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Lessons from the successful national malaria campaign of Italy 1900-1962

March 16, 2015 - 15:59 -- William Jobin

How could a fascist dictator realize how to control malaria in Italy 80 years ago, when we can’t figure out what to do in Africa today ?

NOTE; He did it in 3 steps: larval source management with larviciding, improved housing and education, and finally medical treatment

In 1899, by field experiments in the Italian countryside, Grassi confirmed findings from Cuba, Panama and Malaysia that anopheline mosquitoes transmit malaria, and that people can be protected by sleeping in houses with metallic screens. As he repeated these field experiments in other parts of Italy, he gradually convinced health professionals and the general public, who had previously been skeptical (Snowden 2007 The conquest of malaria, Yale University Press.)

Details on the origins and accomplishments of the successful Italian campaign against malaria can be found in Snowden’s prize-winning book. It is the most detailed, perceptive and analytical report on any country’s fight against malaria. Snowden’s book is also an important source of lessons on how we can succeed in the fight in Africa.

Drainage of the marshes

After 1930, in another large field experiment on the Italian coast west of Rome, the dictator Benito Mussolini drained the 80,000 hectares of the Pontine marshes, the first of 3 steps in a process he called Bonifacio Integral, or “Integrated Improvements”. The drainage was part of a detailed engineering effort to ditch, dike and pump surface waters out of the marshland and into the sea. In addition this attack on the larval stages of the mosquitoes included chemical larviciding with Paris Green.

The Pontine marshes, along the Appian Way, had been known as a malarious hazard since antiquity, also described more recently by Lord Byron and by Goethe.

Housing, screens and education

The second step in the Bonifacio was to construct healthy housing, schools, health centers and extensive roadways for 60,000 settlers brought in to reclaim the land. Although Mussolini claimed credit for this effort, in fact he had good advice from a number of Italian malaria experts like Grassi and Celli who had gradually accumulated an understanding of the local problems. Previous experience had shown that simple drainage was not enough; it was also necessary to maintain the drainage system and develop the new settlement by reclaiming the land for agricultural purposes. This area is still the most productive agricultural area in Italy.

The third step was medical treatment of malaria infections. This three-step program developed by Mussolini and his malaria advisors was a direct and carefully planned attack on disease and poverty, aimed at the impoverished country people, the paisanos.

Because of illiteracy and superstitions, paisanos had initially been suspicious of all government officials, including physicians who were insisting that people take the bitter quinine, which the paisanos suspected was a poison. Initially these superstitions impeded the medical effort. This is why Snowden concluded that education was fundamental to the success of the anti-malaria campaign.

Successful experience in the Pontine marshes was used to reclaim agricultural land elsewhere in Italy. Thus after the Second World War when DDT and chloroquine became available, suppression was simplified and economical, as the extent of transmission was reduced geographically and seasonally.

The spread of education as part of the three-step program made government efforts to spray houses and treat infected people more successful as people understood and trusted government. The attack on malaria was thus part of the formation of the modern state of Italy.

Although the disease persisted in many parts of Italy up to the Second World War, the death rate had been reduced 80%-90% by the Bonifacio Integrale and social improvements.

Lessons about timing

From 1900 when the malaria problem was finally understood and control methods were developed, it took 60 years to eliminate it from the national territory. Even after DDT and chloroquine became available, it still took another 20 years before elimination was achieved. And this was in Italy with a European climate and cold winters which impede the anopheline mosquitoes.

Thus suppression of malaria in Africa - with its ecology favorable to mosquitoes - should be organized with the understanding that several decades will be needed before real progress is achieved.

Comments

Submitted by jobin (not verified) on

Sorry, the term I should have used is "Bonofica Integrale."

Submitted by Giancarlo Majori on

Pardon, I’m Italian
I was going to add some comments to the paper “Mussolini’s war on Malaria” with special emphasis to the worrying question “How could a fascist dictator realize how to control malaria in Italy 80 years ago?” But the initial statement “Grassi confirmed findings from Cuba, Panama and Malaysia that anopheline mosquitoes transmit malaria, and that people can be protected by sleeping in houses with metallic screens” disappointed me at the point to avert my first intent. I would like to stress the point that the faint acknowledgement that a number of Italian malaria experts gave a good advice to Mussolini is just humiliating and gives wrongly to the dictator the halo of a “skilled malariologist” . I don’t want to enter into the detailed contents of the Snowden’s book, but I’m wondering how come in the paper it has been kept under silence the huge research work of the Italian School of Malariology and mixed up with the unlikely echo of malaria research imported from Cuba, Panama, and Indonesia. From Panama just a batch of the larvivorous fish Gambusia affinis was imported to Italy, and through the Rockefeller Foundation, the experience on the use of pyrethrum extracts, that initially gave few sporadic results. The secret of the success of malaria control in Italy originates from 1898, when the Italian malariologists, Giovanni Battista Grassi, Amico Bignami, Giuseppe Bastianelli, Angelo Celli, Camillo Golgi and Ettore Marchiafava demonstrated conclusively that human malaria was transmitted by anopheline mosquitoes, while the transmission cycle in culicine mosquitoes and birds infected with Plasmodium relictum was elucidated by Ronald Ross in 1897 (Nobel Price in 1902). This huge scientific background and the national antimalaria structures made possible the control of the disease in the whole country. In the Pontine Marches just the political exploitation of a long standing malaria control experience took place. No miracles! Finally, when after World War II, DDT became available P. falciparum malaria was stopped after only one year of residual insecticide spraying (1948). Few foci of P. vivax malaria reappeared, the last one in 1956 in Sicily, five years after the conclusion of the National Malaria eradication Campaign (1947-1951). DDT and the efforts of the Italian second generation’s malariologists were the key factors in getting rid of an unstable malaria from Italy. Nothing exportable in benefit of malaria control in Africa.

Submitted by jobin (not verified) on

Dear Dr. Giancarlo,

I am so pleased that you did submit your comments, and I apologize for over-emphasizing the role of Mussolini. If you read Snowden's book, he gives proper emphasis to all of those Italian scientists that you mention. I used Mussolini's role in the drainage operation because his name is so well known, and I hoped it would get people's attention.

Snowden mentioned the three principal groups in Italy who guided the fight against malaria, and in fact devoted an entire chapter to the influence of the 'Rome School' which included the scientists you mentioned.

Snowden also devoted several pages to the last point you mention - whether the Italian campaign has relevance to Africa. He felt it was relevant, primarily because the Italian success was based on a national and multi-faceted effort, guided by local scientists and governmental groups, whereas the current efforts in Africa such as Roll Back Malaria and the US Malaria Initiative are largely outside groups with very narrow strategies based on temporary mehtods.

Thank you for your comments, and pardon my poor spelling.

Bill

Submitted by Anton Alexander (not verified) on

Dear Dr Giancarlo,

You are correct. There was no miracle. (And Mussolini should not be given credit for any inspired thoughts on his part in the battle against malaria.) Italy in the 1920s was considered a centre for malaria research, and yet in 1924, the League of Nations Malaria Commission reported it still couldn't suggest 'any single plan for dealing with malaria which would certainly be permanently effective in actual practice'. But the Commission reported a year later, in 1925, after inspecting the antimalaria works in Palestine that others should follow the methods used there, and the people involved in Palestine with the antimalaria work were benefactors of the world (not just of the Palestine population). The result was that almost only Palestine/Israel (apart from North America and Europe) is shown as the only place in the world by 1970 as having eliminated malaria. The unique contribution made by Dr Kligler in 1922 in Palestine had been his emphasis on education. He stressed education was as important as destruction of the mosquito breeding sites (which breeding site destruction methods were different in every case according to the locality).
This emphasis on education is exportable for the benefit of malaria control in Africa, and Bill Jobin is correct to point out that several decades will be needed before real progress is achieved. But perhaps that is why the malaria professionals are too impatient in their search for the magic bullet, the quick fix, to realise or overlook the role that education plays in malaria elimination.