What Ails the Doctors? -- Richard Tren, TechCentralStation, 2004-06-03
What Ails Doctors?
On a recent flight from Johannesburg to London, I sat next to a South African nurse named Queeneth who was returning from a short holiday to her job in Wales. She decided to swap working at Chris Hani Baragwanath Hospital in Soweto, the largest hospital in the world, for a quiet, well paid job in a nursing home in the north of Wales. Although she admitted that she missed South Africa terribly, she isn't planning to return for at least 10 years. "The money is far too good and I get treated well" she admitted to me. But if South Africa's Minister of Health gets her way, the overseas opportunities for nurses such as Queeneth may dry up.
Manto Tshabalala Msimang, South Africa's controversial Health Minister, has just been elected as one of five vice presidents of the World Health Assembly (WHA). Her election could be both good and bad news for millions of people around the world. The Minister's position on malaria control has been excellent and the policies that she promotes to control the disease have saved thousands of lives. The news will be good if her new position gives her the power to extend South Africa's polices elsewhere. The news will be very bad however if her other ideas on healthcare -- which punish the private sector, drug companies, doctors and other health professionals are -- allowed to take root at the Assembly.
South Africa has a long and proud history of malaria control. It recently controlled one of the worst epidemics in the country's history by reintroducing indoor spraying of the insecticide DDT along with the new, highly effective artemesinin combination therapy drugs (see the study I co-authored with Roger Bate for the Cato Institute). South Africa's Minister of Health has been outspoken on the topic of DDT spraying and, based on the successes in South Africa, has encouraged other African countries to follow suit. Her leadership has allowed both Zambia and Zimbabwe to reintroduce DDT and Uganda will also begin spraying soon. The Minister's DDT advocacy is highly commendable as it will reduce disease, save lives and promote development.
Unfortunately the good news ends there. Minister Tshabalala Msimang has proposed a resolution that she hopes will stem the flow of qualified health personnel from developing countries to wealthy western countries. The loss of medical personnel is a serious concern, especially as countries like South Africa attempt to roll out complicated long term health programmes such as HIV/AIDS treatment. Yet WHA resolutions and government interventions are not the way to go; in fact, they will probably make matters worse. Indeed so far, the South African government's health sector reforms have done more to chase doctors and nurse out of the country than anything else.
In recent years, the South African government has brought in a number of far reaching health sector reforms. Among them, newly qualified doctors are required to complete 2 years of community service before they can begin practicing medicine in the private sector. While the compulsory service may provide them with some good experience, the mere fact that doctors are treated as cattle of the state doesn't do much to encourage them to remain in the country.
Most state doctors and nurses are poorly paid and work under very trying conditions. A qualified and experienced nurse can expect to earn no more than $700 per month, for which she is expected to work at least 60 hours a week. Apart from the poor pay and long hours, working conditions are often unsafe. "Sometimes we feel threatened, especially if we have to drive to clinics in dangerous areas," says Dr. Ralf Brummerhoff, psychiatric registrar at the University of Witwaterand. His concerns are real; last week a colleague of his was shot and her car stolen as she entered Chris Hani Baragwanath Hospital.
Yet instead of trying to offer better pay and conditions, the government appears to be turning on doctors themselves. The new Health Act which was passed last year requires doctors to obtain a certificate of need before they can practice in a particular area. In an effort to ensure a greater spread of health professionals around the country, the government looks set to deny doctors the right to practise in some urban areas and may force them to set up practices where the Minister deems appropriate.
In many poor and rural areas where there are no pharmacies, patients usually get their medicines from doctors. Yet the Minister of Health has outlawed the right of doctors to dispense medicines and now requires doctors to get a licence to dispense. Doctors are required to go through an expensive and time consuming procedure to apply for the licence, which may or may not be granted by the Department of Health. Doctors are understandably outraged, not only with the interference in their businesses, but with the effect that this will have on their patients, particularly poor and vulnerable patients.
The government's aggressive position towards research based drug manufacturers is very well documented. The new drug pricing regulations will ensure that South Africa is far less profitable than before and therefore less worthy of investment. Much of the continuing professional development was paid for by these companies in the past and so without their continued investment and commitment to the country, medical personnel may well fall behind their peers in other countries.
Earlier this year, South Africa's doctors, led by Dr. Kgosi Letlape of the South African Medical Association marched on parliament to demonstrate against government policies. We have reached a low point when educated professionals are treated so badly that they have to resort to street demonstrations. If South Africa wants to keep its medical personnel it should start treating healthcare as more of a business and encourage the private sector, which can pay its staff more and treats them better, to invest. Yet unfortunately the government has done quite the opposite; hence the exodus of Queeneth and her colleagues.
If the Minister's WHA resolution is anything like her health policy prescriptions we should get ready for more demonstrating doctors and unfortunately more healthcare problems in poor countries.
Tren is a regular contributor to TechCentralStation and a director of the South Africa based health advocacy group Africa Fighting Malaria.
In Defence of DDT -- Dr Roger Bate, National Review Online, 2004-06-03
June 03, 2004, 9:04 a.m.
In Defense of DDT
A hated pesticide saves lives.
By Roger Bate
Forgive and bear with me for this important confession. As a Brit (technically a nonresident alien) living in D.C., I don't get to vote in the upcoming presidential election. But if I did, given my personal interests, I'd probably vote for Ralph Nader. He's the only candidate who backs the use of DDT for malaria control.
Back in 2000 Al Gore's campaign was damaged by Nader, and Democratic soon-to-be nominee John Kerry is worried that his campaign may suffer a similar fate. As Robert Kennedy Jr. put it four years ago: "Nader's candidacy could siphon votes from Al Gore the environment's most visible champion since Theodore Roosevelt and lead to the election of George W. Bush." And he was right.
Current polls put Nader at five percent of the vote in a couple of swing states (notably Washington, Oregon, and Wisconsin), and the unthinkable might just happen again.
Looking at the various websites of the mainstream and fringe political parties, it is clear that they all rate the environment and the poor as high domestic and international priorities. But there is no mention on Nader's various sites of the one project he should be most proud of: the funding of the Malaria Project from his Center for the Study of Responsive Law in Washington, D.C.
The Malaria Project fought, in the face of massive environmental opposition, for the continued use of DDT for mosquito control in poor countries. Since DDT is such a totemic baddie for the Greens, it is probably politically unwise for Nader to support (even tacitly) its use. And this probably explains why the Malaria Project site at CSRL doesn't mention DDT at all.
John Kerry is unlikely to repeat Vice President Gore's mistake of visiting the birthplace of anti-DDT author Rachel Carson prior to the election. Carson was one of the first to allege that DDT would harm wildlife. Indeed, used massively in agriculture, it caused eggshell thinning in birds of prey, and numerous other alleged (though few proven) environmental problems. But Kerry isn't exactly going to support DDT use, either.
DDT was banned from the U.S. and most of the rest of the developed world in the early 1970s. Before that, the U.S. National Academy of Sciences claimed that it had saved "500 million lives from malaria." All of southern Europe and the southern U.S. had eradicated malaria by using DDT in the early 1950s. But reduction in aid budgets, complacency in spray programs, and environmental concerns resulted in a significant reduction of DDT-spraying around the world starting in the 1960s.
DDT was quietly used in developing countries, such as South Africa, Botswana, Indonesia, and India for the past three decades, almost without comment. But last month (May 17), the United Nations Environment Program Stockholm Convention on Persistent Organic Pollutants came into force. It will eventually phase out the use of DDT, and already makes its procurement and use harder resulting in more babies killed by malaria. But Nader's malaria project was a key player in keeping DDT from being banned outright.
Given that "three children die every minute in Africa from malaria, and DDT is still the most cost-effective means of controlling the disease, this would have been a scandalous waste of life," says Prof. Don Roberts of the Uniformed Services Hospital in Maryland. Furthermore, the spraying of DDT is contained inside buildings and very little reaches the wider environment, and hence "causes no problem," according to toxicology expert Gerhard Verdooren of the Endangered Wildlife Trust, an environmentalist group from South Africa.
While many Greens will be shocked about Nader's fight to protect DDT and other insecticides, perhaps they should ponder that thousands of Americans were harmed by West Nile virus last year. And where the disease has hit hardest, local media have been surprisingly sanguine about insecticidal spraying to control this deadly mosquito-borne disease. But the chances of catching West Nile are very small: For most Africans, when surrounded by major dangers such as malaria, minuscule theoretical threats from pesticides do not figure.
Courage in politicians is rare. There is no doubt that John Kerry was a brave man in Vietnam, and President Bush has held firmly to his convictions. But for them the support of DDT is just too much.
The fact that Nader could put humanitarian concerns above his well-known dislike for DDT is commendable and strategically sensible. He could foresee, where no one else could, the harm to the environmental movement of being saddled with the blame for millions of dead children from malaria. It is likely that's how the history books would have written it had DDT been banned (and it still may be). Nader will never be president, but he has the kind of conviction I like (even if most of his policies are batty). So if I could cast a vote, he'd get mine.
Dr. Roger Bate is a visiting fellow of the American Enterprise Institute and a director of Africa Fighting Malaria.
Copyright 2004 The Financial Times Limited
Financial Times (London, England)
May 31, 2004 Monday
The sick are taxed to death in poor countries: ROGER BATE:
In the debate about combating disease in poor countries, pharmaceuticals companies have been berated for being slow to cut drug prices, while the World Health Organisation and other agencies have been blamed for buying the wrong treatments. So far the extraordinary tax policies on life-saving drugs adopted by the poor countries themselves have received little attention. It is time campaigners got them in their sights.
The pharmaceuticals industry has for the past few years been donating free drugs to poor countries or charging them less for drugs that treat the biggest killers - tuberculosis, Aids and malaria. Even the patent-breaking generic drug producers have lowered prices to compete, all of which is good news for patients in poor countries.
But some countries\' finance departments see a way of making big money from imports of these life-saving drugs. Of course, African governments can legitimately choose to tax what they wish, even though many leaders have not been democratically elected. However, it does seem odd that they place tariffs, levies, duties and other taxes on pharmaceuticals that can save the lives of citizens - especially when numerous studies show that the economies of these countries would grow faster if diseases such as malaria and TB were brought under control. And growth means more revenue for the Treasury.
Southern Africa does relatively well compared with the rest of the continent: most countries have no import duties on medicines, although Tanzania does charge a 10 per cent import duty, Malawi a 15 per cent import duty and South Africa a 14 per cent sales tax. Each of these countries has a bad Aids and malaria problem and could treat thousands more patients with the removal of such duties.
The most odious tariffs and duties are to be found in countries further to the north. The incredibly poor Democratic Republic of the Congo charges at least 30 per cent tax on all drugs crossing its borders, and has further taxes adding another 13 per cent to the price. Ethiopia charges an import duty of 30 per cent. Burundi and Egypt charge more than 10 per cent in port inspection charges and the former imposes other small taxes (clearance and freight duties, bank and currency charges, import margins and domestic taxes) that take its total closer to a 30 per cent overall mark-up. Rwanda charges a massive 9.5 per cent just for bank and currency charges.
These charges and taxes add significantly to the price of drugs. Even where drugs are donated free some countries, notably Egypt, levy tax on an estimated price. The result is that the lowest prices people pay are sometimes far more than double the figures usually quoted in the press.
Ever since the Clinton Foundation announced in October last year that it had \"brokered\" a deal to lower the price of HIV drug \"cocktails\" to Dollars 140 (Pounds 76) a person a year, for instance, this is the price that has been widely cited. Nowhere has this price been achieved. A study published by the Hudson Institute think-tank two weeks ago, based on the Medecins sans Frontie`res drug price guide, found the price on the ground is, at its lowest, Dollars 285. In Mozambique it is Dollars 389; in Honduras Dollars 426. The study also debunks the myth that generic Aids drugs are always cheaper than brand drugs. Brand versions were much cheaper than generics in eight of the 13 most commonly used anti-retroviral, single-dose drugs.
In the battle to increase access to essential medicines, many campaigners cite \"high drug prices\" as the main barriers in the developing world. This notion will probably be on full display this July at the Bangkok Aids conference. Instead, Aids activists hoping to increase access should take issue with some of the governments - Argentina (21 per cent), Bangladesh (15 per cent), the Dominican Republic (28 per cent), Greece (15 per cent) and Turkey (18 per cent) - that charge sales tax on life-saving drug imports. Brazil, considered to have the best HIV programme in a developing country, charges an 11.7 per cent import duty on medicines. Perhaps worst of all is India, with more than 3m HIV cases and only 17,000 people on treatment, which charges at least 25 per cent duty on medicines.
Commentators often say all that is needed to combat diseases such as malaria is political will. Something that all countries can do is to remove the taxes on drugs to treat the sick. It does not matter whether the drugs come from India, the US or Thailand - none should be taxed.
The writer is a visiting fellow at the American Enterprise Institute and a director of Africa Fighting Malaria, the health advocacy group
LOAD-DATE: May 31, 2004
Where Will Malaria Be The Day After Tomorrow? -- Richard Tren, Wall Street Journal Europe, 2004-05-28
Where Will Malaria Be
The Day After Tomorrow?
By RICHARD TREN
May 28, 2004
"Where will you be?"
This ominous question, which accompanies the latest Hollywood disaster film, "The Day After Tomorrow," will no doubt have some people mulling over an appropriate answer. In the film, the earth's climate topples over a hypothetical "edge" as a result of anthropogenic global warming. This then leads to terrific global storms and a sudden ice age. Mark Gordon, one of the producers of the film, hopes that the film will "raise consciousness about the environment," a statement akin to the producers of Peter Pan saying they hope that film will raise consciousness about air travel.
However, unlike the film, the film's Web site attempts to be somewhat serious as it discusses global catastrophes associated with global warming. One scenario that it promotes is the spread of mosquito-borne diseases such as malaria. This is a popular scenario, but it's not a serious one. It's a fantasy that should be confined, along with marauding glaciers, to Hollywood plot lines.
The notion that climate change will spread malaria to areas that were previously malaria free has increasing cachet because it seems logical. If temperatures and rainfall increase, there will be more mosquitoes and therefore, the argument goes, there will be more malaria. Yet science and the long history of man, mosquitoes and malaria belie this scenario.
A letter published this week in the medical journal The Lancet by some of the world's leading malaria experts, including Professor Paul Reiter of the Pasteur Institute in Paris, cautions against reckless claims that global warming will affect malaria transmission. The relationship between climate and malaria is exceedingly complex, and the authors warn that we cannot rely upon simplistic models that predict increased malaria cases.
We associate malaria with hot tropical countries, but its distribution wasn't always this limited. Malaria was widespread throughout Europe and the U.S. for many centuries, despite wide climatic swings.
In Europe for example, temperatures cooled considerably during the Dark Ages, but rose again during the Middle Ages (around AD 1200) -- so much so that wines could be produced in England -- and then plummeted again during the "little Ice Age" that began in the mid-16th century and lasted for about 200 years. Despite these climatic changes, malaria transmission continued unabated. Some epidemics even occurred within the Arctic Circle.
Wealth and malaria have a far closer relationship than climate and malaria. As people in Europe and North America became wealthier, malaria started to recede. As people drained wetlands for agriculture, could afford physical barriers between themselves and mosquitoes (such as screens and glass windows) and other mosquito-control measures, malaria transmission declined.
As you read this, people, mainly children under the age of five, are dying of malaria, a preventable and curable disease. They are dying because they are too poor to afford drugs. They are dying because even if they had the money to buy the drugs, their countries are too poor to establish sufficient clinics to supply the drugs. They are dying because wealthy Western governments refuse to fund interventions that save lives, such as indoor insecticide spraying, because these governments feel that such crucial interventions don't fit in with their ideas on "environmental sustainability."
Malaria is a complex disease, but the best long-term cure for it is for people in malarial regions to become wealthy. The global-warming treaty, the Kyoto Protocol, will not help these people achieve that goal. Even pro-Kyoto scientists admit that the protocol will cost a fortune and do very little to affect global warming, and if economic growth slows to reduce carbon emissions, poor nations will have a harder time becoming wealthy through development. Poverty-related diseases will simply tighten their grip on a captive population.
As the Lancet paper on global warming and disease points out: "We understand public anxiety about climate change, but are concerned that many of these much-publicized predictions are ill-informed and misleading." If you see the film, enjoy it for what it is, a diverting spectacle, but, for the sake of millions of Africans who are at risk from diseases of poverty, reject the film's political agenda -- that slower economic growth averts disaster. We already have a disaster on our hands. It's called malaria. It kills a child every 30 seconds, and we need wealth and good science to control it.
Where will mosquitoes be the day after tomorrow? Right where they are today, spreading disease and death. How effectively they spread that disease and death, however, depends entirely on us.
Mr. Tren is the director of the health advocacy group Africa Fighting Malaria, and is based in Johannesburg, South Africa.
Wall Street Journal Europe
Copyright 2004 Dow Jones & Company, Inc. All Rights Reserved
Uganda's New War -- Richard Tren, TechCentralStation, 2004-05-26
Richard Tren writes on Uganda's attempts to reintroduce DDT spraying for their malaria control programme.
Poverty, Not Patents -- Roger Bate, National Review Online, 2004-05-18
The 57th meeting of the Geneva World Health Assembly began on Monday, May 17. Inevitably the focus of activist groups has been on the role that drug patents play in blocking access to essential medicines in the world's poorest countries. Big pharma, on the other hand, is highlighting the importance of drug patents to ongoing research into cures for diseases. Both positions are exaggerated and draw attention away from the real and pressing issues that lead to poverty, disease, and death for billions of people.
What Patent Problem? -- Roger Bate, National Review, 2004-05-17
As the world's health experts gather in Geneva today for the World Health Assembly, it is time to assess the main AIDS debate that has raged for all of this decade. Without clarity on the problems of the spread of HIV AIDS there can be no hope of a solution.
Amir Attaran, a fellow with the Royal Institute of International Affairs (and a board member of my own organization, Africa Fighting Malaria), has for the past four years done his best to provide light to an otherwise heated debate. Specifically, he has exposed the various fallacies of anti-globalization public-health activists who attempt to undermine the patent system for the sake of manufacturing and exporting generic drugs. He has also done his best to expose the hyper-sensitivities of the pharmaceutical industry. His recent analysis of drug-patent exploitation in developing countries, published in the May-June issue of Health Affairs, does both. In it Attaran points out that patents have rarely been a problem for drug consumers in poor nations; in fact, only 1.4 percent of the WHO essential-drug list is on patent in the poorest 65 countries. Because of this fact, Attaran concludes that "poverty, not patents, imposes the greater limitation on access." At the same time, he also points out that the patent system is not as likely to be undermined as pharmaceutical companies might believe or imply.
Baghdad Boil to Return -- Roger Bate, Tech Central Station, 2004-05-13
It's heating up in the Southern Iraqi desert and sand flies are returning. They bring with them "Baghdad Boil," a nasty disease, more properly known as cutaneous leishmaniasis. They go about their ghastly business of extracting a blood meal and laying its eggs in human skin. In the previous 12 months there have been over 650 cases of the disease. Poor planning, imprudent regulations and military incompetence mean the Boil will be worse this summer than it otherwise should. It is unfortunate that young men, fighting for their country and being shot at on a daily basis, are contracting a largely preventable disease.
Arcane rules about drug protocols and lack of Food and Drug Administration approval for the best drugs means all cases have to be hospitalised back in US where treatment can last a month. As such, the cost is exorbitant and unnecessarily adds to a burgeoning war bill. Each case costs the US taxpayer over $20,000 in terms of flights, medical testing and other interventions, medical staff time, drugs and opportunity cost of soldiers incapacitated. As one Iraq-based medical entomologist put it: "We were better off during the Second World War since doctors in the field had experience of the disease and could use drugs and insecticides in situ as required."
The vast majority of US soldiers sent to Iraq were not issued with proper bed nets and mosquito repellent. This is an odd oversight: In Operation Desert Storm in 1991 there were 34 cases of the disease and so the military was fully aware of what to expect this time around.
"It is understandable that these items are not top of any soldier's equipment list, but [the current] failure rate is ridiculously high," says a senior US military medic. One reason for the lack of supply is that the military units have to buy these items from small internal budgets that were unable to cover supplies -- a false economy given the costs of treatment. Furthermore, not all the bed nets deployed by US and other allied forces are adequate. Bed nets must have a very fine mesh, at least 18 holes per sq inch, otherwise the tiny sand fly can penetrate them.
Failure of management and command has also led to inappropriate requisitioning. Deltamethrin is the insecticide that has been most widely used by soldiers, even though it is known to break down in sunlight and sand storms. The choice was made partly to appease contentious environmental concerns about impacts on wildlife (not sand flies, presumably). The military should impregnate all equipment with the best insecticides, including DDT, which is better and cheaper than deltamethrin. Indeed, the Iraq-based entomologist I spoke with would love to use DDT, but he cannot since it's not available due to the US Government ban. Taxpayers could save several million dollars if DDT was used instead of Deltamethrin (and the soldiers would benefit too from fewer sand flies).
Although the inability to use DDT is annoying, the entomologists' largest frustration is that in some instances requests for insecticides last summer went unanswered for many months. The results were immediate. "We started seeing soldiers basically eaten alive, 1,000 bites a night in a handful of cases," said one military medic. It is incredibly hot in the desert in the summer and most soldiers sleep in shorts and nothing else, with their tent flaps wide open to keep the air flowing.
One solution is mobile air-conditioning units, which keep the troops cool enough so they can shut the flaps on the tents and sleep in more than just shorts. Where these tents have been used, biting rates and infections fell massively. A-C tents should be deployed immediately in some locations, such as Nasiriya, because 10-15% of troops in some units are coming down with the infection -- compromising their military potency.
More broadly a massive spray program using the best insecticides should be undertaken of the areas where the sand flies are most likely to carry the Leishmaniasis parasite. The US military has done some of this and looks set to expand on the current program before the summer really starts. This would lower the incidence of bites, and hence disease, not just of the military but of the children of Iraq, who are most likely to die from the nastier form of the disease (visceral leishmaniasis).
For the soldiers returning home, carrying visceral leishmaniasis - which the CDC describes as when "leishmanial parasites replicate in the reticuloendothelial system (e.g., spleen, liver, and bone marrow)" -- remains a possibility. In Desert Storm over a third of the 34 cases were visceral, with organ damage occurring in a few cases. So far none of the 650 cases in Operation Iraqi Freedom has been visceral; this might be because in Desert Storm (in 1991) most of the troops were stationed in Saudi Arabia, where visceral leishmaniasis is more common, but it may also be that the soldier's immune systems are fighting off the disease at the moment. But immunity may not last long; some soldiers may have the disease and currently be asymptomatic. Recently two visceral cases were reported in Afghanistan; we may yet see cases in Iraq.
Since the parasite can survive in the body for years, it could start damaging the organs of soldiers years from now. Vigilance is required for returning troops, they deserve better than waiting and hoping they do not develop a potentially fatal disease.
Take One Large Dose of Capitalism -- Roger Bate, National Review, 2004-05-12
Walk into an increasing number of quarantined hospital wards in England and the United States and see patients with hacking coughs, fevers, and the look of death. Propped up in beds, these unusual patients are taking drugs to help fight their infection the age-old disease of tuberculosis. At least for the majority, they are responding to treatment, but some have multi-drug resistant Tuberculosis (MDR-TB). All patients have to stick with six months of treatment, but for the MDR-TB sufferers, the future is less certain.
Every year we mourn the two million who die annually from this disease, and praise the achievements of those who combat this age-old scourge. TB is so bad that along with AIDS and malaria, it has its own special funding arrangement for treatment through the U.N.'s Global Fund. But treatment is becoming less possible because MDR-TB is increasing, and for 400,000 new MDR-TB cases each year there is only one drug that will defeat the disease. Once resistance makes impotent this drug capreomycin the millions of MDR-TB patients will be in the same position as those who faced this disease in the 19th century. It is scary and remarkable that Americans could perhaps one day face the same lack of treatment as the tragic literary figure, Camille, who died so painfully from consumption (the old name for TB).
TB is a highly contagious airborne bacterial infection that can spread through the lymph nodes and bloodstream to any organ of the body, but is most commonly found in the lungs. It is very easily transmitted through coughing, sneezing, and just breathing, which is why the World Health Organization (WHO) estimates that each patient transmits the disease to 20 others.
Unlike malaria, which requires numerous mosquitoes, and HIV, which requires sexual transmission or blood transfusion for transmission, TB is easily transmitted through the air. As a result, quarantining TB (and especially MDR-TB) patients becomes important. In Europe and U.S. this is relatively easy because there are significant resources and relatively few cases. But in Africa (and in Eastern Europe, Russia, and elsewhere) resources are absent and caseloads are high, consequently transmission flourishes. Not only does this mean millions of new cases, but it also indirectly helps drug resistance to build.
Treating TB takes a very long time. Failure to complete a course of treatment encourages the development of MDR-TB. Furthermore, if a doctor prescribes the wrong drugs, or does not provide the correct regime for the drugs to be administered, resistance can also develop. Patients who develop MDR-TB can then transmit this new, more dangerous strain to others, just as in "normal" TB.
But the bad news does not stop there. MDR-TB takes an horrifically long 18-24 months of treatment. We have all taken drugs for an infection, and started to feel better after a few days, and wonder why we are bothering with the last few days of treatment. We sometimes don't finish the course, and it provides a training ground for any surviving bacteria. For the vast majority of us, and on most occasions, this doesn't matter. But for MDR-TB it can be fatal, not only to the existing patient but to everyone else who might contract it.
Failure to properly treat and contain MDR-TB could result in the creation of a new, even deadlier strain of the disease, which would be resistant to even capreomycin.
Capreomycin is a drug developed and patented by Lilly Pharmaceuticals. Fortunately MDR-TB is susceptible to it, although MDR-TB resists streptomycin, isoniazid, rifampin, and other drugs. Lilly donate large amounts of drugs to the World Health Organization for public-private partnership programs to treat MDR-TB.
Given the extremely long treatment time for MDR-TB, the treatment programs follow Direct Observed Treatment (DOT), where drugs are only administered in a setting where patients cannot forget (intentionally or otherwise) to complete their course of treatment. These programs are currently operating in numerous locations around the world, including South Africa...and keep the number of new MDR-TB cases to under 400,000, when it would be far higher without them.
Given that Lilly cannot make enough capreomycin for the world, it transfers the drug-making technology to small, but competent, drug companies in poor countries. They can then manufacturer the drugs themselves for distribution to WHO programs. Lilly takes no royalty for this production.
The only real long-term hope for tuberculosis sufferers in poor parts of the world is that those countries become wealthy enough to combat the disease in the same way that richer countries do today. Making people healthy enough, through good diet, decent housing, and clean water is the best way for them to fight off TB. But before Africa, Russia, Eastern Europe, and elsewhere embrace capitalistic institutions and become rich, public-private partnerships like the WHO-Lilly one are essential.
There are also lessons for treating AIDS patients from the treatment of MDR-TB. HIV treatment is not a cure, so it lasts indefinitely. The DOT approach adopted for MDR-TB for over 18 months of treatment should be copied for delivery of HIV medicines. Since resistance to HIV drugs is even more prevalent than to TB drugs, this can't happen soon enough.
For most TB patients the pain is obvious but compared to those with two-year treatment courses, or worse those without treatment TB is a painful lottery and for many the result is a death sentence
Dr. Roger Bate is a fellow of the American Enterprise Institute and a director of health-advocacy group Africa Fighting Malaria.
The WHO must drop old-style politics and get back to saving children\'s lives -- Roger Bate, Daily Telegraph, 2004-05-10
Personal view: The WHO must drop old-style politics and get back to saving children\\\'s lives
By Roger Bate (Filed: 10/05/2004)
Next week the World Health Assembly begins in Geneva. The annual meeting of the World Health Organisation is sure to be a splendid affair, with much self-congratulatory speechmaking, but underneath the WHO is getting increasingly politicised and is failing to combat the diseases of poverty, preferring to look at fashionable western problems, notably obesity and smoking.
WHO officials are adept at using media and political systems to increase their influence, funding and power. Now they are taking an increasingly \\\"Old Europe\\\" approach to foreign policy, as demonstrated in their treatment of Taiwan and Palestine in particular.
The tobacco control convention and obesity initiative show that the WHO is pandering to the desires of its western, especially European, donors, rather than the malnourished millions of Africa and Asia. Smoking and over-eating may have public health aspects to them but they are largely individual lifestyle choices, rather than involuntary causes of death.
It is surely the role of individual countries to decide whether to influence the lifestyles of their citizens. Spending western taxpayers\\\' money on removing Coca-Cola vending machines from schools, and placing anti-smoking billboards in African cities, are strange priorities when every five seconds an African child dies of preventable Aids, TB or malaria.
Last year, for the seventh time, the WHO turned down Taiwan\\\'s request for membership. It remains shut out from participating in and benefiting from WHO programmes because the organisation argues that Beijing is the country\\\'s true political master. The WHO completely ignored the fact that Taiwan had confronted the Sars (Severe Acute Respiratory Syndrome) virus openly, while Beijing\\\'s response was obfuscation and delay - and 600 unnecessary deaths.
Of course the WHO, like all UN agencies, must deal with the realpolitik of nations. China\\\'s power means that its \\\"one China\\\" policy commands acceptance, but the WHO\\\'s reputation should spring from its willingness to bring medical assistance to wherever it is needed. Even in times of war, medical emergencies can lead to ceasefires.
Where Taiwan acted to restrict the spread of Sars and send regular updates to the WHO, the People\\\'s Republic kept silent. Yet the WHO would not even respond to cries for help from Taiwan for expertise to counter the spread of the disease, because it refuses to recognise the existence of the country.
It was left to Tommy Thompson, US Health and Human Services Secretary, referring to Taiwan, to tell the WHO last May: \\\"If we are truly serious about stopping this disease in its tracks, then we cannot ignore millions of people who are at risk.\\\" After months of restraint, Taiwan eventually lost patience with the WHO and said that: \\\"The WHO should not become a political stage. Politics should remain out of healthcare.\\\"
For the WHO to ignore Taiwan is inexcusable, since its own charter calls for political reorganisation in the interests of public health. It also claims that \\\"the Israeli occupation [of Palestine] is a serious health problem\\\". Its \\\"solution\\\" is to reaffirm \\\"the inalienable, permanent and unqualified right of the Palestinian people to self-determination, including their right to establish their sovereign and independent Palestinian state.\\\"
Israel is the only country to be repeatedly attacked by the WHO, despite the evidence that the Palestinians\\\' health has improved under occupation. Mortality rates have fallen in the past 30 years in the West Bank and Gaza, and the life expectancy of Palestinians has jumped from 48 to 72 years - rather better than the Arab or North African averages.
Steven Menashi, of the Hoover Institution in California, points out that instead of concerning itself with health matters, \\\"World Health Assembly resolutions and WHO reports condemn the Jewish state for requiring security checkpoints, building settlements, and responding militarily to terrorist attacks.
\\\"All these may well be worthy of criticism and debate within a deliberative political body, but by presenting them as health concerns, the WHO attempts to pass off its political preferences as scientific expertise.\\\"
We shall see next week whether the assembly will once again condemn Israel and ignore Taiwan, or whether it will return to its charter and put health above politics. We should not hold our breath. Since 1998, the organisation has become progressively more politicised, adopting Continental European attitudes and earning the distrust of commentators and nation states alike.
In the last decade, the numbers dying annually from infectious disease have increased from 17m to nearly 19m, while the WHO has played politics. By focusing on smoking and obesity and promoting a Franco-German world view, the WHO has lost sight of its mission to save the poorest from easily preventable and cheaply curable diseases.
Next week is its chance to get back to basics, if it will only take it.
Roger Bate is a visiting fellow of the American Enterprise Institute, a fellow of the Institute of Economic Affairs and a Director of Health Advocacy Group Africa Fighting Malaria.
WHOs to Blame? -- Roger Bate, National Review, 2004-04-30
The multilateral health agencies are at it again. Facing exposure for failing to combat a health problem in this case, malaria their only reaction is to try to pin it on someone else. When African kids die every minute from terrible diseases (like malaria), it is shameful that groups spend precious taxpayer resources deflecting blame.
The champion responsibility-dodger is the World Health Organization. In the past two weeks the WHO and its affiliates have had to listen to scads of commentators in the New York Times, the Wall Street Journal, the Washington Post, and other papers complain that malaria rates are increasing when the WHO promised six years ago to halve them. The consensus is that the failure of existing therapies like chloroquine and the lack of use of insecticides like DDT are the cause. In less than a week, the WHO has masterminded its policy response: Blame the usual suspects.
In doing so, the WHO employs the vast network of NGOs and campaign groups that they directly or indirectly support. For example, the WHO's Roll Back Malaria initiative (among other groups) told the BBC on Monday that "governments, donor agencies, and pharmaceutical firms must take action now to prevent a shortfall in malaria treatments, next year."
Where DDT Works -- Richard Tren, TechCentralStation, 2004-04-26
Richard Tren marks World Malaria Day by highlighting the extraordinary successes against the disease achieved with well managed spraying programmes that use DDT. He also castigates the WHO and other agencies that refuse to support these tools.
Managing Malaria -- Jennifer Zambone, National Review, 2004-04-26
Prevention and treatment are everything.
By Jennifer Zambone
This past Sunday marked "Africa Malaria Day," a day to remember that malaria continues to rage on that continent, killing at least one million people each year. We should remember these deaths after all, we helped cause them, even though not so long ago malaria killed us too.
For three centuries, malaria plagued the United States, from the deep south up to Michigan. When falciparum malaria entered the colony of South Carolina in the 1680s, the area developed an international reputation for "unwholesomeness." "Those who want to die quickly, go to Carolina," ran an English saying. "Carolina in the spring is a paradise, in the summer a hell, and in the autumn a hospital," commented a German traveler. As late as 1914, 600,000 people in the United States suffered from locally transmitted malaria.
Mosquito abatement measures, such as draining wetlands and using pesticides, effective drugs, and lifestyle changes ended malaria's grip on the U.S. The disease still occasionally appears in the United States, though. In July of last year, for example, eight residents of Lake Worth, Fla., contracted malaria. Since none of them had been out of the country, doctors concluded they had caught the disease from mosquitoes in Florida. That wasn't any consolation for these victims, who experienced what malaria sufferers around the world experience daily: "It's probably the worst night of my life," said Jeff Smith. "I mean just cold sweats. I mean you don't eat, you just, you know vomit. You just headaches like you wouldn't believe... I hope nobody else gets it. It's horrendous."
Sadly, other people do get this horrendous disease. Three to five hundred million become ill from it annually, and one to two million people a year die from it, 90 percent of whom are pregnant women and children under the age of 5.
These people suffer because the developed world won't help them use all measures possible to stop the spread of the disease. Indoor Residual Spraying (IRS) the spraying of tiny amounts of residual insecticide on the interior walls of houses remains one of the best ways to prevent malaria cases. Safe for the environment and for human health, IRS causes mortality and morbidity to plummet yet donor agencies, most notably the World Health Organization (WHO) and the Unites States Agency for International Development (USAID), refuse to support it and have been encouraging countries to reduce or abandon it. They object particularly strongly when IRS employs the most effective pesticide available: DDT.
South Africa used DDT to quell a malaria epidemic in 2000, reducing the number of cases by 77 percent in one year alone. Yet despite DDT's successful track record, USAID threatened to withdraw support from Belize if that country's government continued to use DDT in malaria control. USAID also refuses to fund its use in African countries that have specifically asked to use it.
Additionally, international aid agencies are reluctant to fund the most effective drug to treat malaria: artemisinin. The Global Fund for AIDS Tuberculosis and Malaria spends twice as much on two other drugs, chloroquine and S-P, as it does on artemisinin, even in areas where paying for chloroquine and S-P are known to be ineffective. At least the Global Fund purchases some artemisinin-based drugs; USAID doesn't buy any. But then, USAID doesn't buy many drugs to treat malaria, period. Even though it has one of the largest malaria budgets of any aid agency now about $80 million per year USAID says that it "typically does not purchase drugs or medicines other than in exceptional or emergency circumstances for any of our programs." Instead its money goes to "building the systems to procure, manage and use the drugs." A valuable task, no doubt, but pointless if the countries with these systems don't have the money to procure effective drugs.
The United States should support the use of IRS and artemisinin-based drugs to conquer malaria. Besides being a truly humanitarian action, reducing the incidence of malaria in Africa will also benefit us. As the West Nile experience shows, the world is getting smaller. Diseases from abroad can find a niche in the United States as long as they can find a way here, and in these days of international travel it's easy for diseases to find a way here. As the Florida experience shows, malaria can still spread in the U.S. Our recent malaria experiences have been small and localized, but that doesn't mean they'll stay that way. Our best chance to stop a coming plague of malaria from hitting the United States is to stop the current plague of malaria in Africa.
Jennifer Zambone is Washington, DC, director of Africa Fighting Malaria, a South African health advocacy group.
What An Unnecessary Disaster -- Roger Bate, Washington Post, 2004-04-25
What an Unnecessary Disaster
We\'re Fighting Malaria With Outmoded Techniques -- For No Good Reason
By Roger Bate
Sunday, April 25, 2004; Page B02
Last month in Jonizi, South Africa, I watched my friend Jocky Gumede happily bounce his grandchild on his knee. The recent malaria epidemic had subsided, and Jocky was relieved that the child had escaped death -- for this year, anyway. Jocky can\'t erase the memory of the toll the disease has taken on his family. Still, he is relatively lucky. In South Africa, the malaria rate is falling.
In the rest of sub-Saharan Africa, by contrast, the disease is on the rise. This development has more than one cause, including factors such as insufficient insecticide use, the malarial parasite\'s resistance to widely used drugs, and malnutrition. But the main cause is the failure of the very campaign organized to combat the disease.
In 1998, the World Health Organization (WHO), under the leadership of director-general Gro Harlem Brundtland, the former prime minister of Norway, made \"Roll Back Malaria\" its flagship initiative. It aimed to cut malaria deaths in half by 2010. But nearly halfway through the allotted time, the malaria rate has instead increased. It was about 10 percent above 1998 levels at the end of 2002, and recent unofficial estimates point to a further 2 percent to 3 percent increase by the end of 2003.
WHO has pointed to global warming as a partial cause of the increase. Malaria, the agency declared in a recent report, is \"the disease most sensitive to long-term climate change.\" But this claim is questionable; experts say that climate change\'s role in the malaria increase is minor at best. A large portion of the blame for the increased incidence of malaria can be laid at the feet of WHO itself, as well as other aid agencies such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the U.S. Agency for International Development (USAID).
These agencies\' mosquito-prevention and drug-treatment policies in Africa are in tatters. A group of prominent malaria experts has even charged the agencies with malpractice for their reluctance to supply new, more expensive and better drugs for treatment, and for sticking instead with essentially ineffective medicines. But if WHO and its partners are serious about reducing the malaria threat, they need to reconsider their approach and start using all the weapons available to combat malaria -- and soon.
While AIDS gets all the attention for destroying the young adults of Africa, few Westerners are aware that malaria kills more children than any other disease. Imagine filling half a dozen Boeing 747s with children and crashing them every day. That is the death toll from malaria -- 3,000 deaths a day -- in Africa alone.
Since the connection between mosquitoes and malaria was first made in 1898, many methods have been developed to control the disease. But the key lesson that has been learned, and perhaps must be relearned, is that overreliance on any single method of combating malaria leads to inevitable failure. There are tried-and-proven methods that in combination are highly effective, but WHO and other aid agencies seem reluctant to fund them.
Preventing malaria means creating a barrier between the mosquito, which is the carrier of the malarial parasite, and the parasite\'s primary host -- humans. Since malarial mosquitoes bite only between dusk and dawn, WHO\'s campaign has promoted bed nets, which can protect those who sleep beneath them. But this policy has had limited success. Nets for a whole family are expensive, and mosquitoes can take many blood meals between dusk and bedtime. Also, nets work best if treated with insecticide. But a recent survey in Kenya found that 21 percent of households had one single bed net, and only 5.6 percent of these were insecticide-treated. Moreover, mosquitoes are growing resistant to the type of insecticide with which the nets are coated.
By contrast, South Africa -- which is rich enough to fund its own public health programs and doesn\'t need to rely on WHO\'s largess -- has reduced malaria transmission by 90 percent in recent years, by a combination of returning to an old insecticide and investing in a new drug. It chose to spray insecticides, especially DDT, on the inside walls of dwellings to prevent mosquitoes from entering the buildings. This protects everyone inside all the time, not just when people might be sleeping.
In the past, environmentalists have opposed such spraying -- particularly the use of DDT, which was banned in the United States in 1972 after massive spraying caused damage to wildlife. But there is no evidence of harm to humans or the environment when the insecticide is used responsibly, in small amounts, for mosquito control. Unfortunately, Brundtland, who is a medical doctor but was formerly an environmentally active politician, opposes the use of insecticides such as DDT, as does USAID, which means that the agencies do not promote them and rely solely on bed nets.
Another major reason for the recent increase in malaria is a failing drug policy. Over time, many drugs become obsolete, as the pathogens they target mutate and develop resistance. Chloroquine (CQ) and sulphadoxine-pyrimethamine (SP) have been used for many years to cure malaria, but in some countries, they have become all but useless. Ethiopia has an 88 percent failure rate with CQ, and South Africa had 60 percent failure with SP before it switched to a new type of drug, artemisinin combination therapies (ACTs). Since these drugs kill the parasite quickly, it doesn\'t have time to build up resistance. In addition, the time during which a mosquito can pick up the parasite from a carrier and pass it on to a new victim is drastically reduced. But ACTs are 10 times more expensive than CQ or SP.
All the same, South Africa adopted ACTs as a first-line treatment in 2001, soon after it reverted to indoor DDT spraying. This program is successful because spraying has reduced the number of cases to a level where all patients can be treated with the new, superior drugs within the overall budget.
Meanwhile, WHO and the Global Fund, although rhetorically supportive of ACTs, have continued, through inertia, to supply primarily the failing drugs to poor countries. The agencies also claim, with some justification, that the poor countries themselves are demanding CQ and SP because they are familiar with these drugs. But of course, part of the agencies\' role is to provide expert advice, and they should strenuously advise against drugs they know are increasingly ineffective.
In a recent issue of the British medical journal the Lancet, 13 malaria experts accused the agencies of medical malpractice for persisting in this approach, and now some U.S. senators are becoming concerned that African lives and American taxpayers\' money -- the United States supplies nearly 40 percent of the Global Fund budget -- are being wasted. Sens. Judd Gregg (R-N.H.) and Russell Feingold (D-Wis.) recently wrote to Health and Human Services Secretary Tommy Thompson, current chair of the Global Fund, asking why U.S. funds were being used to purchase less effective drugs.
Last December, WHO published a paper claiming that climate change is causing 150,000 extra deaths a year -- a substantial amount -- from mosquito-borne disease such as malaria. But experts challenge the assumption of a link between climate and disease. Paul Reiter, a medical entomologist at France\'s Pasteur Institute (and formerly the leading expert on mosquito-borne disease at the U.S. Centers for Disease Control and Prevention), told me he believes it is \"immoral to mislead the public by attributing the recent resurgence of these diseases to climate change, particularly in Africa.\"
Even if a warmer planet has caused the 2 percent increase in malaria cases that WHO claims, that still leaves about 10 percent that would be due to policy failures. The reality is that combating this ancient scourge requires the full arsenal of control methods: insecticide spraying of walls; spraying of larvicides on breeding grounds; other forms of source reduction, such as eliminating standing water near homes by turning over old tires, trash can lids and the like after rainfall; the WHO-approved bed nets; and effective drugs.
There is no one simple solution to the malaria crisis in Africa, but there certainly is a better solution than the one being offered by Western aid agencies today. Malaria can be combated effectively; all it takes is the will to do so. Let\'s hope that WHO and its partner agencies find that will soon, so that my friend Jocky\'s African brothers to the north can see their grandchildren grow up, too.
Roger Bate, a visiting fellow at the American Enterprise Institute, is a health economist and director of a South African health advocacy group, Africa Fighting Malaria.
Talking While Africa's Children Die -- Roger Bate & Richard Tren, Business Day - South Africa, 2004-04-22
Roger Bate and Richard Tren expose the failure of Roll Back Malaria and in particular the refusal of USAID to fund interventions that work - such as Artemesinin based combination therapy drugs.