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Will Canada Gamble on Malaria Treatment?

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Wednesday, April 25 was World Malaria Day, and there is news about a disease that afflicts 225 million people and killed about 650,000 in 2010.

First the good tidings: In the last decade, deaths from malaria have been cut by one third in Africa and the number of at-risk people contracting the disease globally has fallen by 17 per cent.

The worrying news is rumours of an about-face in Canadian policy that would divert millions in scarce aid money to a risky experiment, while proven strategies go unfunded.

The UK Guardian was right to cite malaria control as "one of the most notable achievements of international aid." Much of the credit goes to two initiatives: the Global Fund to Fight AIDS, Tuberculosis and Malaria and the U.S. President's Malaria Initiative. They have enabled massive distribution of insecticide-treated bed nets and indoor spraying, and access to free diagnosis and medicine via trained community health workers.

Yet this success is fragile. Cuts to aid budgets led the Global Fund to cancel its latest funding round, casting severe doubt on the ability of developing countries to maintain, much less scale up, their malaria control efforts.

The logical move would be to redouble Canada's contributions to such proven interventions. Instead, CIDA is said to be contemplating a $20 million grant to the Affordable Medicines Facility for malaria (AMFm), a pilot project run out of the Global Fund.

AMFm is a controversial experiment to try to reach more people with ACT, the latest anti-malarial medication, by selling it at a subsidized price in local shops. Due to inadequacies in public health systems, the majority of poor malaria sufferers buy medicine at such corner stores, where it is sold off the shelf along with cooking oil and sugar.

Artemisinin Combination Therapy (ACT) is currently the only effective malaria treatment that exists, since the parasites have become resistant to the more inexpensive medicines chloroquine and sulfadoxine-pyrimethamine.

Corner Store "Doctors"

Innovation is laudable, but not all experiments make sense. To its credit, since its inception in 2010, AMFm has managed to negotiate hefty price reductions from drug manufacturers. But that did not allay the concerns voiced by many NGOs, the U.S. government and -- until now anyway -- the Canadian government regarding the risks of AMFm's approach and whether it offers value for money.

The first problem is the initiative's reliance on unqualified and unregulated shopkeepers to diagnose the disease and prescribe the medicine. Such corner store "doctors" commonly sell malaria drugs to anyone complaining of a fever -- missing other killer diseases like respiratory infection, which remains the main cause of child mortality. What a scandal when poor families sacrifice their meagre earnings to pay for the wrong medicine for their children.

The second problem arises when the shopkeeper gets the diagnosis right. AMFm presumes that poor people will pay for the full treatment if the price is subsidized. The reality is that when medicine is not free, people living in poverty purchase pills as they can afford them, often taking less than a full course of treatment.

Such mistreatment vastly increases the likelihood the malaria parasite will become resistant to ACT, which is the only effective malaria medicine left. This was the sad story of chloroquine -- an excellent malaria drug now rendered useless in Africa precisely because of incomplete treatment.

The first cases of resistance to ACT were identified a few years ago along the Thai-Cambodia border where resistance to chloroquine first emerged over 50 years ago). Alarmingly, recent research has found more cases of ACT resistance on the Thai-Burmese border.

Guard Aid Dollars

Containing resistance should be a global priority, and donors should steer clear of experiments that put that effort at risk.

Sadly, the problems with AMFm don't stop there. Last year, uncontrolled ordering by AMFm buyers threatened to destabilize the market for ACT and in the process depleted the initiative's funding. For example, buyers in Zanzibar, a country where malaria has almost been eliminated, ordered over 240,000 treatments when the number of malaria cases is only around 10,000 per year.

Spending of precious aid dollars should be guided by evidence of what works. In the case of malaria, the evidence is overwhelming: delivering professional services and medicines free of charge via trained community health workers or primary health clinics has achieved historic progress in countries across the globe.

That is what the Global Fund to Fight AIDS, Tuberculosis and Malaria was set up to do and does well. Given cuts to CIDA's overall aid budget, I worry that the money for a new grant to AMFm would be subtracted from Canada's proud and steady support for the Global Fund's proven malaria-control programs.

Canada would be wise to listen to its allies and partners, and stick to financing malaria-control programs that work.