Malaria Misappropriation

Roger Bate | 13 Feb 2004
National Review Online

Recent editorials in the Wall Street Journal and New York Times report that the WHO and the Global Fund for AIDS, Tuberculosis and Malaria are implicated in the wastage of American funds intended for malaria treatment in Africa. Both newspapers draw on an original claim of "medical malpractice" by 13 malaria physicians and scientists writing in the top-ranked British medical publication, The Lancet. The implications affect not only the health of those with malaria, but speak volumes about the infirmity of the WHO and Global Fund to tackle the treatment of other diseases, and especially AIDS.

The Lancet authors are angry that these two U.N.-affiliated agencies in 2003 helped to provide malaria medicines that are obsolete to patients in Africa, in conditions which almost certainly will kill many of them. Specifically, WHO and the Global Fund first approved and then funded applications from poor countries for two obsolete malaria medicines (chloroquine and SP) that, because of massive drug resistance in the deadly malaria parasite, fail to treat up to 80 percent of patients who take them. The WHO and Global Fund provided these obsolete medicines in stark violation of their own policy-both say they give priority to a new sort of treatment, known as artemisinin combination therapy (ACT)-but as the experts discovered, the agencies "routinely approve and finance inferior [medicines]" and violated their policy more often than not.

At the core of the allegations are these facts: acting with WHO approval, the Global Fund in 2003 financed and helped to procure obsolete medicines, where official, published WHO treatment advice said to use ACT instead. Across Africa, the Global Fund spent more money to buy the obsolete medicines rather than ACT, in quantities large enough to treat at least 10 times as many patients. Those obsolete medicines were supplied to countries where drug resistance is known to be rampant, and where child mortality of malaria is shown to be up to 1,100-percent higher because of this. As a result, tens of thousands of children died of malaria-and continue to die-who needn't have.

Although both agencies reject the experts' analysis as "wrong", neither has denied any of these core facts, which are unassailable.

The consequences of this mismanagement are so dire that the Lancet, not given to broadsides on the U.N., published the experts' paper in only weeks — warp speed for the academic world — and circulated a press release to draw attention to it. Though WHO and the Global Fund have protested vigorously in public-health circles, on each occasion they look dishonest and more concerned with saving their reputations than with saving lives. Sounding like the consummate flat-earther, the WHO's top man in Ethiopia told the press that no scientific proof of drug resistance exists. It is probably no coincidence that, according to Medecins Sans Frontieres, Ethiopia now has Africa's largest malaria epidemic.

These facts are hard to face for those who think the U.N. can do no wrong, but if their concern for patients in poor countries is genuine, the realities must not be ignored. About 40 percent of the Global Fund's funds originate from the United States, and 60 percent of its grants flow to Africa. That means when the world's top experts condemn its decisions as medical malpractice, both American money and African lives are being wasted.

Roll Back, Malaria?

In 1998, the WHO and the U.N. as a whole launched a flagship campaign to "Roll Back Malaria." The goal they set was to halve the number of malaria deaths by 2010. The pledge was made at the highest levels — it was the top priority for the WHO's former boss, Dr. Gro Harlem Brundtland — and with all the subtlety of mafia dons, WHO made partners of all the world's aid agencies (including USAID) to signed up as partners to WHO goal.

So in 2004, at the halfway mark to halving malaria deaths, what has happened? Malaria has indeed "rolled back" with a vengeance. Rather than declining by 50 percent as the U.N. promised, or even five percent, actually malaria deaths have risen. In WHO's words, there is a "background of increasing malaria burden," though of course WHO avoids to say how much.

If the U.N. ever sincerely meant to Roll Back Malaria, which is doubtful, it would have done at least two things differently. First, it would have used every defensive weapon against malaria in the arsenal, including spraying homes with DDT. Second, WHO would have followed scientists' advice to field ACT much sooner and before drug resistance reached cataclysmic levels. But the U.N. did neither of these things because it was too eager to please another notoriously incompetent bunch, the U.S. Agency for International Development, which for years has stood by its own unscientific reasons why neither ACT nor DDT and not effective and should not be used. No properly informed expert would disagree with using those tools, but it is the fact that USAID disagreed, and held so many of the purse strings for Roll Back Malaria, that the system collapsed under scientific ignorance and achieved nothing.

All this leads to a fascinating question: If the WHO, the Global Fund, and USAID bumbled it so badly with Roll Back Malaria, which was their poster-child campaign of 1998, why should they be trusted in the pole position of the latest global campaign to treat three million AIDS patients by 2005?

According to health scholar Dr. Amir Attaran, who is the principal author of the critical Lancet article, and incongruously, also the intellectual father the Global Fund (he and Jeffrey Sachs first proposed it in a meeting at Harvard in 2000), the problem is scientific incompetence. "We don't want to kill the Global Fund because it is the goose that lays the golden egg," says Dr. Attaran, "but we are not happy that it and USAID were so technically dumb as to blow money on useless medicines." He advises putting independent panel of malaria scientists in charge of deciding what medicines and insecticides are paid for, so that international aid follows the same kind of peer-reviewed quality control that the scientific establishment already uses. He cites the example of South Africa, where scientists run the national malaria program, and where their very unpopular decision to use both DDT and ACT reduced malaria cases 91 percent in only 3 years.

Left to its own, the Global Fund will never accept Dr. Attaran's idea. Congress should therefore force it: either replace the Fund's useless internal scientific review, which made all the errors with malaria medicines and so wasted American money, or forget about American funding in the future. Ditto for USAID: either create a peer-review mechanism, like the National Institutes of Health has, or kiss your appropriations goodbye. Those firm rules — take it or leave it — plus an investigation by the GAO and hearings in Congress to figure out who dropped the ball and killed tens of thousands of kids with the wrong malaria medicines, are the worst nightmare of the Global Fund and USAID, and the best gift for malaria patients. That is why it has to be done.

Roger Bate is a visiting fellow at the American Enterprise Institute in Washington, D.C. and a director of health-advocacy group Africa Fighting Malaria.