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Six Experts, Six Answers


Six Experts, Six Answers

How likely is it that the Plasmodium parasite will acquire resistance to artemisinin on a global scale, as it has with chloroquine?

Nicholas WhiteIf we control malaria, it won’t. But if we don’t control malaria, global resistance is inevitable, and whether that’s in 1, 10 or 1,000 years we can’t be sure. There is clearly evidence of resistance to artemisinin in western Cambodia, and there’s a lot of talk about it having spread, but none of that is strongly evidence-based. 

All the treatments for falciparum malaria are based on artemisinin combination therapy. The worst-case scenario is that artemisinin resistance will do what chloroquine did before it, and that would be to [lead to the deaths of] between 1 and 10 million African children. The possibility is so horrendous and awful that we should take some radical action. 

One form that might take is to treat everybody in western Cambodia with antimalarial drugs to eliminate all malaria from the region. That means treating a lot of people who aren’t sick and exposing a lot of people to toxicity. I’m not saying that is the right course of action or that I have all the answers by any means, but we need to get the best scientific opinions, and try and reach a consensus, and we haven’t done that yet. We’ve basically asked people on the operational side, “What do you want to do?” And, as they are all generally doing a good job already, why would they want to take a more radical and uncomfortable course of action? 

International health is very politically based. It’s difficult to take executive action and move quickly, the various donors all pull strings in different directions, it’s not clear who’s in charge, and we just don’t have the appetite for making difficult decisions. But this is a really serious problem with the potential to derail current malaria control and elimination efforts, and it may be preventable—so to do that will need a truly high-level, coherent international effort.

Nicholas White, FRS, is chairman of the Wellcome Trust South-East Asian Tropical Medicine Research Programmes.

Comments

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  • Dr. C. Nagaraj

    Bangalore, India 02/08/2011 10:47:20 PM

    I wish to inform you that already resistance of Pf has occurred and I have detected resistant Pf from Karnataka, Maharastra and Orissa in India - resistant to ACT (Artisunate +SP) by therapeutic efficacy method (in vivo). I can send my findings to you if are interested. I have lot of interesting findings which I wish to discuss - gametocyte increase after ACT, side effects of ACT, etc.

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