Ending malaria in Africa any time soon is nearly hopeless. And in trying, Jeffrey Sachs and Bill Gates may be doing more harm than good.
Image by Chris Nurse Wellcome Images
In early 2008, I rented a house in Zouérat, a little Mauritanian town at the western end of the Sahara. I was working for a Canadian mapping company, and needed a place to house a crew of pilots and geophysicists used to splitting time between Toronto apartments and Saudi hotels. Pickings were slim in a place where the few houses with flush toilets were almost all occupied by tan Frenchmen working as overseers at the nearby iron mine. After about a week, though, my fixer found me something perfect. It was right on the road to the airport and had air conditioning and a pool. It even came with a cook, merrily grilling kebabs on the patio when I came to sign the papers.
None of the locals believed me at first, and it took an old Canadian pilot, the kind of Africa hand who flies a Cessna in a turban, to make the diagnosis.
It was only later, after we’d moved in, that I thought to ask the fixer why he’d taken so long to show me the house. He waved his hand. “They had to clear out the Australian that was there,” he said, absently. “He died of malaria.”
“Malaria?” I wasn’t taking any prophylactics.
“He must have got it on a trip to Guinea.” He laughed, like the poor Australian had died of herpes. “There is no malaria here.”
Two months later I had my own case. None of the locals believed me at first, and it took an old Canadian pilot, the kind of Africa hand who flies a Cessna in a turban, to make the diagnosis. Still, most of the Mauritanians I worked with shared the fixer’s view—that I was overreacting, and malaria wasn’t a problem in Zouérat.
Malaria kills about a million people every year. It’s a guileful disease, not a brutish one like yellow fever or smallpox. Unlike those two illnesses, it doesn’t attack in big sweeps, killing some and leaving survivors with permanent immunity. It can hide out in cysts in the liver for years. It’s likely that much of the adult population of Zouérat was infected and that few if any of them knew or cared. Certainly, few of them knew the statistics that worry Western aid agencies: 90 percent of the people who die every year from the disease are Africans, most of them very young children, most of them undiagnosed.
A 2010 book by the journalist Sonia Shah helps explain how the disease could be so widespread but widely ignored by Africans. The Fever: How Malaria Has Ruled Humankind for 500,000 Years, is a history of the disease, but also an attempt to look at the dialectic between Africans—who have lived with the disease for years—and those Westerners who attempt to cure it. In the West, one of the fundamental assumptions of the axis of development economists, philanthropists, and NGOs involved in plotting a happy new future for Africa has been that malaria is a primary cause of misery on the continent, contributing to poverty and the AIDS epidemic. The ubiquitous Columbia economist Jeffrey Sachs has written that Malaria in Africa could be controlled with an investment of just three billion dollars a year. In one of the foundational papers of the Western aid movement, he argues that doing so “offers the potential to initiate a virtuous cycle in which improved health spurs economic growth and rising income further benefits human health.” In other words, Africa could be transformed by attacking a single mosquito-borne disease, and for the amount of money it takes to build a mid-market baseball stadium. What are we waiting for?
Shah complicates this picture. Might malaria be a symptom rather than a cause of poverty? Might the billions of dollars spent fighting malaria by Western organizations like the Bill and Melinda Gates Foundation be, at best, another example of misspent Western dollars and misplaced Western hopes, or, at worst, another example of neo-colonial meddling?
Malaria kills about a million people every year. 90 percent of the people who die from the disease are Africans, most of them very young children, most of them undiagnosed.
The parasite that causes malaria, plasmodium, probably started out as a microscopic pond scum, floating on the top of still water and surviving by photosynthesis. It then invaded the gullets of the mosquitoes that bred in the same pools. The one genus of mosquito it infested, anopheles, deposited its little tenants in the blood of the humans it fed on. Eventually, somewhere in East Africa, it learned to live in the rich medium of human blood, and a disease was born.
About 50,000 years ago, when the first virulent malaria parasite, P. vivax, evolved, it killed its way across Africa with cataclysmic efficiency, eliminating almost all its potential human hosts. Today, almost all sub-Saharan Africans are descendants of the people who survived, and are totally immune to P. vivax. The other major species of malaria, P. falciparum, emerged much later, and now that humans have had time to evolve some resistance to vivax malaria, it accounts for almost all malaria deaths worldwide.
Falciparum affected the genome of Africans too. Sickle-cell, the trait that sometimes causes sickle-cell anemia, is a way of making blood cells too slippery for falciparum parasites to attack. Sickle-cell is a genetic liability, but in malarial areas it was a good evolutionary bet, and today as many as 40 percent of Equatorial Africans have the sickle cell gene, and are mostly immune to both major forms of malaria.
By the start of the colonial era, when the Portuguese first began raiding the West African coast, the relationship between Africans and malaria seemed downright symbiotic. Malaria killed many children and some pregnant women, but it rarely killed other adults. In much of Europe and North America the winters that forced the Anopheles mosquitoes into dormancy broke the cycle of infection and made it impossible for sufferers to ever really develop immunity. Falciparum attacked European explorers with relish, and prevented any sustained white penetration of the tropical interior until quinine became widely available, in the late nineteenth century. Shah retells the story of David Livingstone’s trip down the Congo River, which was the first missionary expedition to successfully penetrate the heart of the continent. Livingstone made it by taking a quinine dose that was fifteen times larger than what most white colonists rationed from their meager supplies, and he began the long process of liberating the interior natives from, as he put it, their “Kingdom of Darkness.”
Knowing this history, some Africans actually look fondly upon a disease westerners think of as a scourge. At one point in The Fever, Shah describes a scene in which a group of earnest malariologists have assembled at an international meeting in Cameroon in 2005. Somehow, a nattily-dressed local journalist gets onstage, and, instead of thanking the good doctors, he begins to hector them. “Channeling the 19th-century king of Madagascar,” Shah writes, who claimed that “no invader could take on his country’s hazo (impenetrable swamps) or tazo (its malignant malarial fevers), he extolled ‘General Anopheles’ for thwarting the armies that would have attacked Africa.” Shah goes on: “‘And now you scientists,’ the journalist said, smiling and gesturing at the crowd, ‘are trying to take him on again!’”
The problem Bill Gates and Jeffrey Sachs face is the white man’s burden in the twenty-first century: how to call the shots without looking like an overseer.
Shah’s book may be a good antidote to simplistic ideas about the history and politics of malaria in Africa. But its main argument is also a bit troubling. “Not everyone living under P. falciparum’s spell considers their situation an unmitigated misfortune,” she writes, summing up her thesis. “It isn’t easy to live with malaria, but those who survive the gauntlet (sic) of a falciparum-infected childhood gain a powerful immunological advantage over others. P. falciparum, deadly for outsiders, can no longer kill them.” In other words, Shah is almost proud that people living in poor and pestilential parts of the world have learned to live with a disease that kills hundreds of thousands of their children every year. And malaria does come off as righteous in this book, punishing hubris and rewarding decency and simplicity.
It certainly comes off better than the people trying to eliminate it. Throughout the twentieth century, almost all the famous malaria fighters were confident to the point of delusion, and such egotists that they make Mussolini, who drained the Pontine Marshes to try and eliminate Malaria from the environs of Rome, seem collected and humble by comparison. William Gorgas, famous for clearing malaria from the Panama Canal Zone, clearing an epidemiological path for the diggers, actually did nothing of the sort, and only really succeeded in preventing malaria among the white engineers on the project. The black diggers suffered an infection rate ten times as high. Gorgas became a celebrity in the United States, and was rewarded an honorary Knighthood of the British Empire.
Another, Fred Soper, led a maniacal anopheles eradication drive in the nineteen fifties, trying to spray every inside wall of every house in every malarious zone in the world. Soper, backed by the Rockefeller Foundation and working for the World Health Organization, sprayed DDT in more than 1.4 billion homes. His Global Malaria Elimination Programme eliminated malaria in some wealthy places, like Singapore and Sardinia. But by the nineteen seventies, partly as a result of Soper’s efforts, the break in infections allowed malaria to come back deadlier than ever. When mosquitoes began to develop resistance to DDT, which was the first successful treatment to the disease, and the world lost interest in malaria, it attacked with new intensity people who had initially benefited from western spraying programs, killing adults like unexposed children and leading to new epidemics in places like Brazil and India. He never even attempted to spray in sub-Saharan Africa.
In his papers, Soper kept a card with a quote from another Rockefeller foundation veteran on it: “Experience proved that the best way to popularize a movement so foreign to the customs of the people…was to prosecute it as though it were the only thing left in the universe undone.” You could put this in a bullet point on the website of the Gates Foundation, or of the Roll Back Malaria partnership, a WHO-sponsored umbrella group founded in 1998. Like the Rockefeller foundation’s attachment to the one-shot kill of DDT spraying, the Gates foundation is particularly invested in developing a malaria vaccine, something Shah notes would probably be too expensive and ineffective to save many lives. But it could be developed and distributed almost entirely without the involvement of African governments and would be the kind of centerpiece achievement that wins Nobel Prizes. Roll Back Malaria explicitly prohibits local governments from involvement in its drug and net distribution campaigns.
For half a century now, malaria has been attracting interlopers, just as it once repelled them. Shah’s response to this irony is to argue that “the only way” to get rid of malaria is for westerners to back off. Sort of. She wants western governments and companies to hand over technology and know-how—the production and distribution of nets and drugs—to African governments. Which is another way of approaching the problem that Bill Gates and Jeffrey Sachs face: the white man’s burden in the twenty-first century is to call the shots without looking like an overseer.
And here Shah seems to have fallen into the middle of the conflict she raises: If Africans aren’t, by and large, consumed with fighting malaria, how can they lead a drive to eradicate it? In fact, as Shah points out, that experiment has already been tried. Five years ago the Global Fund to Fight AIDS, Tuberculosis, and Malaria gave a $170 million dollar grant to various sub-Saharan African governments to buy advanced anti-malarials from the French pharmaceutical firm Novartis. “Novartis had knocked down the price considerably,” she explains, “and, expecting a flood of new orders, kicked up production.” They had grossly overestimated demand. “Despite the available funding, African governments ordered less than half of Novartis’ supply, and the company had to destroy millions of the arduously produced tablets.”
The real way to get rid of malaria is to reverse the dynamics of rural-to-urban migration and build comfortable, stable rural communities first—something that is probably never going to happen in Africa—and then to attack the disease. The key way the disease is spread is by infecting people without resistance. Rural to urban migration, the kind that dominates in Africa today, promotes the spread of the disease. Malaria disappeared from the Fenlands of England before anyone even knew it came from mosquitoes, and before quinine had been synthesized. Living conditions went up, people began buying cattle, which gave mosquitoes an alternate source for a meal of blood; the tradition of migrating back and forth to London died out, and malaria died out with it. It only disappeared from the American South after the slow death of the sharecropping system.
In this sense, Jeffrey Sachs and the Gates Foundation are working against themselves, by pushing development and fighting malaria at the same time. Development, in its African form, helps plasmodium, by encouraging people to move from rural areas to cities full of fetid pools and open water tanks, by bringing huge projects like dams and mines that draw migrant laborers and disrupt natural drainage systems, thus exposing those without any immunity to the disease. There’s no way, for example, that malaria could exist in the part of the Sahara where I worked if it weren’t for the French-built mine that brought infected farm workers from the south of the country to live in Zouérat, next to a fecal oasis where the sewage from the expatriates’ houses drained into a swampy grove of palm trees—a perfect place for anopheles to breed. The people in Zouérat mostly lived in tents, and would never have used bed nets. An anti-malaria drive there would have saved no children, but it might have killed a few adults, by exposing them to a new infection. We didn’t need Shah’s book to tell us that there’s probably no hope of getting rid of malaria any time soon. Its real value is in showing that we may do more harm by trying.
When I got it, I had no idea what was wrong with me. My main job in Mauritania was to keep the crew healthy—pilots in Mauritania often spend as much time in latrines as cockpits—and I had looked at Canadian government maps that showed Zouérat to be malaria-free. The fever, though, wasn’t like the stolid fever that comes with the flu. Malarial fevers are capricious, and demoralizing. It’s a relief when a flu fever breaks—the sickness is almost gone. My malarial fever would swing, within a couple of the Sopranos reruns I watched to pass the time, from 102 degrees down to 96, and back again. The climb back was always the worst: my temperature would rise so quickly that it felt like my sweat was freezing on me like frost on a windshield.
The other classic sign of malaria is an achy and weak back. When I was lying down—which was most of the time I was sick—I had a constant, maddening sense that I was lying in some strange contortion, and that if I could only sit normally my back would stop hurting. I would adjust, and the pain wouldn’t go away. Ten minutes later, my brain muddled by fever, I’d switch back. When I walked around my head felt so heavy that I let it hang, and went everywhere looking like I had just dropped a quarter. I have never been a hardy descendant of the Bantu, but it was much worse than the flu, and I thought I was going to die.
I laid up in my hotel room for a week, until the pilot figured out what was wrong with me, and for a week after that, waiting to see a doctor and finally convalescing. During that time, the only person I saw or spoke to regularly was the owner of my hotel, a bald, cranky Mauritanian Arab named Lembrabott. Every few days, when I came downstairs for my breakfast of baguette and Tang, he would inspect me, grabbing my chin and lifting my head up. “Still sick?” he’d ask.
When I mumbled an affirmation, he’d laugh and drop my head back to quarter-searching position. “Americans complain about everything,” he said once. Then I would shuffle off to bed.
Lembrabott refused to believe I had malaria, and didn’t think it would have been something to whine about even if I did have it. My company wouldn’t pay for a Medevac, though. So eventually he took me to his personal doctor, who gave me quinine, which cured me within days. “Hm,” Lemrabott said the day I went back to work, “You look better. You shaved. ”
Lemrabott made the same assumption Shah would: that, had it been he, or another Mauritanian in my place, he would have held his head up. This is probably true, if only because he assuredly had some immunity to the parasite. For both of them, malaria calls up questions of honor that go beyond an already complex epidemiological fight. Summoning the spirit of Malagasy kings and attacking Bono are appeals to a kind of pan-African dignity. For some Africans, resistance to malaria is literally in their blood; for many of the rest, they’ve earned their immunity, without drugs, and without asking for Western help. Guys like me, only there to profit off what’s under the ground, ought to be able to handle a couple weeks of fever.
James Pogue is a writer living in Brooklyn and a researcher at Architectural Digest.
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