About a century ago,Ghana was ambushed by a deadly disease called Malaria,a disease caused by plasmodium species and transmitted by the female anopheles mosquito. Malaria's mortality rate was between 1-2 million deaths annually and had an infection rate of 300-500million people worldwide.90% of these infections and deaths was in Africa(Ghana inclusive),with approximately 25 thousand Ghanaians losing their lives yearly to a disease that is very ubiquitous,preventable, and treatable.Such was the enormity of the carnage visited on this otherwise peaceful medically serene country that the medical fraternity was prompted to develop chloroquine in 1943.Chloroquine was an ideal anti-malaria drug but its efficacy has decreased dramatically in the last few decades.

The call for the abrogation or nullification of chloroquine as a first line of treatment of uncomplicated falciparum malaria in Ghana was not based on hearsay but rather on professional, emperical, clinical and epidemiological studies which gave a true picture of the astronomical and unprecedented increase in the resistance of the malaria parasite to chloroquine.The reason for the immediate need to change the chloroquine policy was better echoed by Dr Fred Binka,professor of epidemiology,University of Ghana in a statement which read, 'in poor countries like ours, children have only one chance. They struggle just to visit a health center and if they get the wrong drug the first time,they are found dead?. Inspired by such a sagacious and thought provoking statement, the Ghana Health Service(GHS) opted for a policy change from chloroquine to Artesunate Amodiaquine.

THE NEW ANTI-MALARIA DRUG POLICY-ARTESUNATE AMODIAQUINE

In November 2004,the GHS, adopted the Artesunate Amodiaquine combination therapy as the first line treatment in uncomplicated malaria,a decision which was informed by numerous studies both inside and outside Ghana,studies which showed artesunate amodiaquine to be of commendable efficacy.

A study funded by the GATES MALARIA PARTNERSHIP and carried out in the Kintampo district of Ghana between July 2005-2006 showed that Artesunate ?amodiaquine was very efficacious and safe,producing a rapid clearance of parasites and malaria symptoms.A related publication by MEDECINS SANS FRONTIERS, a Switzerland based non profit health service provider,revealed that artesunate amodiaquine use in South Africa?s Kwazulu Natal Province resulted in dramatic reduction in malaria cases from 41,286 in 2000 to 9443 in 2001 that is about 78% reduction.In further support of the efficacy and reliability of the artesunate amodiaquine combination; a study was conducted by Neils Quashie and Co of the Noguchi Memorial Institute into the comparative efficacy of artesunate amodiaquine.The study showed that the cumulative Polymerase Chain Reaction(pcr-corrected )cure rates on day 28 for 168 children were 25% for chloroquine,60% for Sulphadoxamine- Pyremethamine,97.5% for Coartem and 100% for Artesunate-Amodiaquine.This finding just like the others, established and authenticated by reputable and unquestionable authorities in medicine worldwide clearly exonerates the chemotherapeutic excellence of the artesunate amodiaquine drug policy.

With such a wonderful policy notwithstanding,we are engaged in a debate about the reliability of artesunate amodiaquine in the wake of some reported unwanted effects recorded in some patients.The undermentioned arguments raised by a substantive fraction of Ghanaians have been mentioned and dealt with by myself so we don?t frustrate the smooth execution of the policy.

ARGUMENTS

Why not an artemisinin based drug alone? As a country, we can?t afford to use an artemisinin based drug like artesunate alone knowing too well from our experience with chloroquine that monotherapies;that is the use of one drug alone develops relatively quick resistance thereby rendering yhe drug impotent within a considerably short period.With a combination therapy like artesunate amodiaquine ,toxicity by individual drugs is reduced since lower doses of each add up to culminate in a total dose,also due to the sophisticated interplay of the pharmacodynamic activities by the two drugs,the malaria parasite is unable to easily develop resistance to the combine drugs.Consequently, combined therapies are able to maintain their efficacy for as long as ten decades.

Why not the other combinations?

Coartem(Artemether-Lumefantrine) combination was not opted for despite its efficacy because it costs about $6 per adult,approximately two times the cost of the artesunate amodiaquine combination.Artesunate Sulphadoxine-pyrimethamine couldn?t be a choice either because of its low efficacy coupled with a high susceptibility to resistance development.

What about cost?

People keep on bringing up the issue that artesunate amodiaquine is expensive as if it were a reason not to start using them.What would you rather do?,waste money on old cheap drugs that you know don?t work or fund a relatively expensive treatment that would save lives.The cost of malaria treatment using artesunate amodiaquine is about forty thousand(4 Ghana cedis) per adult,that is should a Ghanaian single parent with three children between ages 10to 16years all experience malaria attack five tmes a year, this unfortunate single mother would have to cough out 800,000 old Ghana cedis.If this had been the case,it would have been very frightening,however with the National Health Insurance Scheme(NHIS) ,accomodating malaria treatment,an affordable yearly contribution of about one hundred and twenty thousand old ghana cedis only,is enough to take care of the single mother and all her children.

Fellow compatriots,with the health insurance in place coupled with the costs of revisiting hospital from chloroquine treatment failure,you immediately realize that both the rich and the poor can access artesunate amodiaquine and thus making the numerous calls for the policy?s abrogation or nullification on cost grounds not only unfounded but also inimical to the state of health of Ghanaians as well as their right to unadulterated and uncompromised health delivery.

What about the combination?s unwanted effects?

An average 60kg adult requires about 600mg of amodiaquine a day for three days in combination with artesunate.The drug manufacturers in a desperate bid to help with patients? compliance produced single strength 600mg tablet which actually proved quite strong and resulted in some unwanted effects.However these occurences have decreased significantly after the pharmacovigilance unit in consultation with the national malaria control progaramme asked the pharmaceutical companies to withdraw the 600mg strength tablets and replace it with 75mg and 150mg tablets ;a directive which the local drug manufactures have duely respected.

As a member of the medical fraternity, I am aware that any foreign substance consumed has the potential to produce unwanted effects as clearly detailed in PHARMACOTOXICOLOGY(a facet of medicine dedicated to studying the unwanted effects of substances taken into the body),yet thesubstance or drug is still introduced into the body provided the therapeutic or wanted effects overwhelm the unwanted effects.

CONCLUSION

Having revealed to you the remarkable efficacy of the artesunate amodiaquine combination and the weightlessness and untenability of the arguments against the policy,you and I can comfortably agree that the only way to move the health agenda of Ghana forward is for every medic to spend any energy available in informing the public on patient compliance,that is sticking to a doctor?s or pharmacy's directives on the use of the artesunate amodiaquine combination therapy so that together we can perfect t this new policy. As a nation, its not been that easy addressing the manifold health challenges that have come our way for the past fifty years of our existence and with all our health records singling out malaria as the number one medical condition reported to our hospitals, chosing the right drug for malaria?s treatment is an obligation and not an option.I would also like to mention for the purpose of educating the public and establishing the comprehensive make up of the new anti-malaria drug policy, that the policy takes care of the provision of free insecticide mosquito nets to mothers as well as a provision for appropriate drugs for pregnant women. As a 50 year old sovereign country, we have battled the storms of debilitation born on malaria?s wings ,we have wrestled th e jaws of death that come with malaria?s visits and have almost succeeded in overcoming the glaring gloom that malaria promised the first time it visited Ghana about five score years ago.Our success not withstanding,we as a country aren?t satisfied and would not be satisfied until every son and daughter of this beloved country of ours comes to appreciate the hope that artesunate amodiaquine offers,and not only that but more importantly ensure that every soul from every hamlet in every city of our beloved country,Ghana,is economically positioned to afford,access and consume the new combination therapy drug when malaria pays its discomforting and life threatening visits. We have come too far as a country,infact far too far in our research,development and adoption of this efficacious,and reliable artesunate amodiaquine drug policy and I don?t think it would be politically prudent,financially wise ,or medically ingenious to let go of this policy because of discontentment from a section of the public;discontentment that has nothing to do with the efficacy and safety of the policy but rather a communication gap, which in itself serves as an enough incentive for all stakeholders to optimize their input and make the implementation,sustenance and perfection of the new anti malaria drug policy a reality.

Okoe Boye Bernard,Bsc. Human Biology,MBCHB 2

KNUST-SRC VICE PRESIDENT,2005.

dragadra@yahoo.co.uk SCHOOL OF MEDICAL SCIENCES, KATH KUMASI-GHANA.