In Ghana, both guinea worm and eradication itself are symbols for something. For rural farmers, the guinea worm once signaled social tensions that might be materialized through magic, whereas in health discourses the eradication of parasites has come to symbolize an exorcism of poverty. Guinea worm is a grotesque parasite and captures a policy and media imagination by its visual aesthetic. We talked yesterday about what is visible and not visible in humanitarianism. It seems that guinea worm is now so visible that it was prioritized out of turn. I became interested in the fact that people acquired and valued guinea worm filters, but often didn’t use them, and were even asked to wear the straw filters around their necks in ways that coincidentally mirrored a local type of talismanic necklace worn for protection. I thought the appropriation of these devices into magical systems was reflective of the ways in which “magic bullet” health policy was being deployed. In global health discourse, they are treated as protective objects as well. There is the notion that just by distributing them, health is created.

I want to return to an important ethnographic moment in the paper. After you explain the magical properties of how the filters were used as amulets and hanging on walls, you puzzle over why the “common-sense” usage is not adopted by the villages. Maybe this is a kind of Marshall Sahlins reversal of magical thinking? Why is it that these agencies feel that they have to use secrecy (or show expertise) to distribute these objects? Perhaps it is not exactly secrecy, but a vehicle of authority. This shift from focusing on clean water to focusing on the guinea worm is part of the larger critique that we are all working on.

The conflict between community members and health workers that you look into reminds me of stories of people resisting vaccination campaigns, responding to rumors that vaccines are killing them. Avian flu comes to mind. Locals kept health workers – dressed in biosafety suits – out because they knew that the health workers were going to kill their animals. They defended the village with pitchforks.

On the visible and the invisible: guinea worm was not a priority for many countries initially. Benin, for example, reported 5,000 cases annually, but a survey supported by the Carter Foundation found 500,000. It was initially invisible because it affected the poorest, those with least access to health services.

The idea behind the vertical eradication game was that it was meant to be very short term, a “quick win.” While there was criticism that eradication did not support sustainable health systems, those promoting eradication campaigns countered that what was sustained was the elimination of the disease, or that the knowledge of the strategy of eradication was sustained. When I worked in Togo, the village health workers in one district who worked on surveillance and distributing guinea worm filters announced they had formed a union and were negotiating for formal incorporation into the Ministry, as well as for raincoats, bicycles and notebooks. There was resistance to the idea of a quick, temporary campaign.

Your discussion of magic and meaning nicely troubles much of what has been written in the anthropology of policy. I would suggest extending the idea that biomedicine also posits a magic—like the magic in the magic bullet—to avoid any impression of exoticism. Biomedicine is also a magical approach. Take the randomized controlled trial as an approach to public health. Or the swine flu vaccine, which can be taken as a talisman. Genechips as a way to personal health are talismans.

Yes. By taking the “magic bullet” literally, I mean exactly to draw out the way biomedicine has its own exotic ritual forms and amulet-like objects. For me, this text opens like it might unravel into a sort of dated Anthropology 101 story of “cultural barriers”—which is how these institutions often recount it, local people who believed the guinea worm was caused by witchcraft and needed health education. But by the end of the chapter, the rural people in Ghana who are contesting the intervention turn out to have extremely meaningful insights and grounded concerns, while the health policy officials are also caught in biomedicine’s magical logics and political webs. I tried to let the plot thicken in a very understated way, so the reader can come to this realization along with me. Maybe this narrative arc is also my own movement from a young grad student’s culturalism to something else. But seeing biomedical technologies through the eyes of villagers attributing supernatural meanings to them can help us to denaturalize and reexamine these “magic bullets” in global health, to consider their talismanic qualities seriously and what such properties mean for uptake. Plenty of scholars have critiqued the guinea worm program’s vertical structure, but I saw ethnography as a way of beginning with local people’s own views and critiques of the campaign’s magic bullets, instead of my own.

Still, the promise of technical efficacy in global health campaigns makes it really tragic when the only thing left to a biomedical intervention is its ritual form or talismanic function. There is one image that will always stick with me from Ghana, of a mother scooping water with a ladle through her nylon guinea worm filter and into a clay vessel. Guinea worm had already been eliminated from her village for many years, and all her work was not protecting her family from anything: her children were still at risk for every deadly water-borne pathogen. She told me that the filter was to protect her water from diseases, and I’m sure whoever told her that meant to do good by simplifying the program’s message. But why wasn’t she given a ceramic water filter in the first place? What are the ethics of a technology that outlasts its disease?

Two questions. First, what happens when projects end? This is something real to consider. When a few of us were at a conference in Kenya, a number of people were looking at a massive British project in the Gambia, a massive number of laboratories that have now just become debris (left over from colonial interventions). This is the landscape that people now live in. Second, what goes in and what goes out of an ethnography? Nobody wants to be just a critic, which is agonizing. This is an ethical dilemma of our research, and it relates to why the institutional review board is missing entirely the ethical dilemmas encoded in our work.

It appears that eradication had different meanings for different people: donors, fieldworkers, communities. It would be interesting to analyze how these play out. Second, compliance is a big problem in vertical programs. What did the eradicators do to try to gain the compliance of the people before intervening? Lastly, on the relevance of rumors to demonstrate the gap between health workers and the community. Rumors are so important, particularly as they relate to vertical health campaigns and in societies marked by acute inequalities.

We know how activism can be co-opted and brought in to stand for the work of the state, but I wonder what kind of politics would be necessary for people to effectively take over projects after they end? Before they become ruins, what else could they become? There is an imaginative component here: how to harness it, mobilize it? There are alternative voices throughout Marcos’ book on the history of the eradication of malaria in Mexico, but somehow they fail to critically gel together at that very time. It is the historian who retrieves them. But there is something about the temporality of critical imagination: how could it pragmatically become part of interventions as they are unfolding?

It seems that village health workers made the intervention work through aspects of their personal relationships and through what they saw they were getting out of it. This idea of patronage and clientship might be relevant here. What is being exchanged is more than just guinea worm filters. Those have a life of their own that may actually be productive, outside the life of the project. It might be useful to look more closely at what the people who volunteer get out of this. Some move on to other health projects, some open up drug shops.

Magic, economic insecurity, and the kind of inequality generated by structural adjustment programs. Ghana is one of the poster children of structural adjustment programs for the World Bank. You are doing work in a place devoid of services, lacking government. There is a whole literature on the denial of services, which may or may not relate to guinea worm. There is no public sector to pick up when the program leaves.