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.