The Fever: How Malaria Has Ruled Humankind for 500,000 Years (36 page)

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.
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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.
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Indeed, the Institute of Medicine’s review, while agreeing with all the objections WHO outlined, concluded that IPTI was worthwhile, nevertheless.
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The World Health Organization’s Arata Kochi, a fierce freethinker who took the helm of WHO’s malaria program in 2006, was not pleased.
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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.”
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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.
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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.
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“The barbarians have taken over,” explained another. “The people who don’t really know what they are talking about.”
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“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.”
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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.
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Roll Back Malaria, the United Nations, and others quickly signed on, issuing reports and holding press conferences on the new goal.
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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.
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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.
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Twenty million of Africa’s one hundred and ten million children under the age of five sleep under treated nets.
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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!”
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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 cannot afford into the cornerstone of our malaria treatment.”
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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!”
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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.”
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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.
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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.”
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While we debate, and argue, and haphazardly collect our strength to fight malaria, the parasite refines its plague upon us. Unlike us,
Plasmodium
does not reenact failed strategies and weak defenses, its historical memory shot. The evolution of its predation is progressive, methodical, probing.

Plasmodium
may have evolved a fifth species to prey upon humankind. In 2008, researchers found that more than a quarter of a sample of one thousand malaria patients in Malaysia harbored something altogether unexpected:
Plasmodium knowlesi
, a parasite previously believed to be confined to monkeys. As booming, tree-felling human populations increasingly intrude into monkey habitat, experts suspect, they’ve offered themselves as a new blood source for
P. knowlesi
to exploit. The parasite has already been found in humans in Thailand and China. Whether it will make its rounds into the rest of the malarious world remains unknown. For now, its victims must hope
for quick diagnosis and prompt treatment. With the shortest life cycle of any malaria species,
P. knowlesi
can unleash tremendous masses of parasites rapidly.
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Chloroquine-resistant falciparum parasites have arrived on the doorstep of the global economy. As drug traffickers and others ply the Caribbean’s cerulean waters on their way to the Panama Canal, they stop at the remote beaches that fringe the Panamanian coast, where Kuna communities live much as they have for centuries, untouched by road or rail. When an especially virulent strain of malaria broke out there in 2003, the Panamanian authorities couldn’t do much about it. The dissolution of the global eradication campaign and the political neglect of malaria that followed had seen spending on mosquito control in Panama drop from $1.20 per capita per year to just 19 cents.
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In 2005, the coastal Kuna paddled their dugout canoes through miles of jungle until they arrived at Chepo, just outside Panama City, for a meeting of Kuna leaders. They strung their hammocks alongside their Kuna brethren who lived there. Every night, Chepo’s plentiful mosquitoes feasted on their blood, and then flitted over to the next hammock and bit the locals, too. In the morning, the Chepo Kuna, especially the young ones, who are eager to abandon the old ways, went off to their jobs in the pizza parlors of Panama City, where their warm bodies jostled with those of the tourists, from Michigan and New York and Essex and Rome, discharged from the cruise ships anchored in the canal.

The entire economy, it is said, would have to break down in order for malaria to resettle in developed nations such as the United States. And yet mosquito-borne West Nile virus and Japanese encephalitis have spread unchecked. In 2002, California had a single case of West Nile virus; in 2003, there were three, according to the Centers for Disease Control. By 2004, there were 779 cases nationwide; in 2005, 873. In 2008, there were more than 1,300.
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The economy survives, despite it.

The U.S. economy tolerates, too, those pockets of humid, neglected anarchy where
Plasmodium
builds its strongholds, such as the drowned cities of the South, deprived of electricity and order in the wake of the 2005 hurricanes. Malaria parasites continually shower upon the nation. Between 2005 and 2006 more than three thousand people in the United States fell ill with malaria picked up from West Africa, Asia, and elsewhere.
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Every now and again, the local mosquitoes start to transmit the parasites to people who’ve never broached a U.S. border. Between 1957 and 1994, American mosquitoes infected seventy-four people in the United States with malaria.
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