Category Archives: Article

12 Apr

The Gadfly and the World Bank

Amir Attaran

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.

31 Mar

Dr. Ross and the cunning seed

Sir Ronald Ross

In 1902 Ronald Ross received the second Nobel Prize for Medicine. Those who knew him while studying medicine in St. Bart’s in London twenty years previously would have been dumb-founded by his achievement.

He was a feckless student. Pushed into medicine by his doctor father and the need to earn money, he concentrated more on his bad poetry, and worse novel writing than on his studies.
On graduating he cast around for a career. His childhood spent in India, he happily took a position with the East India Company in Madras, convinced that this would provide a leisurely medical practice that would allow him to continue with his writing.

As the months passed in the dead heat and stifling humidity of the subcontinent his interest became piqued by the ongoing mystery of the transmission of malaria. Tending to the East India troops he noticed that of two battalions stationed by a swampy pool , the battalion camped on the windward side suffered far less fevers then the soldiers camped on the lee side.

It had long been held that malaria was transmitted to humans through air polluted by swampy ground. This was known as the miasmatic theory which gave us the misnomer by which we still know it, ‘Mal aria’: ‘Bad air’.

Until the late nineteenth century no one had proved that the mosquito was the vector for the transmission of the disease to humans. Very few scientists had even discussed it as a possibility.

A confluence of serendipities led Ross to question the received wisdom. Firstly his complex personality underwent a change while in India. His focus moved away from the arts to a vocational approach to his medical practice.
‘I was neglecting my duty in the medical profession. I was doing my current work, it was true; but what had I attempted towards bettering mankind by trying to discover the causes of those diseases which are perhaps mankind’s chief enemies?” he wrote of the time.

Secondly, returning to England on a furlough in 1894 he made contact with Dr. Patrick Manson, a senior clinician and a leader in malarial research. Manson held the view, incorrectly, that mosquito larvae deposited in water and the water then drunk by humans was the mode of transmission of malaria.

Manson suffered from chronic gout, a painful condition brought on by high-living, that prevented him from traveling to the tropics to prove his theses. In Ross he found his avatar. Ross was not brilliant, but he had an innate energy and a rigour and elegance in the construction of his experiments which Manson recognised.

The main difficulty in proving the link between mosquito, malaria and man lay in the bewildering array of varieties of mosquitoes that existed. Take the anopheles mosquito, the primary malaria carrier. Within its category there are many subcategories, some that do carry malaria, others that do not, their distinguishing feature often being a subtle difference in the colour of their tiny eggs.
Ross was not aware of this and so, catching thousands of mosquitoes and dissecting them without finding the malarial bug, the proof seemed to slip from his grasp like mercury on a mirror.

The breakthrough came on the 20th of August 1897. On dissecting a type of mosquito he poetically named ‘dapple-winged‘ he found malarial organisms in its stomach wall. He went on to find these organisms in other mosquitoes of similar type, in some swarming through the insects head to its proboscis. This led him to think, as opposed to Manson’s theory of humans drinking the larvae, could it be that the mosquito acted as a direct vector, puncturing our skin and introducing the bug directly?

Ross could not find human subjects willing to be stung by a dapple wing and then pricked to show the presence of the bug. His letters show an almost comic reluctance by the Calcutta street people he tried to enlist.

Instead he used birds. His experiment proved conclusive, mosquitoes directly introduced malaria to birds through their bite, the extrapolation being they did the same to humans.

The thousands of hours he had spent in a dark room in Calcutta in stifling heat peering through a rudimentary microscope as he carefully dissected mosquitoes had come to fruition. During these months as the menagerie of birds and vermin in cages surrounding him, brought from the treetops and sewers of Calcutta, chirped and hissed, his perspiration proved a greater boon than his inspiration, until at last, the moment of discovery.

In celebration he wrote these lines:

“This day relenting God
Hath placed within my hand
A wondrous thing; and God
Be praised. At His command,
Seeking His secret deeds
With tears and toiling breath,
I find thy cunning seeds,
O million-murdering Death.
I know this little thing
A myriad men will save.
O Death, where is thy sting?
Thy victory, O Grave?”

Author: Dr. Sam McManus

Sir Ronald Ross