On 18th September 2009, Bart Knols submitted an article ‘Eradication, elimination, and control: Knowing the past of malaria.’ He wrote that malaria elimination requires a change of approach and a different way of thinking. Community ‘soft’ approaches will give you control, not elimination, and he pointed at historical successes in eliminating malaria which were based on rigorous military-style organised campaigns. http://www.malariaworld.org/blog/eradication-elimination-and-control-knowing-past-malaria
This seems to have been borne out in Palestine by the example of the unsuccessful pre-1914 malaria-elimination attempt and of the subsequent successful attempt in 1922, the beginning of probably the first successful national malaria eradication campaign anywhere. Before then, 100 years ago, Palestine had been soaked in malaria, and was either thinly populated or uninhabitable in many areas. Even the British in 1918 considered the malarial position ‘almost hopeless’. Yet approx. 45 years later, malaria had been eradicated there.
A report has recently been found in a series of articles printed in 1911 entitled ‘Zionist Work in Palestine’ on behalf of the Zionist movement explaining the movement’s activities in Palestine in its attempts to make the land habitable. The 1911 report dealt briefly with malaria .
It is necessary to understand the background to events in Palestine during this period in order to really appreciate the significance of this 1911 report.
Palestine before and during World War 1 (1914-1918) had been a part of the Ottoman/Turkish empire, and after WW1 was part of the British Mandate.
The 1911 publication explained the Zionist programme, formulated in 1897, as follows: “The aim of Zionism is to obtain for the Jewish people a publicly-recognised and legally-assured home in Palestine”. For centuries, Jews had experienced persecution, and during the latter half of the 19th century and later, many Eastern European Jews were still living in poverty, and still subject to anti-Jewish restrictions and pogroms/massacres. Their situation was desperate, and between 1882-1914, approximately 75,000 idealist Zionists arrived to settle in Palestine (not to be confused with the religious Jews who for centuries came to try to live –and die - in the Holy Land). However, by 1914, about half this number of Zionists either had died or had left unable to cope with the severe pestilential conditions.
The 1911 report commented on sanitary and drainage anti-malaria measures as part of an anti-larval attack on the disease. It even reported some 400,000 eucalyptus trees had been planted to drain the soil:
“‘The campaign against malaria must be conducted in Palestine on the principles which have been successful in other infected regions, but obviously the special circumstances of the country must be considered, and these require detailed study. There is already in existence a map of Palestine showing the distribution of six varieties of anopheles. If the means were available, work could be commenced at once in draining the marshes of Chedera, and in constructing a water supply and drainage system in Jerusalem. The infection of malaria is always a limited one, because the mosquitoes do not fly very far, and therefore it is worth while for separate colonies to undertake their own work of sanitation. It is quite different, for instance, in an epidemic of plague, where means of prevention are ineffectual unless the whole country is comprised in the scheme.
Even if it be not possible to start extensive operations against the ravages of malaria, there are milder measures which could be instituted forthwith, as has been done in Ismailia and Port Said. These measures include the use of quinine as a prophylactic and as a cure, and the employment of mosquito nets. Sanitary inspectors should undertake the covering in of pools, removal of manure heaps, the destruction of sewage and putrefying material, by petroleum, and the covering over of stagnant water by a thin layer of the same liquid. Cisterns must be occasionally disinfected with sulphur overnight, and drinking water also covered over with a thin layer of petroleum or dusted over with certain powders. Wells must be carefully covered in, and pumps used instead of buckets. The formation of ditches must be prevented, mosquitoes must be exterminated from their haunts on the roofs of barns, in stables, and in cellars, by means of sulphur fumigation. These comparatively simple measures would in themselves be followed by excellent results.’”
And yet despite this, despite the Zionists’ co-operation and enthusiasm, their desperate wish and need to succeed and make the area habitable, malaria continued to savage the area, and many of the early Zionists either died or left. Despite some basic knowledge of the transmission of malaria, but perhaps also on account of their mistaken understanding of other aspects of the disease, the attempt to settle these Zionists faltered. Nevertheless, the 1911 report is instructive by what is not mentioned.
After World War 1.
In 1920 Dr Israel Kligler arrived in Palestine. He was a public health scientist, a Zionist, and became the architect of the successful malaria eradication campaign in Palestine. In 1921/2, he introduced the method of eradication which was inspected and studied by the Malaria Commission of the League of Nations in 1925 which concluded its inspection report with the comment that the men involved with the eradication were ‘…. benefactors not only to the Palestinian population but to the world as a whole’. Israel was declared free of malaria in 1967.
In 1930, Kligler published ‘The Epidemiology and Control of Malaria in Palestine’ and which sets out the methods he employed. His book may also be seen at www.kligler1930.com .
Kligler explained that it was neither good economics nor sound practice to settle people in malarious areas unless provision was made to make them habitable beforehand, and as a result, the settlers came to realise that it was a foolhardy kind of martyrdom to succumb to malaria. Malaria was robbed of its inevitability, it was revealed as a preventable – and eradicable – disease.
Kligler introduced the organization of a malaria control area, and which may be studied at pages 134 - 140 in his 1930 book. He emphasised that malaria was eminently a local problem, and that a successful attack was possible only after a careful study of the local conditions combined with systematic experiments with the method or methods most likely to give the desired results.
Kligler did not bring any individual unique or novel methods of eradication. Instead, he combined and applied all the following particular methods together, and it is possible to appreciate how piecemeal and incomplete the 1911 attempts had been compared to Kligler’s combined inclusive, very organised and thorough package.
The League of Nations noted the particular methods which Kligler employed for dealing with malaria, briefly as follows:
- Preliminary investigation of the incidence and epidemiology of the disease, including the malaria survey of the area.
- Arrangements for treating cases of the disease, including detection and treatment of carriers.
- Arrangements for quinine prophylaxis. (This was only mentioned for completeness but not practised in Palestine under Kligler except in rare circumstances).
- Measures against mosquitoes – the anti-mosquito campaign. In general, the work was anti-larval in character and was concerned with limiting the breeding in wells, cisterns and other ‘man made’ water collecting and storage receptacles by regular inspections and ‘oiling’. Also drainage of the swamps would have come under this heading.
- Ordinances and Regulations were made after consultation with the British Mandate Health Department’s Anti-malaria Advisory Commission of which Kligler was eventually a member. These Ordinances and Regulations were made in accordance with which anti-mosquito measures at (4) were carried out in Palestine. Work was done in accordance with the Anti-Malaria Ordinances which obliged the population to co-operate with the eradication procedures. The number of prosecutions for failure to comply was 292 in 1922 and 453 in 1923. (Dr Cropper in 1905 wrote that efforts to influence the Turkish authorities to initiate anti-malaria measures had been unsuccessful. The British Department of Health in their review of malaria in Palestine after 1918 wrote that the testimony of pre-war residents in the country had definitely confirmed the fact that no adequate and practical medical organisation existed under the Ottoman empire. So measures obliging co-operation with any anti-malaria measures under the Turks would have been unthinkable.)
- Measures for improving the social and economic condition of the people, including measures of ‘bonification’. It succeeded in inducing the people of the country to take an interest in health problems and to co-operate in measures for the prevention of disease. (It will be noted there was no reference to education of the population in the 1911 report. Kligler pointed out that it was possible to obtain the population’s active co-operation only after the population understood fully the significance and value of the work. The population would also then have appreciated the maintenance of anti-malarial-engineering work is at least as important as the original project.)
It will be noted that methods (5) and (6) were absent from the 1911 report. Kligler stressed that (6) was as important as the other methods, and (5) ensured co-operation which was also essential. The failure of the pre-WW1 anti-malaria attempt was probably a lot to do with the fragmented/haphazard approach, the general population’s lack of understanding of malaria transmission, and no proper direction, whilst the success of the post-WW1 anti-malaria campaign would have been due to the combination of all the methods together, including the ‘rigorous military-style organised campaign’ at (5).
"The determined attempt by communities of Jews to colonize in Palestine might almost have been doomed at its inception, and, indeed, because of the prevailing hyperendemic conditions might have proved a most disastrous failure, had it not been for the particularly able manner in which defensive measures [against malaria] were gradually introduced. In the near future it will be no empty claim that country wide malarial control has been established. ........ The Jewish colonists [had previously] most frequently settled in the neighbourhood of that precious commodity, water, with the result that in a very short time malaria was rife, and, as in the village of Hulda, the settlement could only be maintained by annual replacement of part of the population." (21st November 1931 - The British Medical Journal - Control of Malaria in Palestine)
Zionist enthusiasm alone was insufficient to defeat malaria. There was no alternative to a complete and thorough firm methodical and systematic approach.