by Nina Munk
“That’s wonderful!” enthused Sachs, standing up. “Here’s my card. E-mail me anytime with ideas. And let’s get that investor roundtable on the calendar, okay?”
Part Three
It just blows my mind how little money has been spent on malaria research. What has prevented the rich world from attempting this? I just keep asking myself, Do we really not care because it doesn’t affect us? Is that what it is?
—Bill Gates
Chapter 8
A Pipe Dream
Jeffrey Sachs likes to say that malaria represents the great divide between rich and poor. Illustrating the point to his students, he superimposes two color-coded maps: a map of the world’s poorest countries, and a map of countries with the highest burden of malaria. With few exceptions, the colored zones on both maps are nearly identical. The poorer a country, the more likely it is that its people will suffer from malaria.
In an academic article published in 2001, “The Economic Burden of Malaria,” Sachs and a colleague used cross-country regression analysis to show that even if you control for all sorts of other factors (economic policy, geography, life expectancy, initial poverty levels), countries with high rates of malaria grow substantially more slowly than do countries without malaria. There’s a corollary to this conclusion: as soon as a country has malaria under control, its rate of economic growth starts to increase.
It’s obvious, when you think about it, that a nation’s productivity and wealth can be sapped by malaria. The Italian government concluded as much a century ago. “Fever destroys the capacity to work, annihilates energy, and renders a people sluggish and indifferent,” a prefect for the Sicilian province of Girgenti wrote in 1908. “Malaria shackles the development of industry and agriculture.”
In the West, an all-out offensive against malaria-transmitting mosquitoes got under way in the early part of the twentieth century. To destroy their breeding grounds, government agencies started from the bottom up, draining swamps, wetlands, bogs, and marshes—anywhere that stagnant water accumulated. They dug canals and trenches and made certain that screens were installed on windows and doors. They distributed massive quantities of quinine, an antimalarial drug made from the bark of the cinchona tree, and of chloroquine, quinine’s synthetic substitute.
By the 1950s, malaria had been eradicated in the United States and most of Europe. In poorer countries it was brought under control in the 1960s, thanks to the chemical compound dichloro-diphenyl-trichloroethane, the insecticide better known as DDT. Between 1955 and 1969, the World Health Organization’s Global Malaria Eradication Program, underwritten with billions of dollars from the United States, established hundreds of DDT training centers in infected areas, distributed hundreds of tons of DDT, and sprayed and fogged millions of homes, inside and out. The program was a triumph. In India, for example, where malaria had killed 800,000 people a year, fatalities by the 1960s dropped to zero.
Following the publication of Rachel Carson’s widely influential book Silent Spring in 1962, however, DDT became suspect. It was poisoning the environment. The death of birds, of animals, and possibly of human beings could be traced to the widespread use of the pesticide. In 1963 the United States stopped funding the Global Malaria Eradication Program. Research grants dried up. Finally, in the 1970s, DDT was officially banned in the United States and most of Europe.
Meanwhile, the malarial parasite had developed a resistance to DDT, and also to the antimalarial drug chloroquine; in self-defense, it mutated into an even deadlier species. In some countries where malaria had been more or less eliminated—Sri Lanka, for example—the disease resurfaced. In sub-Saharan Africa, a region that had been bypassed by the Global Malaria Eradication Program, malaria continued to claim millions of lives every year. The hopeful goal of eradicating malaria worldwide was nothing more than a pipe dream.
“All you have to do is fly over the Amazon basin or go up the rivers of Surinam,” an epidemiologist told The New York Times in 1966. “How are you going to find the people to treat? There are 20,000 aborigines in Malaya. They live in lean-tos. They’re here one day; the next day they’re gone. Now how in hell are you going to eradicate malaria in people you can’t even find?”
By the early 2000s, malaria prevention was once again a fashionable humanitarian cause. Among its most ardent supporters were Bill Gates and his wife, Melinda, whose foundation has since then spent hundreds of millions of dollars to support medical research on malaria.
“It just blows my mind how little money has been spent on malaria research,” Gates told a reporter in 2005. “What has prevented the rich world from attempting this? I just keep asking myself, Do we really not care because it doesn’t affect us? Is that what it is?”
That same year, in a speech given at the World Economic Forum, in Davos, Switzerland, the president of Tanzania informed his listeners that countless Tanzanian children were dying of malaria. Suddenly the actress Sharon Stone stood up, reached for a microphone, and raising a clenched fist in a sign of solidarity, called on the audience to support the cause. “Just stand up! Just stand up!” she cried, tears welling in her eyes. “People are dying in his country today, and that is not okay with me.”
In a single decade, between 1997 and 2007, thanks in no small part to the Gates Foundation, global funding for malaria control soared, from almost nothing to nearly $800 million. No one was naïve enough to claim that malaria could be “eradicated”—the goal now was to “control” and “prevent” the spread of the disease. Roll Back Malaria, a new global partnership started by the World Health Organization (together with UNICEF and the World Bank), aimed to cut deaths from malaria in half by 2010. Thanks to the new insecticide-treated mosquito net developed by Sumitomo Chemical, there was good reason to believe that the timeline was realistic.
In contrast to older mosquito nets, bed nets treated with insecticide kill mosquitoes on contact. Study after study has shown their effectiveness: the distinguished Swiss parasitologist Christian Lengeler, one of the world’s leading experts on malaria control, has predicted that the number of malaria cases worldwide will drop by half once insecticide-treated bed nets are used by 80 percent of Africa’s population.
In more practical terms: distributing millions of mosquito nets to Africa’s rural poor is a complicated business. Imagine the logistics of packing, unpacking, sorting, and transporting enormously heavy sacks of bed nets to communities with no paved roads or no roads at all. (Lengeler reckons that the task of moving one million bed nets from one place to another is equivalent to the manual labor of two thousand men, each one pulling a fully loaded cart.) As well, there’s the very real problem of looting: safeguarding the mosquito nets requires precise record keeping and oversight, especially in the most remote rural districts. Warehouses have to be guarded. And someone has to teach a largely illiterate population to use the nets correctly.
Even if you ignore that catalog of obstacles, there’s the matter of cost. In 2007 some African shops were selling insecticide-treated bed nets for around five dollars apiece. Can anyone living on a dollar a day afford to buy a five-dollar bed net?
To Sachs, the answer to that question is obvious: you cannot expect poor Africans to pay for mosquito nets, just as you can’t expect them to pay for polio or smallpox vaccinations or antiretroviral drugs. In his Millennium villages, every household was already receiving insecticide-treated bed nets free of charge. With enough determination (and military precision), he argued, free bed nets could be distributed to every African in need. Refusing to donate bed nets to poor Africans is “unethical,” he added; it is “one of the shocking crimes of our time.”
But where would the money come from? Who was prepared to underwrite the cost of distributing 300 million bed nets in Africa? Those sorts of questions enraged Sachs: “The amounts of money we’re talking about are insignificant. I can’t tell you how small this is. I’ve got neighbors down the block from me in Manhattan who could do this without skipping a beat. Do you know what the C
hristmas bonus was on Wall Street this year? Twenty-four billion dollars! Do you know how much that is? That’s four billion bed nets.”
Repeatedly he’d point out to anyone who would listen that the cost of preventing malaria in Africa was equal to just “one Starbucks coffee a year” for every person in the rich world. On other occasions, he’d weigh the “truly tiny” cost of 300 million mosquito nets against America’s colossal military budget: “One day’s Pentagon spending could cover every sleeping site in Africa for five years with antimalaria bed nets.”
In the summer of 2007, Sachs headed to Tanzania’s biggest city, Dar es Salaam, to meet a group of influential foreign aid donors. His goal was to convince them to underwrite and distribute millions of mosquito nets in Tanzania, a country on the front line in the battle to prevent malaria. Every year epidemiologists count 250 million cases of malaria worldwide; 85 percent are in Africa, most of them in just five sub-Saharan countries, including Tanzania.
The big foreign aid donors had spent years developing a program to control malaria in Tanzania. It was a textbook case of what’s known in the trade as a “market approach to development.” Starting from the ground up, the donors had created a market for insecticidal bed nets. First they’d encouraged private manufacturers to convert failing textile factories into bed net factories. Then they helped six thousand shopkeepers and street vendors get into the business of selling bed nets. Finally they established a voucher program to subsidize bed nets, so that even the poorest Tanzanians could buy one for $1.50 or so, a fraction of the retail price.
There’s more: donors had to make sure that the treated mosquito nets were being used properly. Sometimes people hoard nets and then barter or sell them. Sometimes they use them to catch fish or to protect goats from mosquitoes. It may seem strange to outsiders that people at high risk of malaria have to be persuaded to use a simple, inexpensive device that may one day save their life. Then again, some people may not care deeply about a mosquito bite that may or may not kill them. In much of sub-Saharan Africa, just finding water to get through the day is enough to worry about without fetishizing mosquito nets. In her book The Fever, Sonia Shah argues that many Africans don’t take malaria all that seriously—they’re resigned to it. She compares a rural African’s view of malaria to the Western view of the common cold: an inconvenient but inevitable part of everyday life.
To convey the mortal dangers of malaria and to promote the use of bed nets, foreign aid donors in Tanzania spent years and millions of dollars on “social marketing”: handing out pamphlets, putting up posters in health clinics and schools, hiring theater troupes, and plastering the country with billboards. Zinduka! Malaria Haikubaliki!—Swahili for “Wake Up! Malaria Is Unacceptable!”—was one popular slogan.
And yet by 2007, despite the donors’ best efforts, no more than a third of Tanzania’s households owned long-lasting insecticidal bed nets. Even fewer people were actually using them. The reason Tanzanians weren’t using bed nets, Sachs assured the donors, was the prohibitive cost; even at the subsidized price of $1.50, the nets were far too expensive for poor Africans.
For Sachs, the market approach to development was wrong-headed: it was “simplistic free-market ideology.” “Malaria is not a market,” he informed the group of foreign aid donors in Tanzania. “It’s a pandemic disease and a killer. We’re not selling Buicks here—we’re trying to keep people alive!”
In his model Millennium villages, Sachs had witnessed at first hand the dramatic effect of handing out free beds nets: it stopped malaria in its tracks. He was sure that similar results could be achieved in Tanzania. The entire country could be covered with 15 million bed nets; at five dollars apiece, that would cost no more than $75 million. Taking into account the expense of setting up and implementing and following through on a program to distribute millions of bed nets all over the country, the cost to donors would be no higher than $200 million.
From the donors’ point of view, however, distributing hundreds of millions of bed nets to Africans for free would undermine self-reliance and create a “culture of dependency.” It was a “hand out instead of a hand up.” The program was unsustainable. “Giving away free bed nets is not development—it’s charity,” Julie McLaughlin, the World Bank’s lead health specialist for Africa, assured me.
In any case, where would the $200 million come from? “If you ask any of us if bed nets should be free, most of us would say, ‘Yes, absolutely,’ ” McLaughlin went on. “Health care should be free too. But there are choices to be made, and you’d think a macroeconomist like Jeff Sachs would know that.” Then, for good measure, she added: “Jeff’s a televangelist, which seems to go over with some people, but I don’t find him all that articulate or charming. And I don’t want to be lectured to.”
In the weeks leading up to his arrival in Tanzania, a flurry of e-mails sped back and forth between Sachs and the donors. The whole exchange was leaked to me. I counted fifty-nine e-mails, each one longer and more hostile than the one before.
Momentum built up until, at one point, so many people were being cc’d that at least fifty names appeared in the address field, including the regional or local representatives for all the big national development agencies (USAID, DFID, Irish Aid, Denmark’s DANIDA, Switzerland’s SDC, Germany’s GIZ, etc.); global health organizations (WHO, the Centers for Disease Control, the President’s Malaria Initiative, Roll Back Malaria, Population Services International); UN agencies (UNICEF, UNDP, UNFPA); multilateral agencies (the World Bank, the Global Fund, the African Development Bank); and major foundations (the Bill and Melinda Gates Foundation, the Clinton Foundation).
The donors regarded Sachs as an intruder; that became obvious to me. They didn’t like his ideas and they didn’t like his attitude and they didn’t like him. A representative for Germany’s GIZ (Deutsche Gesellschaft für Internationale Zusammenarbeit) went so far as to accuse “Sacks” (sic) of “harassment”: “With due respect to his renown[ed] reputation as [an] economist, I myself am a Senior Public Health specialist with 34 years of experience in Africa, and I believe [I am] entitled not to be treated like a young boy.”
For his part, Sachs was outraged that the donors refused to admit that their market approach to malaria was unworkable. In his e-mails he described it variously as “profoundly flawed,” “misguided,” “ill-advised,” “ineffective,” “inexcusable,” “completely ill-informed,” “not acceptable,” “outdated,” “mind-boggling,” and “shameful.”
The parasitologist Christian Lengeler took the lead in defending the donors. Point by point, his e-mails presented a case for retaining the status quo in Tanzania. Yes, he acknowledged, fewer people were using bed nets than the donors had anticipated and planned for; nevertheless, real progress was being made. Moreover, giving away millions of free bed nets would destroy the private market that the donors had so carefully built up in Tanzania. Local factories would be shuttered. Retailers would go under. And then, in four or five years, when all those free bed nets had to be replaced, where would the money come from?
“A mass net distribution on its own is not the best solution at this point in Tanzania,” Lengeler concluded. “On a final note,” he added, addressing Sachs directly, “I am not a policy maker and it is not my call to make decisions for the country. And neither is it yours.”
“Frankly,” Sachs informed Lengeler, in yet another mass e-mail, “I find your approach disreputable as well as economically ignorant.” International donors handed out free antiretroviral drugs to HIV/AIDS patients in Africa; why on earth wouldn’t they hand out free bed nets?
Sachs didn’t stop there: “One day’s Pentagon spending would provide for five years of comprehensive coverage for all of Africa. And you are worried about ‘sustainability’??!,” he wrote. “Get over it. You have everything upside down. The only true lack of sustainability is the millions of lives being lost in Africa as you dribble out bed nets in this ridiculous social marketing campaign.”
Chapt
er 9
Complacency and Fear
On Thursday, July 19, Sachs boarded his flight from Zurich to Dar es Salaam, where he would have forty-eight hours to make his case, in person, to the donors. Even before boarding the plane, he was agitated. At the gate he paced back and forth, like a caged animal. “Yah? Well, he’s a punk!” he yelled into his BlackBerry, referring to Lengeler. “He can go to hell!”
Ten hours later, standing in the aisle of the business-class cabin, waiting to disembark, Sachs was at it again: “These deaths are on your hands!” he shouted at a fellow passenger. It was Lengeler.
Lengeler was surprisingly calm. “You are stubborn,” he replied with a French accent.
“No!” insisted Sachs. “You’re the one who is stubborn—and people’s lives are in your hands.”
“You do not know the facts,” said Lengeler wearily.
“What I know is you’re letting people die!” Sachs went on in a rage.
“I do not need to be insulted,” said Lengeler.
Sachs wouldn’t let up. Passengers were trying to squeeze by him.
His wife, Sonia, intervened. “Come on,” she said urgently, taking his arm. “Let’s go.”
Sachs shook her off. He was red in the face and his hair was disheveled. Lengeler turned his back and walked away.
“Your actions are reprehensible!” Sachs yelled after him, getting in the last word. “I hope you know that!”
VIP Security Detail rushed Sachs out of the Julius Nyerere International Airport and into a black Mercedes (license plate STATECAR 10) with pale blue curtains and two small flags fluttering on its polished hood. Traffic going into the city was backed up for miles. Maybe it was rush hour or there’d been an accident. Looking out the tinted windows of the Mercedes, Sachs could see mopeds and rickshaws and rusted Toyotas and a packed dala-dala bus with JESUS LOVES YOU painted across the back. Pedestrians were threading their way around the stalled vehicles, followed by a line of schoolchildren dressed in bright pink uniforms. The air was heavy with exhaust fumes.