The Rise in the Morbidity and the Mortality of Malaria is a Global Threat:
Evidence from Multiple Antimalarial Drug Resistance, continued
by Nestor Sapathy
Malaria as a Global Threat
In malaria-endemic regions globally, the disease has become difficult to combat because the parasite developed resistance to chloroquine, the most common and cheapest antimalarial drug. This has become a global threat because drug resistance promotes transmission of malaria to new areas, as well as to regions where the disease has been eradicated. According to Smolinski, Hamburg and Lederberg (2003), malaria cases diagnosed in the United States and its territories were imported from Africa, Asia and the Americas and a similar trend occurs in Western Europe (p. 31). Spielman et al, (2002) noted, "Malaria can impose a substantial economic burden on firms operating in endemic regions due to direct health care costs as well as opportunity costs due to loss of productivity" (p. 14). According to them, malarious areas of the globe are attractive for international travel and commerce due to the following: oil and gas, mining resources, unique agriculture products, tourism and cheap and abundant labor, etc.
Malaria imposes heavy burdens on the establishment of industry in the poor Third World countries. And the school of thought that economic globalization is the solution to poverty failed in some areas of the world due to infectious malaria.
Why Does the Parasite Become Resistant to Antimalarial Drugs?
According to the laws of Darwinian evolution, antimalarial drug use creates a selection pressure on microorganisms (parasites) by which weak ones are killed, but stronger ones might adapt and survive. It means that after sometime antimalarial resistance is inevitable as the parasites mutate and adapt. However, antimalarial resistance can be delayed with appropriate drug strategy. White (1999) has explained, "Antimalarial drug resistance usually arises when the arising mutant parasites are selected by antimalarial drug concentrations that are not sufficient to reduce the susceptible population, but less inhibit or do not inhibit multiplication of the parasites" (p. 739).
The pharmaceutical companies developed many antimalarial drugs in single-pill form that are effective to kill all stages of the parasites in the blood, and these are less expensive compare to combination therapy. Indeed, single-pill kills the parasite and cheaper, yet a drug developed in "monotherapy encourages resistance, " said Dr. Kochi, the chief of the World Health Organization's global malaria program, McNeil Jr., 2006a, para. 17). Consequently, Dr Kochi stopped 18 pharmaceutical companies from selling artemisinin in single-pill form.
The antimalarial drug, chloroquine was the first ever known drug to lose its prophylactic and therapeutic armamentarium, and it rapidly spread to other regions of the world. In the words of John and Petri Jr. (2006), "resistance to chloroquine often is associated with resistance to other antimalarials," which leads to multidrug resistance (p. 100). In order for antimalarials to remain effective long enough we must contain resistance, so Dr. Kochi asked the pharmaceutical companies to make drugs in combination form (McNeil Jr., 2006a). This is not in the interest of the pharmaceutical companies because of the cost involved. For instance when drug companies were to standardize TB drugs for patients for 6 months worth of pills, tuberculosis hospital and makers of BCG vaccine were "very unhappy" (McNeil Jr., 2006a).
Reidenberg and Conner (2001) cited studies showing that many pharmaceutical companies developed substandard and counterfeit drugs intentionally "to deceive the sick and profit them" (p. 4). Spielman et al, (2002) reported, "Diverse substandard and counterfeit drugs have been aggressively infused into the market of Africa," because most of these developing nations "lack the infrastructure required for quality assurance of imported drugs" (p. 14). Reidenberg and Conner define a substandard drug product as one that does not meet the official specifications for what it is claimed to be (p. 4). These imitation drugs are the ones which parasites quickly develop resistance to. Reidenberg and Conner (2002) cited examples of substandard and counterfeit medicine as follows: studies conducted on chloroquine efficacy revealed that some tablets had less than 50% labeled chloroquine. In like manner, a W.H.O. study on quality of drugs in Cameroon, Madagascar and Chad found that "12 of 157 major antibiotics formulations contained none of the labeled antibiotic." Likewise, in Australia 41 companies were charged with 577 crimes involving counterfeit drugs over a period of 5 years (1992 - 1997), and out these 34 were convicted of crime during the time" (pp. 5, 6, 8).
The rate of development of antimalarial resistance is accelerated by the use and misuse of antimalarials. White (1999) reported drug resistance could be induced if patients are inadequately treated for malaria infections. He also pointed out that resistance occurs with insufficient medication "as a result of inappropriate prescribing, poor compliance or, occasionally, because of unusual pharmacokinetic properties of the drug" (p. 745). In many countries, other factors responsible for resistance are self-medication without laboratory diagnosis, over-the-counter prescribing and drugs sold in roadside stalls with no knowledge of dosage regimens.