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Lessons from the failure of the WHO Garki Project

March 11, 2015 - 12:50 -- William Jobin

Do any of you have experience with the Garki Project, to add to my comments below? I would especially appreciate comments from those of you who knew what the thinking inside WHO Geneva was, at the time.

What lessons can we learn from the failure of the WHO Garki Malaria Project in Kano, Nigeria, 1970-1980?

After the failure of the First Global Malaria Eradication Program (GMEP) in 1969, there was a crisis of confidence in WHO Geneva about the value of Indoor Residual Spraying and Rapid Diagnosis and Treatment with chloroquine, the two mainstays of the WHO Global Strategy. Because of the large costs and efforts incurred in the GMEP (even though it had deliberately avoided the most difficult areas in West Africa), there was fear that the WHO Strategy might have to be applied for decades (thus inevitably getting on the Resistance Treadmill), in order to achieve satisfactory suppression. In response to these fears, the Garki Project was developed with great care, by the best minds in WHO, in order to answer two questions. The first was:

a. in the most tenacious malaria zones of West Africa, could the conventional but ephemeral measures of drugs and insecticides significantly reduce prevalence to tolerable levels in a few years, if religiously applied ? and secondly,

b. could transmission be brought sufficiently low to reduce the Reproduction Rate below one, after which the disease would gradually disappear?

The Garki Project was launched near Kano, Nigeria in 1970, and featured very careful and precise application of the drugs and insecticides, as well as detailed monitoring of every aspect of malaria transmission. This included computer simulation and monitoring of transmission in the area, using a model developed by the best epidemiologists and entomologists in the WHO (Molineaux and Gramiccia 1980, The Garki Project, WHO Geneva.)

The answers to both questions was the same - no.

Unfortunately, within a short time, the answer to both questions was clearly no. Despite 3 years of intensive application of the insecticide propoxur to the inside of houses, and widespread distribution of the drugs chloroquine and sulfadoxine-pyrimethamine, the prevalence among children only dropped from 80% to 30%. Within one year after stopping the suppression measures, the prevalence returned to 80%. It appeared that the intensity of transmission in northern Nigeria was too high to be controlled by the ephemeral measures used by WHO. This was partly due to the Immunity Trap, but more directly because of the intrinsically high Epidemiological Inoculation Rate due to the principal vectors and the malaria ecology of the region.

Perhaps the basic and most important weakness of the WHO Strategy was that it did not change the basic malaria ecology. It did not change the mosquito ecology through larval source reduction, nor did it change the human ecology through the provision of safe and healthy housing with metallic screens.

George Macdonald had warned of this problem, using his transmission equations for malaria which indicated rapid rebounds in a population with a high Epidemiological Inoculation Rate, in which transmission was suppressed temporarily. (Macdonald G. Epidemiological basis of malaria control. Bull. World Health Organ. 1956;15:613–626).

The successive failures of the GMEP in general, and then the Garki Project specifically, were followed by a long hiatus in concerted attacks by WHO on malaria in Africa because both of these failures called into question the wisdom of a strategy based on drugs and biocides. The generation of malariaologists familiar with the failures of the GMEP and the Garki Project were apparently not willing to repeat the mistake of relying on drugs and biocides in Africa.

But then that generation retired or passed away, and despite the negative experience in Garki, the current strategies initiated in the last ten years by the new generation of malaria enthusiasts who developed Roll Back Malaria and the US Presidential Malaria Initiative were started without dealing with the intrinsic weaknesses in the strategies. The new programs did nothing to change the malaria ecology, neither of the mosquitoes nor of the people. The addition of treated bednets is a pale approximation of the ecological protection offered by improved housing and metallic screens, and will have little effect.

Thus the basic weaknesses in the strategies remain, and the failures will be repeated.