Battling a Scourge
To reach the most malarial town on earth, head north from Kampala, cross the Victoria Nile and, just before you come to the refugee camps that mark the southern edge of Uganda's 20-year civil war, turn east to Lake Kwania. Africa's other Great Lakes are known for freshwater beaches and cool evenings, but Kwania is more of a giant swamp: shallow, full of crocodiles and choked with lily, papyrus and hyacinth. The malaria parasite loves it here.
Kwania's creeks, looking like a million silver fish bones from the air, are perfect for a deadly subspecies of mosquito, Anopheles funestus, which feeds almost exclusively on humans, with an appetite to shame a vampire. The nearby town of Apac is packed with a living blood bank of people. The average funestus bites human flesh 190 times a night. The average resident is bitten tens of thousands of times a year, including 1,586 bites — four a day — that carry malaria.
Driving into Apac late on an August day last year, I saw a naked man lumbering toward me. Tall and thin, he was gray with dust, and his hair bristled with twigs and grass. He was talking to someone only he could see. Edging past, I was surprised by a second naked figure lurching out of a side street. He had the same cracked skin stretched over the same slender frame. Ahead, a third naked figure sat by the side of the road, his head in his hands. I felt as if I'd arrived in a town of zombies.
Apac's empty streets reinforced that impression. The town seemed to exist only for sickness and death: on one road I counted 12 medical centers, 10 drugstores and a crumbling, windowless nursing school. Soon I found a building that belonged to the Ministry of Health. I pulled in, entered and followed a dark corridor to a door marked "District Health Officer." I knocked. Behind two sets of fly screens and under a ceiling fan, Dr. Matthew Emer sat at his desk. I explained I was following a new campaign to rid the world of malaria and was in Apac to see what it was up against. Who were the naked men? I asked. "Brain damage," Dr. Matthew replied. "Severe malaria can do that to a baby. You never recover."
Dr. Matthew thought I should see some statistics. Apac is home to 515,500 people. Between July 2008 and June 2009, 124,538 of them were treated for malaria. That meant 2,000 to 3,000 patients a week for Dr. Matthew and his three fellow doctors, and the number rose to 5,000 in the rainy season. Of Apac's malaria patients, nearly half were under 5.
Signboards erected by the side of the road announced the presence of two foreign-assistance programs. One was a European-funded child-protection group, which had no malaria component to its program. The other was the National Wetlands Program (NWP), funded by Belgium. Partly because of NWP's influence, the draining of malarial swamps is banned — which amounts to preserving wetlands at the price of human life. Spraying houses with insecticide — which in 2008 cut malaria infections in half — is also forbidden. Why? Because of objections from Uganda's organic-cotton farmers, who supply Nike, H&M and Walmart's Baby George line. Chemical-free farming sounds like a great idea in the West, but the reality is that Baby Omara is dying so Baby George can wear organic.
The Problem with Helping
This, too often, is how aid goes: good intentions sidetracked by ignorance; a promising idea poorly executed; projects that are wasteful, self-regarding and sometimes corrupt. The people being helped often see things this way, as do the ones doing the helping, who ask why the hundreds of billions of dollars given to Africa since World War II have changed so little. It was in the face of such controversy that in 2007 the aid world unveiled one of its most ambitious goals: eradicating malaria.
The history of malaria is a long one. Originating in West Africa, it spread to half of humankind by the mid–19th century and has killed tens of millions and infected hundreds of millions more, including eight American Presidents. Malaria played a role in stopping Alexander the Great in India. It contributed to the fall of Rome, the relocation of the Vatican and the U.S. defeat in Vietnam. It still rages in the poverty-stricken world: it killed 863,000 people in 2008 — 89% of them African, and 88% of those people children under 5 — and infected 243 million more, says the World Health Organization (WHO). The lobbying group Malaria No More reckons that the disease costs Africa $12 billion a year — 1.3% of its economic growth. Fixing that would be the biggest boost to health and development in history. It would also be a stunning riposte to aid's critics.
It could happen. A previous campaign against malaria in the 1950s and '60s effectively eliminated the disease in Europe and the U.S. but made little progress in Africa and Asia, in part because health officials concluded that those places were simply too tough to fix. This time things are different. Now more than ever, it's unacceptable — indeed, immoral — to see Africa and Asia as beyond help. Today's funding is unprecedented, exceeding $10 billion. So is the leadership, from the U.S. President to the Sultan of Nigeria to soccer star David Beckham. Their goal is threefold: universal protection by the end of 2010 via the distribution of 700 million insecticide-treated bed nets; no more malaria deaths by the end of 2015; no malaria at all a decade or two after that.
The logistics of such a plan are less complex than they seem, because while malaria affects half the world's countries, just seven — the Democratic Republic of Congo, Ethiopia, Kenya, Nigeria, southern Sudan, Tanzania and Uganda — account for two-thirds of all cases. So how might this malaria campaign succeed where so many others have come unstuck?
The Unlikely Leader
High above the Serengeti, Ray Chambers unclips his safety belt and beckons me to follow him to the back of the plane. At 67, Chambers, the U.N. special envoy for malaria, is graying and a little stiff, but with his square jaw, Clint Eastwood voice and the plane — his own — there is still something of the Master of the Universe about him. The son of a Newark, N.J., warehouse manager, Chambers was in his 20s when he came up with the idea of the leveraged buyout, a concept that made him fabulously rich — but not happy. In 1987 he found himself visiting a project for inner-city teenagers in Newark. He promised to pay the college tuition of 1,000 kids "if they stayed the path." That made him feel great. So in 1989 he closed his investment firm and became a philanthropist, giving away $50 million by 1993.
In 2005, Chambers was looking at a photograph of sleeping Mozambican children taken by his friend the Harvard economist Jeffrey Sachs. "Cute kids," he remarked. "You don't understand," replied Sachs. "They're in malarial comas. They all died." Chambers was mortified. "So I said to Jeff, 'I'd like to kind of come up with business concepts to see if we can't save 1.3 million children a year.'" The next year, he established Malaria No More — a group that raises money, implements programs and stands as a case study of how aid can change.
The ethos of Malaria No More is that aid should be seen not as a noble act of charity but as something that's in everyone's interest. Eradicating disease boosts productivity, creates markets, stabilizes governments — even gives celebrities a point. It's a route to prosperity. Official endorsement of Chambers' approach came in 2008 when U.N. Secretary-General Ban Ki-moon appointed him special envoy. "You could see Ray was the guy to get this done," says WHO head Margaret Chan.
To be fair, he was not alone. Many companies are doing well by doing good, realizing that, say, an HIV program at a South African mine cuts absenteeism. A nuanced vision of a successful company is taking hold, one that elevates social responsibility to a core mission — and was backed with $14.5 billion in the U.S. in 2007, according to the Chronicle of Philanthropy.
Partly as a result of Chambers' prodding, that new way of giving aid has encouraged Western governments to open their wallets too. Funding for malaria has exploded from $50 million in 1997 to $6.6 billion for the Global Fund to Fight AIDS, TB and Malaria and $5.5 billion for the President's Malaria Initiative, a U.S. program launched in 2005. A good example of how aid is creeping into our lives in subtler ways is Unitaid. Founded in 2006 to raise money for AIDS, TB and malaria through small taxes on air tickets and check boxes on e-tickets, it has so far raised $870 million.
Religion has caught the bug too — as it were. Rick Warren's Saddleback Church in Lake Forest, Calif., is training health workers in western Rwanda. The heads of the Muslim and Christian faiths in Nigeria are training hundreds of thousands of imams and priests in malaria care and net and drug distribution. Help also comes from retired politicians like Bill Clinton and Tony Blair, who have both set up aid foundations. Blair, whose Faith Foundation is assisting the Muslim-Christian collaboration in Nigeria, told Time, "The nature of help is changing. The malaria campaign is about as good an example as you get of rebalancing the respectability of the aid case."
Real Results
The payoff can be spectacular. malaria has been at least halved in nine African countries since 2000. Ethiopia and southern Sudan should reach universal protection this year; Chambers predicts global bed-net coverage in the first quarter of 2011, just months past his target. A visit last August by Chambers and Chan to the children's ward of a Zanzibar hospital produced whoops of joy from Chan. It was empty.
That success is hardly universal — or permanent. Zanzibar has eradicated malaria twice before but each time reimported it from mainland Tanzania. Kenya, an early success story, has slipped. Congo has only just got going. What do these failures have in common? Bad government. When Chambers visited Tanzania in August 2009, he found an approved $111 million Global Fund grant lying unclaimed for want of a single signature. In Uganda, Global Fund grants totaling $367 million were suspended over allegations — now before the courts — of corruption involving three health ministers and several aid groups. "The house is on fire," Chambers told a meeting of ministers and aid groups in Kampala last August. Chan was blunter: "We will hold you to account on behalf of the 350 women and children who die every day here." That, too, is a face of aid.
In Apac I visited the town hospital the morning after I arrived to find 30 newly admitted babies. When I returned that night, there were another 10. Martin, 27, was the only nurse on duty, and he was equipped only with quinine — long ago phased out in the West when malaria became resistant to it — headache pills and sugar solution. I watched him try to stick an IV needle into a 4-month-old girl, Doris Amang. He tried the backs of both her hands, then both sides of her head. Doris screamed and kicked. After pricking her 12 times, he gave up. Her veins had collapsed from dehydration. The windows were wide open. I watched a mosquito settle on Doris' cheek.
The next day, I returned. There were 50 babies now but no sign of Martin or any other staff member. The mothers were looking to me, but I had nothing to offer. I left the ward, walked quickly to my car and headed for the gates. Nearby was a naked street walker, feeling his way along the fence. As I roared past, I caught a glimpse of his startled expression, his emaciated face. I drove out of town and didn't stop until I reached Kampala.