Sick at the World Bank

Amir Attaran & Roger Bate | 19 May 2006
WASHINGTON - The World Bank is failing miserably on malaria, like it failed on HIV/AIDS before. Although it has a $20 billion budget that, deployed intelligently, could lower sickness and accelerate economic growth, the World Bank is instead making a mess of its reputation and costing patients their lives through its unwise medical judgments. Along with 11 academic colleagues, we overcame stringent peer-review at the world's top medical journal, The Lancet, to publish what we describe here.

Six years ago, the bank made a promise to Africa's heads of state that it would expedite $300 million to $500 million to control malaria on their home continent. It was a landmark promise, but one that the bank now admits it never honored. Years and millions of lost lives later, the bank is keen to get past that failure and has launched another malaria plan, this one costing $250 million to $500 million (i.e. less money) from its own budget.

But the bank's past record suggests that its new promise should not be welcomed. We want more money for malaria, but not at the price of scientific judgments that are negligent and able to kill.

The bank has always played fast and loose with science. In The Lancet, we revealed how the bank in the 1990s published a scientific paper containing false epidemiological statistics that claimed it reduced malaria in Brazil. The bank's internal documents show statistics different from what it published, suggesting that the falsehood was intentional. And although the bank's error has now been caught, it still has not withdrawn the false scientific paper. If it did so, it would have to admit that at the end of the 1990s, Brazil had more malaria cases than when the bank started its work.

The bank's mishandling of science continues today. Just last month, the bank vocally reaffirmed its decision to use an obsolete malaria treatment — chloroquine —in parts of the world where the clinical evidence shows that it fails to cure patients with the life-threatening species of malaria (called "falciparum").

In India, the bank purchased more than 100 million chloroquine treatments, worth about $2 million, even though dangerous strains of chloroquine-resistant falciparum malaria are rampant there. The bank knows this to be true, but tries to divert blame from itself by saying that chloroquine is a good cure for other, nonfatal species of the disease.

Fine, but so what? Just because chloroquine may work for patients having a nonfatal species of malaria is no excuse to furnish it for patients in danger of dying from chloroquine-resistant falciparum malaria. These patients are usually children and, for them, chloroquine is hardly any more curative than aspirin or jellybeans. The dangers of chloroquine are such that, since 2003, the World Health Organization has instructed that it never be used in settings where more than 10 to 15 percent of patients have resistant falciparum malaria.

Which brings us to the nub of the problem: Even when the science is obvious and the WHO gives clear guidance, the bank still gets it wrong. Buying chloroquine for falciparum malaria wastes money and costs children's lives.

So why is the bank in the disease control business? After all, most people who fall ill would never think to phone their banker for a diagnosis or a prescription.

The evidence suggests that the bank lacks a core competence in the medical sciences and finds itself mired in disease control through a woeful "mission creep." The bank could help more people, more effectively, if it returned to its true strengths in creating and maintaining systems, such as financing the building of clinics and laboratories, or top-up the salaries of doctors and nurses to encourage them to stay in Africa and aid their fellows. Buildings and salaries are not sexy like disease control, but the world needs them, and the bank can provide them.

As for true disease control, the bank should cut a large check to organizations with that core competence — organizations like WHO, or the Global Fund to Fight AIDS, Tuberculosis and Malaria — and exit the field. But rather than taking this pragmatic approach, the World Bank is furiously protecting its "turf", even if it means publishing flat-earth science or risking children's lives. The longer it fights the obvious — that bankers don't cure disease — the more embarrassing it becomes to itself.

Amir Attaran is Canada Research Chair of Law, Population Health, and Global Development at the University of Ottawa. Roger Bate is a director of Africa Fighting Malaria and a resident fellow at the American Enterprise Institute.