Elimination at Work: Towards an Anthropology of Trachoma in Malawi

The concept of elimination continues to shape many global health policies for infectious diseases. Trachoma, the leading infectious cause of global blindness is no exception. The WHO’s Global Elimination of Trachoma by 2020 policy, foregrounds ‘SAFE’ - Surgery, Antibiotics, Facial cleanliness and Environmental improvement – a public health strategy celebrated for its perceived holism. In common with other strategies for neglected tropical diseases, it is touted as one of the more convincing ways to ‘make poverty history’. Despite these bold claims, there is insufficient research documenting how SAFE works in practice. Multi-sited ethnographic fieldwork in Malawi with strategy implementers, policymakers, health care workers, and a Yao village population, reveals mistaken assumptions embedded in SAFE: it has been designed to intervene at discrete stages along a narrow biomedical understanding of trachoma pathology, with little attention to the social, political, economic, and historical issues shaping delivery. Consequently, biomedical assumptions of universal disease experience, discrete, linear pathological processes, and rational human responses are made. The thesis focuses on two dimensions of the elimination programme: diagnostics and surgical camps; and demonstrates how on-going social, political and ophthalmological complexities are persistently set aside in pursuit of the elimination goals. Tools, technologies, and metaphors do political work which is strategically ignored by the multi-million-pound global elimination assemblage. The SAFE strategy undermines the effectiveness of the existing health system, and resistance to interventions is explained by projecting ignorance and pathologising culture. Pressure to sustain international funding by preserving the reputation of the policy drives a steadfast but false optimism, counterproductive for tackling other important health concerns in Malawi. In light of these findings, this thesis calls for a more humble, and ‘slow’ public health practice for trachoma and beyond. Such modesty could help shape public health to not only be more responsive to context and complexity, but also locally meaningful and sustainable.