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Alternative Investment Strategies for the global attack on malaria

June 13, 2014 - 20:45 -- William Jobin

TWO INVESTMENT APPROACHES

Two investment strategies have been used historically in the global fight against malaria: the Generalist Approach and the Specialist Approach. Understanding the difference in these investment strategies is important in planning the global attack on malaria because of the intricate and fundamental linkage of investments in malaria suppression and in national development. This linkage has been ignored by WHO Geneva, and the USAID folks in Washington DC. However there is evidence that the linkage is very important in the fight against malaria because slow economic development of Africa is more closely linked to malaria than to any other major historical factor such as colonialism or even slavery (Bhattacharyya 2009. “Root causes of African underdevelopment” in J. Afr. Economics v18 645-780).

SUCCESS OF THE GENERALIST APPROACH

The historian Snowden described the successful Generalist or Holistic Approach used by the Italians to eliminate malaria from their national territory by 1962. (Snowden 2006. “The Conquest of Malaria” in Yale University Press.) They began with land reclamation and permanent improvements in rural housing, turning malarious wastelands such as the Pontine Marshes into profitable agricultural zones. They also concentrated on improving education, in harmony with improved health care and investments in community development. Finally, as Italy developed economically after the War with further improvements in housing, health care and education, and as better drugs and biocides became available, they made a concerted and successful extra and final push to stop malaria transmission completely.

In like manner but with less detail, Greenberg and Alexander documented the Generalist Approach used by Kligler in the Holy Land during the early part of the Twentieth Century to control malaria through larviciding, health education, case detection with rapid treatment, by careful water management, and by ditching malarious swamps to convert them into productive agricultural use (Greenberg and Alexander 2011. “Israel Jacob Kligler” in Korot, Jerusalem). Again, as the region developed economically with improved housing, health care and education, and as better drugs and biocides became available, malaria was eliminated from the Holy Land by about 1950.

FAILURE OF THE SPECIALIST APPROACH

In stark contrast to the success of the Generalist Approach, another historian, Webb, has documented the abject failures of the Specialist Approach in Africa (Webb 2014. “The long struggle against malaria in Africa” in University Press, New York and Cambridge). In each attempt at fighting malaria in Africa, specialists tried to jump-start the attack on malaria by repeated distribution of drugs, biocides and more recently, bednets. These attempts ignored the local state of economic development of the countries involved, but instead relied on huge infusions of ephemeral cash from outside agencies such as the UN, the World Health Organization, the USA and other northern countries.

About 1970 the first global attempt at malaria eradication collapsed, due to failure of the drugs and biocides. As their strategy collapsed, this group had no reserves of cash to invest in supplemental measures. They were completely committed financially in buying drugs and chemicals which were needed every year to maintain their strategy.

More recently a second large-scale attempt in Africa was developed by USAID in Washington DC as the US Malaria Initiative, using the same failed Specialist Approach of the first attempt. Although initially successful by some measures, it now faces the same Resistance problems that caused the collapse of the first Specialist Approach. And because of their over-commitment of funds for purchasing drugs and biocides, they have no reserves to add supplemental measures.

No country following the Specialist Approach has been able to eliminate malaria.

The strength of the Generalist Approach and the weakness of the Specialist Approach can be seen as differences in investment strategies. Also the Generalist Approach is done in harmony with general development, while the Specialist Approach tries to bypass it.

GENERALIST APPROACH DOES NOT STRAIN BUDGET

The Generalist Approach begins with permanent changes in human and mosquito ecology that minimize mosquito populations and transmission potentials, followed by a final stage in which the biocides and drugs are employed in a financially logical sequence. Because the initial investments were in permanent improvements and thus did not require repeated expenditures every year, stable national budgets could easily support this final stage.

This Generalist Approach is the one followed by all countries that have been successful in suppressing malaria.

The financial consequences of the two different paths are drastically different. The Specialist Approach requires repeated expenditures on temporary efforts, leading to inexorably increasing expenses if coverage is to be expanded, such as the $800 million spent annually now by the US PMI. With this investment strategy, there are no discretionary funds available for adding additional control methods and thus no flexibility in the approach. The repeated application of drugs and biocides over large areas will also lead to ultimate collapse of the strategy because of chemical and drug resistance

In contrast, the Generalist Approach can operate with a relatively steady budget because the initial reductions in habitat and transmission are permanent and do not require annual repetition. Thus the program can move on to new areas without incurring higher expenditures. The Generalist Approach can be adopted by any country which is willing to make a modest but continuing investment in suppressing malaria.

It is doubly important that one of the key methods in the Generalist Approach is the conversion of swampy mosquito-breeding sites into productive agricultural land, at the same time as it makes the area more inhabitable by potential farmers because the malaria risk drops. Thus a method of fighting malaria also directly feeds agricultural and thus economic development. Two for one.

It is also important that the reclamation of waste lands occurs normally as a nation develops. Waste lands are converted into usable land for all manner of purposes: agricultural production, urbanization, and even golf courses! Urbanization also contaminates water, land and air to the detriment of malaria mosquitoes. Thus malaria mosquitoes are pushed out by bulldozers, paving machines, and housing projects as the national economy flourishes.

SEQUENCE IS IMPORTANT

An important difference between the two approaches is the sequence of applying the two kinds of methods. In the Generalist Approach the durable, permanent methods are applied first. When mosquito habitats and transmission potential are reduced to their minima, then the final assault with drugs and biocides begins. By reducing transmission potential first, the cost-effectiveness of the drugs and biocides is maximized.

In contrast, when the expensive drugs and biocides are used first, they exhaust the financial resources available, and leave no opportunity to add the more durable methods later.

IN HARMONY WITH DEVELOPMENT

By working in harmony with national efforts for economic and social development, the Generalist Approach aids development by reducing the economic impediment of malaria and thus stimulating economic productivity (Jobin 2014 “Suppression of malaria transmission and increases in economic productivity in African countries from 2007 to 2011” in MWJ v5.4). Thus the country develops increasing national resources to pursue not only a final push for distribution of drugs and biocides, but also for enabling a final Exit Strategy.

THE EXIT STRATEGY

As national development spurred by malaria suppression provides affordable and reliable supplies of electricity, people in rural malarious areas can close up their houses at night and sleep under the breezes from electric fans, and the malaria mosquitoes stop transmitting. This becomes an Exit Strategy from the fight. This Exit Strategy has been followed as malaria has been eliminated from the USA, from Puerto Rico, by countries in Europe, and by Egypt, Turkmenistan and Mauritius.

Unfortunately the health specialists in Geneva and Washington see only the apparently quick results of the Specialist Approach, without realizing it is not in harmony with general economic development, nor does it have an Exit Strategy.

SUMMARY

Every country which has successfully suppressed malaria has used the Generalist Approach, and has harmonized its malaria control efforts with its national development program. No country following the Specialist Approach has successfully suppressed malaria. It is clear that the Generalist Approach is not only the superior investment strategy for the fight against malaria, it is also the preferred public health approach.

Comments

Jeff Juel's picture
Submitted by Jeff Juel on

I agree with everything in this very important post - with one exception. The practical environmentalist in me says: Wetlands are not Wastelands.

I am a devout Global Warming skeptic/heretic, however I have no doubt that wetlands are important habitats for a vast array of flora and fauna. (Even malarious wetlands.)

Being in harmony with development while out of harmony with nature will not pass muster under the current political/environmental climate. What worked in the past is not acceptable given the First World's post-1970 environmental sensibilities.

In America (beginning around 1900) we oiled (apply 30 gallons per acre & repeat ad infinatum), poisoned (with Paris Green and later with DDT), filled, and diked & drained our wetlands to oblivion. (Patterson 2009, "The Mosquito Crusades - A History of the American Anti-Mosquito Movement from the Reed Commission to the First Earth Day")

Levees for flood control (along with their associated drainage infrastructure) played a major role in the reclamation of America's wetlands beginning in the early 17th century It is estimated that America presently has over 100,000 miles of levees. (That is enough to circle the planet four times!)

America's levee-building days are long past. Even in the face of imminent catastrophic sea level rise (mythical, in this heretic's opinion), we are not building new levees and we are not properly maintaining our existing levees. Levees are not PC.

If USAID et al could somehow muster a comparable crusade/war on the wetlands of Africa, the political backlash would be incredible.

IMAGINE

Imagine a wetland that never floods. Imagine a wetland that is filled and then drained - with water - once (or twice) every day. Every time the wetland fills, the high water level is exactly the same as it was the last time the wetland was filled. When the wetland drains, it drains nearly completely.

Imagine that the filling and draining occurs without human intervention, without consuming energy, and with virtually 100% reliability.

This imaginary wetland would not propagate swarms of mosquitoes, however the wetland would retain it's environmental benefits. In some ways the wetland will actually be enhanced compared to it's natural state.

I have demonstrated a water control device (a type of a tide gate) that does this. It (in conjunction with a levee) will work for any wetland area that is within a meter or two of mean sea level. (Note that a considerable fraction of the world's wetlands are below or marginally above sea level.)

Reclaiming wetlands for agricultural development and for human habitation (sans flooding) is vital for economic development as well as for regional eradication of malaria.

The importance of preserving some fraction of a region's wetland habitats should not be ignored while we wage war on Malaria and other vector-borne diseases.

An innovative and environmentally sensible approach to land reclamation - with coincidental chemical-free larval source management - is a win-win-win proposition!

Jeff Juel, PE
www.jueltide.com

William Jobin's picture
Submitted by William Jobin on

Thanks Jeff, for your thoughtful comments about the need to preserve wetlands in Africa, and the equally important need to eliminate anopheline mosquito breeding around populated areas in Africa. You have touched me directly, as I have always been uncomfortable in the knowledge that what I advocate in terms of larval source management for the African situation, I fight in America for environmental protection. Your comments are helping me to work toward a resolution of that internal contradiction of mine.

It is clear that your ingenious tide-gates will be very useful in coastal wetlands around populated areas in Africa. One that I ran into in 2005 - when we started the US Presidential Malaria Initiative in Angola - was a coastal focus of malaria transmission in an area just north of Luanda. Your tidegates would save a great deal of effort and expense to suppress malaria transmission in that zone - known as Cacuao.

Another might be the water-bodies behind the coastal barrier near St. Louis in Senegal, at the mouth of the Senegal River. This is also an important fly-way for migratory birds coming from Europe and heading for southern Africa.

A third geographical site for using your tide-gates might be all the coastal swamps around the islands of Zanzibar. This would ease the need to continuously apply biocides and thus the drive toward resistance in the anophelines.

And I agree with you that wetlands are not wastelands. I used the term wastelands to note the impact of population growth and economic development in urbanizing all manner of generally difficult to develop wastelands - rocky land, desert, and steep hillsides.

So you have helped me start to deal with the issue for Africa. Coastal wetlands, especially around population centers - should be prime candidates for your ingenious tidegates. However, inland, around population centers, perhaps there are identifiable local zones where the value of malaria suppression outweighs the ecologic value of the wetlands. That is a difficult equation to construct.

And in reality, economic development and urbanization are destroying wetlands in Africa now, without the influence of our anti-malaria efforts. Ironically, this ecologically destructive impact of population growth will have the positive impact of permanently reducing mosquito habitats in urban and peri-urban foci. This is a bitter-sweet effect similar to the air, water and land contamination which accompanies urban growth - it wipes out the malaria.

Thus forecasting and guiding suppression of malaria in the face of urban growth in Africa is complex. Wetlands that have no role in anopheline breeding should surely be protected. And if they are coastal wetlands, the obvious way is to use your tide-gates. Thus the folks in Washington DC running the US PMI, and the specialists in Geneva running Roll-Back-Malaria, should realize that they need ecologists and engineers to tailor their obsession with biocides, drugs and bednets, and to thus deal realistically with the complexity of malaria transmission in rapidly developing Africa.

Bill, just starting to think about the issue

William Jobin Director of Blue Nile Associates

Jeff Juel's picture
Submitted by Jeff Juel on

Hi Bill,

I really appreciate your thoughts and encouragement. I wrestle with the fact that my drainage trick can only be performed using low-lying land adjoining a watercourse that experiences tidal water level variations.

On the other hand, deploying this in the right place would demonstrate that engineering & drainage infrastructure is vital for regional vector control. Other engineering solutions can be applied elsewhere.

The icing on the cake is that the modified wetlands would be enhanced with most of their environmental functions preserved - and some parameters would actually be improved by the tidal exchange.

The folly of nets is, or will soon be, apparent. This will create interest in finding better approaches. I'm biased and optimistic, but I believe that drainage engineering will be given serious attention for the next round.

I've been thinking about coastal drainage for 25+ years and I still find new related sub-plots that I hadn't realized. It's fascinating!

Keep thinking about it! - Jeff

Jeff Juel, PE
www.jueltide.com

William Jobin's picture
Submitted by William Jobin on

Thanks Jeff,

Classically, most successful attacks on malaria have started with drainage works, so maybe you are right, we should add it to the strategy. I am appealing for more engineers to join us in the quest, and to make their comments on this website.

Bill

William Jobin Director of Blue Nile Associates