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About the Author

Bart Knols
Medical Entomologist (Dodewaard, Netherlands)

Bart G.J. Knols (1965) is the Managing Director of MalariaWorld, the world's first scientific and social network for malaria professionals. He is a malariologist with a Masters degree in Biology and a PhD in Medical Entomology from Wageningen University, the Netherlands. He also obtained an MBA degree from the Open University (UK) in 2006, for which he won the prestigious international ‘MBA Student of the Year 2007 Award’ as well as the Alumnus of the Year Award from the Open University. With 11 years of working experience in Africa he has managed large-scale research and vector control programmes on malaria for ministries, international or national research institutions. He has worked for the UN (IAEA) as a programme manager for three years, has served as a consultant for the World Health Organization, and is currently a Board Member of the UBS Optimus Foundation, the second largest charity in Switzerland. He has published over 130 peer-reviewed research articles, has written 16 book chapters, and has served as senior editor on a WHO/IAEA sponsored book on implementation research. In 2007 he co-edited a best-selling book titled 'Emerging Pests and Vector-Borne Diseases in Europe'. He received an Ig Nobel Prize (2006), an IAEA Special Service Award (2006), and in 2007 he became a laureate of the Eijkman medal (the highest award in the field of tropical medicine in the Netherlands). He has been a member of the Royal Dutch Academy of Arts and Sciences since 2004. Bart held an Assistant Professorship at Wageningen University until April '09 with projects across Africa. He currently directs K&S Consulting, a firm he founded in the beginning of 2007.

Post

China clashes with the West over the battle against malaria

Published 30th July 2010 - 61 comments - 65947 views -

Yesterday morning, my office received a phonecall from Geneva. It was Doctors without Borders (MSF) that requested us to send out a corrective statement to the global malaria community via our platform (MalariaWorld) regarding inaccurate information that was distributed by the Chinese company Artepharm

Artepharm, in a press release dated 19 July, stated ‘The Company is very pleased to report that Doctors Without Borders/Medecins Sans Frontieres (MSF), a Nobel Peace Prize winning humanitarian organization, will monitor and analyze the results  of the current project.’ MSF, however, denies any collaboration with Artepharm and firmly distances itself from any involvement with Artepharm’s activities in East Africa.

Moheli island

moheliMoheli (or Mwali) is a small island belonging to the Comoros archipelago in the Indian Ocean. Malaria is one of its biggest health problems for its 36,000 inhabitants. But beyond the radar of western science and without the go-ahead of the World Health Organization, China crafted an unconventional and now widely disputed approach to eliminate malaria from the island.

Using an artemisinin-based combination therapy, Artequick, for which Artepharm holds the patent, the Chinese dosed every inhabitant of the island twice with the drug over a 40-day period. Everyone. The approach is called mass drug administration. The concept is simple: By clearing the parasites from the bodies of all Mohelians, the disease would be wiped out. The Chinese reasoned that the remaining malaria mosquitoes would be harmless as there would simply be no parasites left to transmit. 

On 16 July, Artepharm declared victory over the disease on Moheli. And to avoid humans bringing in new parasites, everyone entering the island in future will have to take a mandatory dose of the drug.

China vs WHO

China is not just conquering Africa in search of its resources. China gives back, and uses an approach to malaria elimination that would be a hard sale in any democratic setting where people cannot be forced to take a drug without their consent. But then, do the inhabitants of Moheli care about this? Probably not – the ancient scourge has been removed from their island.

But western science and the World Health Organization alike, were not all that thrilled by the Chinese success. Richard Feachem of the Malaria Elimination Group in San Francisco warned  that ‘It falls way short of  a peer-reviewed scientific publication’. Apparently the Chinese declared victory without seeing the need for some high-profile article in a medical journal like the Lancet.

East meets West

‘These results will be very very scientific’ argued Professor Song Jiangping when interviewed on the island. He went on to say: ‘Because it was a new technique, many experts were doubtful when it was first introduced. To them, it would be impossible to eradicate malaria. They thought that could only be an illusion’.

Jiangping should have known that his approach on Moheli was not new and novel. Already in 1991 a similar approach proved successful on the island of Aneityum in the Solomon archipelago, albeit on a smaller scale. Only 718 people were drugged back then, again with malaria elimination as the end result.

All of this will not be of interest to the inhabitants of Moheli. They’ve seen the end of malaria and don’t care what Geneva’s WHO thinks of this. They also don’t wait anxiously for some high-profile publication.

Jiangping now wants to move on to other islands and even talks of the whole continent of Africa. ‘We can eradicate malaria from the whole continent within a decade’, he argued passionately. 

I guess the time has come that the giant from the East will start showing the world how diseases like malaria can be tackled ‘Chinese-style’. Malaria elimination is not an exclusive ‘right’ of WHO and the Chinese ignore the concept of ‘double-blind, randomised, placebo-controlled trials’. They move in and get the job done.

No surprise that Africa is embracing China.

 

[The quotes in this blog originate from interviews that can be seen here: ]http://www.artepharmglobal.com/news_events/news_videos.php]

 


Category: Health | Tags: africa, africa, malaria, china,


Comments

  • Bart Knols on 02nd August 2010:

    @John - it is estimated that at least 3 million people inhabit islands around Africa (excluding Madagascar) where malaria is endemic. All of these islands could in principle have the same approach to malaria elimination. Go in, wipe out the reservoir of the parasite in humans, wait long enough for infected mosquitoes to die, then have the second round of drug administration. End of story - no publication needed…

    The question of course is one of resistance popping up. However, the Chinese have played this in a clever way, by combining artemisinin with two other compounds, of which one is gametocidal (primaquine). Risk for resistance development in this way is pretty minimal, and if you swipe through an area, you may be ahead of evolution…

    @Jim - I fully agree with your statements ref GIS. Modern technology has a great role to play to make (already successful) disease elimination campaigns of the past even more successful (in economic terms). I also wonder often where the baldness to move in and eliminate has gone - we have much better tools these days, but seem to lack the courage to do it. This example, of the Chinese, shows the opposite, and it is very interesting to note their different perspective. As for another major success story against malaria, see my other blog: http://development.thinkaboutit.eu/think3/post/the_man_who_saved_brasil/ as well as my suggestions for malaria elimination on Zanzibar: http://development.thinkaboutit.eu/think3/post/if_you_do_what_you_did_you_get_what_you_got/

    Getting out there and doing it by applying the best of our knowledge and technology. No more need for costly conferences…I’m all with you!

    @Hieke - it is complicated and yet it is not. As I say, the people from Moheli island will not care if this was ethical, legal, moral, and so on. They got rid of malaria, basta…


  • Luan Galani on 02nd August 2010:

    Bart, nice stuff as always. I believe it is imperative to do as the red giant is doing to grapple with malaria. Just a short quick note: the first link on the press release (second paragraph) is not working. I would love to read it in full.


  • Bart Knols on 02nd August 2010:

    @Luan - well, the link did work, but the press release has been removed from the website from the pharmaceutical Artepharm… I am leaving it the way it is, to show how such things turn out…

    When writing this article it crossed my mind that I should save the websites I listed. And fortunately I did find the press release in my cached pages.

    You can read it as the attachement under the statement made by MSF: http://www.malariaworld.org/story/doctors-without-borders-msf-corrective-statement-inaccurate-information-communicated-artepharm

    In the meantime I have formally (be email) invited Artepharm to comment…I hope they will.


  • Luan Galani on 02nd August 2010:

    Yeah, you’re right. Better to leave it the way it is to show how they act. Btw, thanks for the link. I’m just off to read. I look forward to their reply, then.


  • Bart Knols on 02nd August 2010:

    @Luan - I really hope that they will respond to the invitation. They have accomplished something remarkable and I am sure this approach can work in many other parts of the malarious world. But removing a press release from their site is not the most clever thing to do. This will make many people suspicious. Much better to admit that you made a mistake, right?


  • Luan Galani on 03rd August 2010:

    @Bart, absolutely!


  • Bart Knols on 03rd August 2010:

    @Luan - I can almost guarantee that Artepharm is reading this blog and MalariaWorld. They now realise that 6000 malaria professionals in 105 countries have access to this information, and if they play their cards well, they will hopefully come forward.

    If anything, if indeed they did eliminate malaria from Moheli, than this is a huge step forward. Morocco was recently declared malaria-free by the World Health Organization, but that’s where it stops - no other country in Africa endemic for malaria will be declared free in the foreseeing future - so their success on Moheli is quite something!


  • Bart Knols on 04th August 2010:

    @Torsten - the issue of malaria resurgence is the one always topping discussions when it gets to malaria elimination. Let me give you four examples of islands where resurgence has not been the case. First, Taiwan. Malaria was eliminated during the late 1950s and 60s, and never came back. Second, Mauritius, which was declared malaria free in 1978. Malaria never came back. Third, all islands of the Caribbean had malaria (now only Hispaniola), and they never got malaria back…And as far as I know the island of Aneityum mentioned above never saw malaria after it was eliminated during the 1990s. That’s millions of people now living free of the threat of malaria.

    It is my firm belief that there is an awful lot to gain in tackling malaria on islands (take Indonesia and the Philippines as examples). The key issue after elimination is surveillance. As long as this is appropriate, elimination can and will be sustained.

    As for your article and the fact that mosquitoes have weak point in finding water to lay eggs I have no idea what you mean - can you elaborate?


  • Bart Knols on 05th August 2010:

    @Tom - I very much agree with you, and it is also not clear to me why there was such public withdrawal from WHO and MSF regarding this Chinese project on Moheli. It is high time for daring and bald projects like you suggest, and there are no half-way measures that will yield success. There is, perhaps, more to learn from the Chinese than we think…


  • Bart Knols on 05th August 2010:

    @Torsten - Don’t know if you have seen my article on Brazil: http://development.thinkaboutit.eu/think3/post/the_man_who_saved_brasil/

    where Anopheles arabiensis was eliminated from 54,000 sq km of Brazil. That’s a massive sign that also over large areas area-wide approaches can work. Source reduction can indeed play a role, particularly in areas with unstable and seasonal transmission (with a short rainy season). Using vegetation around the perimeters of such sites is futile. You will never get people to undertake this task - much easier to control larvae in the water itself (with botanicals or biopesticides).


  • Bart Knols on 05th August 2010:

    @Torsten - thanks for your continued input in this discussion.

    Ref Brazil: The elimination campaign there was almost completely undertaken through larval control using the toxic chemical Paris green. One would not want to use such chemical today - but we have perfect biological alternatives that have absolute minimal impact on non-target organisms and the ecosystem at large. I am merely arguing to use the same approach as in Brazil, not to use the same chemicals.

    That farmers are interested in using your approach is fine - the spin-off comes from other benefits (meat as you say), but to get people to do this solely to avoid malaria will never work.

    Iron supplements have indeed shown to be beneficial but are not a means to eliminate malaria - they will solely serve to improve health whilst elimination efforts are underway.

    Closing the eaves of rural houses can be an important contribution towards reducing house entry by mosquitoes. These can be sealed completely but are traditionally used to increase ventilation. Such measures will reduce transmission but are by far not enough to halt transmission alltogether.

    Tom’s comment makes much sense to me: what the Chinese have accomplished on Moheli can be sustained with proper surveillance to avoid re-introduction and the approach can be repeated across large chunks of Africa where transmission is marginal at present, besides islands.

    The problem lies in the fact that large-scale (I mean really large-scale) elimination campaigns are not undertaken at present and it will just be a matter of time before they emerge - what and how we need to conduct them remains the crux of the story…


  • Bart Knols on 05th August 2010:

    @Torsten - I completely agree that pills and spraying will not be sufficient to eliminate malaria, and that new tools will be needed to augment existing strategies.

    The link to the article does not work, can you please re-send?

    Pyrethroids are indeed highly toxic for fish and crustaceans, so cannot be used for larval control. The perfect biological is Bacillus thuringiensis israelensis, which is highly specific for mosquito and blackfly larvae (blackflies vector onchocerciasis or riverblindness).


  • Bart Knols on 05th August 2010:

    @Torsten - thanks, I know this article.

    You make an important statement here ‘It is too expensive…’. My question is simple: why? If you consider the amounts of money currently being spent on temporary measures in malaria control (nets, indoor spraying) you would be surprised how much larval control (to eliminate malaria) could be done with that money. Moreover, if it would come to Europe or the USA, would we be talking about costs if we would still have malaria? No, we wouldn’t.

    Look at the millions of dollars we have thrown at swine flu vaccines, only to be destroying them now, because they’ve become useless. Money cannot be and should not be an issue when it gets to tackling malaria…

    Why, one could argue, should malaria control (if not elimination) in Africa be undertaken on a shoestring? Why should it be cheap?


  • Bart Knols on 05th August 2010:

    @Torsten - as you can see, I co-authored this article… Seven years down the line it is still hardly being used in Africa…


  • Bart Knols on 05th August 2010:

    @Tom - That’s a great and fascinating question. My personal opinion is: if we ascertain that such islands will set up a proper surveillance system (which will be a fraction of the cost compared to what malaria is costing them now), then we should proceed, definitely… (PS: I will tweet you comment to draw in more responses).


  • Bart Knols on 05th August 2010:

    @Torsten - If Bti can be produced in a cheaper (fermentation process) manner, than that is fine and is to be applauded.

    Your efforts to push for more funding for decades have been bearing fruit. The amount of money now going into malaria is in the order of billions - it is not a shortage of funds, it is merely the wise application of these funds.

    A huge mistake that has been (and is still being) made is that ‘cheap solutions are unfortunately essential’. This stance, as part of malaria elimination, is the devil that will continue us all to fail to make a real difference. Getting rid of malaria costs - anything on the cheap will lead to (again) dismal failure.

    @Tom - that’s two in favour of your suggestion ref islands. Elimination, no matter how costly, will always become beneficial in economic terms if it is sustained. The elimination of tsetse flies from Zanzibar cost 4 million USD, but the island has been free of sleeping sickness in cattle for almost 11 years now. All the benefits accrued over that period largely outcompete the heavy upfront investment in the programme. With malaria it will be similar, no doubt.


  • Bart Knols on 05th August 2010:

    @Bart - I wish, thoroughly wish, that tsetse would only fly 300 m! This may be so for certain riverine species in West Africa but certainly not for members of the savannah group that may even be passvely dispersed over large distances.

    Your remark regarding the stealing of medicines is not clear to me.

    Malaria in upland areas has seen a resurgence over the last three decades. Some attributed this to climate change, others to ecological changes, then others to both or more factors. Yet, like physical islands, elimination of malaria in upland ‘ecological islands’ should be perfectly feasible in certain countries. The Usambara increase in malaria was linked to climate change in a paper by Matola and White in 1987.


  • Bart Knols on 05th August 2010:

    Thanks Torsten - let’s focus on malaria for now. Another time we can discuss tsetse dispersal wink

    Your second point is highly valid. If cleaned zones get visitors coming in with parasites there is the real danger of epidemics (such as happened in the Gezira area of Sudan, where after a 10-year all low of malaria because of integrated control strategies, funding ceased and a massive epidemic struck). Serious backlashes can occur, but this should not stop us from moving in and getting the job done as we did in parts of the world where now 800 million people live free from the threat of malaria.

    Malaria vectors are still common in the southern USA, and once in a while a parasite carrier comes in (from Mexico for instance) and may infect local mosquitoes followed by a few more cases. Vigilance is all that matters - something that African nations can set up and execute in exactly the same way. Where there’s a will, there’s a way…


  • Bart Knols on 05th August 2010:

    @Tom - I agree with every word you say in your comment. Happy to find a person with similar convictions - we are a small but growing group…


  • Bart Knols on 06th August 2010:

    @Torsten - thanks again for you input in this discussion. Having worked in Africa for 11 years, and having run community based vector control programmes and cannot see the use of contour hedges as a means to control malaria. We differ in opinion here and I am not convinced (yet).

    @Tom (1) - I agree 100% with your statement ref ACTs and ‘waiting’ and ‘talking’ rather than ‘doing’.

    @Tom (2) - This is tricky. We need a stronger voice but have to play our cards carefully. I used to be invited to WHO expert meetings and consultations, but when you become vocal about certain issues the invitations stop coming in…

    @John (1): So true. Malaria has become an industry with people in it that have never seen malaria in the real world. That is a major obstacle. See my article on science actually inhibiting progress: http://development.thinkaboutit.eu/think3/post/can_science_cripple_development
    Perseverence is the key, and not spending all our time trying to convince sceptics and don’t believers. With a small but growing group I am developing ideas for elimination in specific settings. We just move forward with it…

    @Tom (3) - again, I agree entirely with your views here.

    @John (2) - Yes, I have a number of places in mind that we are working on in terms of elimination plans. The idea is to get the full elimination strategy, costs, tools, human resource needs etc. worked out before knocking on doors. Happy to share these places with you outside this public forum.

    @Tom (4) - indeed, from now on, I will use Moheli in my presentations. It is a very powerful signal to the global malaria community that IT CAN BE DONE. All the talk that we need this and that and another tool before we can tackle malaria… well, Moheli shows that there should be much more implementation right now with what we have at hand!


  • Bart Knols on 07th August 2010:

    @Torsten - thanks. We tend to differ on the potential of this methof for malaria control, but so be it.

    @Shaloo - thanks for chipping in. I indeed see that the Qatar Foundation will put up big amounts of funding, supposedly to free the other islands of the Comores from malaria too (in total 800,000 people. I hope they will succeed. If so, that we will a very important lesson for all of us who believe that we first need more tools before we can go ahead with elimination campaigns.

    @Tom - we’re in the same boat and speak the same language - thanks.


  • Bart Knols on 10th August 2010:

    @Tom - thanks for this additional information. I have found the full TV documentary about Moheli here: http://www.sbs.com.au/news/article/1013581/Researchers-claim-malaria-success

    This shows that by March last year, they had nearly wiped out malaria. The big question is: where are they now? Have they indeed eliminated malaria from Moheli?

    On the TropIKA website it says that they want to tackle Madagascar next. That would be a big mistake - I would select more small islands around the world first, document these elimination efforts well, before moving on to larger islands.


  • Bart Knols on 10th August 2010:

    @Martin - thanks very much for this additional insight. Clearly, what is needed here, is collaboration. The west shying away from the Chinese efforts, or worse, turning their backs to it, is precisely the recipe that may lead to disaster.

    I agree entirely with you that care should be taken that resistance doesn’t develop, which would be a real issue on much of mainland Africa. However, if you can sweep islands free this way, why would you NOT do it?


  • Bart Knols on 11th August 2010:

    @Tom - Excellent, although I did not manage to download the pdf of the article. Did you get it?

    In any case, many thanks for your enthusiastic input in this discussion!


  • Bart Knols on 20th August 2010:

    @Tom - thanks for additional information. Indeed, like with many other issues, China will move ahead regardless. Malaria will not be different. In the end, what matters to Africans will be to see malaria disappear. Who, when, or how it is done is of secondary importance. To form an alliance with the Chinese initiatives is indeed important.

    @Ole - Thanks for chipping into this discussion. I know that treatment of whole villages in north-east Sudan with gametocidal drugs just before the onset of the dry season did miracles. It add further proof to the viability of this approach. Tom asked a very valid question above - if we can, than why aren’t we doing it on ALL islands (to start with)? Next, your suggestions for parts of the Sahel with seasonal and non-intense transmission sound equally interesting…


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