Archbishop Albert Chama, primate of the Church of the Province of Central Africa and chairman of the Council of Anglican Provinces in Africa; Rebecca J. Vander Meulen, executive director of the J.C. Flowers Foundation; and Robert W. Radtke, president and chief executive officer of Episcopal Relief and Development, discuss mobilizing Anglican communities toward eliminating malaria with Reverend Canon Charles K. Robertson, canon to the presiding bishop for ministry beyond the Episcopal Church, moderating. The event took place as part of CFR's Religion and Foreign Policy Program.
ROBERTSON: Well, good morning. I’m Chuck Robertson. I am the canon to the presiding bishop of the Episcopal Church for ministry beyond the church and have also served as canon to presiding Bishop Katharine Jeffert Schori before Michael Curry came. It is a pleasure to be here as a member of the Council on Foreign Relations, to be here for this important roundtable as we discuss mobilizing the Anglican communities toward eliminating malaria.
We have a distinguished panel with us today. But before we get to our panel, let’s just talk numbers. First number, 440,000. Approximate number of malaria deaths per year. Now, that number is down from 2010, where it was as high as 487,000. But what we have seen in recent years is that this wonderful decrease has plateaued. And trying to see in some places where it has even, in a sense, kind of reversed. Let me give you another number, ninety percent. 90 percent of these deaths occur in Africa. In sub-Saharan Africa, mostly where we are seeing, again, in some places, a resurgence, even as we have seen significant work towards preventing and eliminating. It’s still a constant battle.
Perhaps the most important number today for us to reflect on is 2030. That’s the year in which we are looking at the World Health Organization’s global technical initiative towards elimination of malaria, with landmarks along the way to be able to see how we are doing. But by 2030, to look at four major goals: reducing malaria mortality rates compared with 2015, reducing malaria case incidents globally compared with 2015, eliminating malaria from countries in which malaria was transmitted in 2015, and preventing the reestablishment of malaria in all countries that are malaria-free. It is a noble goal. It is a doable goal. But it’s one that requires new partnerships and a holistic approach as we move forward. And that’s much of what we are going to discuss today.
With me, we have the Most Reverend Albert Chama, bishop of northern Zambia and, since 2011, the archbishop and primate of the Anglican Church of the province of Central Africa. This province consists of sixteen dioceses in Zambia, Zimbabwe, Malawi, and Botswana. Archbishop Chama holds degrees from the University of Zimbabwe, Bishop Gaul Theological College in Harare, and the University of Birmingham in the United Kingdom, where he received a master’s degree in community management. Archbishop Chama also serves as the chair of the Council of Anglican Provinces in Africa, or CAPA as it is known, as is a respected leader in the worldwide Anglican Communion.
Bishop Chama, it’s wonderful to have you here.
We also welcome Rebecca L. Vander Meulen, the executive director of the J.C. Flowers Foundation. Also managing the Isdell:Flowers Cross Border Malaria Initiative, which supports malaria elimination programs in several countries, including Angola, Namibia, Zambia, and Zimbabwe. For fifteen years, she served as development director in the Anglican diocese of Niassa in northern Mozambique, where she has overseen the formation of more than four hundred social action groups with over ten thousand volunteers. Ms. Vander Meulen holds a master’s in international public health from Emory University, which in 2009 awarded her with the Matthew Lee Girvin Young Alumni Award in recognition of her dedication to the field of international public health. She also is a recipient of the St. Mellitus Medal conferred by the bishop of London in recognition of her HIV and community development work.
It is a pleasure to have you here, Rebecca.
Finally, we have Dr. Robert Radtke, president and CEO of Episcopal Relief and Development since 2005, having previously served in various senior leadership roles at the Asia Society. The motto of Episcopal Relief and Development is: Working together for lasting change. And certainly Roberty Radtke has worked continuously and tirelessly on that effort, providing strategic leadership to the agency’s programs in over thirty countries across Africa, Asia and Latin America, as well as in the United States. The organization is committed to demonstrating a measurable impact in three transformative program priorities: Women, children, and climate. And in his role as president and CEO, Dr. Radtke has overseen a number of major initiatives, including Nets for Life, the agency’s award-wining flagship malaria prevention program which, to date, has reached over forty-seven million people in seventeen African countries. He also is a member of the Council on Foreign Relations.
Rob, it’s good to see you.
To all three of you, welcome.
I’d like to start this off by having a chance to ask each of you something. Archbishop Chama, let’s start with you. You originally hosted Chris Flowers in 2004 as the Isdell:Flowers Cross Border Malaria Initiative began. Could you share a few thoughts about how this partnership and the role of the church in health issues, especially in areas of the world with malaria such as sub-Saharan Africa—how is that going? If you could say something about the role of the church.
CHAMA: Well, thank you so much. Malaria is—as you may all know, that it is a devastating disease. It has no boundaries, one would say. Whenever you go into an area where there are mosquitos, you are likely to get malaria.
I always recall some years back, when I was a parish priest in some parish, I had gone to see my brother who was ailing in the village. There was little clean drinking water, and, of course, no mosquito net. Mosquitos are feasting on me, and I got it. I came back home, and I was supposed to be inducted the following Sunday. I ended up in the hospital. I couldn’t be treated properly because all the drugs failed until I was given quinine. That’s the last drug for malaria. And then I recovered. And I experienced how painful malaria can be in a person. Now, think of a child who’s under five years old or a woman who’s pregnant and they go through that process. It’s quite painful, and it leads to death.
As a church, you might ask why are we involved in malaria when we’re not hospitals or, you know, doctors? But we take advantage of our presence in these communities. And I’ll speak mostly of Zambia context, where I work, where the government just released a simple policy that malaria is no longer the domain of the health sector, but the community, in the sense that whenever there is anything to do with malaria they are sensitizing people. The health centers write to churches to say: Please, you’ve got the set audiences. Could you inform your people about this? We are going in the community. We will be doing the spread of mosquito nets. We’ll be doing the spraying in the homes. We’re bringing six thousand people to clean their surroundings so that mosquitos are repelled.
And they write to us. And we do speak about it in the churches. And then they saw that we’re doing a good job. They ended up saying, oh, you are doing a good job, you guys. Can you bring some people whom we can train as malaria agents, we call them, so that these people are able to teach other people in the communities in terms of noticing symptoms of malaria, encouraging people to go to the health centers, and access to treatment where possible? And we began to do that.
From that point, we did move further. Instead of just teaching people, began to be distributors of mosquito nets. They said, in your case, you do this job properly because as a church you don’t discriminate. You give a mosquito net to any person who needs a mosquito net, from whatever faith and those that are nonconformist. You’ll be able to look after them. And we did that thoroughly. And that gave us a good name. As a church, we did a good job. And of course, in the end, we did partner with the Flower Foundation. We said, we’re doing such a good job, but we need to carry this work forward. And you know, Mr. Flowers is a person like I’ve never met in the world. When he was looking at the statistics he simply did this, and he got the figures right: how many have got it in this area, in the district, and how many people would be cared for if you provided this and that. And I said, this is interesting. And of course, he becomes so happy with our work, and from then we began to work together.
And we’ve been doing a good job in the sense that as a church we happen to have been recognized by the Malaria Council to become an advisor to the government on how best they can reach communities because they realize that the church and other faith-based organizations are a better place to do the work. So that’s how we’ve been working. So as a church, we are also saying, since we’ve done a good job and the malaria instances have dropped from being higher to lower, we are saying we cannot stop anywhere. We need to carry this work forward. And for us to move forward, of course, we need partners to work with us. Of course, in terms of knowledge, research, financial, because we are the church.
Maybe some of you might have that knowledge in terms of understanding how malaria comes in and et cetera, et cetera. But we on the ground will be able to reach every household, even the places where our governments might not reach. We are able to be there because of our setup, our structures, and just because we go there for a different thing. But in the end, we find that we have to care for a person holistically. And health becomes part of our responsibility, by being there as a church in the communities. So that’s how, in a nutshell, we are doing the work.
ROBERTSON: Thank you for that. Thank you. Rebecca, this 2030 goal, we hear that this is doable and it’s possible. It seems remarkable. What is the status right now? What do you see as where we’re at now in terms of the road towards malaria elimination?
VANDER MEULEN: Thank you. Well, malaria is one of the most ancient diseases that we definitely have definitive DNA proof that it existed even in mummies in the pyramids in Egypt. There is DNA of malaria in those bodies. So it is not a recent disease. But we really are coming, we believe, to the end of what has devastated so many people over the course of history. Even in the United States, there was malaria until 1951, which is why the CDC is actually based on Atlanta not in Washington, because it began as a malaria control initiative. And so that’s where—that’s—we had malaria in our—not in my lifetime, but in many of our lifetimes malaria was part of the United States. In Europe as well.
So already we’ve made major, major progress. But there are indeed now concentrated areas of malaria, particularly in sub-Saharan Africa. And that’s also where the most death is occurring. 2000 to 2015 was a phenomenal period in terms of the history of malaria. So if there’s ever sort of one chunk of time, it was then. There are a whole set of factors that came together at the same time: Funding, which is obviously critical for all of us, both through the Global Fund to fight HIV, malaria and TB, and also through the President’s Malaria Initiative here in the U.S. The U.S. is by far the largest donor to malaria initiatives of any global partner. About a third of the world’s money spent on malaria comes from the United States. So that’s something we should give thanks for.
But with that funding there was also advances in technology. So there was a new treatment called ACT. It’s an artemisia-based treatment. Artemisia is a plant that’s been used to treat malaria, again, for thousands of years in China, but was developed into a regulated formulaic package in a way that could be easily given over just three days. Very few side effects and effective. So that changed the mortality levels. Treatment options before were beginning to develop resistance and malaria was not always succumbing to them. So as Archbishop had to take quinine, that was a last stage, quinine has many horrible side effects. It’s still effective, but with these new treatment options it means that treatment is very safe, easy, and effective.
Also, as was mentioned, Nets for Life, both with ERD and with Archbishop Chama. Mosquito nets—twenty years ago people thought there’s no way we can get them to scale in Africa. And that has happened. It’s still not perfect, but more than half of Africans in areas with malaria are sleeping every night under a net. And it’s important to know that the nets are not just a physical barrier, though they are. There’s also an insecticide in the net fiber. So actually when the mosquito land on the net they either sort of get drowsy or, ideally, they die. And so there is not just a barrier, but also an actual insecticide. So all of these things have meant that from 2000 to 2015 there was remarkable progress.
Progress has stalled. It has not fallen down, but the mosquitos are beginning to develop resistance to those insecticides used in the nets, which means that new insecticides need to be developed. In Africa, there’s still no resistance to this amazing medication, though there are signs in Asia that there’s some resistance developing. Funding has become stable. That’s fine. That’s great, in terms of not going down. But the reality is, this last bit is harder to—the last bit of malaria is harder to address than the earlier bits.
The reason is that a human being, especially one who’s been exposed to malaria over time, may not have symptoms of malaria, even though they have malaria in their blood. They will not seek treatment, because they don’t even know that they have malaria. But when a mosquito bites that person, the mosquito gets malaria from the person. We think of people getting malaria from mosquitos. But actually, mosquitos are getting it also from people. And so we have to proactively find every person with malaria in order to keep the mosquitos from being infected. So this last bit is, indeed, the hardest and the most expensive.
In some countries, particularly and Zambia is leading the way, when someone has a positive malaria case, a team from the health department will go and test everyone within 150 meters of that house, because possibly the same mosquito bit someone else as well. And that’s a way to proactively find these people who may not have symptoms but who, if they’re not treated, will continue to pass malaria onto others. So reachable. The global malaria world is a bit anxious because of these challenges that have emerged in the past two or three years. But there are new technologies, new vaccines, that are coming, and new pesticides, new insecticides. So a lot of work ahead, but worth it. We’ve gotten so far. To give up now would be a waste.
ROBERTSON: Dr. Radtke, Rob, I’ve heard you in the past talk a little bit about the benefits of integrated health programming, as opposed to just a vertical, stand-alone response. Can you say something more about that, and what you have seen firsthand with that?
RADTKE: Well, let me start by saying that we wouldn’t be able to do integrated vertical—integrated health programming without the foundation of the work that’s been done in malaria. It’s been an extraordinary effort. And to keep pushing towards elimination is important. But it’s not something that Episcopal Relief and Development in particular has the technical capacities around. Our approach, as an organization that is both faith-based and partners with faith partners, like the Zambian Anglican Council, Zambian church, or Anglican partners around Africa, is to take a more holistic approach.
We certainly understand malaria as a leading cause of mortality amongst children, but it’s not the only cause. And there are many, many terrible diseases. And indeed, the SDGs—SDG 3 talks about a whole suite of diseases—water-borne diseases, neglected tropical diseases, pneumonia. And what we were finding is that in the communities where we had done huge net distributions, monitoring of the nets, following up, we had indeed reduced malaria. But what we were not doing was addressing the broader concerns of many of these families. So we’ve shifted our emphasis to more of an early childhood development focus, to look really at the first three years—the first six years, but with a special emphasis on the first three years because those are absolutely essential years that if you miss those years both developmentally and from a health point of view, that child can never fully become the person that they’re meant to be.
And so we see malaria is a key piece of early childhood development, but not the only piece of it. It includes nutrition. It includes providing access to a whole suite of vaccines that are available through most government agencies, or most governments. So we’ve stepped back a little bit from it, looked at where we thought our strengths were and where the needs were, and have recalibrated our program away from being solely vertically focused on malaria into an integrated program looking at early childhood development.
ROBERTSON: Thank you.
Well, getting us off to a good start. I’d like to open it up to conversation and questions. Do remember, of course, this is on the record. And would love to take your thoughts or questions. So to any or all of the respondents. So, please, who’d like to go first? Please.
HART: How do I operate this thing?
ROBERTSON: No, I think it’s automatic. Just face it towards you. And say who you are, please, and who you’re with.
HART: Hi. I’m Curt Hart. I have a number of responsibilities. I’m an Episcopal priest and I’m on the faculty of Weill Cornell Medical College, the division of medical ethics, down the street. And I’m also the editor of the Journal of Religion and Health, which may be pertinent to things later.
But I’m interested, because part of the work that I’ve done for years at Cornell is being a member of its institutional review board committee on human rights and research. And I’m wondering what efforts have been made, or could be made, through your programs to advance scientific and/or public health knowledge. Is there a way you can inform us of the things that have been done or might—the way you might contribute to the fund of scientific knowledge?
ROBERTSON: Who would like to tackle that?
RADTKE: Well, I can take a bit of a stab at it. We certainly collect huge amounts of data on monitoring and evaluation—
HART: It’s very important that you have this fund of data.
RADTKE: Right. And we work with other academic institutions to analyze the data and do monitoring and evaluation. It is important—and one of the barriers that we found, frankly, to being able to publish the data is that we do not do RTCs, random controlled testing—trial testing, because from an ethical point of view, as a Christian faith-based organization, to, you know, deny one part of the population access to our services in order to justify as a document the success of a certain intervention with another population has proved complicated. And it’s something that we are struggling with and trying to find ways of addressing because we’ve found that most of the data that we’ve acquired has been rejected by the scientific community as not being valid enough for, you know, deep academic use.
ROBERTSON: Anyone else want to add to that?
VANDER MEULEN: I’d say we also have partnered with, for example, the Harvard T.H. Chan School to try to come and document what they see as the results of the church activities. We, at the J.C. Flowers Foundation, don’t see ourselves primarily as a research institutions, though absolutely data must inform these strategies. Over and over we’re beginning to see where malaria strategy is used in Asia, automatically applied to Africa without understanding the components that made them work in Asia don’t work. So I think that the malaria community overall is also seeing the need for this data.
And so I would say our work has been more at the—at the national level where the bishops and other church leaders are actively involved in the national malaria control programs of the ministry of health. And, again, not in a randomized control trial type context, but very much making the case at the national level of where the church can do things that others are not able to do. So there was a big, massive mosquito net distribution campaign in southern Angola last year. And the church—the Christian Council of Churches of Angola found many communities that the government said had received mosquito nets but actually hadn’t. And they were the far-away, no roads, no way that anyone could have gotten that information if they weren’t already there. But the church is everywhere. So it’s that side of information that’s being shared at a national level. I think we would welcome sort of ideas on how to make this more useful at a—at a global level. It’s something we care about but recognize it’s not the church’s primary identity to be—to be doing research.
HART: But the very fact of what you’ve collected in terms of public health is very significant, insofar as I understand what you’ve said. I mean, this is a major—a major opportunity to at least in a macro sense—not in—maybe in a, you know, controlled trials, you know, sense—be able to make a significant contribution.
RADTKE: Well, I think we certainly both believe that we have made—or, all three of us believe—that the church is making a significant contribution. We use the results of our own monitoring and evaluation to constantly improve the programs along the way. In terms of—and sharing it amongst the malaria community, absolutely. But in terms of—the point that I was making, in terms of getting it into scientifically refereed journals and things like that, we have not been successful at doing that.
ROBERTSON: Others, please. Again, say who you are and where you’re from.
MACKINNON: I’m Jock MacKinnon and I’m a lawyer in New York and also a member of the board of Episcopal Relief and Development.
Hearing this discussion, you know, the progress is obviously very impressive. I was looking forward to, in terms of the future, and where the resources might come. And is this something that the multinational organizations—clearly there’s an interest worldwide in this, but how do you sort of funnel the right resources to attack the problem to get this last sort of bit across the goal line? So who do you all see as entities that could help?
CHAMA: If we look at the future, that’s why we look at the sustainability of the program, of course, how this is going to go on or be carried out. But through the Isdell:Flower, the Coca-Cola Company last time, they are also very eager to work with us as a multinational company, to try and do that, as well as AMT in South Africa, as well as South African Breweries, though there are issues there—ethical issues, whether we get money from them or not. But we try by all means to engage them if they come onboard, to say that they are willing to work with us. And of course, we need to find a very good, sustainable way of continuing the programs so that the work does not stop at any one point.
VANDER MEULEN: I would echo that, that it’s not just a single one magic solution. I think that private corporations, especially where they have their own workforce in concern—that’s an issue. For example, many of the oil companies in Angola who have many staff people who get malaria regularly and are not at work because they have malaria, that has attracted a lot of attention among the corporate social responsibility of Angolan oil companies. So that would be one example. I also think there’s a growing call in the malaria community for domestic government financing. So the government of Namibia, the government of Angola, the government of Zambia—it’s an investment. It’s not just some nice charitable activity. It’s going to save that country money in the long run as well. And so there’s an increasing awareness. Zambia’s domestic financing from their own pots has gone up every year for the past three years. --significantly, not just by a small amount. So that’s another recognition.
The Global Fund, as a fund, it’s had some challenges, but it’s been a very useful way to coordinate donor spending. Instead of having each government do its own specific strategy, it’s one fund with one national ministry of health making a strategic plan. The U.S. government has topped up that with the President’s Malaria Initiative funding, but only working in countries where the Global Fund has already done that groundwork. And so it’s a supplement to that. The Gates Foundation has made malaria elimination a priority. Actually, Bill Gates, I believe, back in 2001, was the first to really say: We are going to eliminate malaria. And people laughed at that point. But I think there were enough scientists who were eager to take advantage of Bill Gates’ publicity to actually show the data saying: He’s not making this up. This is within the realm of possibility.
So I would say all of that, and any new funding structures that emerge would be wonderful as well. But it requires the intervention of all.
RADTKE: Just to add to what Rebecca said, I think shifting the thinking amongst ministers of finance within Africa is really essential. And Jim Kim at the World Bank has been very powerful on this point, especially if you look at it from an early childhood development lens, because you can actually measure the ROI, the return on investment, of investing in the overall health of your under-threes to the long-term economic success of both that individual, the community, and then the broader country. So it’s a long game, but I think that’s ultimately the most sustainable strategy is that it’s not going to be external resources necessarily or alone. It will have to be paired with a reallocation of internal resources within many of these countries, justified on the basis of it’s a necessary investment for the health of the population and therefore the economy over the long run. And I think he’s getting some success with that conversation with ministers of finance, but it’s by no means won yet.
VANDER MEULEN: And just to add to that, in terms of the early childhood development, there’s the obvious mortality which is an issue. Seventy percent of the deaths are in children under five. But the scientific community has moved away from the term asymptomatic infection. Yes, these people—there are many people, because they’ve been exposed to malaria enough, that they don’t have fevers, they don’t realize there’s anything going on in their body. But actually, it’s not asymptomatic, because there are developmental brain damages—different underlying things that are going to affect a child’s ability to learn, their growth, their ability to develop an immune system to fight other diseases. So even these children who are playing, have no obvious signs, in some parts of Africa fifty percent of them have malaria in their body.
ROBERTSON: Following up on that, you’ve mentioned the multinational piece. You’ve mentioned the international business, NGOs. I want to go back to something you just briefly mentioned earlier, Archbishop. What about the role of interfaith or interreligious work in all of this?
CHAMA: Well, that is very, very critical I have explained before, that as a church or other faith-based organizations, they have a very, very important and critical role to play in the elimination of malaria. As I’ve said, we have the presence all over the place, and also the influence on the decision-makers, like the governments. In Zambia, you can easily knock on the door at the minister of health and begin to talk about malaria. And when we have that kind of collaboration, that kind of relationship, it is easier for them to say, oh, yes, you’re working in that area. OK. I’ll phone somebody there to make sure that you get access to what you’re asking for. So we do have that influential role as well, as faith-based organizations, wherever we are working. And that’s what makes the work of malaria elimination easier, when we’re a partner. Though it cannot be scientific, relying on other people, other partners doing that work. But we, as community-based, we do have that influence.
ROBERTSON: And are you saying this not only between churches, but also, say, Christian-Muslim partnerships?
CHAMA: Yes. You know, when it comes to issues of malaria and other epidemics, you stop thinking about your own faith. We do forget about all those things. Our goal is to serve the humanity, to serve the community. Even in places where you think Islam is so strong and percent is low, but when it comes to telling issues of that nature, I’ll give you an example. In Zambia, if we are advocating for something which would be a benefit for every person in Zambia, we don’t think of a Muslim, a Buddhist, or anybody. We think as people of faith. And when we stand together, the government sits up. These people have got influence. What are they saying? So, in that sense, it also brings us together.
ROBERTSON: Other questions, comments? Jamie.
CALLAWAY This is a powerful case study. And in my work over time the untold story of the church in Africa, particularly, was their closeness to the community and their ability to take on community betterment. However, malaria’s—this case study is very interesting because the fit is just so powerful and integral. It doesn’t always work that way. In the Bush administration, there was this desire to address HIV through abstinence. And actually, probably as much money as is going into malaria went into abstinence prevention, including in Africa. And these projects seek to use the church on the ground as an infrastructure for delivering this abstinence training, et cetera. But it wasn’t a very good fit. Probably the sexually vulnerable population wasn’t that close to the church, in terms of the age group and the connection. So the abstinence project wasn’t a good fit, and malaria is powerful. Can you say a little something about the church’s capacity to take on community betterment and what are the best fits?
CHAMA: First of all, we do have numbers. I’ll give an example. In the current scenarios, the people we see in the pews—women, like, in our case, mother’s union, yeah, and the father’s union, and the young people, young adults—when the government in Zambia wants to propagate something of that nature in malaria context, they say, let’s go and train—change people. One, they know that they are faithful; they are going to come, and in big numbers. And they will take the messages seriously. And when they go out in the community they will ensure that we deliver what we’ve been asked to deliver. Because the motivation as well, we do not only say we are doing it for the community. Their motivation is because of our faith, to say actually we are doing this because this is what we have got to do, to help everybody in the community as Christians. We begin from that and then we move. So, in terms of numbers, certainly we do have that. We do have that.
And of course, there are issues at times when they are doing—fumigating houses. There’s always someone saying, oh, this thing they are doing to your house is going to harm you. They propagate that false story about what they are trying to do. But as a church we say, no, there’s nothing like that. There’s nothing like that. The truth about this is A, B, C, D. And they are able to get information from you properly than they’re getting from another person.
RADTKE: The other thing I would just add—and I see this over and over again when governments or other organizations want to ask the church to take up their priority, it tends to become an instrumentalization of the church. And that very rarely works successfully. I mean, if you come with your own outside agenda and your own outside strategies about how you want that agenda addressed and you say, well, here it is, and plug it into the church, I think it’s a recipe for failure.
It’s somewhat analogous. We’ve had quite a bit of success on using faith networks to address the issue of gender-based violence. Again, it crosses over into human sexuality issues, which is always complicated, but our success has come not from our coming from outside with our own prescription of, you know, what paradise should look like, but a conversation with the local faith leaders about, and the communities, about what is the future that they want for themselves? And have them own their own solutions. And I think that—you know, I haven’t studied the—in detail the topic that you raised. But I would suspect that some of the reason it didn’t succeed may point to some of those—some of those issues.
VANDER MEULEN: And even just changing their language. In terms of the instrumentalization, I think sometimes we talk about the church has access to remote communities. No, the church is in—it is those remote communities. (Laughter.)
RADTKE: It is the communities.
VANDER MEULEN: And so to think—we need—this is us. This is who we are as a church. Not something that the church does to someone else. This is the church.
ROBERTSON: Yeah. Excellent point. Not an outside entity.
Others? And please, again, say who you are and what—who you represent.
PINCUS: My name is Daniel Pincus. I’m in the medical field and I do a bit of humanitarian interreligious work on the side.
It’s a fascinating case study of cooperation from domestic, international, regional, scientific, business, religious, NGOs, foundations, the U.N. In my experience, whenever you have such a complex network of interests and parties—or, I should say, maybe there’s a common interest, or we’d like to think there’s a common interest, because sometime maybe the interest is aligned but the approaches differ. Can you share, in your experience, some of the tensions or some of the areas in which people disagree? What are the conflicts that so many parties might run into along this very long journey towards addressing the problem?
RADTKE: Never had a problem. (Laughter.) Collaboration works smoothly at all times. (Laughter.)
Well, I’ll speak to this, because Episcopal Relief and Development was very much at the beginning of the Nets for Life, which has been mentioned, which was a collaboration amongst government, faith-based organizations, private sector, private foundations. And it was a big success. I will, you know, just say that right up front. And it couldn’t have been a success without everybody’s participation.
But there was a lot of work that had to be done about identifying what success would look like, and what were the metrics that we were all going to use to measure that success. You know, was it going to be a geographic reach? Was it going to be numbers of nets distributed? Was it going to be the reduction in mortality related to malaria? And so it was a very complicated discussion. And each constituency came with its own idea of what success would look like from their own—from where they sat. You know, the corporates had a public relations metric that they wanted. They wanted visibility out of the success. The church wanted other things. The private foundations wanted other things. And, you know, it was—we held that in tension. And, you know, it achieved the goals that it was meant to achieve.
Episcopal Relief and Development’s thinking evolved, as I’ve indicated, to taking more of a holistic early childhood development approach. And so when we did that, we found that some of the stakeholders, their funding was tied specifically to malaria. They were not as interested in a broad approach to early childhood development. And so that tension led to, you know, a recalibration of that work.
VANDER MEULEN: Just to take it a different—a different direction, I think one tension in some parts of Africa is the debate between malaria control and malaria elimination. From a global perspective, we want to eliminate malaria. But taking the case of Angola, for example, Namibia on the southern border is very close to elimination and Angola’s southern border needs to address malaria so that Namibia can be free. (Laughter.) So from a SADC Elimination 8 secretariat point of view, let’s focus on the south of Angola. From the Angola minister of health point of view, the south is pretty OK. It’s actually the north where malaria is most prevalent. And so the minister of health has to decide: Am I looking at the region or am I looking at my specific country? Ideally, the answer is both. We do control and we do this last elimination work. But the elimination work is more expensive, again. And so just—that’s a specific contextual conflict that is an ongoing debate. Who’s going to decide where the priorities are for our foundation?
CHAMA: I think I’ll follow up on that one as well. That conflict, or that tension, can exist geographically and also how people—how much knowledge people do have in a given community. Because others will say, you know, they did that in that place. Those were the side effects. And they want to bring that to us. So already that tension is created. How do you take this community to say: No, what they’re saying is not true? So you have to labor in terms of working around their culture, their beliefs. We are all Africans. We’re one nation-state. But different tribes, they have got their own belief systems. And you have to navigate that. That tension can exist, that then on the ground you understand how you can persuade people to make sure malaria is tackled.
ROBERTSON: Did you have a follow-up for that, Daniel?
PINCUS: I probably do. (Laughter.) How much is language a barrier? When it comes to—when it comes to the language of discussing the disease itself, is language a barrier to addressing the issue? Or is there a high level of awareness, or is there an alignment of understanding of what it is that we’re facing and how we’re going to approach it?
CHAMA: Example of our context. We have ten provinces. And we do have seventy-two dialects, Bishop David? We were seventy-two dialects in Zambia. There are places where I can hardly understand a single word. But they are Zambians. Neither can they speak my mother tongue, my mother language. But through the ministry of health, when the people—like, I’m coming from the north, I’m going to the west. The ministry of health do set up people—of course, all English—but the locals also, they are employed by the ministry of health, and most of them are entry points to language. And they begin to do the explanation, the teaching, in their local language. And of course, they understand their local settings better than we can from the north.
So normally it doesn’t mean a barrier at all in our case, from our perspective. We did very well North-Western Province, the Central Province, Copperbelt Province, Eastern province, wherever we have been we are managing very well. So language has never been a barrier at all, only because we’ve got people who can explain this properly. And also, there are times when—like, in Zambia—the minister of health do labor to translate certain things in the given local language settings.
VANDER MEULEN: But I would say this is exactly the case for the church. In many contexts, those who are nurses trained by the government are not native speakers in the place they’re posted to work, at a health post. Who can do that real convincing heart to heart work is someone who speaks the same language. And that’s typically someone in the church.
So another language issue, one issue that we’ve discovered is that in many languages the same word is used for malaria and fever. There’s not a differentiation. And that really complicates teaching about malaria, because people say: I went to the health post. I had malaria—when they mean fevers. And they didn’t give me anything. They didn’t want to treat me for malaria. Well, they did a test. And the person had fevers, yes, and didn’t have malaria. But until you can clarify that you end up with having to undo wrong assumptions that people have made because fever and malaria is the same word. And so differentiating that has been an important part in many contexts.
ROBERTSON: I want to go back to something you said about the cross border. What you were just talking about, Archbishop, was within Zambia and the different dialects—the seventy-two different dialects. But going back to what you had said, Rebecca, about—about the cross border, about what is—what does ministry of health do in terms of national interest versus regional interest. How much are you seeing this—is—are the efforts getting stronger for the region or are they just staying stable? Are you seeing struggles due to any geopolitical issues going on?
VANDER MEULEN: Though I do think that there is more of an awareness that we have to do this together and a physical border is not going to—someone said—Bishop David said yesterday a mosquito doesn’t have a passport, so. (Laughter.) But there are—there’s a Mekong collaboration working towards malaria elimination in that part of the world. SADC has a E8 secretariat—E8, Elimination 8, which aims to eliminate malaria in the eight most southern African countries by 2030. There is a West Africa consortium that’s developing. So I think everyone recognizes that we have to deal with this from a broader perspective because diseases don’t have borders.
Interestingly, on so many of our borders as well, it’s the same families who live on both sides of the border. Go to school on one, go to the health post on the other. And so you can’t artificially—some of our borders in Africa are incredibly porous. You can’t say: We are going to eliminate malaria. And if you want to cross this border, you get to get a malaria test. Because the border is thousands of kilometers that is open. And people are daily interacting on both sides of the border. So, yes, there is a growing regional awareness, which sometimes has conflicting goals with the country-specific goals. But a recognition that we have to do that. If we don’t deal with the borders, we can’t eliminate malaria.
ROBERTSON: And with that, what about political realities of changes that have occurred in Europe and the U.K. and the U.S.? What impact is that having?
VANDER MEULEN: So far we haven’t seen anything specifically. And I think that the Global Fund is up for replenishment—2019 will be the replenishment for the period of 2020 to 2022. And that will be critical. We’ll see what happens there. But so far, funding has remained stable, which is—ideally it would go up, but there are many chances in which it could have decreased over the past years.
HART: I’ve been interested, as I’ve been listening to you, if you try to address any kind of mental health concerns through any of these? And you may not even call them mental health concerns. They may be called by other things culturally in those settings. And do you use at points local, indigenous healers to add or facilitate your work?
VANDER MEULEN: Yes.
HART: Yes and yes. (Laughter.) Because depression is called by different things in different places—you know. Yeah.
VANDER MEULEN: I mean, I think the reality is just from a bigger perspective as well. In some of the areas with high malaria, there is such a poor health system that by developing the malaria infrastructure you’re automatically having a ripple effect on bringing more nurses into the area, who then bring in other skills and other things. And I think that reflects a big the ERD perspective, that you’ve moved to ECD, early childhood development, not just malaria. This is not directly what you’re asking, but I think one issue is epilepsy, which is a significant—often malaria that’s treated, the person does not die, they recover. There may have been brain damage that later leads to epilepsy. So a lot of the epilepsy in Africa has malaria roots. Not all of it, but that’s another issue that some of these malaria programs are beginning to address.
HART: Well, the difference between—divisions between psychology and neurology anyway these days are pretty porous.
VANDER MEULEN: Exactly. Exactly.
RADTKE: Yeah, one of the things that we’re finding in our work with early childhood development is that you really have to provide a lot of support to the caregivers.
HART: And that’s kind of where I was wondering how you were managing that.
RADTKE: So, you know, putting together as caregivers mothers’ groups or grandmothers’ groups that are—might come together around a savings group, for example. However, it’s also a support group—(laughs)—for sharing of stories, for sharing of understanding, about best practices, and for reinforcing and building resilience amongst the caregivers. So it has a mental health implication. It doesn’t—it’s not framed as being mental health work. It’s framed as economic development or something like that.
The same with addressing gender-based violence. I mean, violence within families is a huge—has a huge impact on early childhood development. And so helping families, and men in families in particular, understand that violence has a detrimental long-term effect on the health of their child and, you know, coming up with strategies to reduce violence also touches on that mental health space.
And in terms of traditional healers, I don’t know, maybe Bishop Chama would like to speak to that. But, you know, broadly speaking, we want all of the people who have status within a community singing from the same hymn sheet around malaria prevention. If that includes traditional healers, then they need to be brought into the conversation, because you certainly don’t want anybody out there undermining the public health messages that you’re trying to promulgate throughout the community. Maybe Bishop Albert has a—
CHAMA: That’s why we get prominence as a church, because the traditional healers—like, some people in some areas, they would first go and approach such kind of a person. They’ve got a fever. They’ve got malaria. They’ll think, oh, somebody is playing games on me. That’s some spiritual forces from somewhere. And that person, if they’re not clever, they’ll start telling them stories. So instead of saying now go to the health center, actually you need scientifically tests on you. But they begin to look at this. And as a church, that’s why we become important, to begin to disband that kind of thinking in people, that this is a disease, it’s a sickness, it can only be healed when you go to the health center, you access the medication, you get whole, or you get better, and you go on with your life. That’s why the teaching becomes so strong.
You know, just like—I know that you’ve been reading a lot of things relating to malaria in other countries. For example, in Nigeria, when they went for vaccine, you know, in other diseases, the Islamic community in some difficult areas where Islam is misinterpreted, they are saying don’t do that; they are trying to make women not have children, et cetera, et cetera, et cetera. So they are resisting that. So that is very common in the malaria areas as well. You begin as a church to say no. When you have this—that’s why the training of caregivers as well as agents. Maybe—as we call them back home, malaria agents. That is their responsibility. To say: The way you are feeling, the way you’re explaining to me, you need to access the health center so that they can give you the drugs. That is their role. And that’s where they become effective, is to do well with that kind of, you know, misinformation, so to speak, from the traditional healers.
CALLAWAY: Sometimes a panel raises larger questions. And so I’m struck with one of the larger questions. Usually this kind of work is sort of a cause du jour. And, Rebecca, you have mentioned government funding. Government funding is always going after some cause du jour. But in the case of the three here, you’ve taken on a long-term commitment to kind of an ordinary, persistent problem. And that’s remarkably unusual. And yet, in the case of malaria if you hadn’t undertaken a long-term slogging through, you wouldn’t have—be in the place where you are today. What were the issues in making it a long-term commitment instead of one thing among others, as new waves kept coming in on the shore.
CHAMA: I think for us as a church, as I said, the motivation, first of all, it is our responsibility, it is our call through our faith, through our beliefs that we have to care for people who are God’s people. For me, everybody is God’s person. And knowing the nature of the disease, malaria is not one-off thing. When I grew up in a mining township, my father was a miner, and we had health public officers who came in to talk about environmental issues. Clean your surroundings. Do A, B, C, D. They even came to our schools. In lower grades, about grade five, primary, they would talk about—they would talk about hygiene. And that was helping. And they would always come around with the cans spraying on the grass to make sure malaria and mosquitos are killed.
But I look back then and now, how many years? I’m fifty-seven. Malaria are still there. So for us as a church it’s for us to say, this is the kind of situation where we have to work alongside communities, because it is a long-term thing. I’m fifty-seven. If I look back, malaria issues are still on. Therefore, it’s not the only thing that you can say yes. It’s a long-term commitment. And hopefully that this will be passed on to other people for the sake of health of people in the communities. And that’s from the personal religion.
RADTKE: Yeah. And you have to insulate yourself from the—you know, from the diseases of the day kind of trendiness. And because, you know, everybody will get behind something for three years, five years, whatever it is, and then interest dissipates. But I think what Bishop Albert has said is that, you know, because we’re embedded in the communities, we know that that sort of waxing and waning of attention is just a reality, that you have to calibrate your strategy to do it, to address it. And because we don’t wax and wane. We’re going to be there over the long term. And if this remains the priority for the community, it remains the priority for us. It’s not really complicated.
CHAMA: I also want to talk about, Jim, in our case as a church, when there are certain epidemics and as we go to preach, you start raising questions in people’s minds. Why is this going to persist? When they talk about this God can do miracles. But it is by being with them, by knowing that we are part of this problem and we are part of this problem and we shall work together. They begin to say, actually, God is working through us to change the situation. We are being practical and visible.
COPLEY: Bishop Chama, given that malaria—I’m sorry. My name is David Copley with the Episcopal Church.
Given that malaria has been endemic for so long, and is as common as the common cold in many parts of Africa, is there a sense that you can never eliminate malaria? And how much of that is a barrier to the work that you’re trying to do?
CHAMA: I think, David, you also have to look at the environment that we have in this place where you are. When it is very cold, malaria—mosquitos will never die. Now, this remains to say if I drink water from the well, I’ll get malaria. If I get soaked by—you know, because of the rains, I’ll get malaria. It is now we’re saying, no. Being soaked because you have walked through the rain does not cause you to have malaria. It is a mosquito parasite that causes that.
So there is no sense to say we will never win. We will win because in some areas, with evidence provided, malaria instances, and we have been working in certain communities, have reduced. The question comes back when you ask about sustainability. How do we sustain that elimination? Because I can talk of Chavuma, where I work in Kalulushi, it’s a jungle area. And people went to live in that place in a plant environment. But now things have changed. You’d expect that malaria would ever be there because the stream, the place. But because of our work as a church in terms of education, the spread of mosquito nets and ensuring that people when they get symptoms are rushed to the health centers, we’re seeing a lot of transformation.
Malaria instances have just dropped. Then of course, they ask what has happened? What have we done? It’s because of that persistence. So for me all this has come to say, yes, we will never eliminate it, because there’s evidence in some places which was quite prevalent, they have been reduced. And that could be the road to elimination.
VANDER MEULEN: And in some of the areas with lower health literacy, the message has to be this normal that you know as your normal doesn’t have to be the normal. And that, to me, is a message of hope. And if the church has any message to bring, the message of hope, this does not need to be your normal, is what we should be seeing.
MACKINNON: So as an observer to this, you understand increasingly how complex all these relationships are, governments, other organizations. And I’m looking forward at the next five years. What do you see is the potential for the increased cooperation among various of the churches, various religions, working maybe more with government on a regional basis versus individual countries? Sort of what leads forward out of this? And you can see malaria as a test case in terms of being important, but there are obviously other societal issues too—like, gender-based violence, childhood development.
ROBERTSON: Excellent question. Who wants to?
CHAMA: Walking alone, you might not reach where you are going if it is a far distance. But if you are two, there are two things that could happen. You could be chatting, you’re not looking at the distance, or what you see we will have reached. I forgot, we are so invested in our discussion. So by coordinating through networks in the next five years, yes, the difference will be made because even the aspect of religion is changing the way that’s been the approach in terms of teaching. In the church, we don’t just talk about, you know, you are saved, you believe in Christ. But now we are looking at the message holistically. The person has to be well spiritually. They have to be well physically. They have to be well materially. All these things are now being taken as well—they are being packaged as one thing.
And now people—like in AIDS. You talk about look after yourself, abstinence, et cetera, et cetera. You want people to be healthy from the pulpit. So you’re saying, by networking we are doing the foundations, the governments. We are opening up international organizations, regional governments. Yes, the difference will be made in the next five years, as long as we stay close together, the tensions that we talked about they can be eliminated because we have a common goal or a common cause. And we can reach that. And in the next five years we will be there, as long as we keep together. On the part of religion, we don’t bring falsehoods. We are religious people. We need to be honest and sincere. And on the part of the government, they have to be committed to serve the people who elected them. On the international partners, they have to be sympathetic. We are not the same. Some places are moving forward. They need their hand. So by answering your question, certainly in the next five years if we all work together and walk together, we can change things in the course of malaria.
VANDER MEULEN: And I don’t fully know the spillover effect yet, but in Angola where I do a lot of work the Christian Council of Churches of Angola has taken this on as a priority. It began in the religious scene in Angola with an Anglican focus. And how the Christian Council has taken it on. They regularly meet with the minister of health to discuss the malaria strategy. The minister of health is using churches as a way to—official ministry of health policy—to get malaria messages out. I would love to see that then go onto all these other health issues as well. Right now it’s been limited to malaria and a few little epidemics that have come over the course of the past year or two. But I think there’s hope. And I think it’s something we need to proactively work towards, instead of just waiting for it to happen on its own.
CHAMA: And I am happy that Rob talked about, the MDGs. MDG 3, it talks about—malaria is mentioned in there. And that means the whole world has taken that responsibility that we need to work and eliminate malaria through the MDG 3. So that means even as a church—especially, like, in a Communion, where I belong, we are very much into the MDGs to ensure that they are implemented, because through them we have seen that you can actually change people’s lives; not only malaria, but other epidemics and other issues that humanizes a person. If we go through that, certainly a difference will be made.
ROBERTSON: Any final questions as we begin to wrap up here? Something that’s still germinating there?
Q: Where are your—you know, your best—I’ll use the word—targets for fundraising? What—besides religious groups, where can you—where do you want to go? Where can you go to get the kind of help that you need at this point? I mean, who are the people that are most apt to, you know, give you the resources to take this next step?
RADTKE: Well—(coughs)—excuse me. From the early childhood development perspective, there’s a broad range of private foundations that are very committed to the early childhood development space. The most notable being the Conrad N. Hilton Foundation. But, you know, certainly the Canadian aid agencies. You know, there’s a deeper understanding of the importance of integration and situating malaria amongst other issues in early childhood development. So that opens up a broader window for potential funders as well.
VANDER MEULEN: And I think the private sector is one that is increasingly being tapped, especially private sector with a workforce in Africa. People who are affected, their own workforce, by malaria, they are beginning to pay attention to the reality that it’s altruistic but also in their own self-interest as well.
ROBERTSON: So international corporations would be—
VANDER MEULEN: Multinationals, yeah.
ROBERTSON: So not to leave that totally, in some of my more recent visits I’ve been struck by how much—how much business is coming from China into different areas. So what kind of multinational corporation are we seeing as we’re seeing new players as well as longstanding players?
RADTKE: I have not yet seen China play a positive—not that they’ve played a negative role. But I haven’t yet seen—their international aid has been focused on infrastructure, not health in general. It would be interesting to see if they shift as they’re—as they begin to recalibrate their strategy in the developing work. But as of yet, they are not either in their private sector or from a government point of view been a major factor in the political space now. I don’t know, have you seen anything different?
VANDER MEULEN: Little signs that perhaps it’s changing, but there definitely has been—there’s such a Chinese presence in Africa. And China has had its own malaria issues. It’s not a foreign concept. So I think it’s something that conversations are beginning.
PINCUS: Maybe one last question. The role of pharmaceutical or product development when it comes to treatment for this can sometimes be in tension with the availability for the consumers or the patients to pay. Has that been—have you encountered that to be an issue as an incentive or a disincentive for industry to develop and distribute medications for this?
VANDER MEULEN: Coartem is our absolute wonder drug now. But it’s being supplied at cost. I think there is a challenge, as there’s beginning to be resistance towards these new drug development. We would love to see more investment in new drug development. But also there is—there is an initiative at the University of Cape Town that’s doing some good work. And it’s great to see something coming from Africa, as opposed to only from Europe and the U.S. The reality is that if we do get resistance there will be a huge market, even if those people have very low—they can pay low per dose. There will be a need for good malaria drugs. And so there is some potential cost recuperation because it’s not like some of these neglected tropical diseases, where there are 50 cases a year. We’re talking millions and millions and millions. And so there is that motivation. So more could be done, but it’s not a completely dead field in terms of new product development.
ROBERTSON: Well, I want to thank our panelists and thank all of us. But I want to thank Rob Radtke of Episcopal Relief and Development, Rebecca Vander Meulen of J.C. Flowers Foundation, and Archbishop Albert Chama of the Anglican Province of Central Africa. Thank you. (Applause.)