The new boom in malaria

On World Malaria Day (25 April) the world's eyes naturally turn to the vast belt of tropical Africa, where poverty and lack of healthcare make the disease among the top killers of children. But the real story is quietly unfolding thousands of miles away in Cambodia where new, drug resistant strains of the parasite are emerging. Left unchecked, these new strains could make whole classes of modern drugs useless, seriously undermining the fight against malaria.

With the disease still prevalent in Bangladesh, this could undermine the battle for eradication. For the last few years, patients have had a powerful new drug-artemisinin, derived from the sweet wormwood plant indigenous to China. Unlike other increasingly elderly classes of malaria drugs, artemisinin has until recently been completely effective in clearing malarial parasites from patients' blood, making it the most effective malaria treatment available today.

Back in 2005, however, researchers working on the common borders of Cambodia, Laos and Thailand began to notice parasites were taking longer to clear. In November 2009, further studies found artemisinin resistance already in Myanmar, China and Vietnam, where between 12-31 percent of patients still harboured the parasite after three days' treatment.

According to Dr. Charles Delacollette from the World Health Organization, "the fear is what we're observing right now could be the starting point for something worse regionally and globally." Around 880,000 people died of malaria in 2006 but, if the most powerful anti-malarial gun is spiked by drug resistance, this figure could escalate rapidly.

One of the biggest drivers of drug resistance in this Greater Mekong area is bad medicine. Research published in the academic journal Public Library of Science in 2008 showed that up to half of all artemisinin drugs in the region contained too little active ingredient, proscribed chemicals or both. When malaria drugs contain sub-therapeutic levels of active ingredient, it can be enough to fool quality inspections but not enough to knock out the parasite. Aside from harming the patient directly, this helps the parasite learn how to outwit the drug and then multiply, which it appears to be doing with increasing ease.

All other malaria drugs have suffered this fate. Chloroquine, the cheapest and most common malaria drug, is becoming increasingly useless in almost all endemic countries. Resistance to another important drug combination, sulfadoxine-pyrimethamine, is now global.

It is vital that the same fate does not befall artemisinin. Given that drug resistance is currently only sporadic and localised, it may not be too late. The key is taking steps to improve the quality of the drug supply. Certain parts of South East Asia are awash with substandard Chinese-made artemisinin. Some are copies made by legitimate yet inefficient companies but many are made by criminal counterfeiters, often in deeply unsanitary conditions.

To stem this tide, the region's governments have to give far greater protection to intellectual property. In particular, the manufacturers of certified, high-quality medicines need to be sure that bootleggers are not infringing their trademarks. As any business or consumer knows, trademarks signal the quality of a brand. But if other people start copying a trademark with impunity, it might as well not exist.

Unfortunately, countries such as Cambodia, Thailand and Laos--and indeed most countries where fakes are a problem--do little to uphold trademarks. Courts are corrupt and bureaucratic, and it can take years and cost millions to successfully conclude a prosecution. This legal vacuum gives free rein to the counterfeiters, crowding out more expensive but reliable drugs.

Some have called for stricter regulation but this will not help much in countries where corruption is a problem and regulators themselves often become compromised by counterfeiters. In 2007, China executed the head of its drug regulator for allegedly accepting bribes from counterfeiters. Also in 2007, drug inspectors in Orissa, India, were accused of working in cahoots with counterfeiters.

World Malaria Day will no doubt focus on activists pleading for more money for medicines and bednets. But unless weak governments and their neighbours in Asia get a grip on fake drug production and trade, the outlook for malaria victims is about to get a whole lot worse.

The writer is a Senior Fellow at International Policy Network, a London-based think-tank.