An interview by Caroline Jones
You’ve spent the last 25 years working as a medical anthropologist. Can you talk a little bit about how medical anthropology is applied in the fight against malaria?
Medical anthropology helps us gain a better understanding of the contexts within which malaria occurs and the factors that contribute to its persistence. For example, if you think about malaria from a clinician’s perspective, you tend to focus on the disease and the specific preventive or treatment actions an individual needs to take.
From the perspective of a medical anthropologist, malaria is just of one of the many things people have to think about and cope with in their daily life. A person may know when they need to seek malaria treatment, but there are many factors that determine whether or not the person will actually be able to get treatment. The road to the clinic might be flooded. Or maybe the person doesn’t have money to go to the clinic, or they can’t leave because their crops need to be brought in. Or they might know that the clinic might be out of drugs or diagnostic tests.
The key point here is that malaria does not exist in a vacuum. Medical anthropology looks at all of the different factors that influence malaria transmission and why people do what they do. Rather than focusing just on curing an individual, we seek to understand the broader contextual and structural issues that can help or hinder health-seeking behaviour.
What is an area where this approach has the potential to make the biggest impact
Understanding the strength of country health systems and the level of political will to provide access to high quality preventive and treatment services is key. If health facilities are closed due to staff shortages, or patients are left untreated or undiagnosed due to stock-outs of drugs and rapid diagnostic tests, then health education programmes or new malaria treatments are unlikely to impact on treatment seeking or malaria.
Intermittent preventive treatment in pregnancy (IPTp) is one example. WHO recommends that for women living in areas with a high risk of malaria, IPTp is administered at least 3 times during pregnancy, starting after the first trimester. Accurately dating pregnancy can be difficult without ultrasound and nurses may be reluctant to provide services unless they are certain the woman is beyond the first trimester.
IPTp is only one of many services provided at antenatal clinics and a lack of staff may lead to some services being overlooked; sometimes the recommended medicine (sulfadoxine-pyrimethamine) is simply not available. Admitting you are pregnant can be challenging in some countries resulting in delays in accessing antenatal services; these delays are often compounded by financial and structural barriers to accessing health facilities. Identifying and addressing all of these challenges requires a multidisciplinary approach, and that’s where anthropology comes in. I think the discussion always comes back to the relationship between the public and the health system. When you have a good system, you have good malaria control.
How effective has the malaria community been in approaching the disease from this perspective?
I think the malaria field is starting to recognize the need for this type of perspective. We’ve evolved from thinking about new tools and technologies as a silver bullet for fighting disease, to a broader understanding of what it actually takes for these tools and technologies to be successfully implemented. There’s a better understanding of the role health systems play and a greater emphasis on the need for health systems strengthening.
We’re also seeing more funders acknowledge this approach. For example, a call for proposals for a new vaccine will also request a strategy for how that vaccine will be implemented and how it will fit in with existing EPI1 programmes. Twenty years ago, no one was thinking about things like that. So it’s a step in the right direction.
What has been your experience as a woman in the science field, starting out for the first time?
Well, as an anthropologist, you’re already viewed as a bit of an outlier – perhaps as useful as someone who does underwater knitting (laughs). But in terms of gender, I would say that it was never really an obstacle for me, though there were certainly far fewer women in the field at that time than there are now. I remember attending the first Southern Africa Malaria Conference in Maputo in 1997. The meeting was predominantly men, and so I and a few other female attendees decided to set up a buddy group. We called ourselves SAM, short for Sisters Against Malaria, and we’ve met at every Multilateral Initiative on Malaria (MIM) conference since then.
It’s been a great space for us to meet over the years – and drink cocktails (laughs again). But things have really changed since we first formed our group. Now when you go to the conferences, there are a huge number of women, with more women scientists, project leads and technical staff. It’s really great to see.
How has the application of social sciences in global health evolved since you first began your career?
Working as a social scientist in public health can be tough. It can often feel as if you’re stuck in the middle between traditional anthropology and hard biomedical research. It can be a fine line, and it does take some time to learn how to walk it and be effective. But I love what I do. It’s incredibly interesting and challenging. You have to be really interested in others’ views and perspectives, and able to listen to and work with all sorts of different people. I think that the more that programmes use social scientists in their work, the more pleasantly surprised they are when they discover what they learn and how useful this approach can be.