WORLD HEALTH ORGANIZATION REGIONAL COMMITTEE Ninth Session I'1anila
REGIONAL OFFICE FOR THE WESTERN PACIFIC TECHNICAL DISCUSSIONS WP/RC9/TD1 14 April 1958 ORIGINAL: ENGLISH
The following four technical papers are presented as backgrqund information for the participants attending the Technical Discussions to be held during the ninth session of the Regional Committee for the Western Pacific. These papers were prepared by the regional office secretariat from material contained in the sixth report of the \rJHO Expert Committee on Malaria\ "Malaria: A \rJorld Problem", by Pampana and Russell, which appeared in the February 1955 2 1 number of the Chronicle of the 1 Jorld Health Organization and from other available sources. They are intended to focus attention on the administrative aspects :t-1ii.IARIA ERADICATION, of the the:me for this year Is Technical Discussions:
It is hoped that these working papers will be useful to the representatives in preparing for the Technical Discussions. arA invj.ten AJJd
Comments regarding these documents
should be directed to the HeeionRl Director.
lwld Hl th Or g. techn. Rep. Ser. ., 1957, 123 2 Chron. ~Ud Hlth Org. (1955)
2,
33-_97
C 0 NTE NT S
1
PRINCIPLES OF 1.1 General
MAL~IA
ERADICATION
1 1 1 2
Methods of attack
1.3 2
Aims of antimalaria campaign
PLANNING AND ORGANIZATION OF AN ERADICATION CAMPAIGN 2.1 Organization of national malaria services Budget Personnel
7
8
9 10 ~VLLARIA
3
OTHER ASPECTS OF
ER1\DICATION
12 12
The relation of malaria eradication to other public-health activities The relation of malaria eradication to other government activities
14
3.3 4
The r,elationship between inter-country malaria projects MAL~RIA
16 18
ECONOMIC CONSEQUblNCES OF
WP/RC9/TD1 ORIGINAL: 1, 1.1 Q.eneral PRINCIPLES OF MAUL~IA
ENGLISH
ERADICATION
The epidemiology of malaria does not differ in essentials from that of any other disease~ If one case of malaria gives rise to more than one secondary case, the disease will increase. If it gives rise to less than one secondary case, the disease will eventually disappear. The lowering of the reproduction rate to below unity is the aim of all malaria control schemes. The transmission of malaria depends on four factors, each of whicb is liable to attack, First, the density of mosquitos in relation to man; seco~dly, their expectation of life; thirdly, the frequency with which they bite men rather than animals; and fourthly, the proportion of the human population that can infect the mosquito, usually expressed as the gametocyte rate. These fac.tors are of varying importance in the transmission of the disease. Reduction of the length of life and decrease in the man-biting habit have much more effect on the transmission rate than reduction of the density of mosquitos or of the ga;netocyte rate" Probably the best measure of the density of malaria in any district is the number of infective bites received by any member of the population during the year. There is enormous variation in this number and in many areas in the Western Pacific Region it is of the order of one :to two infective bites per year. In areas vJhere malaria transmission is intense, such as New Guinea, the number may rise to above 100. It is clear that the difficulty of malaria control will depend on this figure. 1.2 Methods of attack
There are three practical methods of breaking the transmission of malaria: larvicides, residual insecticides and drugs. 1.2.1 Larvicides
Larvicides killing the aquatic forms of the mosquito would appear to be the method of choice, the mosquito being attacked in its early stages before it can transmit the disease" However, the mosquito which survives the larvicide has a full expectation of l:i.fe as an adult and may become an efficient vector. To be successful, larviciding must reach near perfection. In most rural areas the breeding places of mosquitos are many and difficult of access, s'o that it would be economically impossible to keep the area around every village free from larvae. In towns, on the other hand, where population density is high, destruction of the sites of mosquito breeding is usually the most reasonable method of control. It improves the general amenities of a town to remove standing water and it is an advantage to kill all mosquitos, although the majority may not be concerned with malaria transmission.
/1.2.3
Residual insecticides
WP/RC9/TD1 Page 2 Residual insecticides The present world-wide attack on malaria is based on the use of residual insecticides to kill the adult mosquito. This method has,several obvious advan .... tages. The long residual effect of the insecticide means that application can be ~ade at infrequent intervals. As most malaria-carrying mosquitos bite inside houses, the insecticide is applied indoors and is protected from the effects of the weather. Larvae breeding sites by their very nature must be treated frequently, as the insecticide will be washed away by every shower of rain. The attack on the adult mosquito does not have to reach perfection to prevent transmission of the disease, as no mosquito less than ten days old can transmit malaria. If residual insecticides increase the natural daily mortality of the mosquitos by a quite small amount, the transmission of the disease is broken, the exact figure depending on the intensity of transmission and the habit of the mosquito. In. a few countries a very high mortality has been achieved, resulting in the complete eradication of some species of mosquito. This extremely satisfactory result is unusual and most campaigns with residual insecticides will not eliminate mosquitos. It is important to stress this fact in the early stages of the project, otherwise the continued presence of mosquitos will be considered evidence of the failure of the campaign. 1.2.3 Antimalarial drugs
The third form of attack is by the use of antimalarial drugs. Although these drugs are usually employed to treat or suppress clinical malaria, in eradication projects they are used for their action on the reservoir of gametocytes in the human population. 'l'he reduction of the gametocyte rate will result in a reduction of the reproduction rate, although the effect is not nearly so marked as that produced by a reduction in the expectation of life of the mosquito. Drugs can be given to large numbers of the population in the form of single dose mass treatment to decrease the size of the human reservoir infective to the mosquito and such mass treatment can easily be in,corporated into a spraying campaign with :residual insecticides., Special groups can be given repeated dosage with antimalarial drugs to produce complete suppression of malaria. This is usually possible only in communities under some form of discipline. Antimalarial drugs must be considered as accessory to residual spraying; malaria has been eradicated in several areas by spraying alone, and never by drugs. Another method of attack, still in the experimental stage, is the incorporation of an antimalarial drug in some widely used article of the diet, such as salt. 1.3 1.3.1 Aims of the antimalaria camEaign Vector eradication
The complete elimination of the malaria vector is, in most circumstances, not yet technically feasible. It is clearly the most desirable result and research into methods to achieve it must continue. /1.3.2. Malaria eradication
WP/RC9/TD1 Page .3 1 • .3~2 Malaria eradication
The eradication of malaria is not only a theoretical possibility; it has already been achieved in several areas and is in prospect of achievement in many. The criteria of malaria eradication are, that malaria transmission should have been broken, that the reservoir of infected cases in the human population shall have been removed, and that an organization shall have been set up which will prevent the recurrence of transmission from imported cases of malaria. The practical test of eradication is that the disease does not recur even when antimalarial measures have been stopped. 1 •.3 • .3 Mal~ria
control
Malaria control is the reduction of the number of cases of malaria to such a low level that the disease is no longer a public-health problem. If control stops short of eradication, the disease will recur when control measures are stopped. The disease may in fact recur in a more serious form, as a period of effective control is liable to lead to a reduction in the general immunity ' of the population. Resistance of anophelines to insecticides is more likely to occur in long continued control schemes, The radical differences between an eradication programme and a control programme are shown in the following table~ Table I
ITEM
CONTROL PROGRAMME The reduction of malaria May depend on degree of endemicity, on accessibility and on social, political or economic importance. Good: reduction of transmission to a level at which it ceases to be a major public-health problem.
ERADICATION
PROGRAl~
I Objective
The definite suppresion of malaria transmission. ~llierever
IArea of operations l
transmission takes
place.
! standard '
I Minimum
acceptable
Perfect: transmission must be interrupted in the entire area. Should new cases occur, the cause must be determined and removed. 1 I'
--------~--------~--~------continuod /Duration of operations
WP/RC9/TD1 Page 4
ITEM Duration of operations.
CONTROL PROGRAMME 'VJithout limit.,
ERADICATION PROGRAMME Programme concluded when malaria transmission h~ been ended for three years and been confirmed by adequate surveillance. Expenditure will represent capital investment and not a permanently recurring cost. Not always feasible, because eradication has a specific, well-defined objective to be attained within a limited time. Of paramount importance, by notification or otherwise. Of primary importance.
Economic aspects.
Expenditure constantly recurring. Often convenient and feasible in an integrated public-health programme. Of secondary importance ..· Relatively unimport-. an.t. Of minor interest mostly academic. Of little value.
Integration with other :insectcontrol pr:ograrnmes. Case-finding,. Parasitological verification of suspected cases. Imported cases; Epidemiological investigation of individual cases. Epidemiological evaluation. Administrative standard of progress
Very important, especially when eradication is achieved. Of increasing importance and, finally, essential, as eradication is approached. Proven disappearance of in• digenous malaria cases. Measurement of what remains to be accomplished.
Reduction of spleen and parasite indices. Measurement of accomplishmen"l!s.
1.4
The three phases of eradication
The malaria eradication programme can be divided into three phases: preparatory, attack and consolidation. Successful eradication is followed by maintenance. /1.4.1 Preparatory phase
WP/IC 1/TDl Page 5
1.4.1
Preparatorl phase
The preparatory phase has generally three stages: initial survey, planning, and preliminary operations. The purpose of the survey is to delimit the malarious area of the country and to determine the order in which the various zones will be attacked. The planning of the projects must take into consideration not only the characteristics of the problem, as supplied by the surveys, but also existing facilities for an attack on malaria and should prepare an estimate of operations covering such essential items as personnel, supplies and equipment, transportation, budget, and timetable. The preliminary operations start with recruitment and training of ,staff at all levels. If the malaria eradication service is built up on a pre-existing control service, the latter should be re-organized. Offices, operation bases, manuals, working procedures, and other essentials are established. Administrative boundaries are set, houses to be sprayed are enumerated, itineraries are arranged and a transportation and supply system is organized. A pilot operation of significant size is then carried out, to test the plans, staff, and organization. Such a pilot project will disclose many lacunae and will do much to assure adequate planning and preparation for the main attack. The preparatory or preliminary phase will require several months, but should preferably not last more than a year.
1.4.2
Attack
The phase of attack begins as soon as the preparatory phase has ended, continuing with total coverage until the cessation of malarial transmission and the emptying of the parasite reservoir have been achieved. Absolute freedcm from any small persistent foci is not necessarily obtained in this phase, the intention of the succeeding one being to discover and eliminate any such foci left over from this phase. Vivax infections may not die out in less than twoand-a-half to three years. In most circumstances, this will indicate the minimum duration of the phase. There are, however,"circumstances where briefer periods may be appropriate, as, for instance, where spraying is started during a time when trapsmission has been naturally interrupted or where the vector disappears as a result of the spraying. During this phase evaluation and assessment of results should be carried out from time to time to measure what remains to be done rather than what has been accomplished. In some areas, for special reasons, anti ...larval measures may be required.
So, too, the use of antimalarial drugs may be introduced during this phase, their extent and use depending on local conditions and costs. But the objective of complete interruption of transmission remains, whatever the method employed. During this phase of attack, a surveillance system is organized. may be found practicable to introduce notification of malaria cases and It
/parasitological verification
WP/RC9/TD1 Page 6 parasitological verification of fever cases. The degree to which these two helpful measures can be employed in this phase depends on local conditions, but a start should be,made on the establishment of the services essential in the succeeding phase. • Active-finding by house-to-house search or by other effective methods is required as soon as the reservoir of infections has sufficiently diminished and,usually, after the first year of total coverage. This early start makes possible a quick recognition of residual and previously unsuspected foci and leads to the recognition of freedom from transmission soon after this is attained. Special action to intensify operations in persistent foci may be based on the findings. This may prove a very considerable economy, as it may shorten the duration of spraying and accelerate the process of eradication. The public and, especially, the medical profession, whether in private practice or government service, should be fully informed of the objectives of the programme and of the benefits to be expected from it and so encouraged to give their full co-operation, particularly in case~finding. The least propaganda emphasis should be put on the control or reduction of the mosquito and the greatest on the eradication of the disease. Consolidation The phase of consolidation begins as the active attack on the insect ends. During this phase, all residual pockets of transmission should be eradi~ cated and the small remaining reservoir of parasites in man should be eliminated. Case-finding and the use of antimalarial drugs have first importance. Spraying may be repeated locally if necessary. Surveillance must be active, intensive, and complete in its coverage of the area. The facilities of local governmental, medical, educational, and administrative establishments should be utilized wherever practicable, to facilitate the discovery of new cases. Full investigation of such cases is necessary, to discover and deal with the source of infec~ tion. This phase of consolidation ends after three years of active surveillance have shown the absence of any new indigenous cases. 1.4.4 Maintenance
The phase of maintenance begins when the criteria of eradication have been met in an area. Every effort should be made to take advantage of the special training and skills of the staff of the malaria eradication organization, either by transforming the organization into one for the control of arthropodborne diseases or by absorbing the staff into the health department in other ways. The epidemiological experience ofmalariologists makes them valuable epidemiologists also for other fields. In some instances, the malaria eradication service will form the nucleaus of a rural health service. In all cases, the personnel and experience of the malaria eradication service constitute a national asset not to be discarded. The phase of maintenance will last as long as malaria exists in the world, but it does not require special staff. The regular health department would add malaria to the list of non-endemic diseases for which it is always on the alert. The disease would remain notifiable and any imported or introduced cases would be handled as a routine matter by the health department. /It will need
WP/IP 9/TDl Page 7 It will need careful co~operation between the malaria service and the other branches of the national public health to ensure that the services of this staff are employed so as. to afford the maximum benefit to the public•health service of the country; but their rele~e cannot be considered until it is certain that they can be spared from the eradication programme. 2. PLANNING l\.ND ORGANIZATION OF AN ERADICATION CAMPAIGN
Eradication of malaria should be looked on as an urgent measure, outside the regular routine of health departments. But this state of urgency will per ... sist for several years, and it cannot be successfully met for such a long time unless exceptionally good organization and planning go into it, It is not only as scientists that malariologists are called to direct eradication campaigns, but also as administrators. The difficulties in eradication are rarely insurmountable problems pre~ sented by parasites or anophelines. They are, first, lack of understanding of what can be done with these means, and, secondly, a lack of ability in applying them appropriately. Both obstacles stand on the human side. It has been recognized that the practicability of malaria eradication depends on management, method and money. The methods to be used have required the solution of such fascinating technical questions that relatively little attention has been paid to the problems connected with the management and money, or, in other words, with administration. Considerable funds are available at the present time from international sources to assist in such programmes. Efficient management at all levels is the factor which requires the greatest emphasis" First-class workmanship cannot be had with second-class personnel. The selection, recruiting and training of staff and the prompt promotion of efficient workers become of paramount importance in mobilizing the ablest persons for the programme. Salaries should be attractive to competent men and vacancies should be filled quickly if efficient men are available, even though.more senior men are passed over. To build up the high esprit de corps needed for an eradi~ cation programme, staff should be attracted to stay with the organizatio:p., as high turnover in personnel means low quality work. Loyalty, discipline and effi~ ciency are hard to achiev.e among personnel 1orith financial worries. The director of the scheme must be a man of sound technical kn~wledge and of wide experience in administration. The temporary recruitment of foreign staff maybe essential in some countries. The organization of the service should be based on a clear-cut distri.... bution of activities, defined fields of responsibility and clear lines of command. /Planning ahead will
WP/Rc9/TD1 Page 8 Planning &head will keep the whole organization running smoothly; prompt collection of data and their analysis will ensure their most profitable use and also the early correction of errors. 2.1 Organization of national malaria services
A country planning to eradicate malaria needs a malaria service which should be a primary division of the national health department. The central organization should be strong, and should provide advice on technical and administrative aspects of the work. In many countries a national malaria council has been organized to advise on the general management of the programme so as to secure co~ordination with other services. Scientific institutes within the country are invaluable for providing technical support and guidance. Where none are available arrangements may be made with neighbouring countries or help obtained from international agencies. An eradication programme is developed along two main lines of work: epidemiology and administration must be represented both in central and in field organizations. The structure of the central and the field services will depehd naturally upon the size of the country. But in any case, centralized direction and decentralized execution seem to provide the best solution. The epidemiological service should first determine the malarious area; this done, the areas to be included in the campaign, and their boundaries, can be decided. Some localities should be defined at an early stage as indicator districts. Within these, periodic measurements should be made of the amount of malaria and of its effect on the people, so as to check the efficacy of the work and the techniques used and to decide when general surveillance throughout the whole area should be started~ Adequate and constant supervision by the central organization is essential. In a large campaign field laboratories will be controlled by a central laboratory which will be the supreme authority deal~ ing with the diagnosis of blood films. The actual campaign of eradication is organized and supervised by the central organization. The general norms of action on which the local plans will be based should be established by it. This service should be organized in branches. One branch should study equipment and make anY. changes necessary to adapt it to local conditions. Another branch should be devoted to the chemical study of insecticides, their specifications, formulations, deterioration after transportation, storage, application, etc. All data on spraying should be examined in the central service in order to determine adequate levels of efficiency under different field conditions and to guide budgetary estimates. In small countries where these services are not available every eff9rt should be made to secure them from abroad or from international agencies. /The field services
WP/RC9/TD1 Page 9 The field services plan the itineraries for the spraying squads and the chain of supplies. Houses are counted in each locality, transport planned and a timetable prepared. The type of squad must be adapted to the terrain; maps, if not already available must be prepared. Time spent in reconnaissance is seldom wasted. Administration, whether central or in the field, is an auxiliary service, established to serve and not to rule technical services a concept which is very important and should govern the whole antimalarial organization. The main objective of administration is to supply materials, equipment and s.taff at the right place and at the right time. Efficiency is essantial in the store, the workshop, and the office. vJi thout a sound technical basis no project can succeed. Bad administration can wreck a project which is technically sound. 2 .. 2 Budget
An eradication programme must be looked on in its entirety. Adequate financial provision must be made for the whole scheme from the start, even though governments usually vote money by annual allocation. Every effort should be made to estimate for the full needs of the scheme, by drawing up carefully costed schedules of staff salaries and wages, field and travel allowances, superannuation, housing and associated staff maintenance charges; as well as full estimates of outlay on insecticides, including freight, insurance, and other charges; transport costs; cost of equipment, including repair and replacement; rent and other charges for premises; and other expenses. These items should then be classified under the main heads used in the national budgeting system, which are frequently the following four: capital assets, expendable material, personnel, and other expenses. The point should also be made that the programme is essentially a continuous and dynamic one. Any interruption in it may well reverse its progress and not merely postpone its achievement. This characteristic applies both to the scheme as a whole and to its component funds, punctuality in the provision of which, centrally or locally, is essential to eradication. Expenditure under the various headings of the estimates will vary considerably as the programme progresses. At the beginning, substantial provision must be made for equipment, insecticides, and the costs of a spraying campaign. La~er in the campaign, the bulk of the expenditure will be on salaries, field and daily allowances, travel expenses, and similar items. The time when the transfer from one type of expenditure to the other is to be made cannot be accurately foreseen, and it is essential that, in framing the original estimates, there should be liberal provision for the transfer of expenditure from one heading to another. Normally, programmes will include large sums to be spent in foreign currency on transport, equipment, insecticides, and other materials, and /these items ·.may
WP/RC9/TD1 Page 10 these items may demand special scrutiny. It has been a very valuable aid to eradication programmes that international assistance has often lifted this burden from countries ill able to bear it. Although every effort must be made to provide an accurate budget at the start of the campaign, malaria eradication is a biological .process and not amenable to exact rules. As much flexibility as possible must be maintained. 2.3 Personnel
The two basic activities in an eradication programme are operational -the application of insecticides to premises -- and epidemiological -- the finding of malaria cases. Staff of several grades are employed and their designation varies from country to country. In order to avoid confusion, no specific titles are given to staff in this section, the description given being related to function only. The men who actually spray premises are semi-skilled workers, so instructed and disciplined that correct spraying technique becomes such a normal habit of uork that, in the long they find it more difficult to spray a house improperly than properly. The possibility of building up this discipline is greater in areas where spraying is required all the year round. Small groups of spraymen form a spraying squad, which works under a leader who is responsible for the efficiency of the spraying. These leaders are an important group of workers and should be men with ability to direct the activities of their squads and report on their Hork. It is desirable to keep these men on a permanent basis. The work of several squads is under the direction and supervision of an inspector. This man ~s the key to the quality of the spraying and, hence, to the success of the stage of attack. Supervision should be carried out by someone who is not himself actively engaged in the process inspected. In the later stages of the campaign surveillance personnel, by visits from village to village or from house to house, actively look for cases, taking slides and giving treatment. These can be the same men who carried out the original surveys. Their work is supervised by more senior men who seek out the probable origin of any infection found •. Field epidemiological services are responsible for the examination of blood films, the identification of mosquitos, and the correlation of the work of the surveillance personnel. The field administrative service should be under the direction of an efficient administrator who is responsible for stores, supplies, and transport. /\11 these field
WP/F.C9 /TDl
Page 11 All these field services should be under the direction of a. field chief, responsible technically and usually administratively to the central organization. This central organization should be under a director distinguished by his qualities of leadership, courage, faith and persistence. Assisting him would be the chiefs of insecticide operations, epidemiology, administration, research, and training .. The second-in¥command is in chArge of insecticide operations. He should be a man with sound knowledge of mal~ria and epidemiology and with a special experience in logistics and administration. A chemist with a staff of technicians can be of considerable value, particularly in the checking of m3terial. The chief of the central administrative service should be a man with very considerable experience of administration and supply. If such a man is not available locally, he must be recruited from outside; in addition h~ should have a briefing in malariology and in the objectives of the campaign. He may require assistants -- administrative technicians for costing and accounting, for requisitioning and for handling the movement and storage of supplies. It is important that, where possible, men should be recruited who have a good knowledge of the transport, supply and administrative system of the country ~nd of how these are operated, otherwise equipment, especially vehicles, may be adopted that are not suitable to the terrain and for which spare parts and service facilities are not available. The operation of transport and mechanical equipment will necessitate the provision of vJorkshops; in each squad, there should be at least one man who is fully versed in the equipment used ?nd is capable of undertaking complete maintenance and simple repairs. Men of high quality are needed in the central research service to solve the many problems that will present themselves. Such personnel may well include epidemiologists, entomologists (especially those conversant with biological techniques), and chemists. The special training service is typically small, being in the charge of a co-ordinator of courses, who makes wide use of the knowledge available to him in the malaria institute and among staff ehgaged in other services and activities of the organization. In small projects with few professional staff, a broad outlook. and wide
experience is particul9rly important in order to cover all the technical aspects of the campaign. Indeed, in some countries, where communications are particu~ larly bad most of the administration must be decentralized and made the responsibility of the officer in charge of a local unit. /It may be
WP/RG9/TD1 Page 12 It may be difficult to recruit and keep a group of people with enthusiasm in a scheme which is necessarily short-lived, unless some arrangement is made by which their services can later be used in another field. There are certainly other diseases susceptible to mass treatment and other preventive techniques which members of the malaria service may carry out with benefit to the whole community. The national director should look for these new fields of action and propose them to the higher health authorities well in advance, pointing out the value of his men as the foundation of a rural health service. They are usually the first men to visit every house in the country. The essential quality to be looked for in any employee, whatever his grade) is his ability to carry out the job to which he is to be assigned; there need be no hard and fast adherence to standards of professional qu'llification for atiy appointment. Examination of the resources of the country will show to what extent the skills and ability are available. In some, there is an adequqte supply of' men with special training of different types and with wide ex~rience in administration and it would be unwise in such cases not to make the fullest possible use of these resources. In other countries professionally qualified staff may be rare. It is important to maintain the essential criterion of suitability for the post, which may in such a case sometimes necessitate the appointment of foreign staff. But the absence of graduate qualifications should not be taken as a bar, to any candidate. It is notable that success has been achieved in eradication in some countries .where professionally qualified people are few, since their rarity has proved no more than a handicap • .3. .3.1 OTHER ASPECTS OF MALARIA ERADICATION
The relation of malaria eradication to other public-pealth ~tivities
Malaria eradication projects differ from other public-health projects, particularly in their stricter adherence to a time-schedule... Although all · public-health projects must be based on a sound technical foundation, there is no rigid time-limit within which they must be successfully completed. It is often more important to proceed slowly,.in order to allow a change of attitude towards new concepts, even at the expense of a more rapid progress to healthy conditions. This does not apply to malaria projects; unless eradication is carried out as quickly as possible, the opportunity may be lost forev~r. Public relations must be cultivated and resistance from the population to eradication techniques avoided, but this resistance must be considered as a technical problem to be overcome, in the same category as resistance of anophelines to insecticides and the resistance of governments to the prov~s~on of funds to complete the eradication of a disease which is no longer a serious public-health problem. /It is important
WP/RC9/TD1 Page 13 It is important that the nature of malaria eradication is clearly under ... stood by other public-health -vrorkers in order to avoid friction, which is likely to arise as a result of the apparently preferential treatment received by the malaria eradication team. Several aspects of malaria eradication are particularly closely related to other public-health activities. 3.1.1 Notification of malaria
In the initial stages of the campaign, the information available in the public-health department and hospital records give a good indication of the malaria situation in the country. During the active phase of eradication, reports of malaria cases from hospitals and dispensaries will give an unbiased measure of progress, although the fallacies inherent in epidemiological information derived from hospital statistics must be borne in mind. In the later surveillance stages the notification of fever and suspected malaria cases by medical units outside the malaria project will help to give an independent assessment of the success of the campaign, revealing foci of infection that might otherwise be missed. 3.1 .. 2 Health education
The visit of spraying squads, the carrying out of a definite technical operation, and the consequent improvement in the health of the population serves to emphasize the value of scientific medicine, especially in rural areas. The reputation of the public-health department is strengthened, making easier the provision of other services with a less dramatic appeal or less obvious results. 3.1.3 Curative services
In many malaria projects in underdeveloped countries, spraying squads and malaria survey teams visit inaccessible rural areas much more frequently than any other units of the public-health department. These visits often afford the first contact between the people in their houses and scientific medicine. The objective of the campaign - the eradication of malaria - must be kept constantly in view and no deviation towards curative medicine must be permitted; essential supervision must not be submerged in an interminable sick parade. Only the minimum amount of curative treatment - such as the giving of aspirin can be allowed, in order to maintain good public relations. Even this must be forbidden where the services of other health units are available. Antimalarial squads are trained in a few techniques, their deviation to others, of which they have no knowledge may result in the loss of all.
3.1.4
General
The malaria eradication scheme has brought into the field an efficient body of men, adapted to difficult travel under hard conditions. Once malaria is eradicated, these teams will be available for the mass treatment of other endemic diseases; the medical officers associated with the project will have /gained valuable information
WP/RC9/TD1 Page 14 gained valuable information about other diseases during their travels round the country; the junior staff will form a disciplined body o~ high morale, already associated in the minds of the people wi;th the effective alleviat:i,.on of disease. Eventually, the general public-health services will take care of the maintenance stage of the eradication scheme, becoming responsible for the early recognition of imported cases of malaria and for dealing with any new focus o~ infection that may arise.
3.2
Relation of malaria eradication to other government activities
Malaria eradication schemes are country~wide and there is practically no ·branch of government which is not affected by them directly or indirectly. The willing co-operation of various government officers makes much easier the 1vork of the spraying squads and of the surveillance teams, particularly the explanation pf the objects and methods of the campaign. To most people, all government officers are the same. Departmental distinction does not exist. It is, there~ fore, essential that all officials are accurately informed about the methods and plans of the eradication campaign. If the first information a government officer receives about eradication project is a message from his wife that the newly painted walls of his house are being defaced by a man with an infernal machine, co-operation will be lost. Of the various departments who can give valuable help, the following are perhaps the most important.
3.2.1 Administration The responsible government administrative officer must know what is going on within his district and he is justifiably annoyed if widescale programmes take place before he has been informed. It is extremely foolish not to take advantage o~ his specialized knowledge of his district; he will be able to advise on the most suttable methods of transport; and he will have information about other activities that are in progress. He will also be able to advise , on the correct approach to the population particularly to those living in difficult and inaccessible areas. A wrong approach to such people, due to ignorance,. may often make the work of the spraying team almost impossible. Although cooperation with the administration is essential, it is better for the malaria units in some countries not to identify themselves too closely with the forces of law and order, particularly the police. Otherwise, it will be suspected that the various items of information which anti-malaria units must obtain from house~ holders are required for taxation or other unpleasant purposes.
3.2.2 Finances It is well to remember that officers in charge of budgets are human beings and that an explanation of the reasons ~or the financial privileges demanded by malaria eradication teams will often remove difficulties due to a failure to realize that malaria eradication is an emergency operation. The campaign must not be held up by petty budgetary res trw tions or by a refusal to admit a reasonable amount of flexibility. Even more important is the prompt payment of /wages of all
~'JP/RC9/TD1
Page 15 wages to all members of the eradication team. Nothing destroys morale more quickly than delay in the payment of money which has already been earned. These difficulties are usually due to over zealousness on the part of the junior members of financial services. Explanation and discussion beforehand with more responsible officers will usually avoid them, but care must be taken to ensure that these financial difficulties are not due to weak administration within the malaria unit. 3.2.3. Public information The co-operation of the public information service is essential. In many inaccessible areas with a low standard of literacy the radio-may be more valuable than the newspaper. The m~st important information to be broadcast is factual information about the dates that the malaria teams will visit particular districts. It is essential that, once this information is given, the timetable be adhered to as accurately as possible. The second type of information is of ~ore general nature. It may be a description of the work of the team, high-lighting exciting or amusing incidents, or it may be a talk or article explaining the technique of malaria eradication. Co-operation with public in-· formation services should not be one-sided. The staff of the malaria unit should be willing to help in providing interesting ~nd worthwhile programmes. It is important to remember th~t information about malaria eradication and discussions of the benefits achieved should not be limited to the malarious areas of the country.. The non~malarious areas are usually the most prosperous and are therefore paying a large proportion towards the costs of the campaign. It is necessary to point out that the economy of the country as a whole will benefit from eradication. 3.2.4 Public works
The public vJorks department contains a high proportion of personnel with some technical background. They are usually the people most interested in the techniques of malaria eradication. Once a spirit of co-operation has been built up between the public-works department and the malaria units, their help and advice in matters relating to transport and the maintenance of equipment will be invaluable. The public-works department, transportation agencies and private companies are often responsible for moving large number of labourers from one part of the country to another. The danger of such groups contracting or disseminating malaria must be remembered and explained to the responsible engineer. Although emphasis in malaria eradication is now on the use of residual insecticides, a blind eye should not be turned to unnecessary mosquito breeding. Since increase in the number of anophelines makes it difficult for the residual insecticide to produce the mortality required to break transmission, every effort must be made to ensure that engineering works do not lead to conditions favourable for mosquito breeding and consequent man-made malaria.
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Legislation will be necessary to prevent a few obstructionists from preventing eradication. It is hardly necessary to point out that legal powers should seldom be employed. Unless it is possible to gain the co-operation preferably active - of the great majority of the population, there is little hope of a successful campaign .. 3.2.6 Other departments It is also necessary that the aims of the .malaria campaign are well knovm to the other branches of the government who will be vitally interested in the results achieved. These are, in particular, the agricultural department who will soon find that farm vJOrkers have become more numerous and more efficient, and to the education department who will have to provide instructions for an ever-increasing number of children. For this reason, continuous efforts must be made to prepare for the results of eradication, while the active campaign is still in progress. 3.3 The relationship between inter-country malaria projects
The concept of malaria eradication implies a state of constant vigilance against the reappearance of the disease in an area or country freed from malaria. Obviously, no country can declare its eradication programme complete nor safely interrupt spraying operations throughout its territory if there exists, at its frontiers, a zone where malaria is not controlled or where malaria carriers or infected anophelines are present. It follows, therefore, that the essential feature of malaria eradication programmes conceived on a continental or subcontinental basis would be for the countries concerned to undertake to co-ordinate their efforts and to discharge certain responsibilities tmvards each other. If each country were to resolve to make an all-out effort to achieve eradication of malaria within its own frontiers, this would ultimately lead to a state in which no country could be a source of danger to its neighbours. Until such widespread eradication materializes, however, it is essential that, in the plannin~ and execution of malaria eradication programmes, intercountry co-operation be secured on the following points: (1) Each country should undertake to give due importance to eradication, or to a full and continued programme of malaria control, in the frontier zone bordering o~ a country in which eradication is being practised. (2) An arrangement should be made which would ensure the rapid exchange of accurate epidemiological information and of reports on the progress of antimalaria measures, especially in the fr.ontier zones. / (3)
Special consideration
WP/RC9/TD1 Page 17 (3) Special consideration should be given to movements of the population across frontiers, to avoid the risk of re-introducing infection to territories freed from malaria. ~~ere malaria is seasonal, the most effective and economic measure might be to restrict such movements to non-malarious months. If this is not feasible, it would be necessary to establish "sentinel" health units on both sides of the border, for treating malaria cases, and, in special cases, spraying the temporary shelters of nomads. (4) In countries where periodic mass aggregation of population .takes place, special priority should be given to the eradication of malaria in the countryside around such places and along the routes used by the visitors. As a safeguard against the re-introduction of malaria into such malaria-free zones by infected travellers or pilgrims, it may be necessary to undertake intensive insecticidal operations each year before the aggregation occurs, in such a way as to ensure continued insecticidal activity for at least two weeks after it is over.
irJHO has assisted in securing internatj.ona1 co-operation and in promoting inter-country arrangements by holding a series of regional and interregional meetings. These meetings provide an excellent opportunity for malaria workers and public-health administrators to review the development of malaria progrrumnes, to discuss problems of mutual interest, and to become alive to the advantages of co-operative and co-ordinated effort. They also provide an opportunity for co-ordinating campaigns with regard to time, place and intensity of application; as a result of such meetings, it is easier to initiate research on relevant current problems and to integrate regional training course. The award of fellowships to be held in neighbouring countries leads not only to the solution of technical problems but also to the. appreciation of common difficulties and to the formation of personal relationships which can often help to overcome previously insurmountable difficulties. Measures must be taken to avoid undue delay in the passage of information from one country to another, often caused by time-consuming protocol. In one group of countries situated in two adjoining WHO regions, this problem is being solved through the establishment of an anti-malaria co~ordination board whose secretary has been charged with the responsibility of facilitating the exchange of technical information.
A system of mutual notification of imported cases of malaria between countries from which the disease has been eradicated, or in which it is in process of being eradicated would be valuable. Public-health authorities df countries where such programmes are well advanced might be invited to submit monthly reports to the regional offices of ~~0, stating the number of microscopically-confirmed cases observed. As soon as a year has passed without an indigenous case being discovered, each new infection, classified according to source, should be reported as soon as possible to enable prompt measures to be taken against foci of infection, .which might endanger any of the neighbouring countries.
/4. ECONOMIC CONSEQUENCES OF
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4. ECONOMIC CONSEQUENCES OF MALARIA Malaria is a chronic, invalid-producing disease which does not directly kill a high percentage of its victims, although it is often a major cause of infant mortality. The disease results in an increased number of deaths from other causes and lowers life expectancy; but, except in epidemic times, it is insidious rather than dramatic in its effects. Nevertheless, over the centuries, malaria has had a profound influence on thousands of communities throughout the world.. ~Jhether or not, as some historians assert, it was decisive in the downfall of Greece and Rome and in the mysterious depopulations that left massive ruins in Polannaruwa, Ceylon and Angkor-Wat, Cambodia, cannot be determined; but there is ample testimony to the fact that malaria has been one of the great scourges of humanity because of its stunting of physical and mental development, its notorious restricting of social growth, and its blighting of agriculture, com.. merce and industry. Christophers, 11
1
a most careful observer, wrote in 1926:
1tfuether from the point of view of enhanced mortality, sickness and individual suffering, or from the effect of preventing natural increase and sapping the vitality of populations, or the paralysing effect on industry and exploitation of mineral or other natural wealth of the country, or in the direct loss to Government in a variety of ways, malaria is universally recognized as the most important sanitary problem with which India has to cope. 11 NovJ that malaria eradication is possible, it is necessary to draw up a balance sheet to show whether the costs of malaria to the community out-weigh the expenditure necessary to bring about eradication. If it can be shown that malaria eradication is an investment for the country and that the expenditure incurred will be more than offset by the actual cash benefits, it will be much easier to obtain the necessary funds from assemblies and legislatures. Malaria eradication has the added advantage that it is limited to a comparatively short period, in contra-distinction to other social services which, once started, demand a continuous and often increasing recurrent expenditure that canreldom be$afforded by countries, whose economy is based on agriculture. The calculation of the economic effects of malaria can be made in two ways: (a) The negative approach works out how much malaria costs the country and then assumes that if eradication is carried out the national economy will be saved the amount attributable to the disease. /(b) The positive approach
1 christopher-s,s.R. (1926) Re • Med. Res. 1rJorkers Conf. for 1925, pp 30-38. Quoted in Sinton, J.A. (1935 Rec. Malar.Surv. India, 2' 225
WP/RD9/TD1 Page 19 (b) The positive approach measures the actual benefit that has been achieved by the removal of malaria. This gives a more accurate figure for the results obtained but it is much more difficult to calculate in terms of actual money. Representative calculations for the negative effects of malaria have been worked out in many countries. Two examples from India and one from Taiwan are given below. The first was calculated for a single v~llage by Russell and Menon in 19421 ; the second for all India by Viswanathan a few years ago. (1) "The annual payments per person to quacks, priests, and doctors for the treatment of malaria fevers was equivalent to US ~~0.80; and lossas due to other money paid out and to cash wages not received because of malaria amounted to ;?1.24 per person per year. Malaria could certainly be controlled in this village by pyrethrum spraying to kill adult anophelines, for about :H10.08 per person a year. Few villages in India were on a much lower economic level than this one, where the total annual income per person was equivalent to only :~11.26. Viewed simply as a matter of rupees and annas, malaria was a burden to this village • 11 (2) ttEven at the most modest estimate the annual toll of malaria in India may be said to be about 50 million people. Assuming that one attack of malaria involves a loss of wages and about 25% are wage earners, there is a loss of Rs 150 million in wage earning capacity every year. Assuming further that malaria decreases the efficiency of an individual's output by about 25% during the year, the total loss on this account would be about Rs 2250 million. The total loss is thus Rs 2400 million per year • 11 Now these Rs 2400 million correspond to 1~ 500 million a year. This sum is at least about 2-1/2 times more than the most conservative estimate of the total cost of the malaria eradication programme all over India. In Taiwan it has recently been possible to calcu~ate more precisely than usual the various liabilities of malaria during an epidemic outbreak which occurred in the Kao-shu township in southern Taiwan in October 1953. Out of a population of 5256 people, 3005 persons, that is 57%, contracted new infections from July to October 1953. Excluding children under ten years of age, or those attending school, the total period of incapacitation amounted to 17 680 days. The lowest local wage for unskilled labour, is NT~ 8, a total cost of NT$ 141 440. The outside labour hired to compensate for the above loss of labour during a season which coincides with the autumn rice crop represents 2284 man~days, which; multiplied by NT::;; 8, is equal to NT\:i 18 272. /Expenses of treatment laussell, P.F. & Menon, M.K. (1942) Indian med. Gaz., 77, 167 2 Fr.om a~ unpublishec::l paper, Mal/Inform/25, "Facts and Figures Concerning the Economic Damage Caused by Malaria in some Countries•"
WP/RD9/TD1 Page 20 Expenses of treatment of malaria cases, either with anti-malaria drugs or with herb doctors' treatments, with doctors' fees or with temple visita... tions, amounted to a total of NT$ 96 333. It has also been calculated that miscellaneous expenses such as special food for invalids, charges for religious ceremonies, and funeral expenses (of two deaths) amounted to NT~~ 17 015. This makes a total of NT~p 273 060, which divided by the total population of the villages gives an expenditure of about NT.~ 52 per person. Now the total cost of malaria control in other parts of Taiwan was then below NT~p 4 per capita., The positive effects of malaria control are most usually seen in the opening up of new lands for agricultural and industrial exploitation which had hitherto been rendered impossible by the presence of the disease. Examples of success in this field are taken from Afghanistan and the Philippines. Afghanistan is a land vdth great natural resources and a hardworking population estimated at twelve million. One of its most important publichealth problems was, until very recently, malaria. ~vhile it affected fewer than a million people, it struck the potentially ~ichest areas which could not be developed because of the ravages of the disease. Today, the government is carrying out a nation-wide eradication campaign. The total cost of operations from 1952 to 1959, including government and UiUCEF contrib~tions, is estilnr,tod to be less than three-quarters of a million dollars compared with the previous annual cost of malaria to the country \vhich was estimated to be 20 million dollars. In the Philippines, road construction projects, m~n~ng, logging and other industrial enterprises have been permitted to continue and to prosper after malaria has been controlled ·in areas where it would formerly have caused the failure of such undertakings. It was extremely difficult to get settlers to work in land settlement projects; now that malaria is controlled the difficulty has been eliminated and a great socio-economic development has been made possible. The economic effects of malaria can also be calculated from its impairment of the efficiency of social services such as education. In Ghana it was shown that children were absent from school for roughly six days per year due to sickness. Preventing malaria reduced such absences by 50%. If it is calculated that primary schooling costs ,1Jil per week per child, there is a saving of :W500 per thousand children per year. It is note-worthy that these results were obtained in a holoendemic area where it is usually considered that the damage caused by malaria is limited to infants and very small children. In other areas, the saving from the point of view of education should be even greater than the figure quoted above. Business concerns working in malarious areas seldom fail to control malaria amongst their staff. Such measures are taken partly for humanitarian reasons but there is no doubt that savings resulting from control more than offset the expenditure incurred. /Non-malarious countries
WP/RC9/TD1 Page 21 Non~malarious countries suffer indirectly from the effects of malaria in other parts of the 1-JOrld. Even now that malaria has been eradicated from the United States of America it still levies an enormous hidden tax first because such imports as basic minerals, hard woods, coffee, cocoa, vegetable oils, waxes and certain fruits which come from the malarial tropics are priced at least 5% higher than they would need be, i f it were not for the costs of malaria control - or lack of control, an even greater expense - in the exporting countries; and secondly, because the market for every item of export to the tropics must naturally be smaller, if malaria constitutes a heavy local financial burden on the people themselves and on their governments. Today, malaria eradication can be achieved without placing an undue burden on the finances of these countries and without making demands on foreign currency, which is often hard to obtain. At the present time, international agencies are willing to bear a large proportion of such foreign expenditure, which usually occurs in the earlier stages of the project, for the purchase of insecticides, drugs and transport. In the later stages expenditure will be largely on personnel occupied on surveillance, 1-vhich involves very little drain on foreign currency. It is clear that in are"s where it is practicable - and this includes most malarious areas of the world - no government can afford not to undertake a campaign to eradicate malaria,
Hoffm:m, in 1928, summed up the economic aspects o.f malaria control thus: The cause o.f malaria eradication, therefore, rests upon sound economic as well as self-evident humane considerations, leaving no escape .from the final conclusion th8t the entire subject most urgently demands the intelligent coordination of all existing governmental agencies and related health-conserving activities, on the one hand, and a broad-minded public policy, on the other, with specific reference, however, to the expenditures on behalf of local antimalarial measures on the part of the general public. For economic reasons alone, the effort would be worthwhile, since the economic results of effective antimalarial measures are a foregone conclusion. 11 1 · 11
1 Hoffman, F.L. (1928) Malaria problems, Newark Quoted in Sinton, J.A. (1936) Rec. Malar. Surv, India, 6, 157