Is eliminating malaria hopeless?

The real way to get rid of malaria is to reverse the dynamics of rural-to-urban migration and build comfortable, stable rural communities first—something that is probably never going to happen in Africa—and then to attack the disease. The key way the disease is spread is by infecting people without resistance. Rural to urban migration, the kind that dominates in Africa today, promotes the spread of the disease.

…In this sense, Jeffrey Sachs and the Gates Foundation are working against themselves, by pushing development and fighting malaria at the same time.

That is James Pogue writing in Guernica. The tagline for the piece is “Ending malaria in Africa any time soon is nearly hopeless. And in trying, Jeffrey Sachs and Bill Gates may be doing more harm than good.”

Skeptical though I am of massive, idealistic, cash-driven interventions, I have to hope that policymakers regard Pogue’s article skeptically.

First, if there’s one success Big Aid can claim in the 20th century, it’s disease eradication. Western donors and African governments may be crap at generating jobs, but man did they wipe out some persistent sickness.

I’ve just come from Vietnam and Thailand where malaria has not disappeared, but ceased to be a major concern (unless you live astride the border with Burma or Laos). To the public health specialists out there: is this so? And is the goal really so much more elusive in Africa?

Ultimately, what other cure to malaria is there other than development? To run effective eradication campaigns, governments must be staffed with well-educated bureaucrats and backed by stable tax revenues. People must be able to afford treatments and preventions. And citizens and businesses must hold the government accountable for providing this public good. Few of these factors arrive without economic development, and most are going to be tied to population movements away from agriculture.

Governments and businesses across the continent are already taking action. Many capital cities have lower transmission rates in part because they drain swamps. Rural home spraying is increasingly common. Some mines and other private businesses have eradicated malaria in their environs.

I’m all for pursuing scientific advances, but for Africa to sit in poverty and wait for a cure to be discovered sounds like madness.

Pogue’s parting paragraphs suggests even the cure may be overblown, and that malaria isn’t much concern (indeed it’s a source of pride):

For some Africans, resistance to malaria is literally in their blood; for many of the rest, they’ve earned their immunity, without drugs, and without asking for Western help. Guys like me, only there to profit off what’s under the ground, ought to be able to handle a couple weeks of fever.

More than one friend or coworker in Africa has lost a child to malaria. I cannot imagine anything more emotionally painful or antithetical to “development”. There’s very little here to be proud of.

12 Responses

  1. Thanks Chris for starting this conversation. I often wonder whether articles by people like Pogue are having a positive or negative impact on efforts to increase public awareness/knowledge of malaria. Pogue clearly knows very little about the epidemiology of malaria. If I have an aneurysm does that make me a brain surgeon? Perhaps if I write about my aneurysm experience with some funny jokes I can publish my story and, while I’m at it, make some sweeping statements about how I think the field of brain surgery needs to change. Malaria is a complex problem. The Pogue piece includes some statements that are totally not true (his generalization of the characteristics of breeding sites, rural to urban migration). Only 1 disease that affects people has ever been eradicated – smallpox. That’s it. There’s no magic bullet to eradicating malaria. Eradication and elimination do not mean the same thing (see wikipedia). Yes, development is important for many reasons. It often enables families to increase the quality of their housing (which prevents malaria vectors from entering) and increase their access to prompt / adequate care. Malaria vectors do not only breed in swamps. Indeed, in many parts of sub-Saharan Africa the most productive breeding sites are NOT swamps. Just because there were swamps in the US / Europe that were productive for malaria vectors doesn’t mean that the problem has to have exactly the same characteristics in all of Africa. The impact of interventions/development in suppressing malaria will vary greatly over space and time. The same factors that led to malaria being suppressed in Vietnam/Thailand will not have the impact in most of sub-Saharan Africa (due primarily to differences in the malaria vectors in each region). If the interventions are applied with a much greater intensity, they may achieve a similar impact over the short term (ignoring the role of development factors for a moment).

  2. There’s one effective way to get rid of malaria : Drain swamps. But not just swamps, get rid of all stagnant waters. You must rigorous and systematic.
    That’s the way every country until now made it. Do you know malaria was rampant in the US in the earliy 20th century with 6 millions cases a year ? That is was not fully eradicted from Europe until 1975 ?
    I think this page is really interesting http://www.malariasite.com/malaria/history_control.htm especially the part about how giving up allowed malaria to come back massively in the 80’s.

  3. Pogue got it all wrong. Development itself will help stop the spread of malaria. Initially there will be an increase in cases of it but over time the numbers will fall. Yes, progression is a western idea but with progress comes knowledge. I agree with Blattman that stop development would be hopeless to malaria. We ought to be proactive and be held accountable for the needs of our world and right now one issue is overcoming malaria. Sitting back and letting Africa disintegrate because we’re scared of catching this disease is not okay.

  4. On the issue of rural to urban migration in Africa, I would draw your attention to some recent work by Deborah Potts, including her new book “Circular migration in Zimbabwe and Contemporary sub-Saharan Africa”, (which I haven’t read but I’ve seen her present her evidence). Her research challenges the strongly held belief that migration is unidirectional (rural to urban) in most countries; instead, she shows that the rate of urbanization and its character is much more complex (and as the title suggests) circular, as well as much slower or negative in some cases.

  5. “What other cure is there to malaria other than development?” I completely agree with your critique of Pogues article. His claim that some Africans actually look fondly upon a disease is outrageous. While maybe resistance is a source of pride to some, I can’t imagine those with dead children are too fond of the disease. Seems like a cruel game to me. The best way to eradicate malaria is by increasing the infrastructure of countries. In that, funding to provide medicine and care for those infected. I don’t think preventing the presence of malaria is possible as there have been recent outbreaks even in South Florida. But to have treatment readily available. And with that rations and educations so that they can recover completely and the medicine can do their job. I’m curious about Pogue’s validity in his thesis, as his research and approach seems to be flawed and coming from left field.

  6. Pogues attitude is infuriating.
    During my short stint living in very rural Africa (as a Peace Corps Volunteer in Mali) I saw plenty of death and suffering due to Malaria. Yes, some adults are proud (and relieved) that they have developed a resistance to the disease, but they are just as traumatized when their children, spouses and friends are sickenend and/or die from it. Rural communities are by no means safe havens from malaria. I can’t imagine what made Pogue assume they are.
    His statement that “some” Africans look “fondly” on the disease is clearly B.S. (and that’s why it’s an unnamed source).

  7. One more thing, and then I’ll disabuse your comments section of my ranting:

    I find the term “white man’s burden” shallow, tasteless, and offensive. I got into development because I was interested in economics but struggled to find any sub-discipline more interesting and meaningful than development (see https://chrisblattman.com/2010/08/06/is-aid-depressing/). Unlike David Livingstone and other 19th century racial-imperialists, my race had absolutely nothing to do with it. I’ll also note that plenty of Pogue’s “white men” are in fact black, brown, and Asian women. How does he explain their involvement? When will we retire this ugly phrase?

  8. Excellent critique of the article.

    @Schenck: “Polio prevents bicycle accidents.” Brilliant!

    One issue: what can an individual and society do about sensationalist views that we disagree with? Engage them? Or just ignore them? I don’t know if there’s a right answer, and something like Wikipedia might be the best we can do . But it’s tough to read about these things, whether it’s privileged and abusive parenting (Chua) or just short-sighted cruelty (Pogue here).

  9. Pogue’s piece is just silly. “Might malaria be a symptom rather than a cause of poverty?” Might it be both?

    “Might the billions of dollars spent fighting malaria by Western organizations like the Bill and Melinda Gates Foundation be, at best, another example of misspent Western dollars and misplaced Western hopes…” Um, what? At best, might people be alive and well today who otherwise would be stone-cold dead in the ground? He does know the word “best” is a superlative, right?

    “…the relationship between Africans and malaria seemed downright symbiotic. Malaria killed many children and some pregnant women, but it rarely killed other adults.” This belongs on Wronging Rights’ WTF Friday. I get the point about malaria keeping the Portuguese at arms length, but so what? This point is useless today. Are the Sachs’ and Gates’ of the world as bad as the Portuguese (actually Pogue compares them to Mussolini, but…)

    “Knowing this history, some Africans actually look fondly upon a disease westerners think of as a scourge.” Yeah. And some Africans don’t.

    “The problem Bill Gates and Jeffrey Sachs face is the white man’s burden in the twenty-first century” I wonder where he got that idea (not!). I also wonder… when American troops were liberating Jews from Nazi death camps, was that the Goy’s burden? Was that neo-imperialism? Does it even matter? (yes, I know there were some Jews, but they were mostly goyim)

    “It isn’t easy to live with malaria,” and how is it to die? “…but those who survive the gauntlet (sic) of a falciparum-infected childhood gain a powerful immunological advantage over others.” Hence the scramble to develop a vaccine, courtesy of the Gates’.

    But wait, “the Gates foundation is particularly invested in developing a malaria vaccine, something Shah notes would probably be too expensive and ineffective to save many lives.” Really. More inexpensive and ineffective than letting everyone come down with malaria. Why didn’t we try that with polio? It’s worth pointing out here that Shah is not an economist, an epidemiologist, a statistician, nor an actuary, but a journalist. I’d love to know how she came to that conclusion.

    “Jeffrey Sachs and the Gates Foundation are working against themselves, by pushing development and fighting malaria at the same time. Development… helps plasmodium… urban-rural migration… [yada-yada]” Doesn’t this contradict the first quote I provided above? He said malaria is a symptom of poverty. Now it’s a symptom of development. Why am I even still reading this?

    Ultimately Pogue’s thesis cries out for its own death. Western interlopers are as persistent as the disease they are trying to eradicate, which is bad for Africans. OK. Develop a vaccine, which after all is a dead or watered-down version of Africans’ favorite virus, give it to African governments, and after a generation or two there won’t be any role left for Western interlopers (vis-a-vis malaria anyway), except in having developed the vaccine. A holocaust will have been quietly defeated, and there won’t be any more reason to feel victimized by the white man’s bednets than I do by my Indian measles vaccine or my laptop made in Japan.

  10. Wow what a horrible peice. This guy thinks malaria is no biggie, because it only infects people with no resistance, and those people are foreigners? The people that have resistance are the people that some how managed to not die when they got it. And its not like malaria gives you fever once in your life and thats it. Depending on the parasite species, it can return years later. Even those that it doesn’t kill as children can have severe brain damage. The author was lucky to get the very treatment he is disdaining, and there’s no certainty that he’s been cured. At least he got to watch DVDs of the Sopranos in his servant attended Air Conditioned house with a pool. And seriously, who goes to do aid work in rural africa, in a house with a POOL, and doesn’t bring any anti-malarial medicine? But I suppose now he has ‘street cred’.
    And Sickle Cell Anemia is hardly a good alternative to draining swamps and lariam et al. Its like saying Polio prevents bicycle accidents.

  12. Nice piece.

    Both Ethiopia and Zanzibar have experienced huge reductions in Malaria recently. Ethiopia may have relatively a stable rural population (I don’t know; certainly I wouldn’t say they looke ‘comfortable’).

    Zanzibar has urbanised immensely over the last forty years or so.

    Pogue’s thesis wouldn’t seem to hold in these places.