Signs of resistance
“We always hoped artemisinin would keep its full efficacy,” said De Smet, the leader of MSF’s Malaria Working Group, based in Brussels. “But in the past six to seven years in Southeast Asia, particularly Cambodia, we’ve been increasingly concerned about the efficacy of the drug.”
Artemisinin works quickly, staying in a patient’s blood stream for just a few hours. Normally a course of treatment with ACT takes just three days. So when the drug started taking longer to eliminate the malaria, De Smet and his team became concerned—not just that the falciparum parasites were developing resistance, but that this resistance could spread.
Resistance to older malaria drugs historically began in Southeast Asia, spreading through countries like Myanmar and India before arriving in Africa, De Smet said. No one knows precisely why resistance seems to originate in this region, but it could have to do with the use of artemisinin without so-called “partner” drugs, or the widespread availability of substandard malaria medicines. The threat was still relatively low in these cases, however, because ACT treatment was still highly effective.
So when malaria in Cambodia began showing signs of resistance to the usually reliable treatments, De Smet and his team knew they had to act. In collaboration with Cambodia’s National Malaria Control Program and the Pasteur Institute of Cambodia, MSF put a plan in motion. “The philosophy of the intervention was that we wanted everybody who had malaria to end up being diagnosed and treated,” said De Smet. “That means well-functioning diagnosis and treatment in all health care facilities."
However, in Cambodia’s Preah Vihear province, where the project focused, there was a problem: in this region, many people live in villages deep in the forest, where accessing health facilities is difficult or impossible, especially during the rainy season.