Lifeblood

by Alex Perry

Once Phillips had proved his bona fides, he set about reforming the malaria world further. Like Chambers, Phillips saw no reason to abandon business methods. On the contrary, he saw every reason why aid would benefit from some business discipline. “The private sector is accountable, by pay, by bonus, by careers—all those make people directly answerable. But the biggest issue in Africa and development is executive capacity. And one of the biggest issues in global health is that there is no reckoning of performance. People aren’t measured. There are no metrics.”

  Phillips funded a study to discover the cost of handing out a bed net, which came back with the figure of 50 cents—far less than most NGOs were calculating and charging. Using economies of scale, he worked out a delivery program with the United States Agency for International Development (USAID) that pooled the purchase of bed nets for Nigeria, Ghana, Cameroon, and Kenya and negotiated a 50 percent bulk discount from the manufacturer. He rode around Mozambique for weeks in the cabs of Coca-Cola delivery trucks, trying to discover why they could get millions of bottles to the customer but not nets they were also given to hand out. (Answer: poor performance incentives. Coke’s drivers were paid to deliver Coke, not nets.) He raised $130 million from ExxonMobil for malaria research and health programs. That included $10 million to put toward a new $100 million venture capital fund that lent money to start-ups investing in malaria, like A-Z Textile Mills in Tanzania, a bed net manufacturer partnered with the Japanese manufacturer Sumitomo, which, within five years of being established, was employing seven thousand people. In Ghana, where incomes were higher than in most of Africa, Phillips discovered some people were willing to pay for their own nets, which signaled not only the existence of a nascent commercial market—and so perhaps an eventual end to the annual problem of funding—but reassured Phillips that in Ghana a bed net would be used properly. “There was no big ideological debate,” he says. “We were just trying to maximize the utility of what we were doing.”

  But this was an ideological shift. This, potentially, was how to lift the resource curse. The curse existed because neither governments nor companies cared enough about the communities in which resources were located. Both would build hospitals and schools—but more as a sop to conscience or an attempt to boost image than out of any determination to lift the population. And while it was true that only governments could fix something as big as a nation, a company that saw its fortunes tied to the wellbeing of the communities in which it operated was a company that would try to ensure resources benefited everyone. The traditional “exploitative” model of resource extraction in Africa, says Phillips, was “we go in, we take out, we leave problems. An attitude of: ‘That’s business. We pay our taxes. These other things are the province of government. It’s their job.’” ExxonMobil was changing that model. In its areas of operation, it was working alongside African governments to deliver health care. It was spreading wealth, evening inequality, assuaging anger. It saw its profits as linked to Africa’s development. Under Phillips’s guidance, the world’s worst disease was giving birth to a better business ethos. “Malaria is the centerpiece of a new philosophy,” says Phillips. “It opens the path to a completely new way of business.”

  ExxonMobil was big in Nigeria. Ghana, its neighbor, didn’t discover oil until 2007, and ExxonMobil was not involved. But the country had its own resource curse, one that went back centuries. And there too, malaria was the key to breaking it.

  During the seventeenth and eighteenth centuries, Ghana’s Ashanti tribe became one of the most advanced civilizations in Africa, with a king and an empire that took in much of West Africa. The kingdom was administered by a highly centralized bureaucracy in the Ashanti capital, Kumasi. Gold was the source of Ashanti wealth and influence—at the height of the Ashanti empire, the king was said to be able to call as many as five hundred thousand men to arms. Gold was even woven into the founding Ashanti myth. The kingdom began in 1701, it was said, when the high priest to Osei Tutu, the king of the Ashanti, called down a golden stool from the heavens.

  Perhaps inevitably, gold brought trouble. The Portuguese reached Ghana as early as 1470, drawn by legends that Ghana was the location of King Solomon’s Mines, and built forts along its powder-white beaches—what became known as the Gold Coast. Soon afterward, the English, the Dutch, and the Swedes also arrived and did the same. The Europeans fought among themselves and, as they vied for ascendancy, backed different sides in wars between Ghana’s tribes. The nineteenth century brought a series of conflicts, with the British in particular rapaciously pursuing Ghana’s natural wealth and the Ashanti defending their possessions. In a total of four wars, the British initially suffered heavy losses, then annexed the kingdom in 1896, then quickly lost their authority again when the British governor, Lord Hodgson, traveled to Kumasi and demanded to sit on the Golden Stool. Only after a three-month siege of Kumasi did Hodgson escape. The British claimed nominal rule afterward. But it was no coincidence that Ghana was the first country in Africa to win formal independence from Britain, in 1957.

  Free Ghana went on to become the world’s second largest exporter of gold, behind only South Africa. But the curse lingered. Foreign exploitation now came not in the form of colonialism but as Western corporate practice. Only foreign miners had the equipment to mine Ghana’s gold in bulk, and many continued their operations without interruption. The new independent government took first 20 percent, then 55 percent of the shares in Ashanti Gold, which ran Ghana’s main mine at Obuasi, an hour’s drive south of Kumasi. But none of the revenues—neither those received by Ashanti Gold nor the government—found their way back to Obuasi. “The way gold mining was done, the perceptions of the company, it was terrible,” says Steve Knowles, who joined the company in 2004. “We did a lot of damage. We took away people’s land. We were polluting the ground with chemicals from the gold extraction process, including cyanide. The open pits were just left like that. The communities would say we were taking things away but giving them nothing back, and we would answer: ‘But we give taxes and revenue shares to the government.’ But the community didn’t care about that. They wanted the money.”6

  Knowles was originally trained as an industrial hygienist. He began his career in 1970s South Africa monitoring noise, dust, and heat stress at a sugar plant in Natal (now KwaZulu Natal), South Africa. Part of his job was pest control—and in hot, humid Natal, that meant mosquitoes. In 1999, Knowles took a job working for the Australian mining giant BHP Billiton at a colossal new $1.34 billion aluminum smelter—then the world’s largest—they were erecting outside Maputo in Mozambique.

  The reason Knowles’s experience made him a good fit for BHP Billiton and Mozambique was the Lubombo Spatial Development Initiative (LSDI). The LSDI is an opaque name for one of the best health programs in Africa. It has its foundation in an agreement signed in July 1999 by South Africa, Swaziland, and southern Mozambique. The three countries declared their mutual interest in fighting malaria in an area bounded by the Indian Ocean and the Lubombo Mountains, a range of red earth hills that rise up from the plains east of Johannesburg and run five hundred miles north through the Kruger National Park and Swaziland to beyond Maputo in southern Mozambique, the most malarious areas of all three countries. The LSDI was created out of the realization that malaria ignored borders. Good programs in South Africa and Swaziland, for example, would never succeed if mosquitoes and people were still filtering in from Mozambique. Maputo province was divided into zones. Sprayers and doctors with treatment drugs moved steadily through these, south to north.

  This could have been a standard state health plan, but for one element. The LSDI agreement was specific that malaria was an economic problem. The disease was so endemic in Lubombo, the agreement read, “that no development could occur in the region if the burden of malaria was not reduced.”7 On the other hand, fixing malaria would be a boon to investment and tourism, and create jobs. As the area’s biggest business, BHP Billiton stood to be the campaign’s biggest beneficiary. That made it a n
atural host and funder for the LSDI, the more so since the company would be implementing its own malaria control program and the governments of Mozambique and South Africa were coinvestors in its plant.

  The LSDI began in 2000, run by Brian Sharpe of South Africa’s Medical Research Council. Knowles and BHP Billiton were Sharpe’s chief implementers on the ground. Within three years, the LSDI was recording extraordinary results. Measured from the 1999–2000 malaria season, the year before the program started, malaria nose-dived. In South Africa’s two border regions, KwaZulu-Natal and Mpumalanga, the incidence of malaria fell 99 percent and 86 percent by 2003–2004. In Swaziland it plummeted 90 percent. In Mozambique, parasite prevalence in children—the chosen measurement there—dropped from 60 percent to less than 10 percent. As the program continued, the results only got better. From 2000 to June 2007, in two areas of Maputo, the proportion of children who contracted malaria fell from 62 percent to 1.9 percent and from 86 percent to 12.6 percent. Meanwhile South Africa began marketing its St. Lucia wetlands wildlife park, previously the most malarious spot in the country, as “malaria free.”

  The LSDI worked, says Knowles, because it was run like a business. The key was marketing. He wasn’t trying to sell science or technical solutions. Like any good private-sector marketer, the LSDI was selling a better life. “We don’t say: ‘We’re spraying walls, we’re killing mosquitoes,’” says Knowles. “We say: ‘We’re saving lives. We’re creating jobs.’ A malaria campaign is a tedious thing—it’s the same thing over and over again. The exciting stuff is how it improves your business and your ability to live safely and comfortably.”

  In 2004, at the age of fifty-six, Knowles was asked by the now renamed AngloGold Ashanti8 if he could replicate his Mozambican success at Obuasi in the green hills of central Ghana. Like ExxonMobil and BHP Billiton, says Knowles, AngloGold Ashanti “had woken up to malaria.” None too soon, perhaps. As with oil, gold and malaria often overlap, and most of the twenty-two countries in which AngloGold Ashanti operated were malarious. By 2004, the company had reached the same conclusion as Phillips. “Malaria remains the most significant public health threat to AngloGold Ashanti operations in Ghana, Mali, Guinea and Tanzania,” read a company statement at the time.9

  Obuasi was a particular concern. Malaria was the biggest and most lethal disease in the town, accounting for 48 percent of illness and 22 percent of deaths at the mine hospital. That was blowing a big hole in the bottom line. The company calculated its hospital was seeing 6,800 malaria patients a month in 2005, 2,500 of whom were mine employees (out of a total workforce of 8,000). Even if each sick worker only took three days off, that was 7,500 shifts a month lost to malaria. To make up the shortfall, the company was employing 1,600 more workers than it needed. Treating sick workers was also costing it $55,000 a month.

  For Knowles, the chance to create a malaria program from scratch, and with a generous budget, was an opportunity to combine “all the best ideas and procedures from all the programs I had worked on.” As in Mozambique, Knowles reckoned malaria was a business problem and should be tackled as one. For too long, he says, malaria programs had been the preserve of scientists and academics, experts at investigating ways of stopping malaria in a lab but amateurs at applying their ideas on the ground. But it was precisely their dexterity in tough environments that had made companies such as ExxonMobil and AngloGold Ashanti the world leaders they were. “The aid guys, the UN guys, the academics, they sit in Geneva with twenty centimeters of snow outside and say: ‘If everyone uses a net, there will be no more malaria.’ Well, that’s true, but in reality people don’t go to bed from 6 PM and rise at 6 AM. It always takes a human element. To run a malaria control program in the developing world is the same as running a successful company there. It takes people like me. It takes implementers.”

  At Obuasi, Knowles decided, implementation would be total. To cover Obuasi’s population of two hundred thousand, AngloGold Ashanti would train 116 workers to spread out across the town and the surrounding area. They would spray each of the 139,000 buildings, including 36,000 houses, every five months. They would put up nets on every bed and screens on every window, and distribute repellents to every home. They would treat every piece of stagnant water with larvicide. And they would make malaria treatment drugs available to everyone. Knowles projected the cost, including wages, sixty spray pumps, eight trucks, and nine trailers, at $1.7 million a year in 2005 and $1.3 million thereafter. To save money, he offered to run the program from a disused mine building.

  The results were just as spectacular as Mozambique. Cases of malaria treated at the mine hospital fell from 6,800 a month in 2005 to 2,800 by the end of 2006 and 1,000 by the end of 2007. In the surrounding area, they fell from more than 10,000 a month to 5,000. The proportion of the workforce contracting the disease every month decreased from just under 25 percent to 4 percent. The cost to the company of treating malaria plunged from $55,000 a month in 2005 to $8,235 in 2010—itself a saving of $560,000 a year. Days off sick because of malaria plummeted from 6,983 a month to just 282, meaning the company could save another $5 million a year that it had been paying for extra labor to cover the gaps.

  Phillips had made the business case for malaria. Now Knowles had—twice—proved it. On March 12, 2007, Knowles presented his results to a private sector forum on malaria sponsored by the Global Business Coalition at the Brookings Institution, the renowned Washington think tank. In attendance were Chambers and Phillips, now an advisor to Chambers. “The results were astounding,” says Chambers. “And I remember Steve Knowles made this clear: this was about the economic interests of AngloGold Ashanti. It was in their interests to protect people. They could not tolerate so many absences due to malaria. You could see people file that away. ‘We shouldn’t have to be pushed to do this. We shouldn’t do it out of altruism. This should be part of our business plan.’”10

  AngloGold Ashanti’s transformation from Ghanian asset stripper to a partner in Ghana’s development was made official shortly afterward when it was appointed coordinator of the country’s national malaria program. For the Ghanian government, appointing a private-sector company made sense. It increasingly saw malaria in financial terms. “The total cost to our economy from malaria in 2007 was $760 million,” said the then Ghanian health minister, George Sipa Adja Yankey. “That’s 10 percent of our GDP.” The new job was also a logical extension of the work Knowles was already doing at Obuasi, where the data strongly suggested the program needed to grow. Knowles suffered his worst reversal in November 2006, when two thousand of Obuasi’s mine workers traveled to Kumasi for the funeral of a local chief. Outside Knowles’s operating area for the first time in months, eight hundred people had contracted malaria.

  With government support, AngloGold Ashanti applied to the Global Fund for a grant of $133 million, proposing to scale up the Obuasi model to the forty most malarious districts in Ghana, about a quarter of the country. The Global Fund agreed. In early 2009 AngloGold Ashanti became the first private company ever to be approved for a Global Fund grant. The transformation was complete. Business had become aid, and a national aid program was now run by a business. “Yeah, sure, a few people ask me: ‘Why are you doing this?’” says Knowles. “‘It’s not your bloody job. It’s the government’s job.’ But more and more people understand that what’s happening here is a fundamental shift.” Combining business and aid worked, says Knowles, because it worked for everyone. Ghana got to control malaria. AngloGold Ashanti got to cut its costs. And a small corner of Africa got to banish the resource curse. “After all those years when nobody liked us,” says Knowles, “now people love us. The hospitals are empty. The children aren’t getting sick seven or eight times a year. The housewives get a free pest control service. Obuasi has changed beyond recognition. It’s a great, prosperous, happy little town.”

  CHAPTER 6

  Levers of Power

  As business began to see the value in fighting malaria, so the disease also moved up gover
nment agendas. The shift began in 1993, when the World Bank’s annual World Development Report made the link between disease and economics when it quantified, for the first time, the relative burdens that different diseases placed on efforts by the poor world to develop. Malaria and tuberculosis emerged as far bigger constraints than other diseases. Christian Lengeler at the Swiss Tropical Institute says with that discovery, “the world was changed forever. For the first time, we had hard evidence of how important these diseases were, not just to health, but to prosperity and development.”1

  Still, it wasn’t until October 1997 that the World Bank, various UN agencies, and donor governments such as the US and Britain met in Washington to discuss how, after three decades of dormancy, they might revive efforts to fight malaria. Economists like Jeffrey Sachs and celebrity campaigners such as Bono and Bob Geldof were noisily demanding action on health in the poor world, and the world was gradually responding. The meeting decided to form the Roll Back Malaria Partnership to coordinate the international battle against the disease.

  Back then, few people had any idea of what that fight might look like. Lengeler did. The last bed net trial had finally wrapped in 1996, and Lengeler was asked to present the data in Washington. The results showed how powerful a tool the simple bed net could be. They also demonstrated the bigger the campaign, the better. And bigger, of course, meant money. In 1996, the WHO spent $9 million on malaria control and prevention in Africa. Even in 1999, the total funding for malaria around the world was just $33 million. After he presented his results, says Lengeler, the consensus at the meeting was “‘this is very convincing, this is what we need to do’ and an eventual $700 million was raised to fund the fight against malaria.”

  That first surge in funding was the foundation of what would later grow into a second global campaign against malaria. It had many elements. In 1999, the Millennium Development Goals made tackling malaria a priority. On April 25, 2000, at a meeting in Abuja, Nigeria, forty-four African countries, including nineteen heads of state, committed themselves to halving malaria deaths by 2010. Meanwhile, new malaria-specific charities, campaign groups, and fund-raising organizations sprang up with names like the Malaria Consortium, Against Malaria, Nothing But Nets, and Africa Fighting Malaria. Established aid groups began reviving or expanding their malaria programs.