Feeding the Parasites

“Malaria deaths down by sixty percent,” headlined the World Health Organisation in December 2015. The Bill and Melinda Gates Foundation claimed the achievement as due to their and other international aid programmes. But an investigation by the African Investigative Publishing Collective in partnership with ZAM shows little evidence of a victory in the fight against the mosquito-spread fever that kills hundreds of thousands children and pregnant women worldwide, mainly in Africa. In the partnership between donors and corrupt local elites, only the glossy consultants’ reports look good.

By Zack Ohemeng Tawiah (Ghana) and Francis Mbala (DRC), with contributions from Janneke Donkerlo (Amsterdam, Geneva) and Erick Kabendera (Dar es Salaam)

Kinshasa, October 2015

Chantal Nzuzi, 23, has been sitting next to her kids’ beds in Mwinda clinic in the suburb of Ngaliema, Kinshasa, DRC, for the past four days. The toddler and the four year old, drifting in and out of a fretful sleep, are both burning hot. “I didn’t want to come here because I don’t have money,” says Nzuzi, exhausted. “But I had to. This is a good centre but it is so expensive. I was given a script but the meds will cost me US$ 55.” So far, the children have not been given even paracetamol for the fever. That they have malaria is beyond doubt. Nzuzi: “They have been tested. That cost me US$ 10, it was all I had on me.”
Just a few kilometres away, in the patient ward of the Kasongo clinic, sits Julia Ngongo, 19, next to her brother of 24, who lies in bed on a drip. The two, students studying in northern Equator province, have been here for 2 days. They, too, can’t pay for the medicine. Says Ngongo: “We were busy studying for our exams when my brother started having body pains (back body pains are characteristic of malaria, ed).” His sister gave him some quinine tablets she had in her suitcase, but they did not help. “I had to wake up a friend to help us get home to Kinshasa. We came late at night but they didn’t attend to us because we didn’t have money. Next midday a friend came with money for the tests, for some first meds and for the drip. We have now phoned our families because they must bring more money.”

IN OVER TWENTY INVESTIGATED VILLAGES AND CLINICS PATIENTS WERE NOT GIVEN ‘FREE’ MEDICINES

Over fifteen other Kinshasa health centres and hospitals visited by Congolese team member Francis Mbala over a period of months show the same picture –nowhere does he encounter any malaria patients getting affordable help. This is in spite of the fact that the Global Fund against Malaria, TB and HIV/Aids (famously established by millionaire Bill Gates and mainly funded by the US and Europe) makes 43 million dollars available for free medicines and test kits alone to health centres in the DRC every year.

Unpaid underlings

“We sell the medicines to patients and to private pharmacies,” confesses a nurse in a clinic in the Bandalungwa area of Kinshasa, when Francis Mbala, undercover as a visiting fellow health worker, enquires about ‘assistance.’ She is not ashamed to admit that she, in fact, steals from the patients by ‘selling’ medicines they are supposed to receive for free. But the nurse assumes that the ‘visiting health worker’, like she herself, simple needs money to live on. Health department salaries, meagre as they are (around US$ 100 a month) are often not paid out by the DRC government for months on end.
The nurse doesn’t even consider the national government as a possible source of income. Talking to Mbala, she simply complains about the NGOs: “These (NGO) people give us nothing. Only medicines. No money at all, even though they (the NGO officials in charge of the malaria programme, ed.) enrich themselves with heaps of money from the Global Fund and other donors. They just treat us as unpaid underlings. We have to do something for ourselves.” The shiny cars and the expensive laptops in the offices of SANRU, the NGO that is in charge of the distribution of malaria medicines in 219 designated health zones in the DRC, attest to the observational powers of the nurse in Bandalungwa.

SANRU does not check that the medicines, which it receives for free from the Global Fund and passes on to the health department’s structures, reach the patients. Even the health department’s own chief director for the distribution of malaria medicines to Kinshasa’s health centres, Dr Anta Insa Boblaman, doesn’t seem to verify their usage. Instead, he assures Francis Mbala, who meets him in the shoe-box size central distribution centre, that there is no corruption at all. “If I would find anybody being corrupt, I would just sit on them, and that would hurt a lot,” he jokes. (Boblaman is very fat.) He adds that “all centres have been provided with free medicines already just this month.” The clinics visited by Mbala during this same week are all part of the area under Boblaman’s supervision.

Doctor François Xavier Mwema, chief in the malaria training and medicines distribution division at the National Malaria Control Programme in the DRC’s ministry of health, readily agrees that the clinics often don’t report back on their medicines stock. “We don’t have a culture of issuing stock reports. There is total lack of information on how donated goods are used.” When asked why nurses and doctors’ salaries are often delayed, or not paid at all, he responds that “that remains a major headache for us. But we are working on it. The needs are enormous.”

YOU WANT TO INFORM THE PUBLIC ABOUT MALARIA? WHY?

A few days later, on a quest to compare his public sector findings in a private clinic, the Cliniques Universitaires de Kinshasa (CUK), Mbala is arrested when he takes a picture of people in the waiting room. “You want to inform the public about malaria? Why?” shrieks the deputy director of the CUK before he has Mbala hauled away by the judiciary police, who keep him locked up for three days, confiscating his phone and passport. To date, Mbala has still not been able to get these back.(1)

Ghana, Hohoe, September 2015
In Ghana, we don’t find many donated free medicines either. “We run out,” says doctor Felix Doe, health director for the Hohoe municipality in the Volta region. “The (health authorities) won’t like me saying that. But it’s true.” Local health worker Richard Nenyo, who works in a Hohoe district village called Lomnava, confesses that he is desperate. “I only have one packet of amodiaquine left.”

RATHER THAN HELP PATIENTS, DONATED MEDICINES FEED INTO A CORRUPT ECONOMY

It could be that stocks in Lomnava are still low as a result of the warehouse fire in Ghana’s capital, Accra, that destroyed 300 000 doses of malaria treatment packets (among other medicines) in January 2015. A government commission of inquiry is presently investigating reports that the fire was set on purpose to hide evidence of theft of the very same medicines shortly before the blaze. The commission has strong indications to suspect this: a signed form by the chief of the Ghanaian NMCP shows that the malaria tablet consignment has in fact been taken from the warehouse shortly before the fire. The NMCP chief, Dr Plange, has already said that she didn’t sign for this and that the signature on the form has been forged (2).
Though measures are said to have been taken to restock all the regional health centres, the new stock clearly hasn’t made it to Lomnava. Meanwhile, pharmacies in Ghana’s regional capitals sell supposedly free –or heavily subsidized- malaria treatment packets (3) for up to 8 US$: a week’s income for most of Ghana’s poor.
Tanzania, Dar es Salaam, August 2015
“Tanzania is one of the countries that are supposed to receive subsidized malaria treatment but most of the medication is sold expensively and patients can’t afford it,” reports our colleague Erick Kabendera. “It is also unavailable in most government hospitals and patients are often asked to buy their medicine from privately owned pharmacies.”
Kumasi, Ghana, October 2015
Even in the Komfo Anokye Teaching Hospital in Kumasi, Ghana’s second city, it’s hard to get malaria treatment. Pregnant women are supposed to get the preventive Fansidar free of charge. ‘But you have to queue for hours in the hot sun, which is difficult for pregnant women or women with small children,’ with, additionally, a substantial risk of disappointment at the end of the day, says a doctor who works at the hospital. “Because sometimes they are not available. And sometimes you can’t get them for free even in the hospital itself.” Journalists in Ghana have reported in the past on ‘hospital medicines’ which, having left the hospital ‘somehow’, are sold ‘outside’ at elevated prices.

Corruption tax

Global Fund-donor Bill Gates has famously said that it’s OK with him if some donor aid is lost because of corruption, calling the slices that are creamed off “an inefficiency that amounts to a tax on aid (4).” Such a ‘corruption tax’, he says, does not matter because the ‘rest’ of the aid still reaches those who need it.
Sadly, whilst this could arguably work in the case of medical programmes that don’t deal with resistant germs or parasites, this is not true for efforts to fight virulent ‘sick-makers’ like TB, Aids, or indeed the malaria parasite plasmodium falciparum. Incompetently executed programmes, leading to half-finished, interrupted treatments and people resorting to –often fake or expired- treatments ‘from the street’, are at risk of making the malaria epidemic much, much, worse. “You start getting a more resistant malaria parasite as soon as treatment is discontinued or people take fake or expired medication,” says Dutch University of Wageningen’s Sander Koenraadt.

Geneva, October 2015

Like in the case of SANRU in the DRC, donors resort to partnering with NGOs or the private sector when they have doubts about the capability of governments. After the fire in the medicines warehouse in Accra, the Global Fund terminated its working relationship with the Ministry of Health in Ghana. “Procurement and distribution of medicines is now in the hands of a South African distribution company,” says fund portfolio manager Mark Saalfeld at the Global Fund headquarters in Geneva, adding that that is better for ‘continuity.’
However, according to the Ghanaian Malaria Control Programme’s year report over 2014, even where medicines distribution to regional centres is organised, medicines often still don’t ‘land’ properly. Health workers don’t get informed when and where they can find the new stock. Also, in many places, the phones don’t work. “We sit here and wait to see if we get medicines,” says Dr Doe in Hohoe, Volta. We don’t have ownership. I don’t even know what the budget is. Or the content of the malaria programme.”
It seems, then, that relying on NGOs or private companies doesn’t solve all the problems. Back in Kinshasa, old doctor (and ex journalist) Gaston Nkinti (76) grimaces in anger when the topic arises. “Maybe Bill Gates could send his own doctors and nurses and stockists and transporters and officials and just do everything.”

Victim blaming

In Lomnava village, health worker Richard Nenyo, now totally devoid of medicines, has resorted to shrieking at people to use their malaria nets properly. “What else can I do? It is the only instrument we have now. The nets, at least, we receive.”

Blaming ordinary people for lack of use, or incorrect use, of the massively donor-distributed insecticide-treated mosquito nets, has become a stock response of health workers in civil society. SANRU’s deputy director Pomi Mongala in Kinshasa –seemingly unaware of the fact that in many places in her country, nets don’t even arrive because of bad or non-existent roads- talks of ‘educating’ people to ‘prevent.’ In Ghana, the deputy director of the Ghanaian coalition of health NGOs, Stephen Oracca-Tetteh, rages against the ‘ignorants.’ “Ghanaians are so ungrateful. These donors work hard to bring us all these malaria nets and the people don’t even use them.” Oracca-Tetteh feels that there should even be ‘sanctions’ for people who use the nets wrong: for fishing, for example, or in soccer goals.

If only it would be so easy. But in villages where up to eight people sleep on the floor of one hut, -often in suffocating heat-, the nets are cumbersome and really uncomfortable. “It’s hot and it irritates my skin,” says Enyonam Tsigha, three months pregnant, in Hemang village in Ghana’s Ashanti region. When she shows us where she sleeps, in a one-room hut shared with five other family members, we try to imagine a set of mosquito nets put up here, each on poles, over the sleeping bodies of six people. The poles would have to be set up every night and removed during the day. “Can you see how difficult it is, let alone that they want us to sit under such a net from sunset? Have you tried doing that together with your small children? We get bitten anyway.”
(5)
Tsigha’s neighbour, Opanin Osei Yaw , is using his insecticide-sprayed malaria net to cover his palm seedlings. The harvest, safe from predators, will guarantee an income and food for his family for several months next year. Yaw sees no reason to remove the net from the seedlings and rather use it to protect himself and his family: food, not malaria risk management, is his family’s most basic need. He does, however, feel that something should be done about the mosquitoes. He was happy when the government started spraying insecticide in his village two years ago. “But after a year the spraying stopped again,” he says. He doesn’t know why.

Health worker Richard Nenyo concurs with Yaw. “If only they could start spraying again,” he says. “That really helped.”

INCONSISTENT TREATMENT LEADS TO GROWING RESISTANCE OF THE MALARIA PARASITE

Tsigha’s, Yaw’s and Nenyo’s experiences illustrate the fact that mosquito nets on their own cannot protect you. Spraying insecticide in a consistent manner is –together with bed nets, regular testing and treatment- an indispensable part of eradication programmes. And the key word here is consistency. Because, like with treatment, where spraying and is irregular and interrupted, the parasite becomes resistant to the insecticides and the tablets. The WHO’s global malaria programme director Pedro Alonso sounded alarm in this regard in the Financial Times on 23 April last year. “A tipping point” in the fight against malaria had been reached, he said, and warned that “gains of past decades may be reversed.” (6)

Yaw’s five-year-old grandson Kwaku has mosquito bites all over his body. He also feels warm. “Malaria,” says Yaw.
Kumasi, Ghana, December 2015

The numbers game

“These programmes aren’t working,” says doctor Ernest Kwarko, gynaecologist at Komfo Anokye hospital. Kwarko, who says dozens of pregnant women and their infants every day, says one in four show symptoms of malaria. Though the NMCP recently celebrated a decline in cases, he says, he has not seen such a decline. Neither has Richard Menyo in Lomnava, who says that every week four people come to him ‘with their babies complaining of malaria.’ Lomnava counts only 400 inhabitants: if Nenyo is right that there are four cases per week, that would mean 200 cases –half the population of the village- presenting with malaria every year.

The official numbers are way lower than that: 8,4 million cases per year on a population of 28 million, meaning one third of all people presenting with malaria annually (7). “But the real numbers of people who die of malaria could be higher than the official ones,” warns health NGO-man Stephen Oracca-Tetteh. “Because deaths at home are not counted. And also some (health) facilities are not counted.”

MOST PEOPLE WHO DIE OF MALARIA DO SO AT HOME, WHERE THEY ARE NOT COUNTED

The official numbers are puzzling all by themselves, too. Though they show a decline in Ghana between 2014 and 2015 (from 11 million to 8,4 million cases of malaria per year), they also show a massive increase between 2003, when the donor-aided effort to fight malaria started, and 2014: from three million to eight-and-a-bit million cases per year. Did more people get sick or did more people get counted? What would the figures be like if the ‘home deaths,’ -likely the majority of cases, since poor, sick people usually don’t have the means or strength to make it to an often faraway hospital-, were counted too?
In the DRC, the WHO figures of confirmed malaria cases have gone up since 2006 from zero to twenty percent of the population in 2014. But that is, again, probably a result of better counting in the hospitals than an approximation of the real situation –if you believe these numbers you’d have to believe that there were no malaria patients in the DRC in 2006. And even today in the Congo, most people fall sick and die at home, far from any medical facility, too.

The elephant in the room

Ghanaian Global Fund partner representative Collins Nti confirms that insecticide spraying has stopped in most areas in Ghana and that ‘malaria is back’ in sixteen of the country’s twenty-five districts. “That has been the case for over a year. We now only spray in the north.” Asked if this doesn’t increase resistance of the malaria parasite, he agrees. “You are a hundred percent right! Malaria is back with a vengeance in these sixteen districts. That’s why I say it is terrible!”

It is the interview with Collins Nti, chairman of a civil society structure called the Country Control Mechanism, -established by the Global Fund as its Ghanaian working partner-, that the crux of the problem emerges again: local governance. Or rather, the lack thereof.
When we talk of responsibility for insecticide spraying in his country, for example, Nti blames only the Global Fund. “Money for spraying was in our proposal. But then they didn’t give us.” But surely donors can’t carry the accountability for everything that goes wrong in Ghana? Couldn’t the health authorities have found alternative funding to continue the spraying? “We had a meeting with them last week. We are looking for other funds.” Isn’t that a tad late? “It’s just that we did think that we would get the funds,” he says.
The African Union decreed in 2001 that all member countries should spend ten percent of their budgets on health care. None do (8).

A different universe

The experience of the African journalists on the ground during this investigation shows just how unaccountable the ‘malaria elites’ in their own countries are. Apart from some lucky breakthroughs –as per the interviews above- Francis Mbala has been refused documentation, has been stood up at fixed appointments more than a dozen times, and has been arrested. In Tanzania, Erick Kabendera has not been able to get the list of beneficiaries of the Global Fund’s most recent grants. Zack Ohemeng Tawiah, in Ghana, has travelled three times from Kumasi to Accra (a five hour journey each way) in vain to try and see a Malaria Control Programme official. In the end he has been telephonically referred to the website of the Global Fund in Geneva. “All that the Global Fund wants to put out, it puts on its website,” spokesperson Eunice Adjei said before hanging up the phone.

LOCAL MALARIA PROGRAMME OFFICIALS REFER TO THE WEBSITE OF THE GLOBAL FUND

The donor industry keeps partnering with, financing, and therefore empowering, scores of such unaccountable, opaque and incompetent malaria elites.

October 2015, Geneva

When the Global Fund’s chief risk officer Cees Klumper decided to visit Niger, north of Ghana in West Africa, he was able to call a minister to meet him on a Saturday. “He showed up with his entire team. It was a public holiday, too.” Klumper tells the anecdote as an illustration of how beholden some of Africa’s elites are to donors: dependent on them for money, they won’t risk offending them. Klumper does, however, feel that the programmes are working properly and that the Fund manages to keep corruption to a minimum. “We calculate that only 1,7 to maximum six percent of funds is lost to corruption,” he says.

Reading the multitude of programme reports by consultants, in development jargon about targets and projections, with impressive graphs, on the Global Fund website, gives the impression that all is really well. Global Fund Programmes executed by the Global Fund are rated ‘adequate’ by the Global Fund. Numbers of people accessing treatment are in the seventy and eighty percent range in most reports we see. The general figures about insecticide spraying are also apparently on target everywhere.

It is like our team has operated in a different universe. An enormous gap separates the realities of Bandalungwa, Volta, Ashanti and Dar es Salaam from the world of donors and their ‘malaria elite’ partners.

INCOMPETENT ‘MALARIA ELITES’ ACCOUNT ONLY TO DONORS, NOT TO CITIZENS

December 2015, Geneva
Karel van Kesteren, ex ambassador for NL in Tanzania and author of a book 'Verloren in wanorde' (Lost in confusion), which deals largely with the aid question, compares donor aid to a hospital drip. 'Developing countries are hooked to a permanent drip of which only the elites draw benefits,” he says. “Local people do not.” Nobel Prize winner for economy in 2015, Angus Deaton also argues against the type of aid that reduces accountability of governments vis a vis their own citizens. “We cannot help the poor by making their already-weak governments even weaker,” he says in his essay ‘Weak States, Poor Countries’. Deaton has said repeatedly that, where this happens, donor aid is actually harmful.
25 January 2016, London
Bill Gates pledges another four billion Euro in the fight against malaria.

Notes
(1) See: http://www.zammagazine.com/chronicle/chronicle-15/256-a-malaria-arrest
(2) The Ghanaian Commission of Inquiry issued its report late January 2016 and found that it was indeed arson. It held twelve officials responsible for systemic theft of large quantities of medical supplies.http://www.graphic.com.gh/news/general-news/57340-12-busted-for-role-in-central-medical-stores-fire-as-arsonist-is-on-the-run.html
(3) Besides free medicines distributed by the NGO SANRU, the Global Fund also supplies heavily discounted malaria treatments for private sales. These so-called ‘Green leaf’ medicines packets are supposed to be sold for around US$ 1.
(4) http://www.bloomberg.com/bw/articles/2014-02-03/bill-gates-is-right-corruption-isnt-the-biggest-aid-problem.
(5) Tsigha is right. Though the malaria-parasite carrying anopheles mosquito used to bite only in the middle of the night (hence the traditional usefulness of mosquito nets), the pesky insect has recently been found to develop different patterns. It now bites much earlier in the evening and even during the day.
(6) It is also not clear that declines in malaria cases where they have actually happened (as far as this can be known), are a result of donor-aided malaria programmes. An in-depth article on malaria reduction programmes in the Financial Times http://www.ft.com/intl/cms/s/0/73b423ce-d3cc-11e4-99bd-00144feab7de.html#axzz3z5wilRwL published in April 2015 noted that “there is debate about the explanations for reduced malaria cases in recent years and hence how best to respond in the future. Case numbers in parts of Africa began falling before the big upsurge in funding from the early 2000s. That implies other factors than health programmes — such as infrastructure and broader economic and social development — were at least partly responsible for the decline in cases.”
(7) Annual case numbers can be higher than the actual number of patients, since one individual –especially children- can suffer various bouts of malaria in one year.
(8) http://www.who.int/healthsystems/publications/Abuja10.pdf

Bibliography
Website African Investigative Publishing Collective www.investigativecollective.com
DRC grant document Global Fund https://www.documentcloud.org/documents/2487425-grant-agreement-zar-m-sanru-grant-agreement-0-en.html
Ghana GF grant performance report https://www.documentcloud.org/documents/2483587-gha-m-moh-grant-performance-report-0-en.html
Tanzania grant implementation letter https://www.documentcloud.org/documents/2483578-tnz-m-mofea-implementation-letter-3-en.html
Malaria incidence and death numbers DRC 2014, WHO: http://www.who.int/malaria/publications/country-profiles/profile_cod_en.pdf
Ghana NMCP 2014 report: https://www.documentcloud.org/documents/2465665-2014-annual-report-final.html
Interview at Global Fund office in Geneva with Cees Klumper
Interview at Global Fund office in Geneva with Mark Saalfeld
Interview with Collins Nti of the Country Coordinating Mechanism in Accra https://www.documentcloud.org/documents/2717913-TI-Malaria-CCM-Collins-NTI.html
Interview Stephen Oracca-Tetteh of the Coalition of Health NGOs, Ghana https://www.documentcloud.org/documents/2465683-transcription-of-interview-with-national-vice.html
DRC interviews and reports 1 https://www.documentcloud.org/documents/2484296-ti-malaria-drc-francis-first-interviews.html
DRC interviews and reports 2 https://www.documentcloud.org/documents/2509629-ti-malaria-reportage-francis-english.html
Ghana interviews and reports https://www.documentcloud.org/documents/2488118-ghana-findings-zack.html
Karel van Kesteren, Verloren in wanorde (Lost in confusion)LM Publishers, Amsterdam, 2010
Angus Deaton, ‘Weak States, Poor countries,’ http://www.project-syndicate.org/commentary/economic-development-requires-effective-governments-by-angus-deaton

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