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Malaria control: history shows it's possible by Jose Antonio Najera-Morrondo

alaria has always land and the lowering of its value, so the cause of . been one of the that the least productive areas became Medical treatment for also has most serious even more intensely malarious. This a long history. Besides magic practices, obstacles to man­ direct association of agricultural neg­ many herbal remedies were prescribed kind's efforts to lect with this is enshrined in an in different areas of the world, some of develop , establish per­ old Italian saying that "malaria flees them with proven antimalarial action. manent settlements or in any way before the plough." At least four different remedies, includ­ modify the environment. The earliest ing qinghaosu ( annua), were civilizations recognized that unhealthy Early measures used in during the last 2000 conditions could be created by natural Protective devices against years. disasters, destructive wars or uncon­ also date far back in history. Herodotus Nobody knows how long the ­ trolled cultivation of the land. (484-425 BC) observed that in parts of vian Indians knew of the properties of It is no exaggeration to say that , above the marshes, people slept before 1500 AD, when an malaria has been responsible for much in lofty towers which mosquitos could Indian chief offered the bark of the of the suffering and misery not reach, while people living in the "fever " to the Jesuit missionary accompanying the process of social marshlands slept under nets. In the Juan Lopez. Nearly three centuries and . It has 13th century AD, Marco Polo noted later a physician and "inspector of also largely "fuelled" the vicious cycle that the wealthier residents of the epidemics" recommended to King of , ignorance and disease. A Coromandel Coast in India slept on Charles Ill of Spain that "since well-documented example occurred in bedsteads with curtains which could be cinchona is so effective in treating and southern Europe where, in periods of closed at night. Later, nets preventing this disease, I cannot but war or economic depression, the use and window screens were regarded as and the care of land declined; this protection not only from mosquito In 1630, the Countess of Chinchon favoured the of malaria, bites but also from "miasma! exha­ cured her recurrent fever with a decoc­ tion from the bark of a Peruvian tree. which contributed to further neglect of lations" (bad air) , then thought to be

4 WORLD . September-October 1991 beg Your Majesty to take the most @ ~'-1<>-u.~~""'".,-''-;1":., .; ,, widely from one area to another. appropriate measures to ensure that .g The main lesson we have learnt all the villages of this continent be ij from history is that many spectacular provided with such an effective anti- ~ _,. successes were ephemeral and fol­ dote, and that it be sold at a moderate ] lowed by severe resurgences, while price, so preventing the frequent adul- ~ · areas where malaria control was in terations that apothecaries (chemists) ~ ~ tune with local health and social make of this bark" Cinchona is the iil ' development have maintained their origin of today's and its ~ malaria-free status. derivatives. -~ :t Appropriate control Colonial times ~ Specialized technical competence is Malaria was a serious obstacle to the .§ essential to the planning of appro­ colonization of Africa, where the early J5 priate control measures, as well as to colonies-particularly in West Africa- i the training and reorienting of health paid a heavy price to this disease. ..9 and medical services so as to improve Although Europeans were conscious ~ . their performance and ensure the of the risks and even had some f of the local popu­ knowledge of preventive measures, lation. their urge to exploit natural resources Great expectations are now being as well as strategic considerations often placed on the development of a forced them to establish settlements in malaria . But, again, history highly malarious areas. From the late shows that some of the major break­ 18th century, better sanitation at the Malaria. Cartoon of from throughs in research were hailed as the trading posts and the increasing use of the French paper "", 1908. final solution to the problem. The cinchona and later of quinine permit­ discovery of the curative effect of ted large-scale European settlement, Guyana (then British Guiana), Taiwan cinchona, the isolation of quinine, the the massive exploitation of African (province of China) and . discovery of the malaria parasite and resources-and a century of intensive Tropical Africa and certain parts of its transmission by anopheline mosqui­ slave trading. South-East posed different prob­ tos, and the recognition of the residual By the mid-19th century, quinine lems because of their very high ende­ effects of DOT and other synthetic was being routinely taken as prophy­ micity, their underdeveloped state and all led to proposals for the laxis, a method later standardized by their lack of human and financial mass control and even eradication of in 1900, after the resources. Successes elsewhere, malaria. discovery of the malaria parasite. although slower than had been Looking back at such proposals, the Nevertheless the disease provoked anticipated, were nevertheless remark­ Second Report of the Malaria Com­ major disasters. Apart from the failure able. But as more and more areas mission of the in of the French corporation of Ferdi­ embarked on the consolidation phase 1927 commented: "The history of nand de Lesseps during the construc­ of the eradication programme, the special antimalarial campaigns is tion of the Canal, the expectation that a surveillance chiefly a record of exaggerated expec­ construction of many roads and rail­ mechanism would be sufficient to keep tations followed sooner or later by ways approached the grim mortality areas malaria-free once the spraying disappointment and the abandonment rate of the Mamore-Madeira Railway in operations stopped was not fulfilled. of work" Unfortunately that comment north-west Brazil, of which it was More and more frequently, there is still valid, after the renewed optimism said- perhaps with some exaggeration was a resurgence of the disease, that had been engendered by DOT. - that it left a dead man for every particularly in Central America and A healthy scepticism towards pan­ sleeper laid. South-East Asia, culminating in a mas­ aceas for malaria control does not Specific control of the disease began sive epidemic in 1958 in Sri Lanka, mean it would be justified to abandon with the discovery of the malaria where malaria had been almost eradi­ the more than one hundred million parasite in 1880 by Laveran, and of cated. Evidence began to accumulate people now suffering from the disease, the mosquito by Ross and that, although it was possible to reduce or to forget that nearly half of the others in 1897. These findings led and even interrupt transmission by world's population is at risk Although rapidly to practical proposals for the spraying over large areas, it malaria eradication is not feasible at interruption of transmission, and for was very difficult, if not impossible, to present, malaria mortality and a great appropriate diagnosis and treatment of maintain efficient surveillance in the deal of the suffering caused by the malaria. absence of a solid health infrastructure. disease can be eliminated by the The expectation of global eradication judicious use of available technology. DDT insectidde of malaria was finally abandoned in Eventually, as part and parcel of The idea of malaria eradication, 1969. health, social and economic develop­ which had been put forward as early as Present antimalaria strategies are ment, the malaria risk itself can also be 1916, gained fresh currency after the based on the recognition that, while it eliminated. • Second World War-when epidemics is relatively easy-provided there are had ravaged the devastated areas of sufficient resources-to bring about Dr Jose Antonio Najera­ southern Europe, while the insecticide rapid success in controlling malaria by Morrondo is Director of the DOT had appeared to be extremely effective interventions, the sustainabi­ Division of Control of Tropi ­ effective, not only in controlling those lity of malaria control depends on a cal . WHO. 1211 epidemics but also in dealing with complex of ecological, epidemiological, Geneva 27 . Switzerland. malaria in such areas as social and cultural factors which vary

WORLD HEALTH, September-October 1991 5