WHO failures led to hundreds of thousands dying from malaria, say medical experts

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The Independent Online

Two of the world's most powerful medical organisations have been accused of medical malpractice for knowingly promoting useless drugs that have led to the deaths of hundreds of thousands of children.

The World Health Organisation and the UN Global Fund, which was set up to buy drugs for poor countries, have allocated millions of dollars to malaria medicines that are no longer effective against the disease, a group of specialists said. They claim negligence by the two organisations contributed to a rising death rate from malaria, which has doubled in a decade in some parts of Africa because of growing resistance to older drugs.

The WHO launched its Roll Back Malaria programme in 1998 with a target to halve the number of deaths by 2010, but six years into the 12-year programme deaths have risen from between 600,000 and 800,000 to over one million annually, of which 90 per cent are in children under five.

Amir Attaran, of the Royal Institute of International Affairs in London, who made the accusation of malpractice in The Lancet with 12 malaria specialists from Britain, the US, Africa and the Far East, said yesterday: "I am angry because I know hundreds of thousands of kids have died for nothing; possibly millions. It is really negligent for these organisations to have made no progress towards the target in six years. Why should anyone connected with the programme still have their job?"

In 2003 the Global Fund, acting on advice from the WHO, spent $41.4m (£22.5m) on the outdated anti-malarials, chloroquine and sulfadoxine-pyrimethamine, which have been rendered useless by growing drug resistance, but only $18.3m on artemesinin-based therapies, which are effective.

Countries worst affected by malaria in sub-Saharan Africa have proved reluctant to buy the new artemesinin drugs because they are more expensive at $1 to $2 a dose, 10 times more than chloroquine. Although they get help from the Global Fund, they fear they may be left to foot the bill themselves. As a result, patients treated with the outdated drugs in Africa outnumber those given the effective artemesinin drugs by more than 10 to one.

Mr Attaran, a lawyer and malaria expert, said: "If a hospital consultant were to provide medicines to patients which 80 per cent of the time were ineffective, would that not be malpractice? And if it is wrong for an individual doctor to behave in that way, how can it be right for a global medical organisation?"

Bill Watkins, co-author of the Lancet paper and research fellow at the University of Liverpool, was director of the Wellcome Research Unit in Nairobi, Kenya. He said: "I spent 30 years working on malaria in Africa and we have been getting more and more frustrated at the lack of progress. The figures speak for themselves. Vast sums are being spent on chloroquine, which should not be used anywhere in Africa."

Other scientists have supported the specialists. Nicholas White from Mahidol University, Bangkok, with colleagues from Sweden and Kenya, says in The Lancet that says deaths in eastern and southern Africa have doubled in the past decade.

"Provision of ineffective drugs for a life-threatening disease is indefensible ... We have failed to roll back malaria and we in the developed world bear the responsibility for this humanitarian disaster."

The World Health Organisation said yesterday that changing countries' approach to malaria treatment was "a process, not an event". But Allan Schapira, co-ordinator of the policy team for the WHO Roll Back Malaria programme, admitted mistakes had been made.

"The principal charge that people have had insufficient access to the right drugs is correct. The impediment has been the anxiety of policy-makers in the affected countries over moving to more expensive [artemesinin-based] treatments. The Global Fund says they have the money but the policy-makers worry that it may be withdrawn in a couple of years."

He added: "I would concede we should have come out more strongly with our guidance. We should have spoken with a louder voice. We were aware there was a lamentable use of funds for better drugs. Too many countries applied for chloroquine and we should have said more strongly they can't go on with this."

Mr Schapira said the financial consequences for the global community were serious. WHO's estimate is that spending on anti-malarials will have to rise from the present $50m a year to $1bn.

Aids distracts attention from an even deadlier epidemic

In Malawi malaria still claims more lives each year than Aids, but attracts a fraction of the attention. Coachloads of overseas visitors come to view the Aids drugs projects run by Médicins Sans Frontières outside Blantyre, which hand out free antiretrovirals, to people with HIV, but few are interested in malaria.

Malaria is old and Aids is new. Malaria has never captured the public imagination as Aids has done, even though children are its chief victims. Most important, malaria is not a disease that bothers the west - except for those fortunate enough to holiday in the tropics - whereas Aids threatens us all.

Yet the scale on which the parasite, transmitted by the mosquito, kills is breathtaking. It causes 300 million cases a year and more than one million deaths. About 40 per cent of the world's population is at risk, in the tropics and sub-tropics.

Six years ago the World Health Organisation (WHO) set a target to halve the number of deaths by 2010, but instead the toll has risen by at least a quarter, and in some areas by as much as 50 per cent, because victims have not had the right drugs. Hundreds of thousands of children have died needlessly and it has gone virtually unnoticed in the West.

Sub-Saharan Africa is the worst-affected region, accounting for 80 per cent of the world's cases. A child under five in Malawi can expect to get malaria three or four times a year, while an adult will go down with the fever at least once a year. Nine out of ten of those who die are children.

For 40 years chloroquine was the standard treatment. Patients swallowed a couple of pills at the onset of the fever and within 48 hours they would be better. It was safe, effective and cheap.

But over recent decades, a drug-resistant strain of malaria, Plasmodium falciparum , has been growing in Africa and now accounts for well over 90 per cent of cases. Surveys in East Africa show that almost two thirds of patients given chloroquine and nearly half of those on its successor, sulfadoxine-pyrimethamine, have died. The only effective therapies are those based on artemesinin, a drug derived from a weed that grows wild in Africa and the Far East.

It has been used in China for 2000 years with no observed resistance, but it is new to Africa. However, it costs $1 to $2 (£1) a dose, compared with 13 cents for chloroquine and 14 cents for sulfadoxine-pyrimethamine.

One dollar is not a lot to save a life, but because of the vast numbers affected - 600 million people in Africa - countries have been afraid to pay for the new drugs, even with full financial support from the UN Global Fund. The WHO advises countries which drugs to buy and the Global Fund provides the cash. Both organisations have argued that it takes time to persuade countries to change their treatment policies - it is a "process, not an event", they say.

But how much time is enough? After six years of the WHO programme, malaria deaths have soared. Thousands more children will die until these life-saving artemesinin drugs reach the people who need them.