Sickening Incompetence

This column was written by Philip Coticelli and Justin Schwab.
The World Bank is publishing inaccurate data to save face rather than face up to its failure to control malaria. Worse still, it is promoting ineffective treatments in India, resulting in the death of an unknown number of children. The Bank is incapable of disease control work and it should leave the field to more competent agencies.

In the 20th century, malaria all but vanished from the developed world. Chloroquine and DDT helped eradicate the disease in North America and Europe, and brought it to a nadir worldwide. In Africa and parts of South Asia and South America, however, the effort was thwarted by lack of basic infrastructure. Today, sub-Saharan Africa is home to 90 percent of reported cases.

More money and attention are devoted to the disease than ever before. We can readily produce drugs, bed nets, and pesticides. So why does malaria remain among the world's deadliest diseases? We have been waging a cheap, sloppy war against malaria, without using all available weapons.

Six years ago, the World Health Organization (WHO) met with the World Bank, USAID, and African heads of state at the Abuja Summit to Roll Back Malaria. Although the attendees committed to halve malaria cases by 2010, it was not a sincere commitment, since they failed to establish baseline figures for the disease — one cannot halve an unknown amount.

While figures are speculative, WHO admitted in its World Malaria Report 2005 that the rate of infection in Africa is likely equal to or higher than that in 2000. But this has not stopped agencies from claiming progress.

A new study in The Lancet disproves these claims. Dr. Amir Attaran et al. charge that the Bank concealed its real expenditures on malaria; reneged on commitments of $300-500 million; cut its staff of malaria experts from seven to zero; published inaccurate data to exaggerate the effects of its programs in India and Brazil; and purchased chloroquine against WHO recommendations and in spite of high rates of parasitic resistance to the drug.

Suprotik Basu of the Bank's malaria-program staff responded to these accusations swiftly, telling Reuters, "Any insinuation that the bank's support for malaria control in Africa or worldwide has been responsible for the deaths of children is misleading and grotesquely incorrect."

The Lancet authors asked the world's top expert for an opinion: Dr. Nick White, professor of Tropical Medicine of Oxford and Mahidol Universities, and chairman of the WHO committee that sets that organization's guidelines for malaria treatment.

Professor White was so horrified by the Bank's false justification, he wrote to them saying "Chloroquine resistance in Plasmodium falciparum has fuelled the resurgence of malaria in India over the past two decades. In much of malaria affected India, both malaria species [vivax and falciparum] are present. I cannot find evidence in the public domain that supports your contention that chloroquine still works well for falciparum malaria in areas where the World Bank has supported chloroquine deployment. Do you have this evidence? It is the cornerstone of your defense. It is clearly wrong to support ineffective treatments for life threatening infections."

Professor White — and India's children — awaits the Bank's response.

Like other donors, the Bank has relied too much on bed nets and too little on indoor residual spraying (IRS) with insecticides. Bed nets appear convenient since one can pretend that distribution equates with use. For example, the U.S. Agency for International Development (USAID) passed out the equivalent of one net per home in Togo and Zambia and claimed 90 percent coverage against malaria. It relegated to a footnote the fact that only 56 percent of those nets were being used (and that amount does not mean they were used properly all night).

After much congressional pressure USAID is now promoting IRS — and allegedly with DDT, a chemical that has long been stigmatized. Contrary to popular belief, DDT has not been shown to cause human cancer. In addition to ridding the developed world of malaria in the mid-20th century, DDT has been used recently in Africa to great effect.

DDT use has been restricted by donors taking a passive stance, requiring countries to pursue every alternative before using DDT. Some donors are more overt in their opposition. Last year, the EU threatened Uganda with trade sanctions if it purchased DDT for public health programs.

Africa Fighting Malaria, a health advocacy group we work with, is lobbying USAID and the World Bank to spend more on anti-malarial drugs, nets, and insecticide and less on technical advice and conferences. They hope to see DDT de-stigmatized and used more widely by African countries. Signatory supporters of their work include Nobel Laureates Archbishop Tutu, F.W. de Klerk, Norman Borlaug, Roy Innis, and Patrick Moore (co-founder of Greenpeace).

AFM's campaign has contributed to recent shake-ups in malaria control at USAID, but it is unclear if their message will reach the World Bank and the greater Western public, which has long been told that DDT is unacceptably dangerous.

Dr. Attaran et al. argue the Bank should end its haphazard management and donate the money to the Global Fund to Fight AIDS, TB and Malaria. In contrast to the Bank, the Fund disburses money quickly, and is already the largest single donor for malaria control. The Bank disbursed a mere $150 million over the past five years, while the Global Fund disbursed $151 million in under 7 months. The Fund operates more transparently than the Bank, publishing and updating records on its website. It is committed to using all available means to control malaria. Along with bed nets and effective drugs for worldwide use, the Fund is buying DDT for targeted use in South Africa, Swaziland, Mozambique, and Zambia. We agree that the Bank's money would be better spent by the Fund — where it will promote the image of DDT not as a killer but as a life-saver.

Philip Coticelli is a consultant for Africa Fighting Malaria and works at the National Institute of Neurological Disorders and Stroke. Justin Schwab is a graduate student at the University of California (Berkeley). They received no remuneration of any kind from the chemical or pharmaceutical industries for this article.

By Philip Coticelli and Justin Schwab
Reprinted with permission from National Review Online