Date of this Version
N Engl J Med 2005; 352: 1565-1577, April 14, 2005
The opening of the panama canal in 1914 initiated an era in which efforts to control malaria were aimed at the anopheline mosquito. The World Health Organization’s Global Malaria Eradication Campaign in the 1950s and 1960s marked the apex of these efforts. The use of dichlorodiphenyltrichloroethane (DDT) rid vast areas of endemic malaria virtually everywhere except in sub- Saharan Africa. The eradication strategy was abandoned in 1969, because it came to be considered logistically, socially, and politically impractical, especially given public concern about the effects of DDT on the environment. It took two decades and a global resurgence of malaria before a new strategy emerged, one that was focused on treatment rather than prevention.1 This treatment strategy is currently being debated, and its efficacy is unproved. 2,3
Both the broad collapse of preventive efforts and the waning efficacy of standard antimalarial drugs 4,5 account for the global resurgence of malaria. New therapies are available, but the use of older drugs persists for social, economic, and clinical reasons, despite resistance of the organisms to the older drugs. Efforts to use new antimalarial drugs may be hampered by regulatory requirements or economic obstacles as well as by important questions about safety for the large numbers of patients who treat themselves. Public health agencies continue to support the distribution of older therapies, despite strong criticism from scientists conducting research on the disease and its treatment and prevention. 6
In addition to inadequate drug efficacy, new therapies may fail because of inappropriate use, inadequate absorption, poor adherence, contraindications, intolerability, the use of counterfeit drugs or improper manufacture of drugs, or prohibitive cost. Chloroquine and sulfadoxine–pyrimethamine, which for several decades were the foundation of malaria therapy, had a low risk with respect to this array of problems. However, the emergence and consolidation of resistance to these drugs eroded their clinical usefulness.