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).