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Malaria, past and present

Paul Russell, the main architect of the Malaria Eradication Program, had promised the Eisenhower Administration that the DDT-spray teams would extend a hand of friendship to wavering Cold War allies, revive the entrepreneurial spirit of populations made dull and sickly by malaria, open up huge areas of fertile land for cultivation, pro-mote economic development, end poverty, and spur demand for American products. But the global DDT campaign turned out to be one of the most famous and costly failures in the history of public health. Although by 1970 the disease was eradicated in eighteen countries, most were already controlling it relatively effectively before the program began. Where malaria had been an unmanageable problem, the DDT program had little effect. After retreating for a few years, the malarious mosquitoes returned, now resistant to the chemical, and in some places killed more people than before. Third World poverty did not abate.

This paragraph comes from an excellent essay by Helen Epstein in the March issue of Harper’s.*

What I love about the piece—actually a book review of Sonia Shah’s “The Fever: How Malaria has ruled Humankind for 500,000 years”—is the way it shows the historical roots of a struggle still raging in public health assistance today.

As early as the 1920s, a group of researchers from the League of Nations put forth the theory that to fight malaria you also had to fight the social and economic conditions that caused it to flourish. Their recommended program of “rural uplift” called for swamp drainage, economic development, better housing, education, and health care in malaria-stricken areas. According to Epstein, this strategy had a steady string of successes, slowly eradicating malaria where it was tried in Italy, Borneo and the American South.

But scientists from the Rockefeller Foundation thought that mass-production of powerful insecticides (DDT) would be the silver bullet that would wipe out the disease, without having to improve people’s basic living conditions.

Recent anti-malaria campaigns like that of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, are similarly “predicated on the optimistic notion that fighting malaria is easy;” that if we can just distribute enough insecticide treated bednets, malaria will become a thing of the past. But Epstein’s main takeaway is that malaria is ultimately a political problem as much as a medical one, and “local politics, rather than the charity of outsiders, determines how successfully it can be controlled.”

*The link is, unfortunately, gated. But if you are a student or professor, check to see if your university has electronic access to Harper’s- NYU does.

 

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11 Comments

  1. Silver bullet thinking abounds. The fight against malaria has bednets and DDT, agriculture has GMOs and petrochemical pesticides and fertilizers. And the biggest silver bullet of all? The ‘free’ market.

    Posted March 24, 2011 at 5:28 am | Permalink
  2. geckonomist wrote:

    So what are the final results:

    1) League of nations with development economics blablah and lots of public money = no tangible results, malaria keeps on killing through the years. Tons of public money down the drain.

    2) Rockefeller foundation scientists: 18 countries eradicated (!) malaria , Tangible result : millions of lives saved.
    Most countries did controll malaria effectively before the DDT program began”. Ergo, at least one country did not : Thanks DDT for 100% saving REAL lives in at least one country!

    Guess which program gets the support of “aidwatch – just asking that aid benefit the poor”?

    Posted March 24, 2011 at 6:06 am | Permalink
  3. Thanks for this post. You might be interested in a related post ‘How do you solve a problem like Malaria?” posted on the Aid on the Edge of Chaos website in January, on the need for more evolutionary strategies to deal with malaria – it suggests that in malaria response, as in so many other aspects of international aid: ‘silver bullets are red herrings’.

    http://aidontheedge.info/2011/01/27/how-do-you-solve-a-problem-like-malaria/

    Posted March 24, 2011 at 9:58 am | Permalink
  4. Richard Tren wrote:

    Thanks for this post – the idea that controlling malaria is easy and that if you ‘buy a net’ you ‘save a life’ is of course false. It is the local politics that determines the success of any public health program, but Epstein (and Shah) are wrong in their statements about DDT. To characterize the malaria eradication program which relied on DDT as one of the most famous and costly failures of public health is misguided and wrong. While the program failed to eradicate the disease globally (while eradicating it from 18 countries) but it did save around 1 billion lives according to the WHO. By any other measure this was a spectacular success.
    Epstein says that where malaria had been unmanageable, DDT had little effect – but in these areas it was never really tried. Some pilot studies showed that in some heavily malarial countries, like Uganda, DDT would have worked spectacularly, but the pilots were never turned into programs.
    Opposition to using insecticides – DDT and others – increased from the 1960s onwards and by the 1970s malarial countries were having difficulty in obtaining it following the US banning of DDT for most uses – this is well documented by WHO.
    Malaria control is difficult but to blame the failures of programs on DDT when in fact it was much more often due to the inept program managers is absurd and something that any researcher could easily check. For a different, less sympathetic review of Shah’s book, see http://www.fightingmalaria.org/news.aspx?id=1592

    Posted March 24, 2011 at 9:59 am | Permalink
  5. Tim Ogden wrote:

    The conclusions drawn here by Shah, Epstein and Bill seem to be egregious examples of the common critique (which Bill often cites) of experimental approaches: program delivery and local context matters so findings cannot be assumed to be valid in other contexts.

    There are many many reasons why DDT programs may have succeeded or failed, or that other programs may have been working or not. Making broad conclusions from these findings reveals more about confirmation bias than anything else.

    Given what we know about the terrible state of malaria statistics today–which Bill and Laura have played a big part in making well-known–it’s also very questionable that any conclusions about malaria programs can be taken seriously.

    Posted March 24, 2011 at 10:34 am | Permalink
  6. William Easterly wrote:

    Tim, Please note the author is Laura. I am not disagreeing with the post, but it’s only fair that she be acknowledged and she can stand up for herself. Bill

    Posted March 24, 2011 at 12:22 pm | Permalink
  7. Tim Ogden wrote:

    Laura–apologies.

    Bill–when I click through on your tweets I tend to assume they are your pieces, without ever looking. Note to self: always look.

    Posted March 24, 2011 at 1:09 pm | Permalink
  8. Charles Kenny wrote:

    Dear Laura (and Bill)—

    I should admit up front I don’t have a subscription to Harpers and haven’t read the book…. So discount what follows…

    On DDT the story is that for some countries already doing quite well, spraying was the last nail in the coffin for malaria.  But in countries with rampant malaria, DDT was at best a partial and temporary victory.  Swamp drainage and other expensive and institutionally complex solutions really were the only way to completely defeat the disease, and most places failed to implement them (and still do).

    I’d certainly take the lesson from that ‘beware technological silver bullets.’  Yet another case where early hopes were out of proportion with actual impact (see also land titling, microfinance, rural Internet kiosks… although note even these, like spraying *did* have some impact, just not what was hoped).

    At the same time, ‘beware’ doesn’t equal ‘abandon.’ The smallpox vaccine is a silver bullet that worked.  Again, as a wise development thinker once put it “immunization against diarrheal diseases, micronutrient supplementation and oral rehydration therapy (ORT) have all been found to work in randomized trials in the fight against diarrhea….Case studies suggest ORT is another health aid success story, accounting for a substantial drop in diarrheal mortality since 1980.”

    In fact, I’d argue that the big success of development in health worldwide has been taking problems where the solution used to involve lots of money and very complex institutions and turning some of them into problems involving a lot less money and less demand on institutions.  Take, for example, waterborne disease.  It used to be the only way we knew to effectively respond was millions of bricks and huge amounts of digging to lay expensive sewage systems.  Today, ORT, handwashing, adding bleach to disinfect water and so on are approaches that very poor people can use on their own to improve outcomes without the need for strong institutions and obscene amounts of cash.

    My hope (and I admit it is a hope only) is that bednets plus antimalarials plus spraying plus maybe one day soon a vaccine might altogether provide a far cheaper and more straightforward approach to wiping out malaria than waiting until countries become rich.  Because we know getting rich can take an awfully long time. So, please, let’s not give up yet.

    Best,

    Charles

    Posted March 24, 2011 at 1:15 pm | Permalink
  9. Jsmes Moore wrote:

    Stephanie, I do not believe that free markets would be classified as a “silver bullet” tactic. Seemingly quick fixes such as the DDT campaign target the symptoms of less developed countries but true financial development and accumulation of wealth in those countries should help lift the people out of these hazardous conditions. I do not see free markets as a fix all solution but as a system through which developing countries can advance themselves through trade. Of course there is no way to ensure success of a country simply because they practice a free market economy, but it seems to be the best ideology for promoting equality and creating economic advancement opportunities.

    Posted March 25, 2011 at 2:32 am | Permalink
  10. Maria Victoria wrote:

    Research on malaria vaccines and insecticides definitely reduce the burden of the disease. However, only increasing housing conditions and better access to health services can malaria be eradicated. I have analyzed the socioeconomic determinants of malaria in Honduras and have found that: i)information campaigns are positive and produce externalities, ii) having access to a public (free) health service reduces the probability of having malaria.
    Maria V. Aviles, MSc.
    http://www.amazon.com/s/ref=nb_sb_noss?url=search-alias%3Dstripbooks&field-keywords=aviles+malaria&rh=n%3A283155%2Ck%3Aaviles+malaria&ajr=3

    Posted March 25, 2011 at 6:47 am | Permalink
  11. The great blues-gospel singer Blind Willie Johnson died of Malaria, in Texas, in 1945. The disease was eradicated from America by 1951.

    I wasn’t aware that the disease even occurred in America at that time until I started listening to Johnson!

    Posted March 29, 2011 at 6:59 am | Permalink

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