Lifeblood

by Alex Perry

  But celebration was still something that did not come naturally to much of the aid world. One reason why the malaria campaign had grown so large, appearing on prime time television and at the top of the Western agenda, was Chambers’s presentation of its subject as approachable, even entertaining. But the rest of the aid world was still finding it hard to give up the old ways of “raising awareness”: intimidating the public with dire warnings of imminent crisis. When, in the teeth of a recession and government debt crisis in October 2010, Western donors still pledged $11.5 billion to the Global Fund for 2011–2013, up from $9.7 billion in 2007, the aid world reacted with outrage and moral blackmail. “The outcome of this conference is absolutely key for millions of people around the world, and this will not take us to where we were hoping to be,” said Michel Kazatchkine, the Global Fund’s executive director, explaining that the target had been $13 billion. Médecins Sans Frontières declared the decision to “massively underfund” the Global Fund “will cost lives and severely weaken the ability of countries to implement programs” to beat back disease. Asia Russell of Health GAP, a US HIV/AIDS and human rights activist group, called the donor announcement “a flop.”20

  Likewise, in October 2010 Greenwood’s former student Bob Snow published a report warning that although annual international funding for malaria had increased since 2007 by 166 percent, from $730 million to $1.94 billion, this was still 60 percent short of what was needed. Only twenty-one out of ninety-three countries had enough money to implement effective control measures, wrote Snow in the Lancet. “Any decline in malaria-funding commitments will run the risk of a resurgence of malaria,” he added. “A failure to maintain the momentum will mean money spent so far will have been for nothing.”21 Snow was correct to argue that the campaign had to be maintained. The WHO’s failure to sustain its earlier efforts had been a disaster. As Richard Feachem, former executive director of the Global Fund, said, with malaria “success is the enemy of sustainability, because if you blink, it will come back with a vengeance.”22

  But the malaria world’s lack of acknowledgment of its own achievements was striking nonetheless and hinted at the same motivations that persuaded other aid workers not to solve crises but merely manage them. Success wasn’t something the malaria world wanted to hear. Its interests demanded continued catastrophe, even when that flew in the face of reality.

  An inability to rejoice could not explain away the criticism the campaign was attracting, however. Some of that came from within. Marcel Tanner predicted that if Plasmodium falciparum was beaten back, Plasmodium vivax, long a far lesser threat, would surge in its place. “It’s crap to talk about elimination without talking about vivax,” he said. “If we reduce falciparum, a good indication that we have been successful will be that vivax comes up.”23

  Outside the campaign, others argued the goal of eradication was too far-fetched, and perhaps even counterproductive. Critics said a more modest one—control—would be more effective. In October 2010 Sonia Shah, the malaria historian, wrote a front-page essay in the esteemed French international affairs newspaper Le Monde Diplomatique with the headline “Live with It.” She argued that new evidence indicating malaria was passed to humans from gorillas and monkeys meant malaria might be impossible to eradicate. “What if there’s a secret reservoir of pathogens in the bodies of wild animals, unreachable by medical interventions, as there is in yellow fever, cholera, and influenza, diseases from which humankind can never hope to be completely free?” In those circumstances, controlling the disease was the only sensible goal. “When public health leaders want to control a disease, they devote the majority of their resources to the areas of greatest need. When their goal is eradication, then they must spend their resources on areas where eradication is most likely—the areas with the least need. If malaria eradication campaigns fail, their resources and political capital will have been lavished on the lowest priority areas with the lightest burdens of disease.”24

  The same month, the Lancet published a series of articles on malaria that echoed those criticisms. Eradication, while a noble goal, “could lead to dangerous swings in funding and political commitment,” read the magazine’s editorial. It accused Margaret Chan’s World Health Organization of failing “to rise to their responsibilities to give the malaria community essential direction. The quest for elimination must not distract existing good malaria control work.”25

  The critics made a good theoretical point: fighting malaria in places where other diseases were a bigger problem would be a waste of money, and elimination of malaria was not feasible in the worst places in the short term. But some of the critiques ignored the reality that Chambers and his team weren’t targeting countries peripheral to malaria in the hope of knocking off some easy targets for eradication. They were focusing on the core. Nor were control and eradication two different things. The first was a stepping-stone to the second—which, as both sides pointed out, was anyway several decades distant and unlikely without an effective vaccine.

  Other critics were guilty of displaying another old aid world weakness: burying themselves in academic debate while a changing reality superseded them on the ground. As the malaria campaign progressed in 2009 and 2010, development specialists found themselves distracted by a technical dispute over the merits of “vertical interventions”—single-focus projects, such as a project to build a well or a campaign to fix malaria—and “horizontal inventions”—broader programs to improve, say, an African government’s ability to deliver clean water or its national health system. The malaria campaign was actually both: it targeted a specific disease and also built up capacity and health services in the course of doing so. “We can use these systems, and the things we have learned, on multiple diseases,” said Chernin. “We are learning how to get the message delivered, how to use celebrities and faith leaders and football stars, and that has implications far beyond malaria.” That didn’t stop the theorists from doing battle, or even dismissing the malaria campaign for its supposed vertical focus. Comments about the malaria campaign from Professor Ian Linden, director of the Faiths Act Programme at the Tony Blair Faith Foundation, were typical: “I think there is a serious issue that the massive vertical intervention is not necessarily going to be positive for building up health systems,” he said. “It’s not necessarily sustainable. When you drive off into the sunset, the community is left behind.”26

  It was a similar story in the Grand Aid Debate. By combining business and aid, Chambers had carved a middle path between the pro-aid evangelists such as Jeffrey Sachs and aid critics such as William Easterly and Dambisa Moyo. “On malaria, we have an example where aid is working,” said Basu, “because it’s being done in a different way from the way traditional development has been done. You see it in the results and the efficiency.”

  But Sachs and Easterly carried on sparring regardless. On May 24, 2009, Sachs posted a furious essay in the online Huffington Post headlined “Aid Ironies.” Sachs did cite the malaria campaign in his post and elaborated on its achievements in a follow-up. But the thrust of his article was a personal attack on Easterly and Moyo. “The debate about foreign aid has become farcical,” he wrote.

  The big opponents of aid today are Dambisa Moyo, an Africanborn economist who reportedly received scholarships so that she could go to Harvard and Oxford but sees nothing wrong with denying $10 in aid to an African child for an anti-malaria bed net. Her colleague in opposing aid, Bill Easterly, received large-scale government support from the National Science Foundation for his own graduate training. I certainly don’t begrudge any of them the help that they got. Far from it. I believe in this kind of help. And I’d find Moyo’s views cruel and mistaken even if she did not get the scholarships that have been reported. I begrudge them trying to pull up the ladder for those still left behind. Before peddling their simplistic concoction of free markets and self-help, they and we should think about the realities of life, in which all of us need help at some time or other and in countless ways, and ev
en more importantly we should think about the life-and-death consequences for impoverished people who are denied that help.... Rich people have an uncanny ability to oppose aid for everybody but themselves.27

  Easterly responded the next day under the headline “Sachs Ironies: Why Critics Are Better for Foreign Aid Than Apologists.” He wrote, “Official foreign aid agencies delivering aid to Africa are used to operating with nobody holding them accountable for aid dollars actually reaching poor people. Now that establishment is running scared with the emergence of independent African voices critical of aid, such as that of Dambisa Moyo. Jeffrey Sachs, the world’s leading apologist and fund-raiser for the aid establishment, has responded here with a ferocious personal attack on Moyo and myself.” Easterly stressed he didn’t oppose all aid, just bad aid, and that Sachs knew that, not least because Sachs had quoted Easterly in his work. “Sachs suffers from the same acute shortage of truthiness as did the Bush/Cheney administration.... Any aid critic is immediately denounced as a heartless baby-killer, which protects the establishment from the accountability so badly needed to see aid reach the poor.”28

  The following day Moyo weighed in, writing that Sachs’s personal attack was “just the latest example of using this tactic to obfuscate the facts and avoid addressing the fundamental issues regarding aid’s manifest failure to deliver on its promise of generating growth and alleviating poverty in Africa.... There is no country—anywhere in the world—that has meaningfully reduced poverty and spurred significant and sustainable levels of economic growth by relying on aid. Mr. Sachs knows this; how do I know? He taught me while I was studying at Harvard.”29

  Sachs could not let that lie. “Ms. Dambisa Moyo’s recent Huffington Post article exposes the confusions that underlie her slashing attacks on aid,” he wrote the next day. “Moyo is not offering a reasoned or evidence-based position on aid. Moyo wants to cut aid off dramatically, even if that leaves millions to die.”30

  If all that wasn’t enough to overshadow the malaria campaign, the big malaria stories of 2010 and early 2011 were about celebrities who had contracted the disease: British tabloid favorite Cheryl Cole, the Ivorian and Chelsea soccer player Didier Drogba, and George Clooney. Between a corruption scandal, the noise of clashing aid heavyweights, and the drama of sickly superstars, one of the most successful aid campaigns of all time was forgotten.

  It might have been different if the campaigners could say how many lives they had saved. In business, profits are tracked by the week and reports issued on a quarterly basis. Aid doesn’t announce its results in the same regularized fashion. That’s partly because aid is slow—in malaria’s case, somewhat unavoidably, since gathering data from tens of thousands of villages is a long process—and partly because aid agencies have no common measurements.

  But mostly it is because malaria is very difficult to measure. Lengeler said that because malaria often went undiagnosed and since most malaria deaths happened outside a hospital and were not reported, it was all but impossible to measure quickly and accurately how many people died from the disease. The total number of child deaths in a country could be estimated by taking a sample and multiplying it, and a number for malaria deaths extrapolated from that. But even those statistics took two to three years to come in. Moreover, they generally measured average child mortality rates over the past five years, figures that would underplay the effect of a dramatic, all-out attack on malaria.

  That meant the World Malaria Report 2010 was actually a misnomer. Its conclusions and assessments were based on data from 2009 or before. Chambers wouldn’t know how many lives he had saved for another year or more. The belief was that millions of children were walking around who otherwise wouldn’t have been. But the only thing anyone knew for sure was that Chambers had missed his targets.

  But surely it was possible to work out a rough idea of the results? I asked Lengeler to help me make two estimates: lives saved and at what cost. Taking the second part first, figuring out the cost was relatively easy. The Roll Back Malaria report of 2010 estimated 42 million nets distributed to Nigeria would save 121,000 children’s lives. That meant every 347.1 nets saved one child’s life. Lengeler’s own estimate was more like every 180 nets. Either way, if every net cost $10, that was somewhere between $1,800 and $3,500 for every child’s life. That was a lot more than “$10 buys a net, saves a child’s life,” as Chambers had it in his catchphrase. But $3,500 is still pretty cheap for a life. It also compared well with Easterly’s figure of $3,521 to raise a poor person’s income by $3.65 a year, not least because over a lifetime, even in the poorest countries in the world, every saved child could be expected to earn considerably more than $3,500. This was further proof of the proposition that by helping others you helped yourself. Fighting malaria didn’t just save lives. It saved money too.

  But the big question was: How many children had Chambers saved? The 2009 World Malaria Report reported that malaria cases around the world were fairly constant from 2005 to 2008, falling slightly from 244 million to 243 million. After Chambers began his campaign, they plunged. By 2009, the number of malaria cases was 225 million. The fall in deaths was more impressive: from 863,000 in 2008 to 781,000 in 2009—82,000 lives saved in a single year.31

  Chambers had delivered twice as many nets in 2010 as 2009. So the numbers of lives he saved should also have roughly doubled, to a ballpark hundred fifty thousand. That made a total of around a quarter of a million lives saved during the thirty-two months of the campaign.32

  That rough estimate was backed up by Roll Back Malaria’s 2010 report, released in September of that year. It estimated that by 2010 around 175,000 lives were now being saved every year because of the campaign, although it added a wide margin of error: the figure could be as low as 120,000 or as high as 250,000. Plus, because it had used a far lower figure for coverage in Nigeria than was now the case, the real figure for lives saved per year by the end of 2010 was probably 121,000 more—making a median figure of 300,000.33

  Roll Back Malaria made predictions for the years ahead too. If universal coverage had been achieved by the end of 2010 and was maintained through replacement of worn-out nets for the next five years, then the number of lives saved by the end of 2015 would be 2.95 million. If universal coverage were only achieved by 2015, that figure would still be 2.15 million. In an excited email in June 2011, Basu told me Kenya was done—“Truly amazing turnaround, Mugo delivered, her and Ray now have a close friendship, we really need her.” He added that Tanzania, Nigeria, Uganda (now without a sacked Minister Mallinga) and even the DRC should all join in between August and October. By finishing in 2011, Chambers could be expected to be somewhere between 2.15 and 2.95 million lives saved. Lengeler said that felt about right. “Whether it’s 2 million or 2.5 million or 2.7 million, it’s still a lot,” he said. “It’s millions. There’s no doubt about that.”34

  I realized the sheer number of people saved—millions—was actually hindering attempts to count them. Measuring malaria deaths was all but impossible. Now that so many were being avoided, any effort to add them up was also hopeless. The number of people saved was literally countless. You couldn’t quantify it with any precision. But maybe you could feel it.

  CHAPTER 15

  Fine and Fair

  My taxi driver, David, is late picking me up from Entebbe airport, and we hit the evening rush hour in Kampala, so it’s 10 PM before we cross the Nile and start on the road to Apac. Twenty-one days before the end of 2010, after all the lofty talk and frantic campaigning, I want to see whether the fight against malaria is working in the place it faces its stiffest challenge. But as David edges off the tarmac and onto the rutted mud tracks to Apac, I begin to worry. The funestus feeds at night. Crossing Kwania’s swamps, we have to keep the windows down to stop the windshield steaming up. The last time I visited Apac I drove myself, but this time David has insisted on making up for his lateness by taking the wheel—and while I did warn him about malaria, his manner suggests he thinks I am exaggerating.
And I have doubts the campaign has reached Apac. It is remote, and Uganda has been one of Chambers’s biggest headaches. As we drive deeper into the swamps, David tells me he’s just returned from three years in Iraq working as a security guard. He should be home with his wife and son, Newton. Instead I’m taking him to the global epicenter of our oldest and deadliest disease.

  About three miles outside Apac, we see light ahead. We’re upon it, then past it, in a flash. I struggle to process what I’ve just seen: a large open fire in front of a roadside beer stall and perhaps forty people dancing, singing, and drinking. Soon we see another light. This one belongs to a restaurant, with plastic seats and a small fence. There’s more music, and here perhaps a hundred people are dancing and chatting. David mutters something about crazy country folk. Crazy is right, I think. They’re out in the open.

  As we roll into Apac, I can see that, despite the hour, the streets are packed. People are walking, cycling, chatting with their neighbors, sitting in a number of open-air bars. I direct David to the Lamco B. It’s full. We try another place, the Tani Guesthouse. It’s also booked up. The receptionist directs us to a bungalow on the outskirts of town that is hiring out rooms for $10 a night. I am shown to a clean-looking bedroom containing a double bed and a bed net. I scan the walls for mosquitoes and am mildly surprised to find none. I cover myself in repellent, take my Malarone pill, dress in long trousers, long-sleeve shirt, and socks and climb under the net.

  The next morning, December 11, we drive to the Apac district hospital. Sixteen months before, the streets had been deserted except for three naked men. Now we find ourselves forced to slow to walking pace as we push through crowds of hundreds. There are scores of young women dressed in blue and white uniforms—trainee nurses, I discover later. Where shops had been shuttered before, now mechanics are banging wheel frames, metal workers are soldering iron gates, timber merchants are unloading wood, and soda stores are unloading the latest delivery from trucks. Several places have a fresh coat of paint. One of them is the Sunset Lodge, which now also boasts a packed café in front. I realize I haven’t seen a single mosquito. I check myself for bites. Nothing.