LESSONS FROM THE MALARIA ERADICATION CAMPAIGN And possible applications to MALARIA ELIMINATION IN THE AMERICAS

Achievements of the Global Eradication Campaign Radical change in the global distribution of malaria First global public health programme to aim at "total coverage" Set up contact with the community: voluntary collaborators Serious attempt to use maps throughout its activities Attempt to focus attention on the remaining problem vs. what had been achieved

Some serious problems of the campaign Exaggerated confidence on existing knowledge and neglect of research Assumption that a global campaign could start without knowing what to do in Africa Breaking with the past: poor relations with Health Services: disregard of case management Reliance on one measure everywhere; Inability to adapt to the unexpected. Disregard of local epidemiology as well as social, political & cultural barriers Expectation that epidemic risk would not recur after elimination

Research on malaria “Throughout the world support for further research into malaria, even that concerned with insecticides and chemotherapeutics, contracted swiftly. Worse still, the apparent imminent demise of a once important disease removed the necessity for training scientists in malariology. It took 10 years and a war to halt this tragic trend”. McGregor (1982)

The economic and political argument For reasons not alone altruistic, it (the PHS) has been concerned with overseas malaria problems. … Such diseases as the tropical fevers, which handicap labourers, also increase the cost of rubber, coffee, minerals, certain fruits, assorted fibres, hardwoods, oils and waxes. … Added to them is the fact that malaria is a factor that, among others, helps to predispose a community to infection with political germs that can delay and destroy freedom Paul F. Russell (1955) Man’s Mastery of Malaria. Oxford University Press Between malaria control and eradication there is as great a difference as that between night and day. Control … is a primitive technique UNICEF Regional Director to the Executive Board

Progreso de la Campaña Global de Erradicación ( )

Annual programme expenditure is converted to equivalent 1970 rupees

Some questions worth looking for an answer Why almost all the countries certified by WHO were only those with a long history of control? Why many other countries succeeded in interrupting transmission, but failed in the consolidation phase? Should a better understanding of different types of local epidemiology allow the design of tailor made control/elimination strategies? Up to now research in antimalarials blossomed only in time of war (WWI, WWII, Vietnam), shouldn’t we be able to get a steady support for research in peace time?

LESSONS "SMALLPOX PROGRAMME" LEARNED FROM M.E.’s ERRORS To stress epidemiological analysis and coordination To require flexibility in management To attract research needed to solve problems To encourage programme staff to innovate and adapt To consider targets mainly as indicative of possibility, but insisting that real assessment was in surveillance To design a phased surveillance programme, through –Morbidity indicators –Investigation of clusters of cases and containment of outbreaks –Investigation of individual cases

IT COULD HELP TO: Encourage flexible planning and adaptability Recognise that the success of elimination depends on a good control, capable of: –Typifying the problems & finding suitable interventions –Focalising transmission: delimit and study foci Beware of indicators and look at denominators Articulate surveillance with health services Stage epidemiological studies: –General stratification –Problem areas –Residual or new foci –Individual cases