Artemisinin: Malaria's Magic Bullet?

"Years of vaccine research have produced few hopeful candidates and although scientists are redoubling the search, an effective vaccine is at best years away. Science still has no magic bullet for malaria and many doubt that such a single solution will ever exist."

- Statistics Division of the United Nations (January, 2002)

In May 2004, the World Health Organization (WHO) gave the thumbs up to the miracle drug of malaria, Artemisinin. This Chinese herbal remedy has been recognized as a 97% effective in curing Falciparum malaria and is now due to be distributed globally, especially to Africa where one child dies from malaria every 30 seconds. Apparently reacting to a conclusive report in the medical magazine, The Lancet the WHO (in co-ordination with the Global Fund for AIDS, Tuberculosis and Malaria) authorized the purchase and distribution of one million doses of Artemisinin and the cancellation of orders for other ineffective medications.

The Killer
Alongside tuberculosis (TB) and AIDS, malaria is the most deadly disease on the planet with over 300 million persons directly infected every year. Although over 70% of deaths occur in Africa alone, almost half of the world's population lives in tropical or sub-tropical regions and is therefore at risk.

Diagnosed by Hippocrates in the 5th century BC as being caused by breathing too close to fetid swamps, the disease became known as malus aria, that being Latin for "bad air". It was not until 1880 that A. Laveran, a French doctor discovered the true cause of the disease: a single-cell parasite called plasmodium. Later a Sir R. Ross working in India discovered that the parasite was transmitted from person to person through the bite of a female Anopheles mosquito seeking blood to nurture her eggs. Inside the human host this parasite evades the immune system and quickly begins infecting the liver and red blood cells. Malaria symptoms will appear about 9 to 14 days after the infectious mosquito bite: fever, headaches, vomiting, and a hot-cold torture of profuse sweating broken up with shaking chills. If drugs are not available then the condition can become life-threatening. Malaria can kill by infecting and destroying red blood cells (leading to anemia) and by clogging the capillaries that carry blood to the brain (cerebral malaria) or other vital organs. There are two main strains of malaria, neither of which is particularly desirable: Falciparum, the most deadly, can leave its victims with permanent brain damage; and Vivax, which doesn't attack the brain, but which does tend to recur.

The Secret Recipe
Natural extracts are nothing new in the fight against malaria. Hundreds of years ago, South Americans treated the sick with the bark of the cinchona tree. Then in 1820 two French researchers, Pelletier and Caventou identified the active substance in the bark as quinine. This became the main drug used to prevent and cure most forms of malaria. British colonials in the Indian subcontinent tackled malaria in their own inimitable way, ingesting quinine through pitchers of gin n' tonic each evening. It's the tonic water - not gin - that contains tiny amounts of quinine.

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Artemisia annua

The discovery of Artemisinin is nothing short of romantic, peppered perhaps with a sprinkle of luck. During the Vietnam/American war, Ho Chi Minh (whose life had been saved some years previously by quinine parachuted in by CIA agents) approached Mao Tse Tung and requested aid in the form of a cure for malaria, the disease that was ravaging his jungle-borne troops. The Americans were likewise working on their own prophylactic remedy, which resulted in the introduction of mefloquine. In the meantime, an archaeological dig in Southern China unearthed a herbal recipe quite by chance. The tomb raiders were amazed to discover that this decaying script was in fact ingredients for making an ancient medicinal tea. The recipe dated back to 168 B.C. when a Chinese pharmacist isolated the active ingredient from artemesia annua L (sweet wormwood) to concoct a remedy for fevers. The secret formula was hurried to the North Vietnamese government and dispensed to the malaria-ridden Viet Cong soldiers, who ultimately regained their strength and went on to win the war.

What is Artemisinin? Where does it come from? And why does it do what no other substance can?
Artemisia annua is a two-meter high plant with aromatic leaves and tiny yellow flowers. It is native to China where it is known as �qinghao'. Plantations of Artemisia annua were initiated around Hanoi and by the 1990s a crushed powder remedy known as Artemisinin was widely available in Vietnam. Studies soon proved that this new �miracle drug' was an amazing 97% effective in treating Falciparum malaria infections.

Colin Hinshelwood / CPA

Thai-Burmese border.

None of this is news to refugees at the Thai-Burmese border who have been fortunate enough to have been receiving Artemisinin treatment at the Shoklo Malaria Research Unit in Mae Sot since 1991. Under the watchful eye of Dr Fran�ois Nosten, the Shoklo Unit has treated a total of some 20,000 patients with an Artemisinin derivative over the past 13 years. As pioneers of the treatment in Thailand, Dr Nosten claims the drug has yielded similar success rates to Vietnam and is delighted by the WHO resolution. "We don't yet fully understand the mechanism in this crystalline compound that kills the plasmodium," he concedes. "But Artemisinin is without doubt the most effective [anti-malarial] drug by far to date". The age-old problem with malarial treatment has been the obstinacy of the mosquito-borne parasite itself in constantly building immunity to whichever drug is in the marketplace at that time. As with chloroquine in the 60s, sulfadoxine-pyrimethamine (Fansidar ®) in the 70s and mefloquine (Lariam ®) in the 90s, ultimately the plasmodium builds a resistance which is passed on through the genes of future malaria-carrying mosquitoes, rendering the drugs impotent. To prevent the parasite becoming resistant to Artemisinin, the drug is being used in combinations with other active antimalarial drugs such as mefloquine . It is hoped that by constantly altering the 'recipe' of the drug, the parasite will be unable to keep pace and will be unable to build resistance. All this is wonderful news, especially for pregnant women and children in Africa who are the highest risk group by far. The drug relieves the tortuous symptoms within days and, so far, has shown little or no side effects. In Tanzania plantations of Artemisia annua are now being cultivated on a massive scale.

Of course, it's not all plain sailing. Agencies that have been distributing chloroquine for years are loath to halt treatment in the middle of their programmes and may be reluctant to change drugs unless they have an ironclad guarantee that a constant flow of effective Artemisinin will be at their beck and call. And in parts of Africa, where strife and malaria go hand in hand, logistical difficulties and corruption could see much of the assigned treatment go missing. Whereas a dose of chloroquine costs no more than 10 cents, an Artemisinin combination such as Coartem will retail at clinics for between $1 and $2.50. The expense of Artemisinin has already led to counterfeits and a black market in the drug. At small pharmacies and medical stores in Vietnam, Cambodia or Burma for example, it is common for chemists to offer two packets of Artemisinin - a cheap one and an expensive one. Naturally, the cheaper alternative will be fake and of no use in combating malaria. With a higher value likely to be attributed to this anti-malarial drug than any before, it will undoubtedly be the poorest, the most rural and the neediest who are exploited and suffer from any black marketeering.

Nonetheless, the battle against plasmodia - one which doctors never looked like winning - may finally be swinging in humans' favour. Most of the 1,000,000 prescribed doses of Artemisinin compounds are destined for Africa where help is most needed.

Sweet Wormwood, a tall, single-stemmed plant with minute yellow flowers, appears to be nature's counterbalance to one of the world's most powerful killers. Aptly named after Artemis, the Greek Goddess of Light, this Chinese herb is carrying the beacon of hope for the millions who become infected every year. But will the combinations of Artemisia cocktails be varied enough to evade resistance in the future? "That's the million dollar question," admits Dr Nosten. With a million souls dying every year, let's hope that million dollars is well spent.

For tourists coming to Thailand, there appears no need to seek out your own secret stash of Artemisinin. "Travellers to Asia should not be unduly concerned about malaria," assures Dr Nosten. "Only if you intend to spend time in the jungle should you take prophylactic medicine. Malarone ® is the best prescribed drug you can buy at the chemist."

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