Interview with Amir Attaran, Institute of Population Health, University of Ottawa, Canada, and member of the Royal Institute of International Affairs, London, UK.

As the lead author of a January 2004 Lancet article that accused the World Health Organization (WHO) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) of medical malpractice, Amir Attaran remains concerned that not enough is being done by either organisation to prove him wrong. The article argued that for largely financial reasons WHO and the Global Fund were signing off on country proposals requesting ineffective and inexpensive antimalarials. In essence, Attaran and his coauthors maintained that the organisations were prescribing medicines that worked only about 50 percent of the time, while knowing that another, more expensive treatment – artemisinin-based combination therapies (ACTs) – should have been administered. WHO and the Global Fund have said these accusations were unwarranted, unfair and irresponsible.

QUESTION: Are you happy with the changes you’ve seen since the viewpoint piece in the Lancet medical journal appeared?

ANSWER: Not at all. The greatest scandal right now is that chloroquine and SP [sulfadoxine-pyrimethanine] are still being used in Africa and they are both startlingly ineffective. If a doctor in the West prescribed a medicine that worked half of the time, he’d be sued. When it’s done in Africa, it’s called a policy decision. Come on, is expecting a [treatment] turnaround in two years asking too much?

Q: What about the notion that recipient countries requesting these drugs ought to have the final say on what medicines they use?

A: Yes, individual governments have a large say in what treatment is provided. I know WHO says it’s a country’s choice and it’s not their business to insist. That remains WHO’s stock answer – or excuse – up to this day. And my response to that is:..[expletive] When you’re spending Canadian tax dollars then, as far as I’m concerned, you’re accountable to Canadian taxpayers for how you spend that money. I know I’m not [as a Canadian taxpayer] supporting this atrocious expense, this waste of life and money on drugs that all too often are no more effective in treating malaria than jellybeans.

Q: Why is it that many malaria experts and WHO continue to talk about an article that was published two years ago?

A: One, WHO didn’t do the right thing and they know it. If they felt otherwise, they would have said the Lancet article was ridiculous and walked away. That’s obviously not what happened, and they’re now left in an awkward spot. Second, far too little progress has been made since the article came out. Third, which is a corollary of the second, is that the financing of anything to do with malaria continues to be woefully insufficient. This is the fault of donors and WHO for not putting its foot down more strongly in the first place.

Q: You say malaria is not adequately financed. Why doesn’t it get the level of funding of other diseases, such as HIV/AIDS?

A: The biggest reason HIV/AIDS receives the funding it does is because patients in the West – white-skinned people – people in New York, Washington and even Geneva get this disease. That’s not the case when it comes to malaria, and that is the biggest reason why you don’t see malaria getting the same sort of funding. Malaria is almost completely an African disease.

There is the Western world, then the developing world and then there is the black African, who is the least important in an inexcusable hierarchy. There’s AIDS in the West, there’s tuberculosis in India, and 80 percent of all malaria is in Africa – and it’s because of that that you see the differences in funding.

Q: What about those who say the current problems with controlling malaria in the developing world involve more than just money? What about the claim that a lot of the funding is in place but many countries just don’t have the staff or the health system to absorb it?

A: If capacity is a problem, then fund countries to address the problem. Donors should include capacity building in their programmes. When I hear the words “capacity limitations” – what it says is that the donors underinvested in capacity.

Q: Why did so many African countries not meet the targets of the 2005 Abuja Declaration?

A: This is what happens when you set numbers as part of a political exercise. What do you think is going to happen when you set a random number as a target? Well, of course you are going to miss it. It’s a fanciful number. As long as the United Nations is willing to indulge in fanciful numbers this is what is going to happen. A decade from now I’m sure you’re going to be asking me why we didn’t reach the MDGs (Millennium Development Goals), and I’m going to be telling you what I’ve just told you about Abuja: The numbers were utter fantasy. Look, if you want to reach these sorts of numbers, if you want to actually achieve something on the ground against malaria, you need to pay to do it, you need the financing.

Q: What are your thoughts about the Roll Back Malaria Partnership?

A: Roll Back Malaria is a total failure. The clearest proof of this is its target of halving the number of the world’s malaria mortalities by 2010. Well, we’re half way to 2010 and malaria mortality rates have actually gone up. No matter what spin you try and put on this, it’s hard to see Roll Back Malaria as anything short of an utter and complete failure.

Q: Finally, many experts see an opportunity to get malaria under control in the next decade or so based on the quality of tools in hand and the increasing political interest in the disease. Do you agree?

A: When it comes to malaria control, we’re probably better off than we’ve been since the last two decades. But we were better poised to deal with it in the 1950s when we didn’t have drug resistance to chloroquine and we had no qualms about using DDT. But even acknowledging that we’re in a better place than we have been for a while doesn’t mean it’s all that great. This is more a case of relative improvement rather than absolute merit.
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