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Quinine syrup

Not what you clinicians are thinking (i.e. the suspension). My drink of choice has long been tonic water for it’s antimalarial components. This might be the new favorite (hat tip: Priyanka) once I find the cinchona needed.

A vision of science

Ramachandra Guha, whose writing has brought me much profit, described the three tests for science in a country such as India formulated by the British-born Indian architect Laurie Baker: 1) is it eco-friendly? 2) is it non-violent? 3) is it poverty-reducing? This vision of science complements the notion of the method as a means of greater service promulgated by others. It eschews the public persona and elicits, instead, quiet determination. It is fundamentally outcome oriented and that too with the long-view. In this age of accomplishment evaluated on the timescale of press releases and serious matters adorned with glossy sentimentality, I wonder how we can build such an ethos in our own research community? At the risk of non-attribution (for I cannot find the source), we must recall that true dharma requires the unification of knowledge with action.

Paid writing of malaria trial results

The New England Journal of Medicine recently reported phase III trial results for artesunate + pyronaridine and tucked away in the acknowledgments I noticed this:

We thank Naomi Richardson (Magenta Communications) for developing the first draft of the manuscript and for editorial assistance.

I wondered, why? On one hand, for a well-defined type of study such as a phase III randomized controlled trial the writing can be fairly formulaic and easy to outsource. The data analysis was also conducted by another corporation. As an industry-sponsored study, no doubt the funders wanted a quick, and efficient process once the trial was complete. The additional cost of these services (anyone know how much?) which I suspect are expensive may not be much compared to the entire study budget. Still, it is somehow disappointing to me to see a paper which was not analyzed or written by the scientists who conducted the work. Is the process not important and what are we losing to the CRO culture which dominates these days? By all accounts (number of previous publications), Dr Ronnatrai Rueangweerayut who is the first-author, could have benefited from the writing experience. How else will we build scientific capacity?

Nature outlook on malaria

A fantastic collection of news pieces, reviews, and infographics at Nature on malaria (thanks to Ashwani Kumar).

Some of my favorites included the scrutiny of the interim RTS,S vaccine results, an outlook for the Global Fund by the ever sharp Laurie Garrett, and a description on the ecological role of mosquitoes.

A flood of artemisinin resistance

Articles that is. The spread of resistance to artemisinin drugs, the main-stay of modern Plasmodium falciparum (and even P. vivax in some places) malaria therapy, would endanger control programs globally (previously discussed here, here, here, and here). Last week saw a series of high-profile publications which received an impressive amount of coverage in the general media, here’s the list:

  • Evidence for a genetic basis for much of the observed resistance – are molecular markers in sight?
  • Another combination therapy trial with prolonged clearance in both treatment arms among patients from Western Cambodia
  • Longer clearance half-lives among patients with a high parasite load treated with just artemisinin on the Thai-Burma border, it’s already spread
  • An accessible narrative providing a glimpse of the operations of the Thai-Cambodia containment program (thanks Matt)

Measuring malaria incidence

Why are disease burden estimates important? There are two sets of reasons: 1) technical, e.g. national priority setting etc and 2) political economy of health, e.g. advocacy and visibility, donor influence, etc. Thus, estimates are often quite contentious apart from the methodology used. The practical applications of burden estimation are on the other hand limited. Monitoring and evaluation systems can, with valid measurements of trend, help allocate regional resources, determine impact, and respond to outbreaks without necessarily measuring the magnitude of disease.

There are broadly two competing approaches for estimating malaria burden. One extrapolates from maps and surveys of population cross-sections, the other extrapolates from routinely collected surveillance data. Both have certain assumptions and biases: the former tends to overestimate, the latter generally underestimates. How should countries proceed? A new article from WHO in PloS Medicine (open access!) describes and contrasts each in a careful and informative way including actual results from 2009. While neither method is perfect, the authors present a compelling case for investing in surveillance-based approaches in the long run particularly outside of hyperendemic settings and in the context of intervention scale-up and declining transmission. Only that approach can improve the health system, and provide disaggregated and timely data amenable to frequent updates.

An accompanying editorial by Mueller, Slutsker, and Tanner broadly agrees with the author’s outlook though it includes a careful placative statement:

The two methods thus have their unique strengths and weaknesses, and rather than seeing them as competing approaches, they should be synergistically combined.

At first pass this seems a sensible assertion but on closer examination, and without other supporting text, it’s not clear what to make of it. Which distinct synergies do they envision? Should the two methods be used globally, i.e. one in countries without quality surveillance and the other elsewhere? Or should the two methods always be used in each nation? Why? Should they be used indefinitely – what about when surveillance systems mature? Are there not trade-offs both in time and space? Such discussion, drawing on the considerable program experience of the writers, would have been more helpful than conciliatory statements of questionable sincerity.

More on the not-so-Affordable Medicines Facility for malaria

The evidence just keeps piling up with this new report from Africa Fighting Malaria and a series of papers in Malaria Journal (1, 2, and 3). Not only is the availability and cost falling short of goals as we’ve discussed (here, here, here and here), the patient-centered outcomes which actually matter, are likely far worse. In addition to flaws in the logic of the program and its operations, the report adds a previously undocumented dimension of AFMm failure – leadership. The leaked minutes from its board meeting display an unflattering preoccupation with “reputational risk” for the Global Fund and its donors and a disregard for data that suggests the program may not be working as planned. The report concludes:

Evidence to date suggests that the AMFm was pushed forward too far, too fast and with too much money.


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