Introduction:

Just because a cure for a disease exists, does not mean that it will be delivered to those who need it or used effectively. This lesson is clearly embodied by the current global crisis in treating malaria: the essential philanthropic aims of medicine are at constant odds with market forces and the economic logistics of pharmaceutical development and distribution. Additionally, even the most altruistic of aims are sometimes opposed as in the debate over the use of DDT. Do the health risks of the insecticide outweigh its benefits in killing malaria-bearing mosquitoes? The following section summarizes some of the current debates on some of these ethical issues.

Chloroquine, ACT, and Vaccines: Supplying Drugs to Those in Need

As with antibiotic-resistant strains of bacteria, malarial Plasmodia that are resistant to traditional treatments such as chloroquine are becoming more prevalent in malaria-ravaged Africa. Indeed, drug resistance is a monumental problem as chloroquine resistant Plasmodia strains have been documented along with strains of quinine and artemisinin-resistant parasites³⁷. The more widespread a drug is, the greater the likelihood that parasites will develop resistance to it through spontaneous mutations that are passed on to the parasite’s progeny.

Certainly, artemisinin “cocktail” therapies (ACT), in which more than one drug is mixed together to prevent the parasite from developing resistance to any one treatment, is a far more effective therapy than pure chloroquine. However, ACTs cost 10 times more than mono-drug therapy⁵⁹. Since pharmaceutical companies stand to gain little financially from ACT sales in the developing world, their use remains low as no incentive structure exists to encourage their wider distribution⁵⁹. Consequently, chloroquine continues to be prescribed throughout Africa despite the obviously rising ineffectiveness of this drug⁶⁰.

Many have suggested that large subsidies be given by governments to offset the cost of artemisinin supplies, allowing them to be distributed at prices that African nations can afford⁶¹. Whether such plans will reach fruition remains to be seen. Such economics concerns have also spelled trouble in the area of vaccine development. Given the choice of vaccines to pursue, world leaders recently placed malaria on a lower funding bracket due to the lower financial demand⁶². Further, because many African nations have poorly developed scientific research infrastructures, they often find themselves at the mercy of international colleagues in the vaccine development game, who do not listen to the concerns of African researchers about these projects^61,62. Thus, the problem is not merely one of resources, but also, perhaps of autonomy.

Discussion Questions:
1. What is the best way to create incentive for the development and distribution of antimalarial compounds to the developing world where they are needed?
2. Do governments in the first world have a responsibility to less fortunate nations in distributing these kinds of supplies?
3. To what extent are such activities the responsibility of a government, and what aspects should be handled by non-government organizations (NGOs) or other philanthropic groups?
4. Do citizens in the developed world have caused to be concerned about these issues (ethically, medically, or otherwise)?

Background reading (for the teacher) provided: “Making Antimalarial Agents Available in Africa” and “Why the World Needs Another Malaria Initiative”.

DDT: Insecticide or Homicide?

The insecticide DDT has certainly proven effective in reducing instances of malaria infection in many countries where the disease is endemic. In Sri Lanka and India, cases dropped by 99%, and two strains of malarial mosquitoes were eliminated in South Africa^63,64. Also, as mentioned earlier, insecticides such as DDT were instrumental in eliminating malaria in the US. DDT is usually applied in only small amounts on the interior surfaces of homes, as opposed to the mass spraying that caused earlier environmental concerns (see above). Thus, it operates on the principle of “consecutive probability” –the spray will prevent a proportion of mosquitoes from entering a home, deter a large percent that enter from biting before they leave, and kill a portion of the remaining insects before they can cause harm⁶⁴. A nice simulation of this is given at

http://www.malaria.org/teachingmodules/ddt-malaria-container.html.

Many, however, have expressed concerns that DDT disrupts hormone function, and animal tests have revealed some deleterious effects though the veracity of such studies is contested. One notable example of such dissension is Rachel Carson’s seminal environmental text Silent Spring, which outlined how DDT made its way from insects through the food chain, accumulating in the fatty tissues of animals consumed by humans and potentially causing cancer and genetic damage⁵⁷. The fundamental question, perhaps, is whether the health hazard of DDT outweighs the need to eradicate malaria-causing mosquitoes: which is the greater risk?

Discussion Questions:
1. Is it okay to use a treatment for one illness that might cause other harmful effects? How does one go about weighing the risks?
2. What measures should be taken to determine the safety of DDT? What should be done during the process?
3. Should DDT’s low cost be a factor in weighing its efficacy?
4. What guidelines should be placed on the use of DDT (e.g. residential vs. agricultural use)?

An optional case study (To Spray or Not to Spray: A Debate Over Malaria and DDT) and accompanying teacher’s notes are provided.

Cultural Sensitivity in Research

Since malaria is most prevalent in some of the less developed sections of the globe, a frequent concern is how to conduct field research on the disease while remaining sensitive to the particular cultural dynamics in these areas. One example is obtaining consent from tribal communities in which it is often necessary to approach community leaders first in order to effectively negotiate a research protocol⁶⁵. In general, medical ethics is predicated on the notion of individuality – of single patients making decisions about their participation in treatment or research. Indeed, “informed consent” is one of the three primary components of the modern biomedical ethics triumvirate (the others being justice and the Hippocratic ideal to “do no harm”). However, this individualized notion of consent may not fully apply to communal societies, and imposing an outside system of ethics is arguably insensitive to such cultural differences.

Discussion Questions:
1. What barriers to medical research might exist in a different culture?
2. What are some things that doctors can do to overcome these issues?
3. Is treating a patient more important than respecting their culture?
4. What possibilities for abuse exist when doctors do research on subjects from a different culture than their own?
5. What might the subjects do to protect themselves against such abuse?