Interview: Dr Kundai Manamere

Dr Kundai Manamere is a medical historian at the University of the Free State, South Africa. She recently presented her research on the Roll Back Malaria Programme in Southeastern Zimbabwe at the African History Research Seminar of the University of Basel. Here, she argued for the inclusion of local perspectives and voices in the formulation of global public health policies and interventions. We asked her to tell us more:

Please start by telling us about the Roll Back Malaria Programme and how this fits into your research?

KM: The Roll Back Malaria (RBM) programme was initiated in 1998 by the World Health Organisation and other global health partners with the aim of reversing the global resurgence of malaria, particularly in Sub-Saharan Africa. It had the ambitious goal of reducing the global burden of malaria to 50 percent by 2010 and 75 percent by 2015 through the adoption of ‘new approaches’ to malaria control that would overcome the problems encountered by earlier efforts and particularly by the WHO’s ill-fated Global Malaria Eradication Programme (GMEP) of the 1950s and 1960s. As a medical historian, who is deeply interested in the historical relationship between public health interventions and livelihoods in Southern Africa in general, and the ways in which Africans perceive, narrate and understand public health interventions in particular, the RBM programme is of particular importance to my research.

What is the value of taking a historical approach to public health interventions such as the RBM?

KM: The RBM programme is part of a long history of malaria interventions in Africa. Malaria is an enduring disease. Over a century after its discovery, the disease has remained impervious to eradication. Although its incidence has been drastically reduced in many countries, efforts to curb it have registered limited success. Therefore, histories of past interventions are crucial in informing current understanding of the disease, its distribution, as well as control and elimination efforts. Historical approaches to public health interventions such as RBM help us to reflect on the strengths and weakness of the methods employed. There is a need to understand the impact of efforts to control disease and the ways in which interventions have transformed patterns of disease and influenced disease transmission over time. 

Why did you choose to focus on the experiences of communities subject to malaria control, and how did you go about investigating this historically and in the present?

KM: Existing studies on malaria and malaria control consistently reflect the views of scientists, governments, and international organisations. We do not know about the experiences of the human subjects of malaria interventions, whose health the programmes aim to improve. Current local understanding of public health remain characterised by a mixture of resistance and cooperation, and I believe it is crucial to know what subjects of malaria think about the problems that are being dealt with, in order to curb non-cooperation in malaria programmes. I investigate rural and sugar-farming communities’ experiences with malaria control in Zimbabwe’s southeast lowveld from the early twentieth century to the present through archival research and oral histories. I have recovered subjects’ voices from diaries, letters, minutes, memorandums, novels, opinion pieces and editorials in newspapers. Oral interviews also reveal experiences, emotions and opinions, from which I derive public understandings, perceptions and attitudes to intervention programmes.

What were your most important findings in this regard?

KM: Public health officials in Zimbabwe have consistently viewed some subjects of malaria control as ignorant and non-cooperative. From the early 1920s, colonial public health reports are replete with complaints by officials who labelled white farmers, miners, prospectors and Africans in rural areas as ignorant for failing to apply malaria control strategies. Contemporary reports cite low levels of community involvement and cooperation in malaria programmes as a threat to the sustainability of the gains attained to date. Yet, while some subjects understood and accepted biomedical interventions, others, as Randall Packard argues, viewed them as an intrusion into their lives. Others viewed interventions as pointless, some were indifferent about them, yet others thought they were necessary but not an immediate priority. These responses and perceptions reflected these people’s needs and priorities and affected the effective implementation of malaria control. My research reveals reduced cooperation among Zimbabwean lowveld rural communities from the colonial period to present, which indicates not only a decreasing faith in the effectiveness of insecticides particularly, but also an indirect resistance to the scientifically conceived and externally implemented control measures, the rationality of which is questioned in their personal experiences.  Knowledge of causes and preventive measures of malaria is good, showing the dominance of biomedicine in rural areas. But, on the whole, while the dominant scientific views on malaria have influenced the rural conception of the disease, locals only selectively conform to the intervention program as it suits their immediate concerns.

You argue that global health debates should pay more attention to the voices on the ground. How would an understanding of local experiences and interests change the identification of public health issues and the implementation and assessment of existing interventions?

KM: One of the major challenges confronting the global health community at present is the need to find a balance between health and livelihoods in the absence of vaccines. I believe current intervention approaches to re-emerging and emerging infectious diseases require increased public acceptance of and compliance with measures to contain transmission and the progression of illnesses. This calls for increased community engagement and human-oriented research to understand local epidemiology in situ and tailor-making universal solutions to public health challenges, to suit local contexts. I believe that subjects’ perspectives need to be accommodated and inform malaria control strategies with a particular focus on local contexts.

My work places people at the centre of analysis and uses localised case studies to understand variations in what subjects of interventions think about malaria as a problem, their priorities and the success of interventions. This approach narrows the geographical range of malaria epidemiology by looking at a particular area and, in so doing, creates space for the perspectives of the subjects of control, which have been missing in global health histories. Widening the scope of perspectives and considering how target populations frame malaria interventions allows us to question the effectiveness of intervention methods and the progress made in controlling the disease. It fills a knowledge gap within the global narrative, where the assessment of progress made in control efforts is analysed and quantified through statistics and not qualified through people’s experiences and perspectives. There is need to complement biomedical statistics with the views of target communities on malaria and malaria control.

Where can we find out more about your research?

KM: Be on the lookout for my forthcoming book: I am currently writing my first monograph on the history of malaria control in the Zimbabwean lowveld, under contract with Ohio University Press’ Perspectives on Global Health series. The book is provisionally entitled Moving Subjects: Mobility and Malaria Programmes in Zimbabwe’s Southeast Lowveld. In this book I draw connections between malaria epidemiology and human mobility resulting from large and small scale farming, fishing, labour migration, as well as colonial displacement and war, to argue for a complementary understanding of the human contexts in which malaria occurs and in which biomedical advances have to be applied. You can also visit the University of the Free State, International Studies Group webpage and ResearchGate for more about my research.