When we say that people come first, which sets of people are we talking about? Is the project of eradication really top-down, singular and hegemonic? What about counter-models for thinking about malaria? In Southeast Asia, for example, can you really separate malaria from dengue or other diseases? What about the counter-model of Partners in Health (PIH), of building health system capacity from the ground up (using disease as an emergency vehicle to build capacity in the public sector)? Also, what are the difficulties involved in developing and rolling out a vaccine? In India, the technology is available, but patent rights and scaling up from small amounts to large amounts has been a real problem. I see this as analogous to the PIH example – there are so many concrete steps involved in negotiating what has to be attended to in the scale up.

Just to confirm your angle on what has happened with the Tropical Disease Research (TDR) program at the World Health Organization—it was innovative and led the field when it started, but has been overwhelmed in recent years by other players such as the Gates Foundation. The Gates Foundation seemed to think TDR, like the rest of WHO, was too bureaucratic, too slow moving. Other well-funded actors wanted a product (a magic bullet), whereas TDR was still committed to developing research capacity as well as doing the research itself. TDR has been left with research capacity, the “soft side” so to speak, while other organizations with little commitment to capacity building in the developing world, have taken the limelight in product development.

Indeed, which people do we have in mind? In Nepal, activists lamented the fact that malaria was eradicated because as a direct result the lowland became accessible to upper-caste people.  The forests became cultivatable and rice production took off. But the original inhabitants are not the ones making a living from it. With this model of eradication, how might inequalities increase or alter?

Malaria isn’t a good thing, but perhaps it limits a kind of global exploitation. Moreover, once it’s gone, how does nature protect people? What about land grabbing in the Third World for modern agricultural security, and how does malaria eradication fit into this?

An important goal of malaria eradication was demonstrating the potency of public health. Its failure caused a loss of faith in public health. How is public health recouping power for itself?

Yes, as you mentioned, there is a chaos in global health, who is in command and who sets the priorities, but there is new power in the Gates Foundation. And there is a general unwillingness to criticize them (on the record) and to push back on their technology-centered approach.  New vaccines and scientific breakthroughs hold promise, but technology and nature also interact in ways we do not predict. Global warming, for example, is expanding the zones in which malaria is being seen. What technology do we have to deal with this?

I am also not optimistic about a vaccine. It’s always five years out. There are four species of malaria and complicated genetics. Ten years ago, there was little confidence in bed nets, a worry that it would delay the onset of partial immunity to malaria in kids. DDT was also bitterly contested and the World Wildlife Fund was in the middle of huge arguments about whether to prioritize the environment or kids. There was even a scandal over the tobacco industry’s funding for organizations that were criticizing the WHO and pushing for DDT. How to get at the corporate interests in the choice of technology?

Today it’s big pharma. In the last ten years, charities and philanthropic organizations have been financing drugs in partnership with the pharmaceutical industry that the industry itself considers non-money-makers.  A case in point is the alliance of Medecins Sans Frontieres (MSF) with the industry to develop drugs for neglected diseases in the Third World. Isn’t the optimism about a malaria vaccine further legitimating this new kind of pharmaceutical humanitarian discourse?

We have been close to the vaccine for twenty years. But twenty years ago, the main model was primary healthcare and integration of malaria efforts within this model, which meant not prevention, but treatment. What’s happened to this model? Has the old model of treatment through primary health care simply been abandoned?  Also, what you say about humanitarianism being dominant in malaria eradication in the50s and less so now seems counterintuitive. How do you define humanitarianism then and now?

Yes, I need to refine my notion of humanitarianism and highlight differences in its usage in the 1950s and today. I need to look further into which kind of humanitarian discourses and practices are tying these issues together in the present campaigns against malaria.  There was a point in the 1950s when the word humanitarianism was being used by politicians, the State Department, and international health leaders to link the arguments about technology’s importance to top-down programs.  They talked about the possibility of disease control and specific health advances without broader public health improvements. These alliances argued that achieving eradication would bring physical and mental health benefits, but also something else. Eradication had to be construed as something that would increase the economic productivity of the world, promote western-style modernization of poor countries, and serve “peace”–a code word of the Cold War.  These were the humanitarian rationales of the 1950s. I believe they are less salient now, perhaps because malaria is not necessarily as much of a priority. In any case the use of children is particularly prevalent now in campaigns.

Today, there is belief that the biomedical side of health and disease are more important than social conditions and processes, like clean water, housing conditions, and behavior.  The parasite is the real problem now, addressed by quick technological fixes. Little attention is paid to social and institutional factors like the state of the health care system. Disease is believed to cause poverty, not the other way around.

The promise of the holistic primary healthcare approach has remained on the drawing board. What was implemented instead was selective primary health care, or a narrower version of the program approved at Alma Ata in 1978.  The fact is that in the 1980s, it was never perceived by most of the major agencies as a feasible goal.

In the case of malaria, it is difficult to find alternatives to the top-down approach. Perhaps it is easier for TB or HIV/AIDS.

There are critics, and they can be found inside the major international agencies or inside national health organizations. But there is no counter-discourse gaining traction. For me, the main issue is not eradication, but whether health systems are robust and flexible. This leads me to the question: is there flexibility in global health?

Two methodological points: How can one do a project like this? How do you grapple with the sheer amount of material out there and number of different perspectives? How do you deal with the ‘off the record’ nature of global health politics?

Malaria rates are declining in East Africa, but we don’t know why. It’s so complex a disease.  Incidence of morbidity and mortality have all been going down for a number of years now, and I have seen articles saying that there has been a very large decline in Zambia, but no one seems to know exactly why. The bed nets and the combination therapy came after the decline, so we’re not sure why the decline. Students of mine have said that the nets were not really getting to people. Yet, there are reports from the Gates Foundation that claim complete credit for it. Interventions and changes in disease happen, and then they are open to interpretation.

It is important to think about the ideas and measures that justify the vertical approach. In the early 1990s, when the World Bank released its report “Investing in Health” that was when the criteria of cost-effectiveness was put out there with the DALYs (Disability-adjusted life years). Now there is a lot out there about more diagonal approaches. What about them? The Gates Foundation is notorious for being opaque.

Is the return to verticality an act of nostalgia? I wonder if it is nostalgia for a time when it was so much easier to consider disease control in a streamlined way. But this isn’t the same verticality. The Gates Foundation can articulate a better version of the vertical dream than the WHO, which had begun to move towards other models, models coming from places like China, (barefoot doctors, etc.), but there was still a persistence of vertical programs all throughout the 1970s, 80s and 90s. What has happened with those organizations?