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The Global Dreams and Local Complexities of Malaria Eradication

In a surprise announcement at a 2007 malaria conference, Bill and Melinda Gates stunned many observers by calling for the eradication of malaria in their lifetimes. “Did they really say ... eradication?” ran the headline in Science.1 Yes, they really said eradication, and influential voices from the director-general of the WHO to the editors of the Lancet endorsed their call.2 Within a few years, a research agenda aimed at achieving eradication was created. The strategy focused on the development of technical fixes: improved drugs, new vaccines, better insecticides and easier diagnostics. But many malaria researchers remained deeply skeptical. Disease eradication is an extremely ambitious goal; unlike the usual public health objective of disease control, it entails the complete obliteration of a disease from the face of the earth. Because the goal is so difficult, eradication as a project has a checkered history. Seven diseases were targeted for eradication in the 20th century, but only one, smallpox, has been successfully wiped out. What’s more, malaria eradication had been tried once before. The Global Malaria Eradication Program lasted from 1955 to 1969, consuming about a third of the WHO’s operating budget during those years. In a postwar climate of deep faith in technology, the program relied heavily on spraying houses with DDT and treating cases with drugs. It failed. A major shortfall of the program was its lack of attention to local political, social and economic factors. Spray teams, for example, often arrived with no warning, demanding that people remove all of their belongings from their homes; resistance to indoor spraying was at times countered with force.3 Such approaches did little to foster collaboration. In their call to eradicate malaria, Bill and Melinda Gates cited Tanzania as a place where coordination with national governments had led to improved interventions to fight the disease. By sensitively exploring the politics, social dynamics and economics of malaria control in Tanzania, Vinay Kamat’s book, Silent Violence: Global Health, Malaria, and Child Survival in Tanzania, complicates the Gates’s optimism. On the whole, Kamat makes a compelling case that any malaria control or eradication program must be informed by an ethnographic understanding of the micro-interactions between patients and health systems, and beyond technical fixes, include measures to improve housing and sanitation. This is because, as Kamat makes clear through thick ethnographic description of malaria treatment in a town in rural Tanzania, the choices parents make when their young child has a fever are complex and critically important.