The Herculean task of removing the threat of malaria has become even more daunting with reported resistance to the world's most effective treatment.

International scientists have spotted a trend in western Cambodia where it is taking longer to clear malaria parasites from the blood even with artemisinin-based combination therapies (ACTs) , the world's best defence against the most prevalent and deadly form of malaria.

The efficacious drug usually cleared all malaria parasites from the blood within two or three days, but in recent trials along the Thai-Cambodia border, this took up to four or five days.

Assistant Director-General of the World Health Organisation (WHO), Dr Hiroki Nakatani, says this early warning sign of emerging resistance is of particular concern because previous generations of malaria drugs have been undermined by resistance which started in this way.

Resistance started with chloroquine, followed by resistance to sulfadoxine-pyrimethamine and mefloquine, drugs used in malaria control several years ago. And it started around the same region along the Thai-Cambodia border.

Rude Awakening

Now it appears that if the World Health Organisation's (WHO) drive to eliminate artemisinin-tolerant parasites does not succeed the worlds malaria prevalent regions will be confronted with a full-blown resistance not to mention the ramifications of a global health catastrophe.

It is superfluous to say that the Global Malaria Action Plan to reduce malaria deaths and cases by 70 per will then become a fleeting illusion.

The obvious lesson here is simple: prevention is better than cure. But that sounds too simple to many people. It has been agreed that the best fight against the disease which claims a million lives annually is prevention of mosquito bites using insecticide treated nets.

However mankind’s attitude to the problem is as unchanging as the spots of a leopard. Yet, quite unlike that perceptive and elusive creature, we have tended to play the ostrich with heads buried in the sand and our bodies exposed to mosquitoes.

Yet a child is killed every 30 seconds, pregnant women are dying and many more continue to fall victim to malaria. There is the story of a 20 year old Briton, Harry Yirrell, who spent four months in Ghana as a volunteer but died from malaria a week after returning home.

Now, Mrs Jo Yirrell, mother of the malaria victim, has since Harry's death three years ago, worked tirelessly with charities to raise awareness about the disease. She has joined forces with a charity, Malaria No More, to get every man, woman and child at risk in Africa a mosquito net by the end of 2010 - a target set by the United Nations in 2008.

The reality in Ghana and Sub-Saharan Africa dictates that malaria be attacked with urgency because it is an emergency!

This demands a constant march forward, not two steps forward, one step backward.

Attitudes

Having made the case that malaria is an emergency; we must now face the mighty task of changing people’s attitude towards it. Attitudes of patients, government and even doctors, all come under the microscope.

In the case of the unfortunate British volunteer, it has been seen as a tragic irony because malaria doesn't need to kill anyone. He had the tablets with him - he just didn't take them.

Instead of taking the tablets to protect him from the disease, Harry gave them to his Ghanaian girlfriend. Another irony!

A tour of the guest house where Harry stayed revealed why he contracted malaria. There was no mosquito net in his bedroom. Even worse, he loved to sleep outside in a hammock.

Considering the fact that malaria has always had a reputation as a ruthless killer, you really wonder why anyone would want to test his luck in such manner. The unfortunate result here is that though no Ghanaian can be held liable for the loss of Harry’s Yirrell’s life, the whole country has had to bear a weird feeling of shame for the tragedy.

Even more shameful is the mentality that the African body fears no germs or bacteria. It may be true that having been born and bred in the malaria region we have some immunity against the disease.

Be that as it may, ignoring bed nets and prescriptions is foolhardy at a time when the WHO is confronted with the recent drug-resistant malaria situation that has been documented around the Thai-Cambodia border. There is genuine fear that this form of malaria could spread rapidly to other susceptible countries. It has happened before.
 
In some areas where mosquito nets are already widely used, it has been estimated that less than 5% are re-treated to achieve their expected impact. WHO says it has worked with mosquito net and insecticide manufacturers to make re-treatment as simple as possible.

However, the best hope lies with newly developed, long-lasting treated nets which may retain their insecticidal properties for four to five years, the life span of the net, thus making re-treatment unnecessary.

On the government’s side, the blame is simply not providing enough insecticide bed nets. These bed nets which have been known to be the most effective prevention against malaria, has been subsidized though, but it needs to be in every household to serve the purpose.

The other big issue are fake drugs. Counterfeit medicines have been identified as one of the obstacles to malaria control.

Government may claim to be cash-strapped but there is so much more it can do through communication, community mobilization and advocacy to engender comprehensive behaviour change.

When it comes to blaming doctors, it is true to say that those who know the right thing, must be more accountable

Dr Constance Bart-Plange, Programmes Manager of the National Malaria Control Programme (NMCP) has revealed that only 22.4 per cent of malaria cases are confirmed before treatment. Clinicians, sometimes, under the pressure of work or in the absence of laboratory facilities, in diagnosing malaria, have to base their diagnosis on only clinical suspicion depending on symptoms the patient presents. This has often led to wrong diagnosis and wrong treatment.

There is a mission to reduce malaria deaths and cases by 70 per cent in line with the Global Malaria Action Plan. The health professionals know how much complications do arise when they fail to thoroughly diagnose patients to confirm their status before treatment.

Yet they blame everything on the failure of government to provide facilities and motivate personnel in order to reduce long queues at hospitals.

One wonders what happened to the malaria rapid diagnostic test made up of a simple kit, the adherence to which could reduce wrong diagnosis and treatment.

Ghana, now in the malaria control phase, has set to reach the elimination stage by 2015 where the pandemic would no longer remain a public health concern. But the one thing lacking here is a sustained effort by all.
 
Expectations

There are promising signs that malaria will one day cease to pose a threat to life.
That day will come when trial vaccines lead to the real final solution- protective inoculation.

Some charities have set themselves the mission to ensure that leaders of G8 and EU countries deliver their goal to provide 100 million bed nets to sub-Saharan Africa by the end of 2010.

But as future promises do not always materialise, we have to make a focused effort at making current malaria-fighting strategies work. That way, when future realities derail the malaria eradication agenda, we can still be on top.