by Alex Perry
As it was across Africa, malaria was a prison for millions of Congolese, trapping them in suffering and poverty. But this particular prison was one of the most remote in the world, and many questioned whether it was even reachable, let alone somewhere a jailbreak could be engineered. Readying a national bed-net distribution would take nine months. Transporting millions of nets upriver by barge from Kinshasa and then across the country would take three more months. “Can you fix the DRC?” asked Marcel Tanner of the Swiss Tropical Institute. “We do the best we can, but anyone who speaks about elimination in the DRC is seriously naïve.”1
Chambers’s team understood early on that “in the DRC,” as Alan Court said, “we needed proof of concept. We had to show that it was doable.”2 On the ground, pessimism and apathy affected the effort from the start, says Basu. “The DRC’s one of those places where you cannot get anyone to do any forward planning. They are so used to unmet promises of aid and development that unless they know things are on their way, they’re just not going to get going.”3 Raising the stakes further, Tanner said that without tackling malaria in the DRC, Africa itself would never be rid of the disease. “This is a reservoir of malaria at the center of Africa,” he said. “And it’s huge.”
It wasn’t all hopeless. NGOs in the DRC had run effective campaigns for vitamin A shots and antiworm medicine and against river blindness, even during the years of fighting. Three times—in 2000, 2001, and 2002—the soldiers had declared a cease-fire for a week to allow for a national polio vaccination. In 2008, the American NGO PSI (formerly known as Population Services International) distributed two million bed nets in Kinshasa. That operation was, says Basu, “a nightmare”: Kabila’s opponents first accused him of trying to buy off voters, then spread rumors that the nets actually caused malaria. But the nets had gone out.
A second small distribution in 2007 in South Kivu, on the edge of the DRC’s wars, saw net coverage in the area rise to 45 percent and child mortality drop 15–20 percent. In 2008 a third handout of 1.5 million nets had gone ahead in Equateur, through which I had traveled to see the bonobos. “All those distributions went incredibly well,” says Court. “It was hellishly complicated to organize, but the nets were extremely popular, and the usage rate was incredibly high.”
Encouraged, the Global Fund in 2008 set aside $150 million for a bigger net distribution in the DRC, including more than five million nets handed out by UNICEF in two more provinces: Maniema in the center and Orientale in the northeast. The operation was slow—the nets took nearly a year to arrive—but the distribution went ahead in 2009 through missionary groups, NGOs, and community organizations and was successful. By then other funders were also stepping in. The World Bank added another $60 million. USAID announced it would pay for two million nets in the southern province of Katanga; it would distribute them using the DRC’s creaking railways.
In Kinshasa in June 2009 I met Patrick Mullen, a World Bank health specialist. Just getting any bed nets out at all in the DRC had been a “huge boost,” he said. “There’s now a real potential that we can achieve this massive program,” he said. The deadline of the end of 2010 looked extremely difficult, he added, but then nothing in the DRC was ever easy. “We’ve proved it is feasible to do these things. It’s a logistical challenge, sure, but UNICEF and PSI are very good at meeting that. They’ve done Equateur, one of the most difficult places on the planet—no roads, just jungle and river, and some of the poorest people anywhere in the world. Given the funding, this can be done in the DRC.”4
Paradoxically, Mullen added, the harshness of the DRC—the lack of development, the breadth of poverty, the absence of almost anything resembling government service—was in some ways an advantage. That environment had produced a resilient population used to taking care of their own health and paying for it. That, in turn, had attracted the DRC’s professional class. As Mullen described it, health was one of the DRC’s very few “revenue-generating activities.” “There is a surplus of trained nurses and even overstaffing in hospitals in some areas,” he said. “Everybody wants a piece of the business, and it’s good business: the DRC’s never going to run out of sick people.” That made distribution easier, said Mullen. In the province of Katanga, aid workers had carried out an experiment with incentives for health workers: subsidizing drug prices to allow more patients to buy their own drugs. “The subsidy worked,” said Mullen. “Utilization of drugs shot up, and without the whole rigmarole of building a health center and training people. Just cash, used well, can make a difference.” “From the point of view of the antimalaria campaign, even the DRC’s wars hadn’t been all bad,” said Mullen. Parts of the humanitarian effort that accompanied them had been adapted to form a rudimentary health system.
So there was hope. But there were problems too. The government wanted to take control of the malaria fight but was in no position to do so. “The government’s capacity problems are the reason the aid groups were required in the first place,” said Mullen. “They want to focus on inputs—the money—rather than results. They want to centralize procurements [buying nets and drugs], but procurements take forever in Kinshasa. The government has had to repay money to the Bank that was not spent at all. And, of course, we’re very concerned about corruption.”
Sure enough, the next year, 2010, the World Bank suspended all funding to the DRC when the government sold a $20 million gold mine the Bank owned to the Chinese. Chambers met Bank president Robert Zoellick, with whom he had now developed a close working relationship. Zoellick duly made an exception for malaria. “Bob Zoellick put out the message: ‘Stop everything in the DRC, but I want my malaria project to go ahead,’” says Basu. “Bob’s leadership pushed that through.” On April 25, 2010—World Malaria Day—the World Bank even raised its funding for net distribution in the DRC by another $100 million, enough to pay for the last of the thirty-two million nets. The money was in. There was not a day to lose, but Dr. Benjamin was adamant the DRC would make the end-of-year deadline. “It’s still possible,” he insisted.5
CHAPTER 12
Buzz
The slow progress of the campaign in Uganda, Kenya, and the DRC was one reason to worry. Elsewhere, I wondered if the campaign was growing too big, too fast. I saved a clipping from a Kenyan newspaper on September 23, 2009, that I found particularly striking.
POSH’S RING CREATES BUZZ
Victoria Beckham created a buzz for a life-saving charity on Tuesday—by showing off a £15,000 jeweled ring as she flew in for London Fashion Week. Posh is backing Malaria No More UK by wearing the ruby and diamond encrusted mosquito ring which will raise money for the campaign. She was seen wearing the item—created by designer Stephen Webster—on her right thumb as she touched down at Heathrow on Tuesday morning. Beckham said: “It’s a fabulous statement piece and I’ve loved wearing it. It’s inspiring to see designers like Stephen working the power of fashion to save lives. I’m crossing my fingers this collaboration will generate loads of buzz.” Her ring is made of rhodium-plated white gold set with ruby cabochons, white diamond wings, a silver diamond tail and a black diamond band. Retailing for just under £15,000, it will be auctioned off by MNM with all proceeds from the highest bid going to the charity . . . Victoria is mom to Brooklyn Joseph, 10 1/2, Romeo James, 7, and Cruz David, 4 1/2, with husband David Beckham.
I had other examples. On July 8, 2010, the eve of the soccer World Cup Final, I attended a concert at the Coca-Cola Dome on the outskirts of Johannesburg. Star performers were the tenor Andrei Bocelli and Canadian rocker Bryan Adams, who performed a duet of Yesterday as a finale. The event’s sponsor was United Against Malaria, a soccer-related coalition of malaria groups that tries to raise malaria’s profile through the sport. During the concert, advertisements and slogans on giant overhead screens drove home the message, as did guest speakers. At one point Cameroon’s goalkeeper appeared on stage and announced: “It takes a team to score victory. Help us build the strongest team ever!”
I watched the show f
rom a VIP area, picking at sushi and sipping flinty white wine. With me were representatives from most of the world’s malaria organizations, such as Malaria No More, the World Health Organization, and UNICEF. There was a lot of networking and a fair amount of drinking. Everyone had dressed up for the night, and smart young women in black with clipboards kept checking my ID and telling me I was standing in the wrong place or needed to be quieter or had to meet someone else on their list.
And as the evening wore on, I began to feel distinctly queasy. Sashimi and Sauvignon Blanc don’t mix well with disease and destitution. With every sip and every bite, I realized, we were consuming money intended to save lives. Hundreds of thousands more dollars would also be spent when the people around me claimed days of expenses for food, international travel, and hotels from their own malaria organizations. And I started to wonder: were we getting more out of this than malaria? What about the celebrities, who were appearing before a global television audience? American Idol had given malaria a whole new profile. But was I alone in feeling there was something not quite right about Victoria Beckham’s work with rings? Did fashion really have the power to save lives?
There was certainly something inappropriate about a £15,000 jewel-encrusted mosquito ring. Malaria was a disease of poverty. The ring was a dazzling reminder of the global inequality that ensured malaria endured. It suggested Beckham knew little about malaria. Such ignorance was the main reason Marcel Tanner at the Swiss Tropical Institute had little time for celebrity campaigners, a group in which he now placed Jeffrey Sachs. “If you have Sachs and Bono, it’s a problem,” he said. “It’s helicopter action. The helicopter lands, and there’s lots of dust. But when the helicopter goes, the dust remains.” Tanner said high-profile campaigners “don’t get a lot of dirt on their shoes. That’s very important—it helps a lot. You have to see reality, what malaria means, how people interact, how hot the sun is. I get nervous people aren’t in touch with reality. I start asking them: ‘Friends, do you understand the life cycle of malaria?’”1
There was also the question of who benefited more from the publicity: the campaign or the celebrity? In the pictures that accompanied the Beckham story, the ring could scarcely be seen. Likewise, in early 2009 the American actor Ashton Kutcher was dutifully sending out Twitter messages about malaria every day, but as Kutcher’s following soared, the malaria message was eclipsed by a new story: who, between Kutcher and CNN, would be first to have a million Twitter followers?
Another star involved in the campaign was the British tennis player Andy Murray. I emailed him to ask whether he thought celebrity endorsement did any good—and if it did, for whom? I received a sincere and well-intentioned lecture in reply. Murray said that his role was “to help raise awareness about what needs to be done” and described “an unforgettable day at Wembley Stadium,” when he played tennis with David Beckham over a giant net made out of mosquito netting. “We also visited the former Prime Minister Gordon Brown and hung a mosquito net over the iconic door of Number 10 Downing Street,” he wrote. “The point was to show the vital need for nets in Africa. Meeting these goals would transform the African continent saving literally millions of lives. Stakes don’t come much higher than this.”2
Murray was right on message. But the questioned remained: why did it take a tennis player to sell it? Sarah Kline, who runs Malaria No More’s London office and manages the involvement in the campaign of the Beckhams, Murray, and others, said my concerns were misplaced. If Beckham or Kutcher or American Idol received more coverage than malaria, she said, that was just the way of the world. Stars didn’t need malaria to make them famous. It was the other way around. “Victoria comes to London Fashion Week every year, and what she wears as she comes through the airport is a huge event,” said Kline. “We chose that moment for her to wear the mosquito ring and that picture went to almost every newspaper in the world—and every report talked about malaria.”3
It was true that celebrity involvement in a campaign was rarely selfless, said Kline—“Managers will only let their celebrities do something that works for them”—but this was self-interest that helped. Celebrity endorsement only worked if it fit a celebrity’s image, reflected their interests, and complemented their profile. Otherwise, it wasn’t credible. David Beckham was believable as an ambassador for UNICEF because “he has kids—those are his interests.” For Murray, “it’s about nets, something he works with every day.” She continued: “Victoria Beckham is a fashion icon, and we were trying to sell replicas of that ring,” she said. “We’re not asking her to be a scientific expert. That wouldn’t be credible. But if she wears a new ring and talks about fashion, then that has authenticity. That’s who she is.”
This was classic leverage, added Court: playing different elements off each other to create a bigger whole. It was something UNICEF understood half a century ago when it employed Danny Kaye and Audrey Hepburn as spokespeople. “Celebrities leverage not just the media and, through them, the general public, which in turn influences politicians and legislators and thus policy. They also leverage corporate and aid agency leadership.”4 Chambers was convinced there was a strong link between celebrity involvement and influencing Capitol Hill. It was a politician’s job, after all, to respond to the popular mood.
And the influence was plain to see. There was the huge audience attracted by “Idol Gives Back” and the tens of millions of dollars it raised. Likewise, when Kutcher reached a million followers on Twitter, he donated enough money for 10,000 nets—something that inspired his followers to give funds to buy a further 79,724. Imagine that effect two hundred times over, said Chambers. “We’ve got two hundred people—from Queen Rania of Jordan to Bill Gates to Shaquille O’Neal—mentioning malaria at least once a month on Twitter or Facebook. Combine all their followings, and we’re reaching two hundred million people.”5
If there was something uncomfortable here, Kline argued, we should look to ourselves. The problem wasn’t Victoria Beckham. The problem was that we needed her—and Ashton Kutcher and Andy Murray and Bryan Adams—to make the poor world interesting. In Britain, about 10 percent of the audience cares about international development, said Kline. “The other 90 percent don’t read international development news, but they do consume celebrity magazines and reality TV. So that’s what we use.”
CHAPTER 13
Trade Not Aid
If there were pros and cons to mixing celebrities and malaria, the problems with the campaign’s burgeoning rank and file were less ambiguous. In November 2009, a month before Chambers met Mugo in Nairobi, I attended a weeklong conference for malaria scientists in the city. So did around two thousand other delegates, most of whom had flown in from around the world. For a week, in between shopping trips and dinners in their five-star hotels, they discussed ways of preventing and curing a disease that has been preventable and curable for more than a century. This was an old aid flaw writ large. There were now thousands of people working in malaria—development specialists, scientists, researchers, academics—not because they were expert in it but because that was where the money was. Everyone proposed never-ending assistance programs. No one was planning on going out of business any time soon.
To be fair, there were some innovations. Several groups of scientists were working on different vaccines. One company was proposing using insecticide-treated wallpaper instead of nets. There were discussions about rising mosquito resistance to different pesticides and the malaria parasite’s varying resistance to different drugs. But in paper after paper, the scientists proved—at length and in a hundred different scenarios—what we already knew: bed nets kill malaria, so do sprays, and antimalaria drugs can treat it. At the conference, Tim Wells, chief scientific officer of the Medicines for Malaria Venture (MMV), was as mystified as I was. Fighting malaria was no longer “about science,” he said. “It’s about people. It’s about working out why people are not being treated with medicines or do not have a bed net. It’s about how politicians tick.” I also caught
up with Brian Greenwood. As he surveyed hundreds of delegates crowding the conference coffee shop, he remarked: “You have to ask: ‘Is this whole thing getting out of hand? Is it getting too big?’ And the answer is yes, I think it probably is.”1 Marcel Tanner worried whether quantity was at the expense of quality. “Of course, it’s good to have more people,” he said. “But sometimes it’s too much. It’s overkill.”2
And if there were too many of one sort of delegate, there were not enough of another. You could spot the problem simply by studying the list of scientists and researchers in Nairobi: plenty of Westerners, plenty of Africans working for Western NGOs, but almost no one from an African government. With all these thousands of outsiders working on malaria, why should they bother?
As I watched the malaria campaign grow into the world’s biggest aid drive during 2009 and 2010, the same doubts kept coming up. Was this finally aid that worked? Or was the malaria campaign making the same mistakes of all big aid? Nairobi suggested malaria groups were as wasteful as any other. They were blind to the perennial aid flaw: how removing the responsibility for looking after a people from the leaders of a village—or a town or a country—hurts their ability ever to do so. Skills are lost, duties forgotten, and a dependency created. Short-term success is overshadowed by long-term failure.
Money for malaria came from the West, and it made sense for Westerners—celebrities or others—to make the pitch for funding. But when implementation was in Africa, it had to be Africans who led it. And yet many African governments were relying on outsiders to fix the disease. For foreigners to come galloping to the rescue was fine in the short term, when hundreds of thousands of deaths demanded an overwhelming emergency response. But the long term demanded passing on the skills to fight malaria; at the very least, it prohibited sidelining African governments.
