The Fever

by Sonia Shah

  There wasn’t much interest on the part of international antimalaria financiers in any of this, however. The world’s biggest funder of aggressive attacks against disease, the United States, had all but written off the notion of helping African countries with anything. “It is highly unlikely that most African countries will obtain external assistance or investment on anything approaching the scale required for sustained economic development,” a CIA report noted in 1965. Nevertheless, as one National Security Council staffer put it at the time, “substantial increases in U.S. foreign assistance expenditures [to Africa] are not envisaged.”4

  African development could have constrained malaria’s spread regardless, but over the course of the 1970s and ’80s, the forward progress of the continent reversed. The global recession of the 1970s hit newly independent African economies hard, and by the mid-1980s, the World Bank and IMF had taken over the $1.3 trillion in debt they and other developing countries had accrued. The World Bank, which had become the developing world’s single largest source of healthcare financing, considered free public health programs a thing of the past, and so required debtor countries to decentralize their health services and encourage privately run clinics and hospitals to sell health care to those consumers willing to pay.5 In Zaire, more than eighty thousand clinicians and teachers were fired under World Bank and IMF strictures in a single year. In Zambia, within just two years of such programs, infant mortality rose by 25 percent while life expectancy dropped from fifty-four to forty years.6 In newly crowded African cities, nascent basic services crumbled. Vegetation started to grow in the cracked concrete of urban slums, and residents set out their empty vats and bins to collect rainwater.

  Malaria, long known as a disease of the countryside, started to conquer urban slums throughout Africa in the late 1980s.7 A 1988 flood in the city of Khartoum, for example, set off a malaria outbreak with more than twenty-five thousand cases.8

  The human immunodeficiency virus exploded in this malarious hotbed, reaching epidemic proportions by the 1980s.9 AIDS was like a nuclear bomb to malaria’s slow poison. For years, infectious disease experts noted the geographic overlap of the two diseases. It wasn’t until the late 1990s that scientists started to understand how malaria may have facilitated the spread of HIV, and vice versa.

  HIV-positive people are most infective to others when the levels of virus in their bodies are high, which is why HIV treatment that reduces the viral load also slows the virus’s spread. With each logarithmic increase in viral load, the probability that an HIV-infected person will transmit the virus during sexual intercourse increases by nearly 250 percent.

  Malaria triggers just such spikes. Malaria infection, by inducing HIV to replicate, increases the viral load in HIV-infected people by nearly one log. HIV infection likewise makes its victims more susceptible to malaria. According to mathematical models, since 1980, HIV may have been responsible for 980,000 episodes of malaria, and malaria responsible for more than 8,000 HIV infections, in a single district of Kenya. The global effect of the malevolent partnership between the two pathogens has yet to be mapped.10

  Overwhelmed with the AIDS crisis, WHO excused ailing African governments from any official responsibility to do something about malaria, calling for the dissolution of government-led antimalaria programs in 1992.11 An increasingly untameable malaria in Africa became essentially a private affair. Sufferers could seek out a few doses of medication if they wanted to, or find their way to a clinic if they had the cash.

  Many years passed before malaria reemerged in the public mind.

  Two new antimalarial weapons appeared on the scene. Like DDT and chloroquine, both were easy to use, relatively inexpensive, and relied on the potency of chemicals. One was the ancient Chinese remedy sweet wormwood, which after years of obscurity had been refashioned into cutting-edge artemisinin medications effective against chloroquine-resistant parasites. The other was the humble mosquito bed net, doused with insecticides. In experimental trials in Gambia, researchers found that if meticulously used, insecticide-treated bed nets could slash child mortality from malaria by 20 percent.12

  Artemisinin drugs and treated nets filled public health officials with hope. “We have enough knowledge, skills and tools,” the new head of WHO, Gro Brundtland, proclaimed in 1998, “to launch a new concerted effort” against malaria.13 The new international antimalaria campaign she sparked, called Roll Back Malaria (RBM), started with the World Bank and various UN agencies and soon grew to include celebrities, corporations, and top NGOs. Hosting conferences, press briefings, concerts, and antimalaria projects, the campaign hoped to inspire a new social movement among donor countries and NGOs to help stanch the bloodshed from malaria.

  A new fight against malaria was on. A score of philanthropic, charity, and aid groups formed in RBM’s wake, reaching deep into religious, entertainment, sports, and corporate communities. Some of the most powerful people in the world started new NGOs and philanthropic organizations dedicated to saving Africans and others from malaria, from Microsoft founder Bill Gates, former presidents Bill Clinton and George W. Bush, and British prime minister Gordon Brown to U2 front man Bono, celebrated economist Jeffery Sachs, and News Corporation executive Peter Chernin. Together, they helped increase the annual kitty to fight the disease from a paltry $100 million a year in 1998 to over $1 billion in 2008.14 Along with the well-regarded Global Fund to Fight Tuberculosis, AIDS and Malaria and the Bill and Melinda Gates Foundation, there was Veto the ’Squito, a youth-led charity, Nothing but Nets, an antimalaria basketball charity, and World Swim Against Malaria.15 There was the business coalition’s Malaria No More, and Laifer’s Hedge Funds vs. Malaria, which launched an antimalaria Facebook campaign. Movie stars such as Ashton Kutcher started Twitter campaigns to raise money for malaria.16 The United States’s most popular television program, American Idol, devoted a special televised event to raising funds for malaria.17

  Within ten years of RBM’s formation, malaria had gone from being a forgotten, neglected disease to being the “latest in charity gift chic,” as The Guardian put it in 200718; the “hip way to show you care,” The New York Times added in 200819; a “cause célèbre,” CNN reported.20

  Many of the charitable individuals, philanthropies, and government agencies who help fund the new antimalaria movement promise far more than they eventually commit. In 2004, for example, though nearly $6 billion had been pledged to Roll Back Malaria, the organization had only $146 million to distribute.21 In 2009, the Global Fund to Fight AIDS, Tuberculosis and Malaria foresaw a $5 billion shortfall.22

  What this means is that to maintain its financial base, the new movement must continually court potential donors. This leads to certain difficulties. Malaria is nothing if not a complicated and difficultto-measure phenomenon. But donors want their charitable dollars to work their magic, not in ten years, not after some other complicated social transformation, but now. If such progress is not demonstrable, attention turns to more pressing matters, and the checks peter out.

  For the movement to maintain its momentum, the insoluble problem must become soluble; the complex, simple.

  The treated net, they say, is a simple, effective solution that will be readily adopted, so long as sufficient funds are available to buy and distribute them. One of Malaria No More’s signature campaigns involves enticing American schoolchildren to raise money to buy treated nets. One child, The New York Times reported, built a diorama of an African family in a hut using a pizza box and some Barbie dolls. In the skit she put on, the dolls tucked their little ones into bed with their treated nets. “‘She tucks it in, she says, “You’re safe now,”’” her mother noted proudly. “‘Kids get this in like ninety seconds.’”23 Which is, of course, the whole point. The disease and its dissolution must become comprehensible to a six-year-old in less than two minutes.

  “I have never, ever seen an issue that has greater civic power than malaria,” said Malaria No More’s John Bridgeland. “The individual literally can ste
p forward, make a contribution, buy a bed net and directly save a life.”24 The treated net is a “simple solution to a devastating problem,” CNN noted.25 By donating ten dollars, you can “buy a mosquito net to save an African child from malaria,” The New York Times wrote.26 The Muppets planned a new project to show African children how to use treated nets. “We will save many many lives indeed,” an advocate noted. “I just want to stress the extraordinary power of the net,” the filmmaker Richard Curtis said at a high-level antimalaria gathering. “For ten dollars people can buy something specific that can save someone’s life.”27

  Since ancient times, people have used netting to “catch fish by day,” as the fifth-century BC Greek historian Herodotus noted, and “creep under” by night.28 But twentieth-century malariologists hadn’t been particularly enthusiastic about using bed nets to repel malarial mosquitoes. Ronald Ross considered bed nets useful mostly for capturing mosquitoes, not repelling them. He’d make his servants sleep under old nets with a few holes in them in order to collect the engorged Anopheles in the net in the morning.29 Lewis Hackett dismissed bed nets as “a nuisance and an anachronism” that few would use carefully.30

  After all, many rural peoples in poor countries don’t usually sleep on beds per se, opting for mats on the floor. Sleeping within a tent of gauze is hot, too, an added unpleasantness in tropical climes. It’s a cultural practice in some countries, but primarily during the months when pest mosquitoes are biting. Elsewhere, families in malarious countries are not unlike my own in India, stringing up the bed nets for the foreigners, but reclining in the open air themselves.

  So while it’s true that sleeping under a treated net is simple and effective, it is so only in the same way that, say, physicians washing their hands before attending to their patients is simple and effective. A 2009 study in France, for example, revealed that less than half of hospital clinicians followed guidelines on keeping their hands clean, despite the 150-year-old insight that doing so saves the lives of their patients.31 Just because something is simple doesn’t necessarily mean that people will do it.

  Reaping the benefits of the treated nets depends on the cooperation of those who use them. And many don’t use them as directed, for a variety of complicated social and economic reasons. Anthropologists, reporters, and aid workers have documented how rural Africans handle the nets. They wash them, cleansing them of the insecticides that make them effective. They won’t bring their nets to treatment centers for reapplications of insecticide, because they don’t want to show their dirty nets outside the home.32 They refuse to hang the nets over their children. In Zanzibar, as one woman told a local reporter, people felt that the nets “can cause death to children and also cause infertility in women.”33 In Ghana, nets are used to create privacy, so children are considered to not need them. In Gambia, nets are considered expensive items too dear to bestow upon mere children.34 Elsewhere, the nets are rejected outright. In Ghana, according to malaria expert Philip Adongo, rural people don’t like to use insecticides in their homes.35 In Namibia, people prefer to use the mosquito nets for fishing.36 And they won’t tell distributors about any of these dilemmas. Anthropologists in Ghana, for example, found that “within the local culture it was considered unacceptable to complain about something provided at no charge.”37

  For all these reasons and more, according to a 2003 study, fewer than 17 percent of Africans who received treated nets actually hung them up over their sleeping children.38

  What’s more, the only insecticides deemed safe and effective enough for use on the nets hail from a class of chemicals called pyrethroids. The chemical industry launched pyrethroid insecticides back in the late 1970s,39 as synthetic versions of the natural insecticide pyrethrum, an extract from the chrysanthemum plant.40 African farmers along with agriculturalists around the world have been spreading pyrethroid insecticides on their cotton and rice fields for decades.41 Mosquitoes nurse their young amid the pyrethroid-treated crops, dispatching generations of insects impervious to the toxin. Scientists reported the first Anopheles gambiae that had grown insensitive to the killing action of pyrethroids in 1993, five years before Roll Back Malaria launched its pro-net program.42 Since then, pyrethroid-resistant mosquitoes have turned up across West Africa, and in the Central African Republic, Egypt, Kenya, Mozambique, South Africa, Sudan, and Zimbabwe.43 The treated nets have thus already started to fail in some places. In a 2005 study in Cameroon, Anopheles mosquitoes infected just as many kids using the treated nets as those using untreated ones. The expensive, high-tech insecticide-doused net became just another bit of mesh.

  As it turns out, the genes that allow Anopheles to circumvent DDT also enable it to rout pyrethroids. For these defiant mosquitoes, no insecticide will suffice, the malariologist Josiane Etang said in 2005. “We need a gun to shoot it so it will die.”44

  While privately, malariologists and others involved in the new antimalaria movement acknowledge the various difficulties associated with treated nets, very little of this gets mentioned publicly in the avalanche of press releases, brochures, and fund-raising appeals their groups issue. Most tend to focus myopically on the number of nets they’ve distributed—as if this figure were the most compelling one—rather than the number of nets actually used to good effect. “The malaria initiative is a really cool initiative,” said former president George W. Bush at a private 2009 event described by Politico.com. “It’s measurable. You get to measure how many nets that have been distributed. It’s easy to measure, and it’s easy to implement.”45

  Distributing treated nets is simple. A single volunteer can distribute hundreds from the back of a motorcycle, and doesn’t have to return with more for years. With newer insecticides, the treated nets can repel and poison mosquitoes for up to five years at a time. But equating distribution with use is like counting the bars of soap in the hospital ward rather than the number of clinicians with clean hands. It doesn’t tell you much about how many lives are being saved.

  It does, however, make the fight against malaria seem straightforward, as do claims that similar battles against malaria have steadily beaten back the disease in the past. Youthful, tall, and photogenic, the Clinton Foundation antimalaria activist Oliver Sabot spends his time jetting around the world advising African ministers of health and global business leaders who want to help the foundation end malaria. At a 2008 meeting, Sabot shows pictures of world maps in which each country that has ever experienced a touch of malaria is darkly shaded, with no regional distinctions. This has the effect of making it seem as if malaria once uniformly blanketed the entire globe save for the poles. All of Australia is shaded, instead of just its northern tip. All of the United States, instead of the bowl-shaped blot malaria actually put upon it. Then, in quick succession, he shows the map as it changes over time, as various countries beat back malaria. In one click, half the shaded countries turn color. Upon the next click, another quarter have turned. In his mythical scenario, all that is needed is one final click.

  Cue a new map: Africa, the final frontier. Sabot has pictured lines drawn across the continent, against which malaria can be held at bay, until the line is pushed forward and inward, and all the malaria in the world exists in one tiny puddle.46 It’s a depiction of malaria as a spill that has been methodically wiped away, rather than the tenaciously clinging tick it really is. It gives “an extraordinarily false sense of what we know,” remarked the retired WHO scientist Socrates Litsios, who witnessed the presentation.47 What it lacks in historical accuracy, though, it makes up for in political appeal.

  A similar bias toward political expediency as opposed to accuracy can be seen in the statistically questionable methods that antimalaria organizations often use to track their progress against the disease. Roll Back Malaria, for example, measures the effectiveness of its campaign by comparing the malaria burden in 2000, before their interventions began, to the malaria burden in 2010, ten years later.

  Malaria is a naturally fluctuating phenomenon tied to long-term
trends in climate, environment, and population movements. Measuring changes in malaria by comparing two distant points, regardless of what happens in between, is less than informative. Your results depend entirely upon what part of the cycle you’re on when you start counting. Start from a peak and end on a trough and you can create the illusion of an downward trend. Start from a trough and end on a peak, an upward one. When a delegation of representatives from Myanmar told the RBM organizers that they’d already witnessed precipitous drops in malaria deaths—before the campaign commenced—the organizers’ faces dropped, malariologist Andy Spielman says. Malaria had been beaten back, but RBM’s ability to claim success had been derailed. “Why couldn’t they just wait a year?” Spielman imagined them thinking.48

  Add to that the fact that during the same period during which RBM said it would slash the malaria death toll in Africa by half,49 the World Health Organization shifted its statistical estimation techniques, with the result that their estimate of the global malaria burden fell by 50 percent.50 Half of the world’s malaria disappeared, thanks to math. Finally, the most rigorous data is collected only once every five years, and then only during the dry season.51

  Antimalaria groups tout the flawed numbers, regardless. Not because they have some alternative understanding of their accuracy. Rather, large numbers of distributed nets and rapidly declining malaria numbers create a sense of methodical forward progress, in the five- to ten-year chunks ideal for fund-raising. It fuels the fight against malaria, but it drives the malaria scientists crazy. “It is just not right,” fumed Spielman, clenched fists raised. “It is just playing games! . . . This is science, you can’t just throw numbers around like that!”52

  Many of the most persuasive antimalaria leaders today believe that attacking malaria is not just a public health goal—it is a way to attack poverty itself. The leader of this school of thought is Jeffery Sachs, the economist famous for advising “shock therapy” in the 1980s and author of bestselling books on poverty. Since 2001, when Sachs co -wrote an influential paper detailing the economic burden of malaria, he’s argued in prominent magazines and newspapers that antimalaria work should no longer be seen as a public health expense but as an economic investment. Ridding Africa of malaria, Sachs says, will rid Africa of poverty, too.