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Truly Sustainable Malaria Control? Impossible Without This

January 2, 2013 - 17:08 -- Mark Benedict

I tend to be suspicious of fads. Call me conservative. but even in my 20s, I never bought in to the 1960s saying, “Never trust anyone over 30.” Say what? I’m also wary of public health fads: “community based” and “sustainability” are among them. Don’t get me wrong. These can have value for shaping policy and practices in positive ways. They can also create a cachet that becomes a selling point in its own right without adding significant value. Worse, they can divert attention away from essential characteristics of the intervention that contribute to long-term effectiveness.

Example: I heard a wonderful clearly presented talk during the ASTMH meeting in Atlanta last year. The PowerPoints illustrated a large randomized cluster trial that was being conducted to test a community based dengue vector intervention. It was obviously well-planned and was being conducted carefully. Someone had been convinced to put a lot of money into the effort. It included many kids wearing project tee-shirts, community volunteers and parades. Wow! After I heard it, I thought, “Positive results are so likely that it’s almost not worth doing. This is a no-brainer.” followed immediately by the pregnant question, “And then...?”

When the excitement and parades are over, when the tees have been relegated to dusting cloths, when the donor’s money is dried up, what remains? We should be concerned not only for what happens when the program is operating, but what happens when it ends. Does any benefit remain? I’ve asked the question before, but it’s more timely given the current malaria prospects.

I’ll offer a characteristic of interventions that we should be emphasizing: DURABILTY. Durability is an intrinsic factor that exists independently of external influences. “Able to withstand wear, pressure, or damage; hard-wearing.” It is important to note that it is an outcome that can largely be predicted a priori. It indicates how long the intervention will yield a positive effect when the intensive effort to sustain it is withdrawn. A Ferrari is flashy and goes fast, but for durability, I’ll go with the Toyota. What distinguishes sustainability from durability?

Sustainability in part is determined by extrinsic factors that cannot be controlled: IF resistance does not develop; IF funding continues at the current rate; IF compliance levels remain at the optimal rate: IF the country control plan is submitted on time.

In contrast, following are features of interventions that I suggest lie on either extreme of the durability spectrum.

Excitement is transient. Acceptance is durable.

Intrusiveness is fragile. Invisibility is durable.

Exceptional funding levels are…exceptional. Stable, low-level funding (or less) is durable.

Suppression is not durable. Elimination and eradication are.

Intensive community activity is not durable. Background positive effects are.

Readers will correctly point out several failures and exceptions to all of the above generalizations. Have at it. The fundamental point stands. Interventions that have intrinsic durability are superior to merely sustainable ones. Durability can result from intensive community-based interventions, but only if they result in outcomes on the durable end of the spectrum. Exceptional funding for LLINs can result in durable interventions, but not merely by distributing bednets without consideration of what happens when the campaign ends. HOW an intervention is performed can afffect it's durability.

Durability can be built into any intervention, but the dismal prospects for resurgence of malaria indicate that in spite of spending a lot of money (and exhausting donors?) on interventions that were almost certainly claimed to be "sustainable," precious little durability has been created. I’d like to see this word appearing in a lot more publication titles in 2013.


William Jobin's picture
Submitted by William Jobin on

Thank you Mark for your thoughtful additions to our lexicon for the fight against malaria. Would that the folks in WHO and the US PMI gave such careful thought to understanding the terms of our struggle!

You introduce the term durable, which I believe applies to a certain class of methods we should use in our integrated strategy. So there are durable methods, ephemeral methods, and sustainable methods.

I think you are saying that although WHO and PMI think that their methods are sustainable, they are in fact ephemeral, and will disappear like the falling leaves of autumn when funding is curtailed.

In contrast, durable methods will last beyond the whims of international donors and UN budget fluctuations. So which methods are durable? I nominate

- 1) elimination of breeding sites
- 2) improvement of housing with screens
- 3) clever design of new irrigation and drainage systems, along with their accompanying reservoirs and resettlement villages, and
- 4) careful design and operation of hydro-electric reservoirs which not only avoid production of malaria mosquitoes, but also provide affordable electricity which make possible electric fans in sleeping areas.

I plead with all the readers of MalariaWorld to join Mark in this discussion of the types of methods we should be developing and using in the fight. This will help us all to frame our actions in both research and control operations. It is a good way to start 2013.

William Jobin Director of Blue Nile Associates

Submitted by Wallace Peters on

My attention has been drawn by one of our philosophical readers, Cliff Landesman, to the thoughtful and thought-provoking commentary of Mark Benedict. This, in turn, has triggered Bill Jobin's latest remarks on the distinction to be drawn between these two criteria being pursued in relation what I prefer to call the "management" of malaria, namely "sustainability" and "durability". A few years ago I had the privilege of reviewing Jobin's book in which he set out what he called a "Realistic strategy for fighting malaria in Africa". In this he tried his informed best to guide those involved in fighting malaria, away from fantasy and back to realistic, more rational objectives. Little seems to have changed. Reality, as Mark and Bill have again pointed out, is not politically popular.

At the risk of being called a cynic (which, after a lifetime of involvement in the "management of malaria" I admit I am), I would like to reinforce the view of both these colleagues that "durability" should be the name of the game. However, how to achieve that is the big question. Far be it from me to minimise the major advances in such areas as chemotherapy, molecular biology, parasite and vector resistance to drugs, vaccine development. What I see too little of is the philosophical approach to the management of malaria on which these commentators are attempting to focus our attention.

At the end of the day the major obstruction in our road to freedom from malaria is Man himself. Whether we like to admit it or not, Man is his own worst enemy. I've said it before and I'll say it again. But please, don't ask me quite how we are going to change this patently obvious fact of life. I have to leave this to the philosophers among us.

Wallace Peters

Submitted by Socrates Litsios (not verified) on

I wish I could remember the name of the WHO malariologist (based in New Delhi) who told me about one experience that he knew of but which was not documented. A health inspetor in one of the Indian States had the idea of engaging 15 year olds to educate their parents about malaria and what protective measures they should adopt. At the same time they had the job of training the 14 year old class to take over this responsibility during the coming year. I wish I could tell you more about this bit of history.

Mark Benedict's picture
Submitted by Mark Benedict on

Thanks to all for comments. Realistic approaches to malaria control is a recurrent theme at MW.

Just finished scanning the 2012 WHO Malaria Report, and regardless of what one expects for the future (and WHO is likely too rosy), too little realism is undermining the future of malaria control. In spite of what we might wish, over-promising wears donors down, and it will take donations to develop new measures and implement them. While I believe that malaria elimination is a motivating long-term goal, we have erred in selling the deteriorating tools that are available now (and their successors) as sufficient to accomplish the monumental task.

In my opinion, it is far better to incrementally introduce durable control rather than splashing money over endemic countries with little thought of the possibility that the stream of donations will someday end. While every life saved is precious, indicators of a future without malaria do not consist simply of declining case numbers. Short-term gains, while satisfying, may presage greater future loss.