Before it's too late

The program, which will cost $400 million, is designed to contain and one day eliminate what the World Health Organization (WHO) warns could prove "a serious global health threat."

That threat comes in the form of the falciparum malaria parasite. In recent years a strain of falciparum has shown resistance to artemisinin-based combination therapy (ACT). That is important because ACT, in which artemisinin is combined with one of a number of other anti-malarial drugs, is at the heart of global wins over malaria over the past decade or so.

"If resistance to artemisinin emerges elsewhere - particularly in Africa, which has the world's greatest number of malaria cases - the consequences for global health could be incalculable," says Dr Shin Young-soo, WHO's regional director for the Western Pacific.

Dr. Robert Newman, the director of the WHO's Global Malaria Programme, says that if the resistant falciparum strain were to escape the region - and currently it has been found in four countries - it could reverse the gains made worldwide against malaria.

"If history is any guide [and] if we were not to contain this problem, then it is very likely to spread elsewhere," Newman says. "Especially risky is sub-Saharan Africa where the greatest [malaria] burden still exists. And if we were to lose the efficacy of the ACTs today, this really would be a public health catastrophe in Africa."

As Newman points out, history has shown what can happen: in the 1950s, a strain of malaria resistant to the drug chloroquine emerged in Cambodia and spread across the world. The chloroquine-resistant strain of malaria still kills hundreds of thousands of people a year, most of them children in Africa.

Cambodian lessons

The new program is called the Emergency Response to Artemisinin Resistance (ERAR), and will cover the four countries where the ACT-resistant parasite has been found - Cambodia, Thailand, Myanmar and Vietnam - as well as Laos and a swathe of southern China, which are seen as being at risk from the parasite's spread.

ERAR will be run from Cambodia, which has in recent years done a good job of tackling its outbreak of ACT-resistant falciparum malaria. Starting in 2009, the government and its health partners, including the WHO, enacted an array of measures covering prevention and cure. In addition, a surveillance system tracked the disease and the authorities worked to eliminate fake drugs.

Newman says those successes have fed into the ERAR program.

"[ERAR] is building on the experience of the Cambodia-Thailand border where a lot of experience was gained in how to reach the populations that are actually most difficult to reach - migrant and mobile populations - how to use village healthcare workers, how to more aggressively remove substandard medicines from the market," he says. "The emergency response is built on all of those experiences."

Cambodia's national program, which is ongoing, has worked well to date, says Dr. Steven Bjorge, the WHO's malaria expert in Phnom Penh.

Measures to prevent infection include teaching people how to avoid contracting it, providing hundreds of thousands of insecticide-treated bed nets, and spraying for mosquitoes. Efforts on the treatment side saw two people in every at-risk village trained to test residents for malaria and to provide free treatment to those who were infected.

"Those factors … have been very effective in reducing malaria in Cambodia," Bjorge says.

The statistics bear that out; the resistant strain has not appeared elsewhere in Cambodia, and the number of deaths has dropped year on year. In 2012, Cambodia recorded 45 deaths from malaria; a decade earlier that figure was nearly 500.

Regional Effort

Encouraging though it is that Cambodia's strain appears to have been contained thus far, it does not change the fact that a regional program to tackle resistance is needed. ERAR's biggest funder is the Global Fund to Fight AIDS, Tuberculosis and Malaria, which will provide $100m. The Bill & Melinda Gates Foundation has given around $10m; and the Australian government's development arm, AusAID, is investing $5m.

Ben David, AusAID's principal health advisor, says that since artemisinin resistance is a regional issue, it requires a regional solution - which is one reason Australia has become involved.

"We need programs and efforts which deal with the migrant communities that cross borders and cross countries in the region," he says. "We need to tackle regional surveillance and strengthen that. We need to improve drug quality. So we want to see strong coordination and better coordination."

Success will require political commitments, too. Prior to the launch of ERAR, AusAID led a process that resulted in political leaders giving "a very clear agreement to tackle this issue." David says that will be essential going forward.

"We do need sustained commitment to this issue - it's not going to be sorted out in one or two years," he says. "We need to think of both maintaining the political commitment but also the financing and the programming investment for the next three to five years."

After that point, regional governments will need to start funding ERAR, whose success is, after all, in their interests.

"This is not just about saving the lives of the poor. It's actually got significant economic implications if this problem of resistance continues," he says. "So we really need to continue to make the economic case to governments to invest in this problem."