Introduction
In February 1966 at the World Health Assembly (WHA), Mihai Ciucă (Romania) and Petr Sergiev (USSR) received the Darling Award for outstanding contributions in malariology, the prestigious distinction in the field granted by the World Health Organization (WHO). This acknowledgement connected interwar and postwar disease control traditions. It signalled a shift in the WHO’s eradication strategy from a unilateral focus on eliminating the disease (vertical approach) to multi-sectoral policies that integrated anti-malaria programmes in national health services (horizontal perspective). The recognition of Eastern European expertise symbolized the WHO’s attempt to salvage a withering global campaign that began in 1955 driven by postwar beliefs in the ability of Western technology and medicine to eliminate disease, bring prosperity to and protect newly independent states from communism.Footnote 1
The ceremony in Geneva acknowledged Eastern Europe’s role in international health designs in the context of decolonization and Cold War. The two malariologists also represented social-economic interpretations of disease articulated by the WHO’s predecessor, the League of Nations Health Organization (LNHO). Ciucă had led Romanian anti-malaria programmes for forty years. Since 1934, he was the deputy director of the Institute for Epidemiology and Microbiology in Bucharest. Between 1927 and 1938, he was the secretary of the LNHO Malaria Commission. Sergiev had coordinated the Soviet campaigns against the affliction since his nomination in 1934 as director of the Institute of Medical Parasitology and Tropical Medicine in Moscow. He too was a former member of the LNHO Malaria Commission.Footnote 2
The two experts’ careers epitomized how the LNHO and the WHO integrated Eastern European malariology in the globalization of medical knowledge through interactions among post-imperial, colonial, socialist and post-colonial conceptions about disease control and eradication. Eastern Europe often falls on the wayside of histories of international organizations, considered marginal to or isolated from transnational exchanges and norm production fostered by such entities.Footnote 3 As this article shows, however, disease control in Eastern Europe was integral to post-imperial nation-building and later socialist construction, and it intertwined with colonial governance, medical patriotism in colonies and self-determination in the Global South. Regional experts exerted crucial agency over the transformation of malaria from an imperial disease that tested European rule over ‘tropical’ peoples into an issue of international health politics and nation-state building. The re-integration of Eastern Europe in histories of the LNHO and the WHO expands the chronology of decolonization by revealing that medical self-governance was inextricably tied to political sovereignty. The relationship between anti-malaria programmes and the emancipation of colonial peoples shows that focusing only on the post-1945 years overlooks the long-term contexts of post-colonial governance. The (neo)colonialism of approaches against malaria after the Second World War and the importance of healthcare in Cold War competition indicate that political independence was not the end point of self-determination.
International organizations were platforms for intersecting temporalities and conceptualizations concerning disease control in Europe’s East, South or East Asia and Africa.Footnote 4 To merge these histories of connectivity and change, the article focuses on experts associated with or employed by the LNHO and the WHO. It examines their trajectories in relation with inter-governmental dynamics within these bodies. By placing Eastern European malariology within global expertise networks from the 1920s to the 1960s, the article explores, along with other contributors in this issue (Disha Jani, Giorgio Potì and Elisabeth Leake), the long history, the unevenness and the plural meanings of decolonization. At the LNHO, East-Central and Southeastern Europeans were carriers of ideas about health self-determination that subverted the organization’s role as a medical clearing house for liberal imperial governance. At the WHO, socialist regimes challenged the organization’s collusion with colonial empires and US hegemony over its agenda. Regional experts were key actors in the rise of a new consensus about the relationship between malaria, national healthcare expansion and post-colonial sovereignty.
Eastern European interconnections with (post)colonial spaces were paradoxical. The region played an important role in decolonizing malariology: its representatives emphasized the urgency of developing national expertise, the embedding of anti-malarial activity in local ecological, social and economic contexts, and showed solidarity with non-European peoples. However, before 1945, they did not overtly challenge imperialism, a reflection of the LNHO’s and Eastern European elites’ ambiguity towards colonial rule. During the Cold War, socialist regimes exported their own ‘culture of development’Footnote 5 to the Global South as they joined decolonizing peoples in condemning Western empires. Eastern Europeans were at the forefront of the WHO’s embrace of a cumulative, integrated approach against malaria, which combined technological solutions with socio-economic conceptualizations of disease and centralized state coordinated epidemiological control. Such practices strengthened post-colonial national healthcare. However, they relied on civilizational hierarchies that assigned the decolonized world to a lower tier due to seemingly unassailable endemic conditions. For socialist malariologists, the failure of eradication in Asia and Africa ultimately indicated that developing countries had yet to attain modern (i.e., European) civilization.
Nevertheless, the trans-regional connections of Eastern European malariology de-centre the global history of disease by emphasizing the agency of regions generally described as marginal in international health politics.Footnote 6 Along with other contributors in the issue (Disha Jani, Giorgio Potì and Elisabeth Leake), I argue against explaining global processes through Western-centric diffusion models.Footnote 7 The article reconsiders the story of the LNHO’s and the WHO’s malaria policies written from a Western, particularly North American perspective, or on the basis of local reactions to Western interventions.Footnote 8 I propose an alternative account about circulations and ideas across multiple cultural, social and political spaces: Eastern Europe, (post)colonial territories and bureaucracies of international organizations. The contribution connects conceptualizations and programmes formulated at the LNHO and the WHO, while situating them in accordance with each organization’s particularities, geopolitical landscapes and ideological conflicts from the 1920s to the 1960s.
To de-centre the global history of malariology and frame it in a historical continuum that rejects the caesura of 1945, the article brings together several research fields: Eastern Europe in interwar health politicsFootnote 9 ; histories of (post)colonial medicineFootnote 10 ; and socialist states’ impact on the WHO and decolonization during the Cold War.Footnote 11 I rely on three types of primary sources: first, LNHO and WHO archives about anti-malaria policies in Eastern Europe and (post)colonial spaces (conference reports, field-mission records and WHA proceedings). Second, the contribution uses Romanian archives (ministry of health documents pertaining to relations with international organizations or developing countries) and publications (newspaper articles and biographical accounts). Romania is the entry point for exploring Eastern European malariology’s global impact because the engagements of the country’s experts reflected regional experiences integrated into trans-regional medical entanglements that altered international disease programmes. The continuity of Romanian personnel at the LNHO and the WHO circumscribes the broader temporal and thematic framework for analysing the region’s role in decolonization. Third, I rely on papers published by and about Soviet malariologists to reflect the USSR’s pivotal role in the globalization of socialist anti-malaria approaches. While the term Eastern Europe was seldom used during the interwar period, I employ it to suggest a common post-imperial experience of trying to overcome ill-health among experts from East-Central and Southeastern Europe, and the Soviet Union that carried over and was re-imagined after 1945. Such long-term framework echoes novel historiographical approaches that explore East-South connections as pathways to re-integrating Eastern Europe into global history. The Cold War was certainly a catalyst for the region’s international visibility and status, but Eastern Europe’s participation in trans-regional interactions pertaining to state-building, anti-imperialism, development, trade, medicine, culture, etc. brings into focus spatial, political, economic and epistemic configurations that underline the diversity of world-making in the twentieth century.Footnote 12
The multi-archival and geographically clustered nature of the sources reflects the plurality of vantage points when examining the relationship between international organizations and disease control as part of state-building, imperial rule, decolonization or socialist regimes going global.Footnote 13 Eastern European experts used their countries’ status as borderland of European health and communist anti-imperialism to engage with (post)colonial spaces and ideas. As malariology became a crucial element in the Cold War competition over modernityFootnote 14 , state socialist representatives allied with medical elites in the Global South to challenge Western hegemony over designs for a world free of disease.
Proto-third worlds and malaria control
The end of the First World War brought about a new framework for the international management of health crises and marked a surge in debates over self-determination. Western observers proclaimed at the time the dawn of ‘counter-colonization’, a process traced back to nineteenth century Latin America, but one that had reached new heights as the Ottoman, Habsburg and Tsarist empires collapsed. The new or reshaped states from Europe’s Eastern margins were precedents for colonial peoples who were denied the right for self-government at the Versailles peace treaties.Footnote 15 Eastern Europe transformed into a showcase for the challenges of post-imperial nation-state building.
The ravages caused by the war in Europe, particularly in the East, triggered epidemics of Spanish flu and typhus that wreaked havoc in recently independent states and revolutionary Russia. Because of these crises, the Council of the League of Nations created in 1921 the Provisional Health Committee, which two years later became ‘permanent’. From 1928, it was transformed into the Health Section (LNHO) and it comprised occasional experts and permanent specialized staff representing various regions of the world. Its chair was Polish bacteriologist Ludwik Rajchman, which testified to the importance of Eastern European expertise for the new international organization. Until 1938 when his directorship ended, Rajchman constructed an agenda that indirectly challenged the colonial status quo. He merged health concerns in Europe with those in Africa and Asia, bringing into international focus medical problems among colonial peoples that previously were solely matters of imperial rule.Footnote 16 Rajchman used the LNHO’s experience in Eastern Europe to create blueprints for state-centred health administration and disease control in independent states (e.g., China) and colonial territories. However, LNHO did not contest the authority of colonial administrations or Western claims of bringing progress to putatively backward peoples. Footnote 17
Eastern Europe’s status of borderland of European health transformed it into testing ground for international policies. Between 1915 and 1919, a malaria epidemic swept the Balkans and continued until the 1930s, worsened by the population exchanges of the Versailles and Lausanne treaties.Footnote 18 In the former Tsarist Empire, civil war and the turmoil that accompanied the establishment of the Soviet Union produced between 1922 and 1923 ‘the greatest malaria epidemic of modern times in Europe’.Footnote 19 Infectious diseases wreaked havoc in Eastern Europe because of severe poverty. Footnote 20 Nation-state building was premised on the development of rural societies through agricultural and public health reforms – an experience that drew the attention of indigenous elites in South and East Asia. As Giorgio Potì remarks in this issue, the League system was an imagined site, acquiring meanings in different world regions that went beyond its creators initial intentions. These re-imaginations brought together spaces and knowledge communities that had mostly been isolated from each other.
The LNHO was not the only international organization involved in Eastern Europe. The Rockefeller Foundation was also present, in parallel with its financial support to the LNHO. The Foundation’s International Health Division granted fellowships to medical experts and funded institutes of hygiene in Czechoslovakia, Poland, Romania, Yugoslavia, Hungary and Bulgaria.Footnote 21 Between 1928 and 1933, it collaborated with the Soviet Union, a programme cut short by Joseph Stalin’s fear of nefarious plots engineered by the USA.Footnote 22 The LNHO established its own fellowships and courses for Eastern European experts. The USSR’s relationship with the League of Nations was tumultuous – it joined in 1934 and was expelled from the organization in 1939, but Soviet medical experts cooperated with the LNHO for most of the interwar period, emulating its recommendations.
The LNHO and Rockefeller Foundation integrated the region in global debates about disease control. Initially, this development was premised on transforming the region into a cordon sanitaire for the West against the Soviet Union: health reforms and internationally minded local experts stabilized the new states. However, the two organizations increasingly prioritized Eastern Europe’s function as a laboratory of disease control and public health (USSR included), linking the structural problems of post-Versailles states with colonial reforms.Footnote 23
In 1924, the LNHO’s secretariat tasked a group of experts (national health officials and/or leading scientists) to assess and coordinate anti-malaria programmes in member states and later in colonial territories. Among the initial fourteen members of this Malaria Commission were Evgeny Martsinovsky (Moscow), Andrija Sfarčić (Belgrade), Ciucă and Ludwik Anigstein (Warsaw) – the rest came from Western Europe and North America. The Commission’s activity consisted of investigatory trips that collected information, offered assistance and issued recommendations about malaria control. Its first trip covered Yugoslavia, Greece, Romania, Bulgaria, USSR and Italy (1924). Drawing on its findings, the Commission articulated a social-economic approach to anti-malaria designs. Rural modernization, drainage, quinine distribution and hygienic education were the main tools against malaria, considered both a medical problem and a social evil.Footnote 24 This interpretation was contested by Rockefeller Foundation experts, who favoured measures against the vector of disease transmission – the mosquito. American malariologist Lewis Hackett argued for the separation between the struggle against the vector and care for the patients. He challenged the Commission’s belief that disease control was decisive for rural development.Footnote 25
The overlapping influence of the LNHO and the Rockefeller Foundation in Eastern Europe made local malariologists value syncretic approaches. In the 1910s, United States experts in the Philippines prioritized technological intervention against mosquitos (i.e., species sanitation) in response to native populations’ putative non-responsiveness to hygienic education. Footnote 26 During the 1920s, the Rockefeller Foundation brought this approach to Yugoslavia (until 1929 the Kingdom of Serbs, Croats and Slovenes), Bulgaria and Albania, with the same colonial rationale of technocratic intervention to counterbalance ‘backward’ locales. However, in Yugoslavia, the Foundation implemented its measures in the context of a state plan for rural medicine designed by the country’s minister of health, Andrija Štampar. Anti-malarial dispensaries, specialized in prevention and treatment, were integrated into the national system: disease control was not solely reliant on anti-mosquito interventions.Footnote 27
Mihai Ciucă’s journal notes from the 1924 mission of the LNHO Commission confirm the syncretic approaches adopted in Eastern Europe. He was impressed with the anti-larvae and anti-mosquito arsenical pulverization in Macedonia, Dalmatia and Bulgaria. He praised the Soviet regime’s registration of infected individuals, legislation on new sites of malaria risk created by public works and sanitary education. Ciucă recommended the integration of malaria control within networks of rural dispensaries, the treatment of the population and research on local mosquitos.Footnote 28 Ciucă insisted on state centralized anti-malaria activities. In 1925, a commission was created in Romania that coordinated disease control expertise (malariologists, hygienists, civil engineers, statisticians, etc.), standardized treatment and trained specialists.Footnote 29 Ciucă appears to have based this idea on his experience in Yugoslavia and the Soviet Union. In the latter case, a Central Malaria Commission was founded in 1921 (with subsidiaries at the republican level), comprising specialists and representatives of multiple ministries.Footnote 30
The second report of the LNHO Commission (1927) reflected the syncretism on the ground in Eastern Europe and insisted on the adaptation of malaria control to local conditions. The Commission contrasted its focus on diversity with Rockefeller Foundation’s emphasis on ‘species sanitation’: ‘in some countries in Eastern Europe with very limited financial resources hardly anything had retarded the effective control of malaria so much as their belief that, because mosquitoes carry malaria, their elimination should be the chief concern and expenditure’.Footnote 31 The Foundation’s measures based on colonial experience had made an impression not just in Romania, Yugoslavia, Bulgaria or Poland, but in the Soviet Union too. However, most Soviet specialists embraced the LNHO report’s insistence on treatment of infected persons as ‘one of the most important measures even from the point of view of prevention’.Footnote 32 The contrast between Eastern European experiences of state-managed cumulative anti-malaria policies and US malariologists’ focus on vector elimination outlasted LNHO debates. After 1945, it became the essential difference between socialist and US visions about eradication.
The Malaria Commission’s focus on treatment and research reflective of local conditions entrenched Eastern Europe’s status of epidemiological showcase for non-European spaces. In Romania, Ciucă founded two malaria therapy centres (1927 and 1935) and the country joined the LNHO programme of testing synthetic drugs.Footnote 33 The other participants were Algeria (administered as an integral part of France), Italy, the British-ruled Malay states and the USSR. The cooperation had significant impact on malaria control in the Soviet Union, where, since 1934, the Bolshevik leadership began a nation-wide programme, coordinated by Sergiev (director of the Institute of Medical Parasitology in Moscow) and formally aimed at the elimination of the disease. One of the synthetic anti-malarials tested in the USSR was akrikhin (an analogue of atebrine, a drug first discovered in 1930 in Germany), which in 1937 was recognized by the LNHO as equal to quinine. Relying on domestic production, the Soviet government was able to treat registered malaria cases and attain autonomy from fluctuations in the international quinine market.Footnote 34 This development reinforced USSR’s image as pioneer in disease control, a position acknowledged in 1943 by the report of the Indian Health Survey and Development Committee, an institution set up by British imperial authorities under pressure from local nationalists. Footnote 35
Eastern Europe also became an example of intensive research of epidemiological environments, a by-product of the conceptualization of malaria control as prerequisite for state and nation building. Throughout the 1930s, Romanian malariologists studied different species of mosquitos and their connection to disease transmission. They linked these activities to population surveys to identify levels of endemic infection.Footnote 36 In Yugoslavia, such practices generated epidemiological borders that supplanted the problematic frontiers among ethnic groups in the struggling federation.Footnote 37 In the USSR, the all-union anti-malaria programme aimed to restore the health of the ‘first workers’ state’ as society was shattered by breakneck industrialization and forced collectivization.Footnote 38 Malariologists were tasked with integrating USSR’s ‘less developed’ lands (especially the Central Asian and Transcaucasian republics) into socialist ‘civilization’ through medical and entomological research, treatment, hygienic education and environmental transformation.Footnote 39
In Eastern Europe, malaria control was integral to the ‘civilizational mission’ of post-imperial states – a precedent for the extension of post-colonial governance within newly independent territories. Entire regions and population groups (the peasantry or ethnic minorities) became subjects of internal colonization through the monitoring and prevention of infectious diseases and public health.Footnote 40 After 1945, this ‘civilizing’ of domestic ‘Souths’ was taken up by socialist regimes (or perfected in the case of the Soviet Union), as they achieved malaria eradication in parallel with balancing developmental inequalities that had long ailed these countries.
Eastern European internal colonizations via epidemiological policies were inspired by medical research developed in the colonial territories of Western empires, an outcome of the region’s integration in LNHO networks. In the mid-1960s, just as socialist malariology received global recognition, Soviet experts created a map of the disease’s prevalence and specificities across the world. The document revealed a surprising long-term influence on Soviet malariology: the ‘malarial map of India’ created in 1924, which the authors qualified as ‘legendary’.Footnote 41 This precursor was designed by Samuel Christophers, the director of India’s Malaria Research Centre (later the Malaria Survey) from 1920 to 1932. The map was part of the British Empire’s use of epidemiology to maximize the economic benefits of colonial rule. It was hailed by the LNHO as a breakthrough in disease control planning.Footnote 42
The emulation of Christophers’ map in Eastern Europe showed that malariologists in the region shared their Western colleagues’ utilitarian approach to disease control premised on economic priorities and labour productivity.Footnote 43 Once the Bolshevik government launched its first five-year plan, it channelled healthcare and epidemiological activities towards social groups deemed essential for the economy.Footnote 44 Similarly, colonial governments focused their anti-malaria measures and research on mines and plantations in Africa or Asia.Footnote 45 Colonial metropoles maintained a cost-effective approach that rejected population-wide programmes of treatment or sanitation.Footnote 46 In contrast, Soviet malariologists transferred knowledge about particular groups or locales into a federation-wide campaign. Across Eastern Europe, the underlying idea behind pilot anti-malaria programmes was their future expansion within comprehensive state-funded healthcare infrastructures. During interwar, it proved impossible because of lack of resources, but these policies entrenched the principle that malaria control was a measuring stick for post-imperial governance. A fundamental ambivalence lingered and carried into state socialism: progressive, emancipatory health agendas co-existed with ‘colonial missions’ within Eastern European states towards the subalterns among their populations (the peasantry or ethnic minorities).Footnote 47
Nevertheless, the LNHO-driven internationalization of disease control from Eastern Europe was rooted in conceptualizations of the human factor that departed from colonial approaches. During the late 1920s, a consensus emerged about the crucial role of population movements in malaria transmission because of the insertion of or exposure to new disease strains. However, imperial experts argued that in ‘tropical’ Africa and Asia, where virtually all individuals were infected, entire populations acquired immunity. This narrative sustained colonial authorities’ or plantation owners’ rejection of quinine prophylaxis or state-funded health measures, arguing that they ‘endangered’ native immunities, often seen in racial terms.Footnote 48
The colonial conceptualization of immunity was endorsed by the LNHO, but Eastern Europeans gave it a social-economic twist reflective of the region’s nation and state-building challenges. Eastern European re-interpretations played into narratives of emancipation and self-help among local medical elites in colonies. In 1929, Ciucă was part of the Malaria Commission delegation to India and issued a report – prefaced by Christophers – that took up the theory of non-immune immigration as a major cause for the spread of malaria. In his account of the trip, Ciucă pathologized the tropics: the Ganges Delta was ‘the world’s largest hotbed of infection’ where human beings existed ‘randomly, always in danger of losing their lives like any beast in the jungle’.Footnote 49 However, as he surveyed over 140 villages and several cities, Ciucă condemned the destitution he witnessed: ‘the situation is infinitely more difficult than in Europe… here, in the rural areas, one must walk for 100–150 km to find a physician…a sanitary network exists only in the cities’.Footnote 50 Ciucă’s observations confirmed Indian physicians’ critique of colonial rule, which they blamed for the poverty and ignorance in the countryside that had made malaria a deadly threat for the nation.Footnote 51 Through the LNHO, Eastern European and indigenous doctors converged on re-purposing narratives of racial immunities into programmes for national renaissance to overcome past and on-going imperial oppression.
Soviet malariology experienced a similar paradox of bridging disease control conceptualizations across the Eurasian space by re-deploying civilizational hierarchies for the fulfilment of progressive ideals. Experts considered that epidemics were connected to patterns of welfare, occupation, class, education, gender and religion among ‘backward peoples’.Footnote 52 In contrast to colonial policies, during the malaria epidemic triggered by industrialization and collectivization Soviet malariologists veered towards centralization and specialization, insisting on the treatment of the disease’s human reservoir.Footnote 53 Since 1935, anti-malaria administration was integrated into the expanding health system – a reform proposed four years earlier by Sergiev.Footnote 54 Soviet physicians’ approach to malaria combined with the policy of ‘friendship of peoples’ (aimed at a pan-Soviet identity by strengthening inter-ethnic cooperation) prevented colonial-type management of ‘natural immunity’.Footnote 55 Nevertheless, the transition of malaria-riddled territories to socialist modernity in the Russian Federative Socialist Republic, Ukraine, Moldova, Transcaucasia or Central Asia was a process of empire-building. Interwar USSR remained an essentially uneven space: disease prevalence and medical administration in Central Asia or other territories deemed ‘backward’ were far worse than in the European core of the federation.Footnote 56
Ciucă’s trip to China, Indochina and Singapore, as LNHO expert, exemplified the emancipatory impact of Eastern European re-conceptualizations about disease control as crucial for state-building and patriotic mobilization. In China, the Nationalist government sought to create with LNHO assistance a centralized health system. During the catastrophic floods of 1931, Ciucă implemented pilot projects designed to establish basic infrastructure for disease control. He coordinated malaria surveys in the Yangzi Valley and advocated the same policies as in Eastern Europe: treatment, prevention, public education, research of mosquitos as well as large-scale drainage and anti-larval work. Footnote 57 He and his Chinese counterpart, Xu Yujie, established the Division of Malariology at the Central Field Health Station (Nanjing).Footnote 58 Ciucă’s activity foreshadowed postwar Eastern European anti-malaria solutions in the post-colonial world: syncretic disease control integrated in state-funded healthcare services as conduit to national emancipation.
The transfer of malariological knowledge from Eastern Europe to Asia was consolidated by Ludwig Rajchman through a specialized course for colonial medical officers. In 1932, in Hanoi and Singapore, Ciucă delivered lectures based on his experience in Europe, China and India. Two years later, the LNHO created in Singapore a malariology programme that epitomized the organization’s focus on local expertise as conduit for self-governance.Footnote 59 By the 1930s, colonial peoples and their institutions in South and Southeast Asia had gained greater autonomy in health administration.Footnote 60 Aligning to this emancipatory trajectory, Ciucă’s sought, during the LNHO course, to provide knowledge embedded in indigenous contexts. He taught about forms of immunity reflective of different malaria parasites, an insight crucial to adjusting treatment to entomological and community conditions. He insisted on affordable medicine for mass use as well as on improved housing, farming and drainage.Footnote 61 The LNHO course offered international knowledge for the benefit of colonial rule, while also fostering local self-governance via disease control. By 1937, there was a significant presence of indigenous specialists within the programme: ‘8 British, 2 Australian, 2 French, 2 Siamese, 2 Japanese, 2 Chinese, 5 Indians, 2 Straits Indians, 2 Straits Chinese Medical Officers, and 1 Chinese lady doctor’.Footnote 62 During the 1960s, the WHO expanded the LNHO’s initiative: as I show later in the article, Asian, Latin American and African fellows travelled to Eastern Europe to learn from the region’s specialists. The ability of both international organizations to train indigenous staff from (post)colonial spaces indicated their ambivalent role in decolonization: they were platforms for the re-imagination of imperial rule, but also subverted it by creating medical personnel and norms crucial for self-determination.
At the end of the 1930s, the LNHO envisaged malaria control as a cluster of methods tested in Eastern Europe that combined social-economic conceptualizations of disease, technological solutions and centralized state intervention. In India, China or Southeast Asia, local physicians used this experience to validate patriotic visions about their peoples’ health renaissance.Footnote 63 As Giorgio Potì and Elisabeth Leake remark in this issue, colonial peoples’ representatives took advantage of the League system’s global ambitions to legitimize claims to sovereignty. At the LNHO, the convergence of malariological experiences in Eastern Europe and colonial spaces subverted the segregation favoured by imperial governments between inescapably endemic ‘tropical’ locales and European spaces where disease could be rolled back.Footnote 64
Postwar alternatives and colonialism
The discovery of DDT’s (dichloro-diphenyl-trichloroethane) remarkable residual action in 1939 and its use in anti-malaria spraying during the Second World War appeared to make the LNHO’s cumulative disease control superfluous. During the mid-1940s, Hackett’s successful insecticide spraying in Sardinia as well as Rockefeller Foundation campaigns of mosquito eradication in Brazil and Egypt coordinated by Fred Soper shifted the balance in favour of insecticide-based, military-style campaigns. These programmes side-lined the principle of anti-malaria programmes paired with social-economic reforms.Footnote 65 DDT had a significant impact in Eastern Europe too. Malariologists and governments scrambled to obtain the apparent ‘magic bullet’, as the region grappled with the destruction inflicted by war.
DDT reinforced the ideological divides that affected international health by the late 1940s being integral to US ascendance as hegemon of the post-1945 world.Footnote 66 It was incorporated into Western visions of development for the (post)colonial world that branded disease control as technical intervention targeting one affliction at a time in minimal contact with local peoples. Despite sharing the West’s faith in the new abilities of medical modernity, Eastern European experts incorporated the diversity of LNHO’s programmes into a socialist epidemiological model that relied on state domination over society. Footnote 67 Malariology became an element of a ‘socialist modernism’ Footnote 68 that argued for decolonization not only as political independence but also as state-guided social, economic and health transformation. The WHO was the arena where this vision of emancipation gained a global audience and challenged Western interventions in the Global South.
In 1946, the UN Economic and Social Council created a Technical Preparatory Committee to draft the WHO’s constitution. The Interim Commission, chaired by Andrija Štampar, the Yugoslav reformer who had been a central figure of interwar international health, bridged the time until the new health organization was operational. There were continuities with the LNHO: some of its personnel were hired at the WHO, while the 1930s vision of health rooted in its social-economic determinants was integrated into the new organization’s constitution.Footnote 69 The prominence of extra-European spaces in the last years of the LNHO continued: the WHO was a project advanced by representatives from Brazil and China.Footnote 70 The LNHO system of epidemiological information and management also laid the groundwork for the WHO’s policies.Footnote 71 However, United States officials were keen to move away from the LNHO’s legacy of social medicine, which they associated with communism. On their part, Soviet and other Eastern European delegates openly advocated for anti-colonial health programmes, condemning the LNHO’s inability to challenge Western empires.
The combination of departure from and continuity with the LNHO characterized the founding of the Nuclear Committee for Malaria, the core for the WHO’s future Malaria Expert Committee. Its membership and conceptualization of disease control reflected US influence: Arnoldo Gabaldón (Venezuela) represented the anti-mosquito programmes inspired by Fred Soper’s eradicationism in Latin AmericaFootnote 72 ; Paul Russell had long served with the Rockefeller Foundation and his views overlapped with Soper’s; and Neil Fairley (Australia) had coordinated anti-malaria campaigns among allied troops in the Middle East and Southwest Pacific. The committee’s secretary was Emilio Pampana from Italy, in recognition of the influential work underway in this country; he was former chair of the LNHO group that prepared the Pan-Asian rural hygiene conference in 1937. Ciucă was included because of his experience as secretary of the LNHO Malaria Commission. Sergiev was supposed to be the Soviet delegate, but he never took up his seat.Footnote 73 Reflecting the technological optimism triggered by DDT and new drugs such as chloroquine, the Nuclear Committee declared at its first session that the WHO ‘faced great opportunities over wide areas for the practical control of one of the world’s greatest afflictions’.Footnote 74
Nevertheless, the WHO was confronted with massive challenges in a tumultuous geopolitical landscape. The tensions between the USA and the Soviet Union were escalating. British, French, Dutch, Belgian and Portuguese governments sought to preserve their empires and considered the WHO a threat to their colonial sovereignty. Once decolonization gripped Asia, the WHO had to respond to the expectations of newly independent countries.Footnote 75 Among Western experts, malariology was a form of technical assistance for development, exportable scientific know-how detached from social-economic reforms.Footnote 76 Eastern European specialists agreed with their Western and post-colonial peers on the link between malaria and development, but envisaged disease control as a component of health emancipation through comprehensive reforms, material aid, personnel training and institution building. Such interpretation emboldened the language of decolonization taking shape at the UN.
Early debates within the Malaria Expert Committee reflected Eastern European advocacy for malaria control connected with political, social and economic anti-colonial emancipation. The body was created in 1948 as the Nuclear Committee expanded to achieve better geographical representation, which meant the co-option of colonial officials. The Committee continued to include Russell, Gabaldón and Ciucă. Gordon Covell, who had served in the British Colonial Office, replaced Fairley. John Field represented British Malaya. Maurice Vaucel joined as director of the French Medical Colonial Service. Bagster Wilson stood for Africa as chair of the British Empire’s malariology unit in East Africa. Reflecting the state of decolonization, Dharmavadani Viswanathan, director of India’s National Malaria Control Program, and Monawar Afridi, who created the Malaria Institute of Pakistan were nominated.Footnote 77
Within the Committee, Ciucă called for a ‘comprehensive plan to assist malarious countries’ that would headline ‘any international plan for agricultural and economic production’. For him, the convergence of health and economic solidarity was vital, otherwise poor countries, regardless of continent, ‘cannot fight the evil by themselves [and] will never be able to eradicate malaria [becoming] a permanent reservoir of infection’.Footnote 78 His proposal was side-lined because it diverged from the dominant approach within the Committee.Footnote 79 Western officials were apprehensive about transforming the organization into a provider of aid with a broad development agenda.Footnote 80 Imperial powers rejected the WHO’s presence in the colonies fearing that it drew attention to their inability to insure local populations’ welfare. This attitude changed by the mid-1950s, after belated colonial reforms unravelled; the WHO became a resource for low-cost disease control that deflected anti-colonial criticism. Footnote 81
The position adopted by Ciucă within the Committee reflected Eastern European critiques against Western insistence on targeting one disease at a time. In 1948, during the first WHA, the Soviet deputy minister of health, Nikolai Vinogradov, urged the organization to ‘organize its activity, above all for the consolidation and development of national health services’. Footnote 82 In his view, the WHO’s priorities were war-torn states and ‘the peoples of colonial countries’ because ‘epidemics are due to poverty and colonial oppression’. Footnote 83 Eastern European delegates pointed to unchecked infectious diseases in Asia and Africa as evidence of failed colonial governance, an opinion shared with extra-European anticolonial voices at the UN. Footnote 84
During the first WHA, the delegation of the Ukrainian SSR put forth a draft resolution that articulated the socialist vision of malaria control driven by the expansion of national services in independent states or colonial territories. The document argued for
Systematic registration where practicable of malaria cases; an appropriate organization for detecting new cases; the importance of adequate treatment; … tracing the movements of carriers; … extensive use of insecticides; … making therapeutic and prophylactic treatment available to all …; the improvement of methods of irrigation, cultivation and animal husbandry; planning of housing programmes taking into consideration the relevant data of malaria surveys; the active support of scientific research with a view to improving therapy and malaria prophylaxis.Footnote 85
The draft resolution reflected the centralized programme designed in the Soviet Union during the second half of the 1930s. It also echoed LNHO approaches that emphasized diverse state-funded control measures against structural problems that facilitated disease transmission. A Romanian delegate, Gheorghe Lupaşcu (Ciucă’s deputy at the Institute for Epidemiology and Microbiology in Bucharest and former LNHO fellow) contrasted the Ukrainian SSR’s proposal with US-inspired eradicationism, which extolled DDT spraying at the expense of national health services.Footnote 86
Western delegates criticized the draft resolution for its departure from a vertical approach to malaria control. The document incurred reservations from non-European officials reluctant to embrace massive health investment that postwar technological breakthroughs seemed to make superfluous.Footnote 87 This position showed the dissonance between socialist modernism and the realities of decolonization: most of Africa would wait for another decade for liberation, while in Asia, even when independence was achieved, as in the case of the partition between India and Pakistan, it happened under conditions of extreme violence and instability. States of emergency pushed officials and medical experts to favour anti-malaria interventions founded on their faith in DDT at the expense of the gradual expansion of national health services.Footnote 88 Despite strong traditions of connecting epidemiology to social welfare concerns,Footnote 89 Latin American representatives sided with the USA. They sought to maintain US funding for their countries’ disease control and wished to preserve the autonomy of the Pan-American Health Organization, created out of the Pan-American Sanitary Bureau as part of WHO’s regionalization (Fred Soper was PAHO’s president from 1947 until 1959). Many Latin American states had right-wing governments and saw the USSR a threat to their sovereignty.Footnote 90
The Ukrainian draft resolution was referred to the Malaria Committee for evaluation. In February 1949, the Committee sent its comments to the WHO’s Executive Board. Isolated among his colleagues, Ciucă characterized the draft resolution as the foundation for any programme in ‘malarious countries’. He warned that ‘the lack of systematic malaria control in a country constitutes a serious threat’ for its neighbours, anticipating the dire effects of the WHO’s selective approach to control and eradication across the world.Footnote 91 In contrast, former colonial officials argued, as Covell did, that the document ‘would not serve any useful purpose’.Footnote 92 They claimed that DDT decreased the relevance of integrating anti-malaria measures in health systems for the detection, registration and treatment of old/new cases. Vaucel, Wilson and Field considered the Soviet plan impracticable in ‘tropical areas’.Footnote 93 They reaffirmed the colonial taxonomy that the LNHO had sought to subvert during the 1930s: in territories with high and continuous disease incidence population-wide treatment and surveillance would not work. These views were endorsed by the Committee’s post-colonial representatives, a symptom of their perception of DDT as ‘magic bullet’, of the dire situation of their countries’ budgets and of resilient colonial legacies.Footnote 94
The socialist perspective of combining insecticide spraying with treatment, surveillance, research as well as healthcare and infrastructural reform was rejected by the Malaria Committee. By the second WHA (1949), the fate of the draft resolution was irrelevant: the Ukrainian and Byelorussian delegations withdrew from the WHO. A year later, the other socialist countries followed suit (except Yugoslavia). Socialist governments’ exit was not merely a Soviet-coordinated decision rooted in Cold War competition. It signalled Eastern Europeans’ legitimate accusations of political discrimination, pro-imperialist agenda and unbalanced budgeting at the WHO.Footnote 95 They did not reject the merits of the organization, but considered that they could not influence decision-making and implicitly decolonization because of Western hegemony based on a pro-American voting majority.
At the end of the 1950s, once Nikita Khrushchev, the successor of Joseph Stalin as general secretary of the Communist Party of the Soviet Union, re-engaged with the UN system, Eastern European governments re-joined the organization. The growing number of post-colonial members and their radicalism shifted the power balance at the WHO. As Ewing and Leake underline in this special issue, even though post-colonial countries did not always achieve consensus, their collective voice triggered a watershed at the UN. This new reality created favourable conditions at the WHO for the ascendance of Eastern European malariology that tied epidemiological campaigns to national health development as means to consolidate sovereignty.
The tides of global health
In 1955, the UNICEF and the WHO moved from control to the eradication of malaria. Between 1960 and 1961, the peak of the campaign comprised sixty-six countries. The programme never lived up to its global billing: it focused on Latin America, Western Pacific and Southeast Asia. The Cold War led to the exclusion of newly socialist China, North Vietnam and North Korea, which were not WHO members. In Africa, Western malariologists argued that eradication was unattainable because of hyper-endemic conditions combined with poor health infrastructures and highly mobile, rural populations.Footnote 96 As decolonization swept through Africa, some countries on the continent were included through pre-eradication programmes. The latter pursued malaria control to build capacity but were disconnected from national healthcare.Footnote 97 Until the mid-1960s, the WHO’s guidelines continued to focus on DDT spraying at the expense of the integration of curative and preventive medicine, entomological research and surveillance reflective of local conditions. The return of Eastern European countries catalysed a shift in this agenda: newly independent governments were encouraged to move away from vertical programmes to more comprehensive health reforms.
The turn to eradication also reflected the US-led reconceptualization of the WHO after socialist countries’ withdrawal. For Western governments, health policies became instruments of ideological containment: ‘underdevelopment’ was conflated with the threat of communism, so medical crises in Asia and Africa were seen as security problems. Footnote 98 Just as it happened at the LNHO, the idea of the WHO as anti-communist instrument was gradually trumped by the challenges faced by malaria-ravaged locales. Continuing a trend from the 1930s, campaigns against the disease contributed in newly independent countries to decolonization: they consolidated governmental authority and promised national health renaissance.Footnote 99 Global eradication was not just a product of Cold War dynamicsFootnote 100 ; it was the result of a consensus among WHO members about the capacity of medical technologies and experts to produce rapid societal transformation.Footnote 101
In Eastern Europe, eradication was connected to socialist modernity, a facet of state-funded, universal access healthcare. Communist regimes linked up campaigns against the disease with industrialization, collectivization and urbanization engineered through planned economies and hyper-centralized, authoritarian states. Interwar practices found a place in these programmes: eradication relied on comprehensive networks of anti-malaria stations integrated into national health and medical research systems. Teams recruited from dispensaries and hospitals distributed anti-malarial drugs at no cost to the population. They pursued active surveillance by identifying cases of (re-)infection. The extensive use of DDT was adjusted to local conditions determined through the study of mosquito populations and environmental management.Footnote 102 Eastern European malariologists valued patient treatment to curtail the human reservoir of the disease and community participation for ‘the achievement of eradication in the shortest possible period.’Footnote 103
The significant reduction of malaria morbidity and mortality in Eastern Europe during the 1950s overlapped with socialist regimes’ turn to the decolonizing world. Nikita Khrushchev travelled to Asia in 1955 to express socialist regimes’ solidarity with liberation struggles and commitment to cooperation with newly independent states.Footnote 104 Malariology became an instrument for the East’s challenge against the West and for socialist solutions to post-colonial ill-health. Eastern European eradication programmes were showcased internationally. As their governments returned to the WHO, Romanian, Bulgarian, Albanian and Soviet experts participated at the organization’s conferences on malaria in Southeastern Europe. In 1958, the third conference was attended by representatives from Eastern Mediterranean and Southeast Asia.Footnote 105 Similar to the interwar period, non-European participants drew lessons from these countries, for instance, the ability of socialist governments to curb nomadism.Footnote 106 Eastern Europeans considered the settlement of nomadic populations to be integral to overcoming past ‘backwardness’ through socialist modernization and disease control. Medicalized internal colonizations in Eastern Europe were examples of nation-state building for post-colonial actors.Footnote 107
Eastern European governments situated their anti-malaria programmes in a decolonizing context. In 1957, Romania’s minister of health wrote to Marcolino Candau (WHO’s Brazilian Director-General) that ‘it would not be advisable for our country to use WHO funds. We have the necessary personnel and sufficient experience to achieve eradication. There are other countries in the world where malaria is a serious health problem and where the struggle against this disease is not possible without the WHO’s precious contribution’.Footnote 108 This self-representation also signalled that Eastern European officials considered socialist modernization to take their countries off the map of ‘underdevelopment’ – an implicit affirmation of civilizational superiority over the decolonizing world.
Echoing LNHO practices, Eastern European states assisted the WHO’s malariology training. Yugoslavia hosted a specialization centre in Belgrade that offered WHO fellows from Latin America, Asia and Africa the possibility to travel to Hungary, Romania or Bulgaria to learn about their eradication programmes. Between 1960 and 1962, malariologists in Bucharest showcased their experience to forty-two specialists from ‘all regions of the world’.Footnote 109 In 1962, the Malaria Eradication Training Centre in Moscow hosted nineteen WHO fellows from Nigeria, Nepal, Afghanistan, Indonesia, the United Arab Republic, Iraq and Iran. The lectures of Soviet experts drew on their experience in Central Asia, the Soviet Union’s ‘South’.Footnote 110 Kremlin’s new-found solidarity with the developing world provided ‘the impetus to complete the “decolonization” of Central Asia within the Soviet framework’.Footnote 111 In contrast to interwar, by the late 1950s, success in disease control resembled the official discourse about development in Central Asian republics.Footnote 112 The latter were touted as examples for the potential benefits of socialist medical modernism in post-colonial states.
Eastern European regimes’ ability to present their expertise to newly liberated peoples as alternative to Western visions of control/eradication also drew on circulations within the expanding socialist camp. The massive presence of Eastern European physicians in the People’s Republic of China, the Democratic People’s Republic of Korea, the Democratic Republic of Vietnam (DRV) during the 1950s and 1960s showcased the region’s ability to export know-how into post-colonial contexts, while its specialists used these spaces as laboratories for socialist medicine.Footnote 113 In the DRV, Soviet malariologist G. A. Pravikov coordinated a multi-national anti-malaria campaign that symbolized socialist solidarity with the Vietnamese people. Between 1956 and 1961, local and Eastern European experts worked in 3,000 locations examining 646,277 people and checking 319,087 houses for mosquitoes.Footnote 114
Alexei Lysenko, the acting director of the training centre in Moscow for WHO fellows, invoked the socialist experience in North Vietnam and Tajikistan. His lectures argued that anti-malarial programmes involved the study of ‘not the parasite, but the source of the infection; not the vector but the transmission process; not the susceptible host but the susceptible community’. In this framework, ‘the susceptibility of the population to the infection depends on … its age composition, nutrition, national economic activity, medical aid and epidemic control activities etc’. Echoing the LNHO’s recommendations, Lysenko concluded that malaria eradication was first and foremost ‘a complex social problem’.Footnote 115 Soviet experts reinterpreted the WHO’s standards of cost-effectiveness by designing measures tailored for particular locales: ‘in Tajikistan and North Vietnam we adopted WHO principle of DDT total coverage … But we applied different doses of insecticides and different durations (years) of total coverage’. A similar approach was employed for ‘mass drug administration … carried out in Thai Nguyen after the first DDT spraying was also different in various zones’.Footnote 116 Socialist experts shared with their Western counterparts an eradicationist mentality, but they emphasized adaptability grounded on social-economic contexts and entomological or environmental conditions.Footnote 117
Eastern European malariologists brought their particular approach to the WHO: they joined the organization’s expert panels and were assigned field missions in post-colonial states – their growing prestige gradually superseded Cold War concerns within the organization’s secretariat.Footnote 118 Drawing on the tradition of the LNHO’s Malaria Commission – a connection highlighted by Ciucă and Sergiev in the Darling Award speeches from 1966 – Eastern Europeans infused a new impetus to research on malaria-carrying mosquitos, an issue side-lined in the WHO’s DDT-driven eradication. In 1963, Romanian entomologist Ernest Ungureanu (former LNHO fellow) was employed at the Regional Office for Europe. He and his Bulgarian colleague Dimiter Athanassov evaluated anti-malaria programmes in Africa. Polish physician Jerzy Ochrymowicz, after working in the DRV and Congo (Kinshasa), was employed by the WHO in 1964 to manage pre-eradication campaigns in West Africa.Footnote 119 Soviet entomologist Tatjana Detinova travelled to Africa in 1962 to teach Western and local experts techniques for researching the relationship between mosquito populations and their ecosystem. The aim was to better understand disease transmission, which offered answers about adjusting anti-malaria programmes to local conditions.Footnote 120
From 1961, mirroring the new wave of decolonization, Eastern European representatives once again challenged the WHO’s eradication approach. At that year’s WHA in New Delhi, socialist delegates insisted that eradication was not sustainable by insecticide and chloroquine alone. Gheorghe Lupaşcu underlined that Romania’s success could not be replicated in Asia or Africa without ‘the extension of the rural health network’ and the development of ‘basic health personnel’ who could perform eradication operations and ‘surveillance work [that] was crucial for all countries’.Footnote 121 Bulgarian deputy minister of health L. Stoyanov argued that the WHO had to provide assistance to decolonized countries not only for ‘the control of certain communicable diseases but also … to protect and treat their people against all forms of disease’.Footnote 122
As in the late 1940s, socialist lobbying for anti-malaria programmes alternative to US-inspired vertical approaches was linked to ‘decolonization in the widest sense of the word’, to use Stoyanov’s phrasing.Footnote 123 At the 1961 WHA, the USSR, Cuba and Poland submitted a draft resolution concerning the Granting of Independence to Colonial Countries and Peoples and the Tasks of the WHO. The document was accompanied by a memorandum that blamed hunger, epidemics and low life expectancy in (former) colonial territories on colonial rule.Footnote 124 The document contrasted this situation with post-independence healthcare progress in India, Indonesia or Egypt. While the socialist draft was rejected, a version reworked by Ghanaian delegates passed. It was co-authored by eight countries, including Cuba, the USSR and Poland.Footnote 125
During the next four WHAs, Eastern Europeans relentlessly combined anti-colonialism with criticism of the WHO’s eradication approach. The latter was deemed to hinder sustainable health protection in newly independent states because it did not insure comprehensive medical coverage, epidemiological surveillance and it did not emphasize personnel training beyond insecticide spraying skills. Other voices joined Eastern European calls for a shift in global policy. In 1964, the representative of Guinea, O. Keita, warned that ‘the extension of specialized [i.e. anti-malaria n.a.] national services would lead to the disintegration of a general public health infrastructure’.Footnote 126 A. L. Bravo (Chile) advocated for efforts ‘to incorporate the communicable disease control programmes in the activities of the general health services’.Footnote 127 Between 1963 and 1965, delegates from Italy, Finland or Norway also questioned the WHO’s eradication strategy.Footnote 128 An emerging consensus about change in the global policy signalled the return of principles about disease control, healthcare development, medical education and research initially formulated at the LNHO and resiliently advocated by Eastern Europeans since the 1920s.
In 1965, the WHA president, Monawar Afridi, the malariologist from Pakistan who had opposed in 1948 the draft resolution of the Ukrainian SSR on state-managed integrated malaria control, admitted that a compromise was required between eradication and ‘basic health organization’.Footnote 129 Summarizing the growing discontent, Soviet delegate G. A. Novgorodcev declared that ‘the guiding principles governing the malaria eradication programme should be reviewed’.Footnote 130 Gheorghe Lupaşcu echoed the Soviet proposal. After surveying several West African countries, he declared that programmes relying solely on eliminating mosquitos were doomed to failure, particularly as vector resistance to DDT was reported across the world. Footnote 131
By 1966, when Ciucă and Sergiev received the Darling Award, socialist representatives advocated their vision of anti-malaria action from a position of strength: experts across Latin America, Asia, Africa and some in Western Europe increasingly embraced the focus on national health services comprising eradication programmes. Decolonization was at the centre of Eastern European calls for re-thinking WHO policy. Socialist delegates underlined that ‘a radical reduction in disease’ could only be achieved through ‘changes in [social-economic] conditions’ and the consolidation of ‘a state system of health services’.Footnote 132 According to a Romanian official, the WHO’s oversimplified eradication methods and principles had overlooked broader medical needs of newly independent peoples and social-economic realities in post-colonial states.Footnote 133
The new consensus on malaria eradication became official in a WHA resolution from 1967 drafted by a working group comprising delegates from Colombia, India, Iran, Mauritania, the USSR and the United Kingdom. The document reflected the conclusions reached a year earlier at the meeting of regional malaria advisers in Geneva. The resolution called for accelerated ‘development of basic health services’, ‘the provision of personnel’, ‘the investigation of social-economic implications of eradication’ and ‘the diversification of means of eradication in accordance with the particular requirements of each country’.Footnote 134 The document urged that eradication ‘be resolutely pursued … to secure the protection of peoples of Africa’.Footnote 135 This clause was the result of a multi-year lobby by socialist countries and African states for the extension of anti-malaria programmes according to the continent’s specific conditions. The resolution confirmed the new WHA majority produced by decolonization: representatives of post-colonial governments often allied with Eastern Europeans to challenge the influence of the USA and of former colonial Western powers.
The shift in the WHO’s global strategy was also a response to the decline of malaria eradication across the world. Eastern European experts explained this setback by pointing to frail post-colonial states, colonial legacies and feeble international aid. A Soviet document noted that ‘the lack of economic development, poor health services and political instability’ held back eradication in Asia and South America.Footnote 136 The situation was worse in Africa: ‘the harsh legacy of the colonial past (economic weakness, a lack of trained malariologists, insufficient medical staff) and the evasiveness of the WHO in providing assistance were the true fundamental reasons’ behind the failure of anti-malaria programmes.Footnote 137 By 1966, Eastern European malariologists returned to the idea of ‘malaria control’ for newly independent countries confronted with large foci of infection. G. A. Novgorodcev condemned the WHO for providing assistance only to countries committed to eradication.Footnote 138 While Eastern Europeans considered that control programmes ensured long-term success against the disease, the argument reinforced the taxonomy between a non-malarious North and a South where freedom from malaria was deferred to an undetermined timeline.
Nevertheless, the new consensus at the WHO on anti-malaria programmes integrated in national health services was a fundamental departure from US eradicationism. It questioned the very idea of technological interventions solely targeting disease, oblivious to local conditions. The new East-South alliance at the WHO did not revitalize the global campaign, though some success was achieved: twenty-six countries achieved eradication, while others dramatically drove down malaria morbidity and mortality. The maximalism behind eradication created inflated expectations that ignored the complexities of post-colonial state-building. Discouraged by growing resistance of mosquitos to DDT and of disease parasites to drugs, Western donors were unwilling to convert their commitment to anti-malaria programmes into assistance for nation-wide healthcare.Footnote 139 As Cold War competition intensified in the ‘Third World’, Eastern European regimes assisted integrated disease control programmes only in newly independent countries that pursued state socialism.Footnote 140 By the late 1960s, socialist countries channelled their efforts into the campaign against smallpox, which they considered a better ‘candidate’ for global eradication.Footnote 141 Post-colonial officials increasingly considered economic growth possible despite the persistence of malaria. With limited budgets and struggling for political support, governments mainly funded urban health infrastructures, a continuation of trends from the colonial period. Footnote 142 In 1969, developing countries criticized the WHO’s recommendation to cancel DDT use because of its grievous effects on human health. An Indonesian delegate proclaimed that ‘it might still be considered better in malarious countries to die of cancer in old age than of malaria in childhood’.Footnote 143 Despite endorsing the WHO’s decision, Eastern Europeans continued DDT use as preventive measure against malaria at home and abroad.Footnote 144
During the 1970s, the WHO side-lined malaria eradication and the affliction surged in countries that could not eliminate it. This showed that, as Elisabeth Leake notes in this issue, the achievements of decolonization could be reversed. Once socialist countries joined the rest of malaria-free Europe, Eastern European expertise touted the region’s civilizational superiority over post-colonial spaces struggling with the disease. Commenting on the Darling Award ceremony in 1966, a contemporary Romanian observer noted: ‘Europeans, Asians, Africans, Americans … knew that [for] Mihai Ciucă … malaria would be defeated on earth only when afflicted countries engaged [at the same time with eradication] in civilizing work fuelled by consistent cultural uplifting’.Footnote 145 Eastern Europeans relished overcoming their subaltern status in world hierarchies by way of disease-conquering socialist modernity. Their global gaze however was quasi-colonial – the resilience of disease in the South signalled deficient civilization.
Conclusion
The interconnections between Eastern European malariology, colonial territories and newly independent states show the changing roles of international organizations and the plural meanings of decolonization. While the LNHO was a Eurocentric, neo-colonial forum, it gradually developed norms and programmes that legitimated self-government and anti-colonial ideas. By the late 1930s, its Malaria Commission promoted state-guided comprehensive disease control drawing on Eastern European experiences, thus validating medical patriotism in China, India or Southeast Asia. The LNHO’s role as self-determination incubator via medicine by connecting Eastern European and colonial peoples’ health concerns had a lasting effect on the WHO. The latter partially overcame its initial anti-communist bias as the organization’s approach towards decolonization increasingly prioritized the concerns of (former) colonial peoples at the expense of Western interests in Asia and Africa. Since the late 1940s, the budding socialist camp pushed for malaria control paired with health reforms as conduit for independence from colonial rule. Its representatives joined Global South criticism of Western metropoles’ failure to ensure the well-being of their subjects.
The new wave of decolonization from the 1960s revitalized socialist and post-colonial visions that merged healthcare with sovereignty. It triggered a shift in WHO policy: anti-malaria programmes were linked to debates about comprehensive medical coverage as well as local social, economic and ecological specificities. This watershed did not bring global eradication, but it swung the power balance within the organization in favour of developing states – an alignment that lasted until the debt crisis of the 1980s. Eastern European advocacy of state-managed cumulative malaria programmes as part of national health emancipation facilitated the resurgence of the LNHO’s social-economic contextualization of disease. During the 1970s, this interwar legacy played an important role in WHO debates about healthcare in post-colonial spaces.Footnote 146
The global trajectories of Eastern European malariology show that histories of international organizations that prioritize Western vantage points and/or Cold War divisions tell a limited story. Once this narrative is de-centred through long-term trans-regional entanglements previously ignored or marginalized, a broader picture of policy production and agency emerges. Liberation from malaria was less about communism or liberalism, and more about nation-building, sovereignty and world hierarchies. The story of Eastern European disease expertise at the LNHO and the WHO reveals spaces of interaction, knowledge circulations and policy agendas that sidestepped Western/imperial hegemony and expanded the meaning of decolonization beyond the goal of political independence. However, Eastern Europeans could not overcome their own vacillations about ‘civilization’ and pathogenicity in the South, a reminder of resilient developmental hierarchies underpinning global health politics during the twentieth century.
