Sticking it to the Mosquitoes

Samiha Shafy | 09 Aug 2006
Spiegel

Every 30 seconds an African child dies of Malaria. The new chief of the World Health Organization's malaria program, Arata Kochi, set out to deal with deadly mosquitoes -- but he's also is having to battle angry environmentalists and the prickly pharmaceutical industry.

It's oppressively hot in the small, stuffy conference room at the Geneva headquarters of the World Health Organization (WHO). But 57-year-old Arata Kochi seems perfectly relaxed. The new chief of the organization's malaria program smiles often when he speaks. Sometimes he chortles from his throat -- even if his good humor doesn't really fit the topic of conversation.

One of the stories he likes to tell is that of how he dealt with the delegates of the various nations and groups represented at a conference of the international Roll Back Malaria (RBM) project that was held last November. "I asked them to evaluate their performance. They replied it was so-so. I told them: It's not that your program is so-so, it's that you've failed completely." the Japanese Kochi tells the story in a cheerful tone. "They all hate me," he says. And his look is almost a little pleased as he relates this state of affairs.

But there was little the conference participants could present in the way of facts to rebut Kochi's harsh criticism: Initiated with much pomp by more than 90 organizations in 1998, the RBM project set itself the ambitious goal of reducing the malaria mortality rate by half by 2010. The opposite happened: Today, more people are infected with malaria worldwide than ever before.

In Uganda, the infection rate has risen by about 700 percent during the past 10 years. In Burkina Faso, the rate has increased by 250 percent. Forty percent of the world's population live in regions where a single mosquito bite can mean death. Africa is affected most seriously, especially the sub-Saharan region, where three out of four new malaria infections occur.

Crashing through the bureaucratic jungle

An estimated 500 million people are newly infected every year -- as many as three million of them die from the lethal fever. Children are especially at risk: In Africa, a child dies of malaria every 30 seconds, according to a WHO estimate.

Kochi's predecessors have all failed to meet the challenge these figures present -- the WHO has gone through eight chiefs of its malaria program in the last 10 years. The disputatious doctor could have avoided the risk of suffering the same fate: Until a few months ago, he had a comfortable position as an advisor to the United Nations in New York. He played plenty of golf and felt "ready for retirement." But instead he was talked into returning to Geneva and "getting a grip on malaria" by the now deceased former general director of the WHO, Lee Jong Wook.

In accepting this mandate, the epidemic warrior is now risking his good reputation. And he has one to lose: He's been respected worldwide ever since he was chief of the WHO's tuberculosis program during the 1990s. Even then, he crashed through the bureaucratic jungle like a bulldozer, snubbing even mighty donors like the Rockefeller Foundation. But his success silenced the critics: The number of tuberculosis patients receiving adequate treatment worldwide rose from 2 to 60 percent under Kochi's tenure.

When it comes to fighting malaria, on the other hand, almost everything has gone wrong so far: Many countries have no reliable data on the infection and death rates; aid organizations circulate contradictory information about the proper method of treatment; and there is a lack of infrastructure and qualified personnel in many places.

"The malaria community is fragmented," Kochi says. "Everyone talks a lot, but no one has a strategy." His goal is to provide the countries affected with solid data and the best advisors. He wants to develop a multilateral system to coordinate the worldwide development of malaria medication. "The capital that the WHO disposes of is professional competence and contacts in developing countries," Kochi says. "Other people have the money."

It's clear whom he means: The Bill and Melinda Gates Foundation. The Microsoft CEO's giant foundation is already spending more money than the WHO to curb the spread of epidemics such as AIDS, tuberculosis and malaria -- about $3 billion dollars a year. The WHO's malaria budget for 2006 and 2007 seems laughable by comparison: $137.5 million, and not even half of that sum is certain.

Kochi would love to have a say in the distribution of such foundation's funds. "I sent them my program, and they promised me feedback," he says. But of course he knows the Gates Foundation needs the WHO less than the WHO needs the Foundation: "The only chance to be respected by these people is to give the impression of being more competent and more clever, of having the better ideas."

For now Kochi is using the weapons he has at his disposal. In January he began his first great offensive -- against the global pharmaceutical industry. During a press conference, he called on the pharmaceutics corporations to stop producing medication that contains only the active ingredient artemisinine. The WHO manager says artemisinine should be used only in combination with another active ingredient. Otherwise there is the danger that the parasite will become resistant -- which is what has happened with most of the other medication that used to be effective.

An ultimatum to companies

Kochi gave the pharma giants 90 days to meet his demand. Otherwise, he threatened, the WHO would stop certifying the medication they produce for Third World countries.

Some producers reacted with outrage, claiming that they were being blackmailed. But Kochi's move has turned out to be effective: 17 of 40 pharmaceutics makers have already agreed to begin producing medication with more than one active ingredient. One of them is the German producer of generic pharmaceuticals Denk Pharma, based in Munich.

"We were shocked because we had invested a great deal of money in product development," says export manager Alexander Lenk. "But following Kochi's appeal, the health ministries in many African countries have started to listen up, and they have lost interest in monotherapies."

The next item on Kochi's battle plan is the bane of many an environmentalist -- the notorious pesticide DDT. "We need a large-scale, military DDT campaign in the style of the 1950s," Kochi says.

Back then, spraying houses with the powerful insecticide was the central element of a worldwide campaign to exterminate the malaria carrier the Anopheles arabiensis mosquito. At first, the campaign's success was impressive: The number of malaria cases sank drastically in countries such as India, Sri Lanka and Bangladesh. But new, resistant mosquito strains soon appeared -- the reason, however, was that tons of DDT were also being sprayed on cropfields.

Then environmentalists sounded the alarm: They warned that the poison becomes more potent as it travels through the food chain, to the point where it kills or causes harm to other animals too. True, no one has yet been able to prove that DDT is harmful to humans. But the ecological lobby won out: The chemical was banned almost everywhere in Europe. Many Third World countries were made to stop using the life-saving poison. The use of DDT in houses and huts is now legal in only five African states -- Swaziland, Namibia, Madagascar, Ethiopia and South Africa.

"Of course DDT is a threat to the environment. So what?" asks malaria expert Amir Attaran of the University of Ottawa. "The risks are minimal compared to the threat represented by the disease itself."

Attaran belongs to a group of scientists who are fighting to correct the mistakes made in the current global effort to fight malaria. He's often attacked the WHO. But now the Geneva-based organization's harshest critic has turned conciliatory: "Kochi is the first promising malaria chief the WHO has had. All of his predecessors were terrible."

"If I fail with malaria, that's all people will remember," Kochi says. He's now sitting bolt upright on his chair in the WHO conference room. His smile has vanished. He's giving himself a maximum of three years before he wants to have achieved a success comparable to the one of his tuberculosis program. "I didn't take on this job just to fail," he says.

http://service.spiegel.de/cache/international/spiegel/0,1518,430196,00.html