TCS Daily

Why Consensus In Malaria Policy Is a Killer

By Roger Bate - November 10, 2006 12:00 AM

Last week the Roll Back Malaria (RBM) Partnership, a coalition of multilateral organizations whose aim is to halve malaria by 2010, joined World Bank chief Paul Wolfowitz in musical concert at the Bank to remind the public that the disease is still the leading killer of African children. They called upon development experts and anti-malaria advocates to "Unite Against Malaria," a disease which kills at least a million people worldwide each year. Yet RBM is unlikely to revive its failing campaign by demanding consensus.

Irreconcilable differences are fundamental to human nature because so much of life itself is uncertain. Malaria is no different. It is a complex disease whose control strategies must be tailored to a specific context, location, parasite and vector. Debates about which tools and strategies work best are fraught, but there are some things that can be agreed upon.

To this end, RBM's follow-up to the World Bank event was a "messaging meeting" intended to get US and global anti-malaria advocates speaking with one voice on the basics of malaria. Controversial topics about which organizations would likely disagree were avoided. Instead, the very basics of malaria, its dangers, and methods of control were paraded around the group by an expensive P.R. firm. The very same end could have been achieved by emailing a summary paragraph to the group from RBM's 2005 World Malaria Report. Ultimately, RBM spent a huge amount of money over two days to achieve little, including few news headlines.

This effort was typical of the way the United Nations (UN) system works. Consensus is required to initiate action, and so irreconcilable differences among countries routinely impede progress. What RBM neglects to realize is that controversy has driven the most significant evolutions of malaria control efforts in the past eight years.

The Abuja Summit to Roll Back Malaria in 2000 brought together 44 African countries to agree on specific malaria control targets for 2005, notably covering 60% of at-risk populations with nets and drugs and allocating 15% of country budgets to healthcare. Everyone signed up and almost no one met any of the targets, few even really bothering to try.

In 2004, a team of researchers looking into failing malaria control policies published evidence that the Global Fund to Fight AIDS, TB and Malaria, in conjunction with other partners, were routinely funding outdated drugs. The study made headlines around the world and the result was a dramatic change in the way donors set treatment policy and fund drugs. In 2005, I was involved with a different group of researchers in a study of USAID's malaria control spending, revealing that it devoted around 90% to consultants and technical advice instead of life-saving nets, drugs and insecticides. Various Congressional hearings used this information to put pressure on USAID to account for its policies. The result was a complete redesign of the organization's malaria control operation.

In 2006, Dr. Arata Kochi, new head of WHO's Global Malaria Program, successfully courted controversy from within the RBM Partnership. He made public a list of drug companies producing Artemisinin monotherapy drugs, arguing that this defied WHO's revised malaria treatment guidelines, and would lead to drug resistance and the loss of a valuable weapon against malaria. The result was that about half of the companies agreed to start making the drugs in combination. More recently Dr. Kochi reissued WHO's indoor residual spraying (IRS) guidelines, noting correctly that IRS with DDT was uniquely effective against malaria but consciously sidelined by donors wishing to avoid environmentalist scorn.

RBM's response has been to marginalize Dr. Kochi. Shockingly, neither he nor the Washington, D.C. WHO representative were initially invited to the RBM event at the World Bank last week. Although this author has published more about the World Bank and malaria over the past year, perhaps than anyone else, he was also not invited. The obvious reason for the WHO omission is that in spite of pushing consensus RBM does not want the WHO - a founding RBM partner - involved in its public relations efforts.

Indeed, the woeful RBM partnership (including the reforming USAID, the obstinate World Bank, the dysfunctional UNICEF and many from the private sector) continues to promote its ludicrous target of halving malaria deaths. I say ludicrous because RBM has no real idea of what constitutes malaria rates today (something most accept when you ask them), so halving rates is just a PR gimmick. It set the target in 1998, to be reached in 2010, and still hasn't tried to estimate death rates properly in 2006 - the World Bank at least is trying to measure death rates. But far more damaging is RBM and the Bank's search for consensus; the consensus desired is more of the same policy (bed nets and drugs), which hasn't worked (or at least not noticeably) since the best estimates show malaria rates are increasing.

RBM is currently undergoing a much needed and anticipated "change process." But instead of employing expensive consultants to help it change, it should just allow divergent views on policy. RBM seems to stick its head in the sand, and simply doesn't invite those with different ideas. As long as consensus remains, policies will stay the same, and more African children die.

I had hoped that with major change occurring at USAID, with policies being enacted that will save lives and with the new head of malaria at WHO making lots of sense, and with a rational head of the World Bank, that RBM would embrace change. But apparently not.

Its time to Roll Back RBM. Scrap it and let WHO's Dr. Arata Kochi lead on disease control policy.

Dr Roger Bate is a Resident Fellow of the American Enterprise Institute.



One question, one comment
Having played on the periphery of mosquito control issues for a few years and having met many people trying to work in Africa and Americas, I have one question.

Can malaria be reduced so long as the governments were it exist remain so extremely corrupt from top to bottom? Certainly the UN and all its bureaucracies have not solved the problem [Nor will they in my life time.]

I certainly understand the need for DDT as a surface spray but having worked on environmental policy related to mosquito control for a long time, I have yet to figure out a way around extreme objections of the environmental NGOs.

Pursuing Malaria Policy Change
The UN is a disaster attempting to address let alone complete anything. But how do we pursue whomever to get WHO to be the lead on malaria control?

Don't mention DDT - I did once but I think I got away with it.
That the article is entirely right about the need not to defer to a PC consensus is proven by the fact that the author dare make only 1 mention of DDT by name (end of 6th last para).

Before rich people with nothing better to do in the developed world foisted a virtual DDT ban on the 3rd world malaria deaths were down to 50,000 a year rather than the current half to one million. When it is said that the "environmental" movement has killed more people than Hitler it is malaria deaths due to DDT banning that they primarily mean.

One question
You say you have years of experience "on the periphery of mosquito control issues." Maybe you can elucidate for me just which environmental NGO's have extreme objections to the practise of indoor residual spraying. I can't think of any.

Greenpeace and the WWF, for instance, are on the team now.

The Stockholm Convention, which is the international protocol against the use of persistent organic pollutants (POPs) specifically permits the use of DDT in the form of IRS for the prevention of malaria.

The question is quite separate from that of agricultural uses of massive amounts of DDT in open air settings. This practise is indeed controversial for very good reason. IRS, on the other hand, entails surface applications of tiny amounts of the substance, and is the most effective means of malaria control in most regions-- with only a very few exceptions.

What I have seen appears to be a manufactured controversy. Everyone from the WHO on down supports IRS. No one opposes it. Are you sure the continuing articles we read in the corporate press aren't just a stalking horse to open the door wide to unrestricted DDT use for purposes other than malaria control?

My question, again, is whether you can name any environmental NGO's, or indeed anyone nowadays, who opposes IRS.

Not quite the disaster you describe
They're already there, mrbennett. The WHO advocates the use of IRS for malaria control.

This PC consensus you mention...
The WHO endorses the IRS method of malaria control. So does the Stockholm Convention against POP use.

So does Greenpeace. So does the WWF. In fact I haven't found a single organization that opposes it.

Do you think you might have just uncritically swallowed everything you've read by our Mr Bate, without actually checking to see whether it was true? You can look at my other two comments here (above) for position statements by everyone and his kid brother that the world unanimously approves of indoor residual spraying of DDT in this setting.

The guy that convinced you environmentalists were killing more people than Hitler is pulling your leg. Dust off your search engine and see what people are actually saying.

Greenpeace et al have the blood of millions on their hands
Roy, took a look at that article you posted an url to. To me it looks pretty damning of the far left NGO's actions over the past 30+ years on trying to make sure DDT was not used to effectively combat Malaria in Africa, thereby killing MILLIONs needlessly.

Granted that these NGO's might now be changing their mind, but that does not help the millions killed by their actions.

Some selected quotes
"Spokesmen for Greenpeace and the World Wildlife Fund (WWF), activist environmental groups that have led the effort to ban worldwide use of the pesticide DDT, have admitted to the New York Times that DDT may be necessary and desirable after all.

The admission comes after a de facto 30-year global ban on DDT that has allowed a resurgence of Third World malaria, killing tens of millions of people."

"The U.S. and other rich countries are siding with the mosquitoes against the world's poor by opposing the use of DDT," wrote Kristof.

"The poor countries that were able to keep malaria in check tend to be the same few that continued to use DDT, like Ecuador," Kristof continued. "The evidence is overwhelming: DDT saves lives.

"But most Western aid agencies will not pay for anti-malarial programs that use DDT, and that pretty much ensures that DDT won't be used," Kristof noted. "Instead, the U.N. and Western donors encourage use of insecticide-treated bed nets and medicine to cure malaria.

"Bed nets and medicines are critical tools in fighting malaria, but they're not enough. The existing anti-malaria strategy is an underfinanced failure, with malaria probably killing 2 million or 3 million people each year."

"It might be easy for some to dismiss the past 43 years of eco-hysteria over DDT with a simple 'nevermind,'" asserted Steve Milloy, an adjunct scholar at the Cato Institute, "except for the blood of millions of people dripping from the hands of the WWF, Greenpeace, Rachel Carson, Environmental Defense Fund, and other junk science-fueled opponents of DDT."

Yesterday's struggle
Valid objections to the massive use of DDT in an agricultural context are very well founded in a large body of scientific research. It's not the "junk science-fueled opponents of DDT" who have noted that it wrecks biological webs and creates resistance on the part of the pests we are trying to eliminate. It's the people who have done the science.

To the extent that that has retarded progress in initiating IRS programs where they have been shown to work, it's very unfortunate. But it is history now. Whatever it is you're still fighting, no one is there any more.

You dismiss millions dead with "it is history now" ???
You dismiss millions killed unnecessarily by far left NGO's (I assume you support) with "it's very unfortunate" and "it's history" !!!

What kind of person are you that you can say that?

I'm fighting the stupidity, arrogance, and blind adherence to far left environmental dogma that led to these deaths, and there are plenty of others as well fighting this (see an NGO I contribute to).

Why don't you all examine your belief system that led to these deaths and possibly find a way not to repeat it?

Sovereignty, money and everyone keeps his job...
There's no magic here. Malaria can be stopped. Fast. We have the methods and we have the materials. Therefore, if malaria is still around in 2006 then someone's alternative interests are being served.

Malaria (just like starvation) is a horrible and completely preventable tragedy. Any government that wants to stop it can easily accomplish this. However, if that government makes a reasonable case that it needs outside funding then lots of entities stand ready to pour in lots of money. In fact, entire new entities will be created just to take a share of this cash flow. Of course, the management teams inside such entities and the deliverables generated by such agencies must be world class. Professionals from this level of the food chain cost big money. Because they could easily be partners at McKinsey, Booz Allen or Bain. And that's where a lot of the money goes.

Just like any consulting firm the principals look for ways to keep their engagements alive. Going slowly, setting partial solution goals (that everyone will sign up to) far out into future periods is only prudent. Struggling mightily with impediments such as corrupt government officials who reject obvious, effective, quick and enduring solutions because they are politically impossible protects the engagement.

These nations cannot stomach being dictated to by wealthy foreign (Western) powers. Their sovereignty and their self respect are on the line. The entire process is patronizing and demeaning. So they smile politely and drag their feet.

Could any sovereign government be stopped from applying DDT to the inside surfaces of its buildings and residences? Of course not. They can afford weapons and ordnance. They can afford 55 gallon barrels of industrial chemicals.

The Malaria Entities get close to any government official who might take such a decision and make certain that he will stay with the program and move carefully (slowly). The best way to get the host government aboard is to work only with those officials who seem reasonable and who play nice with you.

You declare a conference in a very enjoyable city and you cozy up to the smooth players who come to all the receptions. You see if they will accept your gifts of entertainment etc. You schedule next year's meeting in yet another wonderful city. During the year you visit the host countries and accept the hospitality of your new friends. You invite them to give presentations or to participate in panel discussions. They spend a lot of time preparing their speeches and you spend a lot of time coaching them.

Malaria abatement money is transferred to the government and it is swept into their general fund. So the diplomat working with your Malaria Entity becomes a "rainmaker". He says: "Well, let's not be hasty. People in Europe think DDT is quite dangerous to our already fragile ecosystem. And how can we be certain that mosquito nets will be used appropriately. Probably we need to train deployment teams. Should they be civilians or military personnel? Should we let foreigners into the country to talk with those tribes we have been treating poorly? We really need more time to study these problems." And his government listens to him.

It is easy to use the word corruption. This gives us an excuse that everyone already believes in. What we actually have is a global infrastructure that is doing stupid things. But everyone has an excuse and everyone keeps his job. If a guy has spent his entire career becoming an international authority (and a celebrity) fighting malaria then what would he do if there was no more malaria? His game plan must carry him up to retirement. If anyone starts rocking the boat (and saying "Let's stop doing all these stupid things and simply kill the mosquitoes!") then he is branded disruptive and not invited to the next meeting.

Are these people venal and corrupt? I'm sure many of them are professional, responsible and well-intentioned. But if they don't play politics they will not get to participate. And this job is how they send their kids to college.

The Answer is . . . All of the above
I enjoyed reading and agree with many of the above diverse quotes. I worked as a physician in rural Africa for many years (till 2004), and have treated many thousands of malaria patients. There is not one easy answer.
Yes, in theory, IRS and Anopheles mosquito control would be easy. But practically speaking, let's say in Zimbabwe, where the infrastructure used to be good, but is now down to the level of most of the rest of black Africa, how does one actually get out to all the huts with the sprayers? One needs to go in the rainy season when the roads are bad and the bridges are washed out. How many sprayers does it take? How do they get out to all the rural areas? The govt doesn't have the money to fix the cars and buy the diesel to get the DDT out to where it needs to go. The labor laws are left-over euro-socialism/Harvard/Pelosi type ones so that the guy in charge of the local Environmental Health team is a drunk and a thief and can't be fired, and none of his workers want to work, and you can't hire short-term guys either because of bad labor laws.
It goes on and on. It is a social, cultural, ethical, religious, political problem which needs a big answer. Until you get a world-view change, you won't find an easy answer.

Fighting the good fight
I can see your emotional involvement-- but you're fighting a fight that is over. Millions of people are also dying of AIDS while we fight to find a cure we can bring to penniless Africans, even though the rich Americans seem to have found a way to live with it. Medicine has to march on. And I don't believe all that many years passed between the discovery of IRS methods and their adoption by everyone concerned. So we're not talking about Hitler here.

On the other hand we do still have some issues that are alive and in need of your efforts. We fought two world wars, so that the world could be free of the aggression of stronger nations on the weak. Yet today we still have two countries being destroyed by a much stronger conqueror-- Iraq and Afghanistan. Why not devote your efforts to change the world into this channel, and add your voice to that of those of us opposing wars of foreign aggression?

As you're interested in the injustice of the DDT flap, I would recommend reading from a source other than that of, in order to gain some perspective on the matter. Scroll down to the article titled "the Great DDT Hoax":

Make CCT freely available
The problems you mention are all inherent in making governments or NGOs the only ones doing the spraying.

The alternative is making DDT widely available & letting people use it themselves. DDT is not proven, despite all the hype, to have ever harmed a human being & even the claims that it thinned bird's eggshells are weak.

Government run entities in Africa are almost exclusively incompetently run & the NGOs no better. Compare Africa's official telephone system with the spread of mobile phones across the continent which have been directly responsible for the serious economic growth of the continent in the last few years.

If DDT is safe there is no case for controling it so that it can only be sprayed by government employees - but indoor government controled spraying is the furthest the "environmentla" lobby will go.

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