We propose that WHO should adopt a holistic Generalist Approach in their new malaria strategy.
W.Jobin of Blue Nile Associates and F.Snowden of Yale University
and including deliberations with many malariologists resulting in the Yale University Declaration on Malaria in 2006, and the Jerusalem Declaration on Malaria in 2013, both of which are available on this website.
8 August 2014
The World Health Organization just opened a public consultation to revise their global malaria strategy, and appointed a new Director for their Global Malaria Program. We applaud them for their openness in encouraging comments and suggestions as they grapple with one of the most devastating problems of global public health. For Africans above all, malaria is a major cause of suffering, underdevelopment, and political instability. As many as a million people die there every year from malaria, primarily children and pregnant women.
In recent reports, WHO has seemed over-optimistic with regard to its campaign against this deadly and debilitating disease. In fact, they are facing some serious fundamental problems, and it is critically important to urge them to avoid mistakes that have caused previous initiatives to fail. A major danger is that of repeating the disaster of the organization's Global Malaria Eradication Program (GMEP) that began in euphoria in 1955 but ended in disillusionment in 1969. It collapsed in large part because it adopted a one-size-fits-all reliance on only two tools -- spraying with the seemingly all-powerful insecticide DDT, and use of the inexpensive and intially effective drug, chloroquine.
The intervention was devised as a "quick fix" rather than a holistic, sustained and flexible campaign against an intractable and ever-evolving foe. When mosquitoes developed resistance to the insecticide and the parasites that cause malaria developed resistance to medication, the program was doomed to failure. The failure was all the more bitter because of the profoundly misleading promises of rapid eradication with which the campaign was launched.
Current WHO programs are worryingly similar. The GMEP adopted what one might term a "Specialist Approach" because the only methods employed were those familiar to physicians and public health specialists. The WHO program today relies on a similar Specialist, short-term methodology. Once again the antimalarial campaigners spray the inside of houses with ephemeral insecticides that are powerful and dramatically effective in the short term. They distribute temporary bed-nets treated with the same biocides, and they administer drugs that save lives in the short term but without making permanent changes to the malaria ecology or epidemiology, thereby leaving the people vulnerable to rebound epidemics in the future. Furthermore, these methods are costly because they must be re-applied continually. Annual expenditures on suppressing malaria exceed $2 billion, with only partial coverage of Africa.
Warning signs have already appeared. Malaria mosquitoes are again becoming resistant to the latest biocide, and malaria parasites are again becoming resistant to the latest medications. Donor fatigue, probably stimulated by over-optimistic expectations of rapid success, is occurring as it did in the wake of the dashed expectations of the GMEP.
It is all too easily forgotten that those countries which have successfully eradicated or controlled malaria have usually adopted a sustainable Generalist Approach. Instead of placing their faith in magic bullets, they have adopted all available tools, including improvements in health services, drainage, management of larval sources, housing, agricultural practices, education and economic development along with insecticides and medication. They have also enlisted populations in protecting their own health and they have provided them with the tools and the knowledge to do so. Well-documented successful examples from the second half of the twentieth century include Italy, Israel, Puerto Rico, the USA, Mauritius and Turkmenistan.
The Italian case is important and illustrative because it was the first antimalarial program on a national level to achieve unqualified success. Launched at the turn of the twentieth century, the campaign achieved final success in 1962, when in 1962 malaria was officially declared eradicated from the entire peninsula and the Italian islands. A major feature of the effort was its realization that malaria is one of the most complex and intractable problems of public health. It is at once a disese of poverty, of occupation, of illiteracy, of substandard housing, and of environmental degradation. As a result the movement followed the famous advice of Angelo Celli, one of the founders of the campaign -- "Do one thing, but do not omit others." What he meant was that the effort to combat malaria should make use of all possible antimalarial methods in the armamentarium. These included not only insecticides and drugs but also education, access to medical care through rural health stations, community economic development, improved agriculture, and housing improvements.
The failure of the Specialist, magic bullet approach by GMEP, the greatest public health intervention ever attempted to that date, had major negative and lasting effects on the global effort to control the disease. The premature and hubristic assumption that DDT and the inexpensive drug chloroquine would lead to rapid eradication, resulted in the elimination, not of malaria, but of scientific interest in malariology. It led to a prolonged period of low investment in antimalarial research, in the loss of a generation of field expertise on malaria suppression.
Under WHO guidance, fine tuning of a revised global strategy is being conducted by a Steering Committee which includes some of the leading figures in global public health. One hopes that the Committee will give careful attention to the lessons of the past, re-directing WHO toward a sustainable, long-term, and multi-faceted approach that will also involve and educate populations in defense of their own health.
It is also important for the Committee to include the voices of people with extensive field experience in suppressing malaria in Africa. The Steering Committee should develop a Panel of Experts on African malaria to guide the new Director in navigating the complex epidemiology of malaria in the several major ecologic zones on the continent. The effort needs to be tailored to local conditions rather than imposing a top-down, uniform effort.
Finally, it is vital to avoid creating unrealistic expectations by promises of rapid eradication with new technological panacea. A realistic campaign should mobilize resources for a long-term commitment to a general and sustainable intervention.
Notes on the co-authors:
Frank Snowden is Andrew Downey Orrick Professor of History and Professor of the History of Medicine at Yale University. In 2006 he published an award-winning book on the “Conquest of Malaria: Italy, 1900 - 1962," and in 2014 he co-edited the volume "The Global Challenge of Malaria."
William Jobin has worked in Africa as a public health engineer since 1963. He led development of a 10-year program on malaria suppression in central Sudan in 1978 and worked on it there for the first 5 years. In 2005 in Angola he helped start the US Malaria Initiative which now operates in 19 African countries. In 2010 he published “A realistic strategy for fighting malaria in Africa,” and has several other related publications.