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After reading this, is there any reason (other than lack of will to do so) why malaria has not now been eliminated from Africa?

April 17, 2012 - 18:23 -- Anton Alexander

90 years ago, Palestine was deemed by the British Mandate to be almost "hopeless from the malarial standpoint". Much of the area was uninhabitable.




"Malaria stands out as by far the most important disease in Palestine.
For centuries is has decimated the population and it is an effective
bar to the development and settlement of large tracts of fertile lands
.... There are few regions actually free from it" 1921-'First Annual
Report of the British Mandate- Dept. of Health'

"Palestine is a small country and, as a whole, thinly populated. ....
malaria .... has always been very prevalent, particularly at Jerusalem
.... at Jaffa, Acre ... and in the Valley of the Jordan" 1925 -
'Malaria Commission. Reports on the Tour of Investigation in Palestine
in 1925. League of Nations Health Organisation. Geneva.'

In Palestine, malaria had been so severe that settlements were
abandoned or only maintained by annual replacement of part of the
population.



45 years later, Israel was certified as free of malaria, by use of anti-malaria measures including control and prevention of mosquito breeding, drainage and reclamation of swamp areas forming extensive breeding grounds, treatment of infected persons, and educational work among the people, giving information as to the origin and prevention of disease - and without using bednets, and without using vaccines.




Yet still Africa is using its bednets (for the last 100 years or more)
and prays for an anti-malaria vaccine (which continues to be elusive),
and still a child dies every 30 seconds in Africa from malaria.


Eradication with bednets and vaccines having failed, perhaps now
Palestine's 90 years old eradication approach should also be considered
in Africa.


To understand how eradication was handled and to see what was possible in 'hopeless' Palestine, watch www.eradication-of-malaria.com


The method may be 90 years old, but it worked. Bednets save lives but
are not sufficient to eliminate malaria. Vaccines may help one day. But
why are we failing to learn from past successes?






 

Comments

Submitted by Guest (not verified) on

why hasn't it been tried in Africa?  Surely there must be localised examples of similar success stories. Anton makes it sound simple ....what have been the barriers to this approach in Africa?

Submitted by Anton Alexander on

Perhaps this blog should be read in conjunction with my earlier blog of 1st March last, PALESTINE'S MALARIA ERADICATION LESSON FROM 90 YEARS AGO. I am surprised that you felt I make it sound simple - it is correct there was hardly anything completely novel or unique in the approach. Kligler taught that each outbreak had to be investigated and examined, and the method of eradication had to be suitable for that particular outbreak. Attention to detail was evident, as was patience, and indeed it took 45 years for the disease to be declared eradicated. I am unsure if it is possible to say that the same continuous application to the task, day in, day out, is simple.

What have been the barriers to this approach in Africa? That is also my question. Does my 1st March blog make any suggestions?

William Jobin's picture
Submitted by William Jobin on

 

MALARIA SUPPRESSION IN THE HOLY LAND

 

Anton, that is a beautiful and thought provoking slide show you made on the suppression of malaria in the Holy Land.  You ask the poignant question - is there any reason why malaria has not been eliminated from Africa?

In one sense we certainly can suppress malaria in Africa, and have done so.  The amount of malaria left in the Maghreb States of Morocco, Algeria, Libya, Tunisia and Egypt is virtually zero.  Also malaria transmission on the tip of southern Africa has been suppressed to a great degree.   And malaria has been suppressed around the Mediterranean Sea in Sardinia, Italy and the rest of Europe for half a century or more (See Snowden's beautiful book "Conquest of Malaria" of 2006 by Yale University Press).

But an entomologist would point out that the anopheline mosquitoes in North Africa and the Holy Land do not include Anopheles gambiae or its sisters An. arabiensis and An. funestus.  The vectors in the Holy Land are An. sergenti and An. superpictus - less efficient as transmitters of the parasite (See "A global map of dominant malaria vectors" by Sinka et al, Parasites and Vectors, 2012, 5:69).

Also Anopheline mosquitoes and their transmission of malaria in sub-Saharan Africa continue on their merry way all year round, uninhibited by cold weather

WHAT CAN WE DO?

An important question is: how can we apply the lessons from the Holy Land to sub-Saharan Africa?

One of the beautiful and clear lessons is how agricultural development in the Holy Land first led to land reclamation which then led to elimination of breeding sites for the vectors.  That lesson can be followed everywhere in Africa, and offers great hope for suppressing malaria at the same time that we increase food production (See my book "Dams and Disease" 1999, at Amazon.com).

Another lesson is that we don’t need to wait for a vaccine to start suppression of malaria, if we carefully learn the environmental limitations of the relevant vectors, and modify their environments.  If the modifications are permanent, we can then wait for the mythological vaccine while keeping transmission at very low incidences.  We can also minimize the use of drugs and biocides, and thus avoid the chemical dependency of the ephemeral and unsustainable WHO and PMI strategies. 

And thirdly, the kind of success you described in the Holy Land has been found in the tropical world too, notably in Malaysia where malaria transmission has been suppressed for half a century by a program based on environmental management of mosquito breeding sites (Google Malaysia and Malaria and look for their section on Environmental Management).  The key to their success was that they first identified the important vectors and found their habitat requirements.  It requires good entomology and an integrated attack, including environmental management of mosquito habitats.  Also we suppressed malaria in one of the most intense transmission foci in the world for 10 years in Sudan (See my Blue Nile Monograph One 2010, which is available at Amazon.com).

If sustainable or permanent environmental management methods are used as the basis for an integrated attack on malaria in Africa, we will succeed.  But I stress, we must understand the vectors and the transmission patterns.  Keep at it Anton.

William Jobin Director of Blue Nile Associates

Submitted by Anton Alexander on
Bill Jobin's comments "One of the beautiful and clear lessons is how agricultural development in the Holy Land first led to land reclamation which then led to elimination of breeding sites for the vectors". I don't think this would have been the early Jewish settlers' experience in Palestine. Before the elimination of the breeding sites, before the arrival of Kligler, attempts at settlement had been either abandoned or maintained by annual replacement of part of the population. Perhaps the Jewish settlers would have fared better if at the same time they had have attempted malaria elimination (if they had known how), but in the interim, that would have left the local population exposed to the disease. Upon Kligler's arrival, he instructed that no new settlement or agriculture was to take place until local malaria had been suppressed. Kligler's experience was that only elimination of the breeding sites, not the agricultural development, eradicated malaria in Palestine.

William Jobin's picture
Submitted by William Jobin on

Thank you Anton for this stimulating blog.  I have given some thought to answering your questions about the relation of land reclamation for agriculture and for mosquito suppression.

Also various readers have asked the question;  if malaria was successfully attacked in the Holy Land, how could we do this in the heart of Africa?

The historical evidence says we can, if we start by suppressing malaria with durable methods such as land reclamation and environmental management.

MALARIA SUPPRESSION CAN SUPPORT AGRICULTURAL DEVELOPMENT

In subtropical countries where mosquito breeding was suppressed by land reclamation, parallel agricultural development eventually paid for the malaria suppression and economic development made the progress permanent.  Historically this process took about 20 years in subtropical countries such as Puerto Rico and Italy, depending on the climate and the efficiency of the local mosquito vectors of malaria.

However in more tropical countries where the climate is extremely favorable to malaria and the mosquito vectors are very efficient, this parallel process of malaria suppression and economic development has taken closer to 40 years to reach a permanent state, as in the Holy Land and Malaysia.  It is important to realize that it was precisely the reliance on environmental management for mosquito control which made possible such long-lasting suppression of malaria.

When ephemeral strategies based on drugs and biocides have been used in Africa to suppress malaria, their temporary success has not resulted in parallel economic development.  In fact the high and ever-increasing costs of drugs and biocides have instead drained the economies.

Looking to the heart of Africa where the climate is extremely favorable to highly efficient local vectors, and human life-style exposes people to the biting mosquitoes, suppression will have to occur for longer periods, perhaps 50-60 years.  Current use of drugs and biocides cannot maintain suppression this long, but integrated use of environmental management can, with public participation and limited use of drugs and biocides.

HISTORICAL JUSTIFICATION

We find clues to support this optimism in the countries where malaria is being suppressed in an enduring manner, such as the southern USA, Puerto Rico, Italy, Sardinia, the Holy Land, the Maghreb countries of North Africa, southern Africa and Malaysia. 

USA

In the USA malaria control was based on environmental management by the Tennessee Valley Authority as they developed the Tennessee River for hydropower, flood control and navigation.  As their 17 dams went into operation, the dams stimulated the economy of the river valley, making it possible for people to improve their homes, screen their sleeping areas, and overcome the deadly fevers.  Summertime malaria became a thing of the past, disappearing within 10-20 years of completion of the TVA.

ITALY

In recent conversations with the historian Frank Snowden, he feels that the two processes of malaria suppression and agricultural development went hand-in-hand in Italy.  Progress started after the First World War with drainage of the Pontine Marshes, for the dual purpose of agricultural development and malaria suppression.  Both development and malaria were set back by the Second World War.   But the processes started up again energetically about 1950, and within 10 –20 years, Italy was free of malaria and the Pontine marshes are now the most productive agricultural lands in the country.  The wealthy farmers live in screened homes, permanently protected against the mosquitoes.

THE HOLY LAND

In the Holy Land, the Zionists tried agricultural development of swamplands as early as 1910, but they were thwarted by malaria.  Then they drained the swamps to eliminate the mosquitoes, before allowing settlements for agricultural development.  After the Second World War mosquito control and agricultural devlopment proceeded together, and by 1970 malaria was suppressed.  They used environmental management methods that also turned swamps into farms and orchards.  The process took over 25 years and resulted in prosperous and healthy communities.

MALAYSIA

In Malaysia, environmental management of malaria started just before the Second World War, especially around the rubber and tea plantations that became the backbone of the economy.  After overcoming the devastation of the war, malaria suppression and economic development began again in the 1950’s.  From malaria incidences in the tens of thousands in 1960, Malaysia now reports only a few thousand new cases each year, having reached enduring suppression of malaria in about 40 years.  They did this while surrounded by failures in Burma and other nearby countries who tried to control malaria using drugs and biocides.

Similar success has occurred in southern Africa around mines and other economically important projects.

As a rough estimate, combining environmental management with swamp reclamation for agricultural development, has helped countries in the subtropics to get out of the malaria quagmire in 10-40 years, depending on how tropical is the climate.

THE HEART OF AFRICA

Success in northern and southern Africa should not thought of as a simple precursor to success in the heart of Africa, primarily because of the torrid climate and the deadly vectors in sub-Saharan Africa.  In any event, if environmental management or any other strategy for malaria control is to go hand-in-hand with agricultural development, we should expect to work at it for at least 50 years before we get permanent suppression.  However along the way we can expect increasing economic development and a decrease in malaria

TWO LESSONS

There are two lessons here.  Firstly malaria must be suppressed for about 50 years if economic development is going to be strong enough to pay for it, in the heart of Africa.  Secondly, environmental management must be the basis for this suppression, as drugs and biocides are too short-lived in their effectiveness due to the inevitable development  of parasite and mosquito resistance, and the financial drain these measures put on government.

William Jobin Director of Blue Nile Associates