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Spielman Et Al Jmedent 1993.Pdf FORUM Time Limitation and the Role of Research in the Worldwide Attempt To Eradicate Malaria ANDREW SPIELMAN, URIEL KITRON,1 RICHARD J- POLLACK Department of Tropical Public Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115 J. Med. Entomoi. 30(1); (1993) ABSTRACT The U.S. Congress established intense, time-limited, worldwide malaria eradication program in 1958 and assigned operational responsibility the U.S. Agency for International Development (and its predecessors). When the progra.Ti terminated schedule in 1963, =$400 million had been consuir.rid and malaria prevalence had greatly been reduced. Transmission began to; increase thereafter. The open-ended WHO global eradication effort began in 1955 ended'in 196,9 and consumed ^Si5 million during the 1958-1963 period of progress,, mainly proyided.by the United States. Intensified anti-. malaria interventions continued after 'Congress discontinued direct support. Although malariological research discouraged', during the' period ".of time'limitation,' it embraced the conceptual basis for the open-ended period of intervention that followed. This effort saved lives but expended ability intervene against future epidemics and reduced human herd immunity. To avoid the "great gamble" inherent in ambi- tious intervention against this disease, future programs should be designed seek incre- mental, local antimalaria gains. KEY WORDS malaria, research, health SOON reduced to its global height of the global malaria eradication effort, nadir in 1963, Clay Huff summarized his presi- and his remarks designed to demonstrate dential address to the American Society of Trop- that "Eradication is the logical goal of every pub- ical Medicine with the words, ". the.promise lic health effort directed against infectious dis- to rid the world of malaria quickly if enough .." (Karefa-Smart 1963). Although the money available somewhat like Rus- physician must render his patients pathogen-free sian roulette. The gamble great; the possi- rapidly possible, the public health practi- bility of failure underestimated ..." (Huff tioner must "Hrst" prevent epidemics. This nat- 1964). The program that he described had largely ural attitudinal dichotomy constitutes proper been created in 1957 by the Congress of the conflict between medicine and public health. United States and endorsed by succession The extraordinary effort required by eradi- of U.S. presidents-Eisenhower, Kennedy, and cation campaign is said to be "intensified" in that Johnson-and assisted by various United the required exceed those of the local Nations agencies, mainly the Pan American economies. Because external inevitably Health Organization (PAHO, then known become exhausted, intensified efforts must be PASB), the World Health Organization (WHO), limited in time. Attempts to suppress malaria and the United Nations Children's Fund particularly time-limited because the anopheline (UNTCEF). vector tends progressively to resist insecticides, '-lealth authorities naturally favor eradication the pathogen loses susceptibility to drugs, finan- Eesser modes of intervention agaipst infec- cial appropriations become exhausted, herd im- tions that threaten their constituencies. John munity declines, the operational staff becomes Karefa-Smart, the Minister of External Affairs of demoralized, and the subject population loses Sieira Leone and the former WHO West African nterest in the effort while learning to expect Area Medical Officer, illustrated this tendency in elatively disease-free state. For these reasons, his well-received keynote address to distin- -my heavily intensified antimalaria program (or guished medical audience that included George intervention against any other vector-borne Macdonald and Thomas H. Weller. One of nfection) must be scheduled to deintensify. (A.S.) also present. Karefa-Smart spoke at the The intervention technologies that support malaria eradication campaign must be fully de- College Medicine, rsity ol' lllim veloped and available for before operations Urbar begin, precisely because the time-horizon is 0022-2585/93/0006-0019S02.00/0 EntomoloRic.tl Society of January 1993 SPIELMAN RESEARCH WORLDWIDE MALARIA ERADICATION short Professional training, too, must be "The period between the late 1920s and the plete because the program aims also toward the early 1930s probably this century's low point extinction of malariologists; they should in acceptance of the eradication concept in the have little to study (Gramiccia & Beales 1988). prevention of communicable diseases." (Soper Basic research and high-level training had 1965). This in part related to the emergence place in the great gamble that Huff described. ofjungle yellow fever and transient outbreak of Such advocacy would be subversive. this infection that struck Brazil. Time-limitation and rejection of research The concept of eradication began to regain fa- appropriately distinguished the highly intense when the Mediterranean fruit fly elimi- phase of the worldwide malaria eradication pro- nated from Florida (1930-1931) and with F. L. gram from other, less-structured efforts. The dis- Soper's remarkable Anopheles gambiae eradica- cussion that follows analyzes the long-term tion campaign in Brazil (1934-1940). This anti- consequences of this discontinued effort. In par- malaria effort based comprehensive ticular, shall identify the conceptual origins derstanding of the ecology of the target insect, of the promise to eradicate malaria, contrast the considered factors such topography, terrain components of bilateral and multilateral efforts, and drainage systems, included excellent follow the line of reasoning that permitted the veillance system and rested varied intervention tactics to remain in effect long after mentarium of intervention (Soper & realistic hope of eradication abandoned and Wilson 1943). Although the sponsoring agency, describe how research attitudes shifted the the Rockefeller Foundation, appeared to avoid prevalence of malaria began its present ascent the term "eradication" in this first An. gambiae toward another zenith. campaign, its largely responsible for the rehabilitation of the eradication concept. This victory followed by campaign against wartime introduction of An. gambiae Early History of Eradication Efforts (in Upper Egypt), and by the program to eradi- Realistic attempts at disease eradication trace cate Ae. aegypti from Brazil (1942) and the Amer- back to the establishment of the Bureau of Ani- icas whole (1947). A final attempt to apply mal Industry in 1884, for the "suppression and the concept of species eradication to malaria extirpation of contagious disease among domes- directed against An, labranchiae in Sardinia in tic animals" and its attempts to eradicate animal 1946-1950 (Logan 1953, Kitron & Spielman tuberculosis in 1888 and 1892, when the 1989). tary of agriculture proclaimed the United States Initially, vector eradication seemed practical free of bovine contagious pleuropneumonia where infection had recently been introduced, (Hagen 1958). in island other "limited geographical units Eradication efforts directed toward agricul- with definite to be cleaned and with tural pests similarly date to this period. The de- natural protection against reinfestation" (Soper liberate introduction into California, for 1948). Eradication considered feasible if the ple, of Australian lady bird beetle greatly public health burden of the relevant disease reduced the damage caused by the cottony cush- ceeds the cost of eradication, if the vector is vul- ion scale, itself invader from that continent. nerable to attack in of its life stages, In the of human disease, early discus- if the vector be eliminated incrementally sion of eradication analyzes Gorgas' work yel- from limited portions of its range, if natural bar- low fever in Havana in 1901, the Rockefeller riers protect cleared regions from reinfestation, if Foundation sanitary commission for the eradica- necessary funding, labor, and authority avail- tion of hookworm disease in 19.10 and yellow able, and if the presence of the vector effec- fever in 1915: "Preliminary arrangements have tively be monitored. "As long evidence for the been made for survey to determine the feasi- existence of the [vector] species continues to ap- bility of undertaking at this time the eradication pear, the campaign has been failure. There is of yellow fever, and for experiments to test the such thing partial in species erad- practicability of controlling malaria." (Rock- ication; either achieves glorious efeller Foundation 1915). Thus, following the dismal failure" (Soper 1948). The Sardinia exper- disappearance of yellow fever from Cuba and iment would to fit into the latter category. Panama, global eradication considered; but A conceptual prelude to the intensified world- for malaria, less-ambitious goals then spec- wide eradication effort launched in the ified. United States during World War II, after The earliest detailed argument for the eradica- DDT became available for antimalaria interven- tion of malaria to have been expressed by tions. In 1943, L. L. Williams proposed that the insurance actuary who presented eloquent U.S. Public Health Service (USPHS) "sponsor plea for national committee the eradication and coordinate program for malaria eradication of malaria and well-reasoned plan for imple- to be executed through state and local health menting that goal (Hoffman 1917). departments, and that the Congress be requested JOURNAL MEDICAL ENTOMOLOGY Vol. 30, to make appropriation
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