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Eradication or suppresion?

September 21, 2015 - 11:36 -- William Jobin

What are the benefits of eradicating malaria, compared to suppressing it?

Eradication is a distant goal, perhaps one not attainable in our lifetime – perhaps never. Even its definition is somewhat vague, as there are so many forms of malaria. However suppression of malaria transmission is real and immediately attainable, something we are actually doing right now, in various degrees.

Perhaps examining the difference between eradication and suppression highlights the importance of the philosophical question: which is most beneficial to Africans, for they are the ones who suffer the most from malaria?

Very recently, WHO, RBM, and the US PMI claim to have protected thousands of people from death by malaria in Africa in the last 15 years. Whatever the accuracy of their numbers, those deaths averted are the benefits from their efforts in suppression, not eradication. Effort, resources and money were invested in preventing or suppressing transmission, and the lives saved were the clear reward.

But what is the clear benefit of our efforts in research or control aimed only at eradication, given that it is so distant? And by investing in eradication, are we foregoing the clear, immediate benefits of suppression currently being realized in Africa ?

Of course if eradication is achievable in the immeidate future, then the value of efforts in that direction is clear. Can we expect eradication in the immediate future? So perhaps the important question is how long might it take to achieve eradication? Or will eradication ever be achieved? Or will economic development and widespread availability of affordable electricity overtake the effort on eradication, and suppress malaria to negligible prevalences before we unleash our final eradication campaign? Remember it took 200 years to eradicate smallpox, with a very effective and easy to use vaccine.

Another aspect of this is - who benefits and when? If suppression occurs now in Africa, then everyone in Africa benefits now and continues to benefit for as long as malaria is suppressed. But if we forego suppression now, and await eradication, the benefits occur only to those who live in the malaria-free future, at the expense of those who are alive now.

Although these questions are somewhat philosophical, we should ponder their implications in the likely event that our current, ephemeral methods of suppression will soon come to naught, as the parasites become resistant to the drugs and the mosquitoes become resistant to the biocides. Then the benefits of suppression would also be ephemeral.

Thus there is a serious risk in attempting suppression by ephemeral methods. This risk is averted if we add durable methods to the suppression effort. Durable methods include permanent ecological changes such as drainage or filling of breeding sites, and permanent improvements in housing, including metallic screens and closing of eaves.

It is important to clarify what we are attempting to do about malaria in Africa. Is suppression with the ephemeral methods of drugs, bednets and biocides enough? Should we await the mythical goal of eradication? Or should we focus on durable and stable methods of suppression, now?