With malaria spread across southern Mozambique, executives at the international mining company Billiton expected some workers to call in sick as it began building a massive new aluminum smelter amid the cornfields here.
What they did not expect was that nearly one in three employees would fall ill — 6,600 cases in just two years. And they certainly did not expect 13 deaths, not after the company had built a medical clinic, doused the construction site with pesticides and handed out bed nets to thwart malaria-carrying mosquitoes.
"You can imagine, it was a huge disaster," said Carlos Mesquita, the general manager. "We could not deal with that level of absenteeism, and we would have had more fatalities. If we didn't treat malaria we could not operate."
But confining measures to the plant, executives realized, would not protect their 1,100 employees, or their $1.3 billion investment, so long as malaria raged all around it, including in the capital, Maputo, just 10 miles up the highway.
And so one of the world's biggest aluminum producers joined in an exceptional partnership with the governments of three countries and with other businesses to take on malaria systematically across a broad region. Six years later, the scorecard is in. Amazingly, malaria is losing.
Wielding a combination of new medicines, better bed nets, old-fashioned pesticides and computer analysis to clean up the most afflicted areas, the smelter and its partners in business and government have turned malaria in one of its former hot spots into a manageable threat.
The results are a rare bright spot in fighting a parasitic killer that has thrived in the face of flawed, inadequate programs by African nations and international organizations.
Last year a United Nations task force singled out the joint effort, which today covers an area the size of Kentucky, as a model for a continent that still has nearly a million malaria deaths a year. The focused effort in southern Mozambique, experts say, may point the way toward a broader and more effective strategy.
The government of Equatorial Guinea and two American oil companies created a similar program three years ago on Bioko Island, whose offshore oil reserves are a magnet for foreign investors. In the June issue of the American Journal of Tropical Medicine and Hygiene, researchers reported initial declines in infection rates there as well.
"There is a trend in the direction of large-scale malaria control projects financed by the private sector," said Brian Sharp, who directs malaria research for the South African Medical Research Council, a quasi-governmental group that studies medical issues. "It is extremely pleasing to see."
Southern Mozambique's success, health specialists say, is rooted in two facts: a realization that malaria can be defeated only if campaigns are taken on regionwide, and a commitment by business and government to put up money and wage war until the disease reaches a tipping point of retreat.
"This is the first time in Mozambique we have used the private sector," said the country's deputy health minister, Avertino Barreto. "The results have been terribly good."
Absences at the plant, once affecting nearly a fifth of the work force, are down to 1 percent. The plant has expanded and doubled its production in the last three years. Even attendance at the nearby primary school is up, officials say.
"We are not suffering from this disease any more here," said Mr. Mesquita, a boyish-looking metallurgical engineer of 47 who greets visitors in a worker's gray jumpsuit.
Malaria is estimated to shave up to 1.3 percent off Africa's growth annually, a cost of roughly $12 billion a year. Health officials here say it remains Mozambique's leading cause of absenteeism and death, even with the advance of AIDS.
Hardly a family, farmer, small business or major investor is immune to malaria's impact. Some companies, like in the sugar cane and tobacco industries, have noted the smelter's success and are now eager to imitate it, if for no other reason than it makes rational economic sense.
Health surveys in the targeted areas in Swaziland and South Africa show that the incidence of malaria plummeted to fewer than 5 cases per 1,000 people last year, from as many as 66 cases per 1,000 in 1999.
In southern Mozambique, surveys show similarly huge drops. Nearly 9 in 10 children who lived near the smelter were infected in 1999. By last June, that had fallen to about 2 in 10, according to the South African Medical Research Council.
The malaria control effort now covers an area that is home to four million people and is expanding with the help of $21 million in grants from the Global Fund to Fight AIDS, Malaria and Tuberculosis. Still, it reaches only a fraction of Mozambique's population, and health experts say a much greater effort is necessary.
The continent missed out on the all-out effort to eradicate malaria that killed off the disease in southern Europe, North America and other parts of the world some 50 years ago. Even though international donations to fight malaria more than doubled from 1998 to 2002, sub-Saharan Africa needs three times as much money as it now spends, the World Health Orgaization estimates.
Indeed, the health organization says, malaria became even deadlier in the 1990's in southern and eastern Africa, partly because of weaker efforts to control it and growing resistance to common malaria drugs.
Children were the most vulnerable: in the 1980's, fewer than one in five deaths among children under 5 in those regions was blamed on malaria. By the late 1990's the toll had climbed to more than one in three. In 2002, 40 percent of outpatients at Mozambique's clinics and 60 percent of children admitted to hospitals suffered from malaria.
For executives in charge of the aluminum smelter, it was obvious that the disease was far too prevalent to fight alone. Andre van der Bergh, regional health and safety adviser for BHP Billiton, the corporation formed when British-based Billiton merged with Australian-based BHP in 2001, estimates that malaria control issues ate up a third or more of his time until the project got off the ground.
"You cannot operate as an island," he said. "I certainly learned the value of partnerships." The government was eager to cooperate. The smelter, known as Mozal — short for Mozambique aluminum — was an important symbol that Mozambique, after a devastating 17-year civil war, was open for business to foreign investors.
Across the border, South African officials were worried that malaria was scaring away tourists. South Africa and Swaziland agreed to join Mozambique in 1999 to fight malaria in the region. Seventy percent of financing for the first three years came from a coalition of 145 South African businesses, which contributed $2.6 million, and BHP Billiton, which kicked in $1.2 million.
Clinics throughout southern Mozambique were supplied with more powerful medicines. The smelter alone distributed 6,141 bed nets — the newest of which repel mosquitoes for five years. And house-to-house indoor spraying of insecticides was begun, including the targeted use of DDT, which remains controversial. Fears that uncontrolled outdoor spraying of DDT would contaminate ecosystems led many nations, including the United States, to ban the pesticide.
Dr. Barreto of the Health Ministry argues that Mozambique should stick to more expensive pesticides that are less risky for the environment. But his superiors were swayed by the World Health Organization's approval of DDT's limited use for malaria control and by South Africa's resumption of its use in 2000 after a four-year break, during which malaria resurged.
Dr. Barreto said the government now planned to apply the indoor spraying of pesticides throughout the country. One day recently, a team of four sprayers hiked down the dirt paths of a neighborhood in Patrice Lumumba, a settlement on the outskirts of Maputo. At nearly every house, residents had a tale of malaria.
Jacinto Maela, 38, a laboratory analyst, hauled buckets of corn and water into his dirt yard. "This is very welcome," he said, "because we suffer a lot from malaria. I have had it three times. The last time, I was off work for three weeks."
Tvete Dimande, medical chief of Maputo's health department, said the campaign's impact was obvious at the clinics. "Previously the hospitals were filled with malaria cases," she said. "People were lying everywhere. Now that number is being reduced. They should have done this a long time ago," she said.
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