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.
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.