Bill Gates is on a
mission - to rid the world of infectious
diseases. One of the biggest challenges involved
is the eradication of malaria, which kills three
million people every year - most of whom are
under five, desperately poor and African.
Michael Specter asked the richest man in the
world how he is going to do it. Illustrations by
Matt Dennis 'It just blows my mind how little
money has been spent on malaria,' Bill Gates
told me. 'I keep asking myself, Do we not care
because it doesn't affect us?'Malaria's ability
to mutate rapidly and evade new drugs has made
it nearly impossible to control 'Global health
is our lifelong commitment,' Gates said. 'Until
there is no real gap between us and them, that
will always be our priority' 'The economic
conditions of the industrial world are better
than at any other time. People should have
strong pangs of conscience'this article
originally appeared in the New Yorker 'We are
watching children die every day. You could save
30 to 50 per cent of them with nets
alone'apnaashon zalk/corbis
Agency
Each May,
representatives from the 192 member nations of
the World Health Organisation travel to Geneva
to set policies for the coming year. The
assembly lasts a week, and the delegates often
find themselves devoting as much of that time to
politics as they do to matters of life or death.
Last year, on the opening day, Elena Salgado,
the assembly's president, spoke bluntly about
the growing chasm between the 'rich world',
where people live in health and comfort, and
everywhere else. The mortality rate for infants
in the developing world is 16 times greater than
it is for infants in the West, she told the
delegates. And at least one woman dies every
minute from avoidable complications of
pregnancy. Half of these deaths occur in Africa,
where hundreds of millions of children, and
almost as many adults, suffer needlessly from
illnesses that most people in the West have
never heard of. The WHO's director-general, Lee
Jong-wook, warned that even the modest health
goals that the United Nations has established
for the new millennium are unlikely to be met.
In fact, he said, in many places death rates are
rising.
The most anticipated speech - and the least
diplomatic - also came on the first day: Bill
Gates addressed the assembly in his role as the
founder of the world's most powerful charity,
the Bill & Melinda Gates Foundation, which
he and his wife started six years ago. The
foundation's endowment is nearly $29 billion,
and its principal goal is simple: to rid the
world of disease, particularly the many
illnesses that are essentially ignored because
they affect the world's poorest people. 'Global
health is our lifelong commitment,' Gates told
me that day. 'Until we reduce the burden on the
poor so that there is no real gap between us and
them, that will always be our priority. I am not
so foolish as to say that will happen. But
that's our goal.'
Gates had arrived from Seattle just after dawn,
going directly to a breakfast with health
ministers from 10 African nations. The meeting
was held in a room panelled in dark-green wood
and filled with enormous mirrors. When Gates
entered, the ministers started to clap. Gates
bowed his head, winced and sat down. 'I know
your jobs are super, super important,' he told
them. 'And I am excited about the progress that
can be made for the health of your people.' He
looked tired. One by one, the ministers told him
their troubles. 'In Nigeria, the health system
simply doesn't work,' Eyitayo Lambo, the
country's health minister, said. His counterpart
from Botswana, Sheila Tlou, echoed those
thoughts. 'HIV and malaria have dismantled our
country,' she said. 'We need help just to get
back to where we were.' Other ministers told
similar stories. Tuberculosis, HIV and malaria
were rampant, as were lymphatic filariasis,
schistosomiasis, river blindness and other, even
less well-known diseases. Each person began and
ended by thanking Gates; in January, the
foundation had contributed $750 million to the
UN's Global Alliance for Vaccines and
Immunisation, to fight easily preventable
diseases, such as diphtheria, whooping cough and
measles. (Gates had also provided funds to
vaccinate 42 million children against hepatitis
B.) The ministers thanked Gates for helping to
promote a safe, cheap drug for visceral
leishmaniasis (a malaria-like disease that
affects nearly half a million people a year),
for investing in the first seemingly effective
new drug for sleeping sickness in 50 years, and
for supporting research into a vaccine for
pneumonia that could reduce African deaths by 15
per cent.
Two days earlier, the Tribune de Genève had run
an article headlined 'The health of the world
depends more on Bill Gates than on the WHO.' Few
of those at the assembly could disagree. The
annual budget of the WHO is $1.65 billion. Since
2000, the Gates foundation has spent $6 billion
addressing health issues in the Third World -
more than nearly every contributing nation, and
far more than any other charity.
It would be hard to overstate the impact that
the Gates foundation has had: the research
programmes of entire countries have been
restored, and fields that had languished for
years, such as tropical medicine, have once
again burst into life. In a world where a fast
reaction to the threat of disease is imperative,
bureaucracies like the WHO - which make
decisions by consensus - are often too
cumbersome to compete with the speed of a
mutating virus. Gates and his wife need
consensus only between themselves. At times, the
foundation appears as brazen as Gates has always
been at Microsoft, which he started 30 years
ago. 'Bill and Melinda don't believe in half
measures,' Richard Klausner, the former head of
America's National Cancer Institute, who, until
late 2005, was the foundation's director of
global health, told me. 'Every time we get a
grant proposal, we ask what fraction of the
problem will be solved by this work. Always. And
if there is no answer there is no grant.'
Lofty goals are often set in Geneva - on HIV,
polio (an effort now heavily underwritten by the
Gates foundation), maternal health and malaria,
for example - but they are rarely met. Malaria,
the world's most prevalent parasitic disease,
kills as many as three million people every year
- almost all of whom are under five, desperately
poor and African. In most years, more than 500
million cases of illness can be attributed to
the disease, although exact figures are
difficult because many people don't (or can't)
seek care. It is not unusual for a family
earning less than $200 a year to spend a quarter
of its income on malaria treatment, and often
what they get no longer works. In countries such
as Tanzania, Mozambique and Gambia, no family,
village, hospital or workplace can remain
unaffected for long. Malaria governs their
lives.
'It just blows my mind how little money has been
spent on malaria research,' Gates told me before
his speech. 'I just keep asking myself, Do we
really not care because it doesn't affect us? Is
that what it is?' Gates looked grim but went on.
'Human suffering as a result of malaria is
incomparable. By many measures, it's easily the
worst thing on the planet.' When Gates gets
animated, his voice starts to slide in
unexpected directions, and so does he. By the
end of our conversation, he was talking in
bursts and rocking back and forth in his chair.
'I refuse to accept it,' he told me. 'I refuse
to sit there and say, OK, next problem, this one
doesn't bother me. It does bother me. Very much.
And the only way for that to change is to stop
malaria. So that is what we are going to have to
do.'
There has never been a time when malaria was not
a major global health problem; its symptoms have
been reported for thousands of years. Only the
plague - and, perhaps soon, HIV - has influenced
the demographic and geographical history of
humans more. Malaria had become widely
recognised in Greece by the fourth century BC.
Treatment and cures have been sought for
millennia. The Chinese qing hao plant - which
today is the source of the most promising
anti-malarial drug, artemisinin - was first
described more than 2,000 years ago, in a
medical treatise called Fifty-two Remedies,
discovered in the Mawangdui tombs in Hunan
province.
Malaria starts suddenly, with violent chills,
which are followed by an intense fever and,
often, disabling headaches, convulsions and
delirium. As the parasites multiply, they take
over the entire body. If it doesn't kill you,
malaria can recur for years. The disease is
transmitted to humans by female anopheles
mosquitoes infected with one of four species of
a parasite called plasmodium; by far the most
dangerous of the four is Plasmodium falciparum.
It is also the most prevalent. Together, the
mosquito and falciparum are the most deadly
couple in the history of the earth - and one of
the most successful. A virus like measles, polio
or even HIV consists of just a few genes.
Malaria has 5,000 genes, and its ability to
mutate rapidly to defend itself and evade new
drugs has made it nearly impossible to control.
It wasn't until the 1890s that Ronald Ross, a
British physician working in the Indian Medical
Service in Hyderabad, discovered that malaria
was transmitted by mosquitoes.
After the Second World War, malaria-control
campaigns were initiated in many countries, and
with the notable help of the insecticide DDT,
successes were striking. Malaria was eradicated
from the United States in 1951; like measles,
polio and other illnesses that no longer
threaten us, it is completely unknown to
children and largely forgotten by adults. In
countries such as South Africa, Sri Lanka and
Mozambique, after extensive spraying, malaria
had almost vanished. India brought the number of
cases down from 75 million in 1951 to about
50,000 in 1961. Large swaths of the disease in
south-east Asia were also on the brink of
eradication. But DDT was seen as devastating to
wildlife, and mosquitoes had begun to grow
resistant to it (many subsequent studies have
shown that the insecticide is not as dangerous
to the environment when used sparingly), and the
US banned DDT in 1972. Other developed countries
followed. In most of Africa and Asia, where
malaria efforts have always been funded by the
West, the pesticide became politically
unacceptable. Six years after Sri Lanka stopped
using it, the number of cases rose from 17 to
more than half a million. By that time, though,
malaria had essentially been banished from the
developed world, and with it any incentive for
continued research.
Less than 10 per cent of all investment in
health research is devoted to the diseases that
affect 90 per cent of the world. To address this
imbalance, in 2002 the UN created the Global
Fund to Fight Aids, Tuberculosis and Malaria.
Richard Feachem, the fund's director, founded
the Institute for Global Health and was dean of
the London School of Hygiene & Tropical
Medicine, which has always been the world's most
important centre for malaria research. Feachem
understands politics, but worries that too many
people have begun to ignore history. 'In the
first year I had this job, the momentum was
entirely about HIV. Malaria was an
afterthought,' he told me in Geneva.
At an annual cost of $12 billion, however,
malaria accounts for almost 40 per cent of
health spending in Africa. Poverty cannot be
addressed unless malaria is too. And the attempt
to end poverty has gained great currency in the
past two years. Gordon Brown has promised that
Britain will purchase hundreds of millions of
doses of any successful vaccine - thus providing
incentive for investment which pharmaceutical
companies had always lacked. Last June, the
Gates foundation, which had already donated more
than $150 million for malaria research,
announced a new round of global health grants,
worth more than $400 million. A few days later,
President Bush pledged more than $1.2 billion to
fight malaria in Africa over the next five
years, by expanding access to remedies that
already exist and that are known to work:
mosquito nets treated with long-lasting
insecticide, indoor spraying and the
distribution of effective medicines, such as the
therapies that include artemisinin. (Bush has
announced such initiatives before and then
failed to fulfil them. Much of the money has
simply been shifted from other commitments.)
'There have been great moments of optimism in
the past, too,' Feachem said, 'but there has
always been this sense of malaria fatalism.
There has been the idea that this is just part
of Africa.' For much of the past 20 years,
Feachem said, political leaders have been
waiting for a vaccine to appear as if by magic.
'It is a moral outrage. This is an utterly
preventable holocaust, and the numbers are far
higher than the WHO says. They have put the dead
at one million for years, and now it is really
three million in terms of deaths to which
malaria might have contributed. So I don't think
it's yet the time to break out the champagne.
You have to remember we almost eradicated
malaria before. And what has happened? Not only
have we failed, but by any reasonable measure
more people have suffered from malaria in the
past 50 years than in the history of mankind. It
has been a remarkable march backward.'
In most parts of the world, malaria parasites
have become resistant to chloroquine, which had
been the first-choice treatment in Africa for
decades. Chloroquine, a synthetic chemical
similar to quinine, costs only 15 cents a dose,
and is easy to make. Sulfadoxine-pyrimethamine,
or SP - the second-choice treatment - has also
failed widely. The only consistently successful
alternatives are the artemisinin-based
combination therapies - a mixture of drugs helps
prevent resistance - but they are 10 times as
expensive as treatment with chloroquine. If
those drugs should fail, nobody knows what would
come next. 'The problem is getting worse,'
Feachem said. 'We are seeing more urban
outbreaks in countries like India; malaria has
become endemic at altitudes where it never used
to occur. Some of that may be because the
mosquitoes are adapting, but most of it is
simply a result of human population density -
people living where they never used to live.'
(Some of the disease's spread can also be
attributed to global warming, as mosquitoes
migrate to newly temperate areas.) Fifty per
cent of the world's population is regularly
exposed to malaria - an increase of almost 10
per cent in the past decade.
African governments, faced with the staggering
burden of HIV (which not only increases
susceptibility to malaria but places impossible
demands on services and medical personnel) and
often civil conflict as well, continue to grow
poorer, and their people become sicker. In 2000,
all 53 African chiefs of state met in Abuja,
Nigeria, and issued a document known as the
Abuja Declaration, in which they pledged to
halve malaria mortality and disability by 2010.
Today, more people are sick and dying than
before. 'The mistake was not in putting out the
targets,' Allan Schapira, a policy coordinator
at Roll Back Malaria, which was created by the
UN in 1998, told me. 'The mistake was in not
putting the hammer down to make it happen.' But
that would have required about $3 billion a
year. 'The economic conditions of the industrial
world are better than at any other time in
history,' Schapira said. 'Affluence is much
greater. People should have strong pangs of
conscience.'
Tuele hospital sits on a low hill in the Muheza
District of Tanzania, halfway between Dar es
Salaam and Mt Kilimanjaro. Much of the coastal
plain is given over to plantations of sisal and
coconut. The roads are rutted and made of dirt,
and along the sides women in brightly coloured
caftans gather to sell cashew nuts, charcoal,
bananas, phonecards, old tyres and bowls full of
a small green fruit that looks a little like a
lime but tastes like a mango. The rains were
late this year, delaying the worst of the
malaria season, but the dry weather hurt the
crops. The day I arrived, last spring, the rain
came down in torrents.
Malaria is Tanzania's leading communicable
disease, with the highest rate of exposure in
the world. In the area around Tanga, a nearby
coastal town, people are bitten by an infected
mosquito an average of 700 times a year (about
twice each night). At Tuele hospital, malaria
accounts for more than half of admissions.
Tanzania spends $4 per person on healthcare each
year, and with that sum doctors confront an
almost epic range of maladies: river blindness,
rotavirus (the most common cause of diarrhoea in
children, responsible for more than 600,000
deaths a year), elephantiasis and sleeping
sickness are all relatively common. So are
measles and pneumonia. But none of those
diseases is as destructive as HIV or malaria.
The infant-mortality rate in Muheza is a 133 per
thousand births, far higher than the national
average of slightly more than 100 per 1,000. (In
Europe, the average figure is about five per
1,000.)
TK Mutabingwa, a gruff man in his fifties who
holds a tenured position at the London School of
Hygiene & Tropical Medicine, has watched
children die nearly every day of his adult life.
He is one of Africa's most prominent malaria
researchers and has been working at Tuele for
more than 25 years. Since the early 1980s,
Mutabingwa has been trying to find the most
effective and least intrusive therapies for
mothers and children. One of the genuine
mysteries about malaria - and one of the
greatest opportunities for researchers - is how
people develop immunity. When a bite from a
mosquito infected with falciparum doesn't make
you sick, it acts like an inoculation; that's
why children who survive to the age of five are
much less likely to die. Adults in Africa may
get very sick, but the disease rarely kills
them. Pregnant women, however, are an exception.
The first time a woman becomes pregnant, she is
highly susceptible to malaria; in subsequent
pregnancies, the risk is lower. For years,
epidemiologists had assumed that pregnancy
simply weakened the immune system.
'That didn't make complete sense, of course,'
Mutabingwa told me. 'Why would these same women
do better in the second pregnancy? And even
better in the third? Those weaken your immune
system, too.' Ten years ago, two of Mutabingwa's
colleagues, Patrick Duffy and Michal Fried,
discovered that a distinct form of the
falciparum parasite binds to a specific receptor
on the placenta. The first time a woman becomes
pregnant, if the parasite latches on to those
receptors, she has no defences. After that,
however, her immune system learns to recognise
the parasite and makes antibodies that provide
at least some protection. The discovery has
immense implications both for drug treatment and
for the development of a vaccine: if those
antibodies can be reproduced successfully, they
may be able to protect women even before they
become pregnant.
Mutabingwa offered to show me around the
hospital. We entered the women's ward, where
electric-blue mosquito nets hung in cones over
every bed. The hospital is often the only place
in which a woman will have the use of a net. We
walked over to the combined HIV and
chronic-tuberculosis ward. A single fluorescent
bulb cast an eerie glow across the room. HIV,
tuberculosis and malaria (which together kill
five million people a year) fuel each other.
Anybody with one is far more likely to fall prey
to either of the others. 'These women are here
because of acute malaria,' Mutabingwa said.
'After five or seven days, they are usually
released. There is not that much we can do for
them after that.'
While I was in Tanzania, I stopped at villages
near Tanga and, with the help of my driver,
spoke to people there. When the subject turned
to malaria, the sense of futility was pervasive.
'We don't have the kind of money you need for
nets,' one mother told me. Nets, which are
remarkably effective, cost about $4 and must be
treated regularly with insecticide. 'My husband
doesn't think it's worth the expense,' the woman
said. Mosquitoes almost always feed at night,
yet only two per cent of the children and women
in Tanzania sleep under nets or live in homes
that have been sprayed with insecticide.
Later that day, I went to visit Stephen Magesa,
an entomologist with Tanzania's National
Institute for Medical Research. Magesa has spent
most of his career assessing the effectiveness
of bed nets that have been impregnated with
insecticide. 'In 1991 we showed that even in
very intense areas of transmission we could
reduce the burden,' he said. Magesa is a quiet,
donnish man. He spoke deliberately but without
emotion. 'The study was not big enough to show
an impact on mortality. But we did show very
clearly that the mosquitoes did not survive.'
More important, the researchers found benefits
even for those people who did become infected:
they had fewer parasites in their blood and less
severe fevers. 'We know the nets work. We have
known it for almost 20 years,' Magesa said.
Actually, it turns out that you don't even have
to sleep under an impregnated net for it to
protect you. In one study, in Ghana, child
mortality increased by seven per cent for every
100 metres away from nets that children slept;
other research demonstrated that death rates,
the incidence of anaemia, and even the level of
parasites in the bloodstream were lowered in
children who lived within 300 metres of houses
that had nets.
Bed nets do require attention. They must be
properly installed, used regularly and treated
with insecticide every six to 12 months. And
although the $4 they cost would be money well
spent for even the poorest family, African
governments have never made much of an effort to
help. New technology should change that. Several
companies have begun to manufacture nets that
have insecticide embedded within their fibres.
They don't need to be sprayed and they last for
nearly five years - the years that are crucial
for infants and young children.
Magesa's arguments have long been ignored. 'I am
sitting here watching my hair go grey waiting
for those nets,' he told me as we sipped iced
tea in his cramped office. 'Every year, a
million more kids die. A decade ago, they were
saying, "Let people die; there is nothing
we can do.'' Then Gates came along and he said
this is not acceptable. That was more important
than his money. He put malaria back on the
world's stage. But will he be able to keep it
there? We are watching children die - our
children - and they die every day. You could
save between 30 and 50 per cent of them with
nets alone. If you added improved hospital
services and proper medicine, you could save 80
per cent. But we already know how much 800,000
African children are worth to the rich world. We
have known it for a long time.'
One afternoon, I met Bill and Melinda Gates for
dinner at the home of the foundation's president
and co-chairman, Patty Stonesifer, who lives
with her husband, the journalist Michael
Kinsley, on the prosperous shores of Lake
Washington, in Seattle. Their house sits
directly across from the technological Xanadu
occupied by Gates, Melinda and their three
children. As I stood on the dock staring at the
boats dotting the water, I noticed a small
motorboat heading our way. Bill Gates was behind
the wheel with Melinda acting as navigator.
Gates was dressed in a T-shirt, a Polartec
sweater and khakis. He looked as if his most
recent haircut had been performed with blunt
scissors and a soup bowl. Melinda was also
dressed casually. She is athletic, and one could
not help contrasting her tan with the definitive
pastiness of her husband.
The Gates foundation - while run by Stonesifer,
chaired by Gates's father and founded by both
Bill and Melinda Gates - has been portrayed
largely as the expression of one man's
obsession. That turns out to be untrue.
Stonesifer has been involved since the planning
stages. Gates and his wife sign off on all
grants larger than $10 million, but Stonesifer
is responsible for hiring staff and managing the
foundation. After working at Microsoft for nine
years, becoming its highest-ranking female
executive, she retired in 1996. She had become
very wealthy, and takes no salary from the
foundation. Stonesifer prefers to work behind
the scenes and can, at times, be underestimated.
But not by Gates. 'If this foundation works,
it's because of Patty,' he told me. 'She is one
of the best managers I have ever known.'
The Gates foundation has more than vast wealth:
it has the power of a government without
actually being bound by a nation's political or
economic constraints. 'We are in this unusual
position where we can spend $100 million on
something we think might work and it can fail
and nobody gets fired,' was the way Gates
described it to me. 'Political institutions just
can't handle risks like that.'
Bill Gates has always had an interest in
science. Yet it was Melinda who first suggested
that they concentrate on global health. Gates
was interested in population control and thought
that improving the world's health might even run
counter to that goal. ('It was only when I dug
into it a bit that I came to understand that
better health leads to lower populations with
more resources,' he said.) Melinda grew up in
Dallas. She studied economics and computer
science at university and joined Microsoft in
1987, helping to develop such products as
Encarta, Expedia and Cinemania. The two married
in 1994, and Melinda left the company two years
later, when their first child was born. Gates
owns more than a billion shares in Microsoft,
which at times have been worth as much as $100
billion. Today, after his contributions to the
foundation, his net worth stands at roughly half
that amount.
On the eve of their wedding, Gates's mother
wrote a letter to Melinda in which she stressed
the great opportunities the two would have as a
couple to improve the world - and the unique
responsibilities that came with immense wealth.
'It was really quite beautiful,' Melinda said.
'And that was what got us going.' Their interest
in population control led them to look more
deeply into public health, and the realisation
that diarrhoea, respiratory diseases and other
syndromes were killing millions of people every
year. 'The whole thing was stunning to us,'
Gates said. 'We couldn't even believe it. We go
to events where people are raising money for
various illnesses where lives are being treated
as if they were worth many millions of dollars.
And here we were learning that you can save even
more lives for a few hundred each. We really did
think it was too shocking to be true.'
Gates began to approach scientists for advice.
One of them, William Foege, is one of America's
most experienced health officials. I ran into
Foege not long ago and asked him about his first
encounters with Gates. He laughed and said, 'The
guy came to me and said he wanted to learn about
public health and he wanted to help. Do you know
how many times before I have heard those sorts
of things? Rich people say that all the time. I
gave him a list of 82 books. I saw him a couple
of months after that and I asked, "How are
you doing on those books?'' And he said,
"Well, I have been so damn busy I have read
only 19 of them.'' I still didn't know whether
to believe him, so I asked, "Which was your
favourite?'' He didn't hesitate. "That 1993
World Bank report was just super,'' he told me.
"I read it twice.'' ' By then, Foege had
signed on as an adviser to the foundation.
The 1993 World Bank Development Report helped
change the way health officials calculate the
relationship between disability and the value of
life. In the report, for the first time, bank
economists focused on the concept of the
'disability-adjusted life year' (Daly), which
has come to serve as the standard measure of how
to assess the burden of a disease. In the past,
the impact of any illness - cancer, the common
cold and everything in between - was evaluated
on the basis of how likely it was to kill you.
But life without good health carries enormous
costs for individuals, families and societies.
The disability-adjusted life year combines years
of potential life loss owing to premature death
with years of productive life lost to
disability. Blindness is an example of a health
problem that, while not causing death, can
dramatically reduce one's quality of life or
ability to function within society. Alzheimer's
disease is another.
Even so, the World Bank report, at 329 pages,
makes for dry reading. When I asked Gates if he
had indeed read it twice, he replied, 'I've read
it more than twice. It's really a nice piece of
work.' The Daly concept led Gates and his wife
to their first large grant, $125 million, for
the Children's Vaccine Programme. They refer to
that grant as 'the 125'. 'That led to the 750,'
Melinda added, an initial $750 million donation
to the Global Alliance for Vaccines and
Immunisation, which they matched this year.
'After the 125, we had a dinner for about a
dozen scientists at the house,' Melinda went on.
'We were both extraordinarily impressed with
their knowledge, their expertise, their desire
to solve problems. And towards the end of the
dinner Bill posed the question "If you had
more money, what would you do?'' and the room
came alive. Just to hear what their ideas were
was so exciting. It was a revelation. We had
been surrounded by people that were so brilliant
at Microsoft. And we saw immediately that these
were the same type of people.'
Governments do not produce drugs or vaccines.
That has always been a job for pharmaceutical
companies, which, like any business, concentrate
on creating products that people will buy. There
is almost no financial incentive to make a
vaccine for malaria; the West doesn't need it.
African children have no money, and neither do
the countries they live in. Philanthropy has not
filled the gap. 'We heard again and again this
recitation of places where all this great work
had occurred and then it would just get
stalled,' Gates said. 'There was just nobody to
push it to the next level. It's all the greater
crime that something like malaria never got more
attention. We gave a small grant at first, like
$30 million, and everybody said, "Wow! That
is the greatest increase in non-government
spending in the history of malaria research!''
And I thought, Oh, you are kidding.'
Drug treatments for malaria require money (lots
of it), vigilance and a functioning healthcare
system, and the emergence of resistant strains
will always pose a threat. A malaria vaccine, on
the other hand, would save many more lives, and
at a far lower cost. 'There is a huge
distinction you have to make between a chronic
treatment and something you take once in your
life,' Gates said. 'Mumps is complicated.
Rubella is complicated. So is polio. But a
one-time treatment and boom' - he clapped his
hands. 'There you go.'
Nobody has ever made a vaccine that works
against a parasite, but scientists have spent
decades trying. The organism itself is
stupefyingly complex; but the relationship of a
mosquito, the falciparum parasite and a human is
far more so. Anopheles mosquitoes require a meal
of blood in order to lay their eggs - and they
almost always feed at night. Malaria begins when
a female mosquito bites somebody who has already
been infected. The mosquito becomes infected,
too, then passes that infection to its next
victim in a form of the parasite called
sporozoites. Once sporozoites enter the body,
they glide into the bloodstream and travel to
the liver, where they divide repeatedly. Two
days later, about the time that the parasites
leave the liver, 10 original sporozoites have
created millions of progeny. They then invade
red blood cells and begin to feed on them, and
within two weeks they will number more than 30
billion.
In 2004, for the first time, a vaccine offered
partial protection against infection. In a study
on more than 2,000 children in Mozambique, the
risk of developing severe malaria was reduced by
58 per cent. The vaccine attempts to stimulate
immunity by using one of the proteins on the
surface of the malaria parasite when it invades
the liver. It was produced by GlaxoSmithKline
and, along with more than a dozen other
experimental vaccines, was supported by the
Malaria Vaccine Initiative. Most of the funding
came from the Gates foundation. Although this
vaccine is not a miracle cure, even partial
protection would help. None the less, the
foundation is intent on finding a vaccine that
works better. Regina Rabinovitch, who directs
its infectious diseases programme, said, 'We
would like to take a vaccine and have it be 99
per cent effective - a mosquito bites you, it
takes a blood meal, shoots some parasites into
you, and within five minutes those parasites are
dead.' The problem is that such a response would
require a high level of the right kind of
antibodies. It would have to work early, in the
blood or just as the sporozoites enter the liver
- before they destroy billions of red blood
cells. 'That is the holy grail,' Rabinovitch
said. 'But let's say we got that immunity and it
waned after five years,' she continued. 'You
would then be immunologically naive. If you were
a child, what would happen if that immunity wore
off? All of a sudden, you would be like an
infant again - the people who are at greatest
risk. So we really want something that provides
protection from severe disease, and death, so
that if you still get infected you will generate
an immune response, and the likelihood that you
will die or become severely sick is lower.
'The goal is to turn a six-month-old into a
10-year-old, so that he has protective immunity.
This is called the "leaky-bed-net model''.
We know that the net doesn't decrease all
exposure. It acts as a baited trap with a human
inside and the mosquito touches the net and
neurologically becomes a little nutso and dies.'
The parasite's greatest weapon is its ability to
avoid the immune system by continually changing
both its surface proteins and its location:
every time it moves from a mosquito's gut to its
salivary gland and from there to our liver and
red blood cells, it changes form. The tools of
molecular genetics are finally letting
scientists attack each different stage of the
infection - and there are now many vaccines in
development. Some work at the blood stage and
some at the liver stage. I asked Rabinovitch how
she chooses which to fund. She smiled. 'We are
supporting all of them,' she said. 'This
foundation is agnostic when it comes to malaria
religion. We just want something that works.'
The Seattle Biomedical Research Institute is
more than 25 years old, and the scientists there
work solely on eliminating infectious disease.
Last year, the institute moved into a new
building a couple of miles from the Gates
foundation, with laboratories equipped with
gene-sequencing machines, microchip arrays and
powerful new computers. It's a Bill Gates kind
of place.
Stefan Kappe, a young German parasitologist at
the institute, has been studying the mosquito
itself. He is trying to find a way to prevent
infection by disabling falciparum before it can
make it to the liver. Exposure to radiation
weakens the sporozoites that mosquitoes carry in
their salivary glands. When those sporozoites
are injected into a person, they stimulate
immune activity and protect him from malaria.
That is how most basic vaccines work. A measles
vaccine, for example, is a live strain of the
virus that has been weakened to the point where
it can do no harm; yet it tricks the immune
system into creating antibodies to defend itself
against genuine measles viruses. Until
sequencing technology made it possible to
manipulate genes in the parasite, this approach
never seemed worth pursuing. The parasite has to
be alive to spark the immune system, and it
would have been unethical to inoculate people
with live parasites - even weak ones. Nor would
it ever be possible to X-ray enough mosquitoes
to protect the world from them. So Kappe is
using genomics to destroy only those genes which
are essential for the parasite to grow in the
liver. He, too, is supported by a grant from the
Gates foundation. 'I would never have received
funding for this particular project,' he said.
'The Gates people know it's far-out. But
sometimes far-out works.'
The only place you can keep enough mosquitoes to
do this kind of research is an insectary - which
is a cross between a zoo for insects and a
laboratory. There are just a few in the world;
they require constant oversight, lots of space
and a perfect climate. The insectary at the
institute is a very humid room, and, as we
entered, several of Kappe's colleagues, working
with dissecting microscopes, were removing
parasites from the glands of mosquitoes. Behind
the researchers lay long pans with hundreds of
tiny eggs about to hatch. A female anopheles
will lay a raft of about 100 eggs at a time. The
males live for sex, last about a week, and then
die. Kappe's vaccine has worked in mice,
stranding the parasite in the liver and
preventing further infection. But he has a long
way to go before he can test it on humans. 'This
association between the parasite and the
mosquito is millions of years old,' he said.
'It's a brilliant example of evolution. But I
believe that with modern technology we can make
live vaccines that are protective. I don't think
that is in the future. I think it's now.'
David Schellenberg, a clinical epidemiologist
from the London School of Hygiene & Tropical
Medicine, has spent much of the past decade in
Africa. On the day of my visit, he was standing
in the middle of his office at the Ifakara
Health Research and Development Centre in Dar es
Salaam, with a young Tanzanian man who works for
him. Schellenberg was excited. A tough wooden
box sat on a table in front of them. Jump leads
snaked out of one end of the box, and a car's
cigarette lighter was at the other end. 'This
could be as important and valuable as anything
we have ever done for malaria,' he told me as I
entered the room. He was not entirely joking.
Schellenberg is running some of the most
important malaria drug trials in Africa -
testing whether a few doses of preventive
medicine will help protect infants from the
disease. The contraption on the table had been
rigged to charge the batteries of computers in
the many study villages where electricity is
often absent. 'We need computers to work out
there if we are to collect data and store it
properly. But, with the electricity so bad, the
computers are completely unreliable.' Like any
doctor who has worked both in the lab and in the
village, Schellenberg is well aware of the
difference between efficacy and effectiveness.
'The difference between what you see in the
clinical world and what you find in the real
world can be enormous,' Schellenberg said. Some
of the earliest trials involving preventive
treatment of pregnant women and children were
conducted at Ifakara. 'Often a clinical trial
proves something can work - the use of bed nets,
for example, or a new regimen of drugs,'
Schellenberg said. 'But does that mean that
everyone in every village or city in Africa will
accept the results?'
Schellenberg and his wife, Joanna, who is also a
malaria researcher, have two sons, aged 11 and
seven. They moved back to Africa from England in
2004. Their first posting had lasted six years,
but their older son contracted drug-resistant
malaria and almost died. 'He was airlifted to
Nairobi and he had chest surgery,' Schellenberg
told me. 'Then he had pneumonia and that led to
abscesses. We very nearly lost him. He is fine
now, but it was scary. You can imagine after
that there was a lot of soul-searching about
whether or not to return. But we are here
because this is where we really belong. Look, we
are lucky. We were able to call a plane and get
him out of there. So he lived. That is not the
way it is for the other children who get this
disease. There are no planes. No drugs. No
doctors. And no real hope of surviving.'
The Gates foundation supports much of
Schellenberg's work. He is grateful. But, like
many of his colleagues, Schellenberg is
concerned about what he sees as a growing
preoccupation with futuristic technology. 'Ten
years ago, we were saying that a vaccine would
not be available for at least 10 years. Now we
seem to be saying the same thing,' he said. 'We
need to be able to deliver what we already
have.' Schellenberg admits that while he is
attracted to the 'shiny, scientifically exciting
stuff, a lot of what we are doing in southern
Tanzania is not scientifically challenging. It's
like that wooden box with the cigarette lighter.
We are making simple things. And the questions
we are asking are not very exciting in
scientific ways. But they are urgent.'
Bill Gates approaches life as if it were a
problem that needed to be solved. At times, he
appears as if he has stepped out of a Henry
James novel: a confounding mixture of innocence,
arrogance and belief in what is right. Gates's
eager, energetic view of the world is stamped on
everything he does: from his house, where guests
can programme their rooms to reflect their
taste, to the software company he founded.
Microsoft, whatever else it is or has become,
began as a collection of smart people who
realised that technology, when driven by the
right kind of intelligence, rules the world.
Gates feels the same way about improving public
health. His faith in progress is absolute. 'The
complexity of biology and how it works is so
interesting,' he told me one day. 'And, in terms
of human welfare, the idea of getting rid of
these diseases - which could be in our lifetime
- is just very exciting.' That final sentiment
makes many people nervous. 'The eradication of
disease and the alleviation of suffering depends
more on developing the skills of talented people
than on technology,' the Lancet recently
declared. Gates has put aside more than a
billion dollars to help disadvantaged Americans
gain degrees. The Lancet suggested that a
similar educational investment in developing
countries might do more good than many
programmes that emphasise science alone. Both
historical and contemporary studies have shown
that the health of a nation improves only
through a combination of social and political
measures. Medicine matters, of course, but it is
far from the only thing that does. (The United
States is the richest country in the world and
the most technologically advanced, yet it ranks
29th among world nations in life expectancy and
38th in infant mortality.)
Gates has heard these criticisms, and the
foundations's recent $35 million commitment to a
full-scale attack on malaria in Zambia, with the
aim of cutting deaths by 75 per cent in three
years, illustrates that. It is impossible to
doubt the sincerity of Bill or Melinda Gates, or
to question the impact they have had, and will
have, on the world. Yet it would be hard to
expect the iconic American technologist, a man
who has made one of the world's great fortunes
by harnessing the flow of information, to
abdicate the future. 'I do believe in progress,'
he told me in Seattle. 'Capitalism is an unusual
system, in that somebody can have so much
wealth. But then again it's an unusual system
because money can actually flow from the
luckiest to the unluckiest and hopefully in
clever ways so that it's not just writing
cheques.
'We do not measure ourselves at all by the
amount given,' he continued. 'We have taken on
the top 20 killers, and for everything we do we
look at the cost per life saved and real
outcomes in terms of how things get improved.
It's fun, and it is also an enormous
responsibility. But having my job at Microsoft
is also fun and a huge responsibility. That is
true for being a parent. Many of the most
important things in life are like that. Why else
would you want to get up in the morning?'
For more information on
the fight against malaria, and a chance to
contribute, visit theglobalfund.org
Copyright:
Telegraph Group Ltd |
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