Towards a Cultural History of Malaria Treatment and Control: Institutions, Methods, and Metaphors Peter J. Brown Professor of Anthropology and Global Health Emory University, Atlanta, GA, USA Global Health Histories Seminar World Health Organization, Geneva September 23, 2009
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Towards a Cultural History of Malaria Treatment and
Control: Institutions, Methods, and
MetaphorsPeter J. Brown
Professor of Anthropology and Global Health
Emory University, Atlanta, GA, USAGlobal Health Histories Seminar
World Health Organization, GenevaSeptember 23, 2009
PrefacePreface• Cultural History
– Anthropological approach• Changing Patterns of Thought
– Metaphors (representations)
• Personal disclosure– Relationship between health (i.e. malaria)
and development• Sardinia Project (1947-51) DDT
Huge Literature on History of Huge Literature on History of MalariaMalaria
(It depends on your social role) Definitions often use metaphors
Malariologists
•• Scientific puzzleScientific puzzle•• Tropical diseaseTropical disease•• Transmitted by mosquitoesTransmitted by mosquitoes•• Too much anophelesToo much anopheles--human contacthuman contact•• Diagnosed through microscopy Diagnosed through microscopy •• Measured by epidemiological surveysMeasured by epidemiological surveys•• Consequence of local ecologyConsequence of local ecology
CliniciansClinicians
•• Serious medical condition Serious medical condition •• ““Great ImitatorGreat Imitator””•• Set of symptoms that can result in Set of symptoms that can result in
deathdeath•• Common cause of mortalityCommon cause of mortality•• Disease of malnourished or Disease of malnourished or
immunocompromised.immunocompromised.•• Treated with combination artemisin Treated with combination artemisin
therapytherapy•• Risk for travelersRisk for travelers
Global Health AdvocatesGlobal Health Advocates•• KillerKiller•• Enemy to be eradicated Enemy to be eradicated •• Block to economic developmentBlock to economic development•• Obstacle to be attacked with multiple strategiesObstacle to be attacked with multiple strategies•• ”” Intolerable burdenIntolerable burden””•• Grand challenge Grand challenge •• Millennium development goalMillennium development goal•• Resurging problem that must be Resurging problem that must be ““rolled backrolled back””•• Priority in the Global Fund Priority in the Global Fund ““trinitytrinity””•• Global disgraceGlobal disgrace•• Feasting on the health and development of African Feasting on the health and development of African
childrenchildren•• Taking costly bites out of AfricaTaking costly bites out of Africa
• Block to economic development• Drain (burden) on economy• Cause of poverty• Enemy of civilization• Socioeconomic problem of agriculture • Housing problem
THE MANY DEFINITIONS OF MALARIA: Six Constituencies
The PeopleThe People
• ““Bad airBad air””•• Inevitable fact of life Inevitable fact of life •• Sudden mixture of humorsSudden mixture of humors•• ““King of DiseasesKing of Diseases””•• Dangerous and costly fever in childrenDangerous and costly fever in children•• Employment opportunitEmployment opportunity
•• Enlightened comprehensive policyEnlightened comprehensive policy•• State monopoly of quinineState monopoly of quinine
–– Distribution out of hands of pharmacistsDistribution out of hands of pharmacists–– Available at State tobacco/salt shopsAvailable at State tobacco/salt shops
•• Epidemiological survey of nationEpidemiological survey of nation
Legge della Malaria (1900)
• Malaria surveillance required• Stage 2: subsidized price• Stage 3: free in persistent malarial zones
– Stage 3: local malaria clinics
• Large effect on mortality but when prevalence does not change, vector control methods
•• Soper and American CultureSoper and American Culture–– Belief technological quick fixBelief technological quick fix–– Strict organizationStrict organization
•• Dir. General Candau worked with Soper Dir. General Candau worked with Soper in Brazilian successin Brazilian success
• Rockefeller Int’ Health Division– UNRAA funding for “experiment”– Multilateral– First use of DDT against indigenous vector– Seen as a key to economic development
Why was Nothing Learned from Why was Nothing Learned from Sardinia Project Failure?Sardinia Project Failure?
•• Failure as species eradicationFailure as species eradication–– A. labranchiae A. labranchiae sylvaticsylvatic–– HUGE cost and time overHUGE cost and time over--runsruns
•• ““SpinSpin”” to make success out of failureto make success out of failure–– Public relations success for RockefellerPublic relations success for Rockefeller–– Meanwhile Italian public health officials rid Meanwhile Italian public health officials rid
malaria from rest of countrymalaria from rest of country•• Soper as true believerSoper as true believer
The Meaning of EradicationThe Meaning of Eradication•• Pull up by the rootsPull up by the roots
–– Rid of the problem foreverRid of the problem forever–– WARWAR–– No toleranceNo tolerance
•• Aggressive allAggressive all--out coordinated effortout coordinated effort–– Always cost effective because benefits in Always cost effective because benefits in
perpetuityperpetuity•• Time limited effort requires specialized Time limited effort requires specialized
independent agencyindependent agency–– Epitome of vertical programEpitome of vertical program–– Alienates local health systemsAlienates local health systems
•• Species eradication morphs to malaria Species eradication morphs to malaria eradicationeradication
The Meaning of Eradication
• Time limited effort requires specialized independent agency– Epitome of vertical program– Alienates local health systems
• Global program– WHO sets priority– “global” without Africa
• Species eradication morphs to malaria eradication
R. Packard (2007) Malaria: the making of a tropical disease
• “The limited effectiveness of recent efforts to eliminate malaria as a public health problem stems in large measure from a failure to appreciate the importance of social and economic forces in driving the epidemiology of the disease. Or, put another way, it flows from the failure to appreciate the lessons of history.”