by Alex Perry
Malariology was also staging a comeback. Bill and Melinda Gates set up the Bill & Melinda Gates Foundation in 1999, and by 2002–2003 they were giving out hundreds of millions of dollars a year to fund health projects in the poor world, with HIV/AIDS and malaria identified as priorities. Early on they invested in the development of new malaria drugs, cures, and preventions, setting up the Malaria Vaccine Initiative (MVI) to hasten work on discovering the secret of malaria immunity; the Medicines for Malaria Venture (MMV) to produce new antimalarial prophylactics and treatment drugs; and the Foundation for Innovative New Diagnostics (FIND) to develop more accurate and rapid testing for malaria and other diseases. Funding was suddenly available for studies into drugs, insecticides, vaccines, even fantastical-sounding ideas such as a microchip to diagnose malaria, 2 irradiating male mosquitoes to sterilize them,3 and interfering with mosquito sex lives.4 Brian Greenwood, who had left Africa after more than three decades for a position at the London School of Hygiene and Tropical Medicine, found himself on the receiving end. “Shortly after I arrived in 2000–2001, we got a grant from the Gates Foundation for $40 million,” says Greenwood. “And that was just the first. The next one was nearly $60 million. I thought I had one more job in me. I just hadn’t realized it was going to be quite such a big job.”5
Bill and Melinda Gates also drew pharmaceutical giants into the campaign. The heart of any drug company is its research and development laboratory, where new drugs are discovered and refined. But science is expensive, and since malaria is a poor-world disease, no company could justify spending hundreds of millions of dollars on developing drugs to prevent or treat malaria if it could not recoup the cost. That was something the world’s richest man could help with. Through funds like MVI and MMV, scientists at universities and research institutes were paid to develop new drugs or treatments. Once a breakthrough was discovered, the innovations were then passed to drug companies for refining and manufacturing into final products for which, since agencies like the World Bank and the Global Fund were now subsidizing them, there now was a viable market.
This wasn’t only about money for the drug companies. But as with ExxonMobil and AngloGold Ashanti, it was always about self-interest. The image and commercial prospects of big pharmaceutical companies in Africa had been damaged by two controversies at the turn of the millennium: less than ethical drugs trials in West Africa and the industry’s fight to prevent Africans from buying anyone’s HIV/AIDS drugs but their own. Tadataka “Tachi” Yamada, head of Global Health at the Gates Foundation, says he quit as head of research and development at GlaxoSmithKline when the pharmaceutical industry launched a legal case to prevent South Africa from using generic HIV/AIDS drugs. (The drug giants lost.) This was more than public relations could fix. Drug companies needed to remake their entire way of business. Occasionally manufacturing medicine for reasons other than profit was one way to do that. By the end of the decade, Merck was supplying Botswana’s entire national HIV/AIDS program with drugs for free and had given a potential new malaria treatment drug to MMV for no charge. GlaxoSmithKline was developing another malaria vaccine, which it was pledging not to patent but to share.
And still the campaign grew. In 2002, the Global Fund to Fight AIDS, Tuberculosis and Malaria was formed as a pooling body to act as a single collector and distributor of hundreds of millions, then billions, of dollars in Western government donations for the three diseases. In April 2005, the World Bank inaugurated a malaria program for the first phase of which—campaigns in twenty countries over three years—it set aside $500 million. Then that June, President George W. Bush announced the formation of the President’s Malaria Initiative (PMI).
The story of how Bush came to plow billions into fighting malaria illustrates how the malaria campaign was founded as much on self-interest—even political expediency—as good intentions. By 2005, despite winning reelection, the Bush White House was painfully aware that history would judge it poorly. Iraq was a disaster, Afghanistan was another quagmire, and the scandals were mounting—Guantanamo Bay, Abu Ghraib, Fallujah, the rendition of terror suspects to foreign torture chambers—while the terrorist threat remained undiminished, as attacks in Bali, Madrid, and London showed. That same year Hurricane Katrina washed away what little credibility the administration had left.
Through it all, British prime minister Tony Blair had been a loyal ally. Blair’s stance was costing him heavily in Britain, where the war in Iraq was unpopular. Bush knew he owed Blair. He also knew Africa was a pet project for Blair and his finance minister, Chancellor of the Exchequer Gordon Brown. As early as October 2001, Blair had told delegates of the annual conference of his Labour Party that African poverty was a “scar on our consciences” that would “become deeper and angrier” if not healed.
In the run-up to a G8 summit in Gleneagles, Scotland, in June 2005, Blair declared he was going use his position as host to ensure the development of Africa headed the agenda. “Tony Blair was taking a major interest in putting Africa on the map at Gleneagles,” says a US medical expert with access to the White House at the time. “Britain was hosting the summit, and would run the show, and Blair was all about ramping up pledges for Africa.” At a previous summit, the G8 committed its members to making foreign aid 0.7 percent of GDP. But come early 2005, US contributions were just 0.17 percent, and in May, with the G8 just weeks away, Blair announced he would be visiting Washington. “The word was Blair was going to shake down Bush,” says the expert. “So Bush said: ‘We have to get ready for this. We are going to respond to Tony. He’s our friend, and we want to keep him as a friend. So what’s our response?’”6
Bush’s team said the US could not commit to raising its donations to 0.7 percent of GDP overnight. Such an increase would involve massive tax increases, the kind of raises against which Bush had campaigned in two successful elections. But, the White House staffers agreed, they needed to give Blair something. “They interviewed a whole bunch of experts in the public health sector,” says one of those who was called in, “and we told them: ‘In terms of a disease that is preventable and curable, it’s malaria. It’s doable. It does not have the political complications of HIV. Plus, this is already a rallying point for donors. The private sector is stepping up. The Gates Foundation is stepping up. This is a winner.’”7
The idea of a presidential push against a developing world disease had precedent. In 2003, Bush had set up the $15 billion, five-year President’s Emergency Plan for AIDS Relief (PEPFAR) to fund prevention programs and treatment drugs in Africa.8 Bush also agreed with Colin Powell that the roots of rage derived from inequality. Though his administration’s foreign policy is chiefly remembered for Bush’s tough-talking vows of vengeance after 9/11, and the subsequent invasions of Afghanistan and Iraq, military might was just one way Bush was trying to counter those who felt the US was an overbearing, overaffluent presence in the world. In Africa—no less suspicious of the US and viewed by the Pentagon as a rising security threat—Bush preferred giving to guns. By 2005, he had tripled overseas aid to the continent. When Blair arrived in Washington in May that year, Bush said he was going to double aid again—and this time, the focus would be malaria. As an initial step in what would become known as the President’s Malaria Initiative, Bush announced the US would spend $1.2 billion fighting malaria over the next five years by providing Tanzania, Uganda, and Angola with insecticide-treated bed nets, treatment drugs, and insecticide spraying.
Initially Bush concentrated on the how. As he left for Gleneagles in June, Bush said he was aware of the growing criticism of aid, and agreed with much of it. The pitfalls of creating “passive recipients of money” were evident. “Overcoming extreme poverty requires partnership, not paternalism. Economic development is not something we do for countries, it is something they achieve with us. . . . Without economic and social freedom, without the rule of law and effective, honest government, international aid has little impact or value. Economic aid that expects little will achieve little. Economic aid
that expects much can help to change the world.”9 Malaria, said the president, would be the arena in which the US would try a new type of aid. This time assistance would mean just that: available only to African governments who would, and could, run the show themselves.
Where the US president leads, others follow. Britain immediately announced another £200 million for malaria. German chancellor Angela Merkel formed the European Alliance Against Malaria (EAAM), a group of ten organizations to campaign and coordinate. “We went from a few million to billions,” said Lengeler. “It was huge.”
It was huge. But still it wasn’t enough. Sachs calculated the need for Africa alone at $3 billion a year. The new resources, unimaginable a few years before, were insufficient to cover that single continent for a single year, let alone the entire world for several years. Nor was everyone on board. Doubters included the then secretary-general of the WHO, South Korean Lee Jong-wook who, mindful of the failure of the WHO’s previous campaign, told a 2004 meeting of the Roll Back Malaria Partnership at the WHO’s headquarters in Geneva, according to one US health professional present: “Malaria is not a winnable war. This will be the world’s Vietnam, and the WHO will not get involved in any significant way.”10
After his January 2006 trip to Kenya, Chambers had cofounded his own malaria NGO, Malaria No More, with News Corporation’s then president, Peter Chernin. To Chambers and Chernin, the way to ramp up the campaign yet further was obvious: leverage. Moreover, two of the three elements of a Newark plan were already in place—political leadership and investment, whether it came from aid agencies or business—and as head of one of the world’s largest media companies, Chernin said he could bring the third. It was Chambers’s job to fit all three together.
But before the malaria world could perform in a triangle of leverage, it had to function by itself. And as Steven Phillips had already discovered, it did not do that well. Malaria lacked coordination. Despite the reforms Phillips had helped implement at Roll Back Malaria, the confusion had only worsened with the rising interest in the disease: the malaria world now comprised a bewildering sea of acronyms—WHO, RBM, PMI, EAAM, MMV—with equally mixed-up responsibilities. Suprotik Basu, then working for the World Bank as a health specialist, remembers how Chambers used his new NGO to convene “a meeting of a bunch of players in the malaria world to understand where the gaps were. The more he dug into the malaria space, the more he realized part of the problem was that malaria was really fragmented.” 11 Says Chambers, “It had become clear that we needed everyone to come together under one umbrella.”12
Chambers went back to the Newark plan: start with the politics. The single most influential political office on earth was being brought to bear in the fight against malaria, and Chambers wasn’t going to waste it. Chernin and Chambers arranged a meeting with Michael Gerson, Bush’s speechwriter, and Gary Edson, whose influence inside the White House was described by his many titles: deputy national security advisor, deputy assistant for international economic affairs, deputy national economic advisor, and chief US negotiator at the G8 summits, as well as founder of PEPFAR.
Chambers told the pair: “This is a wonderful opportunity to show the positive side of President Bush. Forty percent of the children dying in Africa from malaria are Muslim. Imagine if we could get together a united global effort to stop that.”
Gerson and Edson approved. They set up a meeting with Bush’s closest advisor, Karen Hughes, and again Chambers made his pitch.
“Could we have a White House conference on malaria?” asked Hughes.
“Could we make it a summit?” asked Chambers.
“Let’s make it a summit,” replied Hughes.
On December 14, 2006, in the fog and early snow of a Washington winter, Bush convened a White House summit on malaria. Held behind the grand colonnades of the National Geographic Society building, six blocks north of the White House, the list of seven hundred participants read—as it was—like a guest list at an unlikely arranged marriage. Representing aid and development was the then World Bank chief Paul Wolfowitz; Melinda Gates of the Bill & Melinda Gates Foundation; Ann Veneman, head of UNICEF; Richard Feachem, then executive director of the Global Fund; and the new Hong Kong–born director-general of the World Health Organization, Margaret Chan. On the other side of the aisle was the corporate West: managers from ExxonMobil, Marathon Oil, and Anglo American and a host of Wall Street, media, and Silicon Valley tycoons. Chaperones for this meeting of worlds were Bush, his wife, Laura, and Secretary of State Condoleezza Rice.
The matchmaking seemed to work. Aid and business flirted warmly with each other. Global Fund founder Richard Feachem singled out the LSDI in Mozambique for particular praise, calling it “Africa’s most successful malaria control program today.” The WHO’s Margaret Chan drew applause from businessmen in the room when she said: “As a United Nations agency, oftentimes we are criticized for being very bureaucratic, for being very insular. We need to take inspiration from [the corporate sector]. If a soft drink can get to the farthest corner of the world, why can’t our drugs and bed nets?”13
Steven Phillips repaid the compliment by making the reverse case: why aid was good for business. ExxonMobil had become involved in fighting malaria six years before, he said, because as a business it couldn’t afford not to. “When you look at a map of Africa and overlay the pattern of malaria intensity with oil operations, there is a striking confluence. It is a strange coincidence that where there is oil, there are mosquitoes. ExxonMobil is here today because our business presence in Africa caused us to witness firsthand the devastating health and economic impact malaria has had on our workforce.”
ExxonMobil had spent $30 million in six years and sixteen countries on advocacy, research, nets, drugs, and evaluation. In that time, just one ExxonMobil employee had contracted the disease. Phillips said he believed that showed malaria could be beaten and that business had much to offer the effort. Underlining why coordination was so important with malaria, he added that from working alongside African governments, the UN, and other aid groups as a partner in Africa’s development, ExxonMobil had discovered the best results were achieved when everyone worked together. “No one sector, government, or institution can solve the problem alone,” said Phillips. “But when we reach a similar position regarding a business opportunity, we share the risks and rewards by forming a joint venture. And what does that take? Organization. This parasite thrives on disorganized human systems. Conversely, it is defeated by collaboration.”
As Chambers hoped, the summit also offered the promise of more money. The World Bank’s Wolfowitz admitted: “In the first half of this decade none of us were putting sufficient priority on malaria.” Noting that was now being partially corrected by fresh funding from his organization, Wolfowitz added: “There is more coming.” The Global Fund’s Feachem also said his organization was ready to hand out billions more.
Bush spoke last. That a million Africans should die of malaria every year was unacceptable, he said. The US eliminated malaria nearly sixty years earlier. The disparity was intolerable. “We know exactly what it takes to prevent and treat the disease,” he said. “The only question is whether we have the will to act.”
For the first time, Bush also set out why malaria in Africa was a US priority. The president declared he had no choice. The US, and big business in particular, had a moral duty to offset the global inequality that their existence represented. Three times Bush repeated the phrase “To whom much is given, much is required.” Business also had much more to offer besides money, said Bush. The Gates Foundation was a “fantastic example of social entrepreneurship. It was caused to be because of fantastic business entrepreneurship. It is now using the business acumen, and the rewards of being smart, to fund unbelievable programs.”
And then in words that might have been written by Chambers, Bush added that if malaria weighed on the conscience of some, and prompted them to act, that was good. But fighting malaria was in the self-interest of all. “We’r
e sending a broader message about America’s purpose in the world. In this new century there is a great divide, between those who place no value on human life and rejoice in the suffering of others, and those who believe that every life has matchless value, and answer suffering with compassion and kindness. The contrast is vivid, and the position of America is clear. We will lead the cause of freedom, justice, and hope.... We also know that nations with free, healthy, prosperous people will be sources of stability, not breeding grounds for extremists and hate and terror.” Business had to understand that “it’s in your corporate interests that the people of Africa see that you’re willing to invest in the future of their countries.” The same applied to every US citizen. “By helping others the American people must understand we help ourselves. By making the world more hopeful, we make the world more peaceful.”
Chambers had pulled off the all-time piece of leverage. He had brought the biggest name in world politics together with the world’s biggest donors and corporations in front of the world’s media. It was the ultimate Newark triangle.
Notwithstanding the achievement, Chambers was disheartened. For leverage to succeed, the different elements have to work together. But inside the malaria world, the big players barely seemed to know each other, let alone be able to function in unison. Off camera, Chambers chaired a side meeting with the heads of the malaria NGOs and funders. One attendee mentioned her organization had made a large grant to help fight malaria in Nigeria; as far as she knew, no one else was aware of it. Feachem noted the poor quality of applications to the Global Fund from African governments, which meant only 20 percent were succeeding. Chambers exploded. “If all of you were in the for-profit world,” he intoned, “you’d be bankrupt. You can’t go on like this. You’ve got to get it together.”