World Health Day: The battle against Malaria

In honour of World Health Day, Anthropology lecturer Dr Ann Kelly has written a blog on the battle against Malaria.

Benito Mussolini once boasted that his anti-malarial campaign would place a pig under every peasant’s bed. Characteristically grandiose, ‘the Grand Bonification’ combined public health measures with hydraulic engineering, housing construction, novel agrarian technologies and cultivation techniques – a totalitarian vision that linked disease control to the creation of a new class of farmers and the regeneration of the Italian economy. While more propaganda than viable social policy, freeing marshes from the shadow of the fever entailed nothing less than a social and political revolution.

The theme of this year’s World Health Day is vector-borne diseases – a set of public health scourges affecting disproportionately the poor in the Global South. Disease vectors – mosquitoes, ticks, snails – thrive in areas that, in the WHO’s words, “have been left behind by development”. To a certain degree all communicable diseases map onto socio-economic inequalities, the correlation between poverty and vector-borne diseases such as Malaria, Yellow Fever, Dengue, Onchocerciasis and Shistosomiasis is amplified.

Public health experts agree that improved infrastructure – e.g. the pavement of roads, the building of structurally-sound and screened houses, the construction of drains, filtration and sanitation systems – constitutes the most effective strategy in reducing the transmission of pathogens. Thus, in focusing on vector-borne diseases, the WHO brings to the foreground the link between health outcomes and development, disease control and civil engineering.

Malaria is the most famous and, in terms of overall fatalities, deadliest of all vector-borne diseases; the fraught history of its control is the backdrop of the WHO 2014 brief. The discovery at the turn of the twentieth century, by Ronald Ross and others, that some mosquito species of the Anopheles genus were a central component of the malaria transmission cycle opened new courses of public health action focused on prevention rather than clinical care. Across Europe, the USSR, the Americas and Africa, comprehensive programmes of environmental management sought to uproot the mosquito from the landscape through the introduction of engineering works, the pre-planning of urban settlements, and the management and systematic destruction of An. gambiae breeding habitats, from marshland to footprint, septic tank to coconut shell.

These methods are, needless to say, labour intensive and logistically complex and stand in an uneasy relationship to other forms of anti-malarial action. While arguably less effective in the long run, the mass distribution of quinine to treat the disease was cheaper and did not require specialist engineering or entomological expertise. In tropical climates where breeding grounds were abundant and infrastructure weak, Robert Koch’s dictum, ‘treat the patient, not the mosquito’ made a certain financial if not epidemiological sense and throughout the early twentieth century, policies that focused on the life of the Plasmodium parasite in infected humans, rather than on the insects that carry the parasite into and out of the human body, gained the upper hand.

The invention of powerful insecticides such as DDT obviated this debate, enabling a far more direct approach to reducing transmission. Rather than seeking out mosquitoes, one simply needed to spray extensively to kill female anopheles mosquitoes in large numbers. The large-scale domestic application of insecticides or, Indoor Residual Spray (IRS), was the central strategy of the global eradication campaign of the 1950s and 1960s. DDT effectively de-coupled malaria control from the topography of urban settlements – design of sluices and dikes – and linked it instead with the power of a single-bullet technology.

The demarcation of malaria from development tallied with the post-war institutionalization of public health: the creation of the WHO as distinct from agencies such as the International Monetary Fund or the World Bank narrowed the scope of public health initiatives, while the internationalization of public health centralized medical expertise in Geneva and New York.

The ecological consequences of that campaign re powerfully chronicled by Rachel Carson in Silent Spring. Its epidemiological impact – e.g., the spreading of insecticide resistance, the shifts in mosquito behaviour to avoid sprayed surfaces, and critically, the exhaustion and retreat of the global health community from malaria control – are apparent in the current framing of anti-malaria campaigns. The WHO’s emphasis on vector-borne diseases acknowledges the entanglement of disease in broader questions of social improvement. The control of vectors is not simply a matter of the development and application of a technological innovation; the deep entrenchment of mosquitoes and other disease carriers in the fabric of everyday life demands attention to the particular contexts in which humans, vectors and pathogens come into contact.

Vector-borne diseases are resolutely local – vector control, to quote the WHO report “is a national development issue.” That recognition is not a matter of shifting responsibilities, but rather of disseminating the awareness that when it comes to interrupting the transmission of disease community-based approaches are the best way forward. We are reminded of the advice of Ronald Ross not to make mosquito abatement dependent on the resolution of difficult scientific questions, and to rely instead on the systematic and relentless application of what is already known, on the thorough implementation of what is doable from the very start.

 

All this looks very formidable on paper. It is not so in reality. A very few men working day after day will do wonders in the course of a few months. The great thing is to make a beginning: not to form counsels of perfection, not to measure means with ends, but simply to set to work with whatever force there is available, however small it may be. A single private citizen can eradicate malaria from a whole town. In an enterprise of this nature, the means grow as the work proceeds (Ross 1901: 31).

 

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