Towards a Cultural History of Malaria Treatment and ...€¦ · Towards a Cultural History of...

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

• Books

Packard (2007) p113

What is Malaria?

(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

Lab Science ResearchersLab Science Researchers

• Scientific challenge• Target for a vaccine• Intersection of 3 interacting genomes • Funding magnet

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

Economists, Politicians, Development Specialists

• 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

Three Stages of IntThree Stages of Int’’l/Global l/Global Health History Health History (E. Fee 1998)(E. Fee 1998)

Regulation : Regulation : Biomedical Biomedical Standards; TradeStandards; Trade

Disaster and War Victim Relief

Tropical & Tropical & Military Medical Military Medical ResearchResearch

Missionary Medicine & Medical Missionaries

19th Century Cultural Roots

Regulation : Biomedical Standards; Trade

Disaster and War Victim Relief

Tropical & Military Medical Science

Missionary Medicine & Medical Missionaries

Different Dress Rules

Regulation :Regulation : Relief

ResearchResearch Missions

Health Orientation19th Century Roots

Disease specific

Comprehensive Health

Public Health

Clinical Medicine

Regulation Regulation Relief

ResearchResearch Missions

Motivations19th Century Roots

Protection Protection of richof rich

Service to Service to PoorPoor

Science Mercy

Regulation Regulation Relief

ResearchResearch Missions

Political Economies19th Century Roots

Cost/Benefit Cost/Benefit importantimportant

Immediate Immediate action imptaction impt

Public Funding

Private Funding

Quantiphilia Quantiphobia

Stages of AntiStages of Anti--Malaria Malaria StrategiesStrategies

Discovery of 

Life cycle

Control 

Experiments 

DDT  

3 ResistancesACTIVISM

PHC movement

Smallpox EradicationGates $

Stages of Malaria Treatment Stages of Malaria Treatment StrategiesStrategies

Stages of Malaria Control Stages of Malaria Control StrategiesStrategies

Changing Malaria MetaphorsChanging Malaria Metaphors

Vector or Parasite? Control or Treatment?

Problem of “Anophelism without Malaria”• subspecies with difeerent feeding patterns

The Italian Experience (1896 – 1951)

Quinine

Legge della Malaria (1900)

•• 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

Fred Soper and Marcolino Candau

•• 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

Sardinia Project (Sardinia Project (‘‘47 47 –– ’’51)51)

• 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

Silence – a Consequence of Global Eradication Failure

• Metaphor of War– Failure = defeat– Shame after grand prpredictions

• Eradication requires “culture of optimism”– ? Similaitries to Polio Eradication?– Local resistance

1978: Pivotal Date

• Failure of Malaria Eradication• Completion of Smallpox Eradication• Alma Ata –Declaration

– PRIMARY HEALTH CARE• “Health for All” by 2000

Regulation of Trade and Travel

Disaster and War Victim Relief

Tropical Medicine & Military Medicine

Missionary Medicine & Medical Missions

Disease Eradication Strategies

Primary Health Care

The Evolution of Policies: a dialectic?

Selective PHC

Comprehensive PHC

Child Survival; EPI

Human Rights, Access to ARVs

Global Fund: AIDS, TB, 

Malaria;

new

GH

Roll Back Malaria: Sisyphus

• A New Metaphor– Endless labor – New “old” technology

• Punishment for Sisyphus due to his hubris• Camus (1942) sees Sisyphus as

personifying the absurdity but gives meaning "The struggle itself towards the heights is enough to fill a man's heart.“

Roll Back Malaria: Learning from the Past

•• A New ApproachA New Approach–– PartnershipsPartnerships–– New New ““oldold”” technologytechnology

•• Nets = improved housingNets = improved housing

•• Incredible amounts of new moneyIncredible amounts of new money–– Renewed excitementRenewed excitement

•• Effort to integrate Treatment and Vector Effort to integrate Treatment and Vector workwork

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.”

Conclusions

• Metaphors: control, eradication, “roll back”• Technologies: quinine, DDT, ITTN • Treatment: quinine, chlorquine/SP, ACT• Institutions: national, international,

uncoordinated multinational

• History of cultural shifts in conceptualizing Malaria