Essay: In what ways might ethnographic enquiry help to better understand malaria and its control?

Malaria is defined biomedically as a mosquito-borne infectious diseases. It is treatable and preventable. But even so, malaria kills one child in Africa every two minutes (WHO 2015). In recent years, global eradication of malaria has reemerged on the agenda. Despite throwing medicines and technical solutions at the problem, malaria remains resistant, resilient and fully entrenched in peoples’ lives. Eradication is sub-Saharan Africa poses a formiddable challenge where the rapidly evolving Plasmodium falciparum and Anopheles gambiae cause havoc (Kelly and Beisel 2011:72) and where local understandings of disease etiology do not align with biomedicine. In this essay, I will consider the perspectives of biomedicine, global health and local people to reveal conflicting meanings, understandings, and experiences of malaria. I will consider ethnography from Gambia, Tanzania, and the Philippines to challenge the hegemony of biomedicine and seek out locally appropriate solutions. As Mol (2002) argues in The Body Multiple, disease must also be subjected to ethnographic enquiry.
Firstly, it is important to define the malaria problem according to biomedicine before considering other interpretations. In essence, malaria as a conception reflects cultural and historical processes (Packard and Brown 1997:186). The malady has afflicted humans throughout history but has changed through time and space. The malady features in historical accounts characterised by an intermittent fever and associated with marsh lands, stagnant water, poor housing, and trench warfare. It was at first thought to be caused by miasma, the ancient Greek word for pollution and is so named from the Italian, mala-aria or “bad air”. Once the germ theory of disease gained acceptance, the role of the environment appeared to diminish and scientists began the search for specific disease agents. The etiology of malaria eventually changed following Charles Laveran’s discovery of Plasmodium parasites and Ronald Ross’s discovery of the role of female Anopheles mosquitoes in transmission. From then on, the problem stemmed more specifically from parasites and mosquitoes rather than social deprivation (Hausmann-Muela and Eckl 2015). According to biomedicine, the parasite is powerful and, as such, is in danger of obscuring other determinants (Iskander 2016). That being said, as Iskander (ibid) points out, the parasite is not intrinsically powerful but rather made powerful through practice.
Anderson (1992) interrogates laboratory reports from Colonial Phillipines that contributed to defining the malaria problem and configuring control efforts. As the author describes, by implicating parasites, mosquitoes and Filipinos as carriers of disease, colonial scientists recast the ‘inhabitable’ tropical climate as a parasitic environment that could be systematically controlled. Tropical science, the malaria parasite implicit, became a source of power in the fact that it “managed to convert the dirty, humid, teeming, complex environment into controllable specimens” including the ‘diseased’ Filipinos (ibid:525). Put into context, the colonial occupation had in fact given “rise to street filth, poor disposal of animal and human waste, dubious milk and water quality, and (most importantly) to a heavier burden of parasitic disease” (ibid:515). As Packard and Brown point out elsewhere, framing malaria as a natural consequence of the tropical climate enabled biomedicine to get a foothold and control efforts to sustain power and capitalise all the while pertaining as “…a heroic struggle against a natural foe in an effort to liberate poor malarious people” (1997:187).
In discovery of the parasite, control efforts moved away from alleviating poverty and improving hygiene to thoroughly embrace curative medicines and biotechnical solutions (Packard and Brown 1997; Anderson 1992). Eventually, malaria turned into a “global enemy” (Kelly and Beisel 2011:72) and, with the mosquito as the easy target, a global assault was launched against the disease. Between 1955 and 1969, the miltiary-style deployment of the insecticide Dichloro-Diphenyl-Trichlororethane (DDT) was succesful in eradicating malaria from 37 countries out of 143 endemic countries (Iskander 2016). Following its abandonment, malaria fell off the radar. Subsequenly in sub-Saharan Africa, which have been notably missing from ‘global’ eradication strategy in the first place, had a surge in malaria case numbers (Kelly and Beisel 2011). As Kelly and Beisel identify (ibid:71), even though “all except malaria” is often shorthand for neglected tropical diseases,” neglect has been prominant thoughout its history.
The trouble is the ‘biomedical gaze’ is inclined to ignore the complex cultural, economic, social, structural, and political factors in the background and ignores any other interpretaion (Hausmann-Muela and Eckl 2015). If malaria was only a biological problem, or more specifically a mosquito problem, it would be fixed with biotechical solutions. But malaria remains fully entrenched in sub-Saharan Africa and parts of Asia despite bednets, insecticide, and medicines. The narrow biotechical approach falls short. As Birn agrues, “technical interventions will squeeze out one side of the mortality ballon only to find it inflated elsewhere” (2005:518). Sub-Saharan Africa is the most afflicted malaria region in the world and also the most improvished (WHO 2015). To ask the question why Africans suffer the greatest burden of disease, would evoke Farmer’s ideas about structural violence (1999 cited in Parker and Allen 2014:236). As Parker and Allen point out, “[i]t is mostly neglected people who are infected with neglected diseases” (ibid:224). All the while the parasite and mosquito are in the foreground, problems of poverty and social inequality are deposed to the background (Packard and Brown 1997:87).
Today, the Roll Back Malaria Initiative, Global Fund for AIDS, Tuberculorsis and Malaria and the Bill and Melinda Gates Foundation (BMGF) are all working towards malaria eradiction set to set to an agenda involving strategies, schedules, and reports. This time sub-Saharan Africa is not ignored. In the view of BMGF (n.d), malaria eradication will be achived by ‘removing the parasites that cause human malaria from the human population”. With that in mind, the approach is still top-down and configured around the use of bednets, insecticide, medicines, future vaccines, survillance and diagnosic tools, and genetically modified mosquitoes. There is still a fixation on biomedical tools – ‘new tools’, ‘current tools’, and better tools’ (BMGF n.d; WHO 2005). However, it is possible to discern a shift towards “a real rather than rhetorical emphasis on health systems”, ‘locally adapted’, and ‘appropriate interventions’ (WHO 2005).
What is at stake tackling the mosquito vector rather than alleviating poverty and impoving living conditions? Poverty and associated problems such as malnutirition, dirty water, and poor housing, are known to be risk factor for most diseases. Is malaria in risk of overemphasis to the detriment of other disease and other problems? While funding is available for malaria eradiction, others diseases are neglected (Iskander 2016).  Furthermore, by framing malaria as a global problem, obscures the everyday experience of disease. As Mol (2002:127) observes, disease is just one phenomena in peoples’ lives. There  are other problems and other diseases. As Packard and Brown (1997:186) point out, might it not be better to ‘rethink’ malaria as a local problem or more specifically a problem for young children and pregnant women.
As is becoming clear, so-called context-free interventions are not implemented free of context. Because malaria is constantly oscillating between mosquito and human it is susptible to change (Kelly and Beisel 2011:72). Kelly and Beisel (2011) illustrate ethnographically the problem in the city of Dar es Salaam in Tanzania where local people seek out malarias, synomous with mosquitoes, that are invisible in global eradication campaigns. Because of interventions such as bednets and indoor insecticidal spraying, mosquitoes have become dispossessed and are found “no longer on the front lines of global health” but the back alleys of the city (ibid:83). Local people identify mosquito hotspots and spray Bti insecticide in what has become a burdensome everyday encounter with the disease. It necessarily relies upon a thorough knowledge of the living landscape to pinpoint the continuous movements of both human and mosquito.
The challenge is thus to “find better ways to connect labscapes of innovation to landscapes of wellbeing” (ibid:73).
In the pursuit of hegemony, biomedicine often neglects the signifance of traditional knowlegde and local understandings of disease etiology (Jones and Williams 2004). In many settings, biomedicine and traditional healing will co-exist. Medical plurism describes the movement of patients between different healing settings that can be conceptually very different and often results in overlap and misunderstandings in disease etiology. In the case of malaria with its long list of symptoms the situation is all the more difficult to navigate. As Jones and Williams (2004:157) explain, “becoming ill with disease is a subjective process involving the interpretation of the origin and the significance of the symptoms”. While the provision of biomedical knowledge is important, so too is acknowledging divergent understandings that might deter a suffer from seeking hospital treatment.
Divergent explanations can confound malaria control efforts, especially involving ‘black magic’ and witches. According to O’Neill et al. (2015) in Gambia, local people understand disease as caused by either something inside the body aligning with biomedicine or a supernatural force outside the body that a traditional healer (marabout) will diagnose with divination techniques and treat with herbal concoctions. While uncomplicated malaria is widely recognised as malaria and biomedical treatment is sought, local people interpret more severe malaria as having a supernatural etiology, such as a foul wind fonyo jawo or Jinne spiri. Further problems arise as well when local folk illness Kajeje and Jontinooje, which present with malaria-like symtoms, are interpreted as self-limiting. As O’Neill et al (2015:) suggest, doctors and nurses might refer to malaria in indigenous terms such as Kajeje and Jontinooje in the hospital setting. But is the solution as straigtforward as this? Does this attempt to ‘enlighten’ local people on symptoms, overcome the cultural barrier or reinstate the hegemony of biomedicine? How might an anthropoglist mediate between two sets of knowledge that do not correlate and, at the same time remain, to quote Calabrese (2016), ‘relativist about relativism’ when peoples’ lives are at stake.
As Langwick’s (2007) research in Tanzania shows there is no straigtforward translation between the traditional malady known as degedege and malaria despite overlapping symptoms. In this setting, medical practioners will insist that degedege is malaria to encourage sufferers to more readily seek hospital treatment. It is worth noting that local people are quite well informed about malaria and its symptoms. The quesion at hand is more philopsphically, ‘what is disease?’
Rather than focusing on similaries, Langwick conducts ethnography to bring differences into sharp relief. For instance, degedege manifests after an encounter with the devil (shanti) described as a “malicious unseen agent”  (ibid:93). The malaria parasite is invisible but rendered visible through diagnosis. Whereas degedege treatment involves “closing” (kufunga) the body, in effect reinstating the body boundary, biomedical drugs and injections penetrate the boundary in order to destroy the invading pathogen. As Langwick (2007:89) explains, “[d]egedege and malaria are both propositions constitued through the encounters of healers, doctors, nurses, needles, medicinal baths, and innumerable other objects and agents”. Likewise, Mol points out “[t]he body, the patient, the disease…all of these are more than one. More than singular.” (2002:5). In other words, different articulations and practices give rise to multiple malarias.
Moreover, Langwick’s (2007) ethnography draws attention to the conflict between medical practioners and traditional healers. As the author explains, “[w]hen hot, convulsing bodies become a ground for ontological struggles over devils and parasites, the possibility of certain kinds of intervention hang in the balence” (ibid:91). Put differently, doctors and healers set out against one another to stake first claim over the bodies of their patients and afflicting agents. What is to be obtained and lost in making the assertion degedege is malaria? From the biomedical perspective, the problem is children are needlessly dying when traditional healers are relied upon in the first instance to treat malaria. Equally so, from the healers perspective, biomedince cannot cure degedege. Based on a positivist assumption, malaria is treated as the fundamental concept, while degedege is a mistaken belief or misconception. Moreover, the attempt to subvert traditional knowlegde falls short in recognising the problem. In settings such as Tanzania, local people rely upon traditional healers in the absence of sufficient and affordable biomedical care. How, then, can an anthropologist mediate between biomedicine and traditional healing while sidestepping the pitfalls of cultural relativism? As Langwick suggests, the absolutist claim that degedege is malaria should be replaced by an agreeable translation in a setting of “contingent and evolving plurism” (2007:112).
Iskander’s (2015a) research in the Philippines brings to light different versions of malaria not taken account of by practioners and policy makers. Using the methodology of photovoice as a form of phenomenological research, children depict and describe their everyday experience of malaria, most importantly in context, in response to the question “what does malaria mean to you?” In doing so, other understanding and approaches to malaria emerge. Along with mosquitoes children spoke of “too much dampness” and “too much cold” as the cause of malaria and, along with biomedicines, pointed to remedies such as coconuts for good nourishment and pito pito, a traditional herbal medicine for fever (Iskander 2015a). Since malaria is not a ‘modern’ malady, other articulations and practices are apprarent in traditional settings that challenge the hegemony of biomedicine. As the author (ibid:10) describes, Filipino children learnt from “their own lived experience, knowledge and expertise”. In this way, a grassroots approach that empowers, engages and enables local people has a transformative effect in regards to malaria control and equally so promotes health and well-being.
In conclusion, this essay has revealed multiple malarias enacted by practioners, patients, and policy makers. What people say about and do about malaria is as much what malaria is as the parasite. In considering it this way, multiple meanings, understandings, experiences, and narratives emerge that counter the one-dimensional biomedical expanation. It is therefore becomes more approapriate to speak of multiple malarias. With this in mind, ethnographic enquiry can make sense of malaria in its “biological, behavioural and social-political guises” (Kelly and Beisel 2011:72) and point to locally appropiate solutions . Without deposing biomedicine and global health, anthropologists have a seperate research agenda to implement. As Hausmann-Muela and Eckl (2015:2) suggest, it is time to ‘re-imagine’ malaria by drawing attention to what it means to ““different people – in different places and at different times”.