The Fever: How Malaria Has Ruled Humankind for 500,000 Years (35 page)

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.
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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.
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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.
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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,
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the World Health Organization shifted its statistical estimation techniques, with the result that their estimate of the global malaria burden fell by 50 percent.
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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.
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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!”
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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.

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.
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The African continent as a whole loses roughly $12 billion a year due to malaria.
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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.
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Local people in Africa call the companies “oil mosquitoes.”
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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.
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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.
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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.”
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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.
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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.
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In the case of Bioko Island, international funders have been asked to step into the predicted vacuum.
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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.”
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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
.
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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.
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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.
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“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.
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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.”
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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.”
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Crichton aired his views when asked to testify at a congressional hearing on malaria.
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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.’”
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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.”
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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.
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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.
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Disbursing more than $9 billion for global health research between 1998 and 2008,
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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.”
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