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Eradication, elimination, and control: Knowing the past of malaria

September 18, 2009 - 08:37 -- Bart G.J. Knols

I attended a most interesting meeting yesterday in Wageningen (The Netherlands) where some 30 scientists and representatives of donor organisations gathered. Two scientists from disease-endemic countries (Rwanda and Kenya) presented case studies to the audience. These were followed by a mini 'open space' meeting where attendees could submit questions on post-its for discussion in small groups.

This approach is interesting. After all, you can't complain that certain topics were not discussed as you should have posted these yourself. 


Small groups then started debating things like 'how should malaria elimination be organised', 'is social innovation enough or are additional technologies needed?', or 'what exactly is community participation in malaria elimination'?


That's when the problems kick in. Without adequate knowledge about the basics of malaria, its transmission dynamics, its ecology, and epidemiology, people assume that malaria elimination is just like any other development aid project. Well, it is not.


Those that favour community involvement and ownership claim that unless the community buys into the elimination, it should not be done. Sadly, they don't understand that elimination is not feasible unless it is viewed in an area-wide context. You can't have village A say, 'Fine, we want to eliminate', and the village B next door say 'Ah, for us it is not that important'. If this is what you accept, than stop talking about elimination. It is control, and more of the same that we have done over the last two decades.


Malaria elimination requires a change of approach and a different way of thinking. 'Soft' approaches will give you control, not elimination. Although the audience appeared to agree on the merits of hybrid 'top-down' and 'bottom up' organisation of programmes, there was little to show how community engagement can lead to the eventual elimination of a vector-borne disease like malaria. It is, in my opinion, extremely difficult to motivate communities to sustain elimination efforts when disease mortality has long gone reached zero and cases become few and far in between. Community mobilisation against something that affects let's say less than 1% of the community is therefore not practical. Will people not move on to focus on more important matters? I would.


Historical successes in eliminating malaria in developing country settings like Brazil (the Anopheles gambiae invasion of 1930) or Egypt have been based on rigorous military-style organised campaigns. These worked, and worked very well. In the days that there were no Landcruisers, GPS systems and computers. These programmes were based on hard work in the heat of the tropical sun and not lengthy discussion over programme ownership and community buy-in.


Some years ago I organised a debate (in Kenya) where two opposing views were defended for an hour: malaria control using nets, community participation, etc. versus military style campaigns that come in and hammer malaria. After that hour individual members of the audience (nearly all Africans from Kenya, Ethiopia and Cameroon) voted anonymously on the approach they preferred and considered most likely to be successful. 18 out of 24 votes were in favour of the military style campaigns, the remaining 6 believing in the power of community-based control.


Yesterday, a young chap from a major Dutch funding organisation wanted to know why military style campaigns that were so successful in the past were not being undertaken at present. I lost his sympathy when I mentioned 'Sorry, but it is organisations like yours that force us to set up programmes based on community participation, otherwise we will not get funded'. 


This does not mean to say that communities should be excluded in the elimination efforts. On the contrary. However, malaria is not a disease that should be dealt with lightly. I therefore propose to seek hybrid forms to setup and execute elimination campaigns: community representatives that become involved in military style operations.


Malaria control through community participation is feasible. Malaria elimination not.


Hmmm, guess I will upload this as a poll...