Abstract
Among the public health community, ‘all except malaria’ is often shorthand for neglected tropical diseases. The Bill and Melinda Gates Foundation's cause célèbre, malaria receives a tremendous amount of funding, as well as scientific and policy attention. Malaria has, however, divergent biological, behavioural and socio-political guises; it is multiply implicated in the environments we inhabit and in the ways in which we inhabit them. The malaria that focuses our attention crops up in the back alleys of Dar es Salaam, brought into being by local labour and municipal governance – a version of malaria that, we argue, is increasingly excluded in current eradication campaigns. This article considers the cycles of public health amnesia, memory and neglect that construe the parasitological exchange between man and mosquito. It begins by exploring the political concerns and technical capacities that have transformed malaria into a global enemy. Combining these historical accounts with ethnographic material, we suggest how malaria is disentangled from or conflated with particular places. Ultimately, our aim is to reflect upon the relationship between scale of malaria control and its social consequence, attending to the actors and relations that fall outside of contemporary global public health policy.
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Notes
P. vivax, P. malariae and P. ovule are generally milder but chronic: P. knowlesi causes malaria in animals but can also infect humans. As one of our excellent blind reviewers noted, in the context of massive control campaigns that target Plasmodium falciparum, these other malarias are generally considered ‘neglected’.
As Mol (2002) explains in The Body Multiple: ‘ontology is not given in the order of things, but that, instead, ontologies are brought into being, sustained, or allowed to wither away in common, day-to-day, sociomaterial practices. Medical practices among them … Ontologies … inform and are informed by our bodies, the organisation of our health care systems, the rhythms and pains of our diseases, and the shape of our technologies. All of these, all at once, all intertwined, all in tension’ (2002, p. 7, italics in original).
For an ethnographic elaboration of this project please see Kelly (2011a, Forthcoming).
By referencing ‘malarias’ at times in the plural, we seek to unpack the multiple concepts of disease, their attendant differences in intervention and the various biomedical realities that are often elided by the single word ‘malaria’.
Comparable statistics are associated with the American Civil War, when malaria is believed to have caused three-fifths of the Federal casualties and two-thirds of the Confederate losses – 10 000 men in total (Sartin, 1993) and World War II, where malaria felled American soldiers in the Pacific roughly eight times faster than the Japanese soldiers did (Rusell, 2001, p. 116).
Other key actors in this history of discovery were Patrick Manson, also a colonial medical officer in China and the founding director of the London School of Hygiene and Tropical Medicine. Manson postulated the mosquito-malaria theory, for which Ross established scientific proof. Giovanni Battista Grassi, an Italian zoologist, who discovered the transmission process for avian malaria, and simultaneously to Ross, proved the connection between mosquitoes, parasites and humans. The priority of the discovery became an issue of extended dispute. Needless to say, behind the big men, was the work of unaccredited technicians and field workers. For a novelistic treatment of the role of Ross’s laboratory assistant Kishori Mohan Bandyopadhyay, see Gosh (2001).
The hut, made ‘mosquito proof’ with screens in the windows and doors, kept visiting scientists and their servants malaria-free for three months during the height of the Italian fever season. Grassi's telegram to Manson, a telegram dated 13 September 1900, read: ‘Assembled in British mosquito proof hut having versified (sic) [instead of ‘verified’] perfect health of experimenters among malaria stricken inhabitants. I greet Manson, who first formulated mosquito malaria theory’ (Capanna, 2006, 9, pp. 69–74).
A position characteristic of Italian entomologists and enthusiastically taken up by Mussolini, whose ‘bonification’ approach to malaria involved general improvement in the living conditions and agriculture practices of the rural population. Integrating malaria control with social development also characterized the strategies of the Tennessee Valley Authority in the American South (Snowden, 2006; Packard, 2007).
That disease eradication should precede development characterized the thinking of the Rockefeller International Health Division (IHD), a body whose work pre-dated and informed the WHO. For an excellent history of the IHD, see Farley (2003).
The development of the insecticide Paris Green in the 1920s amplified these micro-practices. Paris Green was selective; unlike oil larvicides it targeted mosquitoes, like anophelese that fed on floating particles. Its application, therefore, required comprehensive research into the ecological features of the area (Farley, 2003, pp. 112–113).
It was an approach that drew from a strong, administrative presence, whether in the form of colonial garrisons, occupying forces, or in the case of Carlos Alberto Alvarado, the director of Argentina's malaria programme, militarized populism introduced by Juan Perón (Carter, 2007).
The Naples programme was lead by Fred Soper an epidemiologist and director of the International Health Division, who was responsible for eliminating the Anopheles gambiae from Brazil just three years earlier with the use of foci-patrols and Paris Green. He recalls the dramatic nature of the intervention in the absence of safety testing: ‘it was a very hush-hush subject. The toxicology of DDT was relatively unknown, but we did not hesitate to pump it under the clothing of some 3 000 000 people and assign workers to the pumps in rooms, which were unavoidably foggy from the DDT dust in the air’ (Snowden, 2006, p. 199).
Fred Soper writes about the spatial transformations enabled by DDT: ‘There is no law of diminishing returns and no indestructibility of a biological entity. The mathematics of eradication is simple; what can be done in one square meter can be done in two square meters; what can be done in two square meters can be done in four. Thus, by geometrical progression the world is soon covered’ (Soper, 1962, quoted in Shaw et al, 2010, p. 380).
Edmund Russell makes the striking point that the Insect Control Committee created by Vannevar Bush after World War II to link the work of the National Defence Research Committee and The Committee on Medical Research did not include entomologists.
Malaria control programmes were regarded as weapons against Communism. Sri Lanka is a tragic example of what occurs when governments fail to align with that agenda. In 1963 malaria was nearly eradicated from the island with only six reported cases per year. The socialist tendencies of its government led to the withdrawal of American funding and consequently, malaria cases numbered one million four years later (Packard, 2007, p. 171).
This is particularly remarkable in light of the fact that the scientific community soon realized that DDT's efficacy would sharply decrease over time. In 1945 only a dozen species were known to be insecticide-resistant; in 1960, DDT-resistant species numbered 139 (Carson, 1962, p. 234).
The other central tool of the GMEP was the treatment of infected individuals with choloroquine. Like the pesticide, this drug also became ineffective as parasites developed resistances.
For instance, in the forest-savannah transitional zone in Ghana 58 per cent of the population is infected with malaria parasites at any given time, without necessarily showing symptoms of the disease (Owusu-Agyei et al, 2009).
As articulated by the WHO's Alma Ata declaration in 1978, which underlined the importance of ‘primary health care for all’ enabled by grass-roots community-participation.
In 2005, BMGF became the largest single donor to malaria research in the world and the US Government fell to a distant second. Today it is the largest charitable organization in the world, with an endowment of US $29.7 billion in January 2009. In contrast, the WHO's malaria budget for 2006 and 2007 was a mere $137.5 million, over half of which comes from Gates and the other half not entirely certain.
As quoted in BBC (28 June 2005) ‘Gates’ millions to tackle disease’, http://news.bbc.co.uk/1/hi/health/4629587.stm, accessed 26 August 2010.
The grand challenges are modelled after the list of unsolved mathematical problems produced by mathematician David Hilbert a century ago. The problematic analogy between global health and algebraic puzzles not withstanding, Gates’s Grand Challenges that address malaria are: improve existing and create new vaccines, novel biological and chemical strategies to controlling of insect vectors and limiting drug resistance through development of new drugs. See http://www.grandchallenges.org/Pages/BrowseByGoal.aspx.
As Bill Gates argues: ‘The poorest two-thirds of the world's population have some $5 trillion in purchasing power. it would be a shame if we missed such opportunities’ (Gates, 2008).
The majority of these cases effectively resolved by formalizing the CORP through bureaucratic process and symbolic codification: for instance, informing the municipal malaria coordinator, who wrote a stamped letter or by giving CORPs uniforms.
Working around mosquitoes’ resistance to DDT and other insecticides is a considerable public health challenge. The first cases of drug resistance against the current first-line treatment artemisinin, a compound of history's first herb against the fevers qīnghāo, were confirmed in Cambodia in 2008 (Noedl et al, 2008), and have spread ever since – despite containment efforts resistant parasites have already reached China, Myanmar and Vietnam (Malaria Consortium, 2009). Malaria experts are acutely aware that, with the current tools, eradication in Africa is not achievable (for example, Tanner and de Savigny, 2008, p. 82).
As historians have shown, disappearance of malaria in Europe and the Americas did not come by way of vaccine, but by screening houses, draining swamps, better sanitation, treatment and monitoring of humans in conjunction with general socio-economic developments (Humphreys, 2001; Packard, 2007).
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Acknowledgements
Our first thanks go to Gerry Killeen, Prosper Chaki, Stefan Dongus and the public health entomology team at IHI, Dar es Salaam. This article benefited greatly from the overwhelmingly generous attention of the blind reviewers. For their inspiration, we would also like to thank Rene Gerrets, Javier Lezaun, Steve Lindsay and Annemarie Mol. The research from which this article draws was conducted with a Wellcome Trust Bioethics Grant grant (#2173) and written during a fellowship at the Brocher Foundation.
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Kelly, A., Beisel, U. Neglected malarias: The frontlines and back alleys of global health. BioSocieties 6, 71–87 (2011). https://doi.org/10.1057/biosoc.2010.42
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DOI: https://doi.org/10.1057/biosoc.2010.42