Re: Now that ACTs appear to be failing


 Below is an insightful rejoinder I received from Professor David T. Okpako on my article, “Now that ACTs appear to be failing.


The article in the January 2015 issue of Pharmanews, page 46, with the above title, written by Pharm. Nelson Okwonna, caught my attention and compelled me to write this brief response.

The article dealt with the important issue of emerging Plasmodium falciparum resistance to the artemisinin-based combination therapies (ACTs), now the drugs of choice for the treatment of malaria disease throughout Nigeria. The author raised the apocalyptic scenario of an ‘epidemic of monumental proportions’ for Nigeria, the epicentre of malaria disease, in the event of resistance to ACTs.

I have also raised such alarm before and, again, in a forthcoming book, where I drew attention to modern medicine’s historical experience with the disease caused by tubercle bacillus (TB) which was treated successfully with effective affordable drugs in the 1950s, but which later developed resistance to such drugs, and then to every generation of anti-TB drug that science could invent. Today there are some strains of TB (extensively resistant TB) which do not respond to chemotherapy –a nightmare scenario and one of today’s most intractable chemotherapeutic problems, even in the western world.

Among Nelson’s recommended solutions is a most telling point, i.e., “heading home for answers” -where he suggests that, in our attempt to tackle the problem of multi-drug resistance in malaria,we should look at the possibility of combining our local herbs with known existing therapies. This is a most insightful suggestion for which there is strong scientific evidence, which I may very briefly point to. Basically, malaria is a disease whose pathology is underpinned by inflammatory mechanisms triggered by the presence of the plasmodium parasite.The evidence that malaria is an inflammatory disease is now overwhelmingly incontrovertible. And the herbal remedies used by various indigenous communities in Nigeria to treat fever, aches and pains (FAP), the quintessential manifestations of the inflammatory reaction, have been shown by Nigeria scientists in the last 30 to 40 years to possess anti-inflammatory pharmacological properties.

We can thus say with confidence that ancient Nigerians, in their malaria endemic zones, evolved a rational method of treating what must have been a common ailment, malaria fever,with herbs, that worked.There is no evidence that Africans were near extinction due to malaria disease, before modern chemotherapy came to the rescue.

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The ancients were ignorant of the mosquito/parasite origin of the disease, but they treated the symptoms (many people in Nigeria still do).I argue that such successful treatment of malaria-induced FAP is tantamount to cure in Africans living continuously in contact with the anopheles mosquito.This is because the people have partial immunity conferred on them by anti-plasmodium antibodies and numerous genetic protective adaptations e.g., sickle cell gene and glucoe-6-phosphate dehydrogenase enzyme deficiency; their immune system was primed ready to deal with the plasmodiumparasite whenever it showed its presence. In such people, all that is needed is a successful amelioration of the malaria-induced inflammation (some mediators of inflammation, e. g., the cytokine, tumour necrosis factor, TNF, actually suppress immune activity in the sufferer); the resulting surge in anti-plasmodium immune activity in such people would eliminate the parasite, resulting in a cure of the disease. Moreover, the immune status of the individual against the plasmodium was strengthened after every bout of malaria-induced FAP, and successive attacks would be less severe in a process of natural attenuation of the parasite. This was how Africans living in malaria endemic areas came to attain a state of biological equilibrium with the disease before European introduction of modern chemotherapy with plasmodicidal drugs less than 500 years ago.As we now know, the use of plasmodicidal drugs in the treatment of malaria runs against the grain of that age-old biological equilibrium.

An important advantage of herbal treatment is that the parasite is not provoked into mobilising its considerable arsenal of resistance mechanisms, which is what happens when we use plasmodicidal anti-malaria drugs such as chloroquine and the ACTs whose aim is to kill the plasmodium.The malaria multi-drug drug resistance that we see in Plasmodium falciparum is a defence reflex against extinction by an ancient parasite that sees itself threatened.

Drug resistance was an unknown phenomenon in Africa before the extensive use and abuse of anti-malarial drugs, following the introduction of modern chemotherapy. Even when fully fleshed out, this hypothesis is, at best, a most plausible hypothesis; but it can be tested and represents a challenge to the Nigerian medical community which, up till now, seems to accept foreign prescriptions on malaria without question.

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Pharmacists and doctors and all who are familiar with this science must work together and pressurise the government to fund concerted research into traditional anti-FAP herbal remedies for development as anti-malaria therapies, or as adjunct to conventional therapies, as Nelson wisely suggested in his article. This is to ensure that not every adult otherwise healthy Nigerian with a competent immune status and partial immunity should have to take powerful resistance-provoking plasmodicidal drugs such as the ACTs for the treatment of FAP that has not been diagnosed as malaria disease. This, plus other smart designs in the use of effective plasmodicidal drugs, will increase their life-span by minimising the chances of drug resistance.

I am thus in full agreement with Nelson Okwonna that we should head home for answers by turning to indigenous herbal remedies. The world is turning to plants for anti-inflammatory medicines because the array of anti-inflammatory chemical entities present in plants is mind-boggling and cannot be matched by non-steroidal anti-inflammatory drugs produced by synthetic chemists in the pharmaceutical industry.

All in all, the time has come (aided by science!) for us in West Africa to begin to see malaria disease as our ancestors understood it – that is, a common ailment treatable with available herbal remedies, not a deadly disease of epidemic proportions as we have been conditioned to perceive it by international experts guided by a persisting fear of the disease; a fear reinforced by their memory of numerous malaria deaths of non-immune Europeans in their first encounter with the disease in West Africa in the 19th century.

David T. Okpako, FPS, FAS.

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