by Alex Perry
At the hospital I find Martin, finishing up his night shift on the children’s ward. I ask to see the admissions book. There are three children recorded as being admitted with malaria the day before. There are none the day before that, then two, then one. Most of the admissions are not for malaria but pneumonia, tuberculosis, and burns. I walk onto the ward. The smell has gone. There are bed nets on every bed. I start to count the number of patients, but as I do, I feel my throat tighten and my eyes blur, and I have to step outside. Only ten of the thirty-six beds are being used.
“Martin,” I say when I have composed myself, “things have changed.”
Martin smiles. “We used to have fifteen patients a day with malaria,” he says. “Now it is fifteen a week. The ward was completely full. Now, you see there is a lot of improvement. A lot.”
“Where have all the mosquitoes gone?” I ask.
“Actually, that is the difference,” he says. “There used to be a lot of mosquitoes in Apac. Too many. When you were sitting outside, you had them crawling all over you. But then we got the nets, and they did some spraying, and it cleared them.” He searches for the right words, then gestures to the blue sky. “Now it is fair here,” he declares. “Apac is fine and fair.”
We drive to the Lamco B to find my old landlord, Lameck. The receptionist tells me he is out at his village home three miles away and gives us directions. We arrive to find Lameck overseeing a team of builders putting a second story on what will soon be Lamco C. He bounds out of the site to greet us and takes us on a tour of his new place. To one side, Lameck has planted a copse of young fir trees, a forest of mangoes and bananas, and a field of tomatoes. At the back are pens—Lameck is diversifying into chickens and goats too. Inside the new building, Lameck explains Lamco C will have ten en suite rooms, all set around an open courtyard. Lameck has built two open-air sitting areas where his guests can enjoy the evening air. He anticipates my question.
“Oh, there’s less malaria,” he beams at me. “There’s less mosquitoes. There’s no problem being outside now.” Then, gesturing at the new open-air lounges, “It’ll be nice, no?”
It’s amazing, I say.
We drive to the District Health Office, where I find Dr. Matthew Emer still at his desk. His office has changed. It’s somehow brighter, sunnier. Looking around, I realize there are no longer any screens on the windows. The fan is off. Dr. Emer smiles and says he has “a lot of news.”
In 2010, the district health authority finally won its case against the organic farmers and was allowed to restart spraying insecticide. Worried that their previous partial coverage of Apac could have produced a DDT-resistant mosquito, Dr. Emer’s staff did tests—and sure enough, DDT was no longer effective. A second insecticide had little effect as well. Then in August they tried a third insecticide, Bendiocarb. That worked. And in September and October, a long promised delivery of a hundred sixty-eight thousand bed nets arrived, the first tranche in Uganda’s two-step Global Fund delivery, intended for children under five and pregnant women.
The combined effect of the spraying and the nets, says Dr. Emer, “was fantastic. By the end of the month, we had village after village completely free from mosquitoes. Everybody noticed. The feedback was overwhelming. There was a massive decline in malaria.” He shows me his new figures. Until August, the statistics describe a situation unchanged: as low as 1,550 cases in the first week of 2010, as high as 4,966 in the third week of June, and a rough average of 3,000 to 3,500 a week. But after the spraying began, there was a sudden drop. In the second week of the month, Apac recorded 3,594 cases of malaria. The following week that was down to 2,843, then 2,426, then 2,120. After the nets began arriving, it plunged even more, to 1,684, then 1,385, and 1,269 in the last week of September. For October and November it rose a little before settling at around 1,800 cases a month. In a few weeks, malaria had been halved. “We have high hopes,” he says. “We think we’re very likely to be able to engineer a reversal.”
Success has encouraged him to set up an additional range of antimalaria programs. Pregnant women are now receiving presumptive malaria treatment: automatic doses of antimalaria medicine to protect their unborn babies. His staff is fanning out to all the tin-roofed, wood-shack dispensaries in the area, showing pharmacists how to use new rapid diagnostic tests—small blood examination kits that can prove or disprove malaria within fifteen minutes—and to keep records of what they find. They are also training thousands of village health workers, one for every twenty to thirty people, in malaria diagnosis and bed-net use.
There are still problems, of course. Dr. Emer says he doesn’t yet have the staff he needs. Only one doctor applied to work in Apac and, when he got the job, never showed up. The government in Kampala is also cutting back. And Dr. Emer says it looks as though Apac will miss Chambers’s universal bed-net coverage target by a few weeks. He does not expect a second set of nets until after the new year.
Still, Dr. Emer’s complaints feel perfunctory. He doesn’t look unhappy. Apac feels reborn, I venture. It’s as though I have pressed a detonator. “You can see it!” he exclaims, gesturing wildly at the window. “You can witness it! Less children sick! Parents spending less money on medicine! Mothers spending more time on their gardens and going to the markets rather than spending four to five days every few months in hospital!”
Apac isn’t the only thing that’s changed, I add.
“I am changed,” he acknowledges. “I am happy. I am really, really happy. When you went to the hospital before, it was full, full of people wailing and dying. You saw it for yourself! You couldn’t count them! Now our interventions are working. You can see, for the first time ever, that we are going to get on top of malaria. We’re really doing it! There is a reason to smile here again.”
David and I have one more stop before we leave Apac. We drive back to the hospital, and I walk over to the registrar’s office, where I ask Julius, the statistician, to show me some more numbers. Julius has a record of every outpatient for the last three years up to September 2010 and for every inpatient for the three years up to October 2010.
Among outpatients, I see that when I visited before, September 2009, there were 1,210 children under five treated in the hospital for malaria. A year later that number has come down to 647. The figures are more dramatic for inpatients: in September 2009, 235 children were admitted for malaria. By September 2010, that has come down to 121, and in October it falls further, to 94.
I look at the column headed “Mortality.” In the past, I can see the hospital would lose an average of ten to fifteen children a month. September 2009 was better than average: just three boys and one girl. But by September 2010, there’s been a substantial improvement on even that figure: just one girl died. And then, on the next line, I see it. In the month of October 2010, in the only hospital in the most malarious town on earth, no child dies of malaria.
Acknowledgments
This book would have been impossible without the support of my editors at Time, in particular Michael Elliott, Rick Stengel, and John Huey, who backed my interest in malaria from the start and paid for far more trips across Africa to research the subject than was strictly necessary for a cover story. Time is one of the last news outlets in the world where it’s still possible to spend months or years reporting a single story. As a developing-world correspondent pursuing what are often unobvious stories, I am only too aware that the encouragement and freedom I enjoy likely border on financially unwise. Gentlemen, as ever, I am in your debt.
This book also owes its existence to Michael Dwyer at Hurst, who rescued it when no one else would have it. Michael, thank you for being such a source of encouragement and for taking on such an unlikely sounding subject. Thanks also to Terry Morris, Andrea Nattrass, Wesley Thompson, and all at Macmillan SA, the greatest publishing team in South Africa, with whom I continue to enjoy a fantastic relationship. In the United States Susan Weinberg and Clara Platter, my editor at PublicAffairs, moved with a speed that broke several re
cords in the publishing world, all the more remarkable for the fact that the manuscript landed on Clara’s desk on her first day on the job. My deep thanks to them, and to Lindsay Fradkoff, Jaime Leifer, Pete Garceau, and Sandra Beris, and to Beth Wright at Trio Bookworks.
The story of how Ray Chambers and his team saved millions of lives is not well-known. The only reason I can tell it here is because of the unprecedented access offered to me by Ray and his staff. Not only did they allow me to travel with them across Africa on a number of occasions, but they also agreed to an almost never-ending set of interviews without a word of complaint. Ray, and Protik, Alan, Tim, Sean, Jamie: I only hope I have justified your faith.
The enthusiasm and helpfulness I received from the UN special envoy’s office were replicated across the malaria world. Over the two years I spent reporting on the subject, I spoke to countless individuals with far more important things to do than answer my queries and correct my ignorance. Of particular help were Steven Phillips, who helped me understand how big a story this was on a sickening car ride across Rwanda (thanks too to Steven’s wife, Isabel, who provided advice on structure and narrative); Christian Lengeler, who steered me through the science and whose enthusiasm for the cause infected me every time I spoke to him; Steve Knowles, who not only opened my eyes in Ghana but also nursed me when something (malaria!) laid me low there; Sarah Kline, Roz Hunt, and the team at Malaria No More (UK), who couldn’t have set up more interviews and who answered every request with speed and entrepreneurialism; and Emily Bergantino at Malaria No More (US), another demon at arranging hard-to-get interviews and always on hand to assist. A special thank you as well to Dr. Matthew Emer, Martin, Lameck, and Jimmy Ogwal in Apac, Uganda, for receiving me so graciously and going out of their way to tell their stories.
Others who provided crucial help and support include Margaret Chan and Ian Smith at the World Health Organization; Rebecca Ladbury, who first introduced me to the fascinating world of malaria; Tachi Yamada, Gabrielle Fitzgerald, Deborah Lacy, Laurie Lee, and Katie Harris at the Bill & Melinda Gates Foundation; Peter Chernin; Richard Curtis; Simon Fuller; Andy Murray, Julian Henry, and Matthew Gentry; Brian Greenwood; Bob Snow and Lydia Mwangi in Nairobi; Christina Barrineau and John Allen; Yvonne Chaka Chaka and Louis da Gama; Margaret Bergen and all at the Center for Interfaith Action; Lindsay Crouse, Victor Zonana, and Daniel Gwinnell at Global Health Strategies; John Bridgeland, who allowed me to travel with him through Rwanda and threw me an impromptu party in Kibuye for my thirty-ninth birthday; Marcel Tanner; Salim Abdullah and Gerry Killeen at the Ifakara malaria research station; Kate Roberts, Anna Dirksen, Trey Watkins, and Regina Moore at PSI; Admiral Tim Ziemer and Chris Thomas at the President’s Malaria Initiative; Richard Feachem; Tim Wells and Jaya Banerji at Medicines for Malaria Venture; Christian Loucq, Alexandra Fullem, and David A. Poland at the PATH Malaria Vaccine Initiative; Janet Hemingway; Peter Mullen; Carol Lin Vieira at Burness Communications; Sarah Staedke and Heidi Hopkins in Jinja, Uganda; Allison Branham and Erika Arthun at Williamsworks; the president of Rwanda, Paul Kagame; Joe Cohen and Stephen Rea at GlaxoSmithKline; Ed Scott; Scott Case; Mark Green; Carol Hooks at the World Bank; Tony Blair, Ian Linden, Hannah Wallace, Parna Taylor, and Susie McShane at the Tony Blair Faith Foundation, who provided the introduction to Michael Dwyer and Hurst Publishing; Rob Young at ExxonMobil; Jennifer Gregoire at the Clinton Health Access Initiative; Josh Ruxin; Parag Khanna; Ghanian health minister George Sipa-Adja Yankey; and Martin Dawes and Gaelle Bausson at UNICEF. Not all of these individuals or their organizations are mentioned in the book, but all of them contributed immensely to my understanding of malaria and the campaign.
I was extremely lucky to be able to call upon a host of friends, colleagues, and malaria experts, who all gave up days of their time to read through various drafts of the manuscript and make comments and corrections. Without exception, these were invaluable. Simon Robinson, a former colleague and editor at Time, and someone who shares my experience of Africa and India, went through the text with his usual meticulousness and offered wise and very specific advice on nuance, structure, and logic. Richard Brown went through the book line by line and offered great insight into structure and argument. Max Askew had wise words on narrative and composition and picked up a number of mistakes. Julian Marshall cast his expert eye over the financial sections and brought his eagle-eyed editing skills to bear on a late draft. Colin Perry was also a great help on the sections on business. Any remaining errors are my own.
Thanks also to Pieter Hugo, photographer supreme and friend, for gracefully agreeing to take the author picture and a special mention too to Dominic Nahr, star of Magnum and regular traveling companion, who agreed to let me use his pictures of Apac in some editions.
And finally, thanks and love to Tess, who reads all my drafts, and my girls, Katya, Grace, and now Olivia. Malaria kills children. Mine are why I wrote this.
Notes
CHAPTER 1
1 Paul Edward Okello, Win van Bortel, Anatol Maranda Byaruhanga, Anne Correwyn, Patricia Roelants, Ambrose Talisuna, Umberto d’Alessandro, and Marc Coosemans, “Variation in Malaria Transmission Intensity in Seven Sites Throughout Uganda,” American Journal of Tropical Medicine and Hygiene 75, no. 2 (2006): 219–225, http://www.ajtmh.org/cgi/content/full/75/2/219.
2 Ibid.
3 Interview with Dr. Matthew Emer, Apac, August 2009. All quotations from Emer in this chapter are from this interview.
4 Interview with Lameck Abongo, Apac, August 2009. All quotations from Abongo in this chapter are from this interview.
CHAPTER 2
1 Brian M. Greenwood, David A. Fidock, Dennis E. Kyle, Stefan H. I. Kappe, Pedro L. Alonso, Frank H. Collins, and Patrick E. Duffy “Malaria: Progress, Perils, and Prospects for Eradication,” Journal of Clinical Investigation 118, no. 4 (April 1, 2008): 1266–1276, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2276780/?tool=pmcentrez.
2 Mats Wahlgren and Maria Teresa Bejarano, “Malaria: A Blueprint of ‘Bad Air,’” Nature 400 (Aug. 5, 1999): 506–507.
3 David L. Smith, F. Ellis McKenzie, Robert W. Snow, and Simon I. Hay, “Revisiting the Basic Reproductive Number for Malaria and Its Implications for Malaria Control,” Hay, Public Library of Science: Biology, Feb. 20, 2007, http://www.plosbiology.org/article/info:doi/10.1371/journal.pbio.0050042.
4 Emma Rabino Massa, Nicoletta Cerutti, and A. Marin D. Savoia, “Malaria in Ancient Egypt: Paleoimmunological Investigation on Predynastic Mummified Remains,” Chungara: Revista de Antropología Chilena 32, no. 1 (2000): 7–9, http://www.scielo.cl/scielo.php?pid=S0717—73562000000100003&script=sci_arttext.
5 Sonia Shah, The Fever: How Malaria Has Ruled Humankind for 500,000 Years (New York: Sarah Chrichton Books/Farrar, Straus, and Giroux, 2010). Of all the histories of malaria and malariology, Shah’s has the dual virtue of being the most comprehensive survey of malaria literature and the most recent.
6 Brian Greenwood, “Malaria Chemoprophylaxis in Endemic Regions,” in Malaria: Waiting for the Vaccine, ed. G. A. T. Targett, London School of Hygiene and Tropical Medicine First Annual Public Health Forum (New York: John Wiley and Sons, 1991), 83.
7 John Noble Wilford, “Malaria Is a Likely Killer in King Tut’s Post-Mortem,” New York Times, Feb. 16, 2010, http://www.nytimes.com/2010/02/17/science/17tut.html.
8 Shah, The Fever, 91.
9 “Frequently Asked Questions,” The Resource to the Sickle Cell Disease Patient, http://sicklecell.md/faq.asp#q9.
10 Cheston B. Cunha and Burke A. Cunha, “Brief History of the Clinical Diagnosis of Malaria: From Hippocrates to Osler,” Journal of Vector Borne Diseases 45 (Sept. 2008): 194–199, http://www.mrcindia.org/journal/issues/453194.pdf.
11 Fiammetta Rocco, The Miraculous Fever Tree: Malaria and the Quest for a Cure that Changed the World (New York: HarperCollins, 2003).
12 Telephone interview with Richard Feachem, April 2009.
13 Shah, The Fever, 182–184.
14 Ibid., 189–190.
&
nbsp; 15 http://www.ibiblio.org/hyperwar/USA/ref/Ann/index.html.
16 Shah, The Fever, 194–196.
17 Ibid., 207.
18 Ibid., 199.
19 David Cutler, Winnie Fung, Michael Kremer, and Monica Singhal, “Mosquitoes: The Long-Term Effects of Malaria Eradication in India,” Harvard University, May 2007, http://www.hks.harvard.edu/var/ezp_site/storage/fckeditor/file/pdfs/centers-programs/centers/cid/growth/events/20070531/gates_cutler_malaria_070527.pdf.
20 Shah, The Fever, 199.
21 Ibid., 212–216.
22 Patrick T. O’Shaughnessy, “The Flying Cat Story, or ‘Operation Cat Drop’: A History of This Often-Told Tale,” n.d., http://catdrop.com.
23 Shah, The Fever 211.
24 Ibid., 205.
25 Telephone interview with Feachem, April 2009.
26 Ibid., 216.
27 Interview with Brian Greenwood, Nairobi, November 2009. All quotations from Greenwood in this chapter are from this interview.
28 Interview with Marcel Tanner, Ifakara Health Institute, Tanzania, August 2009.
29 Interview with Bob Snow, Nairobi, May 2009.
30 P. L. Alonso, S. W. Lindsay, J. R. Armstrong, M. Conteh, A. G. Hill, P. H. David, G. Fegan, A. de Francisco, A. J. Hall, F. T. Shenton, et al., “The Effect of Insecticide-Treated Bed Nets on Mortality of Gambian Children,” Lancet, 337 (June 22, 1991): 1499–1502, http://www.ncbi.nlm.nih.gov/pubmed/1675368.
