BY ANA VASUDEVAN
Ana Vasudevan is a second-year student at SAIS with a concentration in International Law and Organizations and a minor in International Development.
Malaria is a mosquito-borne parasitic disease that can be life threatening if not treated. Although global levels of malaria have significantly decreased over the last 15 years, the disease has posed a threat to 3.2 billion people worldwide as of 2015, with a concentration of 88 percent of the cases and 90 percent of deaths in Sub-Saharan Africa (WHO 2016). Additionally, populations such as children, patients of other diseases, and travelers stand a higher risk of disease exposure and contraction (WHO 2016).
Currently, there is no approved, widely available vaccine to prevent malaria, but parasite-killing antimalarial drugs, which can be taken preventatively and given to treat patients, do exist. Several drug-resistant strains have emerged, mostly in Southeast Asian countries such as Cambodia, Thailand, and Vietnam, and there is an ever-growing threat of multi-drug resistant strains of malaria (WHO 2016). Of particular importance is cerebral malaria, a severe complication of the disease that can lead to swelling and brain damage (Mayo Clinic 2016). According to recent developments in antimalarial drug research, cerebral malaria, which causes a large proportion of malaria-related deaths, may be curable.
A team of scientists led by Dr. Ana Rodriguez at New York University’s (NYU) Langone Medical Center recently published research that delves into the possibility of using a blood pressure drug, in combination with malaria pills, to help treat malaria patients (Gallego-Delgado et al. 2016). Cerebral malaria is a quick, lethal disease. As reported by The New York Times, the majority of the 400,000 malaria-related deaths worldwide are young African children who suffer from cerebral malaria (McNeil Jr. 2016). The disease progresses when parasites infest red blood cells, block capillaries in the brain, and allow blood to leak through the cell walls (McNeil Jr. 2016). Cerebral malaria has a quick onset of 48 hours and can be fatal, as it takes the same amount of time for the current drugs to attack the parasites; according to the NYU study, this time period is critical as one-fifth of patients die even after reaching the hospital (McNeil Jr. 2016). The drug used in the study, called irbesartan, would combat the cerebral hemorrhages by strengthening endothelial cells, and giving time for the parasite-killing malaria drug, called chloroquine, to take effect (McNeil Jr. 2016). Dr. Rodriguez saw substantial results, with a 47% reduction in death of the mice treated with both drugs, as opposed to those solely treated with the malaria pill, chloroquine (McNeil Jr. 2016). The cost of the blood-pressure drug is around $4.50 per unit, but some developing countries, like India, make generic versions at even more affordable prices for malaria patients in low- and middle-income countries (McNeil Jr. 2016). Dr. Rodriguez believes there is the possibility of using other common drugs for similar purposes but will continue to pursue human clinical trials with irbesartan (McNeil Jr. 2016).
The potential breakthrough made with Dr. Rodriguez’s research can save thousands of lives, if supported through clinical trials and used in the field. Since research for an accessible malaria vaccine is still ongoing, this advancement will help those being treated with chloroquine get more effective treatment. A combinatory drug remedy is a great example of the utility of medical innovation and how global health issues can be addressed by using drugs meant for certain purposes in alternative ways. Since the drug irbesartan already exists, this medically innovative solution will also save money on the research and development (R&D) of creating a multi-use drug. This would add irbesartan to a growing list of drugs that are being enlisted in the fight against diseases that they were not originally intended to combat. For example, Thalidomide, a drug initially developed as a sedative and known to cause birth defects in pregnant women, has been successfully used to treat leprosy and myeloma bone marrow cancer (Borel 2013). Another drug, Raloxifene, developed to treat osteoporosis, is now used to reduce women's risk of breast cancer (Borel 2013).
More generally, R&D plays an important role in creating drugs and vaccines that can help those in need. In general, pharmaceutical R&D interests focus on the problems that key stakeholders find most pertinent. Since most money donated towards R&D comes from developed countries, there is a focus on diseases that affect their regions, rather than on those like malaria that plague developing countries that cannot afford to allocate such a substantial proportion of national revenue to R&D (Wilson 2010). This example points to a major issue within the R&D system—a bias towards developed countries—which results in a lack of attention paid to the needs of developing countries and a lack of emphasis on global health research as a public good. By spending money on R&D, investors are helping solve some health issues while creating vicious cycles for those that are not addressed.
One important aspect connected to R&D is the great price differential between the brand name version of irbesartan, known as Avapro in the U.S., and the generic brand drug sold in India for approximately 11 cents per pill (McNeil Jr. 2016). The use of generic drugs would allow more people the right to affordable healthcare since the drug will be much cheaper, a major factor to consider for the populations who are at risk for malaria in Sub-Saharan Africa (McNeil Jr. 2016). Additionally, the link between R&D, exclusivity rights, and drug sales elicits the following questions: who has the right to claim ownership of certain drugs and research processes? Who is or is not bound by exclusivity rights? Who can monetize and sell the rights to what many people consider a public good, like global health R&D? (MSF 2016, 4).
Based on the NYU study, the use of irbesartan did not affect other organs besides the brain in mice (Gallego-Delgado et al. 2016, 4). Although this is positive news for the potential use of the drug in humans, the actual effects are unknown, as Dr. Rodriguez awaits clinical trials. A possible future approval of this remedy would perhaps require pharmaceutical companies in the U.S., who are selling Avapro abroad, to lower the price of their drug because they will be undercut by competitors in India and will lose business otherwise. While Dr. Rodriguez’s research helps find a short-term solution, further research on preventative methods, like the vaccine, or faster-acting forms of chloroquine, would also be effective in controlling malaria.
Although there has already been a significant reduction in mortality rate for malaria cases, it is important to recognize the continuing need to address the threat of malaria. As of 2015, malaria was still present in 95 countries worldwide (WHO 2016). Dr. Rodriguez and her team are in part contributing to a WHO-sponsored anti-malaria initiative by coming up with a solution that could assist with the provision of “universal access to malaria prevention, diagnosis, and treatment” to achieve a malaria-free world by 2030 (WHO 2015, 11). Furthermore, since nations around the world follow the lead of global governance in formulating global health policy, international cooperation and empathy should be of utmost importance when conducting research, as well as combating the spread of diseases. Global governance organizations including the WHO can continue to encourage cooperation among nations to create a “fair pricing model” and ensure that there is transparency in the pharmaceutical industry (Kieny 2016). Specifically relating to malaria, the WHO can also promote combinatory drug methods, such as the aforementioned use of irebesartan, to provide innovative and cost-effective solutions to prevent the disease in low and middle-income countries.
SOURCES:
Borel, Brooke. 2013. “9 Old Drugs that Learned New Tricks: The Head of the National Institutes of
Health Shares Medicines that Turned Out to Have Multiple Uses.” TedBlog, March 22, 2013. https://owl.english.purdue.edu/owl/resource/717/05/.
Gallego-Delgado, Julio, Upal Basu-Roy, Maureen Ty, Matilde Alique, Cristina Fernandez-Arias, Alexandru Movila, Pollyanna Gomes, Ada Weinstock, Wenyue Xi, Innocent Edagha, Samuel C. Wassmer, Thomas Walther, Marta Ruiz-Ortega, and Ana Rodriguez. 2016. “Angiotensin Receptors and β-Catenin Regulate Brain Endothelial Integrity in Malaria.” Journal of Clinical Investigation: 4016-4029. Accessed September 29, 2016. http://www.jci.org/articles/view/87306?utm_content=bufferd3f11&utm_medium=social&utm_source=facebook.com&utm_campaign=buffer.
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Mayo Clinic. 2016. “Malaria.” Last modified January 5 2016. http://www.mayoclinic.org/diseasesconditions/malaria/symptoms-causes/dxc-20167987.
McNeil Jr., Donald G. 2016. “Common Blood-Pressure Drug May Work on Malaria, Too.” International New York Times, Sept. 19, 2016. https://www.nytimes.com/2016/09/20/health/common-blood-pressure-drug-may-work-on-malaria-too.html.
Wilson, Paul. “Giving Developing Countries the Best Shot: An Overview of Vaccine Access and R&D.” Oxfam and MSF Report, (2010): 1-28. Accessed September 29, 2016. http://www.oxfam.org/sites/www.oxfam.org/files/giving‐developing‐countries‐best‐shot‐vaccines‐2010‐05.pdf.
World Health Organization (WHO). 2015. Malaria: Global Technical Strategy for Malaria: 2016-2030. Geneva: World Health Organization, 2015. http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_28-en.pdf?ua=1.
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PHOTO CREDIT: "Bracing for a short, sharp jab" by Pete Lewis / Department for International Development licensed under Flickr Creative Commons License CC BY 2.0.