Will efforts to eradicate the killer disease overcome technical, finanicial and political obstacles?

The global death toll from malaria has dropped dramatically in just over a decade – more than 25 per cent overall and 33 per cent in hard-hit sub-Saharan Africa, according to the World Health Organization. Yet the WHO reckons that malaria still kills more than 625,000 people a year – roughly equal to the population of Vancouver – and some estimates, including one published two years ago by The Lancet, suggests that the WHO’s figures reflect only about half the actual total. As well, country-by-country statistics make clear that progress in combating this killer disease is both fragile and spotty. For example, while the number of deaths reported in Tanzania plummeted from more than 20,000 in 2005 to just 840 in 2009, next door in the Democratic Republic of Congo the toll soared from fewer than 15,000 to well over 20,000 in the same period.

Today malaria is almost exclusively a tropical disease, but until a century ago or even less, it was also found in much of Europe and North America. Variants of the anopheles mosquito, which carries the parasite that causes malaria, are still common across Canada and in most temperate countries, but good public health measures have extirpated the parasite. Thus the disease is no longer endemic in any developed country, though imported cases crop up from time to time.

But while the rich places – southern Europe, Washington, D.C., the U.S. South, Ottawa – eliminated it years ago, malaria doesn’t strike only the poor. In the fall of 2013 I set out on a round-the-world trip (supported by my employer, the Vancouver Sun, and funded by a grant from the Canadian Institutes of Health Research) to investigate all aspects of malaria. Most malaria workers I interviewed, even professionals in malaria-endemic parts of the world who are well paid by their countries’ standards, had had bouts of it themselves and had seen it in their families.

In addition to the death toll, the economic cost of malaria is huge. Hundreds of millions of working days are lost in scores of countries when workers fall ill or stay away from their fields or off the job to care for sick children. And health is inextricably connected to education and economic progress. “In a village where malaria is endemic, life expectancy goes down,” says Sir Fazle Abed, the founder and head of BRAC, a multifaceted Bangladesh-based NGO that has grown into one of the largest development agencies on earth. “If half the time I’m sick, my productivity will go down, and I’ll always be a poor person. All kinds of other deprivations will happen because of my poverty, and each deprivation will mean I can never get out.”

Rosemin Kassam, an associate professor in the University of British Columbia’s School of Population and Public Health who has worked on malaria-related issues in Uganda and elsewhere, says the early impact of malaria on children can drag them down for life: “Even if they don’t die, they’re likely to be left with some kind of morbidity. It can be significant – paralysis, brain damage and retardation, a lot of negative consequences. Even just carrying the parasite can create anemia, which can make it difficult to sit in school and concentrate.”

The international effort

Successes to date in controlling malaria are due to many factors – billions of dollars from governments and private donors, better and better-targeted insecticides, effective environmental management, easy and cheap diagnosis, new medicines, education on preventing malaria and seeking appropriate treatment, community organization to ensure that people get the prophylactics and the care they need. But it will take at least as large an arsenal – accompanied by luck and bolstered by a promising new vaccine – if the fight is to be finished.

The catalyst and guiding hand for much of the progress – and no doubt a vital player going forward – is the Global Fund to Fight AIDS, Tuberculosis and Malaria. It has not only funded billions of dollars worth of work on several fronts around the world since it made its first grants in April 2002, but has also marshalled political will in both rich countries and poor, focused prevention and treatment initiatives, and broken down silos and coordinated research to a degree not seen before in the annals of medical history.

The Global Fund’s role was one of my interests in my global investigation. At every major stop – the funding and research hubs of Washington and Geneva and the fieldwork centres in northern Liberia, northern Namibia, western Kenya, the Indian border region of Bangladesh and the remote hills of the off-the-beaten-path Philippine island of Palawan – the depth and breadth of its influence became ever more apparent.

The impact of the Global Fund’s involvement goes well beyond paying for prevention, diagnosis and treatment in countries too poor to cover the costs themselves, says Kishor Wasan, who until his recent move to the University of Saskatchewan was dean of pharmacy research at UBC, where he founded the university’s Neglected Global Diseases Institute. It has also enticed researchers out of their ivory towers by funding only multidisciplinary research.

“The range of work on our campus alone is exciting,” Wasan said in an interview in late 2013. “It’s all the way from drug discovery and development to implementation and understanding the barriers to getting a product from a bench in the lab to the patient on the ground. We’re touching business, chemistry, community geography. Fifteen years ago these researchers would never even have talked to each other.”

The Global Fund’s financial support for research is substantial, and its prevention and treatment initiatives cost much, much more. So much of its success is thanks to the support of donor governments, which have given or pledged more than $30 billion since the fund’s inception, and from private sector partners, most notably the Bill and Melinda Gates Foundation, who have added hundreds of millions of dollars more.

Yet individual interventions are cheap. The international benchmark for health program cost-effectiveness is US$150 per year of healthy life, and a British study estimates that with malaria this cost is between $8 and $110 (depending on the location and distribution complexities) for insecticide-treated bed nets, or $89 for drugs to treat diagnosed cases.

Mosquitoes and parasites

Mosquitoes are usually blamed for spreading malaria, but humans are also complicit, and our forebears helped turn the disease into the scourge it is today. Although the parasite that causes it, a protozoan called plasmodium, has existed for at least 50 millennia, it didn’t become common until the dawn of agriculture about 10,000 years ago, when people started living in larger and more settled groups. Such good-sized pools of human hosts, with our nourishing blood and livers, are vital to the parasite’s lifecycle. The one-celled plasmodium can reproduce only in a human body, and mosquitoes can’t infect new victims unless they first bite people who already have plasmodia in their blood.

Most variants of parasite-bearing mosquitoes are nighttime or early-morning biters that can be foiled – or killed – by insecticide-treated bed nets. The parasite has several variants too, the most lethal being plasmodium falciparum. All are tiny, too small to be seen with the naked eye, but when their manic reproductive cycle takes hold inside a human body, the results can be catastrophic. Infected people get sick – chills, fever, sweats, fatigue. Without treatment, especially if victims are small children with yet-to-develop immune systems, many die.

The fight to control malaria plays out differently in various parts of the world. But every malaria control program shares three key elements.

Cheapest and best is prevention. This may include low-tech environmental measures – things such as clearing brush around water sources where mosquitoes breed or homes where potential victims sleep. But the most effective component is insecticide-treated bed nets, often accompanied by regular spraying of the walls in rooms used for sleeping. Various insecticides are used, even highly effective DDT in a handful of countries that haven’t banned it yet. Treated nets and sprayed walls provide double-barrelled protection. The obvious benefit is preventing sleeping people from being bitten. The not-so-obvious plus is that, even if a mosquito doesn’t die until after it bites someone, at least it won’t live long enough to bite again. This is significant because mosquitoes don’t carry the parasite unless they bite somebody who has it. So a mosquito that dies after biting once is an irritant, but not a danger.

The second essential element is diagnosis, which has become much easier and more reliable than in the past. The Global Fund’s promotion and widespread distribution of new rapid diagnostic tests – strips that react to a drop of a patient’s blood – mean even minimally trained volunteers can get accurate results. This is a major advance. Previously, every fever was assumed to be malaria, which meant expensive treatments were often wasted on people who needed different interventions. And these same patients did not, of course, get the treatment they actually needed.

The final step is treatment. This, too, has become simpler thanks to new combination drugs. Precise combinations vary from region to region and are changed as necessary to combat any resistance that develops in the parasite. Significantly, treatment loops back to prevention to complete a virtuous circle. Because mosquitoes don’t carry the parasite unless they bite an infected human, sick people are essential to the parasite’s lifecycle. So the more who are cured quickly, the more the reservoir shrinks.

But both insecticides and drugs face moving targets. Mosquitoes develop resistance to sprays and parasites become drug-resistant in alarmingly short order. The parasites, in particular, are genetically primed to adapt, says Chris Ockenhouse, senior research scientist with the PATH Malaria Vaccine Initiative in Washington, D.C. He notes that while viruses typically comprise a couple of dozen proteins, the complex malaria parasite has 5,000. Its lifecycle includes six unique environments – three inside mosquito carriers and three in a human host – so it’s inherently adaptable. Thus, widely used medicines rapidly lose their punch as new generations of parasites become immune.

Vaccines, drugs and money

For researchers pursuing the holy grail of an effective vaccine, the question is whether this adaptability will shorten the useful life of what they come up with. It may not, Ockenhouse said, because drugs and vaccines work differently. Drugs attack the infecting agents, so any parasite not killed will propagate its drug resistance. Vaccines, however, stimulate the body’s immune system to protect itself and don’t interact with the invader. So if parasites survive, it’s because of the person’s weak immune response, not the parasite’s genetic resistance.

Several potential vaccines are under development, but only one – a GlaxoSmithKline product targeting early stages of a malarial infection – has undergone somewhat successful trials and is seeking regulatory approval. The most recent trials ran at 11 sites in seven African countries and focused on young children – six to 12 weeks in some cases, and five to 17 months in others. The best results were for the older children, who enjoyed roughly 50 per cent protection for at least 18 months. This doesn’t mean half the vaccinated kids never get malaria. Rather, they experience only half as many bouts of malaria as the unvaccinated – perhaps an average of two a year instead of four.

These results fall well below the performance of vaccines for most diseases, but for Walter Otieno of the Kombewa Clinical Research Centre near Kisumu, Kenya, they’re heartening. For one thing, vaccination halves the risk of a protected child’s death or disability. For another, like every preventive measure, it shrinks the reservoir of human carriers who can infect mosquitoes that will in turn infect other humans. So, Otieno thinks the vaccine should be rolled out for general use, and soon.

Yet 50 per cent efficacy doesn’t look so good to many drug researchers working to refine artemisinin-based combination therapies (ACTs), which cure virtually all cases if the victims receive treatment in time. Viollaine Dallenback, the Geneva-based communications coordinator for the international Drugs for Neglected Diseases Initiative, is more concerned with the push to find drug combinations that stay a step ahead of the parasite’s ability to adapt. Another key goal is a one-pill therapy to replace the current three- to 24-pill treatments, which tempt patients to take fewer than they need so they can hoard the rest for a possible subsequent bout.

Dallenback’s colleague Bernard Pecoul notes that keeping the cost down is also vital. And cost control is a tough challenge. For one thing, both malaria medications and vaccines are unusual in that they’re being developed primarily for poor people. In the past, the poor have had to wait a long time – often a couple of decades – to get access to new preventatives or treatments. This meant that by the time they got the drugs, paying customers in the developed world had largely covered the drug companies’ high overhead and research costs.

As well, says Chris Orvig, a UBC professor of chemistry and pharmaceutical science, new therapies will probably be costly. Old, cheap, plant-based medicines have mostly become ineffective, he said, and new drugs tend to involve synthetic molecules: “If you have to do multiple synthetic steps to put together a molecule, it requires a bunch of PhDs, and laboratories that have safety standards, and chemicals that have to be approved. So it’s inherently expensive.”

Similar cost considerations will no doubt influence decisions on whether or how to roll out malaria vaccine. This issue is complicated by the fact that the cost per shot will depend on how big the rollout is. Drug and vaccine costs drop substantially when massive distribution programs generate huge economies of scale.

If the Global Fund or other funders have decided what combination of cost and efficacy they require to move ahead or what scale of distribution they favour, they aren’t saying. But three main scenarios are possible. One is to roll it out everywhere it’s needed, as Otienio advocates. Another is to wait until the vaccine is refined and results improve. A third is to use it soon in large-scale pilot programs in the worst-hit areas – an approach that fits well with current thinking about strategies for the future.

For more than a decade, the goal has been to “shrink the malaria map” – to eradicate the disease inward from the edges of its range and gradually reduce the percentage of the world that’s affected. This has worked, but with limitations. The problem is that as long as malaria remains highly endemic in the core – more than half the population carries the parasite in some regions – the disease keeps getting reintroduced in areas outside the core. These areas might be malaria-free if no one travelled back and forth. But people now travel more than ever, even in the poorest countries.

So some researchers advocate massive intervention in core areas because fewer infected people would mean fewer parasites carried out. A partially effective vaccine could be part of this strategy, as could various proposals to mass-treat everyone in the worst areas regardless of whether they’re sick.

Of course, whether dealing with the vaccine or a new drug, the question of cost complicates any decision about when to start using a new product and on what scale. Massive rollouts may be cheaper per dose but, as Pecoul noted, they may also trigger resistance in the parasite. And cost, ironically, becomes a bigger issue as countries or regions get closer to eliminating the disease.

In highly endemic places such as the jungle villages of Liberia, the biggest challenge isn’t figuring out who’s ill or what to do about it. Even before the Ebola outbreak threw the medical system throughout the country into chaos, it was a challenge to lay hands on drugs to treat the disease in a place where the fragile supply chain is often disrupted by dishonesty or incompetence. So the lucky would get three pills to take – usually all they would need – and the unlucky would be left to suffer or die.

By contrast, on the dusty plains of northern Namibia, where after a decade-plus of progress authorities dare to hope they’re on the cusp of eliminating the disease, a now-rare episode of malaria triggers a substantial response. First, the victim gets prompt and supervised treatment. Then a team moves in to trace the source of the infection, and to test and, if necessary, treat all family members and close neighbours who may also have been exposed. “So getting close to elimination is expensive,” said Chris Lourenco, who heads the Clinton Health Access Initiative’s malaria program in Namibia. “When you find a problem, you have to carpet-bomb it.”

Cross-border politics and worse

Namibia faces another challenge – sadly, one that’s far from unique – in what in other circumstances might be a straightforward march to eradication of what is now a well-controlled disease. It’s how to clean up the neighbourhood when the neighbours don’t do their part. Northern Namibia’s malaria-prone strip borders southern Angola, where the disease remains rampant. With several thousand people crossing the border every day, travelling Namibians may pick up the parasite in Angola, or visiting Angolans may bring it across. So people with parasites in their blood continue to infect Namibia’s mosquitoes.

Namibia maintains a network of hospitals in its towns, supplemented by stand-alone rural clinics. The clinics, scattered here and there on the scrubby plain that stretches in every direction, are placed to be reasonably accessible to the people living in tiny homesteads, often spaced a kilometre or more from one another. But because health care is free and is seen to be better here than in Angola, many patients come from across the border. So on one hand this network shrinks the reservoir of parasites living in human bloodstreams, and on the other it lures more infected people into Namibia.

Cross-border problems aren’t confined to Namibia – they’re found wherever countries with unequal levels of infection share a common border. In Bangladesh – also close, though not close enough, to eradication – the two parts of the country where malaria stubbornly lingers are the southeast, near the Myanmar border, and the north, next to the Indian state of Assam.

In both Assam and the border area of Myanmar, which is home to the persecuted Rohingya minority, insurgency has strained relations with central governments. “As a result, these parts of both countries have been neglected by their governments,” says Fazle Abed, whose organization, BRAC, is not only the lead agency in Bangladesh’s malaria programs but is also trying to establish similar ones in Myanmar. “At this point, I don’t think there’s any cooperation across the borders.”

But there is a lot of cross-border traffic. Be-Nazir Ahmed, director of Bangladesh Communicable Disease Control, notes that people living on both sides of the line share “the same colour, the same language, the same religion. We have a very close cultural connection.” And with the clashes with the Buddhist majority making life difficult for the Muslim Rohingyas, millions of refugees are flowing into Bangladesh. “We feel very close to them,” Ahmed said. “But they’re a risk.”

This risk is not just that Myanmar abuts the Chittagong Hill Tracts, the worst area for malaria in Bangladesh. This less-developed neighbour is also seeing increasing incidents of drug-resistant malaria parasites, which are slowly moving out from Cambodia and Thailand, where they’ve been a scourge for years. “Without international cooperation to stop it, this will be a nightmare,” says Abul Faiz, a professor of medicine and a prominent Bangladeshi malaria researcher.

The onset of drug resistance in the parasite has been traced to the Vietnam war when American troops used massive monotherapies as a malaria preventative, said Pecoul. Victims of drug-resistant parasites can still be treated, but only at great cost and not with the readily accessible and affordable medications that are generally so effective. As well, the development of drug-resistant strains has made the medical community leery of overusing monotherapies – it’s the reason today’s widely used ACTs are combination drugs, and the combination is occasionally changed. And, because malaria medications appear to have a finite useful lifespan, they’re reluctant to start using new ones until the existing ones have become ineffective,

The cross-border issue doesn’t affect every malaria-endemic country – islands like the Philippines, Zanzibar or Madagascar can run more or less self-contained programs because they don’t butt up against any neighbouring countries. But the issue does complicate the job in most countries to the point where Carl Lowenberger, a biology professor at Simon Fraser University who has worked in malaria control for more than 30 years, is pessimistic about ever seeing the disease disappear. “It has to be a regional, multicountry approach,” he said. “So who’s going to run it, especially in places with tribal tensions? In Africa, for example, you’d have to have 30-some countries coordinating their efforts. I don’t see that happening.”

Difficult as cross-border politics may be, an even more worrisome challenge looms on the horizon, says former British Columbia NDP MP Svend Robinson, who now works from Geneva to coordinate Global Fund relations with governments around the world. It’s to keep both donor countries and recipients focused on – and financially committed to – finishing the job rather than using early successes as an excuse to ease off.

Another former British Columbia MP, Liberal Keith Martin, who now heads the Washington-based Consortium of Universities for Global Health, agrees that maintaining the will to defeat the disease will be key to any future success. “We know how to prevent malaria deaths and disability,” he said. “Yet we still have 650,000 people a year dying from malaria. If we know what to do, why are they dying?”

Two NGOs try to cope with eastern Africa’s overcrowded schools

Kenya, Malawi and Tanzania are among the Eastern African countries that have in recent years dropped their previous small fees for primary education and made it free. These fees weren’t the only barrier to education – parents may still be deterred from sending their children to school by the cost of supplies or uniforms and the lost opportunity to put them to work in the families’ fields – but enrolment has nevertheless shot up, with many schools reporting more than twice as many students as before.

It’s hard to argue against any move to make schools more accessible in a world where education is increasingly a prerequisite to earning a decent living. Yet this policy is bringing with it almost as many problems as it hopes to solve. While the number of students has surged, the staff to teach them and the space to house them have increased scarcely at all. Ill-trained teachers routinely have classes with 100 students or more. Their classrooms often have no supplies, sometimes no furniture and occasionally not even solid walls. And “free school” is reduced to a sad synonym for “poor school.”

During a tour of rural schools north of the Kenyan port city of Mombasa, I got a first-hand look at the problem of schools crowded almost to the point of dysfunction, and an insight into approaches to addressing this problem.

Children are shouting and waving as the Aga Khan Education Services (AKES) four-wheel-drive jounces down what passes for the main road in Marimani, a “village” of 3,000 peasant families with home and fields sprawled over 50 or 60 square kilometres of scrubby land. “Talk about opportunity costs,” mutters Atrash Mohamed Ali, the manager of AKES’s Kenya School Improvement Project. “These children are school-going age. Yet here they are, herding goats.”

He tells me, however, that the number of school-skippers is down sharply from three or four years ago. Today it’s probably no more than 100 of the 800-plus kids in the village – about a fifth as many as it used to be before the Kenyan government waived the low but daunting fees that kept millions at home.

Just down the road I see the result of all those extra kids in school. In Marimani, as in villages and towns and poor areas of cities across the country, scores and scores of kids are shoehorned into unfinished, unfurnished classrooms. With some perched on concrete blocks and more just plunked on the bare concrete floors, their education is in the hands of a relative handful of often ill-trained teachers who, each with 100 or more kids to teach, may need most of the term to learn their names.

When tuition fees were eliminated, enrolment at the government-run Marimani School, for example, shot from 300 to 733 – including 332 girls, who in the past were often kept at home. The school was slated for some new construction at the time, but it didn’t make any difference. It still has just eight classrooms (and nine teachers) because the old adobe-brick classrooms are falling down faster than the money can be found to properly finish the new concrete-block ones. One old classroom with gaping holes in the wall is still pressed into use as a staff room, but the others are fit for nothing at all.

Thus classes are being taught in a new shell that still has gaping windows-to-be left open to the elements. Only a couple of the rooms have desks. In the most crowded classrooms – like Morris Mwavita’s Grade 2 class of 133, or Bessie Randu’s Grade 1 class of 99 – they’ve shortened the school day and divided students into two shifts of “only” 50 or 60 each.

Most of the teachers in Marimani, as in government schools across Kenya, came to the job with no more than two years of basic training. On the job they found no structured mentoring, no easy way to break in – it was sink or swim from Day One.

Bringing some order to the chaos

Aga Khan agencies have been immersed in education in this region for a century, ever since Sir Sultan Mahomed Shah, then leader of the world’s Ismaili Muslims and grandfather of the current Aga Khan, established a network of schools. At that time, the approach was for Aga Khan agencies to set up their own schools and run them according to rigorous standards that tended to raise the bar for education throughout the region. For years, Aga Khan schools provided grounding for thousands of East Africans, including the likes of Firoz Rasul, the Vancouver entrepreneur-turned-philanthropist who built Ballard Power Systems from a start-up to a leader in the emerging fuel cell industry, and his wife Saida. Aga Khan Education Services still runs its own elite schools for the few who, with luck and perseverance, will become the future leaders that sub-Saharan Africa so badly needs. It now also conducts two different teacher-training programs to help the government schools make the best of a bad situation.

And so Atrash Mohamed Ali and his staff come to Marimani often, trying to bring a little order to the chaos of Marimani School. Their tools are training programs both for teachers and for the local school management committees, learning materials to help with professional development and for direct use in the underequipped classrooms, and structured mentoring programs that focus on the most vital challenges, such as how to manage huge classes and how to foster and promote a fair chance for girls.

This approach is a more basic version of a sophisticated teacher-training program pioneered by Aga Khan agencies in rural Pakistan and now run throughout East Africa by the Aga Khan University’s Institute for Educational Development office in Dar es Salaam, Tanzania.

The office, established five years ago with funding from the Canadian government and the Aga Khan Foundation, asks schools to nominate their best teachers for a scholarship to pursue a master’s degree at the Aga Khan University’s main campus in Karachi, Pakistan. Those who make it through the rigorous selection process and earn their degrees come back not only to full-time jobs in the school system, but also with an obligation to volunteer about half-time over the next few years to help upgrade the qualifications of their peers.

Rupen Chande, who heads the office, told me that so far there are only 50 master’s graduates from East Africa – 24 from Tanzania, 17 from Kenya and nine from Uganda – but they have already helped 850 other teachers earn certificates for upgraded qualifications. In a region where the number of teachers who have university degrees “is horrifyingly small” – from zero in government-run pre-primary schools to fewer than 10 per cent in the high schools, where the best-qualified teachers are usually found – this in-service training makes a huge difference, Chande said.

Training a new generation of leaders

Aga Khan schools, too, are changing. Newer initiatives range from the prestigious eight-country Aga Khan University – which welcomed Firoz Rasul as its new president on May 1 – to the 66 humble madrasas, or nursery schools, found in nondescript little buildings in Mombasa and up and down the coast from there.

Seventeen years ago, Naima Shatry toddled off at age three to the very first Aga Khan madrasa in a single shabby room in the heart of old Mombasa. As others recall it, there were just three students in the program at the time, though Shatry remembers “a few” more than that. What she remembers much more clearly is her teacher, Bi Swafiya, and the love of learning she exemplified every day.

Today, having topped her class in high school, Shatry is not only a devout and knowledgeable Muslim – the only goal of the old madrasas that the Aga Khan institutions replaced. She is also acing first-year medicine at the University of Nairobi. That’s exactly the kind of role the modern madrasas are keen to foster.

Najma Rashid, project director for the Madrasa Resource Centre, said the Aga Khan nursery schools were set up in the late 1980s to replace traditional madrasas that focused only on the Qur’an. The limited curriculum left the children who attended them, mostly Sunni Muslims, at a disadvantage when they started primary school, and far too many dropped out.

The imams who taught at the traditional schools were initially suspicious, she told me, but they were consulted at length about what would be taught at the new madrasas. The result is a three-year program that emphasizes not only the core values and beliefs of Islam but also secular learning, especially numbers and letters, both Arabic and English. It’s child-centred and substantially play-based – a far cry from the old days of rote learning and corporal punishment.

The results? The schools attract children from a broad range of backgrounds – a little over half of them Muslims and the rest more or less equally split between Christians and Hindus. And, even though most of the kids come from homes where little or no English is spoken and where there are few, if any, books, most of them can read, often fluently, by the time they start primary school at age six.

Shatry said the multiple legacies of the madrasa have stayed with her. Despite her deep commitment to her own faith, her friends today – the old ones from school days in Mombasa, and the new ones from medical school in Nairobi – come from a broad mix of religious backgrounds. And, she said, “I learned to like school. I still do.”

The network of madrasas has been growing for a decade at the rate of about five new ones a year. Although Aga Khan Education Services subsidizes each start-up, it won’t carry them indefinitely. They are, like virtually all Aga Khan undertakings, expected to sustain themselves in the long term. In the case of the madrasas, that’s after three years. This means that school fees, set by the local committees that run each madrasa, vary widely according to the means of the village or the neighbourhood. Salaries also vary for the mostly young women trained to teach at the schools.

“These are primarily school-leavers – dropouts,” said Najma Rashid. “There are usually no other opportunities for them in their communities. The Kenyan system is very paper-oriented. But we’ve shown that we can take these semiqualified women and give them skills of value … We have been able to empower them to learn new skills and get a good job. The biggest problem we have as a result is that they’re hired away in droves by other schools that can offer them higher salaries. It means we have more turnover than we should.”

When Shatry finished nursery school, she went on to an Aga Khan primary school in Mombasa, not unlike the one in Nairobi attended by Firoz and Saida Rasul. But when the time came for high school, she was a few years too early to compete for space in the latest Aga Khan educational undertaking – Mombasa’s showcase Aga Khan Academy, the first of 19 such institutions planned for Islamic areas in the developing world.¹

The academy, a US$20-million architectural marvel in a country where a dollar goes about two and a half times further than in Canada, opened in the fall of 2003 with classes from pre-primary to high school. But its focus is the high school – its students chosen solely on merit in a means-blind process that provides partial or full scholarships for those who can’t afford the hefty fees (by Kenya’s standards) of about US$2,700 a year. It’s still teaching Kenya’s high school curriculum, but is poised to phase it out in favour of the International Baccalaureate program that was developed in Switzerland and is taught in 3,000 elite schools around the world.

The other 18 schools will all be similar to this one – an 18-hectare residential campus with first-class labs, special areas for the study of the arts, religion and culture, design and technology workshops and a wide range of sports facilities. This first academy, which doesn’t yet have facilities for the boarders who will eventually double its enrolment to about 1,000, has students from pretty well every ethnic group and religion found in the cosmopolitan city of Mombasa. It has attracted faculty from far and wide, including two teachers from Canada. But it is, at least for now, largely populated by students from backgrounds that are somewhat privileged.

Sheliza Darveck, a senior student and one of a small minority of Ismailis who attend the school, says she went to one of the better primary schools in Mombasa, and so did most of her classmates. Students from the overcrowded poorer schools, she said, rarely have marks good enough to get them in the door.

Firoz Rasul sees the web of Aga Khan initiatives to improve basic education as a way to deal with that problem over time – to bring poor schools to the point where they routinely produce students who can compete for elite further training in institutions like the academy or Aga Khan University. The result, he told me, will be a new generation of leaders who are solidly grounded in the humanities and sciences, and who have a network of friendships formed across social, cultural, religious and even national lines.

I find it as hard to quibble with this noble objective as with the goal of free primary education. Yet excellence and inclusiveness seem to be mutually exclusive goals in countries that really can’t afford either one.

Putting pressure on the government

Like the Aga Khan institutions in Kenya and Tanzania, ActionAid in Malawi is committed to seeing the government schools succeed. In a strategy that may seem odd, ActionAid is trying to achieve this goal by backing away from the kind of direct support for schools it used to provide. What led to this change of direction is that old bugaboo of international development – the fungibility of aid.

“We started as a service delivery charity in 1991,” says Collins Magalasi, who runs ActionAid’s Lilongwe office. “We provided schools, water, teachers’ houses, bridges, roads, food when it was needed and that sort of thing … But government was very clever. Where ActionAid moved in, it tended to withdraw.”

When the European-funded charity opened a school, the government was almost sure to close one – or at the very least to change its plans to open one nearby. The result was no net gain in education services for all of ActionAid’s spending. As a result of this experience, ActionAid is shifting its efforts to working with poor people directly and becoming much more rights-based. “It’s the duty of the government to provide for its people,” Magalasi said. “We try to force them to do it.”

ActionAid still does some direct service delivery, “but only as a means to force government to do what it is supposed to do. For example, the government will say it can’t open a school because there’s no place for the teachers to live and teachers won’t come if there’s no housing. So we will build the teachers’ houses, and then we’ll say to the government, ‘Your excuse is no longer valid. Now you must provide the teachers.’”

The boy behind the grille

The challenges facing all these countries are driven home to me by one of the pictures I brought home from the Mombasa madrasa where Naimi Shatry began her educational journey. It’s not the best shot in my album, and its impact is subtle. It shows a group of little boys in simple blue uniforms having fun on a teeter-totter. Behind them – and behind a grille that closes off their play area from adjoining yards – is another little boy who is not in uniform, not having fun, not in school.

I know nothing of this boy and what opportunities may, or may not, be open to him in his lifetime. But to me the image stands as an icon for all those who are excluded from even the “free” schools in poor countries of the world, let alone those that charge, however small a pittance the fee might be.

Yet the value of education can’t be measured by quantity alone. Quality is key. And no matter how much groups like ActionAid cajole and bully poor governments like that of Malawi, schools there are at such a low level that any aspiration to excellence is a long, long way off under even the best circumstances that can be imagined. Ditto in the grossly overcrowded classrooms of Tanzania and Kenya, no matter how good the in-service training for overextended teachers.

So all of these approaches have a valid, and urgent, role in the battle against mass poverty. If schools for the masses can be made good enough to at least give students the basics they need to thrive in a modern economy, and if a few elite schools can produce competent and committed leaders, it won’t bridge the whole gap between the rich and poor worlds. But it will be a mighty step.

Continue reading “Free Education – And Then What?” →

In the article I wrote last year for Inroads (“Haiti: The Island’s Wounded Wing,” Inroads 13, Summer/Fall 2003), I concluded that “Haiti is mired in the worst kind of poverty, spinning its wheels.” By contrast, the neighbouring Dominican Republic has made impressive progress over recent decades. Again to quote myself, “It would fly in the face of every trading nation’s interests to sit back and let the weight of Haitian poverty crush the Dominican progress.”

Since I wrote that article, Haitian political wheels have continued to spin – and have dug in deeper. In March of this year an armed rebellion toppled President Jean-Bertrand Aristide. What should the international community – by which I mean the United Nations and, in particular, the United States, France and Canada – do now? The answer can be found by looking at what it did the last time it intervened in Haiti. The lesson is obvious: there is no quick fix.

In 1994, UN troops took over from 20,000 Americans who had just pushed out the military dictator, Lt.-Gen. Raoul Cedras. Then they escorted back Aristide, who had fled in 1991 after a coup. It was a hopeful time. Aristide, once a priest, was the first fairly elected leader in the nation’s 190-year history. He talked like a visionary – a man of the people. He seemed obsessed with the need to be honest and fair.

Canada was involved big-time with Aristide’s return. Our foreign affairs minister of the day, André Ouellet, flew with him to Haiti in a show of solidarity. Canada donated 50,000 shovels – a modest but practical gift to farm families that had nearly starved during a three-year trade embargo imposed by the U.S., France and others to put pressure on the military dictator. We also reopened schools and hospitals. Our soldiers patrolled the streets, with colleagues from Jamaica, Bangladesh and a dozen other countries. And 100 Mounties helped out, keeping an eye on the work of those deemed to be the best of the old regime’s police officers, who were allowed to stay on the job, while training recruits for what was to be Haiti’s first honest and professional police force. Indeed, reform of all aspects of Haiti’s corrupt, dysfunctional justice system became Canada’s focus for the nearly three years we stayed.

It didn’t take a lot of effort then to maintain order. It was a time before drug thugs turned Haiti into a major transshipment point, and there were few weapons around. Besides, order was something most Haitians craved. Though Aristide asked the UN troops to leave, they were made to feel welcome by most of the people.

In 1997, the Canadians and their UN colleagues decided to go home. Aristide’s dark side began to surface. He led Haiti down a slippery slope of political corruption. By last year, his government had the shameful distinction of being ranked the third most corrupt in the world by Transparency International. He and the Chimères, his armed supporters, embraced violence, intimidation and fraud as political tools to maintain power. All of the reforms launched by Canada and its UN partners fell apart.

The lesson to draw from this failure is that Canada and other countries pulled out before they finished the job. Prime Minister Paul Martin understands as much. Speaking last March, he said, “The international community left Haiti prematurely, and we saw what happened. The international community must not make that mistake again. And Canada is going to stay there and make sure this does not happen.”

But there is no sign that the PM means what he says. Indeed, Canada’s contingent of 450 soldiers is only half what we sent in 1994, and they are to stay only three months. Although Martin has committed Canada to a year’s involvement, officials in Ottawa are already making excuses about not having enough troops to replace the 450 when their tour is up – though we may send some a few months later.

If the 1994 intervention was too little and too short to do lasting good, what does Martin expect to accomplish with a much flimsier effort this time? And if the UN again leaves Haiti on its own before a competent, democratic government is in place, what are the country’s prospects?

The past suggests they are dismal.

Economically, Haiti has been mired in misery for decades. Despite billions in aid from North America and Europe (nearly $500 million from the Canadian government alone in the 1980s and 1990s) and countless millions in private charity, it still ranks a dismal 150th on the United Nations Development Programme’s quality of life index.

In the late 1970s, when we began to get serious about aid, Haiti was an awful place. Men lived, on average, just 51 years, and women not much longer. Per capita GDP peaked at US$3,200 (measured in purchasing power parity terms). There was only one doctor for every 10,500 people and less than one hospital bed per 1,000. People got, on average, just 84 per cent of the food needed to stay healthy.

By 2002, after all that spending, men were living to an average age of 47 years and women to 50. Per capita GDP (again measured in purchasing power parity terms) had declined by 40 per cent and was less than US$1,900. This is one of the world’s worst economic performances – equivalent to the dismal economic outcomes in many sub-Saharan African countries. There has been a slight improvement in the ratio of doctors to population, but a worsening in the ratio of hospital beds. And people were getting just 83 per cent of the food they needed to stay healthy.

The prospects for Haiti’s quality of governance might be even worse.

Haiti is the Western Hemisphere’s second oldest republic, its independence dating from 1804 when its black slaves threw out the French, but it has never once enjoyed a stable democratic government. Its first 150 years saw 102 coups, wars or revolts. Only one of its 22 leaders ever served a full term.

The country had stability, but not democracy, from 1915 to 1934 while it was occupied by the United States, and again during the Duvalier family dictatorship from 1957 to 1986. Since the overthrow of the Duvaliers there has been an unending succession of iffy elections and forcible oustings – three in 1988 alone.

Aristide’s 1990 victory came in what was seen as the country’s first fair and open election, but the army deposed him just a year later. Tragically, since 1994, he has betrayed the trust of the countries that restored him to power and of the people who first elected him. He has maintained power through violence, intimidation and electoral fraud. He has done little or nothing to enhance the public good – for example, public expenditure on education has fallen from 1.4 per cent of GDP in 1990 when he was first elected to 1.1 per cent by 2000. He has presided over the establishment of a huge narcotics trade – perhaps the only growth industry in Haiti – and he stands accused of corruptly amassing personal wealth at the expense of his people.

The interim government cobbled together since Aristide’s departure in March appears to be made up of people who have integrity and some credibility in the country. But the levers of power they have to operate are weak. The country is so poor – not only in terms of per capita income but also in infrastructure, competent personnel and functional institutions – that it is doubtful they can do much no matter how well intentioned they may be. The order that is now imposed by outside forces is fragile, and the armed thugs who overran Aristide’s regime in the early spring of 2004 prior to the intervention may act again. Until it gets on a stronger financial and democratic footing, Haiti will need outside help – money and expertise – to maintain what little infrastructure it has and to deliver its very basic services.

If it does not get that help and it falls apart again, the consequences will not be just internal to Haiti. They may affect much of the hemisphere.

The 1994 U.S.-led intervention was in large measure motivated by concerns about boatloads of Haitians trying to make the 1,000-kilometre crossing to Florida, and there is renewed concern about a mass exodus. A warning last fall from the Canadian military about instability in Haiti noted that desperate migrants could become a problem for Canada too. Yet most Haitians do not have the resources to get to the U.S. or even to try to set out for Canada. The countries at greatest risk of being overwhelmed by fleeing Haitians are in the Caribbean. On the front line is the Dominican Republic, which shares the island of Hispaniola with Haiti.

Haitians already cross the long, wild frontier to the Dominican Republic more or less at will. At any given time, about a million of them – one Haitian in eight – are living and working among the eight million Dominicans next door. The Dominicans need many of these workers. In recent years, their economy has, for the most part, been bounding ahead. And Haitians do the grunt work in many key industries, notably agriculture (rice, coffee, sugar) and construction.

Although the Dominican Republic’s per capita income is nearly four times that of Haiti, its economy is still fragile. It is in chronic danger of being overrun by more poor Haitian migrants than its rudimentary social services can support. If the flow of migrants turns into a flood because Haiti’s economy worsens, political instability may erupt across the island.

The Dominican government of Hipolito Mejia has sought to share its progress by building metaphorical bridges across the border (See “Hispaniola: Two Wings of the Same Bird,” Inroads, Summer/Fall 2003). But, there is a long, nasty history of wars and flareups between the two countries extending from the 19th century well into the 20th, and there continue to be reports of sporadic abuses of migrant workers’ rights. Traces of deep-rooted xenophobia can be found in some Dominicans. And an uncontrolled flood of dirt-poor migrants, and the problems they will inevitably bring, could push even the more tolerant Dominicans over the edge.

To end on a note of faint optimism, this threat might, in the end, be a trigger for the developed world to commit to actually solving Haiti’s problems. A modern mantra of intervention is that it is warranted to stabilize any government committed to democracy, human rights and policies to help the poor. Haiti’s government fails on all three counts. But the Dominicans pass these tests rather well. So if the world does not care to intervene on behalf of Haitians, among the most downtrodden people on earth, perhaps it will to protect the progress of a bright spot in the developing world.