Stifling Dissent on Malaria

Roger Bate | 08 Dec 2008
Nine months ago, The New York Times reported that Dr. Arata Kochi, head of malaria control at the World Health Organization (WHO), was worried the Bill and Melinda Gates Foundation was undermining scientific creativity in a way that "could have implicitly dangerous consequences [for] the policymaking process in world health." According to Kochi, the Gates Foundation's research support comes with strings attached. He expressed concern that Gates-funded studies were adopting "a uniform framework approved by the Foundation," leading to homogeneity of thinking. Gates has created a "cartel," said Kochi, with research leaders linked so closely that "each has a vested interest to safeguard the work of others. The result is that obtaining an independent review of scientific becoming increasing difficult."

Kochi never intended for his remarks to be aired publicly; his internal WHO memo was leaked to the Times. But it had a welcome effect, briefly galvanizing a debate about the best ways to spend aid money—a debate that could lead to new discoveries, more effective interventions, and many more lives saved.

Unfortunately, the malaria community has recently been discouraging debate over a new initiative known as the Affordable Medicines Facility for Malaria (AMFm), which was approved by the United Nations-backed Global Fund in early November. The AMFm will spend some $2 billion on anti-malaria drugs over the next five years. It may increase access to good quality medicines and save thousands of lives. But it may also increase drug resistance by pouring medicines of unknown quality into poor countries with underregulated health systems.

Thus far, debate over the new venture has been suppressed by many of its supporters, who perhaps fear that too much discussion of AMFm would expose its flaws. Meanwhile, Dr. Kochi appears to have quietly exited the global malaria debate. He is still head of the malaria program at the WHO, but he failed to return numerous emails and voicemails requesting comment (after granting me an interview this past February, when the New York Times story came out).

During his tenure as WHO malaria chief, Kochi has ruffled plenty of feathers and irked many activists. But he has also brought important reforms to the world body. In January 2006, under Kochi's leadership, the WHO issued new malaria treatment guidelines for the first time in 20 years, a move which helped ensure that the countries most affected by malaria could direct aid money toward the most effective treatment policies. As part of this effort, Kochi lobbied pharmaceutical companies to cease the production and sale of artesunate monotherapies, which encourage drug resistance and thereby imperil entire classes of artesunate combination drugs. (I am aware of at least eight companies that agreed to Kochi's request but are still making artesunate monotherapies; however, many other companies have complied.)

Kochi has also endorsed indoor spraying with the insecticide DDT, which kills malaria-carrying mosquitoes. DDT has proved very successful in southern Africa. Kochi's advocacy of the chemical provided cover for donors to procure it, saving countless lives.

Kochi knew that his controversial stances carried political risks, but he didn't seem to care. He told The New York Times two years ago that he "did not worry about whether he would lose his job if he took on too many influential players." Perhaps his anti-Gates memo was an imprudent career move. But Kochi was both courageous and correct to insist that global malaria policies would benefit from a more robust debate. After all, dissent is the lifeblood of good science.

Consider the new artemisinin combination therapy produced by Sanofi Aventis, which was approved in October by the WHO. Unlike a similar Novartis product, which pairs artemisinin with lumefantrine, the Sanofi drug pairs artemisinin with amodiaquine, the latter of which is widely used as a monotherapy. Amodiaquine is produced by numerous Big Pharma companies—including Pfizer, Cipla and Guilin—yet resistance to it is significant in certain malaria-ravaged countries, such as Kenya. There may be good reasons to continue to using amodiaquine, but surely there should be some debate about it.

It is wonderful that anti-malaria efforts are receiving more and more funding from donors around the world. But the stifling of dissent among malaria activists is troubling. It was not "consensus science" that revived the use of DDT or improved malaria treatment methods, but rather the outcome of strong debate and leadership. The fight against malaria needs brave and probing thinkers such as Arata Kochi.