by Sonia Shah
Malaria is undoubtedly deeply implicated in poverty, as even a seven-year-old child ensconced in a mosquito net can sense, however inchoately. Malaria makes it difficult for farmers to reap their harvests, undermines investment in children, and diverts precious funds toward the purchase of treatments. In Malawi, for example, the average household loses more than three weeks of work to malaria, hemorrhaging over a third of its annual income on the cost of treatment and prevention and in lost workdays.53 The African continent as a whole loses roughly $12 billion a year due to malaria.54
Casting antimalaria work as an investment rather than an expense has undoubtedly broadened the pool of people willing to ante up for treated nets and new drugs. And yet, while Sachs and others have conducted widely cited studies on the correlations between malaria and poverty, none has been able to pinpoint a cause-and-effect relationship. Does malaria cause poverty, as they say, or conversely, is poverty responsible for malaria? If malaria is the trigger, as Sachs maintains, then banishing malaria should be like turning the tap on poverty. But what if it is the other way around, and poverty causes malaria? Then extracting malaria from a community—as in Sri Lanka and Sardinia—could leave scarcity and deprivation essentially intact.
The desire to support economic development is not the only motive driving the new antimalaria movement, though. Many businesses, government leaders, and philanthropists newly drawn to the malaria cause have stumbled upon malaria while pursuing other interests. Corporations want access to Africa’s natural resources. Government leaders want to diminish terrorism. Ideologues want to berate political enemies. The list goes on. All have found they can use antimalaria activism to help reach their goals.
Oil companies, for example, have been pursuing new petroleum resources in West Africa—where “oil-filled, undrilled . . . treasures await,” as one petro-exploration society put it in 2002—since the late 1980s.55 Local people in Africa call the companies “oil mosquitoes.”56 The oil hunt inevitably entangled those companies in an expensive fight against African malaria. In 2002, for example, Marathon Oil expanded its natural gas operations into Bioko Island, off the coast of Equatorial Guinea, and was forced to embark on a malaria-control program costing $12 million.57 ExxonMobil had faced a similar challenge earlier. In the late 1980s and early ’90s, while ExxonMobil developed new oil finds in Chad, its mostly foreign workers suffered a malaria rate of 20 percent, which ultimately cost the company around $13.5 million. (Each worker who fell ill with cerebral malaria, for example, had to be evacuated to the Netherlands, at a cost of $100,000 per case.) ExxonMobil eventually launched a $3 million malaria-control program.58 One in three workers at mining giant Billiton’s facility in southern Mozambique suffered malaria, even after the company built a medical clinic, sprayed the construction site, and handed out bed nets. “It was a huge disaster,” a spokesperson said. “If we didn’t treat malaria we could not operate.”59
Corporations’ efforts aimed at protecting their own workers naturally extend into local communities. Billiton says it could not protect its investment so long as malaria raged in the capital city of Maputo, just ten miles away, which is why it got involved in a regional antimalaria effort in 2000.60 While the companies and the local people thus share an interest in taming malaria, there are some notable distinctions. What matters most to the companies, says Spielman, who has consulted for some of them, is not “how many people are dying. What really matters is the entomological inoculation rate,” which measures how risky the environment is for outsiders. After five years of spraying insecticides, Marathon’s program reduced malaria parasites in local children by just under 50 percent. But sustaining the gain will require a longer financial commitment than the decade or so that oil and gas companies typically invest in new finds.61 In the case of Bioko Island, international funders have been asked to step into the predicted vacuum.62
As a result of these activities, both Marathon and ExxonMobil have become prominent actors in the international antimalaria movement, a role they publicize widely. On World Malaria Day 2007, Marathon took out a large ad in The New York Times to describe its efforts to reduce malaria on Bioko Island. The ad pictured the company’s director of corporate social responsibility, Adel Chaouch. “It’s been a life-changing experience—for me, and especially for the people of Bioko,” Chaouch is quoted as saying. “Leading by doing. That’s Marathon.”63 In 2008, ExxonMobil sponsored an antimalaria fund-raising television program launched by the wildly popular American Idol. “Its logo was even branded at the end,” noted a commentator for the Rochester City Newspaper.64
For the United States, support for the oil industry was only one part of the political and economic incentives that propelled the government to devote resources to the antimalaria fight in 2005. President George W. Bush had visited the continent in his first term in office, the first time a U.S. president had done so.65 In addition, Africa’s role in supporting the global terrorist network Al Qaeda—the network maintains a base in Khartoum, Sudan, and its leader, Osama bin Ladin, had called for jihad in Africa—had risen in significance after the terrorist attacks of September 11, 2001.66
“There are two reinforcing trends here,” one of Bush’s aides told The Washington Post, describing the motives behind the administration’s antimalaria program. “One of them is the upside of foreign policy moralism. Another one is the growing strategic significance of Africa: the conflict with radical Islam, the problem of failed states and terrorism, and the growing importance of Africa on the resource side: oil.” Accordingly, the first five African countries targeted by the President’s Malaria Initiative included oil-drenched Angola and Equatorial Guinea, along with copper-rich Zambia.67
For free-market conservatives, supporting the antimalaria movement helped score points in ideological wars. They’d long battled the environmental lobby’s push for more stringent environmental regulations. Under the theory that the enemy’s enemy is a friend, free marketeers have rushed to defend environmentalists’ totemic anti-hero DDT. The free-market economist Roger Bate of the conservative American Enterprise Institute, for example, is one of the most vocal defenders of DDT, which he lauds as “the single most valuable chemical ever synthesized to prevent disease.”68 Africa Fighting Malaria, the group Bate founded, is dedicated to promoting the use of DDT against malaria.
Their message—that by maligning DDT, environmentalists have the blood of malaria victims on their hands—has spread widely. “Banning DDT killed more people than Hitler,” the novelist Michael Crichton wrote in 2004. “And the environmental movement pushed hard for it.”69 Crichton aired his views when asked to testify at a congressional hearing on malaria.70 DDT is “the best thing in our arsenal,” the malaria activist Lance Laifer told The Wall Street Journal in 2006. “We need to have people walking around with signs that say, ‘DDT saves lives, environmentalists take lives.’”71 In 2007, Republican senator Tom Coburn blocked bills to honor the anti-DDT crusader Rachel Carson. He explained by linking his website to one called Rachel Was Wrong, which states that millions of people suffer malaria “because one person sounded a false alarm . . . Rachel Carson.”72
President George W. Bush, often accused by the environmental lobby of gutting environmental regulations, pointedly rehabilitated DDT in his antimalaria program. He publicly announced the pro-DDT program at the Hudson Institute, a neoconservative, antienvironmentalist think tank.73
The World Health Organization supported, managed, and oversaw the previous global movement against malaria. Critics may argue over how expertly it performed the task, but however one judges its technical leadership, its authority was both sanctioned by and accountable to the international community, that is, the 193-member nations of the UN.
The new global movement against malaria, in contrast, is led by private interests. Malariologists joke that the industrialized country alliance G8 should really be called the G9, to include the Gates Foundation.74 Disbursing more than $9 billion for global health research between 1998
and 2008,75 the foundation—not public health authorities—sets the agenda in antimalaria research. “It’s true,” re -marked the malariologist Brian Greenwood, “we are all doing what Gates says.”76
As a private entity, the Gates Foundation is not beholden to governments or international agencies. When push comes to shove, the foundation can even eclipse the public health authority of the World Health Organization.
Take, for example, an antimalarial strategy called intermittent preventive therapy for infants (IPTI), which calls for sporadic doses of preventive drugs for malaria. The World Health Organization routinely reviews scientific evidence on new methods to provide well-regarded guidance to public health authorities around the world. Public health agencies are not required to abide by WHO’s recommendations, but most do: it’s considered the standard of care. WHO reviewed the research on IPTI in 2007. Its scientific committee decided not to recommend the therapy’s use in antimalaria programs, because it didn’t alter mortality and it risked some serious side effects.77
The Gates Foundation had funded a host of research on IPTI, however, and felt differently—and so took the unusual step of asking the National Academy of Sciences’ Institute of Medicine to draw up another review to compete with and possibly undermine WHO’s.78
Indeed, the Institute of Medicine’s review, while agreeing with all the objections WHO outlined, concluded that IPTI was worthwhile, nevertheless.79
The World Health Organization’s Arata Kochi, a fierce freethinker who took the helm of WHO’s malaria program in 2006, was not pleased.80 In a leaked memo he complained that the Gates researchers were becoming a “cartel” of groupthink. “Each has a vested interest to safeguard the work of others,” he wrote. “The result is that obtaining an independent review of scientific evidence . . . is becoming increasingly difficult . . . and could have implicitly dangerous consequences.”81
The public conflict with the Gates Foundation proved the last public foray for Kochi. According to insiders, he was put on “gardening leave.” Although his name still appeared on WHO’s website as director of the malaria program, the outspoken director has been conspicuously silent and absent from malaria meetings since 2008.82
Expert opinion has likewise been arrayed against the Gates Foundation’s stance that the antimalaria movement should make complete eradication of malaria its goal, rather than just attempting to hold the scourge in check. Most malaria experts agree that with more resources, malaria could be eliminated from marginal areas, but that elsewhere, nothing has really changed from the 1950s. All the problems that stymied such ambitions in the past—Anopheles gambiae’s tenacity, population movements, resistance to insecticides and drugs, lack of community participation, poor statistics and worse surveillance, and persistent poverty—remain.
In the hallways of malaria meetings and in private conversations, the grumbling has been audible. “I’m appalled . . . They are making all the same mistakes again,” one malariologist said. “It’s amazing how we don’t learn about our own history, isn’t it?” another remarked.83 “The barbarians have taken over,” explained another. “The people who don’t really know what they are talking about.”84 “Go along with it if you want to get funded,” a malariologist said to The New York Times. But don’t sign on to anything unless eradication is tied to a date like 2050, he said, “or far enough in the future so that none of us can be held accountable.”85
Few have been brave enough to air their misgivings publicly.
Bill and Melinda Gates announced eradication as the new goal for antimalaria work in late 2007, at a private gathering. Kochi would almost certainly have scoffed at the notion, but the politically savvy WHO director-general Margaret Chan smoothly agreed. “I dare you to come along with us,” she told the crowd of skeptical malariologists.86 Roll Back Malaria, the United Nations, and others quickly signed on, issuing reports and holding press conferences on the new goal.87
As more money poured in, fund-raisers and donors started to act as if the hard part of the job had already been done. Said the rock star Bono, a prominent supporter and fund-raiser, at a gala antimalaria event in 2008:
I’d like to say that I’m not here as a rock star. Really I’m here as a fan. And I’m a fan of Malaria No More, what you two gentlemen have done is extraordinary. I’m a great fan of Africa, in particular. These leaders, incredible. I’m in their fan club. I’m a great fan of the physicians and the scientists who gathered on this problem. Bill Gates. He’s a rock star. Jeffery Sachs, all the people who have ganged up on the problem. People in Red who have campaigned for Global Fund money, it started with AIDS but now it’s malaria. It just shows the momentum. It just shows what’s possible when you match leadership with funding, a strategic plan. So I’m just going to shut up with that. And just say, what’s the next disease? Pneumococcal? Rotavirus? Because, uh, you know this malaria thing is extraordinary and it just shows what else we can do.88
• • •
The shameful resurgence of malaria in the 1980s and ’90s has, for now, been reversed. After a decade of effort, by 2008, sixty-seven countries suffering endemic falciparum malaria had formally adopted artemisinin combination medications as their first-line remedy for malaria, including forty-one of Africa’s fifty-four countries.89 Twenty million of Africa’s one hundred and ten million children under the age of five sleep under treated nets.90 Grants for scientific research on malaria have created a new generation of high-tech malariologists, who’ve brought experimental malaria vaccines into late-phase clinical trials.
The antimalaria movement may use hype, suffer conflicts of interest, and have a lack of accountability, but despite this it deserves credit. And yet, the uncomfortable truth is that ending malaria over the long term will require much more difficult social and economic adjustments in African communities, just as it has elsewhere. Infrastructure will have to improve. Settlement patterns and housing styles will have to change. Education and healthcare systems will have to be built.
Antimalaria activists know this. But it is not possible for them alone to transform African economies and cultures. The best they can do is offer partial, short-term solutions. That is, in the meantime, they can blanket the continent with treated nets and better drugs. So long as the charitable dollars keep flowing, lives will be saved—at least for now.
After all, the perfect need not be the enemy of the good. The question is how the short-term solutions impact the prospects for the long-term ones. Usually, something good today doesn’t reduce the probability of something better tomorrow. But in malaria, it can. When DDT was touted as a quick win, for example, and when donors promised the imminent arrival of a malaria vaccine, political will and financing for malaria research and other forms of malaria control fell by the wayside. Promised easy victories, political leaders lose the will to fight the long-term battle. And if the short-term solutions prove successful but are not maintained, malaria could resurge, just as it did in Sri Lanka in the wake of last century’s failed global eradication blitz.
This conflict over short-term solutions and long-term sustainability has yet to be adequately resolved. The U.S. antimalaria program, government malariologist Thomas Ritchie says, “is pouring obscene amounts of money” into quick fixes against African malaria, but it is spending little on supporting local antimalaria leadership or building antimalaria infrastructure. Plenty of African clinicians, scientists, and community leaders are dedicated to taming malaria, Ritchie says, but when the world’s richest country decides to help, “they give these people nothing, not a cent!”91
Donors such as the Global Fund offer two-year grants for countries to stock expensive new antimalarial drugs, but leave them with few options when the grants run out. “You cannot make public health policy based on two-year grants, however much money you are being given,” one critic complained to The East African. “What will happen when the same donors accuse us of corruption and withdraw funding? . . . We are essentially making a donor-supported treatment that we cann
ot afford into the cornerstone of our malaria treatment.”92
The conflict plays out in heated debates at international malaria meetings. At one, an official from the Nigerian Ministry of Health became engrossed in a long argument with a representative from the drug giant Sanofi-Aventis, which was at the time the sole provider of WHO-recommended ACT drugs. Finally she turned to me. “Write it in your paper,” she commanded. “We need to build African capacity to make treated nets and ACTs. That is the only way we can solve malaria. They don’t want to do technology transfer,” she said, motioning to the drug company rep. “They just want us to buy, buy, buy!”93
Although it publicly recognizes the need to build infrastructure in endemic countries, Roll Back Malaria has also stated that tackling the disease cannot be the responsibility of local governments. “If malaria control is left to governments to plan and execute,” RBM wrote, “malaria will not be controlled.”94 Which is, of course, exactly backward. It is the only way malaria will be controlled. And malaria-endemic societies have proven this over and over again, from when the Italians distributed quinine to their populace—and built the schools and clinics and roads they needed in order to do it—to when Malawi banned the sale of chloroquine and rid the country of chloroquine-resistant parasites.95
Somehow antimalaria work must unleash the technology, political will, and infrastructure in malaria-plagued countries to hold the line and sustain hard-won gains. One way or another, the schools, roads, clinics, secure housing, and good governance that enable regular prevention and prompt treatment must be built. Otherwise, the cycle of depression and resurgence will begin anew; malaria will win, as it always has. “You can do a lot of good with bed nets, with spraying,” says malariologist Tom McCutchan, “but in the end, you have got to give power to the people who are at risk.”96