CHAPTER 1

A Return to the Magic Bullet?

Malaria and Global Health in the Twenty-First Century

MARCOS CUETO

At the turn of the twenty-first century, international efforts to combatmalaria, one of the deadliest and most insidious rural scourges in modernhistory, entered a new phase, marked by the emergence of new medicaltechnologies and the greater involvement of global agencies and localhealth workers. Initially, these changes raised hopes that a holistic interventionagainst malaria would replace the "magic bullet" approach thatwas launched in the mid-1950s and put an end to the apathy that hadfollowed the failure of that initiative to achieve results. However, after afew years of innovation it now appears that most donors, as well as majorinternational health agencies, including the World Health Organization(WHO), have returned to advocating top-down programs that resemblethose of the 1950s.

An examination of recent successes and failures in malaria control illuminatescontemporary challenges and suggests that traditional assumptionsand a reliance on the medical technology advocated by some expertsstill play a key role in the design of international programs. The relevanceof history to policy discussions also becomes evident. My purpose in thischapter is to examine the recent cycle of malaria elimination and controlefforts and to raise some questions about the future of global health.

The policy changes I discuss occurred against the background of theslow but steady growth of a killer that is second in its global impact onlyto tuberculosis. Despite a general decline in malaria morbidity during the1960s and 1970s, especially in semitropical and temperate climate zones,the number of cases and deaths increased in the following years. Amongthe social factors that explain malaria's increase in the developing worldwere floods of refugees fleeing civil wars and famine, the marked precariousnessof medical systems during a period of structural adjustment, andthe growing number of unemployed rural people moving to previouslyuncultivated lands where infection rates were higher and medical carewas scarce.

In 1988, a malaria epidemic in Madagascar resulted in twenty-fivethousand deaths. By the early 1990s, the disease had resurged in almostall of the regions where it previously had been controlled, so that almosthalf of the world's population was again living in malarial areas. Around1993, over 50 percent of the population living in savanna and forest zonesof Africa was infected. In this area of the world—which had not been fullyinvolved in the previous malaria eradication campaign—malaria was themain cause of death in young children, killing one in twenty before theage of five. At the time, it was estimated that, of the 100 million clinicalcases worldwide, 80 percent occurred in Africa. Between 1994 and 1996,malaria epidemics in fourteen countries in sub-Saharan Africa caused ahigh number of deaths, many in areas previously free of the disease.

At present it is estimated that, globally, more than a million malaria-relateddeaths occur each year (about four-fifths of these in Africa), andthat about 247 million people worldwide became ill with malaria in2006. In addition, about three billion people, more than half the world'spopulation, are at risk of infection. In the Americas, according to PanAmerican Health Organization figures, about 38 percent of the populationlives in malarial areas. Malaria disproportionately affects the ruralpoor, who are more exposed to infection, have the least access to services,and suffer more from the disease's consequences.

The boom and bust of International Health

Between 1955 and the early 1960s, WHO was the unquestioned leaderof a worldwide malaria eradication campaign that embodied the hopesof the recently created field of international health. Although some precedentscan be found, it was only after the Second World War that internationalhealth emerged as an epistemic community, a subdiscipline inAmerican schools of public health, and a web of multilateral organizationsthat formed part of the United Nations (UN) system and worked inclose association with the foreign policy of the US Department of State.Among these organizations were WHO and the United Nations Children'sFund (UNICEF), created in the late 1940s. After flings with European socialmedicine, they became champions of an American-inspired illusionthat social engineering could solve the problems of underdeveloped countriesand thus stave off the communist revolution advertised by the SovietUnion.

To complement the work of these organizations, major industrial countriesreorganized and upgraded their bilateral aid organizations and coordinatedthe roles played by private foundations. An important outcomeof these rearrangements was that bilateral and private organizations assumeda low profile, yielding center stage in terms of prestige and leadershipto the multilaterals. This web of institutions collaborated in thelaunch of a major global effort to eliminate malaria, a decision made inthe 1955 World Health Assembly that took place in Mexico City, in whatwas the most ambitious international and coordinated attack on diseaseever undertaken. The campaign was based on DDT spraying and the useof new antimalarial drugs, and it aimed to interrupt transmission of thedisease in all endemic areas within five to eight years. (The deadline waslater postponed.) This goal explicitly excluded tropical Africa. A 1956 reportby an expert committee considered efforts to eradicate the disease inAfrica "premature," and instead suggested the implementation of a numberof pilot pre-eradication projects.

The decision to eliminate malaria was based on a number of assumptionsthat are important to review here, and that in one form or anotherreappeared on the eve of the twenty-first century. One of the main assumptionsof the campaign, and of international health in general, wasthat technology could overcome any obstacle posed by social conditionsand processes—water use, housing standards, lifestyles, and the like. Accordingto this construction, the malaria parasite and the mosquito thatspread it were the real problems, and they could be addressed by quicktechnological fixes, namely insecticides and antimalarial drugs. Little attentionwas paid to social and institutional factors, such as the state of thehealth system in rural areas or the level of education of rural inhabitants.As a consequence, an understanding of local cultural beliefs and interculturaleducation were de-emphasized.

A second assumption was that disease caused poverty, not the other wayaround. The conviction was that nature was bigger than society—in otherwords, that mosquitoes and parasites were the main phenomena that impededthe evolution of the so-called third-world nations. It followed thatup-to-date medical technology and expertise would solve the main healthand social problems in these societies as soon as well-designed and cost-effectivemagic bullets could be implemented (an idea that would echo inpopular expectations that long-term public health structures could evolvefrom short-term interventions, such as making specific drugs available).

A third assumption revolved around new medical technology itself. Itwas portrayed as so detached from lay knowledge that only a group ofexperts ("malariologists") could design and implement the campaign. Itwas, in other words, the international givers who knew what was best forthe local receivers. A corollary idea was that medical technology couldonly be managed by an elite group of experts, so that a public health programwas necessarily an innovation that came from outside and from wellabove the level of the local communities that it aimed to benefit. Moreover,it was believed that the new cadre of medical experts were uniquelyqualified to convince policy-makers that it was crucial to invest in health.Only experts would know how to craft a compelling and hegemonic alliancebetween multilateral organizations, bilateral assistance programs,private foundations, national governments, and leaders in the field of internationalmedicine.

Linked to this assumption was the conviction that malaria was mainlya global economic problem since it affected the export capacity and buyingpower of workers in developing countries, and that elimination of thedisease would therefore contribute to the health of the world economy.In addition, the thinking went, disease control or elimination could beachieved without major public health improvements in poor countries (forwhich there were no resources available). Linking medicine, economics,and politics, international health touted its approach to the disease as anexemplary application of realistic humanitarianism (and, thus, as somethingthat should not be criticized or resisted).

By the mid-1960s, these assumptions could no longer validate the anti-malariaoperation, which seemed futile to both multilateral and bilateralagencies because of cultural problems such as the resistance of people tothe chemical contamination of their environment. The power of technologyas an antimalaria tool had, in this case, been overstated. Althoughreports had warned against an overreliance on technology since the beginningof the campaign, insecticide-resistant mosquitoes and drug-resistantparasites began to emerge everywhere, rendering the operation useless.Concern for the environment increased after 1962, with the publicationof the bestseller Silent Spring, in which Rachel Carson questioned thewisdom of releasing chemicals into the environment without understandingtheir effects on ecology or human health. The book suggested thatDDT was a cause of cancer and a threat to wildlife, particularly to birds.Among the many consequences of the book was a public outcry that ledto a DDT ban in the United States in 1972. In addition, in a climate ofcontroversy over family planning, malaria eradication was portrayed ascounterproductive because, if achieved, it would worsen the overpopulationproblems of developing countries. As a result, international fundingfor antimalaria programs fell off rapidly.

The 1969 Boston meeting of the World Health Assembly (WHO'sgoverning body) reversed its malaria eradication policy by approving aresolution calling for containment of the disease. This had the benefit ofestablishing an uneasy coexistence between those advocating control andthose favoring eradication. WHO's decision was accepted by other internationalhealth agencies but was questioned by some developing countries,which continued to argue for eradication even as articles in mainstreamjournals questioned the eradication approach. An editorial in theLancet, for example, carried the self-explanatory title "Epitaph for GlobalMalaria Eradication?" In 1974, a new Director-General asked the WHOExecutive Board: "Was malaria eradication a foolish enterprise? Where,when, and how did the program go wrong?" Regrettably, however, thefailure to eradicate malaria did not prompt a thorough assessment of theexperience or give rise to comprehensive countermodels for malaria control,and it resulted in even less effort being devoted to building healthsystem capacity from the ground up. For some years, a disorganized andconfusing coexistence between control and eradication persisted. In practicalterms, it amounted to little more than local health centers offeringdiagnosis and dispensing medication.

In the 1970s, WHO began to insist on better mechanisms for continuoussurveillance of malaria and criticized nationally designed malaria eradicationservices for their attempts to remain "autonomous," independent ofthe work of local health services devoted to a series of issues that werein fact not unrelated to malaria. Some international health leaders andhealth workers around the world became convinced there was no magicbullet for malaria. Technologically driven "vertical" mass campaigns werenot sustainable or feasible. They could deliver only temporary success.Instead, the disease needed to be attacked on many fronts with strategiesadapted to diverse ecologies and cultural settings, undertaken in the contextof permanent rural health services, and tied to significant improvementsin the living conditions of the rural poor. The resulting campaignwas to prove a learning experience for many experts who questioned vertical,magic bullet programs and who, from the mid-1960s on, began topromote the development of basic health services at the local level. Manycriticized the passive surveillance approach (case detection followed bytreatment) taken by most malaria workers, but they did not propose analternative at the time.

Only a few antimalaria programs in poor countries were able to fullyparticipate in the new and more comprehensive international health programs,that is, in the development of the concept of primary health care(PHC). Some individual health workers hoped to use efforts against endemicdiseases like malaria as an entry point for testing PHC's effectivenessat meeting its stated goals, such as exposing and ending the inadequaciesand inequities of health and social systems that predispose people toillness, but this approach never gained popularity among agencies.

The Transition to Global Health

During the 1980s and early 1990s, it was difficult to overcome a growingsense of futility. Low priority was given to malaria work, despite the complexchallenges posed by the disease and its increasing gravity. In the early1980s, there was little research underway on antimalarial drugs, with theexception of some work by Chinese researchers and by the Special Programfor Research and Training on Tropical Diseases (funded by variousagencies housed at WHO) on the drug artemisinin. This work wouldlater prove essential since in the 1980s, some Asian countries, especiallyin the Indochinese peninsula, began to experience serious difficulties withparasite resistance to chloroquine, the drug of choice since the 1950s.Chloroquine would gradually lose effectiveness in many other parts ofthe world as well. In addition, growing resistance to mefloquine (anotherfirst-line drug that was developed in the 1970s at the Walter Reed ArmyInstitute of Research as a synthetic analogue of quinine) was noted a fewyears after its introduction in the early 1980s. In 1989, the World HealthAssembly asserted that malaria control should be a priority and a crucialcomponent in the implementation of primary healthcare.

WHO sponsored a conference of health ministers in Amsterdam inOctober of 1992 to discuss a coordinated attack on the disease. It subsequentlyadopted a Global Malaria Control Strategy advocating early diagnosisand treatment of cases, various preventive and protective measures,and the early containment of epidemics, as well as the strengthening oflocal health services and human capacities in basic and applied research.(It is important to mention that among the participants at the Amsterdammeeting was Pascal Lissouba, the president of the People's Republic ofCongo, a significant presence since African malaria had not been givenmuch attention before by international agencies.) Subsequently, the WorldHealth Assembly, the Economic and Social Council of the UN GeneralAssembly, and the General Assembly itself fully endorsed the new strategy.According to the final report of the Amsterdam meeting, one of themain obstacles to reorganizing and revamping malaria programs was thelack of national political determination to confront malaria, "stemming inlarge measure from doubt and disillusionment created by past setbacks."

The strategy was also the product of regional conferences, organizedby WHO's regional offices and attended by the heads of national malariaprograms, in Brazzaville and New Delhi in 1991 and in Brasilia in 1992.Still, the strategy echoed the broader international concerns of PHC, sincethe 1993 World Health Assembly approved a declaration calling on theWHO Director-General to ensure its implementation in the context ofprimary health care. Moreover, clearly implying that the magic bulletsof the past partly explained the failure of malariologists, advocates ofthe strategy made clear that they did not promise a single and immediatesolution, that eradication was not a realistic goal, and that many standardpractices based on eradication principles were, in fact, inefficient. One ofthese standard practices involved spraying all malarial areas in a givencountry, when a program of selective spraying would be more effectiveand sustainable. The strategy's objectives were to prevent malaria mortalityand reduce malaria morbidity (not to eliminate it) and to promoteintersectoral collaboration (in contrast to the lack of coordination thathad characterized previous efforts).