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.

TROPICAL DISEASE or POVERTY DISEASE
     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'."

COLONIAL MEDICINE
     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.

MODERN IMPERIALISM and the DECLINE OF TROPICAL MEDICINE
     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."

CORPORATE GLOBALIZATION
     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.

WAR and OCCUPATION
     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.

ECONOMIC CRISIS, HEALTH CARE CRISIS
     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."

Cholera: the latest war against Haitian democracy

A cholera outbreak in Haiti has killed more than 250 people killed, and infected more than 3300, in just over one week. Five of those infected were in the capital of Port-au-Prince, raising the specter of a mass epidemic. According to Imogen Wall, spokeswoman for the United Nations humanitarian office in Haiti, "It's tragedy upon tragedy for Haiti. We're working on a worst-case scenario. We're planning for a national outbreak."

     Worse than a tragedy, this is a crime. Cholera is terrifying but easily preventable and treatable. Spread through contaminated water it causes such severe diarrhea that it can kill through dehydration in a matter of hours. But it is treated with large volumes of simple fluids—either intravenous or oral rehydration—and can be prevented with clean water and proper sanitation. The science of cholera prevention has existed for 150 years, ever since Dr. John Snow famously plotted the deaths of a London outbreak on a map and found them to centre around a contaminated water pipe. When he persuaded the authorities to shut off the pump the number of cholera cases dropped.
     Rudolf Vircow, who studied epidemics at the time of Snow, concluded that “if disease is an expression of individual life under unfavourable circumstances, then epidemics must be indicative of mass disturbances”. The emergence of a cholera epidemic in Haiti, like the massive death toll following the January earthquake, exposes the mass disturbance imposed on Haiti by centuries of foreign intervention.

THE WAR AGAINST HAITIAN DEMOCRACY
     Two-hundred years ago Haitians carried out the only successful slave revolution. But France forced them to pay $21 billion for “lost property”, which it took over a century to pay. Throughout the 20th century the US has interfered in Haitian development, invading in 1915 and staying for 20 years, and supporting the Duvalier dictatorship from 1957-1986. The people of Haiti overthrew the dictatorship in 1986, but was saddled with its debt. The IMF provided loans that forced Haiti to privatize services and slash tariffs on rice, which destroyed the agricultural sector and drove people into sweat-shops in Port-au-Prince. The lack of local agriculture has made Haiti dependent on food aid, and--along with poverty and the privatization of electricity--forced Haitians to cut down the forests for income and charcoal for fuel.

     Twice Haitians have voted for Jean Bertrand Aristide—to restore services and raise wages—and  twice he has been overthrown by coups, in 1991 and 2004. Since then Haitians have protested against the occupying UN force, which has done nothing to improve their lives. The war against Haitian democracy has a political purpose that connects back to the original overthrow of slavery. As Haitian-Canadian Ronald Charles explained on the Real News

“you have a country independent for 200 years now, and from the beginning that was a bad example in the eyes of the big powers of the time. So when some people would say, look at them after more than 200 years look at their condition. So all the people around the world, all the people fighting for liberation, for freedom, the colonial powers will point Haiti to them and say look. For example, In Martinique and Guadelope they had elections to see if people wanted to be independent from France, some people said we don’t want that, and one of the arguments is look at Haiti. And many big powers want to use Haiti as an example of what not to do.”

NATURAL EARTHQUAKE, UNNATURAL DEATH TOLL
     Centuries of deliberate interference in Haitian democracy paved the way for two “natural disasters” this year, one geological and one biological. While a 7.0 earthquake in San Francisco in 19189 killed less than 60 people, and 7.0 earthquake in New Zealand this year killed 2, and a 9.0 earthquake in Chile this year killed 1000, a 7.0 earthquake in Haiti killed 230,000.

     This had less to do with events under the ground as on top of them—where centuries of foreign intervention has turned a wealthy and lush nation into an impoverished deforested nation, concentrated in urban slums, living in inadequately built houses on eroded soil, with almost non-existent governmental services, in the midst of a multimillion dollar occupation force that interferes with democracy and development. That the earthquake was so deadly after 6 years of UN occupation exposes its true purpose. According to Peter Hallward, author of Damning the Flood: Haiti, Aristide and the Politics of Containment:

“The international community has been effectively ruling Haiti since the 2004 coup. The same countries scrambling to send emergency help to Haiti now, however, have during the last five years consistently voted against any extension of the UN missions’ mandate beyond its immediate military purpose. Proposals to divert some of this ‘investment’ towards poverty reduction or agrarian development have been blocked.”

CHOLERA
     The same factors that produced a large earthquake death toll have produced conditions for the emergence of cholera. Partners in Health explain how the  environmental destruction of Haiti has magnified natural disasters, which have destroyed infrastructure—along with poverty—concentrated the population in overcrowded areas with poor sanitation:

 “in Gonaives the capital of the Artibonite has been destroyed in two waves of floods and mudslides, after tropical storm Jeanne in 2004 and after the series of hurricanes in 2008, made possible because of the environmental devastation of the region. The destruction contaminated the water supply and left the infrastructure (including the health infrastructure) of the upper Artibonite in ruins, forcing people to seek residence and medical care in St. Marc. The St. Marc region itself experienced significant flooding in 2008, displacing thousands of people. Lastly, the earthquake of January 12, 2010 resulted in the displacement of 1.7 million Haitians. While reliable statistics are not available currently, the last estimate, as of March of 2010 was that 300,000 addition Haitians had fled Port au Prince to the Artibonite. As there are no “camps” in the region, these displaced persons are “home hosted”—joining poor relatives in already overcrowded conditions, without water security or adequate sanitation. The dispersal of displaced people makes it difficult to provide centralized services.”

     In addition, Haitians are subject to poverty and a lack of food (reducing immunity), lack of transportation (impacting the precious hours between infection and death for those who have to travel to seek healthcare), and lack of healthcare. Coming 9 months after the quake, the cholera epidemic exposes how little “aid” has been provided since the quake. While ordinary Canadians delved deep into their pockets and organized fundraisers across the country, our government cynically used aid to justify a military response to the quake while announcing huge aid sums that clearly weren’t delivered. Harper announced $1 billion in aid for Haiti, and yet clearly Haitians don’t have access to the most basic services.

BIOLOGICAL WARFARE
     This is not first time the great powers have colluded in cholera epidemics, doing John Snow’s experiment in reverse. In their Orwellian-named “Sourcebook on Community Driven Development in the Africa Region—Community Action Programs”, the World Bank pushed African nations to privatize their water, explaining that “work is still needed with political leaders in some national governments to move away from the concept of free water for all.” The South African government followed suit by installing pre-paid water meters that cut people off from free water. Predictably, those who couldn’t pay drank stream water, resulting in an epidemic of cholera that killed 180 and infected 80,000.
     During the Gulf War and the sanctions that followed, the US intentionally destroyed Iraq’s water treatment facilities and blocked the importation of required equipment, knowing it could lead to cholera. As intelligence documents explain: “failing to secure supplies will result in a shortage of pure drinking water for much of the population. This could lead to increased incidences, if not epidemics, of disease…unless the water is purified with chlorine, epidemics of such diseases as cholera, hepatitis, and typhoid could occur.”
     While Bush junior was sounding the alarm on Iraq’s supposed “weapons of mass destruction”, he was maintaining sanctions that spread cholera in Iraq, while cutting funding to water treatment in Haiti. Before joining Canada to overthrow the democratically elected Aristide, Bush waged an economic war that included cutting funding for water sanitation—including to the Artibonite region currently affected by cholera. As Partners in Health explain:

“In 2000, a set of loans from the Inter American Development Bank to the government of Haiti for water, sanitation and health were blocked for political reasons. The city of St. Marc (population 220,000) and region of the lower Artibonite (population 600,000) were among the areas slated for upgrading of the public water supply. This project was delayed more than a decade and has not yet been completed. We believe secure and free access to clean water is a basic human right that should be delivered through the public sector and that the international community’s failure to assist the government of Haiti in developing a safe water supply has been violation of this basic right.” 

WATER, DEMOCRACY, AND REPARATIONS
     Humans are made up mainly of water, making access to water our most basic and life-sustaining right. That 100,000 people around the world continue to die of cholera, 150 years after its prevention was discovered, is a clear indication that people’s most basic rights are being ignored. According to Dr. Lyon from Partners in Health:

“70% of the population have no access to clean water or sanitation. People cannot protect themselves. So the country is terrified at this point. It’s a terrifying situation rooted in the lack of infrastructure, lack of sanitation and clean water, which has been very clearly slowed down by manipulation from the outside…cholera will not go away in Haiti until the conditions that make people vulnerable are changed”.

In Haiti, the fight against cholera is part of the fight for democracy--which includes the right to water, the right to their democratically-elected president Aristide instead of an unwanted UN occupation,  and the right to reparations for $21 billion taken as punishment for a slave revolution that should be celebrated.