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Sustaining malaria control in Africa

April 7, 2010 - 14:30 -- William Jobin

The current enthusiasm for malaria control in Africa will bring us much closer to our goal if we build on the successes of the past, and avoid repeating the mistakes. The major mistake in the global Malaria Eradication Program of 1955 was to embark on an unsustainable strategy, which collapsed within a decade. We need to ensure that current strategies do not repeat this mistake.

There is a serious need to understand our history right now, because of the growing unease among donors as they start to appreciate the costs of measures being employed in the current strategies in Africa. The current strategies are based on temporary measures which have to be continued indefinitely: drugs, chemically treated bednets, and spraying of insecticides.

Unfortunately those of us riding the new wave of optimism are missing two important historical points which we must correct, if we want to succeed. The first important point ignored by current planners, is that the sustainability and endurance of successful malaria control during the first half of the Twentieth Century in the USA, Puerto Rico, Europe, parts of Indonesia, and some other tropical islands, was because the strategies were based primarily on permanent environmental control measures. These included improvements in housing and installation of window and door screens. Also larval habitat control included filling and drainage of water-retaining depressions, and water management in large irrigation and hydropower systems.

The second important point being missed by current planners is that the new control methods being implemented in Africa by Roll Back Malaria, the Global Fund, and the US Presidential Malaria Initiative are based solely on the repeated use of drugs and insecticides, very similar to the Malaria Eradication Program of 1955. Given historic evidence for the implacable development of resistance by mosquitoes to any kind of insecticide, and the track record of the malaria parasite to eventually overcome any widely employed drug, our enthusiastic programs are again going to founder in the swamp of biological resistance. Resistance to the new artemisin-based drugs and to the permethrin chemicals used in bednets and indoor spraying is already showing in Asia and Africa.

A correction to our current strategies against malaria is needed to overcome the errors in thinking which have led us to the current programs. The correction required is fairly simple. We have to add permanent control measures to the temporary measures now being used.

As a first step, in addition to using treated bednets which have to be replaced or retreated every few years, we should invest some of that money in permanently blocking mosquito entry to houses through closing off the eaves and holes in the walls, and by putting metal screens on carefully built windows and doors. This is work which can be done by local carpenters. Even the home-owners can help. Covering ceilings with papyrus-paper has been recently employed successfully in Africa.

Secondly, in addition to spraying of houses, and treatment of larval habitats with chemical or biological agents which have to be applied repeatedly, we should enlist the skills of local farmers and laborers to drain or fill the habitats. Local people can be organized to dig ditches that rapidly drain away accumulated rainwater. On a larger scale, improved irrigation and agricultural drainage systems can permanently reduce malaria mosquito production.

Now is an ideal time to harness the enthusiasm for malaria control, especially in Africa. But to do so successfullly, we must read history properly. We will then see that adding permanent control measures to the currently unsustainable efforts in Africa is the only way we can continue the successes that we enjoyed in the first half of the Twentieth Century.

Bill, hoping for sustainability

Comments

Ingeborg van Schayk's picture
Submitted by Ingeborg van Schayk on

Thanks Bill for this interesting blog. I hope a lot of people will read and comment on this. It would be the most sensible thing to do: learning from the past.

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

Bill,
Every single word in this piece of writing makes sense, and the overall message is abundantly clear. I hope MalariaWorld will still be in existence in 2030, and that someone in that year will dig up your writing and hold it in front of the leading people then.

Excellent, many thanks!

William Jobin's picture
Submitted by William Jobin on

A major point of the historian Snowden about the suppression of malaria in Italy is that it went hand-in-hand with agricultural development (The Conquest of Malaria 2007 Yale University Press).  The same point has been made recently by Anton Alexander in his MalariaWorld blog reviewing malaria suppression by Kligler in the Holy Land.  Similarly, malaria suppression in Malaysia by environmental management of mosquito habitats has protected rubber and tea plantations, and then the mining industry, leading to the current economic prosperity of peninsular Malaysia.

This is an important point which should be noted by those attacking malaria currently, especially in Africa.  The attack should go in parallel with land reclamation, agricultural development and environmental management.  Historically this has been successful when land reclamation is the principal measure used to eliminate mosquito breeding sites.  The success stories include not only the subtropical countries of Puerto Rico, the USA, Italy, Sardinia and the Holy Land, but also tropical areas such as Malaysia and southern Africa.

Successful malaria suppression in southern Africa shows another aspect of parallel economic development.  The Roan Copper Mine has had successful malaria suppression for over half a century, despite the local presence of highly dangerous mosquito species.  Protection of the workforce and their families from malaria undoubtedly contributed to the enduring financial success of the mine.

In Malaysia malaria was suppressed around the rubber and tea plantations, and then around the tin mines, helping Malaysia to become an economic powerhouse.  This should be seen in the context of their neighbor Burma where malaria rages unchecked and where over-reliance on drugs has created drug resistance, which is spreading.

The contrast between Malaysia and Burma illustrates the two approaches to malaria suppression:  one which encourages economic development and one which drains the economy.  Historically, land reclamation has led to agricultural and economic development, thus making it possible for the country to prosper and maintain suppression of malaria.  In contrast, reliance on drugs and biocides has drained the economies and is thus unsustainable.  The misguided ephemeral strategies of WHO and USAID in the 1950's using biocides and drugs failed within 20 years as funding agencies lost heart.  The same strategies are being tried in this century and will again drain national and international resources until they collapse.

Snowden pointed out how land reclamation combined with an integrated strategy for malaria suppression was successful in Italy, and Alexander has reminded us how successful it was in the Holy Land.   We should spread this kind of malaria suppression into the heart of Africa.

William Jobin Director of Blue Nile Associates