一人兩顆小藥丸，中國準備把非洲的瘧疾給滅了_風聞

《大西洋月刊》7月4日刊登《中國的剛果計劃》一書作者雅各布·庫什納文章《中國正在領導非洲下一步抗瘧行動》

文：Jacob Kushner

譯：範莉

2007年，比爾及梅琳達·蓋茨基金會宣佈它將致力於在全球範圍內消滅瘧疾。不過，當它邁出這一步的時候已經比較晚了。

正是在那一年，中國科學家們與慈善家朱拉伊的新南方集團合作，已經開始在非洲小國科摩羅消滅當地的瘧疾。現在他們滿懷壯志地把目光投向一個更大的區域：肯尼亞，一個人口將近5000萬的東非國家。

中國-科摩羅複方青蒿素快速清除瘧疾項目團隊合影

當媒體還在頻頻關注西方捐助者為昂貴的、實驗性的瘧疾干預措施籌集資金時，中國的研究人員已經在採取一種經過較完整測試的抗瘧手段。這就是羣體藥物配給（mass drug administration，簡寫為MDA），即同時向給定區域裏的所有人提供抗瘧疾藥丸。中國人認為，與其在全世界消滅通過血液傳播疾病的蚊子，為什麼不直接消滅人羣中的瘧疾呢？

如果這一努力獲得成功，它將大大減輕瘧疾給肯尼亞衞生系統和經濟造成的負擔，同時也將向世界展示中國在非洲的善行，甚至可能有助於改變當地人認為中國製造的商品藥品質量低劣的觀念。不久前，中國超過了美國成為非洲最大的貿易伙伴，其在非洲的年投資總額也在過去15年裏從5億美元翻了60倍達到了320億，中國與非洲的科學和公共衞生部門的合作將向世界表明，中國向非洲提供的遠不止於道路、火車和貨物。

中國國內至少從1981年就開始就採用羣體藥物干預與其它辦法相結合的方式對抗瘧疾；去年，中國本土沒有發現新增瘧疾病例，這可能數千年來的第一次。但是羣體藥物干預在科學和倫理方面不乏爭議。有人擔心它將導致抗藥性不斷提高，使瘧疾病發率陡增到幾十年來未見的水平。還有人認為把抗瘧藥物給沒有感染的人或者不希望服藥的人是有悖倫理的，儘管肯尼亞等國的當地人並不理會這種顧慮。美國的政策制定者也面臨類似的困境，他們在討論如何回應正在興起的反疫苗運動。中國的官員、研究人員和慈善家似乎並沒有這方面的擔憂，肯尼亞的官員也是如此。

伯恩哈茲·奧古圖（Bernhards Ogutu）醫生數十年如一日地在肯尼亞醫學研究所研究瘧疾，他贊同中國的抗瘧方式。他告訴我，長期以來世界抗瘧工作“基本上就是在滅火”：等到人們已經得了病再治療他們。他預計，如果在肯尼亞部分地區採用羣體藥物干預以及其他類似手段，“我們可以在未來五年內徹底消滅瘧疾。”

瘧疾傳播途徑

瘧疾是一種使人虛弱的疾病，可以讓強壯健康的成年人卧病在牀長達數週，也是撒哈拉沙漠以南非洲地區兒童夭折的三大主要原因之一。得病的症狀包括髮燒、發冷、顫抖、肌肉疼痛和嚴重疲勞。

世界衞生組織稱，全球幾乎一半人口有得瘧疾的風險。每年有2.12億人受到瘧疾折磨，其中有43萬人病故——也就是説每天有將近1200人因此死亡。非洲的瘧疾病例佔全世界的90%，因病死亡人數佔全球的92%。

宋健平是廣州中醫藥大學熱帶醫學研究所副所長，該機構的羣體藥物干預研究獲得了中國政府資助，他表示非洲的瘧疾病例和死亡人數都有大幅減少的可能。他説：“問題不是我們沒有藥，也不是沒有治療辦法。問題還是出在觀念上。”宋健平認為光靠預防是不足以對抗瘧疾的，他補充道：“如果非洲可以全面推行羣體藥物干預，10年內瘧疾將不復存在。”

徹底根除疾病不是件容易的事：迄今為止人類只成功從地球上消滅了兩種疾病，天花和牛瘟。為非政府組織“國際人口服務”的瘧疾項目工作了20年的德斯蒙·沙瓦斯（Desmond Chavasse）表示：“羣體藥物配給是非常有爭議的干預手段。”但是它的好處在於一勞永逸。

中國不是最近才加入全球抗瘧之戰的。1972年，中國科學家屠呦呦發現了抗瘧疾化合物青蒿素，並研究出從青蒿類植物中提取青蒿素的方法，最終於2015年獲得了諾貝爾獎。在過去至少2000年裏，蒿都被用來治療發熱和其它與瘧疾相符的症狀。

中國科學家屠呦呦發現了抗瘧疾化合物青蒿素，並找到了它的提取方法。青蒿素是中國援非抗瘧工作的關鍵。

如今，青蒿素是世界上療效最好、應用最廣的抗瘧化合物，每年有數百萬劑青蒿素複方藥物（artemisinin combination therapies ，簡稱ACT）問世。一些幫助研製青蒿素複方藥物的中國科學家現在將注意力轉移到非洲的羣體藥物干預上。中國新南方集團總裁朱拉伊説，他個人已經在非洲的羣體藥物干預研究和實驗上投入了3億美元，並且公司正在和肯尼亞衞生部門協商，在該國港口城市蒙巴薩附近長期受瘧疾困擾的沿海地區對10000人試行羣體藥物干預。

但是與島國科摩羅的情況不同，許多肯尼亞內陸居民經常往來於沿海地區，這就造成一個問題：有些人在配給藥物的時候出城了，回來時血液裏帶着瘧原蟲，又把瘧疾帶回了當地。也有人擔心羣體藥物干預會導致瘧原蟲產生抗藥性。但宋健平説：“如果我們配給的劑量得當，行動迅速，就可以搶在抗藥性產生之前消滅瘧原蟲。

抗藥性已經威脅到了上一項偉大的抗瘧疾技術——蚊帳——所取得的成就。在1990年代，經殺蟲劑處理的蚊帳帶來一個突破，使世界範圍內瘧疾發病率穩步下降。沙瓦斯説，目前的問題在於“我們已經得到了蚊帳可能帶來的大部分好處。科學家指出，如果沒有新的殺蟲劑、藥物和治療手段，我們很快就會看到全世界瘧疾發病率再次增長。許多慈善家和投資人不願意投資羣體藥物干預，因為老辦法的成效是經過實踐檢驗的。“但是像現在這樣抵抗瘧疾，只會讓我們一直病着”，奧古圖説道。

在坦桑尼亞一間紡織廠裏，工作人員在檢查經殺蟲劑處理的蚊帳是否有破洞

肯尼亞政府數據顯示，該國70%的人口有感染瘧疾的風險，瘧疾帶來的破壞性遠大於疾病本身。“患瘧疾的人沒法工作。生產力下降了。如果患病的是兒童，就沒法去上學了，”肯尼亞國家瘧疾控制計劃的瑞貝卡·吉普圖伊（Rebecca Kiptui）説，“如果大家都病了，肯尼亞的經濟就遭殃了。”五年前，肯尼亞37%的門診是治瘧疾的。研究瘧疾對該地區經濟影響的學者表示，肯尼亞每年因病曠工的損失和治療瘧疾的費用加起來達到1.09億美元。

有些人擔心中國的新南方集團是想要分一杯羹，通過推廣MDA來提高它自己藥品的銷量。青蒿科技是新南方集團旗下眾多控股公司之一，2006年這家制藥公司的科學家發明了複方青蒿素抗瘧藥“粵特快”（Artequick），它於2009年被中國衞生部列為防治惡性瘧疾的首選藥物。2010年，它被中國商務部列為出口非洲的首選抗瘧藥品。但是沙瓦斯説：“這裏存在着根本性的利益衝突，為什麼一家中國的青蒿素複方藥生產商會去研究羣體藥物干預？要不要採用羣體藥物干預應當由研究瘧疾的學者説了算，而不是製藥公司。”

宋健平介紹，患者只需在患病24小時內服用兩次“粵特快”即可，療程短、費用低，毒副作用小，適合在非洲推廣

但奧古圖對這種觀點不屑一顧，他認為中國這樣做的背後沒有什麼不可告人的動機。他説：“我們生活在陰謀論中，彷彿什麼事背後都有一些隱秘的計劃。”在新南方集團的案例中，前面提到的擔心似乎有些牽強：抗瘧藥不像抗生素和專用藥物，它幾乎不賺錢，青蒿素類抗瘧藥一片僅售幾分錢。

新南方集團抗瘧行動迫使我們考慮一種可能性，那就是像朱拉伊這樣的中國億萬富翁可能真的是大公無私的，就像已經投入20億美元對抗瘧疾的比爾蓋茨夫婦等西方慈善家一樣，驅使他們的都是利他主義。如果非要説兩者有什麼不同，那就是新南方集團還有一部分動力來自民族自豪感。上個月，曾參與尼日利亞羣體藥物干預項目的彭喜亮在他位於肯尼亞首都內羅畢的辦公室中對我説：“我們想把中醫藥推向全球。”

許多西方人和非洲人對中醫藥的熱情並不高。在中國參與非洲事務這件事上，有種流行的觀點認為中國製造是有缺陷的、便宜的、劣質的，甚至是假冒的。新南方集團的抗瘧行動也遭到了類似的指責。2014年，美國哥倫比亞廣播公司新聞網在報道中對新南方集團的新藥“粵特快”提出了質疑，儘管構成這種複方藥的三種藥物成分都經過了充分的研究，在全球防治瘧疾行動中廣為應用，並且被研究人員認為是治療瘧疾的有效方法。

2014年CBS關於中國在科摩羅抗瘧的報道，文章稱人們需要“數月乃至數年，才能相信中國找到了真實、安全、持久的方法來治療這個致命疾病。”

圍繞此事的爭議和科學關係不大，主要是意識形態的分歧：消滅瘧疾乃至醫療衞生事業究竟是社會事務，還是個人事務？

部分美國家長不給孩子接種麻疹疫苗，毫無來由地擔心疫苗會導致自閉症，我的一些中國和肯尼亞的朋友都對此感到非常震驚，並質疑接種疫苗為什麼不是強制性的。在把衞生視為公益而非個人權利的社會中，那種認為哪怕反科學甚至引發公共衞生緊急事件也必須尊重個人自由的觀念顯得很荒謬。

而且，批評中國的人還忽略了一個現實，在非洲許多地方，通過科學解決問題已經變成了一種協作事務。2018年11月，中國科學院在內羅畢附近開設了首箇中-非聯合研究中心。中國和肯尼亞的科學家合作研究抗旱農作物，提高水稻產量，研發鎖水新技術改良土壤使其適合玉米種植。

中國的藥物為肯尼亞帶來了福音：這裏的藥店貨架上既有中國製造的青蒿素，也有瑞士諾華製藥公司的全球知名產品。自2003年以來，中國向肯尼亞政府捐贈了抗瘧疾和抗艾滋病藥物。吉普圖伊表示，她歡迎“任何符合我們需求的抗瘧合作伙伴”，無論他們來自“美國、中國、泰國，還是任何地方。”

“在公共衞生領域，”吉普圖伊説，“你要為最多的人做最多的好事。”

“人們需要一點時間來理解，”彭喜亮告訴我，不過“在非洲越來越多的人開始認識到中醫藥的好處。”

China Is Leading the Next Step in Fighting Malaria in Africa

In 2007, the Bill & Melinda Gates Foundation said it was committed to eradicating malaria across the globe. By then, it was late to the game.

That year, Chinese scientists working with a Chinese philanthropist and his company, New South, had already begun eradicating malaria from the small African nation of Comoros. Now they’re setting their sights on a more ambitious location: Kenya, the East African nation of nearly 50 million people.

As Western donors garner headlines for funding expensive, experimental malaria interventions, Chinese researchers are undertaking a far more tested approach. Called mass drug administration, or MDA, it involves giving antimalarial pills to every man, woman, and child in a given area all at once. Rather than kill off the world’s mosquitoes, which spread the disease by drawing blood from infected people, the thinking goes, why not simply wipe out malaria among humans?

If successful, the effort would ease the disease’s burden on Kenya’s health system and economy. But it would also showcase Chinese philanthropy in Africa, and may even help change the perception here that Chinese-made goods and medicine are of poor quality. Having recently surpassed the United States to become Africa’s leading trade partner, and with Chinese investment in Africa rising sixtyfold from $500 million to $32 billion in the last 15 years, Chinese cooperation in the continent’s science and public-health sectors may show the world that the country has far more to offer Africa than just roads, railways, and things.

China has employed MDA, along with other methods to fight malaria, at home since at least 1981; last year, for the first time in what is likely millennia, it saw no new native cases of the disease. But MDA is controversial for reasons of both science and ethics. There are concerns that it could lead to increased drug resistance, which could see malaria rise to levels not seen in decades. Others believe it’s unethical to give antimalarials to people who may not even have the disease—or who don’t wish to take them—though such qualms are dismissed in Kenya and elsewhere. Similar dilemmas are challenging U.S. policy makers as they debate how to respond to the rising anti-vax movement.

Chinese officials, researchers, and philanthropists seem unworried by these concerns—as are some Kenyan officials.

Dr. Bernhards Ogutu, who has spent decades studying malaria for the Kenya Medical Research Institute, welcomes the Chinese. For too long, he told me, the world has been “basically firefighting”: waiting until people become sick with the disease, then treating them. He predicted that by using MDA and similar methods, in some parts of Kenya, “we can totally eradicate malaria in the next five years.”

Malaria is a debilitating sickness that can make strong, healthy adults bedridden for weeks and is one of the three leading causes of death for children in sub-Saharan Africa. Symptoms include fever, chills, shaking, muscle aches, and severe fatigue.

According to the World Health Organization, almost half the global populationis at risk for malaria. Each year the disease afflicts 212 million people and kills 430,000 of them—nearly 1,200 deaths each day. Ninety percent of malaria cases and 92 percent of deaths occur in Africa.

Song Jianping, deputy director of the Institute of Tropical Medicine at Guangzhou University, which receives funding for its MDA research from the Chinese government, says those numbers could be drastically lowered. “It is not like we don’t have the medicine. It’s not like we don’t have the methods. The hurdle is the wrong perception,” he says. Fighting malaria through prevention is not enough, Song adds. “If the whole [of] Africa can run MDA, in 10 years, there will be no malaria.”

Eradicating the disease won’t be easy: Humans have only succeeded in wiping two diseases—smallpox and rinderpest—from the face of the Earth. “Mass drug administration—that’s a very controversial intervention,” says Desmond Chavasse, who for two decades has worked on malaria initiatives for the NGO Population Services International (PSI). But the appeal “is that the result is there for generations.”

China isn’t new to the global fight against malaria. Chinese scientist Tu Youyou discovered the antimalarial compound artemisinin, in 1972, and figured out how to extract it from the Asian sweet wormwood plant, eventually earning her the Nobel Prize in 2015. For at least 2,000 years, wormwood was used to treat fevers and other symptoms consistent with what we now know to be malaria.

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Today, artemisinin is the most effective and widely used antimalarial compound in the world, with millions of doses of artemisinin combination therapies (ACTs) given out each year. Some of the Chinese scientists who helped develop ACTs are now shifting their attention to using MDA in Africa. New South, the Chinese company whose CEO, Zhu Layi, says he has personally spent $300 million on MDA research and experiments in Africa, and his company is in talks with Kenyan health officials to do an MDA test run among 10,000 people on the country’s Indian Ocean coast, near the port city of Mombasa, where malaria is endemic.

But unlike those living in Comoros, many on the Kenyan mainland regularly travel or commute around the region, which poses a problem: People who are out of town when the drugs are administered might return carrying the parasite in their blood, reintroducing malaria to the area. There is also concern that the MDA approach could result in the malarial parasite building up resistance to the drugs used in the treatment. But, says Song: “If we can manage to give the correct dose, and do it fast, then we can kill the parasites before they develop resistance.”

Already, resistance is threatening to undermine the gains made by the last great antimalarial technology: bed nets. In the 1990s, the advent of the insecticide-treated mosquito net led to a breakthrough that resulted in a steady decline of malaria around the world. The problem is that “we’ve already harvested most of the benefits you can expect to harvest” from nets, Chavasse says. Without new insecticides, drugs, and treatment methods, scientists say we’ll soon see an increase in malaria worldwide. Many donors and investors are hesitant to invest in approaches like MDA when older methods have worked in the past. “But the current way of doing this is just going to keep us sick,” Ogutu said.

In Kenya, where 70 percent of the population is at risk for malaria, according to government data, the devastation of the disease goes beyond the sickness itself. “People who get malaria are not able to go to work. Your productivity goes down. If you’re a child, you will not be able to go to school,” says Rebecca Kiptui, of Kenya’s National Malaria Control Program. “If everybody falls sick, then the Kenyan economy would suffer.” Five years ago, 37 percent of all outpatient treatments given in Kenya were for malaria. Taken together, lost work hours and the cost of treating patients for malaria amount to $109 million a year, according to researchers who studied the economic effects of the disease in the region.  

Some worry New South, the Chinese company, may be trying to get a piece of the pie—that its MDA campaign may in fact be a ploy to increase sales of its own medicine. Among New South’s vast holdings is a pharmaceutical wing whose Chinese scientists in 2006 invented Artequick, an ACT that China’s Ministry of Health approved as the “drug of choice” for treating malaria in the country in 2009. The next year, Beijing listed Artequick as the preferred malaria drug for export to Africa. But Chavasse says “there is a fundamental conflict of interest for why a Chinese ACT manufacturer would be carrying out a research project on mass drug administration.The thought needs to be driven by malaria academics—not by drug companies.”  

But Ogutu dismissed the idea that Chinese endeavors must have some ulterior motive. “We live in a conspiracy—that there’s some hidden agenda,” he said. In New South’s case, those fears seem misplaced: Unlike antibiotics and more specialized drugs, there is little money to be made from malaria treatment, with artemisinin-based malaria meds selling for just pennies per pill.

Rather, the company’s campaign to eradicate malaria forces us to reckon with the possibility that Chinese billionaires such as Zhu might be driven by the same altruistic intentions that drive their Western counterparts—philanthropists such as Bill and Melinda Gates, who have spent more than $2 billion fighting malaria. If anything, New South’s secondary motivation isn’t only profit, but also pride. “We want to promote Chinese medicine to the globe,” Ethan Peng, who worked on New South’s MDA efforts in Nigeria, told me last month from his office in Nairobi, Kenya’s capital city.

Many in the West and in Africa are not enthused. Amid popular narratives about Chinese engagement in Africa is the assumption that Chinese-made products are faulty, cheap, subpar, or fake. Similar accusations have been directed at New South’s malaria-eradication campaign. A 2014 report by CBS News questioned the use of New South’s new drug, Artequick, even though it’s a combination of three drugs that are well studied, widely used to fight malaria globally, and deemed by researchers to be an effective treatment for malaria.

The real debate may have less to do with science than it does with ideology: Is malaria elimination—or for that matter, health care in general—a societal affair, or an individual one?

Several of my Chinese and Kenyan friends alike are astounded that some American parents refuse to vaccinate their children against measles out of a disproven fear of autism, and question why people even have that choice. The notion that individual liberties should be respected even when they refute science—to the point of creating a public-health emergency—seems ludicrous in societies where health is treated not as an individual right, but as a common good.

Moreover, such criticism ignores the reality that, in many parts of Africa, solving problems through science has already become a collaborative affair. In November, the Chinese Academy of Sciences opened its first-ever research center in Africa, near Nairobi. Chinese and Kenyan scientists work together to create drought-resistant crops, increase rice yields, and develop new methods for trapping water in the ground to better grow maize.

Chinese medicine has been a boon to Kenya: Pharmacies here carry Chinese-manufactured artemisinin alongside more globally recognized products from the Swiss pharma corporation Novartis, and since 2003 China has donated malaria and HIV drugs to Kenya’s government. Kiptui says she welcomes “any partner in malaria as long as they line up with our needs,” be they from “America or China or Thailand, or wherever.”

“In public health,” Kiptui says, “you do the greatest amount of good for the greatest amount of people.”

“It takes some time for people to understand,” Peng told me. But “in Africa, more and more people are getting to recognize that Chinese medicine is very good.”