[Editor’s note: This is a guest post written by Danielle Brown.]

“There is more money put into baldness drugs than into malaria,” said Bill Gates at the annual Technology, Entertainment, Design conference. To underscore his point Gates released a jar full of mosquitoes into the crowd, stating, “there is no reason that only poor people should have this experience [malaria].” He quickly assured the audience that those particular mosquitoes were not carrying malaria.

For many, especially the poor, malaria is a reality and a daily threat to their lives. Gates’ presentation pointed to the fact that malaria has been eradicated in developed nations but remains a problem for many equatorial countries. Approximately half of the world’s population is at risk of malaria, and it remains the single greatest killer of children living in lower-income countries. In 2006 alone, there were 247 million cases of malaria and 880,000 deaths. For a disease that is preventable and curable, these numbers are far too high.

Gates also raised an important question: How do you stop a deadly disease that is spread by mosquitoes? His response for prevention includes insecticide-impregnated bed nets and indoor residual spraying using the insecticide dichloro-diphenyl-trichloroethane (DDT). The two, used in combination, can cut deaths from malaria by 50%.

Despite this potential, the global response to this question is defined in part by a debate over the safety of DDT, framed by the Stockholm Convention on Persistent Organic Compounds and by WHO guidelines regarding use of DDT. The Stockholm Convention outlines a plan for the long-term elimination of the production and use of DDT by 2020, while granting DDT an exemption for use in public health. This exemption is conditional on whether alternative insecticides that are as cheap and effective as DDT exist. However, such alternatives are not readily available.

WHO now faces the double challenge of combating malaria while also upholding a commitment to reducing reliance on DDT. WHO proposes an eventual phase-out of DDT but expects that it will play a continued role in malaria control until effective alternatives are developed.

The organization Africa Fighting Malaria states that the current lack of investment from public and private sources for new public health insecticides makes the future of malaria eradication initiatives highly DDT-dependent. Despite efforts to find a vaccine against malaria, it will be difficult to phase-out DDT without phasing out this vital prevention aspect for people in need.

The EU, a Stockholm Convention signatory, recently passed regulations to limit the use of insecticides for agricultural use in the EU. With DDT banned as an agricultural product, remaining production would be on a smaller scale and at a higher price. Affected countries and international aid groups should consider the consequences of legislation regarding DDT and the potential to make DDT inaccessible and unaffordable for countries affected by malaria.

Don Roberts, a professor of tropical public health at the Uniformed Services University of the Health Sciences, recognizes this potential and urges a commitment to using DDT. He explains: “For years, the rich, developed nations that no longer have malaria have pressured tropical countries, which do, into giving up DDT. When countries stop using DDT, malaria spirals out of control.”

Given this trend, DDT should not be automatically discounted from discussions on prevention and eradication of malaria, but used effectively and with adequate precautions as part of a comprehensive strategy for malaria control. This includes, but is not limited to, usage of insecticide-treated bed nets, antimalarial drugs, environmental changes to destroy breeding grounds for mosquitoes, and strengthening health systems for public health. Although WHO encourages elimination of DDT by 2020, WHO also states that reductions in the use of DDT should be gradual and ensure that the level of transmission interruption is maintained.

DDT is not the only solution to eradicate malaria, but it should be part of a comprehensive plan to eradicate malaria with the same vigor that it was used to fight the disease in America and Europe. WHO states that every country in the world is now party to at least one human rights treaty that addresses health-related rights, including the Universal Declaration of Human Rights. Restricting access to this life-saving tool is a lost opportunity to impact child survival rates in the world’s poorest nations and to advocate for health as a human right. Phasing out DDT requires focus on integration and eventual elimination of the pesticide — not an abrupt halt. With more than 1 million people dying from malaria each year and over 2 million affected, considering safe and appropriate use of DDT merits attention.

[Editor’s note: This is the first in a series of posts covering topics related to drug resistance, including causes, effects, what is being done to fight drug resistance, and what needs to be done to limit the harm caused by drug-resistant pathogens.]

The discovery of penicillin in 1928 was one of the greatest medical discoveries to date, and since their introduction, penicillin and other antibiotics have saved an incredible number of lives. Unfortunately, it didn’t take long for the bacteria to fight back.

The discovery of penicillin-resistant bacteria within a year of the first clinical use of the antibiotic would serve as a sign of things to come. Today, there are few (if any) widely used antimicrobial drugs that have not been rendered less effective by the emergence of resistant pathogen strains. The fast replication cycles of bacteria and viruses and the mistakes made by their replication machinery give these pathogens the ability to respond to and overcome drug pressures. With penicillin, for example, replication errors allowed some formerly penicillin-sensitive bacteria strains to evolve so that the targeted bacterial proteins no longer interact with the antibiotic. Other bacterial strains acquired new genes that allow them to produce proteins that degrade penicillin, rendering it ineffective and allowing these bacteria to survive.

Drug resistance continues to be a major obstacle in reducing the prevalence of the “big three” infectious diseases: HIV/AIDS, tuberculosis (TB), and malaria. The recent emergence of malaria strains resistant to artemisinin, one of the most effective anti-malarial drugs and sometimes the only drug that can effectively kill the deadly Plasmodium falciparum parasite, serves to highlight how troublesome — and downright frightening — drug resistance can be.

Of course, drug resistance is not just a problem for the “big three.” Drug-resistant strains of H1N1 (swine) flu have been found in Canada, Denmark, Japan, and Hong Kong, which does not bode well for the upcoming flu season. Drug-resistant staph infections are also a significant problem. It has been estimated that methicillin-resistant Staphylococcus aureus (MRSA) was responsible for 94,360 infections and 18,650 deaths in the US in 2005.

Drug resistance is not just a public health issue — it is also a human rights issue. Article 25 of the Universal Declaration of Human Rights acknowledges the right to medical care, and as one of humanity’s greatest achievements in medicine, antimicrobial drugs are a necessary part of adequate medical care. Unfortunately, the actions of doctors, pharmacists, consumers, and others — and the lack of appropriate action by governing bodies — continue to promote the emergence and spread of drug-resistant pathogens. Of course, the emergence of drug-resistant pathogens is not in itself a human rights violation, but the (mis)handling of drug-resistance issues by medical and public health practitioners clearly has human rights implications. Human rights implications arise from the fact that much can be done to reduce the emergence of resistant pathogens and to ensure that people will have access to life-saving antimicrobial drugs when they are needed.

Here, MRSA serves as a good example. It has been shown that active surveillance measures in hospitals can reduce hospital-acquired MRSA infections. However, many hospitals in the US have failed to implement such programs. Typically, surveillance programs are not adopted because of high cost or limited resources, even in wealthier countries.

But what about the people who get MRSA infections during their hospital stay? If surveillance programs are evaluated from a human rights perspective, these programs can be viewed as protecting people’s right to health by protecting them from potentially deadly MRSA infections. Put another way, hospitals that decide not to implement surveillance programs are depriving patients of that protection of their right to health. A person’s right to health should not be denied without an extremely compelling reason (for example, because doing so would greatly infringe upon the rights of others) and should certainly not be done simply because of (bearable) cost, inconvenience, or plain unwillingness to adopt life-saving measures.

Human rights issues also come into play when determining how to respond to outbreaks of disease caused by drug-resistant pathogens. In these situations, the rights of a few (the infected individuals) are often in conflict with the rights of many (the general public). Striking the proper balance between protecting the rights of both groups has been a difficult thing to do.

Attaining that proper balance has been widely discussed with respect to multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB, including in a recent Health and Human Rights article. On one hand, the public needs to be protected from the disease, prompting calls for compulsory treatment and quarantine of individuals infected with MDR- or XDR-TB. On the other hand, such measures — particularly forced quarantine — infringe upon the rights of the infected individuals. The example of MDR- and XDR-TB demonstrates the need for medical and public health practitioners and policy makers to consider human rights implications when determining the best response to outbreaks of drug-resistant disease.

Because drug resistance further complicates already complicated issues surrounding infectious disease control, it is imperative that human rights and public health practitioners understand drug resistance so that infections with drug-resistant pathogens can be prevented and treated in ways that best protect the rights of everyone involved.

More Information:

WHO: Drug resistance

CDC: Antibiotic/antimicrobial resistance

The New England Journal of Medicine: Artemisinin Resistance in Plasmodium falciparum Malaria

Infection Control and Hospital Epidemiology: Society for Healthcare Epidemiology of America guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and Enterococcus