The historian Randall Packard gave an interesting talk at Swarthmore last week about the history of malaria eradication. Like many historians, he ends up with a skeptical view of contemporary projects and plans. As he sees it, current attempts to eradicate malaria at the present time are making some of the same strategic mistakes that a post-1945 global campaign to eradicate malaria made. Packard wasn’t arguing that there should be no major global effort against malaria, but instead contended that what we should be aiming towards is a zero mortality campaign focused on pregnant women, infants and children.
I liked the talk and agreed with the argument. I got a bit fixated on one point, far more fixated than Packard does: the contrast between the local context of bed net usage and the technocratic, distant language used about bed net usage in top-level malaria control discourse like the Global Malaria Action Plan. That plan notes very briefly that there are challenges with “end-user compliance”, but not to worry: there’s a place in the plan for coordinated use of communication and behavior change methodologies.
Some of the arguments going back and forth between Jeffrey Sachs and Dambisa Moyo about bed nets are screwed up, partly because Moyo takes a lot of the current critique of development aid from Easterly, Calderisi and other authors and takes away a lot of the complexity and texture of that work. Moyo is convinced that the problem with giving bed nets away is that you put African bed net producers out of business, which really misses the point. I also think the “give bed nets away or sell them” argument isn’t a meaningful or helpful argument about bed net usage in Africa or elsewhere, it’s an argument about an orthodoxy in economics.
Sachs, on the other hand, is pretty much stuck in the same place that the GMAP is when it comes to figuring out why people don’t use bed nets: his perspective is too removed, too far from the actual situations of people who are or are not using bed nets. He knows they should do it, and if they aren’t doing what they should do, then just do some education or something.
Language like “end user compliance” wards off the lived reality of human life like a garlic wards off a vampire. Big plans and sweeping frameworks subcontract out the problem of the local and particular to some yet-to-be-named partner organization who will be charged with dealing with end user compliance in a sensitive, community-engaged, bottom-up, gender-attentive, ethnographically nuanced manner. That way, when the news filters up that end user compliance doesn’t meet expectations, you can just imagine that you haven’t met the right partner organizations yet or that the methodology for securing compliance needs some tweaking. You didn’t get enough medical anthropologists. The medical anthropologists weren’t properly integrated into the plan. Something like that.
The big plan never has to trouble itself with understanding the scene of everyday life or meeting the end users as human beings living in particular places. The big plan doesn’t have to bring what a smart medical anthropologist might tell it about why people use or don’t use bed nets into the language or thinking of the big plan. That’s the subcontractor’s problem. But it’s on these questions that big plans of all kinds stand or fall, and they can only be thought and engaged properly in their own terms, not in bloodlessly technocratic language.
You have to be able think at the top level, in the big plan, about local ideas about illness and local ideas about sleep, local arrangements of household space, local furnishings, local material conditions. And understand that these things vary.
The top planners have to understand that in historic terms, it’s perfectly sensible to mistrust development organizations in many parts of the world. Sometimes they have had actively bad ideas that caused damage to local communities and sometimes even when they have had good ideas, they only pursued them for a short while until they got bored or distracted or there was a new fad or a change in political administrations or the money dried up. Then the people who really bought into the good idea were left holding the sack.
The top planners have to get away from data that shows that bed net usage has a huge impact on malaria transmission to understand that sleeping under a bed net can be uncomfortable and annoying. That many adults who’ve had malaria tend to treat the disease the way we treat the flu: annoying, frustrating, a bit scary, but tolerable. It’s not hard to wash your hands and use hand sanitizer regularly, and those cut transmission of the flu. But for a lot of people, the minor hassle of regular hand sanitizing isn’t quite worth whatever percentage fewer times you’d have a cold or flu.
Every public health campaign that starts from the premise that there’s a simple and rational preventive behavior change that people of course should adopt is setting itself up for failure, because it’s not thinking clearly about how most human beings in general inhabit the landscape of habit and convenience and risk-calculation, let alone local cultural framings of those same things. Public health campaigns sort of start by taking educated professional white Americans and their particular cluster of common attitudes and cultural postures as the norm and everything else as uncompliant end usage or uneducated deviance. Among other things, if you want to convince people to better safeguard their own health and the health of other people around them, you’d better back up a bit and find out whether they care much about their own health and the health of other people around them. That’s not a universal, and not caring doesn’t make someone a monster or a sociopath. If I lived in a world that was full of political disorder, economic failure, endemic violence, if planning for the future was a sick joke, I might find it faintly ridiculous when some well-meaning person kept telling me how important it was to sleep under a bed net.
If you’re planning for action, well, this is what action really is all about. Anybody can make a comprehensive ten-point plan that neatly subdivides the messiness of lived experience into dry subheadings while keeping an antiseptic distance from that messiness.