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March 1, 2012 - 08:12 -- Anton Alexander

The disappointment and criticism about malaria elimination in Africa is palpable. There is an impression that the campaign of malaria eradication in Africa is sometimes rudderless, with money being thrown uselessly or ineffectively at the problem. 

The severity of malaria in Palestine 100 years ago was often about the same as in Africa now. (See to appreciate the extent of malaria in Palestine 100 years ago). Malaria was eradicated in Israel approx 45 years ago, and yet still there can be no reliable forecast about complete eradication (if ever) in Africa. In 1918, Palestine's malaria position was suggested by the British Mandate as 'hopeless', and some have suggested that is Africa's malaria position now. 
Whilst eradication commenced about 90 years ago in Palestine, (even though it may be viewed as an old superseded model) perhaps it would be useful to examine Palestine's eradication methods. Why? - because they eradicated malaria, and Africa still hasn't. There are possibly forgotten principles that could be applied even now to Africa. 
The League of Nations in 1925 in their Report after inspecting the eradication methods wrote 'the success in dealing with malaria in the country (Palestine) generally must be ascribed to the widespread application of all available anti-malarial methods rather than to sole reliance on any particular line of action.' In short, there was no magic bullet, and every infestation outbreak had to be examined and considered individually.
League of Nations delegation during a field visit to Palestine in 1925 (Dr. Kligler in second row left).
A big advantage which existed in Palestine then was that there was an imperative for thinly-populated Palestine to be made habitable before each settlement could begin. Disease would have killed, decimated and destroyed most attempted settlement. With Jewish immigrants desperate to enter Palestine, failure could not therefore be considered an option. Failure was a luxury they could not afford. But is there a fatalism today in African ruling circles and in the West towards Africa's malaria predicament?  
Dr I Kligler was the architect, the scientist who guided the eradication methods in Palestine from 1921/1922 onwards. He began with a modest experiment in malaria control in two or three highly infected sections of the country. Many questions needed investigation including whether malaria could be controlled with a small expenditure where no money was available for drainage. A detailed plan and approximate budget were sent, the plan was approved after some discussion, the money was made available (in fact more than sufficient for the purpose).
The experimental demonstrations in malaria control were conducted in three localities. No radical drainage was attempted. The campaign was carried out along three main lines:
1. Detection and treatment of carriers.
2. Anti-mosquito campaign.
3. Quinine prophylaxis.
and 4. Education.
When the results were tabulated they carried sufficient conviction to justify the preparation of a country-wide scheme with a proportionately larger budget, and as a result, a two years' budget was provided for a complete anti-malaria organisation. By 1925, Dr Kligler could write:
'The future is plain sailing. As the waste uncultivated areas are resettled, as the waters of the numerous springs now running to waste are harnessed for use, as the people learn to irrigate intelligently, the sources of the anopheles mosquitoes will increasingly disappear, and malaria will assume its place among the insignificant diseases of Palestine.' 
The League of Nations in 1931 wrote that they had visited Palestine in 1925 to specifically inspect measures relating to the destruction of mosquitoes and the carriers of the disease and to find out the effect of these measures. Dr Kligler had previously prepared a Report of 31st August 1923 for funding purposes, and which was subsequently sent to the League of Nations early in 1925 by the British Mandate. This Report seems to have triggered the League's interest in Kligler's methods of eradication which they inspected later that year. 
Had he been alive, Dr Kligler would probably also have recognised and empathised with much that was written by Andre Laas on 2nd February 2011 in the Active Forum Topics of MalariaWorld - 'The Role of Community Education and Involvement in Malaria Control'. It is unlikely that Kligler's eradication methods would have been successful without the British Mandate's statutory powers imposed on the Palestinian population, obliging compliance with the eradication methods and regulations. Drainage of swamps alone was not enough. However, whilst the legal machinery to enforce compliance existed in Palestine, it was rarely used because the population quickly came to realise involvement was for their benefit. But can African eradication be taken seriously unless there is the same necessary community involvement as existed in Palestine? And would Africa have the political will or foresight, if necessary, to introduce regulations either at a regional, or national, or continental level to enforce such involvement as existed in Palestine? 
Dr Kligler was not handed cash to spend freely as he thought fit. He had to justify the expense, and the money was to be spent in a planned manner that had been previously formulated. A bank manager usually asks to see forecasts and projections before he will lend money. This is useful because it obliges the borrower to be focused and to plan. Could Africa approach a bank manager for a loan? Does it have a plan? Providing cash without a plan is unwise because the venture will probably fail, and the cash donor may have doubts about giving again. 
A final word of warning that is often overlooked. Works of eradication are only the first stage, the second stage being subsequent regular inspections and maintenance of these works. The funds must be available for years to deal with maintenance, and failure to maintain will quickly permit the return of malaria. 
Unless Africa has a plan of action, it should go back to Dr Kligler's experimental demonstrations, otherwise it may jeopardise future prospects for anti-malaria funding by a lack of eradication results.


Submitted by Guest (not verified) on

What a useful contribution Anton A has made to the huge battle that is malaria.
I hope this article is read by all involved
As an inner London GP I have often been struck by how many of my patients fail to take malaria precautions seriously, and then pay the consequences after visits to family in Africa.

A few years ago we stopped being allowed to prescribe anti-malaria prophylaxis on the NHS.
Since that time, our own practice's number of malaria cases rose exponentially. Thank goodness all were mild, but we are often unable to persuade patients to spend the extra money, even though we of course wave any private prescription charges.