Breakthrough in Cambodia malaria row

A disagreement between Cambodian and global health officials that followed a corruption scandal and froze millions of dollars in funding for the fight against malaria has been resolved, the World Health Organization has told IRIN.

Scientists revealed this month that malaria-carrying parasites in Cambodia have developed resistance to both of the main drugs used to fight the disease, putting millions of lives potentially at risk should that resistance spread.

A critical programme in Cambodia can now receive funding from a $9 million grant from the Bill and Melinda Gates Foundation to the Global Fund to Fight AIDS, Tuberculosis and Malaria.

“Controversies with GF (the Global Fund) were resolved in December 2015,” Dr. Luciano Tuseo, who heads the WHO’s malaria programme in Cambodia, wrote in an email to IRIN, although he declined to explain how.

As government officials and the Global Fund argued over the conditions of the grant, a strain of malaria largely immune to one of the only effective drugs left was spreading in Cambodia. A US National Institutes of Health study published in the Lancet medical journal this month found resistance to the drug piperaquine, sparking fears of a global epidemic.

“Piperaquine resistance is a serious worry to us because it’s one of our main drugs,” explained Nick White, a professor of tropical medicine at Oxford University. “It’s the only one we can use in rapid elimination,” he told IRIN.

The US study examined 204 patients infected with the most deadly strain of malaria in three Cambodian provinces and found resistance to both piperaquine and artemisinin, another major anti-malarial drug.

Piperaquine has been widely used in Cambodia in combination with artemisinin as the main frontline treatment for malaria. The therapy is considered the most effective way to treat the disease, although resistance to artemisinin has been growing for years.

Global outbreaks

The new findings suggest that this method of treatment is no longer working in some parts of Cambodia, which has been at the epicentre of two previous global outbreaks of drug-resistant malaria.

The worst-case scenario is that resistance will spread to Sub-Saharan Africa, where 91 percent of all malaria deaths were recorded last year. In the late 1970s and early 1980s, about two million people died in the region after malarial parasites resistant to the drug chloroquine spread there from Cambodia, according to White.

Sulphadoxine-pyrimethamine was used to replace chloroquine, but resistance to the drug that developed in Cambodia in the 1980s and 1990s again spread to Africa with severe consequences.

Now that resistance to both artemisinin and piperaquine has been detected, there is a danger that the evolved parasite could spread to Africa, according to White. “We know this has happened several times before, so yes, it’s a great concern,” he said.

The results could be even more catastrophic next time, which is why it’s so important to contain and eliminate resistance in Cambodia.

Unfortunately, corruption within the national health system has undermined a programme aimed at doing just that.

Cost of corruption

One of the most effective mechanisms to administer the treatment combining piperaquine and artemisinin was the Village Malaria Workers programme, which was backed by the Global Fund. But in 2012, it was discovered that officials administering the project had pocketed more than $470,000 through procurement fraud and bribes from bednet suppliers.

In response, the Global Fund made all new grants contingent upon stringent fiscal reporting requirements, which infuriated local government officials who said they were impossible to fulfill. A $9 million grant directed partly to the Village Malaria Workers programme was put on hold in mid-2015, just as scientists were discovering that drug-resistant malaria was on the rise.

White told IRIN that the delay in funding could only have made the problem worse, because cutting back on programmes aimed at killing off the parasite would have increased its ability to resist drugs.

It’s unclear what broke the funding impasse, as the WHO’s Tuseo refused to say, and Huy Rekol, director of Cambodia’s National Malaria Centre was unavailable for comment. But Rekol said late last year that the major point of disagreement was over the Fund’s insistence that his staff provide receipts for accommodation. He argued that this was impossible since they often worked in remote locations.

Apparently, the government and the Global Fund have now come to an agreement, which should put the Village Malaria Workers programme back on track. That’s good news for Cambodia – and for the rest of the world, since the only way to stem drug-resistant malaria is to eliminate it where it actually emerges.