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Tools, tools, tools...but what about strategy?

May 30, 2010 - 11:26 -- Bart G.J. Knols

As part of the TH!NK3 blogging competition 'Developing World', I wrote an article last week titled 'The man who saved Brazil'. It was the 11th article I wrote for this endeavour, and I see it as my most important one till now. It is the one I sincerely hope you will read. And let me know how you feel about it.

It's about Fred Soper. The man who remains a hero in small circles, but whose outstanding successes in the history of tropical medicine have been put aside. And what I am after is to find out why.

Simply put, I am not at all convinced that his approach cannot be used again. To put it stronger, as part of the new malaria elimination era that now tops the agendas of the Malaria Elimination Group (MEG) and the MalERA initiative, I see it as a golden opportunity to revive the Soper approach once more.

The success of Soper was the elimination of an invasion of the African malaria mosquito Anopheles arabiensis from a 54 thousand square kilometer area of Brazil. By running a rigorous elimination campaign largely based on larviciding. The tool was larviciding, a method still widely used today. The difference was the strategy: Soper assigned a grid of 25 sq km to one person, and this man had to treat every possible breeding site with larvicide. Again and again, until there were no more mosquitoes left. Simple, effective, and resulting in elimination.

It is this strategy that in all its simplicity fails to be taken up again. Although it is/was tried in The Gambia and Tanzania recently, the results were disappointing. In both cases I see insufficient rigour as the cause for this. It was not the tool that failed, it was the application thereof that killed it.

Current vector control is based on indoor residual spraying and the use of treated nets. Great tools, but the concensus is there that these will not suffice to eliminate malaria. Bring it down to very low levels, yes, but not eliminate.

And so we need more. Are we waiting for new tools to come along (e.g. vaccines, GM mosquitoes, etc.) or are we considering successful strategies of the past. That's the point here.

If we're serious about Shrinking the Malaria Map, we should get serious about area-wide tactics for vector elimination. Anyone in doubt should read Soper's book 'Anopheles gambiae in Brazil: 1930-1940' before dismissing the potential of Soper's strategy.

So let's sum up the arguments for NOT reviving the approach.

Why NOT to recruit young people, train them, and deploy them as part of an elimination campaign. Why NOT to assign grid blocks to them and make them treat all breeding sites using the environmental benign Bti. Why NOT to pay them well and exert military precision in the execution and rigour with which such campaigns will be made a success. 

In the article above I use Zanzibar as an example. Using Soper's strategy, 230 larval control staff should be able to eliminate malaria vectors from the island. Now that Zanzibar has brought prevalence levels below 1%, it is time to play the end game...

It is time for an open and balanced debate on the merits of proven old tactics that were successful in many parts of the world during the first eradication campaign. 

I hope to start it here and welcome your views.

Comments

Patrick Sampao's picture
Submitted by Patrick Sampao on

If Fred Soper's strategy was to be executed in Africa today, a toddler who isnt old enough to read now will one day come across an article, titled "The man who saved Africa."
I agree with you that we are better placed to wage and win a war against malaria than Soper did. The weopons we have today are way more advanced than his. However there is one integral thing we are missing today in Africa that Soper had in abundance, government support.
If African leaders dedicated just alittle bit of their time and government resources to malaria eradication, it would even take a shorter time than it took Brazil.

Regards,

Patrtick

Osvaldo Marinotti's picture
Submitted by Osvaldo Marinotti on

Nice post. This was an inspiring accomplishment.
However it is necessary to remember that approximately 500,000 cases of malaria still occur annually in Brazil. One battle was won. There is much more to be done before we can say Brazil won the war against malaria.

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

@Osvaldo. Absolutely correct. There is still malaria in Brazil and the endgame is still on. Would you believe that a revival of Soper's approach in Brazil could lead to elimination?

Osvaldo Marinotti's picture
Submitted by Osvaldo Marinotti on

Bart
I quick answer to your question, posted on June 2nd, is no, I do not think a campaign in a similar style, against indigenous malaria mosquito species would be equally effective.
It would be impossible to identify, map and treat all or most anopheline breeding sites in the Amazon (3,179,715 sq mi). But similar campaigns would be very effective if targeted to preventing urban malaria in cities such as Manaus and Porto Velho.