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Fighting malaria, for non-malariologists

August 7, 2013 - 14:12 -- Ricardo Ataide

I was asked by a friend, who is not a malaria scientist (in fact, not a scientist at all) to imagine the following situation:

You were chosen by a malaria endemic country to direct their fight against the disease. The government of the country tells you they will adopt three strategies to fight it, solely based on your recommendations. What would those be?

I spent the next 15 min explaining i needed more information on where the country was, what type of vector was predominant, what plasmodium species circulated, what the geography was like, what type of health system was in place, what type of NGO and supply chains were on the ground already, if the country was at war, if there was a lot of migration, what the neighbouring countries situation was like, what were the population's perceptions of malaria and how they fought it until now, rates of other diseases...

He got very frustrated, and I understand him... But what would you have done? How do you begin to explain to someone who knows nothing that there is no magic bullet solution that fits every scenario? Or do you have an idea that would fit the 'magic bullet profile'?

Comments

Bart G.J. Knols's picture
Submitted by Bart G.J. Knols on

Dear Ricardo,
111 countries have already succeeded in eliminating malaria. Rather than measuring a myriad of factors before embarking on elimination campaigns, many of these countries measured a few parameters but were ruthless in their implementation of vector control and case management. If I could propose only strategies than these would be to massively increase larval source management (in a background of LLINs and IRS), and go for house improvements to reduce exposure.
My two coins,
Bart

Submitted by Ricardo Ataide on

Hi Bart,

I do tend to agree with you, although I would not put so much faith on LLINs and IRS. I mean, I would focus on more environmental engineering (including larval control measures) and community living standards (house improvements, reduction of sources of stagnated water, etc.) but still, I would need to know if vivax was present, for example, to know if I should opt for selective drug administration. And there is the question of how good the whole health system is (are there enough health workers, and centres and medicines available?). I guess at some point you have to stop thinking about every little detail and just go for it, you are right. But I'm guessing that to eliminate malaria in countries where the vector is strong and endemicity is high the devil will be in the small details.

Ricardo Ataíde

Bart G.J. Knols's picture
Submitted by Bart G.J. Knols on

All valid comments, Ricardo. But let's turn this the other the other way around - what if you had the choice to go somewhere and eliminate malaria. Where would you start? I guess that this will make it somewhat easier. But before giving you my ideas, where would you start?
Curious...

Submitted by Ricardo Ataide on

Now that is a very tricky question. To be honest, I am also curious! Where would I start? First I would start by admitting to myself that I do not know enough about the subject at hand to make the best decision (as you will probably derive from the rest of the post). Then I would realise that i do need to start somewhere so... let me think... I could go for the obvious choice of a really isolated, small and "turistically" interesting island (because that means I would have all the support i need, a confined territory, a small population that should not migrate much, hopefully only one or two vectors and one plasmodium species...). Or I could opt to hit a major hotspot and try to make some real damage to the transmission there (which hopefully would immediately impact on the neighbouring areas). Now this would have to be a country where there is enough development and a well set-up supply chain infrastructure... And i find I am back to my initial problem! I am probably over-thinking this, I know.

Anyway, you want an answer, so here it goes! Given a choice I would probably start in a country like Guatemala (not only it is beautiful and is the birthplace of the Maya civilization which I love but has all the necessary infrastructure, a not so high transmission, skilled professionals, etc.) or São Tomé e Príncipe (which would fill the previous 'island pre-requisites' and since I'm Portuguese I would have less of a cultural barrier to overcome).

Comments?

Ricardo Ataíde

Bart G.J. Knols's picture
Submitted by Bart G.J. Knols on

Believe it or not, but as I was reading your post I thought of Sao Tome and Principe before reading your similar suggestion. Interestingly, Principe was the first island where tsetse flies were eliminated...but malaria proves to be harder. Nevertheless, a totalitarian and integrated approach should definitely be sufficient to eliminate malaria from those islands. The Cape Verdian islands are similarly suitable and have only few parasites left...

What do others thinks?

Submitted by William Depp-Hu... on

I think that everyone is thinking too big at the begining. Need to show some success early in the process--Start with one village and begining to concentrically move outward. Present process is to throw nets here and there, spray here and there, never consolidate gains, and seem to check back after things breakdown. "Each one Teach one" was used years ago in reading, now we need to teach one MOTIVATED person in each village then they need to share the information with a nearby village. They should be enabled to TREAT patients while they do source reduction work for the mosquitos. Those most effected will need to be assisted in helping their own people. An affordable vaccine will help but as with polio it isn't the whole answer. Better to start with 10 neighboring villages and build from their success than treat 100 disjointed areas and have all throw up their hands when they can't prevent recurrances.

Bill Depp-Hutchinson

Submitted by Anton Alexander on

Ricardo, your friend is unlikely to do better than to start by studying the successful malaria elimination methods begun and used in Palestine 90 years ago. This would appear to have been the start of the first successful national malaria-eradication campaign anywhere in the world.

I can only report some of my findings to you, because the architect of this campaign, Dr I Kligler, has long since been forgotten, and as the active campaign was successfully concluded over 50 years ago, there are no participants around to explain the day to day steps which were taken.

Israel is now free of malaria, and in view of the severity of the disease in Palestine100 years ago, it must be assumed the methods employed were effective. Dr Kligler would have agreed there was no magic bullet solution that fits every scenario, but there were certain principles that can be seen he followed.

The campaign was antilarval in nature, it did not rely on drugs or vaccines, nor on mosquito bednets. Rather than go into lengthy details of Dr Kligler's complete approach, I will merely mention a few points where I think many do not appreciate their significance and may even dismiss them as peripheral to Dr Kligler's approach. This is not an exhaustive list. They were part of an elimination approach rather than one of control at that time.

To Bill Depp-Hutchinson and your comment to Ricardo's blog, I believe Kligler would have approved of your suggestion about showing some success early in the process. Before embarking on a national campaign, in 1921, Kligler demonstrated his methods in three different areas, and which were very successful and consequently enlisted general support for his approach. However, you continue that source reduction work should spread out to neighbouring villages. Before World War 1, before Kligler had come in 1920 to live in Palestine, the early Jewish Zionist settlers had attempted to control malaria, but had been driven back by the disease. There appeared little, if any, organisation in these attempts and in a 1911 Zionist handbook, it was stated to be worthwhile for separate settlements to be encouraged to undertake their own work. But by 1941 and after Kligler was involved, the British Mandate (Health Department) of Palestine reported on malaria elimination " ... it is only by placing work of this nature under the complete co-ordinating control of one Government organisation that successful results on a country-wide basis can be attained."

I further believe your suggestion, Bill, to teach one motivated person in each village would sit well with Kligler who wrote that a specially trained anti-malaria inspector responsible for the carrying out all of the control operations should be placed in each demonstration area. Kligler wrote the inspector should live in his district and have complete supervision of the breeding places, actual and potential. I am grateful to Bill Jobin for pointing out in a comment to a blog in June last that successful malaria elimination cannot be conducted by 'helicopter' people who fly in and fly out to deal with this. The person controlling the work has to be present and be involved all the time.

A point that appears to often be dealt with lightly is the education of the population. Malaria elimination is a long-term and ongoing process, and it is always necessary to ensure the significance and value of the work have been understood by the population. Kligler used to stress repeatedly that education was as important as the initial antimalarial work itself.

I mention the above as examples of the details and points presumably not considered with much seriousness when dealing with malaria elimination. I said above that the list of examples is not exhaustive. For those wishing to read more about Kligler's method, for an overview, see my blog of 10th October 2012 "Enthusiasm alone was insufficient to defeat malaria in Palestine 100 years ago. It required organisation and firm direction". You may also see Kligler's 1930 book on the subject www.kligler1930.com

Submitted by Ricardo Ataide on

Hi Anton, thanks for your comments! As I stated in my post, I'm hardly qualified in the area of malaria elimination efforts and all that it entails to be able to make the best judgment regarding where and how elimination should be achieved. I have read your previous posts about Dr Kliger's work and have also read through his book. I have to admit that it was a fantastic effort. I have my doubts on the applicability of the method in certain countries though, since he points out the great advantage of every village having a physician or a nurse and being equipped with, or close to a lab equipped with, microscopes. In countries without the infrastructure, man power, government organisation and so on it will be more difficult to implement those measures. Nevertheless, his focus on educating the population and thus empowering them is a lesson to all.

Ricardo Ataíde

Submitted by Anton Alexander on

Ricardo, Kligler would have agreed with you, and would not have carried on without the infrastructure, government organisation, etc to which you refer. The organisational experience of the British Mandate was there in Palestine immediately after World War 1 to assist Kligler in creating the environment and infrastructure where the elimination methods he would employ would work. The British understood the importance of organisation. But it was under Kligler's guidance these aspects were shaped and moulded. His basic attitude was that the methods would be thorough, and he ensured all the necessary aspects came together, were available together, and functioned together. Before Kligler came, these things didn't happen. He made them happen, together. That was his unique contribution.

Anton Alexander

Submitted by Anonymized User (not verified) on

The government of the country tells you they will adopt three strategies to fight it, solely based on your recommendations. What would those be?

1) Larval Source Management
2) Larval Source Management
3) Deport international aid agency personnel who advocate nothing but nets.

William Jobin's picture
Submitted by William Jobin on

Dear anonymous reader,

While I appreciate your passion for Larval Source Management, you should broaden your approach. No single method of malaria suppression has worked when applied by itself, with no additional support. So in the Blue Nile Health Project of central Sudan, where we dropped the malaria prevalence from 20% down to less than 1% for 10 years, we used the Kitchen Sink Strategy.

To explain, we used every method we could find, in a rational combination, except of course the proverbial Kitchen Sink.

So Larval Source Management should be used in addition to IRS, drugs, bednets, community involvement, clever irrigation and drainage, metallic screens on houses, extension of electrical service to malarious areas so people have fans for sleeping at night, etc. Use everything possible.

This approach not only hastens the drop in transmission, it provides a safety net when things go wrong, and reduces the pressure on drugs and biocides as they provoke resistance.

Use everything.

Bill

William Jobin Director of Blue Nile Associates

Submitted by Ricardo Ataide on

Hi Bill, I just really wanted to emphasise that key sentence in your post :

"(...) provides a safety net when things go wrong,(...)".

And they WILL go wrong most of the times if the majority of the methods used to combat malaria are deployed by external agencies using short-term solutions.

Ricardo Ataíde

Jeff Juel's picture
Submitted by Jeff Juel on

Bravo Richardo!

Strategy #3: Deport international aid agency personnel who advocate nothing but nets.

There actually is a charity organization working on Malaria named "Nothing But Nets" - and the road to hell actually is paved with good intentions.

Jeff Juel, PE
www.jueltide.com

Submitted by Anton Alexander on

Bill - The comments of the League of Nations, Malaria Commission, in 1925 when they inspected the successful malaria-elimination campaign in Palestine support your view. I quote from the 1925 Report:

"Our discussions were often concerned with particular anti-malarial methods and the available evidence of their relative efficacy. Palestine is sometimes quote as a country where reliance is placed almost entirely on measures for destroying the larvae of mosquitoes and eliminating breeding places of those insects. But the information collected by the Commission seems to show that, although some notable examples of effective anti-larval measures are available, the success in dealing with malaria in the country generally must be ascribed to the widespread application of all available anti-malarial methods rather than to sole reliance on any particular line of action".

Anton Alexander