Kill or be killed

In Africa, mosquitoes go blood hunting after dusk. They often drift in through open windows or doors, but any crack or crevice will do. Inside, they sniff out their prey: a mother scrubbing pots after dinner, a child's ankles as she finishes her homework.

Bedtime is the best time for feeding. Through the quiet darkness comes a mosquito's reedy whine when it zips past your ear. But in Africa mosquitoes mean more than itchy bites; just one can bring death through malaria. And trillions breed anywhere there is fresh standing water, even puddles.

Sleepers sometimes use insecticide-treated bed nets as a defense-the nets often hang over floor mats, not beds-but the mesh turns stifling in the heat. Badly hung nets have gaps, and any tear renders them useless. Trying to stop every mosquito is a dead man's game: They will find a way in.

The only winning way to fight Africa's malarial mosquitoes is the law of the jungle: Kill them before they kill you. This is a story of how those who would save human lives lost their most effective weapon, and how some policy wonks are moving beyond their academic journals and seclusion in order to say, loud and often, give us back the weapon.

The story has to begin with big numbers, a little climatology, and a bit of entomology. The numbers: Some 500 million cases of malaria occur worldwide every year, and 1 million people die, nine-tenths of them in Africa. The disease is the leading murderer of Africans under 5-it kills a young child every 30 seconds-and survivors often suffer brain damage.

The climate fact is simple: Africa is a hot continent. That's relevant here because the process of transmitting malaria begins when a mosquito bites someone already infected and ingests the malarial parasite. Over a two-week period-but one that goes faster when it's hot-the parasite goes through a transformation called sporogony; once it occurs, the mosquito can infect others. The curious part is that the life span of the mosquito is also two weeks, so in cool areas mosquitoes typically die just before they become infectious-but in Africa they bite first, die later.

The entomology, or study of insects, explains why Africa is hit harder by malaria than, say, India. It takes two human bites in a row-one for the mosquito to ingest the parasite, the other two weeks later to infect another person-for malaria to be transmitted. In India, the predominant mosquito type prefers to bite cattle, but in Africa, mosquitoes almost always bite humans. The result is that malaria can be transmitted in Africa nine times more readily than in India.

Trying to stop every human-stinging mosquito is a dead man's game: They will find a way in.

The United States has been contributing about $200 million per year to Africa's war on malaria. Four months ago President Bush promised an additional $1.2 billion over five years in U.S. anti-malaria funding. But last week a coalition of 100 doctors, scientists, and activists said that anti-malaria funds up to now have been misspent.

The "Kill Malarial Mosquitoes Now" coalition-including eminent malaria experts and public health specialists, the former U.S. Navy Surgeon General, the national chairman of the Congress of Racial Equality, a co-founder of Greenpeace, the president of the National Black Chamber of Commerce, and the president of the Association of American Physicians and Surgeons-says most of the annual $200 million currently spent goes to advising African governments on how to combat malaria, not on actual combat.

The KMMN coalition says that only a small fraction of that amount goes to supplying bed nets and medicines. And zero goes to the most effective weapon: the insecticide DDT, which eradicated malaria in Europe and the United States more than half a century ago, but was later banned in the West for its supposed environmental effects.

The coalition's aim is to persuade Congress to devote two-thirds of annual U.S. anti-malaria funds to indoor insecticide spraying with DDT. Bed nets and life-saving drugs are important, explained Paul Driessen of the Center for the Defense of Free Enterprise, "but they just don't do the trick."

What used to do the trick was DDT, dichloro-diphenyl-trichloroethane, a chemical accidentally synthesized in 1874. In 1939, Swiss scientist Paul Muller discovered it killed many insects, including flies and mosquitoes. Allied forces used it in World War II, and scientists soon learned that small amounts sprayed on the inner walls and surfaces of homes repelled and killed malarial mosquitoes for up to a year-a revolutionary length of time compared to older pesticides that lasted only weeks.

By 1952, DDT had helped eradicate malaria in the United States, and a worldwide anti-mosquito campaign greatly reduced infections in Asia and Latin America. Only three countries in Africa got in early, though, and in 1962 biologist Rachel Carson's book, Silent Spring, attacked pesticides for causing environmental damage and singled out DDT as the worst offender.

Ms. Carson said the chemical was behind the thinning eggshells of some birds and was contributing to fewer hatchlings and the decline of species such as the bald eagle. Silent Spring helped the modern environmental movement get its wings, and the movement in 1972 succeeded in having use of the chemical banned in the United States. (In one of history's curious footnotes, the big political push for a DDT ban came from President Richard Nixon, looking to build bridges to the left.)

Soon the World Health Organization (WHO) and the U.S. Agency for International Development (USAID) cut out DDT from its programs, and instead started talking up bed nets. Author and physician Michael Crichton described the results of the de facto ban on DDT this way: "It has killed more people than Hitler." That's because trying to stop every human-stinging mosquito is a dead man's game: They will find a way in.

We've learned two things in the three decades since DDT disappeared from the disease-fighting weapon rack. First, Ms. Carson's concerns turned out to be overwrought. Lab experiments in which captive birds ingested hundreds of times more DDT than their counterparts would encounter in the wild did not thin their eggshells dangerously; bird populations actually increased while DDT was in use. Nor is DDT carcinogenic to humans; that was another Carson claim. Infants nursing where there's been heavy DDT spraying may gain weight more slowly than others, but that's a lot better than dying from malaria.

We've also learned not to trust the foreign aid establishment. Many health workers are dedicated, but Monique Maddy's Learning to Love Africa (HarperCollins, 2004) is one of many recent works to criticize the "endless parade of well-paid experts [who have] little or no incentive to bring a project to fruition. On the contrary, any project that ended, successful or not, would reduce the number of consulting contracts available to the large cadre of international experts dependent on the UN system for their livelihoods."

Ms. Maddy, who was born in Liberia and worked for the UN in Indonesia, Angola, and the Central African Republic, writes of UN-sponsored events she attended in compounds and convention centers where Dom Perignon and vintage French wines flowed not far from shantytowns where rice and beans would be a feast. She describes the pleasure of being "an academic, a self-appointed guru of global poverty, reeling in millions of publicly funded dollars to collect and disseminate data and writing alarming reports that I know will never be read, let alone acted upon."

USAID has not been so bad, according to Senate testimony in May by Roger Bate, a resident scholar at the American Enterprise Institute, who stated that "the Agency would rather allocate its monies to U.S. organizations likely to waste a good portion of it but steal none, rather than local institutions that are in a better position to effectively use resources but are more vulnerable to instances of fraud and embezzlement."

Mr. Bate noted that USAID "uses earmarked malaria funds for peripheral actions. (Read Mr. Bate's full Senate testimony in pdf format). These consist mainly of paying Washington-based contractors to consult with local health ministers on policy matters, give advice on management issues, train selected administrators and health care workers, and help run basic health education programs." Millions in USAID anti-malaria funds never leave the Washington area.

Mr. Bate described a typical USAID-funded project in Kenya that "made no effort to measure whether the project made any progress towards its goal (reduction of deaths and severe illness due to malaria) . . . instead measured several objectives (five in this case) loosely related to its goal . . . revised downward its targets for some of those objectives after the mid-term report revealed unsatisfactory progress . . . failed to meet many of these objectives (even downwardly revised ones) . . . despite unimpressive results, the final evaluation gave the program a positive assessment."

But Lester Munson, chief of staff for USAID's global health bureau, told WORLD last week that the agency was not wasting money, and instead was building "infrastructure" so that new allocations will be well spent. "A lot of stuff USAID has done for the last 10 years has paved the way for these large amounts of commodities to be used correctly," he said. He expects that some future USAID funds will be used for insecticide spraying.

Mr. Bate's testimony had little effect, so last month he-along with Mr. Driessen and four other policy wonks-started doing something more than writing journal articles: They waded into Capitol Hill's political pond and started lobbying strategic Capitol Hill staffers and lawmakers, specifically targeting top members of the Senate and House appropriations committees.

The biggest challenge, Mr. Driessen said, is explaining the basics. He said many staffers ask, "'You mean there's still malaria out in the world?' . . . They think it's maybe a few thousand cases. When I tell them it's more than the combined population of Canada, the United States, and Mexico, their teeth just drop around their ankles."

Mr. Bate and others also note that countries in Africa adopting indoor spraying are already seeing a decline in malarial infections. In Zambia, areas where DDT is used have seen a 75 percent drop in cases and deaths over two years. Health officials hope to expand the spraying program from eight to 15 districts: Naawa Sipilanyambe, coordinator for Zambia's malaria program, forecasts that "in the next two to three years, incidence will reach to almost half in this country." With fewer cases, less money will have to be spent on expensive life-saving medicines.

The nouveau lobbyists are backed up by the "Kill Malarial Mosquitoes Now" declaration (read the full report), which responds to residual concerns about DDT's environmental effects by calling for its use only for indoor spraying and not for aerial or any other form of outdoor application. But that's the only proposed compromise: The declaration insists, "We will fight furiously for every human life now hanging in the balance as a function of current, myopic, errant and unconscionable U.S. malaria control policies."