by Alex Perry
In April, a global malaria conference is held at Wilton Park in southern England, which is when I am first made aware of the campaign. Malaria, I quickly realize, is persuading the business world to behave in unusual ways, and I spend a hectic few days interviewing as many of the delegates as I can by telephone from South Africa. Richard Feachem, then the executive director of the Global Fund, tells me he is noticing “there is suddenly an increasing number of more visionary and worldly CEOs and chairmen. They say: ‘We may have some direct corporate interest in engaging in all these matters.’” This emerging corporate conscience is all to the good, says Feachem, but what “sustains it, what’s the engine of it” is self-interest. “If a big corporation has operations in malarious areas, it gives them a very tangible and direct self-interest to do something about the disease,” he explains. “If you do nothing, two things happen: the expat staff die in significant numbers, and the local workforce, who are semiimmune, they don’t die, but they have episodes that keep them from work.”1
Some businessmen are finding malaria so compelling they are quitting their day jobs. Peter Chernin has. “As a businessman,” he said at the September 2008 malaria meeting in New York, in what subsequently turned out to be his last year at News Corporation, “I firmly believe that no other cause offers the same potential return on investment as malaria.” Scott Case, founder of the discount travel website Priceline.com, has also resigned from his company to become the new CEO of Malaria No More. Case says he finds the ambition of the campaign interesting. But the real attraction is in “how it’s being accomplished,” allowing him to continue behaving as an entrepreneur but one who now directs his energies at public health rather than personal wealth. He describes the fight against malaria as the dream start-up. “I know of no greater place that you can invest great energy, and have such a profound impact than malaria.” It is, he says, “a perfect opportunity.”2
As malaria’s profile continues to rise, Chambers’s campaign stays on schedule. By now I have persuaded Chambers to let me shadow his campaign, wherever it takes him, and August finds him traveling through Tanzania with WHO head Margaret Chan and Tachi Yamada of the Gates Foundation. Chambers is exactly halfway through his campaign and halfway through his nets. Revised population figures for the seven focus countries mean the campaign now has to cover not six hundred million but seven hundred million people, an increase that demands an extra 50 million nets.3 But Chambers is still on track: the latest figures from his office show 182 million nets have been delivered, just over half of his new total of 350 million.
But there are problems. A recession in the West has cast doubt over future funds. American Idol has cancelled the 2009 “Idol Gives Back” for the same reason. Chan and the WHO are distracted by the possibility of an H1N1 flu pandemic. And despite the Global Fund’s stated commitment to spend $1.62 billion on malaria, it is being slow to hand out the money. Alan Court, accompanying Chambers, says the Fund is taking an average of eight months to make good on a grant application it has approved. A grant of $111 million to Tanzania has been delayed for a year for want of a single signature on a single document.
As Chambers, Chan, and Yamada tour hospitals and clinics across Tanzania’s business capital, Dar es Salaam, they hear a single message: give us more money. Health Minister David Mwakyusa tells Chambers the health system is woefully underfunded. He says Tanzania is dealing with ten million to twelve million cases of malaria a year and sixty thousand to eighty thousand malaria deaths, a burden that costs it 3.4 percent of GDP. He adds that the average Tanzanian has to walk five to ten miles to reach a health clinic, and there is one doctor for every thirty thousand Tanzanians. At Amana District Hospital, Alex Mwita, manager of the country’s national control program, tells Chambers malaria cases there have dropped from 35 percent of illnesses in children to 7 percent. He believes his country can distribute the 21.8 million bed nets it requires to achieve universal coverage by the end of 2010. But not without more money. “It might be terrifying, but the bottom line is that our program requires more than half a billion dollars to beat malaria, and the entire health budget for the country for next year is $400 million.”4 For the years until 2014, he estimates the funding gap at $447 million.
In public, Chambers projects unwavering confidence. “We are witnessing something that will never again happen in our lifetimes: a disease that has been around for thousands of years is going to be brought under control,” he tells Mwita.5 In private, he is irritated by the constant demands for cash. “The Global Fund is cutting back. The WHO is making a new focus of health systems. The bubble of $3 billion a year—those days are over. This $447 million they want? They’re not getting it.”6 He is also frustrated by the Fund’s slowness in sending out the cash and uses his trip to embarrass the organization. In speech after speech, Chambers hails the “new” $111 million grant from the Fund. The Fund gets the message. Within days it pays up.
The holiday island of Zanzibar, which has a population of a million, has all but eradicated malaria. But Tanzania still doesn’t feel like the focus of a frenetic, global multibillion-dollar health campaign. There is no sense of urgency. Chambers’s meetings drag on. There is a disturbing amount of self-regard and intellectual showiness. Reading my notes, I realize I have summarized one speech as a meaningless sequence of aid-speak: “Capacity, resources, diversity, mission, stakeholders, targets, partners, decentralization, goals, investment, challenges, public-private partnerships, bridging the gap, Madam Chair, all protocol observed.” 7 More disturbing, the fresh tiling on the floor, the new paint on the walls, the framed photographs commemorating earlier visits by George Bush and Nancy Reagan, all suggest Amana District Hospital is a showpiece, that this is all a performance. I’m not the only one becoming suspicious. “Are we seeing this because the minister is here?” asks Chan, peering into a spotlessly clean dispensary.
Outside a reception for Chambers at a five-star hotel on Dar es Salaam’s waterfront, Court runs me through where the campaign stands in each of the seven target countries. Despite the delays and the lack of haste, he thinks Tanzania can still make it. Ethiopia, after a malaria epidemic in 2003, has become the campaign’s big success story and a striking example of how a good African government needs cash but little else: twenty million bed nets have been handed out in three years, and malaria deaths are down by half already. South Sudan, not yet independent and ruled by a rebel army rather than a government, is the big surprise: all their bed nets are already out, largely because millions of southern Sudanese receive food from aid agencies—a ready-made distribution network easily adapted to nets. Court says he is also optimistic about Nigeria. “The country had 3 percent bed net coverage. But they’ve had several massive distributions, and now the World Bank country director is complaining coverage is only 60 percent, so they’re doing a second wave now.” Such a result in Africa’s most populous country, and one of its most chaotic, is a real boost. “Talk about suspension of disbelief,” says Court.8
But elsewhere there are problems. Kenya, which had been doing well, is now slipping. The country erupted in tribal violence after a general election in December 2007, when President Mwai Kibaki refused to accept the opposition’s victory. After months of negotiations, Kibaki and opposition leader Raila Odinga agreed to share power—Kibaki remained president, and Odinga became prime minister—but the new government is paralyzed by internal fighting and the effectiveness of the health ministry has suffered. Kenya’s last four applications to the Global Fund have been rejected for their poor quality.9 The country now faces a shortfall of thirteen million nets and a possible malaria epidemic: not only are there no new nets for villages that have never had them, there’s also none for villages whose old nets have worn out. That lack of replacement nets could be a disaster. Millions of Kenyans whose immunity to malaria has never developed or has dropped away because they have been dutifully sleeping under nets are about to be naked before the disease. It is an approaching humanitarian calamity.
<
br /> In the DRC, the campaign has barely started. Two million bed nets have been handed out in the capital, Kinshasa, and another 1.5 million in a single province, Equateur. But that leaves 29 million nets to go in a country five times the size of France with a few hundred kilometers of paved road, a place where the entire population of seventy-one million people can expect to contract the disease at least once a year, and a hundred eighty thousand people will die of it. Phone calls and emails to the DRC’s dysfunctional government go unanswered. Chambers can’t get a meeting with the shy and reclusive young Congolese president, Joseph Kabila, despite a visit to Kinshasa by Court. The Health Ministry does at least have a national plan to fight malaria. But the $962 million dollar “Plan Stratégique 2009–2013” extends way beyond Chambers’s timeframe and has less than half—$440 million—of its funding in place. It is also, in any case, little more than a copy of the “Plan Stratégique 2007–2011,” just with the dates changed. Even worse, many of the most malarious areas in the east of the country have, for much of the past year, been consumed by fighting between rebels and the Congolese army. Court tries to be upbeat. “The DRC is doable,” he insists. The two net distributions completed were efficient, he notes. Funds scheduled for later years can be sped up. Chambers will one day get to Kabila. “It’s an enormous country with an enormous need, and there are gaps,” he says. “But it’s not overwhelming.”10
The biggest worry is Uganda. In the early years of the Yoweri Museveni presidency, Uganda was an aid and development darling. But as Museveni entrenched himself in power, his regime has become ever more corrupt. In 2005 Uganda received its grant from the Global Fund. Then it stole it. Three former health ministers and officials from several aid groups are now being prosecuted for corruption running to tens of millions of dollars. In the years since the scandal, the Global Fund has refused to entertain applications from Uganda and has suspended the disbursement of existing grants worth a total of $367 million. Under pressure from Chambers, the Fund has just agreed to begin releasing money again in two tranches: the first to pay for seven million nets, the next to pay for ten million. But now a new row has erupted that is delaying those seven million nets: Uganda is insisting on nets of a particular thickness, made by an African company. Given Uganda’s recent history, there are suspicions of kickbacks. Unsurprisingly, Uganda is where Chambers is going next, and since I’m also heading there, to Apac, he offers me a ride and the chance of a chat.
After the serenity of overflying the Serengeti, we arrive at Entebbe airport in the evening and walk straight into a press conference. It’s a weird idea—asking Chambers, Chan, and Yamada to talk about Uganda and malaria before they’ve even cleared immigration—but it’s clear that for the Ugandan health minister, Stephen Mallinga, protocol demands a few speeches. “This is a very special occasion for us,” says Mallinga. Since the minister seems fuzzy on names, Chan—looking tiny next to Mallinga’s goliath frame—introduces herself and then uses the occasion to go on the offensive. “Three hundred and fifty people are dying from malaria here each day,” she says. “For a government not to take action is irresponsible. The government must come up with a strategy. What are you going to do?”11
Mallinga beams.
A reporter asks Chambers why the delegation has come to Uganda. Chambers tries flattery. “One of the reasons we came to Uganda is that we love Uganda,” he says. “Over a hundred thousand children die annually from malaria in Uganda, and they are the most beautiful girls and the most good-looking boys.”
Mallinga is still smiling. Then he turns to Yamada and introduces him as “someone who represents Gil and Belinda Gates. A very important person.”
Yamada, unprepared, talks briefly about successes elsewhere in malaria—Zambia, Rwanda, São Tomé and Príncipe, and Ethiopia—then hands back to the minister, who concludes the press conference with these words: “Western medicine is much more advanced than African medicine in the treatment of malaria. The question was asked: why are you coming to Uganda? It’s because we are the source of the Nile. There is something about the source of the Nile which draws visitors to Uganda.”
It’s not a promising start, and it gets worse. The following morning Uganda’s malaria community—aid workers, government officials, funders—meets at the offices of its national malaria program in Kampala. Mallinga is a no-show, as is a host of other organizations. Joaquim Saweba and Peter Mbabazi, respectively Uganda coordinators for the WHO and Roll Back Malaria, make a round of introductions so long that Chan interjects: “Cut my part! Cut my part! Go to the others.”12
Then the presentations begin. These focus not on what has been achieved but, worryingly, what might be. By the end of 2010, says Mbabazi, gesturing to a PowerPoint chart that projects total success on every measurement of malaria, Uganda could have scored 100 percent across the board. Injecting a note of balance, he notes that Apac has the highest rate of malaria transmission in the world and Uganda has problems with treatment, diagnosis, and health management and frequently runs out of drugs and nets. Immediately a fight breaks out between Mbabazi and the NGOs, who accuse Mbabazi of being too negative.
Then it is time to hear from the visitors. Yamada goes first. “It’s not clear to me what the actual numbers are, though what’s obvious is there is a substantial gap here. What does surprise me is that if there are three hundred fifty deaths a day, or a hundred thousand a year, that would place 10 percent of all world deaths from malaria in Uganda. That is surprising and alarming.”
There is an awkward silence. Saweba pipes up: “Maybe you forget to tell us what we can expect from Bill and Melinda Gates?” The room erupts in laughter.
Chambers is next. “I will be candid,” he says. “We have roughly fifteen months. And we have 17.6 million nets to distribute. The relationship between Uganda and the Global Fund has not been good. You have to have tunnel vision here. You must recognize that the house is on fire. The first 7.2 million will not get ordered until August 31. That means they’re not likely to be here until December. The distribution won’t be done until the end of February, and the Global Fund will not have the evidence it needs to approve the second tranche until February. Does that give you enough time to place an order for the next 10 million nets and get them out? You do not have time to waste, especially with a child dying every five minutes. You just have to get this done.”
There is another uncomfortable silence. Then it is Chan’s turn.
“Your targets are terrible,” she says. “You do not want to deliver. Why are you sitting here talking? How many children are dying as we sit here? Are you even thinking of achieving the 2010 target? If not, we can close the meeting and say good-bye. I count twenty-three organizations in the room. That means some of them haven’t even turned up. Why are your measurements not up to date? What are you doing here? Think about whether this country will miss you if you disappear tomorrow. If not, that means you are not doing anything to help them. Malaria is a low-hanging fruit. If you cannot even reach out to pick it, I will close the WHO office here.”
Chan finishes. Nobody wants to speak. So Chan continues. “You are all silent. Are my comments falling on deaf ears?” More deadening silence. Chan begins to lose her composure. Angrily, she brushes away a tear. “We will hold you to account on behalf of the three hundred fifty women and children who die every day here,” she croaks. “I’ll be calling you every week.”
Graham Root, who represents a group called the Malaria Consortium, responds by first asking for the media—me—to be ejected, saying my presence is inappropriate. When the request is ignored, he tells Chan he agrees with “70 percent” of what she says and welcomes her enthusiasm. But he adds the WHO needs to clean itself up before it can think of attacking others. In Africa, he says, the WHO is “very political, run by African health ministries as a retirement fund for civil servants.”
Later, as we tour a health clinic in the village of Bulima, a fleabitten truck-stop on the main highway just outside Kampala, Chambers is st
ill fuming. “It’s delay, delay, delay,” he says, “and it pisses me off, and it pisses off the Global Fund. And the one thing you don’t do after the history Uganda has with the Fund is piss off the guy with the money. The ministry of health is pissing around with what type of net.” “The lack of urgency is striking,” I say. “But where is the lack of urgency?” replies Chambers. “We have a hundred thousand people dying every year. How much more urgent does it get?” Court joins in: “It’s so stupid. They’re bottom on our list of countries. And in many ways, they’re much more capable of doing this than a lot of the others. It’s not that they can’t do it. It’s that they are screwing it up.”13
Our convoy out of Kampala has only soured the mood. We are in fifteen SUVs containing a legion of suited officials and four security vehicles in which are a company of soldiers and another of police. We drive at breakneck speed, flashing lights, sounding horns and sirens, forcing other cars off the road and scattering pedestrians. At Bulima, Chan examines the clinic’s records. “Everybody recovered!” she exclaims sarcastically. “How amazing!” She asks the meaning of the ticks next to each name. A woman in a suit and diamond earrings peers at the book. “It means everybody was treated within twenty-four hours,” she declares. “Amazing!” repeats Chan. It’s too much for one clinic worker, Augustine Kyagulanyi, who breaks ranks. “We do not have medicine,” she blurts out. “We are waiting for that. And we are not yet trained. And we do not have bed nets, or any spraying. We just send people to other health centers.”
We roar through forests and over steep green hills to a second village called Balibaseka. Somehow the convoy has grown: we are now thirty-one SUVs, nine minibuses, five sedans, and an ambulance—a giant procession now carrying thirty-five smartly dressed officials, eighteen soldiers, and fifty policemen. We arrive at the village school. A crowd of thousands has been assembled. The school children perform a play about malaria, with a teacher giving a commentary on a PA system:There is a woman coming with her child. She is really suffering. There are a lot of mosquitoes. She is really confused. Ah, sorry! She leaves the child. The baby is crying because there are a lot of mosquitoes. The mother does not want to leave the baby. She comes back. A lot of mosquitoes. Ah, sorry! Two angels come with nets for wings. What to do? They are going to take the child and put it under the net. Wow! That’s good. Now the mosquitoes are not hitting. Wow! They are really happy. That’s why they dance, because they are happy. They are still happy. They are still happy. They are still happy. Because the mosquitoes are gone.