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Has practical malaria-elimination in the field lost its way?

July 25, 2015 - 11:20 -- Anton Alexander

The quest for the anti-malaria ‘silver-bullet’/’magic-bullet’ drug or vaccine. Has this confused, distracted, mesmerised or misled the practical (cf theoretical lab-based) anti-malaria scientists?

Google’s definition of ‘Silver Bullet’ includes “ A simple remedy or a quick solution for a difficult problem”. Simple. Quick. And its definition of ‘Magic Bullet’ includes “A drug or treatment that cures a disease quickly and easily without producing bad effects”. Quickly. Easily.

If that is the theoretical lab-based scientist's target, does also the practical scientist in the field consider malaria-elimination can only be treated as successful if achieved quickly, easily or simply?

Perhaps this is a moment to remind anti-malaria scientists in the field of Palestine over 100 years ago, soaked or drenched in malaria, and which was either uninhabitable or thinly populated. (In 1918, the British Army in Palestine had collapsed from malaria, but fortunately for the British, such collapse took place two weeks only after the final battle against the Turkish Army.)

The malaria position in Palestine in 1918 had been declared as ‘hopeless’, but by 1967, Israel was confirmed by the WHO as free of the disease. The malaria elimination had been conducted without reliance on mosquito bednets, and without reliance on drugs or vaccines.

In 1922, Palestine became the place for the first start of a successful national malaria-elimination campaign anywhere in the world, and it was based principally on the destruction of the mosquito breeding sites. But it was the one-to-one education of the whole population that was the key to the successful durable malaria elimination. The population understood the disease and also the need to ensure all anti-malaria elimination works were maintained. The population understood why thorough, continuous and systematic attention to the maintenance of these works for years was necessary, even though such attention was often tedious, repetitive and dull. But it took patience for approximately 40 years before the area was declared malaria free.

(Incidentally, and as if the above is insufficient to catch the attention of the world, the Malaria Commission of the League of Nations, after inspecting the malaria-elimination works in Palestine in 1925,had reported “Above all, it has succeeded in inducing the people of the country to take an interest in health problems and to cooperate in measures for the prevention of disease.” From this appeared to subsequently flow a result or consequence, namely, during the 1930s, the rate of natural increase in the Palestine population (ie birth rate over a consequently very low death rate) became the highest in the world according to the League of Nations.)

There have been so many false dawns in the search for this silver/magic bullet, and funders are becoming weary. The theoretical scientists should stick to their laboratories and should not be pulled down by the practical scientists out there in the field who persist with their plans around the use of bednets etc. The theoretical scientists will be tipped out with the bath water if the funders decide they are fed up with malaria generally and go on to some other ‘fashionable’ disease. The practical scientists will have to show better results, and could begin to make a start with the approach that had been adopted in Palestine 90 years ago. This will involve reorganising for intensive education of whole populations and also involving governments in the creation of a central health authority in each country to oversee and co-ordinate all malaria and other health activities in that country (and not permit separate organisations to go off to do their own thing.)

But in 2015, there are still no silver or magic bullets, no quick-fixes, no short or easy ways to eliminate the disease. The research must continue, but in parallel with the practical scientists who must begin to suggest a change of direction, and not continue to plan policy only around bednets.

And to remind the reader what is possible, study the following illustration.