Lifeblood

by Alex Perry

  In 2008, Chambers moved thirty-seven blocks north from the offices of Malaria No More to the new UN special envoy’s office, in reality Chambers’s own offices in the city. As he assembled his staff, Chambers reached out to Alan Court, a veteran aid professional with twenty years inside the UN who, at age sixty, was just finishing his contract with UNICEF. Court, a Briton, had begun his aid career in his mid-twenties, helping Bangladeshi volunteers inoculate the population of Dhaka against smallpox in 1973. He had since worked across Asia and Africa, often on malaria, and had also been UNICEF’s director of supply, a role in which he had sourced drugs, nets, and equipment around the world. Chambers’s methods appealed to Court—UNICEF had been the first large aid organization to introduce then–unheard of concepts like targets and deadlines in the early 1990s—as did the intellectual symmetry of returning to where he’d started three decades earlier: working on the eradication of a single disease. Says Court: “Joining Ray made sense. It was a good fit.”6 To Chambers, Court’s unparalleled knowledge and contacts would be a big advantage. He knew who supplied what to whom in the malaria world. He knew the aid community, UN lifers and donors. He knew NGOs and volunteers and health ministers in every country in which Chambers was going to be engaged. “Having someone who can operate inside that world like Alan can, and is respected, was going to be a huge asset—not least because it would take that burden off Ray,” says Basu.

  Other recruits included Tim Castano as chief of staff. Chambers knew Castano from New Jersey, where Castano had worked as a speechwriter for the governor after leaving college. Soon after 9/11, while still in his mid-twenties, Castano had been appointed special advisor at the New York and New Jersey Port Authority. As well as owning and operating the world’s largest airport network, the George Washington Bridge and the Lincoln Tunnel, the Port Authority owns the World Trade Center. In the years after 9/11, Castano’s day-to-day work focused almost entirely on the reconstruction of the site. Dry, neat, self-effacing, and obsessed by detail, Castano would later joke that the emotive and vexed task of rebuilding the World Trade Center was handy preparation for negotiating the byzantine logistics of flying a UN special envoy across Africa.

  The team was completed by Wendy McWeeny, who had advised Chambers for more than a decade at his foundation, and Sean Hightower, another New Jersey native, who took advocacy and media. After Barack Obama replaced Bush in the White House, Chambers also picked up several well-connected former presidential appointees as advisors, whom he charged with plumbing their contacts across the world. These included John Simon, former US ambassador to the African Union and ex-head of the US government’s Overseas Private Investment Corporation, which drove US business investment in developing nations, and Kristen Silverberg, former US ambassador to the European Union. John Bridgeland, known as “Bridge,” a lawyer and former assistant to Bush and director of his Domestic Policy Council, also became an advisor to Chambers and Malaria No More. The former head of PEPFAR, Mark Dybul, who had already helped lead a global fight against a developing world epidemic, also came on board to advise Chambers on strategy and, for a while, led the office as managing director.

  Unusually for a UN office, Chambers’s own foundation covered salaries and costs. Mostly he got whomever he wanted. “Ray could basically handpick his team,” says Basu. “I loved the Bank—it’s a pretty free place and you can say what you want—but in the end you march to the beat of the organization. With Ray, when he was trying to employ people, he would tell them: ‘The one and only job you have—and you have complete freedom in this—is to hit the target. You guys have the freedom and the mandate to crack this in two years. There really are no rules.’ To have the freedom to wake up every morning and know your one job is how to do better or more effectively at winning against malaria—very few people working on critical issues have that freedom or mental space. It was very different from traditional development.”

  The office atmosphere was also unlike any the new team had experienced. On Chambers’s recommendation, the team found themselves consulting regularly with management consultants McKinsey, just as a new business would. Chambers also encouraged an intellectual free-for-all. “We’d have these meetings and just throw around ideas and debate each other about malaria,” says Basu. “It’s not like we were a bunch of private-sector mavericks. But we took people who understood the value of free thinking. Ray is a very organic thinker, and he would empower us to think about doing things differently—and then encourage us to actually do it differently. It’d be: ‘Let’s try that? Why not?’ It was a start-up culture.”

  Chambers had his target, and he had his team. He was missing two things: a plan and money. Chambers decided both had to be in place to present to a global summit on malaria, which he had called for that year, on September 25, 2008, in New York and which was to be attended by twenty heads of state.

  To construct a plan, the team decided to break down the task of eradicating malaria into separate phases. Phase I, as already announced by Ban on April 25, was universal coverage: the distribution of a long-lasting insecticide-treated bed net to everyone in the world who needed one by the end of 2010. Phase II was the end of malaria deaths by the end of 2015. Once malaria was under control and no longer a lethal threat, Phase III would be the eradication of the disease from the planet—no more malaria, ever. That, it was reckoned, would take a couple more decades and probably require a vaccine.

  On the face of it, it was not a complicated plan. The technology to fight malaria was known, simple, and cheap. Universal coverage had two requirements: enough nets and good distribution. Achieving Phase II also looked simple on paper: ensuring nets were being properly used and the global distribution of diagnoses and treatment drugs. Even eradicating malaria was, in scientific theory, not hard. Vaccines were already undergoing late-stage trials. Even without them, sixty years earlier, Europe and the US had eradicated malaria by killing enough Anopheles with insecticide. Chambers liked to say that compared to other public health issues like HIV/AIDS or tuberculosis or international flu pandemics, malaria was “low-hanging fruit.”

  The problem wasn’t the plan per se. It was the scale of it. Walk into the clinic of any doctor who stocks malaria prophylactics, and he’ll show you a map of the world with the malaria hot spots colored yellow, orange, and red, according to risk. On the map, most of the tropical world—much of South and Central America, nearly all of Africa and Asia—is orange or red. In 2008, the WHO was estimating the total number of people potentially at risk from malaria at around half the world’s population: 3.3 billion people in 109 of the world’s 198 countries. Working on the basis of one bed net for every two people, that meant 1.7 billion bed nets. Since each net cost $10 to make and send out, that was $17 billion for the nets alone.

  Even using the mythical powers of leverage, that figure was impossible. Chambers and his team quickly decided taking on the entire world was also impractical. “We couldn’t be in the weeds everywhere,” says Basu. But it turned out that the doctor’s maps were misleading.7 Malaria might be our oldest and biggest disease, but it does not affect the whole world equally. In theory, you can catch malaria in three continents. In practice, you are far more likely to catch it in Africa—more than 90 percent of all malaria cases occur there, and of the thirty-five countries in which the WHO says 98 percent of all malaria deaths occur, thirty of those were in Africa. In Africa, universal coverage would mean covering a far more manageable six hundred million Africans with three hundred million bed nets at a cost of $3 billion.

  Chambers and his team also noted that even within Africa, the chances of illness and death rise further still once you approach the Equator. Nigeria, just north of the line, accounted for a quarter of all global malaria cases alone. This wasn’t merely a reflection of Nigeria’s large population, 150 million people. It was also to do with malaria’s concentration. According to the then health minister, Eyitayo Lambo, across Nigeria malaria accounted for 60 percent of outpatient visits to health c
linics and 30 percent of all children’s deaths. “Stop and think of September 11, 2001, when 3,000 people died in one day in this country and think what it did to us,” Wolfowitz had said at the White House summit. “Then imagine that it’s happening every day, day after day, in Africa.”8 Like the 9/11 killers, malaria took life in pockets. In theory, that should mean it might itself be killed by focusing on a few bad places.

  Chambers’s team worked out that Nigeria plus southern Sudan and five other countries—Tanzania, Kenya, Ethiopia, Uganda, and the Democratic Republic of Congo—accounted for two-thirds of all malaria cases in the world and 85–90 percent of all deaths. “Well, shit,” said Chambers, “maybe we focus on those seven countries, really delve into detail in those countries, and on the old 80/20 rule of business, the rest will be swept along.” The WHO, whose focus was global, would ensure smaller, less malarious places were not abandoned. But by focusing on malaria in just 7 of the world’s 198 countries, the UN special envoy would be hitting most of it.

  So Chambers knew what to do and where to do it. On the drawing board, his team had reduced killing malaria and saving millions of lives to a logistics exercise—distributing 300 million bed nets across Africa. But they still had just a little more than two and a half years to do it, which worked out at pushing out 312,500 nets a day, every day. “This was a marathon plan, taken at a sprint,” says Basu. And it was in the logistics, the team knew, that they were going to have difficulties.

  In places like the DRC or southern Sudan, you couldn’t just put a bed net in the mail. There was no mail. There were no addresses. There were barely any roads. Moreover, a bed net was all but useless unless it was handed out by someone who explained how to use it and how it stopped malaria. Almost every single one of Chambers’s 300 million nets would have to be hand-delivered—and that to some of the most inaccessible terrain on earth.

  This was hardly something to attempt alone. Chambers had long championed the merits of spreading aid beyond those who did it for a profession. Malaria, it turned out, gave him no choice. His target wasn’t possible even if Chambers involved every aid worker in Africa. Malaria was literally bigger than aid. Says Basu: “We had to take malaria out of the traditional realm of the development community. We were exceptionally inclusive. We were trying to build as big a tent as possible.” That meant involving private businesses, religious groups, sports teams—anyone with an interest or a presence on the ground. The response, encouragingly, was good. “They were right there,” says Basu.

  An unexpected bonus, Chambers’s team noticed, was that the involvement of such newcomers galvanized the traditional health NGOs. “When the development community saw outsiders involved, it elevated their sense of importance of the task,” said Basu. Chambers’s hustle and organizational skill, the new players he brought to the campaign, his title—all of it gave aid workers the permission, as Basu describes it, to go to work. “Most of these people are working in development because they truly want to make a difference,” says Basu. “It’s just that the system can beat you down. Ray provided the political cover to go for a stretch target and to break the bureaucratic glass and get the job done. It was classic leverage, what Ray’s always done.” Other business principles were also proving invaluable, adds Basu. “It’s amazing what you can get other partners to do when you incentivize them properly, when you set a deadline. Right there, we were breaking the old mold of development. We were applying business principles to a development problem.”

  Even before distributing the nets, however, there was the problem of having enough to hand out. There were only four bed net manufacturers in the world. An insecticide-treated bed net costs all of $10 to manufacture and distribute, a bargain when you consider it could save two or more lives, but with the scale of Chambers’s operation, that still meant $3 billion. A market of $3 billion should be incentive enough for some large-scale manufacturing. But who would pay for that? Who could?

  As the newly expanded malaria world gathered for their summit in New York on September 25, 2008, Chambers had two stunning pieces of news: he had the plan, and he had the money. The detail of the plan was spelled out by Professor Awa Marie Coll-Seck, executive director of the Roll Back Malaria Partnership. If properly implemented, Coll-Seck told an audience that included Bill Gates, Bono, Gordon Brown, Robert Zoellick, and Rwanda’s Paul Kagame, the plan could halve malaria deaths from one million to five hundred thousand by the end of 2010 and save four million lives by 2015. “The Global Malaria Action Plan is a milestone in the international response to malaria,” said Coll-Seck. “We have had isolated accomplishments over the years, but this is the first time we have drawn together those experiences to produce guidelines to replicate success globally. Putting the plan into action must now become our number one priority.”9 The strategy was essentially an expanded version of the one drawn up by Chambers’s office in answer to the single question he repeatedly asked them: “What would it take?” But crucially for Chambers’s authority, Coll-Seck, Chan, and the Gates Foundation had now ensured it was endorsed by hundreds of malaria organizations and specialists around the world.

  Reporters asking what all this would cost were told fighting malaria across the planet would take $5.3 billion in 2009, $6.2 billion in 2010, and $5.1 billion every year between 2011 and 2020. For Africa alone, the annual cost for delivering bed nets, insecticides, and malaria medicine was set at $3 billion, as Sachs had predicted.

  The mention of money was the cue for Chambers’s funders to take the podium. From 2002 to 2006, the Global Fund had handed out $2.6 billion to malaria programs in eighty-four countries. That had accelerated in the last year and a half, but Chambers still needed more. Addressing a Global Fund board meeting in April, he and Coll-Seck had thrown down the gauntlet. Unless the Fund sped up the funding—the applications process, the Fund’s decision making, the disbursement of funds—Chambers said they all might as well give up now. “He spoke well,” says Court. “He was very eloquent.” Fund chair Rajat Gupta also urged his board to back Chambers’s plan for universal coverage. Chambers was right, he said. The best way to see the best return on their billions was to spend more, faster. The board agreed. Technically it would be November before the funds would be formally approved. But when Gupta took the podium in New York, he announced the Fund had set aside $1.62 billion in its next round of grants for malaria.

  Next up was the new World Bank president, Robert Zoellick. Zoellick announced his organization was pleased with the success of its $500 million Malaria Control Booster Program. He was in favor of expanding. And while most people regarded Nigeria and the DRC as too big, too remote, too corrupt, too inefficient, and too violent to work in, the Bank was different. There was a gap, such a big one that it would wreck the wider plan if it wasn’t plugged. The Bank was now putting $1.1 billion more into the fight, concentrating on Nigeria and the DRC.

  That was already $2.7 billion, a stunning total. Then Bill Gates said his foundation would put $168.7 million toward vaccine development. The Corporate Alliance on Malaria in Africa, a new group of twelve companies, pledged $28 million. DfID promised £40 million to subsidize malaria drugs. The UN High Commission for Refugees chipped in $2 million for bed nets in its camps. That made $2.99 billion, so close to Sachs’s target that the difference was negligible. In addition, several other donors pledged more money for the future. British prime minister Gordon Brown promised £140 million. Henrietta Fore, then head of USAID, announced the budget for the President’s Malaria Initiative had been raised to $1 billion a year for five years.

  Chambers secured his funding not a moment too soon. Within weeks, the financial crisis hit. “That’s how close we came to not having the money,” Chambers would later remark. Gupta’s and Zoellick’s public commitments were key. “Without those,” said Chambers, “we wouldn’t have the money; people wouldn’t have leaned out so far.” It was a leap of faith, as well, for the countries in which the campaign would be based, says Basu. They “stepped up and believed
, even though they had been let down so many times before. Amazing moment.”

  The money was needed to make the plan work. But it also sent a message to the aid world to take Chambers seriously. “Suddenly the goal of universal coverage didn’t seem so unreachable,” says Chambers. Adds Basu: “When Ray began, he had none of the finance lined up. We’d put a target out there with no liquidity behind it, and that could have been just like any other UN target, which comes and goes and nobody says anything much. But we worked to unlock that money, and in five months, we’d lined up the majority of the cash. That was huge, huge, huge.”

  A businessman had shown that by using business methods—targets, leverage, deadlines, transparency, and more than a little Wall Street hustle—he could achieve results in development of which no development organization had ever dreamed. But drawing up the plan was one thing. Implementing it was something else.

  CHAPTER 8

  Gil and Belinda

  It is spring 2009, and more and more businesses are joining the fight against malaria. Attracted by the newly expanded market for bed nets, manufacturers are ramping up production from five million a month at the beginning of the year to what will be an eventual sixteen million by the end of 2010. Knowles says that barely a week goes by when he is not hosting a delegation from another corporation at Obuasi, while he himself is now also expanding, setting up new malaria programs at AngloGold Ashanti mines in Guinea, Mali, and Tanzania. The Global Business Coalition on HIV/AIDS, tuberculosis, and malaria now has two hundred twenty members and its dedicated campaign on malaria, the Corporate Alliance for Malaria in Africa, which includes Bayer, Chevron, Coca-Cola, Halliburton, and Marathon Oil.