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Who was directing the eradication campaigns in those countries certified by WHO as malaria-free?

June 8, 2013 - 07:10 -- Anton Alexander

I wish to consider the situations prevailing in those countries where within the last 90 years, malaria had previously been endemic but which countries have since been certified by WHO as malaria-free. In particular, I wish to examine generally whether or not the methods of eradication were initiated/directed/managed/controlled on a daily basis by persons of that country OR by persons from outside agencies. I do not wish to consider the sources of the finance, but I wish to find out whether or not in those countries thus certified, did they initiate the campaign themselves and then manage and conduct it themselves, or did an outside agency step in, and the population merely complied with the directions given by the outside agency.

Whilst I realise if an outside agency would have been invited to deal with it, the head of that country would have assumed formal responsibility. But I am trying to consider who practically ran each campaign - was that a native person of that country or someone from outside.

I would be grateful if MalariaWorld readers could provide me some examples or information on this based on what they have seen or experienced.

Thank you.

Anton Alexander

Comments

William Jobin's picture
Submitted by William Jobin on

Dear Anton,

You raise a thought-provoking issue which I will try to address, based on my limited experience.

From my experience in Puerto Rico, the first tropical "country" which was declared malaria free in 1962 by WHO, there was no eradication campaign. The small island of Puerto Rico is a US possession with internal self-government, almost a state. Instead of starting an eradication program, malaria control was established within the local Health Department as a normal but major activity, within the normal functioning of the Department. Malaria control was directed and run by Puerto Rican entomologists and engineers, with career positions in the Health Department. When malaria was suppressed, the same entomologists went on to attack other diseases, such as dengue fever. In the Health Department there was a substantial budget for malaria control, and the Secretary of Health protected it, increasing it every year to compensate for inflation, and beyond. Much of the anti-malaria work was hand labor - digging ditches. There were some large-scale drainage projects, especially in coastal swamps around San Juan, the capitol city. Technical advice and assistance was provided by the federal government, through CDC Atlanta and their field station in San Juan, as they did with the other major communicable diseases. This was standard procedure for CDC assistance to the states, not a special eradication program. In the schools children learned about mosquitoes, malaria, the need for screens, along with wearing shoes to protect against hookworm, and to stay out of fresh-water to avoid the snails which transmit schistosomes. The kids taught the parents.

Through persistent, methodical and careful work, malaria was gradually suppressed. As the island progressed economically, people improved their housing, put screens on the windows, and closed their houses up tight at night. This was facilitated when electricity became affordable and reliable as more and more hydroelectric dams were constructed in the center of the island, providing electricity to even the most remote village. Suppression of malaria was a gradual process, mostly all environmental improvements, literacy, and community development. There were no mass drug administrations. Bednets were not used. In the hot, humid summer of the malaria transmission season it was impossible to sleep under a bednet. Even screens made a house feel like a sauna. So the final step really was the advent of small fans that made sleep possible with the house closed up tight. The Puerto Ricans did it themselves.

Even before the 1962 declaration by WHO for Puerto Rico, malaria was gone from the mainland of the US. But the same story about malaria had been true generally in the southern USA, especially in the Tennessee River Valley, a major subtropical region. There was no eradication campaign, just a gradual suppression of the mosquitoes. Malaria was a summer problem in the subtropical areas of the USA and was suppressed shortly after the Second World War, roughly 1950.

A key step in this process was creation of the Tennessee Valley Authority (TVA), an economic program, not a health program. During the Great Depression, the US government created the TVA to build a series of hydroelectric dams on the Tennessee River to stimulate the economy of this rural and subtropical portion of the southern USA. They carefully engineered the 17 dams on the river to minimize mosquito production. but the purpose, and economic justification for the dams, was to produce electricity and make industrial and rural development possible. Along the way, the TVA assisted rural families in community action to improve their homes, teaching them to paper the walls to cut off access by mosquitoes. People were encouraged to put screens on the windows and doors themselves. The climate was less humid in the Tennessee Valley than in Puerto Rico, and thus the advent of affordable and reliable electricity from the 17 dams made it possible to suppress malaria even faster in the southern US, than in Puerto Rico.

Based on what I read in Snowden's book on the control of malaria, I think the same was true of Italy, the next subtropical country to suppress malaria. There was no eradication program, just the steady work of drainage for agricultural improvements and housing improvements. The Second World War caused a major disruption of all government efforts. But economic progress after the war led to improvements in education, literacy, community awareness, electricity and health care, all of which caused reductions in malaria. By the 1960's malaria was a thing of the past in Italy. The Italians did it themselves.

In the rest of Europe, where malaria had been less of a problem, there were no eradication programs. General economic progress, improved housing, literacy, health education, development of low, marshy land for agricultural production, electricity availability, and the use of screens to control houseflies and mosquitoes, gradually suppressed the malaria too. The Europeans did it themselves.

I am not familiar with the history of malaria suppression in the Maghreb countries and others bordering the Mediterranean Sea. I think in Egypt malaria was under general control until the Second World War when An gambiae invaded the country from the South. In this case I think the Egyptians did mount a determined mosquito control effort, which was successful. But others will have to explain the history of that campaign. Of course the construction of Aswan Dam which produces over 2 Gigawatts of electricity since 1960 and supplies it to every small village in Egypt, changed the ecology of malaria drastically, so that people could sleep in closed or screened rooms, with electric fans. Malaria has not returned to Egypt since.

For more information on countries approaching certification by WHO you should look at the series of articles being published by Richard Feachem and Rob Newman, starting with Turkmenistan, Sri Lanka, Mauritius, and Cape Verde. In at least Turkmenistan and Mauritius, stable suppression of malaria coincided with the advent of affordable and reliable electricity. I think they intend to publish a few more reports.

Thanks for raising the general issue Anton. I think that if we are more clear about the key role of general economic improvement including agricultural development, literacy and community participation, and provision of affordable and reliable electricity, we might get rid of the ridiculous ideas of rapid eradication of malaria from Africa by outside agencies with outside funding, using temporary measures like bednets, and relying on fickle donors. I am very much afraid that this current model - which is followed by WHO and USAID - is headed for failure. Again. It is too bad the folks in Geneva and Washington don't pay attention to the history of malaria control. But they are helicopter people, who think they can quickly fly in, eradicate malaria, and fly out.

Instead of their helicopter approach, we have to see malaria suppression as an integral part of Africa's general development. It should be established in the Ministry of Health as a permanent program, with permanent staff, to continue until economic progress brings in agricultural development of marshy areas, literacy, community awareness, improved housing, screened windows, affordable and reliable electricity, and electric fans.

Malaria will be suppressed in Africa when it is seen as a goal by all sectors of society, not as a medical problem, and not something a country should expect to be given to them by outside agencies.

So let's broaden our approach.

Bill, still thinking of ways to do this

William Jobin Director of Blue Nile Associates

Submitted by Anton Alexander on

Thanks Bill for that very helpful comment. I am grateful.

To all other MalariaWorld readers, does anyone know of ANY country that has been certified malaria-free by WHO and where the eradication campaign has been managed or controlled by an outside agency. If yes, please state the country when replying.

It would help a great deal if MalariaWorld readers would reply or comment so that I would know this blog has at least been read or considered. Please don't remain silent.

Either a 'No' or a 'Yes + country' will suffice.

Thank you.

Anton Alexander

Jeff Juel's picture
Submitted by Jeff Juel on

Bill - Your thoughts regarding successful eradication campaigns are a breath of fresh air.

I've been disappointed - to say the least - by the emphasis on mosquito nets, new drugs, and hopes for vaccines or some other silver bullet to end malaria. I am by no means an expert on this, so I am am excited to see that I am not crazy - or at least I'm not the only critic of bed nets.

Drainage, screens, and economic advancement have worked to eradicate malaria in many locations in the past. They will ultimately work in the future. So why are these approaches under-appreciated today?

I have a number of theories:

1) In the first half of the 20th century, engineers in America wreaked havoc on our wetlands in the name of vector control. This approach devastated wetland species. Around 1945, the Mosquito Crusaders began relying on DDT. From today's perspective, this makes the "Old School" look despicable.

2) Modernization is a dirty word. If the people in the third world gain electricity and modern infrastructure, their exotic primitive cultures will be lost. Westerners have a romantic attachment to primitive cultures: "Stay in your huts and be hunter-gatherers or subsistence farmers - just be sure to sleep under insecticide-laced bed nets."

3) Irrational fear of more and larger carbon footprints. If the third world experiences economic growth and increased GDP, they'll consume more stuff and emit more CO2. The "Global Warming and Sea Level Rise" hysteria of the 1990's morphed into nebulous "Climate Change". Exposing this political/bad science will go a long way towards improving the prospects for economic development in the third world. I may be an irrational optimist, but I think that the Emperor has no clothes - and people are starting to talk.

4) Civil Engineers do not blow our horns. We need to be more vocal about we do and why it's important. Civil Engineering is the Engineering of Civilization. It's the most important job in the world!

Thank you for being an outspoken engineer working on malaria! Engineers will not "solve" the malaria plague, but we will play a major role.

Keep thinking of ways to do this.

Jeff Juel, PE
www.jueltide.com