Nov. 3, 2010, 9:10 a.m.
For a man who says he never plans, Nicholas White's achievements are impressive. A renowned malaria expert who has been based in Bangkok since the early 1980s, White has just won the Canada Gairdner Global Health Awardfor achievements in malaria research. He says it's a special award because nominees are put forward by other scientists in the field and “peer recognition is what you value”.
White was a key figure in the development of a malaria treatment based on artemisinin, a derivative of Chinese sweet wormwood. He first heard about the drug in the early 1980s in a Chinese research paper, at a time when malaria treatment was becoming woefully inadequate due to growing parasite resistance to drugs such as chloroquine. The drug had been used for decades in China, and seemed to be safe but effective, but international health authorities such as WHO were reluctant to give the go-ahead for developing treatments based on the derivative. This was a particularly “orthogonal way of thinking”, says White. To put a drug that had already been used in hundreds of thousands of people through the same process as one that had never been used in human beings shows that “common sense has little value nowadays”, says White.
A decade after artemisinin was discovered, little progress had been made in turning it into a malaria treatment. With drug resistance dangerously high, and unwilling to wait for the clunky machinery of the global health community to kick into action, researchers in Vietnam and Thailand, including White's group at the Wellcome Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, pioneered key studies into artemisinin. By the end of the 1990s, White's group and others had produced solid data to prove the drug's usefulness in fighting malaria. Yet there was still a baffling resistance by WHO, the World Bank, and others to rolling the treatment out to people in desperate need of it. The inertia was finally broken, says White, by a 2004 Viewpoint in The Lancet, in which Amir Attaran and colleagues accused WHO and others of malpractice. Eventually, in 2006, WHO issued new guidelines that recommended the use of artemisinin-based combination therapy (ACT) as first-line treatment for malaria everywhere.
The dark cloud of drug resistance is now hovering over artemisinins too, however. The resistant parasites are cleared slowly from the blood, but no molecular marker of resistance has yet been identified. So far, it only seems to be a problem in Cambodia. It could, in theory, have crossed over to Vietnam, Laos, and Burma, “but given the remarkable lack of global response to the problem, there is no way to know how far it has spread”, says White. The idea that the best malaria drug in existence could soon be rendered useless should be provoking an emergency response of mammoth proportions. White would like to see agencies such as WHO seeking pre-approval from member states to be able to create a “war response” to such international health emergencies, rather than having to chug through the slow and political process that characterises global health campaigns.
However widespread artemisinin resistance is, one thing is for sure: the growing problem of counterfeit malaria drugs is only going to make it worse. The uncomfortable truth that fake drugs are rife is “much bigger than anyone wants to accept”, says White. “It's not heroin or cocaine but it kills people just the same”. While drugs that have no active component can kill those who take them, counterfeits that contain a small amount of artemisinin can be as dangerous in the long run by encouraging resistance. Wiping out the fake drugs industry could prove too difficult, White says, but he has backed a plan put forward by the US Institute of Medicine to subsidise drugs to “drive the bad drugs out”. The result of the Institute of Medicine report has been the Affordable Medicines Facility for malaria, now a year old, that is piloting a scheme in 11 countries to subsidise ACTs. “This is the most pragmatic solution to ensuring that people get the drugs that they need”, says White.
Pragmatism features strongly in White's vocabulary. Malaria scientists are once again talking about elimination and eradication. White thinks that it will be a huge challenge to drive the disease out from some particularly endemic countries, but he believes that it is good to have a positive target of elimination, rather than the more negative one of control. To achieve eradication, many researchers are hunting for the holy grail of malaria—an effective vaccine. But White would rather see improvements to existing antimalarial drug treatments, and greater efforts to deploy them together with insecticide treated bednets. He doesn't advocate getting rid of vaccine research, but does think that malaria could be eliminated eventually with the tools we already possess, if they do not fall to resistance. This will mean studies to improve dosage. For example, sulfadoxine-pyrimethamine once held the exalted position that ACTs now do. After drug resistance rendered sulfadoxine-pyrimethamine largely useless, however, scientists realised that extrapolation of the dose regimen from adults was a mistake, and that children should have been given double the dose they had been. White wants the malaria community to value the tools it already has to tackle one of the most pernicious diseases in the world: “We could do a lot of good in global health if a small fraction of the funds dedicated to the uncertainty of discovery were invested in improving the use of existing medicines.”