Former US President Bill Clinton recently warned that governments around the world are ill prepared for disasters, even when they have some advanced knowledge of problem, as in the case of the botched response to Hurricane Katrina. Clinton was speaking at Harvard Universities Kennedy School of Government where plans are underway to study government preparedness and response to problems ranging from global warming to stemming the effects of malaria. While much of the current talk of a malaria crisis revolves around expanding habitats for malaria-carrying mosquitoes, there are other crises in the making in current malaria-endemic environments.
One element of the looming malaria crisis is resistance to malaria drugs. We have been trying to transition from years when cheap monotherapy antimalarial drugs were nearly universally available and health systems could afford to presumptively treat any case of fever as malaria to an era of expensive combination therapies. Challenges along the way include the persistence of monotherapy versions of the new artemisinin drugs as well as major procurement and distribution problems for the new Artemisinin-based combination therapies (ACTs). Countries may be importing ACT supplies at cost from donors such as he Global Fund to Fight AIDS, TB and Malaria (GFATM), but such supplies are usually targeted for children under five years of age, and even then are not intended to be the sole source of a country’s ACT supply for that age group. Thus a crisis persists wherein old drugs like chloroquine are used to treat the remainder of the population with life-threatening results or monotherapy artemisinin drugs, thus drawing the day closer when resistance to this class of drugs arrives. So far WHO reports that there are no confirmed reports of artemisinin resistance in humans, but should this develop there are few if any immediate candidates to fill the gap.
Vigilance is needed by the relevant food and drug agencies in endemic countries work in close collaboration with national malaria control programs and policies and ensure that only ACTs are approved and dispensed or sold. Likewise there is urgency for national policy makers to make funds available to purchase ACTs for the entire population, supplemented with rapid diagnostic tests to ensure that when adults are treated with ACTs, they actually have malaria. Development of national or regional production capacity for ACTs is another need and challenge. Finally countries need to establish and maintain surveillance sites to monitor for malaria drug resistance.