TCS Daily

Medical Malpractice at the World Bank

By Roger Bate - April 25, 2006 12:00 AM

Every year, malaria kills Africa's children by the million and impoverishes their families. The World Bank, as the world's largest aid agency, made a handsome commitment to combat malaria; but the commitment was only partially honored and the investment was misspent. As 12 academic and think-tank colleagues and I demonstrate in the latest Lancet (25th April "The World Bank, False Financial and Statistical Accounts, and Medical Malpractice in Malaria Treatment"), it's time the Bank's directors stopped throwing good money after bad management and leave the malaria business to more competent agencies.

In 1998, the World Bank along with other health agencies launched the Roll Back Malaria campaign, promising to halve malaria deaths this decade. The Bank made an unprecedented pledge before Africa's heads of state in 2000: It would spend $300-500 million to fight malaria in Africa. This promise of funding was warmly welcomed, since contemporary economic arguments held that malaria cost Africa dearly -- perhaps on the order of tens of billions of dollars a year.

But the Bank failed to deliver. And rather than admit such failure with candor, it concealed the fact using opaque and contradictory accounting. In 2001, the Bank made the impressive claim that it had "about $450 million out in various forms of anti-malaria programs." But by 2002, it appeared to backtrack, writing that "Bank direct financing for malaria control activities is over US$200 million." In just one year, the Bank had slashed a quarter of a billion dollars of malaria control funding, and nearly halved the number of countries it assisted.

The Bank has also appeared to misuse epidemiological statistics. For example, the Bank claims that in Brazil, its $73 million malaria control project was a success because it "reported malaria cases dropped by 60 percent, from 557,787 in 1989, to 221,600 in 1996". But none of the other sources of statistics -- all of which roughly agree and seem mutually confirming -- are consistent with the Bank's claim. According to the first-hand statistics of the Brazilian government, the decline was just 23 percent. Overall, neither the Brazilian government nor the Roll Back Malaria Partnership statistics support the Bank's interpretation that its project achieved a deep reduction in malaria in Brazil.

In India, similar discrepancies occurred where the Bank claimed 80 percent reductions that were in fact 48 percent -- and it is uncertain what role the Bank played in said reductions anyway. Since the Bank refused us access to their data, we simply don't know to what degree their claims are exaggerated.

But worst of all, the Bank approved clinically obsolete treatments for a potentially deadly form of malaria in India. The deadly species of the malaria parasite (Plasmodium falciparum) has evolved resistance to the drug chloroquine, so that treatment often fails and patients progress to more severe disease or die. Chloroquine resistance is associated with a two- to eleven-fold increase in malaria deaths, particularly in children. Accordingly, the World Health Organization's (WHO) guidance since 2003 has been that chloroquine should not be used when the treatment failure rate exceeds 15 percent. Instead, the WHO gives preference to artemisinin combination therapies (ACT) as first-line treatment.

The Bank has disregarded these medical realities. Although claiming in 2005 that it "applies WHO policies and guidelines," we found 6 occasions (five in India) in 2004 where the Bank approved purchases of chloroquine in its projects knowing it would be used to treat drug-resistant P. falciparum malaria. The Bank did so despite references in its own Global Strategy & Booster Program to 25 studies which showed chloroquine typically fails to treat 34 percent (and up to 96 percent) of Indian malaria patients. There is known, severe chloroquine resistance in locations where the Bank funds malaria control, such as Maharashtra state. The use of chloroquine in these circumstances violates a very important WHO guidance -- and is both a waste of money and a waste of lives.

Had a doctor or pharmacist done as the Bank -- i.e. ignored professional guidance to prescribe ineffective treatments for a potentially fatal disease -- he would be found guilty of medical malpractice.

My co-authors on The Lancet article suggest that the World Bank sends its malaria allocation to an agency better able to spend it properly. While I agree with this, I hold a less rosy view of some of these agencies than they presumptively do. With all agencies encroaching on others' turf (see here, for example) it is unclear that any such bureaucracy will spend the money very well. But the Bank is probably the least qualified to enact disease control programs. Indeed, it is operating beyond its remit in doing so. At the very least it should be relieved of that burden.

Roger Bate is a visiting fellow at the American Enterprise Institute and cofounder of Africa Fighting Malaria.



Forgive my naivety if it is warranted, but how much would it cost the World Bank to send, say 50,000 Peace Corps. volunteers on a year long mission to spray every corner of every dwelling from Cape Town to Alexandria with DDT?

Anybody who wishes to constructively criticize this idea--Please don't cite that silly 60's book about the ecological damage DDT does to eagle eggshells.

Who's to Blame?
Look --- the World Bank is just that --- a BANK. If it fails to provide the money it promised for a public health program, that's one thing. It hasn't met its obligations. On the other hand, it is not a medical authority and can only provide funds to those medical authorities that it deems will do the job.

To assume that WHO can do the job is an absurdity. If there ever was a bigger waste of time, money and effort, it is the World Health Organization. This highly politicized and utterly inefficient organization shouldn't be given the responsibility for first aid in a kindergarten playground. On top of that, not only are its guideline often based on specious information (or no information, just politically expedient "ideas"), they frequently disregard their own guidelines.

My experience with WHO has engendered within me a permanent feeling of total disgust for the organization. Not only is their medical work substandard (I am being kind here.), they have no control over the money they send as part of their programs.

The World Bank has done a much, much better job of collecting and analyzing public health data; it has provided more cogent strategies for dealing with public health issues; and it has placed all of this into a contextual framework appropriate to the weltpolitik. This has been impossible for WHO --- an organization that doesn't maintain the survey data necessary for any cogent analyses and strategizing, and is influenced by the political positions of the UN --- which is stretching its charter vastly by running WHO.

The World Bank is not responsible for the malaria problems of the globe. The WHO has been addressing the issue ineffectively for far longer --- and with inane policies.

As I said, if the World Bank actually promised to provide money and it did not, that is one thing. It is not, however, an executing medical authority, which WHO alleges it is. And just because you published something in Lancet doesn't make it so.

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