A New Approach to Combating Malaria at WHO

Tina Flores | 25 Jun 2006
Global Health Council
Why the New Guidelines, and What Will WHO Do to Support Countries?
First of all, these are new treatment guides after 20 some years. The new guidelines center around the use of ACTs. We are pushing countries to change their policies and convert to ACTs, in order to prevent malaria parasites from developing drug resistance. We are also supporting them in implementing this policy change.

It usually takes about two years for governments to change policies. Because they currently use monotherapies, each health worker must be trained how to use the new ACTs. Health-facility wise, it is relatively easy. Three days [for ACTs to be effective], what kind of chore is it to get that together?

But how do we introduce ACTs at the community level? That is the real challenge. It calls for better management of the supply chain, improved support and supervision to mothers from health facilities. These are areas that we are prioritizing for support to countries.

Is There a Good Model from Another Disease?
I think it is Oral Rehydration Salts for communities, definitely.

You've Gotten a Lot of Press Because Recommended that Drug Companies Stop the Production of Artemisin Monotherapy. What Has Been Their Response?
Companies' positions on the marketing of oral artemisinin monotherapy have direct implications for the treatment guidelines. The goal is to push ACTs. We cannot afford to lose ACTs. If we do, basically, we are dead.

In order to keep ACTs effective for as long as possible, we are doing a couple of things. First, we are asking pharmaceutical companies that are marketing artemisinin monotherapy to stop. To date, 13 companies, including the main, high-quality producers of ACTs, have declared their willingness to stop marketing artemisinin monotherapies and to re-direct their marketing efforts towards ACTs. Meanwhile, 27 companies have not yet made commitments to stop pushing the monotherapy drugs.

Do You Find that Companies Located in Specific Countries are More Likely to Be Resistant? Maybe Some of the Generic Manufacturers?
Even some of the European companies are leery; they are clinging to the way they run the business. For example, marketing treatment courses that use monotherapies for five days- this is not effective. Monotherapy treatment needs at least seven days. The trouble is that people start feeling better within three to five days and don't bother to finish the required seven days of drugs. The fact that companies sell monotherapies in five-day treatment increments makes things worse. Patients try their luck with the five-day course of drugs that is cheaper- and in the end dangerous for themselves and the rest of us.

This is one part, the companies' part. At the same time, we have asked national authorities to withdraw marketing authorization for artemisinin monotherapies. Some countries already have integrated ACTs into their treatment guidelines and are banning monotherapy marketing. Twenty-seven countries that need ACTs either do not allow marketing of artemisinin monotherapies or are moving toward withdrawing marketing authorization for these products. Forty-nine countries have yet to do so.

Also, we want to have a technical briefing in one of these countries on this issue so that many more countries will decide to ban monotherapies. So, you have to tackle this from several angles, including the regulatory side and production side.

One of the Most Challenging Aspects of Malaria Control Seems to Be Complex Emergency Settings- Refugee Camps, Disasters. What Are the Challenges and How Are You Going to Address Them?
Emergency epidemics are unfortunate, but they are basic realities in health work, and we have to prepare ourselves for them. We can predict a lot of things. We can see rainfall patterns. We can see when the political situation starts to get volatile, and take precautions.

We need good teams to coordinate epidemics and emergencies on a large scale. We have to prepare the emergency stocks, drugs, preventive measures and people we need to operationalize the response. Also, governments and donors have to be realistic about the kind of money we need to operationalize emergency responses on regional and sub-regional levels. When these things happen, they must be tackled aggressively.

The military is a useful partner, just in terms of the logistics. In many of these emergencies, epidemic-wise, logistics is probably the hardest part.

What Lessons Have You Learned from Your Past Experiences as Head of TB and AIDS at WHO That You Will Apply- that You Can Apply- in this Position?
Science comes first. Politics comes second. Take clear positions. Make everybody, including, WHO, accountable.

How Will You Hold People Accountable?
Have clear strategies with timely monitoring and evaluation systems so that we can tell if we are doing a good job or a bad job. Thus, currently our focus is to develop clear strategies for monitoring and evaluation for the respective interventions.

With Each Country Being so Different, How Can You Agree on One Strategy?
I don't know at this moment what exactly that strategy is. First, we got agreement on a generic strategy for case management, outlined in the treatment guidelines, which needs to be tested in countries. If it produces results, then countries will accept it. Then, the issue is with ITNs (insecticide-treated nets) and IRS (indoor residual spraying). What combinations are best, what is required for particular geographies? These things have to be worked out according to the local context in order to accomplish effective scale-up. We want to start by tackling key drugs issues, and then move from there to develop and refine our arsenal of tools to beat malaria.

When You Look Back at Your Tenure, What Will You Want to Have Achieved?
Concerning malaria, once we develop clear strategies, we want to get a consensus. These strategies will be adapted and implemented in many countries. We hope these interventions will produce an impact, and we are crossing our fingers. Because instead of first trying to focus on impact- that's where many public health programs fail- I'm focusing on key, technically sound interventions. We're first going to scale-up a particular intervention well. Only that way will one get the impact.

You've Been in the Public Health for a Long Time, You've Been at the WHO for a Long Time...
Before taking this job, I had a great life. I was adviser at WHO, I was playing golf, I have a great reputation in TB and to some extent AIDS. I was forced to take this job. One of my ex-colleagues told me, "People are going to remember you for your last job. They don't remember what you have done, achieved in the past." So in order to maintain my credibility, I have no choice but to succeed.

Is There Someone in Particular that Drives You or Continues to Inspire You?
Patients and country managers. When I go to countries, the most important thing to see are patients and the people working there. For me, on a global level, whatever we do in Geneva and Washington, those things must make sense for the district managers and patients.