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Durable Malaria Elimination – You can take a horse to water, but you can’t make it drink

May 26, 2015 - 13:39 -- Anton Alexander

On 7th August 2012, Bart Knols brought to our attention a lecture by Margaret Heffernan entitled ‘Dare to Disagree’, and which can be seen at http://www.malariaworld.org/blog/margaret-heffernan-must-see-all-mw-subscribers . Margaret Heffernan spoke amongst other things about a scientist, Alice Stewart, who, in the 1950s, investigated and demonstrated the incidence of childhood cancer and its connection with the practice of X-raying pregnant women. Margaret explained the data was out there, it was open, it was freely available, but nobody wanted to know. A child a week was dying but nothing changed. It was fully 25 years before the British and medical establishments abandoned the practice of X-raying pregnant women. As Margaret commented, openness alone can’t drive change.

And so it also appears with malaria elimination.

For the umpteenth time now, it has been written that 100 years ago Palestine was drenched in malaria, and was either thinly populated or uninhabitable in many areas. And yet the following illustration shows Israel (along with Europe and North America) was free of malaria by 1970, whilst most of the rest world continued to languish with the disease.

 

The method employed in Palestine/Israel 90 years ago for malaria-elimination was based principally on larval-control through destruction of the mosquito breeding sites. It was not reliant on vaccines or drugs. Nor was it reliant on mosquito bednets. Its unique aspect was that of one-to-one Education, which not only ensured the co-operation of Arab and Jew, but also the durability of the malaria elimination through the maintenance of the anti-malaria works.

And perhaps the following will demonstrate the strength of that one-to-one Education, and the resulting commitment by the population to malaria elimination.

Subsequent to the defeat of the Ottoman Empire in World War 1, in 1922 Britain was commissioned by the League of Nations to administer Palestine and Jordan (formerly parts of the Ottoman Empire), and which became known as the British Mandate for Palestine and Trans-Jordan. Each year, the British Government submitted a Report to the League of Nations on the administration of Palestine and Jordan.

However, in 1936 and again in 1937, Britain reported to the League of Nations ‘that public security in Palestine was seriously disturbed by a campaign of murder, intimidation and sabotage conducted by Arab law breakers’. A British Royal Commission reported in 1937 that the manifestoes issued by the Higher Arab Committee under the chairmanship of the Grand Mufti of Jerusalem, the leader of the Palestine Arabs, were clearly prejudicial to law and order and the Mufti had to bear his full share of responsibility for those disorders. The British 1937 League of Nations Report described the violence as a ‘terrorist campaign which took the form of isolated murder and attempted murder; of sporadic cases of armed attacks on military, police and civilian road transport; on Jewish settlement and on both Arab and Jewish private property’. In 1938, the British reported to the League of Nations that the Arab campaign of murder, intimidation and sabotage ‘persisted on lines similar to those followed by Arab law breakers in 1937’, the campaign was intensified and a ‘gradual development during 1938 of Arab gang warfare on organized and to a certain extent co-ordinated lines’ took place. The 1938 Report described not only Arab violence against the British and the Jews but also acts of village and isolated murders and armed robberies by Arabs against Arabs.

Clearly the whole Arab population in Palestine was not responsible for the violence. The Reports referred to brigands and armed bandits escaping into Jordan and Lebanon, and sniping from across the Syrian border, and so it must be assumed that not only Arabs from within Palestine were involved but also Arabs from elsewhere.

There were sections of the Arab community in Palestine which did not sympathise with this violence, and it was these sections which were usually targeted by extreme Arab elements. In order to give an idea of the terror that must have existed, the 1938 Report further stated that many Arabs, ‘as the result of the local terrorism’, left Palestine ‘in the interest of their personal safety’. They became refugees. In 1938, many Jews had fled to Palestine, desperate to escape the Nazis in Germany. But even so, despite such numbers arriving, the Palestine Government statistics for that year show more Moslems and Christians left Palestine than all the Jews who had arrived that year – there was, overall, a negative number of people entering Palestine.

The fact that the Arab and Jewish co-operation with the anti-malaria maintenance works continued throughout  this period, that the co-operation had managed to withstand the violence and intimidation, is a testimony to the effectiveness and strength of the one-to-one Education (which education had been an absolutely essential part of the anti-malaria campaign from the outset in 1922). The Arab and Jewish population in Palestine had previously been educated to realise the anti-malaria work was for its benefit, and accordingly, despite the conduct of the extreme Arab elements, the population continued to cooperate with the work. Despite the above turmoil, despite the threats and intimidation, the Palestine Department of Health in its Annual Report for 1938 could still state:

“There was no cessation in antimalarial measures, either urban or rural. In the case of the latter, mixed areas of Jews and Arabs were sometimes a problem, but the difficulties in ALL cases were surmounted by voluntary Arab or Jewish labour with [the protection of] guards, …”

“Expansion in routine work in both urban and rural areas can again be recorded, although the generally unsettled state of the country probably rendered control of malarial conditions in the rural districts more difficult in this disease than in any other. Nevertheless, routine measures were well maintained and general incidence continued to be negligible. …”

But openness alone can’t drive change. You may read this, and still feel perhaps it is better for you not to have to change course (or perhaps you can’t be bothered to change), or perhaps that you will need to convince yourself why the anti-larval and education method couldn’t work in your area, you can  give-up and return to your mosquito bednets or your elusive search for the ‘silver bullet’.

But for those who are disappointed or disillusioned with anti-malaria progress, remember the malaria elimination campaign in Palestine/Israel worked. It was not a ‘silver bullet’ however.  It took almost 40 years. It was not easy – but it worked. And for those who perhaps wish to examine this further, see

http://www.eradication-of-malaria.com/smokers.html

http://www.eradication-of-malaria.com/malaria-education.pdf and also

http://www.eradication-of-malaria.com/malaria10-durability.pdf

You can take a horse to water, but you can’t make it drink.

Comments

Submitted by Anton Alexander on

The above article was written to try to demonstrate the high priority given to real effective Education of the whole population on a one-to-one basis in Palestine 90 years ago. Dr Kligler had written that the education was as important as the anti-malaria work itself, but it appears today that many pay only lip-service to or patronise the idea of education when considering malaria-elimination. Without that education in Palestine all those years ago, perhaps Palestine would have remained either thinly populated or uninhabitable.
Because of this effective education, it was not a surprise that malaria was going to be eliminated in Palestine with the population (both Arab and Jew) so strongly cooperating with the anti-malaria work.
Kligler’s malaria elimination campaign was begun in 1922 in Palestine. The League of Nations Malaria Commission in 1924 wrote in its annual Report that it couldn’t ‘suggest any single plan for dealing with malaria which would certainly be permanently effective in actual practice.’ But in the following year, in 1925, having been subsequently alerted to Kligler’s work, and visiting Palestine to inspect, the Malaria Commission’s 1925 Report stated the work ‘destroyed pessimism, raised hopes’ and concluded that the men involved were ‘… benefactors not only to the Palestinian population but to the world as a whole.’
President Nocht, the President of the Malaria Commission, also commented ‘Palestine showed the fruits of an energetic and victorious campaign which would stimulate others to follow the methods there employed’.
The malaria experts (from Europe and the USA) were there in 1925 in Palestine, they inspected, and were able to consider the intense education at first hand. Education is not something tangible, it can’t be bottled, and so it was difficult to describe in a precise way. But it must be agreed there was something special or unique going on for the Malaria Commission to have commented in the way it did in 1925. And the article above describes or colours just how effective and strong that education must have been in 1938.
The malaria elimination campaign in Palestine in 1922 was not intended as a quick fix, it was not a ‘silver bullet’, but it worked. This article is intended to highlight Education in the context of durable malaria-elimination, and is not intended as an alternative to or attack on parallel research for that elusive drug or vaccine that will eventually rid the world of malaria.
But in the meantime, remember the saying of Thomas Chalkley in 1713 ‘There are none so blind as those who will not see. The most deluded people are those who choose to ignore what they already know.’

William Jobin's picture
Submitted by William Jobin on

The unfortunate truth is Anton, that your historical analyses and broad insights on malaria suppression in the Holy Land are not being heard, or probably even read, in Geneva and Washington, where policy on global malaria control is made. I think it is largely because the folks in these places are interested in sophisticated research on subjects currently in vogue in the Scientific Establishment, and are not interested in history. Their attitudes led to the collapse of the Global Malaria Eradication Program in the 1960's, and will cause another similar disaster in the near future.

Beyond their deafness to malaria, the internal weakness and defects in WHO are available for all to see, after the Ebola debacle of WHO. These are made worse by the influence purchased by Big Pharma with their voluntary financial contributions, due to lack of financial support from UN member states.

But what can we do to effect positive change?

I am afraid we will not get a response until the next collapse of the malaria effort, and drastic improvements in WHO. In the meantime we should encourage people like Marcia M de Castro of Harvard who demonstrate the efficacy of larval control by community efforts, or by educators, engineers and ecologists who seek to revive or develop new and durable control methods.

The tragedy is that many people will suffer and die until then. I pray that we will live to see the revival of the historically successful approaches.

William Jobin Director of Blue Nile Associates

Ole Skovmand's picture
Submitted by Ole Skovmand on

i would like to pay attention to a much more recent and prhaps more relevant work. It was published in the American entomologist and it was about a university group of students and a few teachers, with students from US and Mali that went to a Mali village in a high endemic malaria area; they broght with them microscopes, larvicides and perhaps bednets,; they showed bloodsamples from the villagers to the villagers, they let them raise mosquito larvae to adults etc etc so they understood the cycle of malaria and the transmission and could see it with their own eyes; once they understood, the villager could manage themselves; they eliminated breeding sites, they took extra care to reduce mosquitoes in the dry season to delays onset in the wet and they used medicine correctly - they did everything with good sense in a discussion with the students and the professors, because they now understood. Nothing comes even close to education and knowledge; i do not know why this article has not been used widely in the malaria community, I think it is the best work ever done for malaria control in an endemic African area and it deserves much more attention

Submitted by Anton Alexander (not verified) on

To Ole Skovmand.
Would it be possible to request the US university to write or blog in MalariaWorld of their experience. Unless more people within the Malaria Elimination community appreciate the importance of education, I fear very little will change.
Anton Alexander

I believe the paper Dr. Skovmand is referring to is Dunkel et al. Sustainable Integrated Malaria Management by Villagers in Collaboration with a Transformed Classroom Using the Holistic Process: Sanambele, Mali, and Montana State University, U.S.A. American Entomologist 59(1):45-55. I'm the director of publications for ESA, the publisher of American Entomologist; if you would like to see a PDF of this paper, feel free to email me at ljunker@entsoc.org. If you have access to American Entomologist, you can view the article online here: http://ae.oxfordjournals.org/content/59/1/45 Thank you for your interest!

Submitted by Anton Alexander on

As a result of Ole Skovmand's comment, I collaborated with Professor Florence Dunkel of Montana University, and we have just published a paper 'Local Malaria Elimination. A Historical Perspective from Palestine 100 years ago informs the Current Way Forward in Sub-Saharan Africa' in the American Entomologist and Oxford University Press at https://academic.oup.com/ae/article/63/4/E1/4713025