Read parts one, two, and three of Zeke Emanuel's Africa diaries.

According to Joe Malone, the CDC Medical Officer working on the U.S. President’s Malaria Initiative, I have just arrived at Disneyland. This after traveling more than 150 kilometers southwest of Addis Ababa, the capital of Ethiopia, and then 45 minutes over gravel and mud roads to Wossilo. On the drive down the unpaved road we saw one bus, no cars, no motorbikes and no bicycles—only people walking. When we arrive, the shacks are made of sticks covered with mud mixed with straw. The floors are all hardened mud. The only sign that this is a “nicer” area is the roofs: They are corrugated metal, not thatched.

By appearance, the health center is not impressive. Outside its front gate you could swear you are in the Wild West—horses and donkeys are tied up to the fence. The paint on the outside of the buildings is peeling; the “waiting room” is a bunch of wooden benches and broken chairs on the balcony, too few to accommodate all the people who are waiting. The grounds are dusty with untended weeds.

But this place really is a bit like Disneyland in one sense: It’s all-inclusive. The health center has put together all the pieces to fight malaria and other health problems. The surrounding village has been systematically covered, so every sleeping space has bed nets. The huts have been sprayed with insecticide. When someone shows up with a fever, the first thing they get is a rapid malaria test.

And not just any test. Unlike almost any other country in Africa, Ethiopia has two types of malaria. One type, prevalent throughout Africa, is P. falciparum, which can be deadly; the other type is P. vivax, which is more prevalent in Asia and is milder, causing relapsing fevers. Until recently, the health center had only “single species” rapid tests that detected P. falciparum only. When somebody came to the clinic, the center would treat that person with expensive anti-malaria drugs, because negatives were assumed to be P. vivax. Only if the patients did not get better after five days were they switched to antibiotics, on the assumption they had something besides malaria.

The introduction of a new, “multi-species” test showed that more than half of the fever cases were not malaria. In addition, it allowed the health workers to distinguish which type of malaria the patients had. Those with vivax could be treated with a drug that cost a third of the expensive drugs. (It also reduced the chances of breeding drug resistance.)

Just as in Senegal, the strong push with bed nets, insecticide spraying, rapid tests and treatment has had tremendous success in just over one year. The comparison of the last two years shows that the decline in malaria cases is even more dramatic than in Senegal.

Disneyland works. When we go another 45 minutes down the mud road, we visit a very small rural village. The health workers here have visited every single house in the village, they have put nets over every bed and sprayed inside every house, and they have put a decal on the door to show the family was compliant with every health post recommendations. The results are amazing.

So that’s two countries in which malaria interventions seem to have worked. And that leaves two real challenges: 1) to scale this package of interventions to the whole country; and 2) to sustain them over time when the malaria threat recedes but has not been eliminated. Here is the problem: If malaria goes down rapidly, how will health workers keep people sleeping under nets? If less than 5 percent of patients who present with fever have malaria, is it cost effective to test everyone for malaria?  That is, how do we make the gains stick?


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Some people think it’s impossible to travel backward in time. Well, they should try visiting Ethiopia, where the year is 2003.

The Ethiopians follow the Julian calendar, which consists of twelve months of 30 days each and a thirteenth month of just five days—or six days on leap years, which occur the same year as our leap years. The Julian calendar dates from 45 B.C. In 1582, Pope Gregory changed it to our present, twelve-month calendar—the Gregorian calendar. In the sixteenth century, only a few Catholic countries adopted the change. In fact, the British did not change to the Gregorian calendar until 1752. (Interesting fact: George Washington was born on February 11 in the Julian calendar, but we celebrate his birthday on February 22 in the Gregorian calendar.) The Russians held out until October 1917, when the revolution came.

As if the different year wasn’t disorienting enough, Ethiopians also have different months and dates. The Ethiopian New Year falls on September 11. We are in the second month of the year 2003—the month of Tikemte. And this is the eighteenth day of the month. So today, 10-28-2010 in the United States is 02-18-2003 in Ethiopia. It makes reading the case log awfully confusing.

Oh, and the Ethiopians also tell time differently. Earlier, I was in a meeting without a watch, so I glanced at the watch on the person next to me. It said 5:00 a.m. He was a volunteer community health worker, and I assumed maybe his watch stopped working, until I noticed two minutes later that it had moved to 5:02. It turns out the Ethiopians start the day at sunrise, not midnight. Our 6 a.m. is their 12:00 am. So their 5:00 a.m. is our 11:00 a.m., and our 5 p.m. is their noon.

Even Einstein would find this confusing.

Ezekiel J. Emanuel is special advisor for health policy to the Office of Management and Budget and the head of the bioethics department of the National Institutes of Health.