An INTERVIEW with Dr. François Nosten
 ccording
to our Special Topics analysis of malaria research over the
past decade, the work of Dr. François Nosten ranks at #9,
with 56 papers cited a total of 1,552 times. Two of the papers
he co-authored are in our list of the 20 most-cited papers on
malaria published in the past two years. In the ISI
Essential
Science Indicators
Web product, Dr. Nosten’s record includes 96 papers cited a
total 2,020 times to date. Dr. Nosten is the Director of the
Shoklo Malaria Research Unit in Thailand. In the interview
below, he discusses his highly cited papers as well as his
current concerns.
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What
are the circumstances which led you to study malaria?
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“For the last 20 years we have lived and worked without any guarantee that we’d be there the following year. This is the nature of working in the field and especially in a border area, in refugee camps.”
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I was working with the French NGO Médecins Sans Frontières (MSF)
in the camps for Karen refugees on the Thai-Burma border starting in
1984. Malaria was the #1 killer disease in the camps, and we started
by setting up laboratories and training technicians and medical
assistants to deal with malaria patients. In 1985, I met Professor
Nicholas White, who was working in Bangkok within the Wellcome Trust
Mahidol University Oxford Tropical Medicine Research Programme. Nick
offered me the chance to work on the prophylaxis of malaria in
pregnancy after the end of my contract with MSF. And that's what I
did in July 1986—started to study malaria in the Karen camps,
initially concentrating on maternal malaria but later expanding to
epidemiology, prevention, and treatment in all patients, because
this region harbors the most resistant Plasmodium falciparum
in the world.
What
is the significance of your work for the field?
The research unit that I started—called the Shoklo
Malaria Research Unit*,
SMRU after the camp where we first settled—has grown into a
reference center for the region. The treatment strategies developed
here have been extensively used by NGOs in the refugee camps, and
also in the surrounding areas. This has translated into a dramatic
fall in malaria-related morbidity and mortality. So for the
populations in the immediate surroundings, the impact of the
research is obvious, especially for the most vulnerable groups such
as the children and the pregnant women. Before the program, 1% of
all pregnant women died every year because of malaria and 45% of the
consultations in the camps were due to malaria. Today maternal
mortality is nil and malaria represents less than 2% of the
consultations. More recently the results of this program have been
applied to other endemic countries and this has led to the global
recommendation that all malaria cases should be treated with an
artemisinin-based combination therapy (ACT).
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According
to the Wellcome Trust, one of the main components of their Programme
in Thailand is the use of artemisinin-based therapies. Would you give
us some background and progress on this aspect of the Programme?
In 1991 we were facing a critical situation as far as the
treatment of falciparum malaria was concerned: the parasite strains
in this area were resistant to all antimalarials available.
Artesunate had just been released by Professor Li and his team (who
re-discovered Qinghaosu in the 1970s) for studies. We started using
this new drug in combination with our failing first-line treatment (mefloquine).
We worked out that the best regimen was a three-day course of
artesunate and a split dose of mefloquine. We have since treated
over 10,000 patients in clinical trials with ACTs and have also used
the artemisinin derivatives to treat otherwise incurable malaria
infections in pregnant women. All these studies have confirmed what
the Chinese scientists had told us about these plant-derived
medicines: they are remarkably effective and safe. But what we were
able to demonstrate is that they also reduce malaria transmission
and prevent the spread of drug resistance, a major concern in this
part of the world and, increasingly, elsewhere. As a result the ACT
strategy is now accepted as the treatment of choice for falciparum
malaria throughout the tropical world.
How
large of a problem is drug resistance in malaria?
It is thought to be the main obstacle to malaria control
worldwide and the main reason for the resurgence of malaria. It is
mainly a concern for P. falciparum but there is also an
emerging problem with P. vivax. It is because of the rapid
spread of resistance to antimalarials that we shall not
"Roll Back Malaria" as planned. Instead of declining,
malaria-related mortality is increasing and this is mostly because
the drugs that are still used don't work. The use of ACTs seems to
be the only rational way to limit the emergence and the spread of
resistant malaria strains.
Where
do you see this work in 5 years? In 10 years?
It is difficult to say! For the last 20 years we have lived and
worked without any guarantee that we'd be there the following year.
This is the nature of working in the field and especially in a
border area, in refugee camps. Now the program has extended to
migrant populations and I think that as long as malaria will not be
controlled in Myanmar, then there is work to be done to improve the
treatments that we have and study the next generation that we shall
need. We are still at least 15 years away from a vaccine, so drugs
and vector control are going to be our main tools for the
foreseeable future.
What
are the political and social impacts of your work?
The social and economical impacts are obvious: the considerable
decrease in malaria morbidity and mortality means that people are
healthier and lose less time from work or school. In families, the
prevention of maternal death makes a huge difference. Apart from
malaria we also worked on thiamine deficiency, responsible for
considerable infant mortality (250 per 1,000), and this has now been
brought under control and also had a huge impact on the families.
The political impacts that interest me are the global ones. And
the picture is less encouraging: after 15 years of accumulating
evidence on the benefits of ACTs there are still people out there
resisting the changes against all evidence. These include decision
makers in big institutions such as the World Bank, USAID, DFID, and,
until recently, WHO and the Global Fund. The main reason for this
resistance is financial (affected populations are too poor to pay
for ACTs and the wealthy countries are going to have to foot the
bill) but also political: there is still reluctance to accept the
fact that all malaria treatments are going to have to contain a
Chinese drug, hence the current debate on the lack of supplies.
Again a very debatable, controversial, and...political question. But
one that was very easy to foresee five years ago!
Dr. François Nosten
Shoklo Malaria Research Unit
Mae Sot, Thailand
| Dr.
François Nosten's
most-cited paper with 107 cites to date: |
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Nosten, F., et
al., “Effects of artesunate-mefloquine combination on incidence of Plasmodium falciparum malaria and mefloquine resistance in Western Thailand: a prospective study,”
Lancet 356(297-302): 22 July 2000. |
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Source:
ISI
Essential Science Indicators |
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ESI
Special Topics, November 2005
Citing URL: http://esi-topics.com/malaria/interviews/FrancoisNosten.html
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