Monday, April 25, 2011

Malaria, "tropical medicine" and imperialism

Today is the 4th annual World Malaria Day, when we recommit ourselves to ending the mosquito-spread disease that infects half a billion people and kills a child every 45 second. But in order to achieve the goal of no malaria deaths by 2015, need to consider why parts of the world are still devastated by it. If we've know the basics of malaria transmission for a century but it remains a threat, then we must be ignoring factors critical to its survival. What follows is a brief history of "tropical medicine" and the changing context that shaped its theory and practice.

     The prevailing medical orthodoxy reduces infectious disease to an abstract interaction between an individual and a micro-organism, without considering the socioeconomic conditions that constrain the individual or facilitate the infection. As a result treatment is reduced to medicine and lifestyle choices, without considering an individuals ability to access medicine or to make certain lifestyle choices. As a result of this reductionst approach, medicine regards malaria and other infections that plague the Global South as 'tropical diseases'. But in 1954 the director of the Calcutta school of tropical medicine offered a critical response published in the British Medical Journal:
"There are not many diseases peculiar only to tropical climates, although admittedly conditions in the Tropics are more favourable to their growth and spread.. Such devastating diseases as cholera, smallpox, plague, malaria, and leprosy that now prevail here were once very common in Western countries. If taken in the sense of latitudes, labels such as 'tropical disease' and 'tropical medicine' are largely misnomers; what is worse, they perpetuate a false idea that tropical countries, try as they may, are doomed always to suffer from these diseases. 'Tropical' diseases disappeared from the West mainly for three reasons: first, better and abundant food as a result of better cultivation at home and the importation of food from overseas; secondly, the removal of poverty as a result of the industrial revolution and the acquisition of colonies; and, thirdly, the institution of public-health measures, which led to better housing and hygiene, improved sewerage, and a safe water supply. If we consider 'tropical disease' in this light much of it is reduced almost to 'poverty disease'."
     But colonialism imposed the exact opposite conditions on the Global South, fanning the flames of infectious disease. "Tropical medicine" emerged in the context of the scramble for colonies--when direct colonial control was an economic necessity--in an attempt to overcome this contradiction: how to bring the infectious diseases under control without altering the colonial conditions that spread them. As the British Medical Journal stated in 1897, "get rid of or avoid these germs and we get rid of a principle obstacle to the colonization of the tropics by Europeans."
     Two years later Britain established two schools of tropical medicine as joint ventures between the state and major companies. The owner of a Liverpool shipping line whose company shipped home loot form Africa became one of the main founders of the Liverpool school, and stated that "money spent in our school of tropical medicine is an investment, and we expect dividends from it." For US colonialism, a major source of funding for tropical medicine came from the United Fruit Company, whose profitable Latin American plantations required cheap and efficient labour. A century ago, when direct colonial control was an economic necessity for empires, companies and states joined forces to pillage the tropics, and the development of tropical medicine accompanied these projects.
     A simple glance at the pioneers in the field should raise suspicion as to the driving force of tropical medicine: malaria advances were made by Alfonse Laveran (a French army doctor in Algeria) and Ronald Ross (a British army doctor in India), advances in yellow fever were made by Jesse Lazear and Walter Reed (American army doctors in Cuba) and William Gorgas (an American army doctor in Panama). Despite their contributions to science, the implementation of tropical medicine was subordinate to colonial priorities. In Sierra Leone, the British used the the discovery of the malaria mosquito vector as rationale for imposing residential segregation, so the colonial officers could sleep at a safe distance from the infected local population.
     In Egypt, Britain discovered that the local poor population had high rates of schistosomiasis. Concern for the economic impact of a possible spread throughout the Empire precipitated a frenzy of medical research to discover how it was spread. But when the disease was found to be spread by sails in pollutd water, and therefore completely avoidable by the British military, research abruptly stopped. The disease and its victims were forgotten. As the leading investigator concluded, schistosomiasis "should not be treated as one of those diseases for which the individual is mainly, if not entirely, personally responsible."
     Whereas efficienty of foreign troops was the main goal of the British military base of Egypt, int he Belgian colonization of the Congo the focus was on labour efficiency. The Congo already had a low rate of trypanosomiasis. But the brutal conditions of colonization turned the disease into a raging epidemic at the start of the 20th century. In response, Belgium threw resources into finding a drug to keep the exploitted work force alive without dampening the proftable conditions of their exploitation.
     In the US conquest of the Philippines, sanitation measures were an excuse for repression. In 1902, after three years of crushing the local resistance, a cholera epidemic swept through the country, killing 200,000. The US launched a "cholera war", a supposed sanitation scheme that was suspiciously similar to the initial war and occupation: quarantines, house burnings, detention camps, and agricultural destruction. Of course this only fanned the flames of the disease.

     The "tropical diseases" that remain are proof that Western intervention has not led to development. Not only has global economic development not shifted to the global south, it has become more concentrated in advanced industrialized countries. As the British economist Chris Harman explained
"It is worth remembering why the European powers retreated from their colonies in the 1950s and 1960s after a century and more of carving up the rest of the world between them. They found it increasingly difficult and costly to hold on to them once modern national liberation movements came into existence and every grievance of any class translated itself into hatred of foreign occupation. At the same time, the economics of capitalism began shifting against the direct holding of colonies. The most important growth areas for markets and profitable investment were increasingly within the advanced countries themselves. Africa, the centre of inter-imperialist conflicts over the division of territory a century ago, today only accounts for around 0.6 percent of total direct foreign investment, and Latin America only around 6 percent."
World pharmaceutical market
     The pharmaceutical companies have mirrored this shift, with the entire continent of Africa now constituting only 1.3% of the global drug market. It is not surprising, following the logic of capitalism, that only 1% of new drugs in the past generation have been developed for "tropical diseases". Trypanosomiasis still kills 40,000 a year, a while life-saving treatment was an obsession for Belgian capitalism a hundred years ago, all production was stopped in 1999 because it was not profitable to save lives (it resumed production when it was discovered it could also be used in facial cream). As the former head of Merck stated, in sharp contrast to the Liverpool capitalist a century ago, "a corporation with stockholders can't start up a laboratory that will focus on Third World disease, because it will go broke. That's a social problem and industry shouldn't be expected to solve it."
     HIV/AIDS is the one 'tropical disease' that also affects people in the global north, though like all disease it spreads along lines of poverty and inequality and most people living with the infection are in the Global South. So while governments and pharmaceutical companies were pressured by AIDS activists to develop effective treatment, they have kept these technologies out of the hands of most people who need them.
     The shift in the global market away from the global south has been mirrored by a corresponding shift in dominant health care views. Once 'tropical disease' was reduced to a biological phenomenon, the solution for which was a 'magic bullet' that could cure the disease without disturbing the profitable conditions of colonialism. Now the dominant theory has become public health nihilism: dismissing medicine and preaching behavioural  and lifestyle changes--mosquito nets for malaria, circumcision for HIV--and economic development under tutelage from the West. Acknowledging that the majority of people in the global south cannot afford overpriced brand-name drugs, but wanting to gouge patients in the North, the dominant view now creates a false dichotomy of treatment for the rich and prevention for the poor. But as Paul Farmer, one the world's leading experts on HIV/AIDS, who has pioneered treatment in Haiti, explained in his book Infections and Inequalities:
"Too often, those who elevate the role of social determinants indict clinical technologies as failed strategies. But devaluing clinical intervention diverts attention from the essential goal that it be provided equitably to all those in need. Belittling the role of clinical care tends to unburden policy of the requirement to provide equitable access to such care."
     But "economic development" along neoliberal lines--with privatization, user fees and budget cuts--has undermined access to care, increased poverty, and exacerbated infections. An article in The Lancet described the impact of neoliberal policies for malaria in Nicaragua:
"I find it ironic that the Contra War was less a barrier to effective malaria control than the Structural Adjustment Program of the 1990s. Neglect for the rural poor has resulted in an epidemic greater than any since malaria eradication began in Nucaragua in 1947. User fees in this area generate few financial resources but sabotage the malaria control program and send the mistaken message that malaria control elective, rather than an essential service and national commitment."
     Meanwhile, structural adjustment in South Africa led to a cholera epidemic. As the World Bank explained, "work is still needed with political leaders to move away from the concept of free water for all." The result of forcibly depriving people of clean water was to drive them to polluted lakes and streams, leading to a cholera epidemic that killed 300 and infected 250,000. While pharmaceutical giants tried to prevent access to generic HIV/AIDS medication in 2001, they were defeated by a global movement led by South Africa's Treatment Action Campaign.

     Whereas most investment is within advanced industrialized countries, there is one commodity that continues to drive war and occupation outside the centres of the global market: oil. The Western-backed occupation of Palestine, in addition to direct attacks on the population, has also spread infections. According to a 2004 report of the International Journal of Health Services,
"The increasing rate of infectious disease in the occupied territories is influences by such factors as lack of sanitary water, overcrowded living conditions, poverty, improper sewage disposal, incomplete immunization, and malnutrition--all conditions that have been exacerbated during the current Intifada and are directly linked to Israel's policies"
     Meanwhile the West is presenting war as a new form of topical medicine,with aerial bombardment cloaked in the language of public health: crackers were dropped along with cluster bombs on Afghaninstan, Iraq was attacked with "surgical strikes", and depleted uranium is bringing "humanitarian intervention" to Libya. The supposed concern for international health obscures the fact that the cost of one B-2 bomber covers the total future spending on malaria research for the next 20 years, during which time the disease will kill 40 million people in Africa.
     But whereas tropical medicine a century ago attempted to contain infectious disease in order to promote the efficiency of foreign troops or local labour, war today spreads infectious disease in the conquest of oil and expansion of markets. A Pentagon report written before the Gulf War theorized that if water sanitation were destroyed in Iraq, "unless the water is purified with chlorine, epidemics of such diseases as cholera, heptatitis and typhoid could occur." This outlined in advance the Gulf War and UN sanctions regime, which deliberately destroyed civilian infrastructure and maintained a situation of malnutrition and disease that killed 1.5 million people.

     While governments have thrown hundreds of billions of dollars at corporate bailouts and military expansion, they have underfunded the Global Fund for AIDS, TB and Malaria. While AIDS medicine can reduce transmission turn the infection into a chronic illness, it is denied to millions resulting in a reversal of life expectancy in some countries. Tuberculosis infections a third of humanity and remains a leading infectious cause of death 50 years after the discovery of curative therapy. Meanwhile malaria continues to kill while treatment is growing old: the leading anti-malarial medication was developed by the US military during the Vietnam War. These three infections highlight the devastating contradictions of 21st century capitalism: each year they kill 6 million human beings, not because we don't have the material capacity or advanced technology to overcome them, but because both are subordinated to profit.
     To roll back Malaria, we need to roll back the socioeconomic factors that contribute to it, and urgently divert resources from military and corporate bailouts to global health and poverty--combining access to medicine with improved living standards for all. As the Treatment Action Campaign said in 2004,
"The effect of the US government's unlawful war in Iraq has been to divert international attenption and resources away from global health and poverty. Hundreds of billions of dollars are being spent on the military instead of investing resources in the biggest threats to human security today: HIV/AIDS, tuberculosis, malaria, malnutrition and poverty."


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