Aside

Packard on History of Global Health: devastating first chapter (we need to do better)

While i intend to write more about Packard’s new book (delightfully if uncomfortably subtitled, interventions into the lives of others) once i am through with it, a paragraph in the opening chapter seemed both so important and accurate as to merit sharing immediately — particularly given the lessons it may hold for the Universal Health Coverage (e.g.) movement. It is not that what Packard has to say here is necessarily new but rather that he sums it up in a neat, indicting list of trends, on which we would all do well to reflect:

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There have been remarkable continuities in how health interventions have been conceived and implemented over the past century… [that] have worked against the development of effective basic-health systems to address social determinants of health:

  1. Health interventions have been largely developed outside the countries where the health problems exist, with few attempts to seriously incorporate local perspectives or community participation in the planning process…

  2. Health planning has privileged approaches based on the application of biomedical technologies that prevent or eliminate health problems one at a time.

  3. Little attention has been given to supporting the development of basic health services.

  4. The planning of health interventions has often occurred in a crisis environment, in which there was an imperative to act fast. This mindset has privileged interventions that are simple, easy to implement, and have potential to quickly make a significant impact…

  5. Global health interventions have been empowered by faith in the superioity of Western medical knowledge and technology…

  6. Health has been linked to social and economic development — but this connection has focused primarily on how improvements in health can stimulate economic development, while ignoring the impact that social and economic developments can have on health. The social determinants of health have received little attention.

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Packard notes that these trends have faltered a few times, such as with the rise in interest in learning about the “social and economic causes of ill health” in the 1920s and 30s and in the Alma Ata / health for all movement at the end of the 1970s. We seem to think of ourselves as standing at a new trend-breaking moment. Hopefully we can do better.

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if it doesn’t kill them, it makes them stronger (III) / why would you do things that way? (II)

well, this is bad and annoying.

bad: malaria resistance to ACTs is being increasingly reported in Thailand.

annoying: the article’s narrator & interviewee go on to say that immediate steps need to be taken.

then, instead of listing some possible steps, they highlight that maybe a malaria vaccine is on the horizon.

1. what should we do now? use rapid-diagnostic testing? encourage proper use (dose-completion) of ACTs? encourage prevention with bednets?

2. what do we think is that actual probability of having a viable malaria vaccine in three years? if so, how likely is its protective immunity likely to last for an inoculated person?

3. why are we so, so, so jazzed about a malaria vaccine when malaria elimination & eradication in the past has been very much about environmental management? is sanitation not sexy enough? do we not think that governments in malarious countries can and should be providing drainage, sewage, and other services that reduce malaria breeding habitats?

from The Making of a Tropical Disease (Packard)

In the end, the book males a simple point. Malaria policy needs to be informed by history. The history of malaria tells us that malaria cannot be understood or eliminated independently of changes in the societal forces that drive it. This is not to argue that past and current malaria control efforts have had no effect on reducing the burden of malaria. Nor do I believe that malaria cannot be controlled before social and economic impediments to health are completely removed. Rather I argue that the array of biological weapons mobilized in the war against malaria needs to be joined with efforts to understand and improve the social and economic conditions that drive the epidemiology of the disease (xviii).

from The Fever (Shah)

The uncomfortable truth is that ending malaria over the long-term will require difficult social and economic adjustments in African communities, just as it has elsewhere. Infrastructure will have to improve. Settlement patterns and housing styles will have to change. Education and healthcare systems will have to be built. Antimalaria activists know this. But it is not possible for them alone to transform Africa’s economies and cultures. The best they can do is offer partial, short-term solutions. That is, in the meantime, they can blanket the continent with treated nets and better drugs… After all, the perfect need not be the enemy of the good. The question is how the short-term solutions impact the long-term ones. Usually, something good today doesn’t reduce the probability of something better tomorrow. But in malaria, it can (237).

The conflict over short-term solutions and long-term sustainability has yet to be adequately resolved. The US antimalarial program, government malariologist Thomas Ritchie says, ‘is pouring obscene amounts of money’ into quick fixes against African malaria, but is spending little on supporting local antimalaria leadership or building antimalarial infrastructure. Plenty of African clinicians, scientists, and community leaders are dedicated to taming malaria, Ritchie says, but when the world’s richest country decides to help, ‘they give these people nothing, not a cent!’ (238).

The conflict plays out in heated debates at international malaria meetings. At one, an official from the Nigerian MoH became engrossed in a long argument with a representative from Sanofi-Aventis, which was at the time the sole purveyor of WHO-recommended ACT drugs. Finally she turned to me. ‘Write it in your paper,’ she commanded. ‘We need to build African capacity to make treated nets and ACTs. That is the only way we can solve malaria. They don’t want to do technology transfer,’ she said, motioning to the drug company rep. ‘They just want us to buy, buy, buy’ (238).

Although it publicly recognizes the need to build infrastructure in endemic countries, RBM has also stated that tackling the disease cannot be the responsibility of local governments. ‘If malaria control is left to governments to plan and execute,’ RBM wrote, ‘malaria will not be controlled.’ This is, of course, exactly backward. It is the only way malaria will be controlled. Malaria-endemic societies have proven this over and over again, from when the Italians distributed quinine to their populace – and built the schools and clinics and roads they needed in order to do it – to when Malawi banned the sale of chloroquine and rid the country of chloroquine-resistant parasites… ‘You can do a lot of good with bed nets, with spraying,’ says malariologist Tom McCutchan, ‘but in the end, you have got to give power to the people who are at risk’ (239).