Arata Kochi: shaking up the malaria world

Sarah Boseley | 17 Jun 2006
The Lancet

Within a couple of months of taking up his new post as head of malaria at WHO, Arata Kochi had launched what he knew would be considered a full-frontal attack on the pharmaceutical industry. It's not everybody's idea of the best way to start a new phase of your career.

But Kochi is not a diplomat. He is a public-health doctor who plays hardball. In malaria, just as he did when he ran WHO's tuberculosis programme, he has begun by methodically reviewing the problems in disease control, mapping out the technical solutions, and then implementing them. The first step was to preserve the effectiveness of the newest malaria drugs, the artemisinin compounds, by ensuring they are used in combination with older drugs to prevent resistance developing. So he set his sights on certain drug companies and publicly castigated them for selling artemisinins as monotherapy. This approach seems to be working. 13 of the 40 companies have already promised not to do it again. Kochi says he will keep the pressure on the rest. "We are shaking up the malaria world", he says with every impression of enjoying himself. "We haven't a chance otherwise of making progress. The first issue is ACT (artemisinin combination therapy)." Kochi will not stop there. Next on his hit list is the Global Fund to Fight Aids, Tuberculosis and Malaria, which, he says, has oral artemisinin monotherapies on its list of approved drugs. Should he not be diplomatic about this? "I don't have the patience", he says. "Why do I have to keep on good terms with the Global Fund? They have to do their job right. If we don't do our job right, we have no progress."

And then, as well as the task of improving the distribution of bednets, there is the question of indoor spraying with pesticides, which is a sensitive issue because of the concerns of environmentalists. "One of the things the malaria community asks me to do is to look at the issues", he says. "I'm learning a lot. This method (spraying) is under-utilised. It has been suppressed in the past but it has worked very well. We're going to push it."

Is Kochi the bull mastiff of WHO? He denies he is confrontational. "Things have got to be done", he states. Furthermore, he says, this is the easy bit. Far more difficult will be helping the governments of malaria-hit countries to get the right policies and strategies in place and encouraging them to spend more money on malaria control. Most people would agree that the malaria world needs shaking up. Roll Back Malaria, the partnership of countries and organisations within which WHO was just one of the players, has been unfocused and ineffective. Kochi's first move was to create a new WHO malaria department as the main technical advisory body, leaving Roll Back Malaria to advocacy.

Much of what Kochi is doing was prefigured in his leadership of WHO's tuberculosis programmes in the 1990s. "That was when WHO finally got the message that they ought to be taking TB seriously again, having ignored it for about 30 years", says Paul Sommerfield, chair of the trustees of Stop TB in the UK. The first task Kochi set himself when he took over, in 1989, was to map the problem. In 1991, he wrote a paper described as a "public health classic" by John Sbarbaro, professor of medicine and preventive medicine at the University of Colorado Health Sciences Center in Denver, USA. Kochi "depicted the devastating impact of tuberculosis around the world in such a clear and forceful manner that it changed the public health focus of the WHO, national governments, and leading voluntary organisations", wrote Sbarbaro. It paved the way for the DOTS strategy that WHO under Kochi assiduously promoted.

But Kochi also had to bring governments on board and in 1993 he pulled off a masterstroke. He used his organisational skills to get a WHO conference in London to declare tuberculosis "a global emergency". It not only made headlines, it also concentrated minds. Kochi is credited with the Stop TB Initiative in 1998, which became the Stop TB Partnership in 2000, bringing together all governments and organisations committed to fighting the disease. According to WHO, the proportion of patients with tuberculosis receiving approved treatment rose from 2% to 60% under Kochi, who moved in 2001 to become director of WHO's HIV department. There he worked towards consensus on standardised antiretroviral treatment in poor countries, which led to the "3 by 5" campaign.

Kochi has a PhD in Social Medicine from the Tohoku University Medical School in Japan and two Masters degrees—in Public Health and in Food Policy and Nutrition—from the Harvard School of Public Health. He worked for UNICEF as a health and nutrition expert in Burma and Afghanistan before joining WHO.

As a true public-health doctor, he has few qualms in pushing for what he sees as the best outcome for most of the people, disregarding restiveness among some doctors who feel they can better treat their patients if they do not have to adhere to the formulaic DOTS regimen. But the Kochi way of doing things has indisputably got results. "I'm happy with what I've done", he says, asked for his own verdict on the tuberculosis years. But he is not without self-criticism. "One thing I didn't do well is develop an additional strategy in addition to DOTS for TB/HIV. That is my regret." The malaria world is watching developments with some excitement.