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Malaria can be eliminated from Africa

October 6, 2011 - 09:30 -- Bart G.J. Knols

A perspective article carrying the above title appeared in the American Journal of Tropical Medicine and Hygiene this month. As it was freely accessible I have taken the liberty to attach it to this editorial (hoping the publisher will not come after me...) for those of you that have not seen it. 

In it, Carlos Campbell and Rick Steketee inject encouragement into all of us that we have made substantial gains in the battle against malaria over the last decade, and that with the same relentlessness we may actually succeed in wiping the scourge off the continent. The article is a pleasant read when one starts up the computer and reads this first thing in the morning...
 
Regretfully, after a few paragraphs, the euphoria is spoiled when they write 'However, it is too soon to celebrate'. Both authors make a case for doing what we have done over the last decade, but than at an even larger scale. 'We have the tools' they claim, so basically the funding and management of scale-up are bottlenecks. And with hopefully a vaccine on the horizon in the coming decade, well, we should be in good shape.
 
When I sit back and contemplate over what I just read, it is hard to keep the positive spirit of the article with me. There is not a word on the dramatic increase in resistance, both against insecticides and, as some believe, artemisinins. Even in Africa. We're even losing DDT, and although Martin Akogbeto's group reports excellent results with bendiocarb in Benin in the article that comes next in this issue of the journal, how long will it be before resistance strikes back? Can we sustain the gains?
 
A few weeks ago I visited the National Library of Medicine in Washington DC, to explore the archives of Dr. Fred L. Soper, a man with major successes in the field of tropical medicine in his name. He was, for instance, instrumental in eliminating malaria in Egypt during WWII. I ploughed through just 9 of the 75 boxes with notes, diaries, reports, and articles and found the same level of enthusiasm about malaria elimination in Africa as I read in today's article by Campbell and Steketee.
 
One of the handwritten notes by Soper relates to the then (1963) recently published book ‘A textbook on malaria eradication’, by Emilio Pampana. Whereas Soper published a nice review (see here) of the book, on the note he scribbles some important issues:
 
 
First, he notes that the book has ‘None of the concept of eradication’. Today, half a century later, Campbell and Steketee write that we still have a hard time defining a blue print for elimination across Africa. What’s more, Soper writes on the note ‘Malariologists are now where Yellow Fever + Aa [Aedes aegypti] were in 1930. They have still not devised the technique of making low level transmission viable’. Again, fifty years later, Campbell and Steketee write about low level transmission by saying: Clearing these infections requires strategies to systematically find and kill parasites in the human population. This is not simply an improved management of symptomatic infections because many infected (and transmitting) people are asymptomatic; to further reduce transmission, we must find and cure all infected people.’ Soper and Campbell/Steketee clearly agree about this critical issue here – sad though, that fifty years have passed and we’re still struggling with such fundamental issues of elimination.
 
Finally, note that Soper states ‘Why should malaria have [a] time limit? [The] objective is zero’. Soper refers here to the opposing views within the League of Nations at that time – where some argued for sustained control yet others (Soper amongst them) argued for massive and immediate action to reach zero malaria transmission.
 
The somewhat political perspective of Campbell and Steketee would surely have been endorsed by Soper if he was still alive (he died in 1977). 
 
Good to see that collectively we are starting to appreciate the lessons from the past. 

 

Comments

William Jobin's picture
Submitted by William Jobin on

Thanks Bart, for the note about the article by Campbell and Steketee,

You are right to be sceptical, even though these two gentlemen are competent and experienced. However I think the sad truth is that they are disconnected from reality. What agency is going to carry out the task of fighting malaria in Africa? It isn't WHO. A friend in Geneva recently informed me that WHO is starting to lay off from 500-1,000 people in the coming year. Does that sound like they have a plan to fight malaria in Africa?

Or maybe the US PMI? The US is just now cutting their foreign aid programs drastically, and this will certainly wipe out whatever plans PMI had for Africa.

I fear that the bland statement that malaria can be controlled in Africa is similar to Bill Gates saying we can eradicate it. Just wishful thinking. You can't fight malaria with public relations and encouragement.

1. We need a realistic strategy, a sustainable approach that Africans can afford.
2. We need an African organization.

In place of WHO, I think it might be smart to go to the African Development Bank in Tunis and convince them to add malaria prevention components to their loans for water projects in Africa. Another group to focus on would be the southern African regional efforts which already have some success and are looking at sustainable strategies, instead of the drugs, biocides and bednets of the failed WHO strategy.

Bill

William Jobin Director of Blue Nile Associates

Submitted by Lauren Pinault on

Thanks, Bart. I especially appreciated Soper's words of wisdom that we ought to be helping our neighbors and not just protecting ourselves. Even when malaria-free countries fund elimination efforts, the "us vs. them" mentality among many people is scarily rampant.

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

Thanks Lauren, I had overlooked these very important words from Soper.

William Jobin's picture
Submitted by William Jobin on

I just attended a Grand Malaria Bash at the World Trade Center in New York on 16 November 2011, put on by Johns Hopkins School of Medicine, and focussing on their expanding field research on malaria control in Macha, Zambia. They will soon expand to another site in Zimbabwe and will become one of the leading field research centers. There were 10 speakers covering a broad range of subjects, mostly their current research at Macha.

It was interesting to note how many speakers alluded to the drainage of swamps in the historical advances against malaria, but how far removed their research was from such environmental approaches. The final and keynote speaker, Jeffrey Sachs from Columbia University said that we cannot expect the successes of the USA, the Panama Canal Zone, and the Pontine Marshes of Italy to be repeated in Africa because the force of transmission in Africa is so much greater than it was in those subtropical zones.

But I cannot forget the story of the Panama Canal. While the French lost thousands of engineers and laborers to mosquito attacks and eventually had to leave Panama, the Americans, by draining and oiling swamps and by screening houses and hospitals, built the canal. I think the force of infection in Panama at that time was pretty high, almost as bad as Africa. And a century later, malaria is still under control in Panama. Not eradicated; but suppressed to an acceptably low prevalence. Sachs doesn’t believe we can expect an analogy when hoping for similar suppression of malaria in Africa.

I summarize the following individual reports made at the Wednesday meeting:

Phil Thuma – Community involvement.
In the area around Macha Hospital, linked to many nearby community health centers, the prevalence of malaria had declined by more than 95% in the last ten years. He realizes that it might be hard to replicate such community involvement in other parts of Africa, but it might be a basic necessity for control. Community involvement is less expensive than a vaccine.

Sungano Mharakunwa – Surprises from the field.
Firstly, in an area where people have long been treated with sulfadoxine/pyrmethamine, the P.falciparum found in local people are highly resistant to pyrmethamine. However the parasites found in local mosquitoes were not resistant, but had high resistance to cycloguanil, despite absence of prior use of cycloguanil in the area.
Secondly, the decrease in malaria around Macha started before the interventions. Meanwhile, in Mutasa near the Zimbabwe border, there is a resurgence in malaria. So they are studying the epidemiology in both places, plus that of Nchelenge where the malaria is remaining high but stable. The center at Macha and a new one in Zimbabwe will receive increasing funding in coming years.

Photini Sinnis – How parasite establishes infection in people.
They are following parasite from its injection into the skin by mosquito, to its movement to liver, looking for weak points that new drugs could attack.

George Dimopolis – Stopping malaria in the mosquito belly.
They are engineering mosquitoes with super immunity to parasite. Then expect to use forced genetic system to get these traits into general population.
Bacteria in mosquito gut, plus Vitamin C, can kill the parasite. My question; why not just kill the mosquito?
***He concluded that no matter their success with genetically engineered mosquitoes; malaria control will require multiple interventions.

David L. Smith – How to lose the battle
The USA has been a prime funder of global malaria control efforts during the last 50 years but there have been irregular ups and down in the dollar amounts, with drastic effects. In 1963 the US contribution dropped, and the Global Malaria Eradication Program collapsed in 1969. Then worldwide efforts increased in 1978 but US contributions were small. In 1994 they went to zero. Why? Republican party took power in 1978, then Gingrich and Republican Revolution was in 1994. Gingrich cut the US contribution to UN, with drastic effects that we still see in the empty hallways of WHO building in Geneva.

Smith and his group has helped Zanzibar deal with question of going for complete elimination of malaria, or just control.

He wants to demolish 4 Myths:
1. MEP failed in 1969 because of DDT resistance. But in fact resistance showed up much earlier.
2. Malaria can’t be interrupted in Africa. No one has really tried.
3. Countries trying to eradicate it are worse off after their efforts failed. No evidence for this.
4. Climate change will make malaria worse. No evidence for this either.

***He concluded that any attempt at eradication would require a highly organized program with multiple interventions.

Jeffrey Sachs – Progress in the Forever War.
With current budget negotiations in Washington, funding for malaria control and research are on the chopping block. Nonetheless there has been incredible progress in last 100 years. By beginning of this new Millenium malaria is now confined to tropics, and is primarily in Africa. Since 2007 and with help from US PMI, attack has shifted away from clinics to homes, using rapid diagnostic tests instead of microscopic exams. Another major step is use of mobile fones. Sachs estimates that we could control malaria in Africa with $3 billion per year.

My comment: Sachs is very optimistic. More recent cost figures indicate about $10 billion per year is needed, and donor fatigue will set in if there is no Exit Strategy. An exit strategy would require permanent measures being added to the unsustainable ones currently in use. The obvious ones are permanent environmental modifications including habitat elimination and improved housing. I cited success in US and Italy, but Sachs did not agree. He thinks situation in Africa is much more difficult. But I think that the impacts from permanent modifications such as habitat elimination and housing improvements are in a different class from those due to drugs or biocides.

This was a strong group from Johns Hopkins, let's hope they continue to flourish.

William Jobin Director of Blue Nile Associates

Submitted by Ricardo Ataide on

Hi Bill,

Thanks for your review of the meeting. It certainly is helpful for those of us who didn't attend.

I'd like to speculate that on the conquest of malaria in the Panama canal area by the United States other forces (rather than transmission force) were at work. Namely, the political and economic forces that were "working their magic" so that the interests of a nation could be achieved. I think that that is a major issue with fighting malaria in Africa. There is no concerted drive or joint will driven by huge economic benefits (or no ability to glimpse them!). Ah, if only the Red Sea didn't exist and we had to build a canal from Senegal to Tanzania...

Cheers,
Ric

Ricardo Ataíde

William Jobin's picture
Submitted by William Jobin on

Hi Ric,

I see your point about the money and resources put into malaria and Yellow Fever control while the US was building the Panama Canal a century ago. There were other factors too. Juan Carlos Finlay and Walter Reed had just demonstrated in Cuba that people who slept in screened buildings did not get malaria nor Yellow Fever, while people all around them did. So the health establishment working with the canal builders was focussed on permanent protection methods and no longer bothered with bednets. This happened long before chloroquine or DDT - so they did not get distracted by these unsustainable measures. They did use simple larviciding however, using oil.

Also the canal engineers knew how to drain swamps, as well as cut canals through hills. So to protect themselves and the workers, the engineers drained everything.

You are right, if we were digging a trans-African canal, it is likely that a lot of swamps would be drained, and the vicious mosquitoes, blackflies and snails would be cleaned out so that the work force could be protected.

Although that might not happen on a grand scale, there are some opportunities of that kind, now developing in Africa, The African Development Bank is considering the Grand Inga Dam and others on the Congo River, to supply the hydropower for a huge part of central Africa. Ethiopia is planning a large series of dams, something like the US TVA development, in order to give them food and energy security in the face of disastrous droughts. These projects could be developed in ways that prevent mosquitoes, blackflies and snails from infesting the reservoirs, and could provide healthy and sanitary housing for the thousands of people who would have to be resettled around them. Thus the drive for food and energy - which is getting stronger all the time in Africa - could be harnessed to also improve the health of nearby populations.

The improved health around the Panama Canal was due to exemplary cooperation of health, entomology and engineering people with a common and clear goal. When we can overcome the current preferences of the health profession for unsustainable drugs and for endless spraying of biocides, and for such ephemeral measures as bednets, then we can make permanent progress against malaria.

The real puzzle for me, is who will do it? To play on words, that was a question, not a statement that WHO will do it. I am afraid WHO is about finished. Their Roll Back Malaria program is unsustainable, and their largest funder, the Global Fund, has just announced that it is out of money. WHO and the US PMI have proceeded blithely along for the last 6 years with no Exit Strategy. And now the people they have protected by these temporary measures are no longer immune to malaria, and will suffer devastating epidemics with the first really wet year.

Maybe we should look to the African Development Bank? Or some of the regional African efforts like SADC? We need to think about this. We need a new organization.

Bill

William Jobin Director of Blue Nile Associates