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Today is World Malaria Day

Kenya (23 of 26)I was supposed to give a presentation, but instead I’m in the Delta SkyClub writing a blog post.

I’m not exactly sure what we’re all supposed to be doing on World Malaria Day that we shouldn’t be doing every day, but at least we have a day! There’s no such thing as “World Helminth Day,” unfortunately.

What I think we should be doing on World Malaria Day:

1. Reducing ridiculous bureaucracy in developing countries which inflates the price of goods at the border.
2. Eliminate ridiculous protectionist policies in wealthy countries which selectively hobbles imports from developing countries.
3. Encourage true democracy in African States (where it doesn’t already exist) and eliminate unproductive authoritarian dead weight.
4. Guarantee rights to representation, legal fairness, political expression and property.
5. Create a global tax on capital and reinvest monies fairly in locally developed infrastructure projects in developing countries.
6. Encourage deep state investments in health care and health delivery in malarious countries while creating conditions favorable for the private sector to meet health needs.
7. Invest in the development of new pharmaceutical tools to prepare for the day when ACTs are no longer effective.

Wait, only points 6 and 7 had anything to do with malaria, you say, but I say they all do. Malaria is a complex disease, the root cause of which is poverty, the root cause of which is politics and economics. We will never be able to eliminate malaria unless we take care of all of the other problems which create the context that allows it to exist.

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Malaria eradication makes the Economist

Not that the Economist has ever made a habit of ignoring tropical diseases. Far from it, the Economist as a British magazine is quite good at reporting on the Isles former colonies.

Here they’ve written on the issues of mass drug administrations as a tool in malaria eradication. Specifically, they focus on a Chinese group seeking to ramp up efforts to create a successful regimen of artemisinin and piperaquine to eliminate the disease by prophylacticly preventing infection, and interrupting the cycle of transmission long enough to eliminate the parasite entirely.

Dr Li’s approach is to attack not the mosquito, but the disease-causing parasite itself. This parasite’s life cycle alternates between its insect host (the mosquito) and its vertebrate one (human beings). Crucially, as far as is known, humans are its only vertebrate host. Deny it them and it will, perforce, wither away—an approach that worked for the smallpox virus, which had a similarly picky appetite. In the case of smallpox, a vaccine was used to make humans hostile territory for the pathogen. Since there is no vaccine against malaria, Dr Li is instead using drugs.

To date, the group has been running trials in the Comoros islands off the coast of Mozambique and had some success, but haven’t come close to full elimination. Elimination on islands surrounded by salt water (mosquitoes which transmit malaria breed in fresh water) should be a fairly easy proposition, but the issue of human mobility from the African continent guarantees reintroduction.

I’m personally involved in an island malaria elimination project in Kenya, but am under no illusions that results from an island are in the least bit generalization to the continent. Falciparum malaria is far too efficient and the lack of a winter renders transmission far too consistent to allow easy elimination. Add the issue of the intense mobility of Africans and one can’t help but be discouraged.

Dr. Li from the Guangzhou group seems to be optimistically under the mistaken impression that all it will take to eradicate malaria is the right combination of magic pills, but he’s gravely mistaken. The only thing that will consistently control malaria on the continent will be a full on, sustained assault using every tool known, along with intense economic development. The continent has only seen gains in malaria control during the 00’s, when incredible amounts of money and effort was thrown at the disease and, not coincidentally, when African economies finally started to take off. Eradicating malaria won’t be about a few pills.

More troubling to me are the ethical issues. Mass drug administrations require the participation. If even a small group of people refuse the medication, the entire effort might be for naught. Obtaining full, informed consent, however, is near impossible in these areas. While most people are willing to participate once the benefits are explained to them, the risks are often glossed over. Moreover, as communities will often follow the behavior of their neighbors or community leaders, it is difficult to judge whether people participate of their own volition or whether they are merely bowing to community pressure. Educational barriers might also compromise the ability to obtain truly informed consent.

Further, I don’t doubt the intent of the Guangzhou group, but I do wonder if Chinese institutions truly have the same level of ethical review and monitoring that United States’ institutions have (which isn’t even perfect and sometimes ill suited to developing countries). I’m sure that China would love to claim a success like malaria elimination, but I worry that a zeal for victory might lead to a violation of basic ethics and even a masking of failures, complicating the issue in the long term. I hope that I’m wrong.

Novartis Japan May Have Overstated Research Results to Sell Drugs: Are Patents the Cause?

The New York Times reported today that Novartis Japan has been discovered to have overstated research results to make the product more marketable.

Advertisements aimed at doctors in Japan reportedly claim benefits of the medicine Diovan, a blood pressure medication, that have not been proven by research.

The ads under investigation, which ran in pamphlets distributed among Japanese doctors, cited studies carried out at Japanese universities that appeared to show that Diovan was also effective in preventing strokes and other heart conditions, according to the Japanese Ministry of Health, Labor and Welfare.

But a number of universities announced last year that Novartis employees had been involved in carrying out these clinical studies, and that the data they yielded was suspect. Misleading ads violate Japan’s pharmaceutical laws, the ministry said in a statement to the news media.

Overstating results, though not unheard of for pharmaceuticals, is common in advertisements for nutritional supplements and other dubious health products. Unfortunately, it is possible that Novartis Japan is using the same tactics in a desperate bid to insure the profitability (or cover losses) of a lagging product. The patent for Diovan is set to expire soon, perhaps increasing the level of desperation.

I was disturbed to find out that Japan’s regulatory body does not recognize research conducted in areas outside of Japan. Certainlt, the country is known for its insularity and protectionist policy, but this seems counter productive. It would explain why many drugs are unavailable in Japan and why availability lags.

I’m not going to suggest that Japan’s health care system is poor. Far from it, Japan’s heavily regulated health care sector insures affordable care for everyone and fair compensation for doctors. I would say that disregarding research conducted aborad must increase overall costs, making Japan an unattractive market. All research for any new drugs must be conducted from scratch within Japan. This strikes me as odd.

The blog of the Center for Education Policy and Research claims that the patent system has induced Novartis Japan to overstate the results:

It’s Novartis and Japan today. The NYT reports on allegations that the company altered test results to exaggerate the effectiveness of Diovan, a drug for treating high blood pressure and heart disease. This is the sort of corruption that economic theory predicts would result from government granted patent monopolies. By raising the price of drugs by several thousand percent above their free market price, patents provide an enormous incentive for drug companies to misrepresent the safety and effectiveness of their drugs.

Odd. While I also agree that the patent system often works to stifle innovation and impedes access to life-saving drugs in developing countries, I’m not so sure that the patent system has caused Novartis Japan to misrepresent the drug. While the author speaks only patents here, I suspect that (though I have no proof), given the emphasis on the “free market,” he or she might oppose drug regulation as a whole providing an enormous opportunity for drug makers to misrepresent just about anything they like.

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