25 Oct

A visit to the malaria heartland

“Do you have malaria in your country?”


“so what do your people die of?”

“well, mostly heart problems”

“ why, what’s wrong with their hearts?”

“we damage them by smoking, and em…..eating too much”

Manyoni studies my face to see if I’m joking. When he realises I’m serious his face creases and he laughs. He finds the idea of people dying from over-indulgence hilarious

We are walking along a dust road towards kaphuka, a village in central Malawi. Manyoni is bringing me to meet Jameson whom he calls his brother. This could mean that he is his brother, a cousin, a friend, or just someone with whom he grew up . Familial relations in these villages are fluid and all-encompassing. We find Jameson sitting in the shade of a baobab tree. It is near midday and uncomfortably warm in the sun. He is taking a break from building a a small hut to house himself, his wife, two daughters and a grandson. It is half-built, the mudbricks to complete it lie drying in the sun. As we talk he picks one up and hands it to me. Pressed into the drying mud I see the flattened form of a mosquito. By its palps, two appendages either side of its proboscis, I can make out that it is an anopheles, the malaria bearer.

Malaria is woven into daily life in Malawi. The word ‘malungo’ in checheyan, the local language, means both malaria and, simply a fever. I ask Jameson when was the last time he had malungo. ‘Last month, and before then, the month before, and before then, the month before that ‘ he answers. He tells me that it usually takes him three to four days to get over a bout. I quickly work out that one tenth of his life is spent in a malarial fever.

The huge incidence of the disease has a significant knock-on effect on the economy of malarious countries such as Malawi. T.H. Weller, a nobel laureate in medicine, once said ‘a malarious community is an impoverished community’. The debate about the relationship between malaria and poverty is ongoing. A paper by the economist Jeffrey Sachs and John Luke Gallup showed that economic growth of malarious countries was 1.3% less then their non-malarious neighbours when other factors were accounted for. Put simply they showed that rather then poverty causing malaria, malaria causes poverty. Sachs and Gallup are sure that it is no coincidence that malarial countries are the poorest in the world, giving the example of Haiti, significantly poorer than its neigbours and the only country in the region to have malaria. If this is true, the eradication of malaria will go a long way to raising people out of poverty.

Throughout our conversation Jameson’s son stands observing us. He is quiet and watchful, unlike the other children I have met here who have been smiling and laughing. He looks undernourished , his clothes are rags and dried mud is smeared on his skin. Before we leave I crouch down beside him and take his hand to try to engage him, to make him smile. I can see his ribs, and, extending below the margin of his rib cage i can see the shadow of his spleen. Even in an emaciated child this is not normal. It’s likely that he has, like his father, been contracting malaria regularly. I ask his father what age he is. “eight” he replies. The child is lucky not to have succumbed to the disease before his fifth birthday. Last year nearly a million people died of the parasite, the vast majority children under five. His chances are much better now that he is a little older, but the malaria has taken its toll. He is very small for his age.

The next day I visit Chawantha, a village set amongst green plains, accessed by a forty kilometre uneven dirt road. As I arrive I hear the swell of multi-harmony singing. From a stone building in the centre of the village the singers come swaying and singing in unison, children around their legs, clapping their hands in time. It is a welcome song and a joyful scene.

The village has been battling malaria for the past ten years by the force of education. Through a scheme provided by an ecumenical church group, funded by US Aid, the villagers of Chawantha and the surrounding region have been taught about the transmission of malaria, the importance of bed nets, how to recognise the symptoms in their children and what to do when they occur. Local female volunteers have responsibility for teaching people about the early signs of malaria and monitoring the use of bednets. It is a simple project but, as Group Village Head Chamwantha, the local chief, tells me, it has had a huge effect.

“ before we started, it was difficult to get any work done in the village. Everyday there was a funeral, and in our culture, everyone has to attend the funerals.”

I ask him how they dealt with malaria prior to the programme

“we thought it was caused by witchcraft, we didn’t realise it was the mosquito giving it to us. Our witchdoctors would give us herbs when the malungo came, or, when pregnant women got it, they would tighten strings around their bellies to expel the fever”

I ask the collected throng if anyone has lost a family member to malaria. A young woman called Katherine Bhri stands and begins to speak confidently. “my child died in 2002. She had a fever one night, I just gave her some paracetamol because I didn’t know then that I should have gone to hospital. She slept that day and when i checked on her in the evening she was dead”

“what age was she”

“two and a half”

She says it without sorrow or pity. Things have changed in the village. It is unlikely any more of her children will die of the disease.

I ask ChiefChawantha what difficulties they had in changing people’s behaviour.

“at first we thought the nets were decreasing our libidos”

I am perplexed. Why would that be? “before the nets the villagers were frequently woken during the night by mosquito bites and as they were awake anyway…. well….’ he looks knowingly at me, cocking his head to the side, the Malawian version of a nudge and a wink, and begins to giggle.

Other, more serious obstacles remain. People now know that when a fever comes that they have to go to hospital, that pregnant women need two doses of a malaria prophylactic in their first trimester and that bednets are necessary. But the hospital is 24 kilometres away on an uneven dirt road; the only mode of transport, if it is available, is a bicycle and the hospital is often without any medications or bednets.

Nevertheless Chief Chawantha proudly tells me that because of what they are doing, they have not had to stop work for any funerals recently. In the fading light, the leader of the women holds her fingers in the air and they begin, singing and dancing in a circle. It is an educational song:

“this is what malaria does, it takes your child away,

so when they have a fever get panadol and L.A

pregnant women in your first trimester

get your drugs in the hospital, sister”

26 Sep

How the Malaria Museum began….

The idea for a Malaria Museum came to Marco Herbst as he stared into a puddle on a street in Maputo, Mozambique. Wild haired and talkative, Herbst tells the story with the enthusiasm of the natural entrepeneur. He had had early success with an internet start-up in Ireland. His simple recruitment website, started just as he left college, and as dotcom mania ruled, had been spotted, and rapidly bought over, by one of Ireland’s richest men. Herbst was happy to take the money and hand over the reins as he already felt a need to change direction. “I wanted to do something for the greater good’ he says.

This feeling led him to take up a position as a voluntary teacher in South Africa. He is unashamed to admit that he soon became bored by the job, ‘it just didn’t match my skill set, I’m an entrepeneur by nature, what can I do?” Still eager to make a contribution he began to follow Bill Gates’ blog about the Bill and Melinda Gates Charitable Foundation: ‘it struck a chord, I would hate to say I recognise myself in Bill Gates but I could see here was a man who was trying, in a realistic way, to use his money and his skills to solve big problems, and doing so by concentrating on first world solutions. He was looking at developing world problems with the eyes of a business man….and I could identify with that’.

After finishing his teaching job, he travelled around Africa when his interest became piqued by the problem of malaria. The disease has been a part of daily life in many parts of Africa for millenia. Since it has been eradicated from the first world it has become largely ignored.

Herbst wanted to get involved in the fight agains the disease. One day as he walked around Maputo he saw thousands of mosquitoes larvae breeding in a pothole on the street. “I know I’m not the person to help fill in these potholes but what else can I do?” he thought. Herbst realised that the solution to the disease was as much about raising awareness in the developed world as it was about distributing bednets in the developing world and so the idea of a malaria museum was born.

15 Sep

The economics of malaria

Jeffrey Sachs is one of the most celebrated economists in the world. He has acted as special economics adviser to the UN, the World Bank and the IMF. In his influential paper of 2001 ” The economic burden of malaria’ written with JL Sachs he tackled the question of malaria as an influence on poverty. In the paper he proposed that malaria, rather then being a consequence of poverty, was a cause of poverty. They  showed that, independent of other factors, the incidence of malaria had a high correlation with economic growth. You can check out a video of Sachs discussing his work on malaria here:


07 Jul

Eradication: a realistic goal?

This week Sam McManus gives us an assessment of the prospects for malaria eradication in an interesting feature article.

Outside the Balseskin Refugee Centre the rain falls hard on a potholed football pitch, the rusting goalposts framing a slate grey sky. In the centre’s health clinic where I sit the decor is as unrelentingly drab as the sky outside. The doctor I am with calls a patient from the waiting room and a sad eyed young Nigerian woman quietly enters. Her bright orange and green robes throw the greyness of the surroundings into relief. On her back is a tiny bundle. She carefully unwraps it revealing a mewling four-month-old girl, her thin limbs outstretched as if beseeching me.

The infant has had a fever for 24 hours the woman says. The doctor immediately runs through a checklist. When did they leave Nigeria? Has she or any members of her family suffered from malaria? The answers to these questions soon has him reaching for the phone to call an ambulance. Even here in Ireland, thousands of miles from the tropics, malaria extends its blighted reach.

The child we have seen is lucky to have fallen sick in easy reach of First World resources. Her chances of survival are excellent. The 850,000 people, mostly children, who died of the disease last year were not as fortunate.

Sam McConkey, now a professor of international health, worked on a malaria ward as a young doctor in Sierra Leone. “It’s a life changing experience to look after children who die despite your best efforts,” he tells me.

The experience made him dedicate himself to the search for a malaria vaccine. A viable vaccine is the long-looked for “magic bullet” that would send malaria the way of small pox.

“The most recent vaccine is 40%-50% effective,” McConkey says. “That’s not good enough, but I am optimistic about it. I like to compare it to the first motor car. It travelled eight miles an hour and was inviable as a mode of transport. But it heralded the car as we know it. Hopefully, we can have the vaccine equivalent of the Model T Ford before long’.

Few are pinning their hopes in the short term on a vaccine, but is progress being made on other fronts? The creation of the Global Fund and the setting up of the Roll Back Malaria campaign a decade ago raised hopes while the private jets of celebrities such as Bill Gates and Bono have been a regular feature at international malaria conferences.

Dr. Malcolm Molyneux who has lived in Malawi for nearly four decades while working on malaria has noticed a difference “In practical terms, things are a huge way on from where they were. Ninety percent of households have bed nets; rapid diagnostic tests and ACT’s, the malaria drug, are becoming more widely available”.

In countries such as Gambia and Zanzibar there has been a marked reduction in malaria deaths over the past five years as a result of these measures. Might these countries act as a model by which malaria can be controlled and then eradicated? Doctor Molyneux is quick to council caution.

“Eradication is not a reasonable (short term) aim. It is maybe forty years away. We need to gradually chip away at things until the goal of eradication appears in the distance”.

Of course, malaria has been eradicated before. The sleepy valleys of sicily and calabria once harboured the disease that in the 1950’s killed up to twenty thousand people a year. Malaria in Italy was eradicated after a concerted five year campaign. If in Europe why not in Africa? Sonia Shah, author of “The Fever: How Malaria Has Ruled Mankind for Five Hundred Thousand Years” explains: “we pretty much know that if we brought all the cities and rural areas in sub saharan Africa up to the level of Europe that would work, but of course, that is not going to happen in the short term’. For the present she echoes Malcolm Molyneux’s call for perseverance. “We need to be in this for the long haul. No expert really believes that there will be zero deaths (from malaria) in a handful of years.’

Despite new momentum in the fight against malaria, the reason that the effort to eradicate malaria is not moving at a faster pace, both Shah and Molyneux agree, remains a lack of political will and funding. The WHO estimates a short fall of $4 billion in malaria funding a year. When Western economies are creaking under double dip recessions and governments are spending trillions of dollars to shore up their banking systems, those combatting malaria must fight to keep the disease on the agenda while making do with limited resources.

For now, NGO’s and local volunteers work on the problem as best they can. As Shah says “we are not going down the right road, we are going down the only road we can go down”. In some places, such as Gambia and Zanzibar, lives are being saved. In others, like the Democratic Republic of Congo, the disease runs as rampant as it ever has.

Back in the doctors room in Balseskin the mother of the feverish infant holds her close to her breast as we wait for the ambulance to arrive. Outside there is no sign the rain is going to stop anytime soon.

03 May

Malaria and Beer: a revolutionary relationship

What do your favourite beer and the cure for malaria have in common? Not much you would imagine, but a game-changing process developed in the University of California Berkeley is using techniques for brewing lager to create an almost limitless supply of a crucial anti-malarial drug.

Jay Keasling , the charismatic Professor of Biochemical Engineering at Berkeley has helped develop a process where yeast, modified by the introduction of synthetic genes, can produce different substances including artemisinic acid, a key weapon in combating malaria.

“The process is very similar to producing beer,” Keasling says. “We put in some sugar and minimal nutrients, and out comes artemisinic acid at the other end”

Previously the amount of artemisinin on the market, and hence its price, has been determined by the supply of Artemisia annua, a chinese herb, that produces the active ingredient of the drug. Now, by synthetically producing some of the Artemisia herb’s genes and building them into yeast, Keasling has produced a low cost means of mass producing the drug.

“With the yields that we are getting now, within 2 to 3 years one 50,000-liter chemical reactor could produce all the drug that is needed in the world” Keasling said.

Initially the company producing the drug is going to release it at market prices, but the hope is that with the ramping up of production the drug will become widely available in the developing world for little cost.

Author: Dr. Sam McManus

12 Apr

The Gadfly and the World Bank

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 on www.caesarsgames.com, 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. If people really want to make some good money what they need to do is to compare the bets at comparethebets.com.

31 Mar

Dr. Ross and the cunning seed

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