An Iron Fist Joins the Malaria Wars

In the war on malaria, silver bullets inevitably morph into rubber ones: the parasite and its mosquitoes develop resistance to every miracle drug and pesticide that comes along.

Now the war has a new general, with a new tactic.

Instead of simply loading the latest silver cartridge — artemisinin, the Chinese anti-malaria drug — Dr. Arata Kochi, the new chief of the World Health Organizartion's global malaria program, has turned an enfilading fire on the whole field: the drug-makers, the net-makers, the scientists and even the donors and the suffering countries they try to help.

"The malaria community hates me," Dr. Kochi said in an interview in the W.H.O.'s small Manhattan office. "I said, basically, 'You are stupid.' Their science is very weak. The community is small and inward-looking and fighting each other."

Dr. Kochi, who in the past ran the agency's Stop TB initiative, has never been known for his diplomatic skills. A 57-year-old graduate of Japanese medical schools and the Harvard School of Public Health, he ruled the Stop TB campaign with an iron fist, colleagues say, and by his own admission, so alienated the Rockefeller Foundation and other partners that he was ultimately forced out of the job.

But even his critics admit that he was a decisive strategist and that the tuberculosis campaign was one of most effective the W.H.O. has run.

"His tactic really worked," said Dr. Jacob Kumaresan, a former chief of the Stop TB Partnership in Geneva and now the president of the International Trachoma Initiative. "With his staff, he's pretty strict — those who don't produce results will be laid off. But he's very bold, and I think he's on the right track."

The tuberculosis world, Dr. Kochi said, used to be just as fragmented and hostile as the malaria field is now. Then, in the early 1990's, an explosion of multidrug-resistant cases everywhere from New York City to Peru to Siberia forced the advent of a new paradigm: four-drug cocktails, taken daily for six months, always under the eye of a nurse or someone else appointed to oversee treatment, even an imam or a faith-healer.

Under Dr. Kochi's leadership, countries were urged to diagnose and treat in standard ways (sputum smears instead of chest X-rays, for example, or four cheap antibiotics instead of exotic drugs and pulmonary surgery). Drug companies were asked to standardize products so each patient could be handed a box with six months' worth of pills. As a result, some partners, like tuberculosis hospitals and makers of the old BCG vaccine, were very unhappy.

Malaria, he said, will need a similar shift, because everything is wrong with the efforts to fight it: lax counting of cases, mixed messages on which medicines to use, counterfeit drugs, expensive consultants, slothful national governments, weak international leadership.

The war on malaria — in theory more winnable than the war on AIDS because a cure exists — is instead being lost, Dr. Kochi says. In the 1960's, malaria was considered potentially eradicable: DDT and chloroquine, a synthetic form of quinine, had been invented, and much of the tropics were under colonial rulers who, whatever their other faults, were good at killing mosquitoes.

Since then, DDT has been withdrawn because of its environmental damage, chloroquine and its successor, Fansidar, have become all but useless and the health systems in most of Africa and parts of Asia and Latin America have collapsed.

The body count is now at least one million a year, most of them children and pregnant women. There are 350 million cases of malaria each year; people may catch it repeatedly in hot seasons and be too weak to work, so it cripples rural economies.

Dr. Lee Jong Wook, the W.H.O. secretary general who died of a stroke last month on the eve of the organization's annual assembly, was about to concede as much.

"Clearly, things are not going well with malaria control," the draft of the speech he was to give to the world's health ministers said. "We accept our responsibility for this. Now is not the time for shyness. W.H.O. will exercise much greater leadership in malaria control."

Dr. Kochi, who had been appointed by Dr. Lee six months earlier, was already proving combative.

In January, he attacked the drug industry, naming 18 companies that were selling artemisinin in single-pill form, and giving them 90 days to stop. Monotherapy encourages resistance, and if artemisinin was lost, he said, "it will be at least 10 years before a drug that good is discovered — basically, we're dead."

If the companies refused to conform, he said, he would disrupt sales of all their drugs by getting the W.H.O. to refuse to certify any drug they made for poor countries.

Executives spluttered, saying they would not be blackmailed, that there was no documented resistance to artemisinin yet and that they had to supply whatever African governments asked for or their rivals would. Dr. Kochi promptly compared that to supplying heroin addicts with whatever they asked for.

"He's a breath of fresh air," said Amir Attaran, a biologist and lawyer at the University of Ottawa who has accused the W.H.O., the World Bank and the Global Fund to Fight Aids, TB and Malaria of squandering millions on old, useless drugs.

"You need to talk tough," he added. "There has been absolute incoherence on fundamental issues."

Dr. Attaran, a longtime W.H.O. critic, also praised Dr. Kochi for being one of the first at the agency to realize that AIDS could be treated in Africa with standard regimens of cheap drugs and simple blood tests, instead of Western-level care costing tens of thousands of dollars a year.

In the 90 days before his deadline expired, Dr. Kochi met with generic drug-makers, many of whom are trying to shift from duplicating Western drugs to researching new ones. He told them, he said, that they would face a public relations fiasco if they made malaria worse.

Caroline Jansen, a member of the family that owns Dafra Pharma, a Belgian company that supplies about 25 percent of Africa's private market for malaria drugs, said her company had agreed to stop selling monotherapy and was developing pills mixing artemisinin with lumefantrine, amodiaquine and other drugs.

Told that Dr. Kochi called Dafra "bad guys" and that he was waiting to confirm their compliance because he didn't "trust them," she expressed surprise, saying: "I understand he had the same attitude about TB — he's blunt and not very nice. But using a strong hand is probably the best way to get this thing done."

When the 90 days were up, Dr. Kochi said all the big companies had changed their policies. "That war is over," he boasted. "We won."

But he had also learned of the existence of 22 more small companies and had started warning them: "Don't come in the back door and try to fill the gap."

Whether he can enforce that remains to be seen. The malaria market in poor countries is a mess: many tiny shops sell pills without prescriptions, and counterfeits are common. Chloroquine is still widely sold because it reduces fevers as aspirin does; patients briefly feel better, but then die of anemia.

In April, Dr. Kochi targeted the Global Fund, through which rich countries buy AIDS, malaria and TB drugs for poor ones. He accused it of ignoring W.H.O. rules forbidding artemisinin monotherapy and buying from suppliers that fail W.H.O. standards. In May, he displayed the reply he got, which he dismissed as "excuses — a lot of 'but, but, but ' " In June, he announced that the fund had changed it policies.

Next he wants to change other weapons in the arsenal.

For example, he wants to standardize mosquito nets so that, instead of a welter of competing styles that must be home-dunked in pesticide, a few makers of factory-coated nets, which kill insects for years longer, are left to compete on price. He dismisses "social marketing," in which nets are branded and sold cheaply instead of being given away, as with an early Bush administration policy that flopped. And, despite the objections of environmentalists, he wants DDT sprayed inside huts to kill mosquitoes where they rest on walls as they wait for dark.

He is lobbying the governments of poor countries, asking them to ban monotherapy, and lobbying Congress for more aid.

Senator Tom Coburn, a conservative Oklahoma Republican who took up malaria as a cause and has demanded that taxpayer dollars be spent on drugs and nets rather than consultants, said he was "very impressed" on meeting Dr. Kochi.

"He's not abrasive compared to me," Senator Coburn, who is also a doctor, said. "A million people are going to die this year. What's more important — having a politically correct strategy or a public health strategy that works?"

Dr. Kochi got his start in public health in 1975 when the Japanese Health Ministry asked for a volunteer to run a tuberculosis project in Afghanistan, and later worked in Myanmar. For interviews, he dresses informally: tie, jeans, no public-relations assistant. His biggest drawback may be his accent — he can make an off-the-cuff impolitic crack in idiomatic English, but then has to go through the agony of repeating it three times to be understood.

He did not want the malaria post, he said. He was "semi-retired and playing a lot of golf" as a W.H.O. adviser in New York, and he had a good reputation for his tuberculosis work.

"Now, if I fail in malaria," he said, "people only remember that."

Dr. Lee, he said, gave him two orders: "Fix malaria, and don't create a Unmalaria." (The second reference was a joking dig at Unaids, the United Nations agency that is W.H.O.'s partner in fighting Aids and rival for funds, experts and glory.)

With Dr. Lee's sudden death, Dr. Kochi was asked, can he keep his job despite his sometimes prickly personality and the usual W.H.O. infighting?

"We'll see," he said. "It will take till November to choose a new director. But I don't pick fights I can't win. Maybe if I achieve results, they'll let me stay. Or let me go back to playing golf."

The New York Times