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First Law for malaria

January 6, 2010 - 16:41 -- William Jobin

FIRST LAW IN THE ATTACK ON MALARIA IN AFRICA
The attack on malaria will be like building a tall cathedral or a beautiful mosque, it will take generations.

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Malaria was controlled in Italy by 1962, about 60 years from the beginning of their multi-faceted campaign. Malaria is still under attack in the Americas, despite a century of effort, with periodic ups and downs, depending on development of resistance by the mosquitoes and the parasite, by political upheaval, by reorganization of the health agencies, and by changes in ecology. In Ndola Province of Zambia, some of the most powerful programs against malaria on the continent were started in 1929. But in 2010, about 80 years later, the disease is still endemic there.

If it took 60 years in Italy, with a temperate climate generally unfavorable for the mosquito, and only a short transmission season in the warmer months, how long will it take in Africa, where transmission can be continuous, where there are an array of adaptable mosquitoes and parasites, and where the torrid climate leads people to sleep outdoors?

There is a popular fantasy among donors and African nations who see a few years of progress and immediately translate it into the beginning of the end. See the inexperienced administrators in the US Presidential Malaria Initiative who appeared to think they could control malaria before the President retired! Instead we have to avoid such fantasies, and get realistic. We must be organize this attack as a long term program, not a quick project.

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Comments

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

Dear Bill,

All of your comments are highly valid and no one will argue that tackling malaria in its heartland Africa will be an easy target.

Nevertheless, an awful lot of 'nibling' can be done, to free major parts of Africa that reside on the fringes of the distribution of the disease.

The tools are there to free the entire north of Sudan (from Khartoum to the border of Egypt), where transmission only occurs along the Nile river. The tactics and strategy to do so can be copied from the campaign that was run in Egypt during WWII. Replace Paris green with Bti and one can start tomorrow.

Mauretania, with its highly focal and seasonal transmission should be able to eliminate malaria with a one-off rigourously executed campaign. The same probably is possible in northern Mali.

In the South, the nibling is possible in Namibia, with only the Caprivi strip becoming the border of transmission, the rest of the country could 'easily' be freed of malaria.

Island states (Cape Verdian island, Sao Tome and Principe, Bioko, etc.) should be able to eliminate disease within a few years - again, given the resources and a real will to do it.

All in all, this would mean that hundreds of thousands of people would be living in areas now free of malaria. Careful monitoring of the situation afterwards should be the way to avoid resurgence of the disease in a then non-immune population.

So 'Yes', it will be a long way to go, but also 'No', we can start here and there and harvest real benefits.

What do you and others think?

William Jobin's picture
Submitted by William Jobin on

You are right Bart, except that you site Sudan and the island states which rank low on my list for any kind of effort. I am not sure of Namibia, but I would start only in those countries with democratic governments which have shown they are stable and responsible enough to have already started to provide solid health services. Otherwise the money and effort is likely to be hijacked.

While dictators ran amok in Italy during the Second World War, Mussolini made some real progress in malaria control by draining the Pontine Marshes, until Hitler - an a fit of anger - reversed the pumps and flooded the marshes again. It wasn't until Mussolini was gone, and Italy developed a stable and democratic govt, that they made solid progress in controlling malaria. Which was a 60 year saga, by the way, from which I derived the First Law.

I have had worse experiences in Sudan, which brings me to the Third Law of Malaria - namely that dictators are worse than mosquitoes.

William Jobin Director of Blue Nile Associates

Mark Benedict's picture
Submitted by Mark Benedict on

Bill Jobin rightly points out that malaria elimination/eradication takes time, sometimes generations. He is correct, though the reasons are often not biological but political, social and economic.

Another reason is that there is no strategy for consolidating gains at the beginning of programs. There seems to be an attitude that any malaria prevented moves us in the right direction. With regard to individual protection and welfare, this is true. But will it move us faster down the road to elimination?

Perhaps a good test for us to apply to the intervention programs with which we are involved is this: If you were told that your funds would decline to 5% of their current level in 5 years, then what would the malaria situation be there 5 years later?

If the answer is "back where we started," the program is not on a road to elimination nor sustainability. The individuals who are benefitted will appreciate the efforts, but they will be disappointed when donors tire and efforts fade. The intense activity of years past will be a memory replaced with the old levels of transmission and few sympthetic donors. Isn't it our duty to do better?

This generation is in a unique role to make sustainable gains against malaria. Rush to reduce transmission should be accompanied by widespread efforts to permanently shrink the malaria map.

Mark Q. Benedict