Le traitement contre le paludisme à base d’artémisinine en Afrique et le rôle de la Chine dans les enjeux globaux de santé publique. Trois questions à Kelley Sams

Kelley Sams est anthropologue, spécialiste des maladies infectieuses et de leur traitement. Elle a travaillé en Afrique de l’Ouest et aux Comores sur la lutte contre le paludisme. Elle s’est particulièrement intéressée à la la politique chinoise de distribution en masse des médicaments à la base d’artémisinine pour éliminer le paludisme aux Comores.

Elle a été chercheure au Centre Norbert Elias dans le cadre d’un projet ANR La vie politique des marchandises (VIPOMAR). Elle travaille actuellement à l’Université de Floride et participe comme chercheur associée au LPED au programme de recherche Confinement et mesures sanitaires visant à limiter la transmission du Covid 19 : Expériences sociales en temps de pandémie en France, en Italie et aux Etats-Unis (CoMeSCo) dirigé par Marc Egrot (LPED) et Sandrine Musso (Centre Norbert Elias). 

Artemisia as a treatment for Covid-19 is a controversial issue. Could you go back over the history of this plant which is traditionally used in the Chinese pharmacopoeia as a treatment for malaria?

The leaves of Artemesia annua (qinghao in Mandarin) have had a documented place in Chinese medicine for almost 2000 years. They are traditionally soaked in water and drunk to treat fever, during fieldwork in China, I also saw the dried plant sold in herbal pharmacies to treat urinary tract infections and even cancer. While this plant has played an essential role in Chinese medicine for years, it was not until the latter half of the 20th century that it began to enter biomedicine and start its path toward Western fame. 

This path began with a Chinese government research program during the Vietnam War. To help communist North Vietnam forces that were being weakened in their fight against South Vietnam and the USA by malaria, Mao Zedong launched a project to rapidly find an effective malaria treatment. This national project (called “Project 523” after the date it was launched, May 23, 1967), mobilized over 500 scientists in laboratories throughout the country. These scientists tested a diversity of synthetic and plant-based substances, eventually landing on artemisinin, an extraction from the Artemisia annua plant. Many years after this discovery, a Nobel prize in medicine was awarded in 2015 to Tu Youyou from the China Academy of Traditional Chinese Medicine in Beijing for her leadership in this innovation.  

It is important to highlight here the difference between the plant and its extraction, Artemisia, and artemisinin. The scientific action of the plant against the parasite that causes malaria is created by the level of artemisinin in the Artemesia annua plant. While a tisane made from artemisia leaves has some level artemisinin that is extracted from the plant as it soaks in water, this level of artemisinin is nothing near the active ingredient level when it is extracted by chemical solvents through an industrial extraction process. Artemisinin has been commercialized and combined with other therapeutic agents to create Artemisinin Combination Therapy (ACT), the malaria treatment recommended by the World Health Organization since 2001. 

While this Chinese discovery of artemisinin occurred in the 1970s, for political reasons, it did not enter Western biomedicine until the late 1990s. Currently artemisinin-based combination therapies are manufactured by major pharmaceutical companies from all over the world. The artemisinin level in the Artemisia annua plant depends on where it is grown, and many of the plants used in artemisinin-based combination therapy are still grown in the mountains of Youyang China. 

Artemisia annua has again entered international news because of its potential role in treating COVID-19. Madagascar’s president, Andry Rajoelina, recently gave a long speech, lauding the plant’s potential as a treatment, and there are also studies being conducted in other countries. However, it is worth examining how perceptions about the efficacity of this treatment are being constructed. In an emergency situation, such as the COVID-19 pandemic, there is a desire to move forward rapidly. The whole world would like to find a remedy and a way to protect themselves. As we have witnessed with the debates around hydroxochloroquine, perceptions of how the virus should be best be treated are steeped in political and economic relationships. 

My work focused on the Chinese malaria elimination program that produced impressive results with a mass distribution strategy of industrial-produced artemisinin-based combination therapy given to anyone living in or entering the country. This program and the particular brand of ACT were at the center of many international debates and provoked many questions about the role of China in Africa and of China’s role in the global pharmaceutical market. 

At the same time that I was in the Comoros studying the Chinese program, there was a Swiss group in the country working with the Comorian Ministry of Health to promote the growth of Artemesia annua plants for use in tisanes for malaria prevention. For many of the people I interviewed, this initiative was a move toward self-sufficiency and away from dependence on international pharmaceutical companies. However, many medical professionals expressed concerns about the lack of rigorous testing of this treatment and a fear that some people may avoid other necessary medical interventions in favor of drinking this tisane.

As a medical anthropologist who is especially interested in how people engage with infectious disease initiatives, I am aware that no treatment is politically or socially neutral. Any tisane, pill, or injection carries with it a particular history and symbolism. In the African post-colonial space, there is a strong desire to engage with medications and medical systems that do not recreate historical relationships of domination. However, it is vital to make sure that the path toward new treatments, especially done in an emergency situation, builds upon previous scientific knowledge and is treated critically until they have properly been proven to work.

Can you tell us about the work you carried out on the treatment for malaria in the Comoros, in particular, how Chinese public health initiatives in sub-Saharan countries can be seen as ‘soft’ power?

My work in China, Geneva, and the Comoros explores China’s increasing role in Global Health in Africa. Over the past two decades, we have witnessed an increasing presence of China across the continent. China has been sending medical teams to staff African hospitals since the 1960s. Throughout the continent, it is common to see these teams working in government hospitals alongside local healthcare workers. Chinese construction projects, bridges, hospitals, roads, are now visible in many countries in sub-Saharan Africa. So are mining projects and petrol exploitation operations, hospitals, stores, and restaurants.

China is known for giving foreign aid directly to governments without interfering in country-level politics. This is in contrast with, for example, a country like the United States that will withdraw aid when undesired political changes occur. Many appreciate this aspect of continued bilateral relationships with China, although others critique this dynamic for potentially fueling harmful government regimes. As a result of this, China’s aid sometimes stays long after other international aid is suspended.

In addition to direct financial support, China also donates medications and builds infrastructure in countries across Africa. Again, the explicit demands on recipient countries seem to be quite limited. For example, during fieldwork in the Comoros, I visited a huge hospital built by China. This new hospital, fully equipped with medical technology, had sat empty for over a year at the time of my visit. This Chinese “gift” did not come with any demands for Comorian human resources or Comorian investment. It was delivered without any apparent follow-up.

Multiple interpretations and questions surrounded the Chinese malaria elimination project that I studied. Was it a gift to the Comorian people? Was it in exchange for access to fishing and oil mining rights? Was it an experiment? Was it a marketing tool for this new brand of artemisinin-based combination therapy? The results of my fieldwork showed that it could be thought of as all of these things at once. 

Going back to the question about Chinese soft power and public health, as someone who has focused on health and development in sub-Saharan Africa for almost two decades now, it seems to me that public health and soft power in Africa are not an exclusively Chinese dynamic. I’m American, and I feel that I can critically analyze the US position because that’s what I know best. The United States Agency for International Development (USAID), for example, leads great public health programs in many countries. However, this aid is only given to countries that meet certain political criteria and can be seen as a way to push countries toward certain policies.

I first started working in Africa as a Peace Corps volunteer in Niger. Since the 1960s, the Peace Corps has given many young Americans a way to get to know different cultures and volunteer their services by doing things such as teaching in local schools or leading health education work. While these short-term volunteer activities are nice, I do not think this is why the Peace Corps has received funding for the past sixty years. It is about soft power. The Peace Corps offers a way for foreign nationals to get to know enthusiastic young Americans who share their passion for the US and the American way of life. One-by-one, Peace Corps volunteers are going to the far corners of the world and offering micro-level positive interactions with a symbolize of the US. It’s a positive and eye-opening experience about life in other parts of the world for the volunteers that are also the cogs in this soft power machine. For the villages that host these volunteers, the students who learn English from them, and the patients who see them in local hospitals, these are beneficial relationships. For the United States, it is a dimension of soft power than can help position larger political and economic relationships. 

So how does this compare to what China is doing in Africa right now? For example, China’s donation of containers with masks, ventilators, and personal protective equipment to the Africa CDC has been referred to as “mask diplomacy”. Is this different from France’s $1.3 billion dollars of aid to support COVID-19 efforts, mainly focused on former French colonies? 

Sociologist Marcel Mauss highlighted the complexity of gift-giving as a social practice and made the point that while in Western society, we often think of gifts as something that should be given for free, they are embedded in reciprocity systems and obligation. How does China’s involvement in Africa relate to moving projects such as the Belt and Road Initiative forward? There is currently much suspicion surrounding China’s interests in Africa, and I do not think that is necessarily wrong. However, I think we also need to expand this critical analysis of soft power and global health to question the historical and contemporary reasons that frame all foreign intervention on the continent. 

While studying the mechanisms of World Health Organization (WHO), you had the opportunity to observe the growing role of China. How would you describe its influence on global health and on the privatization of the pharmaceutical industry?

The growing role of China in Global Health in general can be seen by the increasing presence of the country in the decision-making and funding of the WHO. The current COVID-19 pandemic demonstrates this and shows how international political relationships are being negotiated on the global health stage. Trump recently declared his intention to defund the WHO, in part because of what he sees as the agency’s bias toward China. Meanwhile, China donated $2 billion to WHO for COVID-19 response. This is important since previously the USA was the largest funder of the agency.

What does this mean about how the vision of public health is changing on a global scale? How is China’s contribution to global health different from or the same as other countries? My work as an anthropologist focuses on gathering and analyzing data from social actors involved in and affected by global health, so my thoughts on these changes come from that. You could think of my focus as being on “global health from below”. In the interviews that I conducted in Geneva and the Comoros about China’s presence in malaria control, many interlocutors pointed to how China was working both through and around the mechanisms established by the World Health Organization. 

Going back to Artemisinin Combination Therapy (ACT) for example, as I explained earlier, this was a Chinese invention, but it did not make it to the international market until the Chinese government sold the rights to produce the drug to the Swiss company Novartis in the 1990s. One of the agreements that went along with this sale was that Novartis would source the raw materials to produce this treatment from China and pay the Chinese government a percentage of its sales. 

In the early 2000s, the WHO launched a prequalification program that assessed different ACTs brands and recommended them for procurement. Notably, this seemed to favor Novartis and other European companies. The WHO was critiqued for establishing policies that disadvantaged companies from places like China or India. In the case of India, the situation changed rather quickly and supported by international agencies, many ACTs made by Indian pharmaceutical companies made it to WHO’s prequalification list. For Chinese companies, the struggle for WHO approval was more difficult. In 2007, the Chinese company Guilin Pharmaceuticals became the first to meet WHO’s prequalification for its ACT brand. 

However, this does not mean that the Chinese ACTs not approved by WHO are banned. The WHO list only means that the brands have been assessed for quality following WHO’s specifications. Many international agencies and some countries follow this list for procurement. During fieldwork that I have done in different countries in Africa, I have seen many ACTs not on WHO’s list for sale and for use, even in government health facilities. So how do these get there? From what I have seen in fieldwork, many enter through direct donations from the Chinese government’s Ministry of Commerce to African governments. Others enter the way that any other commodity enters a market, through commercial channels. 

In the interviews that I conducted in Geneva, many interlocutors described how they saw China dodging global health recommendations. This brought up concerns about the quality and efficacy of the products reaching African markets and healthcare systems. In contrast, the interviews that I conducted in the Comoros showed a very different perception. There seemed to be great admiration for Chinese companies forging their own way and not being stopped by limits decided in Geneva. Because the Comoros was late to gain independence, remaining under French rule until 1975, these sentiments of admiration were particularly salient, and China was often described as offering an alternative model of development from that offered by European partnerships and models.  

China’s huge strides in the past two decades in the international pharmaceutical and medical equipment markets have certainly supported its role as a member-state of the World Health Organization. The country also provides many raw materials that are used to produce pharmaceuticals throughout the world. However China’s increasing presence in the WHO leads some to ask if there is a change in global health authority from what has historically been a stage dominated by Europe and North America, and if so, what kind of future does this represent?

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Propos recueillis par Boris Pétric Centre Norbert Elias/CNRS) et Lisa George (Centre Norbert Elias/CNRS).

 

Further reading

Daniel Finnan, “Artemisia: Madagascar’s coronavirus cure or Covid-19 quacker?” RFI, May 5, 2020.

Jia-Chen Fu, The secret Maoist Chinese operation that conquered malaria – and won a Nobel, The conversation, 6 October, 6, 2015.

Elisabeth Hsu, “From social lives to playing fields: ‘the Chinese antimalarial’ as artemisnin monotherapy, artemisinin combination therapy and qinghao juice”,  Anthropology & Medicine, 22(1),  2015, 75-86.

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