a year.

Dr Leonard Ortega, a medical officer with the World Health Organisation in Myanmar, says pragmatism is paramount.

“Artemisinin is very effective. But if you have $100,000 you can treat less than 25,000 cases – yes it’s 100 per cent effective for those 25,000, but if you buy a less effective drug for example, maybe you are able to treat 200,000 cases. It may be 50 per cent effective but 100,000 would be treated. So it’s a balance of technical soundness, operational facility and cost,” he said.

UNICEF and the WHO advocate a policy of treating the less deadly strain of malaria, Plasmodium vivacrum, with chloroquine. Health professionals agree that chloroquine is still effective against this lesser strain, but disagree as to whether the cheaper drug should still be used.

“It’s totally unethical to treat with chloroquine,” said Dr Smithuis. “When you are sick you go to the clinic, and nobody knows whether this is going to be a lethal or non-lethal disease. No doctor can decide whether this will be severe or not, so you should always treat with ACT,” he said.

“If you have patients and you treat them with lousy drugs, patients will continue to have malaria. Transmission will just continue.”

Health professionals say the catalyst for facilitating the change from chloroquine to ACT has been the Global Fund to Fight Aids, Tuberculosis and Malaria, which has attracted sizeable contributions from governments and the private sector throughout the world.

The Ministry of Health has sought funding support from the Global Fund and if the application is approved Myanmar stands to receive more than $9 million to fight malaria in the next two years.

Dr Smithuis says he advised the ministry to ensure that the funding application specified ACT, not chloroquine, as the primary treatment.

“I said if you propose chloroquine, you will not get a dime,” he said.

The Global Fund has effected similar policy changes elsewhere, fuelling what some predict will be a global shortage of ACT. The New York Times reported this month that world agencies are seeking 100 million doses of artemisinin.

“There is a huge demand and the raw materials to supply the demand are not sufficient,” said Dr Ortega.

“Every country, not just Myanmar, will be affected. It depends on who will be able to make the request first and have the money to buy.”

WHO and UNICEF representatives in Myanmar say they have not had any problems procuring ACT, but that may be because they have not sought the drug in large quantities.

Dr Myo Zin Nyunt, a UNICEF project officer, says that until the Ministry of Health can buy large amounts of ACT, a shortage is unlikely to have an effect.

“In the future, when we have the global fund there may be some problems with a shortage of artemisinin,” he said.