An Admiral Wages War on Malaria

from All Africa

By Charles Cobb, Jr.
Washington, DC

Every day, 3,000 African mothers bury children killed by malaria. It is the leading cause of death for children under five in the continent and last year an estimated 1.2 million lost their lives to it.

Yet in many ways a disease that arguably wreaks more havoc than any other seems almost forgotten. Two years ago, in June 2005, President George W. Bush launched a "Malaria Initiative"—a five-year US $1.2 billion effort to fight malaria in Africa. Its goal is to reach 85 percent of the most vulnerable groups – children under five and pregnant women – with proven and effective prevention and treatment measures.

The head of this effort — Admiral R. Timothy Ziemer — the first-ever U.S. Malaria Coordinator – says the goal has been achieved in 15 targeted African nations. AllAfrica's Charles Cobb Jr. spoke with him.

Was there some specific trigger for the malaria initiative? Malaria could almost be called an ancient disease, so why now?

In 2005, just before the G8 (Group of Eight) conference, the President was contemplating health on the G-8 agenda and wanted to keep it there. He has consistently brought international health to the agenda… I think it's really important strategically… HIV and Aids has been one of his key priorities and he has funded that from the very beginning. In 2005, I can't attribute it to any person, but the malaria problem hit his radar screen and when he understood the impact that it was having economically, socially [and] healthwise, it became clear to him that he wanted to elevate that on his priorities.

So he basically set, above and beyond his current agenda, 1.2 billion dollars [for malaria] from 2005 to 2010. There was little money coming in in 2005, but If you look at the funding projection we have accelerated in 2008, 2009, 2010, with 300, 300 and 500 million dollars, so it's a ramp-up through 2010 with specific targets and goals – very much like Pepfar (the President's Aids initiative).

We learned from the Pepfar experience and took away a lot of the best practices. We focused in on 15 of the most endemic countries: on countries that had demonstrated leadership on the national level, that understood and wanted to take care of their people, had strong national malaria control plans, could manage finances with other financial instruments like the Global Fund and the World Bank – so the U.S wouldn't be the only partner but could be a major partner and leverage funding with these other funding sources – and lastly be willing to work with the United States.

The goal of the President's Malaria Initiative (PMI) is to reduce mortality in those 15 countries by 50 percent over the five years. Now those weren't U.S targets, those targets are consistent with the Abuja targets, the Millennium Development Goals and the World Bank malaria goals. Basically the funding was to target the most vulnerable population groups: kids under five years – they are very, very vulnerable to malaria because they haven't built up immunity – and of course pregnant women – as they go through their pregnancy cycle they also are vulnerable, not just getting sick and getting anemic but also it affects development and healthy birth. And so we target the money to cover the entire population group in a country and our coverage is 85 percent of those two population groups.

Your coverage goal is 85 percent, Are you achieving that sort of coverage?

We have met it to date. We're going to be able to [continue meeting] that easily. One other thing from the big picture: the President realized that 1.2 billion is just a drop in the bucket. When you look at the international World Health Organization and the Roll Bank Malaria costs and requirements per year, we're at about four billion a year to try to get a handle on malaria.

So with U.S. Government money and Global Fund money – of which 30 percent is U.S money anyway – it still isn't sufficient to bring enough resources to the table. So President Bush challenged the private sector to step up to the plate… to see if they would match the 1.2 billion. This is an operating principle that he's injected throughout…

I am the new kid on the block here but I have seen that the private and the business sector is stepping up to the plate. Certainly the Gates Foundation is there and has been significantly but also other organizations like the UN Foundation and Nothing But Nets [campaign of providing mosquito nets to save children from malaria], Malaria No More and Exxon Mobil. Some of these other corporate partners are stepping up not only with cash but also contributions in kind that are helping to round out, focusing in on the national malaria control plan. So it's really kind of neat to see all the partners coming in together to take on our host countries' malaria requirements and do what we can to fill those gaps.

What about other governments, their primary contribution is via the Global Fund? Is that basically correct?

As a generalization, I would say yes.

What about additional funding from other governments, particularly governments in the G8? Is that part of your effort?

I would say through the G8 and through our bilateral efforts through the State Department and by the President himself, he is encouraging everybody , all governments to step up to the plate as they can. If they want to fund through the Global Fund or through the World Bank, that's fine. There are numbers of different vehicles that countries prefer to use and that's okay.

You were in Africa recently, Mali, Madagascar, where else?

We were in eight countries and every country we've gone to we try to have a jump start. A jump start is either just a media launch or more preferably to team up with an existing health day [event].

In Angola we teamed up with the Red Cross, and… a measles vaccination and deworming and Vitamin A [effort], and so since the government had already communicated with the media and the networks were in place, the US government, USAID, PMI then came along with our net distribution money and we just piggy-backed on that whole network. What was interesting in Angola was the business interests – they also participated and they made a significant contribution of several millions of dollars which brought a lot of nets and so they also complemented the net distribution campaign.

We've also done this in Uganda and Tanzania. The countries you have just mentioned – Madagascar, Benin and most recently Mali – have used that model and we've found it to be very successful and we intend to do that as often as we can. In fact we are looking right now at four to five additional campaigns next year with the Red Cross and our multilateral partners.

This is good for two points: it allows our business and our private partners to jump in and be part of something significant and they can do it very well because this is a kind of a "onefer". When you get in to program development and trying to tackle some of the systemic problems, HR, buildings , training, it's more difficult for the private funders to jump in and do that. So the national campaigns are real good for awareness and catch up, and to fill existing gaps and then make the long haul a little less long because we are filling some of these holes.

On these journeys, did you learn something that you didn't know in terms of the impact of the disease or how the disease is being fought?

We're always learning different things. What I have seen here is the different lead partners in every place. In Benin the lead partner was the World Bank, where the majority of the funds came from the World Bank because Benin was their first booster country. In Madagascar the lead funder was the U.S. Red Cross and UNICEF. In Mali it was the Canadian Red Cross and CIDA (Canadian International Development Agency). What I learned is that there are multiple partners out there all with the same intent and if we collaborate early enough we can actually leverage everybody's resources really to benefit the host countries' needs.

Other lessons learned are real simple – it's just the logistics. Can we in fact move two million nets in a week in a country like Benin or Mali? That is no insignificant task and it took the Canadian Red Cross staff six months of in-country planning to man, to rehearse to get four to five thousand distribution sites up and running.

Is that a problem of personnel or infrastructure?

Everything. In some of these countries it's a no brainer, in other countries it's like starting from zero. Every place is different, every place takes a little different commitment, investment, passion. It all boils down though at the end of the day to our host country and their leadership. I am really grateful that in every country we have worked in so far, particularly when it comes to malaria… the president of the country has kicked off the national campaign and then we come in and support his plan and it's really been kind of neat to watch the thing develop.

Let me ask you a question that has some political dimensions to it. The United States, unlike Britain, France, Portugal, Spain has never colonized Africa. How is it that the U.S. is taking a lead on this as opposed to one of the former colonial powers?

The first thing I want to do is say we don't want to politicize malaria.

No, but I am curious about this.

That's a good question. As a matter of record we don't want to politicize anything when it comes to public health, no matter where it is. That said, what motivates us as Americans to go to Africa to invest a considerable amount of our treasury in fighting malaria, I think it's because we see the need and we as people respond to legitimate needs particularly where we see we can do something about it.

This Administration has focused on Africa because of significant educational, community social and health needs. If you go back and just look at investments in Africa by the United States over the last seven years you will see that our investment has gone up by 400 percent. In 1997, USAID spent one million dollars in fighting malaria in Africa. This year my budget is 388 million.

What this represents is a commitment to the continent, a significant understanding of need, and a moral imperative to help those who need it the most. I also need to say that fortunately our Congress has given the malaria and the HIV and Aids budget line items strong bipartisan support. So we enjoy not only very strong leadership support at the Administration level but our Congress is fully behind these programs.

Does this initiative at all include either funding or encouragement of efforts to cure malaria, as some money is used that way for HIV-Aids?

Now you are getting technical on me. Let me from a layman's and a generalist's perspective, give you a response to that. First of all there have been many smart scientists and researchers that have been working hard and investing personal time and money fighting malaria. We have been spending millions of dollars on vaccine research and one day we will find it.

But what's changed now are two things: the amount of money being brought to the table to fight malaria by all countries, through the Global Fund, through the Bank, through the U.S. Government, has jumped significantly, so cash on the barrel has enabled researchers, scientists to do even more.

When you add in the Gates Foundation's component to what our government's investment is, it's skyrocketed. The other piece is that for the first time there seems to be a coming together of all partners to basically leverage not only our money but our research in vaccines and anti-malarial drugs along with at the same time using proven, known strategies of prevention and treatment until the vaccine pops up on the scene.

I am told by the smart folks that it will another be another 10 to 12 years minimum before vaccine hits the streets. So until then if in fact a million people die each year, we've got to do something about those 12 million people who are going to die, because we know what causes it and we know how to prevent it. So the PMI and much of the Global Fund investment that's being made right now is being invested in prevention and treatment of those people who are plagued by malaria today.

The Gates Malaria Forum happened in October, and Bill Gates stood up and applauded the ongoing work right now, but then he also challenged the universities, the research and the science community to look beyond and towards eradication. Most malarialogists don't use the e-word.

The e-word being eradicate?

Or elimination. The point is that if we don't shoot for that, then we're going to continue to prevent and treat until kingdom comes, and that's not what we need to be focusing in on. So right now I sense a coming together of the world community to focus in on the future as well as now so that we can collectively do both.

How does an admiral in the Navy become the first U.S. malaria co-coordinator?

That's a hard question for me to answer. I am not a malarialogist; I am not a public health guy. I was raised in Asia. My mom and dad were missionaries and I had malaria, in fact our whole family had malaria… I saw service in action as my parents went from doing what they did in education, training and medical support in Asia. I served my country for 30 years in a different capacity (in the U.S. Navy).

After that I ran World Relief, which was a faith-based, non-profit organization out of Baltimore. We were in 26 countries, many in Africa, many had malaria as a problem that we were dealing with in health sectors.

My engagement here with PMI was not sought, nor intentional. I got a call out of the blue from the Administration and asked if I would be willing to help lead and run this. After some consideration I felt that with the resources, with the expert teams here at USAID and the Infectious Disease Bureau and our colleagues at CDC (Centres for Disease Control), all the technical knowhow and experience was resident, the money was flowing, our rules of operating were clear and crisp, the potential for partnership was there, so as a generalist who likes to take on challenges I feel very privileged and blessed to be doing this at this stage of my life.