Amir Attaran is a biologist and a lawyer by training but a gadfly by nature. The son of Persian immigrants, he is now a professor of law in Ottawa University. He also has undertaken postgraduate research in immunology in Oxford. A polymath and a contrarian, his inquisitive mind has led him to reveal the dodgy practices of some monolithic institutions, from the Canadian Army to the United Nations.
The World Bank became his focus in the late 1990s. The Bank, founded as part of the Breton Woods agreement that realigned the post war world economy, was intended to act as it was described: as a bank. It was to lend to countries that required funding for infrastructural or other projects.
Decisions on what the bank funds are taken by the G8 industrialised nations and within its constitution is the obligation that an American is always its president. An oft-held criticism of the bank is that, despite representing 186 countries, it pushes the liberal economic agenda of just these few wealthy states. In the 1990’s the Bank and the IMF agreed the “Washington Consensus’. This was an understanding that they would act on the mantra of ‘stabilize, privatize and liberalize’ when dealing with developing countries.The bank now attaches conditionalities to its loans that incorporate this thinking. For the governments of developing countries, it is like getting a loan to pay their mortgage while promising to sell their house.
So what has this to do with malaria? In what has been described as an unwanted ‘mission creep’ the Bank became involved in funding healthcare projects. In 1998 it initiated its ‘Roll back malaria campaign’. Malaria was rightly seen as a drain on the productivity of the developing world. As such, the World bank pledged 300-500 million dollars in funding for malaria treatment, hoping to improve the balance sheet.
In an explosive Lancet Article in 2005 Attaran drew the attention of the world’s scientific community to huge failings within the campaign. He showed that the Bank was either falsifying, or at best manipulating, statistics regarding malaria in Brazil, showing a decrease in the incidence of malaria during the course of the Bank’s campaign. The reality was that there had been an increase in cases. The Bank’s campaign had been a failure. Attaran also showed that a commitment to hundreds of millions of dollars of funding by the Bank had been reneged on and then covered up by false accounting.
Some of the claims made by the Bank during this period, even for the untrained eye, were simply unbelievable. One report stated that Kenya had 135 malaria deaths in 2002, and Iran had 1·4 million malaria deaths in 2003 when Kenya is one of the world’s most malarious countries and Iran is one of the least.
How could they get it so wrong? One of the main reasons was that the Bank had no malaria expertise. Prior to the campaign starting they had fired all their malaria experts. Essentially, they were shooting in the dark.
One of the most disturbing failures involved the Bank’s funding of malaria treatment in India. In order to understand the controversy one must know a little about the treatment of malaria. Chloroquine is an old drug, discovered in the 1930’s in a German laboratory and used to treat malaria since the second world war. It is still a useful drug in some areas, but, as the twentieth century progressed genetic mutations occurred in some plasmodia resulting in a chloroquine resistant form of malaria spreading.
At the beginning of the malaria campaign the World Bank referenced twenty five studies showing that chloroquine resistant malaria was present in 34% to 96% of patients in India. The WHO, the body that regulates international health, had said that in areas where there was greater than 15% resistance to chloroquine, a newer alternative drug, ACT, was to be used. Nevertheless in 1998 the World Bank bought 100 million chloroquine tablets to be distributed in India.
Alarm bells began to ring with Amir Attaran and his colleagues and they began to look more closely at the World Bank’s work in India. They showed that on six occasions in 2004 the Bank approved purchases of chloroquine in its projects knowing the drug would be used to treat chloroquine-resistant P falciparum malaria. Attaran claimed that the Bank was complicit in the deaths of thousands of Indians, mostly children, saying that there actions were tantamount to medical malpractice.
The World Bank was already rocked by controversy at this time as its President, and in a former life, the architect of the Bush administrations invasion of Iraq, Paul Wolfowitz, had been forced to stand down due to corruption charges involving his mistress.
Attaran’s article, after an initial denial by the bank, helped spark an internal review of all health funding by the bank . The review found that corruption and fraud was rife within the Bank’s AIDS, child health and malaria programmes. Pharmaceutical companies paid by the bank were found to have been complicit in maintaining artificially high prices for their drugs during the tendering process and providing non-functioning mosquito nets.
Robert Zoellick, Wolfowitz’s replacement as president, announced to the world that the report showed ‘unacceptable levels of fraud and corruption’. On foot of this the Bank revamped its malaria department, employing forty malaria experts to help direct their malaria programme and giving a commitment to root out fraud and corruption..
Attaran, in his article, urged the World Bank to hand over the money it had to fight malaria to organisations who were specialised in the area, such as the Global Fund. However the World Bank continues to be involved in the fight against malaria, and criticism of its involvement persists. After all, when you’re sick, you don’t call your banker.