A historic opportunity

OVER THE SHORT TERM, diseases such as the black plague and AIDS have killed more people than malaria. But medieval generations gradually built up resistance to the bubonic plague, and the discovery of antibiotics ended its deadly rampage. AIDS is a relatively young disease, a couple of decades old, and medical advancements are coming fast.

Malaria, by contrast, has stalked humanity since the beginning of history, reaping corpses beyond counting. It is a killer unlike any the world has known, a parasite that may have snuffed out more people since its origin than any other. And it’s getting worse.

Malaria kills anywhere from 1 million to 3 million people a year, 90% of them in sub-Saharan Africa, most of them children under age 5. A study last year found that the child-mortality rate from malaria roughly doubled between 1990 and 2002, thanks largely to the parasite’s growing resistance to older drugs and a breakdown in Africa’s healthcare infrastructure. Every 30 seconds, or about the time it took to read this far, a child’s heart is stilled by malaria.

Over the last six years, Africa’s misery has become an international issue. Groups such as the United Nations and the World Health Organization have set concrete targets on reducing malaria by 2010 or 2015. Funding of anti-malaria initiatives has risen sharply. The good news culminated in President Bush’s commitment in June to spend $1.2 billion over the next five years to fight the disease.

Yet nobody on the front lines is declaring victory. Future funding for Bush’s malaria project is uncertain. The Global Fund to Fight AIDS, Tuberculosis and Malaria, the largest source of funding for anti-malaria efforts, raised less money in 2005 than 2004, and the outlook for the next two years isn’t promising. The world is spending only about a tenth of what it would take to effectively fight the disease.

At this rate, none of these international goals for reducing malaria will be met. Millions more children will die, and a historic opportunity to crush one of mankind’s most potent enemies will have been lost.

America gets serious

Last year, something surprising happened in the Senate: Key lawmakers began demanding answers from the U.S. Agency for International Development about its malaria programs, a topic that had been widely ignored for years. Congressional hearings on the subject proved highly embarrassing for USAID; at one hearing, a former administrator had to admit that she couldn’t account for how the agency had spent its $80-million malaria budget in 2004.

Finally, in December, USAID released a report breaking down its malaria allocations. The results pleased no one. Only $4 million, or 5% of the malaria budget, was being spent on proven interventions such as bed nets and anti-malarial drugs in other countries. The rest was going to U.S. consultants. Mostly, these consultants help African countries apply for grants from the Global Fund, though some also work on more concrete projects such as building a sustainable marketplace for bed nets in Africa.

During the 1990s, development assistance fell sharply, and USAID’s existence was threatened. Instead of phasing it out, though, Congress transformed it into a contracting organization. Rather than giving money to foreign governments, it began giving money to American contractors. It formed a symbiotic relationship with these organizations: They would lobby Congress for more money on behalf of USAID, and USAID would distribute it to them. How they do it is anybody’s guess. It is nearly impossible for outsiders to track whether USAID programs are effective, or even to tell how the money is spent.

USAID’s report on its malaria funding didn’t placate its Senate opponents, particularly because it was an extremely sloppy document, using only vague descriptions of project activities and numbers that didn’t add up. Sen. Sam Brownback (R-Kan.) responded with a bill requiring USAID to spend a majority of its malaria money on concrete interventions such as pesticide spraying, bed nets and drugs, and to improve its transparency.

The bill never came to a vote, and it is languishing in the Senate. But it had an effect. Brownback, a powerful force in the social conservative movement, discussed malaria and USAID’s shoddy record with Bush. A week before a Group of 8 meeting in July at which aid to Africa would be at the top of the agenda for the club of industrialized nations, Bush announced his $1.2-billion malaria initiative.

The plan seems designed to address the key criticisms of USAID. Dr. Ali Khan, acting chief of the malaria branch at the U.S. Centers for Disease Control, insists the majority of the money will pay for proven techniques rather than contractors, and that every dollar spent will be accounted for on a publicly accessible website. The $30 million needed for the first year of the project has already been approved by Congress, but the proposed funding will ratchet up later, and the initiative’s future is unclear in the face of widening budget deficits.

Although the anti-malaria initiative sounds good on paper, it is still being administered by USAID; given the agency’s lack of transparency and cozy relationships with contractors, that doesn’t inspire much confidence. Malaria could be fought more effectively by giving the extra money to the Global Fund.

And the Global Fund could really use it.

A visionary program in danger

The Global Fund to Fight AIDS, Tuberculosis and Malaria spends more to fight malaria than any other entity. Created by the G-8 and the United Nations in 2001, it has very low overhead and, unlike USAID, its spending records are thorough and easy to access. Global Fund money goes to pay for the treatments and programs that recipients most need, not what outside governments think they need. So far, about 31% of the money awarded by the Global Fund has gone to fight malaria, with the rest spent on programs to fight AIDS and tuberculosis.

One-third of the Global Fund’s budget comes from the United States. In 2004, total world contributions to the fund came to $1.53 billion. This year, they dropped to $1.28 billion. The U.S. contribution dropped during that time to $352 million from $459 million. For 2006, Congress has already approved a $450-million donation, and a pending budget bill could add another $100 million. That still won’t be nearly enough.

The Global Fund estimates it needs a combined $7.1 billion for 2006 and 2007 to keep existing projects alive and fund new ones. So far, not counting contributions from the U.S., it has only $3.7 billion in firm pledges from the rest of the world for those years.

Even if the Global Fund hits its goal for the next two years, the money spent fighting malaria worldwide won’t come close to the amount needed. The World Health Organization estimates it would cost $3.2 billion per year to pay for all the bed nets, drugs and other interventions needed to meet international goals on reducing malaria. According to the Global Fund, last year the actual amount spent worldwide was $295 million. Amir Attaran, a professor of law and world health at the University of Ottawa who has written extensively on malaria funding, estimates that 2005 spending is less than $500 million. The numbers are equally bad for research on new products that could help eradicate the disease, such as a vaccine or cheaper, more effective drugs. A study released last month by the Malaria R&D; Alliance found that the amount spent on malaria research in 2004 represented just 0.3% of total health-related R&D; investment that year -- yet malaria accounts for about 3.1% of the global disease burden. Thus, spending on research should be roughly 10 times higher.

Previous editorials in this series have described other measures that could potentially eradicate malaria but would boost the costs still more. An advance purchase commitment for a vaccine -- a pool of money held out as an incentive for private industry to research cures for malaria, which otherwise is not a profitable pursuit -- would cost about $4 billion. A global purchasing pool to subsidize the cost of malaria drugs for low-income Africans would cost $300 million to $500 million a year.

Not cheap, by any means. Yet far from impossible for a world motivated to stem the problem. In early November, for example, Bush proposed spending $7.1 billion on a program to protect Americans from a flu pandemic. Although there is a real threat of such a pandemic, it doesn’t currently exist, and one might not ever strike the United States again. There’s nothing theoretical about malaria or its victims.

The cost of doing nothing

In 2002, during a U.N. summit in Monterrey, Mexico, leaders of wealthy nations committed to devote 0.7% of their national income to foreign aid by 2015. A handful of European countries have already reached this goal, and the rest of the European Union has strongly committed to getting there. The United States, meanwhile, has been reluctant even to admit it made the promise. Currently, the U.S. spends only 0.16% of national income on foreign aid, making it one of the biggest laggards among industrialized nations.

Given the economic and human devastation wrought by malaria, effectively fighting it would be well worth the multibillion-dollar price tag, which would only be a small portion of total foreign aid spending if the 0.7% commitment were met. Conquering malaria also would rank with walking on the moon and stemming polio as among the greatest achievements of the modern age.