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About the Author

Bart Knols
Medical Entomologist (Dodewaard, Netherlands)

Bart G.J. Knols (1965) is the Managing Director of MalariaWorld, the world's first scientific and social network for malaria professionals. He is a malariologist with a Masters degree in Biology and a PhD in Medical Entomology from Wageningen University, the Netherlands. He also obtained an MBA degree from the Open University (UK) in 2006, for which he won the prestigious international ‘MBA Student of the Year 2007 Award’ as well as the Alumnus of the Year Award from the Open University. With 11 years of working experience in Africa he has managed large-scale research and vector control programmes on malaria for ministries, international or national research institutions. He has worked for the UN (IAEA) as a programme manager for three years, has served as a consultant for the World Health Organization, and is currently a Board Member of the UBS Optimus Foundation, the second largest charity in Switzerland. He has published over 130 peer-reviewed research articles, has written 16 book chapters, and has served as senior editor on a WHO/IAEA sponsored book on implementation research. In 2007 he co-edited a best-selling book titled 'Emerging Pests and Vector-Borne Diseases in Europe'. He received an Ig Nobel Prize (2006), an IAEA Special Service Award (2006), and in 2007 he became a laureate of the Eijkman medal (the highest award in the field of tropical medicine in the Netherlands). He has been a member of the Royal Dutch Academy of Arts and Sciences since 2004. Bart held an Assistant Professorship at Wageningen University until April '09 with projects across Africa. He currently directs K&S Consulting, a firm he founded in the beginning of 2007.

Post

The Man Who Saved Brazil

Published 27th May 2010 - 51 comments - 18661 views -

Natal, Brazil, March 1930

She sniffed land. And decided to leave the ship. Found her way to the nearest pool of water. And dumped the egg load she’d been developing whilst travelling across the Atlantic Ocean.  This mosquito sparked what would later become known as one of history’s most remarkable triumphs against tropical diseases.

dakar natalShe came from Dakar, Senegal, West Africa. Picked up the scent of a soldier sleeping in a cabin on a French marine ship, gorged on his blood, and remained as a stow-away there during the five-day trip to Brazil. Her name: Anopheles arabiensis, a notorious transmitter of malaria in most of sub-Saharan Africa.

Remarkably, her presence in the New World did not go unnoticed for long.  Whilst enjoying a Sunday morning walk a few weeks later, American entomologist Raymond Shannon saw some strange looking larvae in a roadside pool. Shannon was shocked to discover that these were African malaria mosquitoes. But Brazil was in the grip of yellow fever, transmitted by Aedes aegypti mosquitoes, and the authorities were not alarmed by Shannon’s discovery and ignored it.

By the end of 1930, the African invader had seized an area of six square kilometres. She felt so happy in her new homeland that conquering new land was the easiest thing on earth. People for blood, water for breeding, and the tropical sun of Brazil that provided her with a climate similar to that in Senegal. By 1938 she’d expanded over an area of 54,000 square kilometres.

And then she struck. Hard. And caused a massive epidemic of malaria. Nearly 200,000 Brazilians fell victim, tens of thousands perished. All over, people were lying by the roadside, begging for drugs. “The situation was appalling”, reported a malaria inspector years later.

Winning the war

On 5 August 1939, when the world was preparing itself for WWII, president Vargas declared war on the African mosquito. The field marshal in charge of the battle became Fred Soper. The war had one goal: to exterminate the invasion, not to control it, but free Brazil to the very last mosquito of African origin. 

But the enemy did well. Huge chunks of inhospitable and inaccessible land had been invaded. The Brazilian malaria parasite developed even better inside the African mosquito then in native malaria mosquitoes. Freeing 54,000 square kilometres of this mosquito seemed an impossible task. But not for Soper.

inspectorsSoper launched the war by setting up an army. He enrolled a total of 4000 men, and each of these was assigned a 25 square kilometre area. The gun was replaced by Paris Green, a toxic compound used to kill mosquito larvae in standing water.  The men had to locate each and every possible breeding site in their area, and treat it.

Soper staged the war much in the same way as Eisenhower and Churchill did with D-day.  By asking the utmost of their troops (see image), driving and inspiring them to do what seemed to be impossible, yet fraught with uncertainties. Nobody before had declared victory over a mosquito invasion of this magnitude, nobody before had freed Europe from the Nazis through a landing in Normandy.

But these men did. And won. Soper freed Brazil of the African mosquito after a battle that lasted just eighteen months.

Mbita Point, Kenya, June 2000.

The seminar room was filled with 24 of us, mostly Africans. All working in malaria research. Shortly before, Malcolm Gladwell had published a story on Soper in the New Yorker and we decided to have a debate on it. Former colleague Dr. Gerry Killeen would defend our current approach to malaria mosquito control (mostly with bednets at that time), and I would argue in favour of Soper’s strategy. After an hour, all voted anonymously for one of the strategies. Eighteen favoured the Soper approach.

Malarious Africa, 2010

Today, there is no place in Africa where Soper’s strategy is revived. Science has come up with a perfect biological alternative for Paris Green, the biopesticide Bti. We now have 4x4 vehicles where Soper’s men used horses or went on foot. We have satellite imagery that enables you to see a sheet of A4 paper from space. We have geographical information systems. Computers. Mobile telephones. The lot.

Fourteen countries in Africa, where children die of malaria each day, are smaller than the 54,000 square kilometres that Soper’s army freed of African malaria mosquitoes. To the very last one of them.soper

Zanzibar (I discussed the difficulties of malaria elimination here) is 1,554 square kilometres. Just 2.9 % of Soper’s area. With Soper’s strategy you would need 115 men to do the job. Let’s double it – 230.  Train them well, nurture them, pay them well. Give them two years.  End malaria, for good. In Soper’s words: “There is no such thing as partial success. It is either glorious victory, or dismal failure". The man died in 1977, long before he could witness the tools we now have at hand but not use.

If tomorrow an announcement would be published in the Tanzanian newspapers to recruit ‘soldiers’ for such a campaign, thousands of youngsters would respond. With massive unemployment in most of Africa, the army is out there, waiting to be enrolled. And with the sorts of money that are being poured into malaria these days, paying for it all wouldn’t be an issue.

So what are we waiting for?

 

[For a small video on Soper click here]

GF Killeen, U Fillinger, I Kiche, L Gouagna, BGJ Knols (2002). Eradication of Anopheles gambiae from Brazil: lessons for malaria control in Africa? Lancet Infectious Diseases, Volume 2, Issue 10, Pages 618-627

Image Fred Soper: National Library of Medicine, Washington DC.


Category: Health | Tags: malaria, brazil, zanzibar, eradication,


Comments

  • Luan Galani on 27th May 2010:

    Brilliant post, Bart. Incredible initiative. I didn’t know about him. What a shame for a Brazilian, isn’t it? Anyway, always learning.

    This may be the best quick solution. I hope and really expect for countries like Zanzibar to put it into practice.

    Keep it coming fellow.


  • Bart Knols on 27th May 2010:

    @Luan. Somehow expected you to be the first to respond… thanks. Soper, for the record, was an American…


  • Jan Marcinek on 27th May 2010:

    You have very great posts. I like them. Very informative.


  • Bart Knols on 27th May 2010:

    @Jan. Thanks for your kind words. I hope that this article will ignite a debate on the possible merits and potential of this approach, let’s see…


  • Luan Galani on 27th May 2010:

    Oh, right. We really owe it to him. A great achievement.

    Now our preoccupation here in Brazil is with Dengue fever and DHF. Government and its massive campaigns can not help it. So, something is wrong, of course. I will write about it soon.


  • Serge Christiaans on 27th May 2010:

    Wouldn’t it be possible to clean an area of malaria today, like Mr. Soper did back then? To me, it’s just a matter of logistics and politics.


  • Bart Knols on 27th May 2010:

    @Luan. Due to the limited length of the blog I could not go into dengue. However, Soper was heavily involved in dengue elimination in South America, and nearly succeeded! If you write about it, let me know, and I will give you the info about this…

    @Serge. Well, what I hope is that the powers at present will at least consider that in the new era of elimination this approach will be tried. The tools are there, the strategy isn’t. Thanks for commenting…


  • Luan Galani on 27th May 2010:

    Thanks Bart. I will tell you when writing about it.


  • Marit on 27th May 2010:

    Hi Bart,

    Nice post. I think it’s amazing that such a simple and effective approach has been so neglected. Especially considering that bednets are an equally old-fashioned method. Malaria control is now so focused on targeting adult mosquitoes, only because a model in 1957 (McDonald) predicted that that would be the most efficient approach. I don’t understand why we consider fighting a highly adaptive, flying insect easier than its less motile larvae.
    Bednets can also be effective, but upscaling these measures without fighting problems with appropiate use or insecticide resistance won’t be efficient enough for malaria elimination.

    And will all that effort and money that is currently being spent in malaria research to develop new tools be better spent on actual implementation? A massive larval control campaiggn might be laboursome, but so would application of novel insecticides.

    So, I agree with you, let’s make an army of malaria-fighters!


  • Bart Knols on 27th May 2010:

    @Marit. It is indeed true that the focus shifted from larval control to adult control with the advent of good indoor residual spraying options (notably DDT). The evolution of new methods have since been directed against adult vectors inside houses (nets), without a further focus on area-wide concepts that are mandatory if elimination is the goal. Sooner or later we will have to go back to larval control. But that’s not all. Recent trials (including one in the Gambia) has failed to have a major impact on malaria using larviciding. The problem is therefore not just one of tools, but also the implementation of those tools. If larviciding is not done rigorously and with military efficiency, you’re wasting your money.

    We will need a complete change of mindset for this to work in 2010 and beyond…


  • derek charlwood on 27th May 2010:

    In a recent song Bob Dylan says’The world of science has gone berserk, Too much paperwork’.  Perhaps the very existence of the technology that we have these days makes simple approaches difficult.  And of course Brazil still has malaria transmitted by good old Anopheles darlingi.  Perhaps it will always be easier to eliminate an invader than a local species.  I also remember somewhere that a drought, which limited the number of breeding sites, happened making life just a little more difficult for the mosquito.  (Lack of rainfall also helped ameliorate the epidemic of malaria on Sao Tome which claimed so many lives that the archipelago was considered to be the most dangerous place on earth in the Millennial edition of the Guinness Book of Records!)  I think that the most important thing is that different control techniques should be used in different ecosystems with different vectors.  Anopheles arabiensis indeed likes to breed in sunlit puddles that can easily be identified by agents other species might be more difficult.  Nevertheless an unsung success story in Africa is that of Tim Freeman who mobilized schoolchildren for larval control in Zimbabwe.  Not sure if that is written up or not.


  • Bart Knols on 27th May 2010:

    @Derek. The point you raise ref Tim Freeman is interesting. Larval control can be great and can be used for elimination, but I am not a believer that this can be done by schoolchildren… Unless you do it well, you’re wasting money. So better run an efficient campaign with well-trained people that may be costly up front but than succeed, then going half-half. Agreed?


  • Bill Jobin on 27th May 2010:

    Soper is a legend, and his superb and even ruthless management techniques for larviciders are part of his legend.  But I would never vote for Soper’s single track approach in Africa.  Never!  And the reason that we cannot and should not try to infer that this is the way to control anophelines in Africa, is precisely that Anopheles arabiensis (or was it actually An. gambiae?)  was not Brazilian, but African!  Soper was fighting An. arabiensis on territory that was foreign for it and probably hostile to it.  So Soper started with the advantage.  However in Africa we have to fight it on home territory, and that species has he home court advantage.  An. arabiensis had only about 10 years to adjust to the ecology of Brazil.  Whereas they (and all the other anophelines in Africa) have had about 10 millenia to adjust to African ecology.  Where do you think they will hang on the longest?


  • Manuel Lluberas on 27th May 2010:

    Bart, thanks for your article. Having worked in malaria vector control in Africa during the past couple of decades, I can tell you there are only a handful of us who know about Fred Soper and suscribe to his ideas. There are very few universities and malaria programs in the world where Fred Soper and the handful of others like him are mentioned even in passing. In my opinion, the large universities and organizations dealing with vector-borne diseases, malaria in particular seem to concentrate on treating the patient and have replaced doing with thinking and practice with theory. We need to get back to letting the Fred Sopers of today lead the way. After all, if vector populations are not reduced, it will be a matter of time before the diseases they transmit return.


  • Iris Cecilia Gonzales on 27th May 2010:

    Thanks Bart!

    I didn’t know about him at all. Malaria is a serious problem even in the Philippines. But our government says, the MDG goal on malaria is achievable. (http://development.thinkaboutit.eu/think3/post/the_philippines_on_mdgs_goals_1_and_2_likely_to_be_missed)


  • Bill Jobin on 27th May 2010:

    Hey Bart,
    After reading Derek Charlwood’s comments, I could not resist a second comment.  I hope this is permissible.  So Hark! If only one female An. arabiensis came across in 1930,  it means that all the population in Brazil were her children, perhaps identical?  So the lack of genetic variation should be added to foreign worker status, making that group of mosquitoes really easy to knock off. Maybe you can clue me in on the genetics, for I am only an engineer.
    Bill Jobin - again


  • Bart Knols on 28th May 2010:

    @Bill. Thanks for comment. Recent PCR analysis of museum specimens has confirmed that the invasion was caused by An. arabiensis, not An. gambiae. See Am J Trop Med Hyg. 2008 Jan;78(1):176-8.

    Second, if you read the Soper and Wilson book ‘Anopheles gambiae in Brazil: 1930-1940” I think you will come to a different conclusion regarding the ‘hostility’ of Brazil towards the African mosquito. In fact, it thrived better than it did in native Senegal. I quote from the book:

    “During the flood season crops cannot be planted in the lowlands because of inundations, but afterthe surface has dried there remains for many weeks a sufficiently high subsurface water table to permit the growing of crops in the dry river bed. An essential part of this system of agriculture is the digging of shallow or ditches in the sand…are small shallow pools generally completely exposed to the tropical sun and are greatly preferred
    by the gambiae mosquito”

    and

    “During the wet season, the river beds are flooded and unsuitable for the production of gambiae, but at this period there are myriads of small shallow sunlit pools everywhere in the surrounding country, for water permeates the clay soil of the alluvial plains very slowly.”

    So habitat suitability was perfect. And in terms of vector competence, Soper mentioned the data collected by Davis:

    “Dissection of gambiae collected in houses in the epidemic zone showed a truly astounding rate of Infection. Davis found 52 or 30.2 per cent glands with sporozoites and 108 or 62.8 per cent midguts with oocysts, in 172 dissections. Thirteen of the 102 infected midguts had more than 100 oocysts each, one stomach had some 600 oocysts, and another 400.”

    Conclusion: arabiensis did extremely well in Brazil.

    Two more issues here: If you read about the eradication of arabiensis from Egypt (we’re in Africa now), it worked along the same principles except that DDT was added more prominently in the campaign. The point is: It also worked on African soil.

    Then, the Soper strategy virtually eliminated aegypti from South America. Admittedly, aegypti had been there for a few centuries only, but surely had adapted very well.

    I think a major problem in our current thinking is the belief that we cannot do it. This is fuelled by the lack of success in Garki (Nigeria) and Pare-Taveta (Tanzania), and even comments made much earlier on by the big shots:

    “No one has ever supposed it possible to exterminate mosquitoes from whole continents or even large rural areas…we aim only at reducing their numbers as much as possible (Ross 1901)

    “The idea that vast tracts peopled only with natives, could be freed from any mosquito is too silly to require any disclaimer” (Ross, 1923).

    Well, Ross was proven wrong in Brazil and Egypt. So, overall I am not yet convinced that it wouldn’t be worth a try in Africa (particularly on the fringes of gambiae/arabiensis distribution, e.g Eritrea, northern Sudan etc).


  • Bart Knols on 28th May 2010:

    @Manuel. Many thanks for your support. I am convinced that if the world gets serious about malaria elimination, that area-wide larval control will have to come into play. Sooner or later it will happen. I’d rather make it sooner through this debate. What we need next, is a part of Africa where through collaboration with the exisiting programmes and scientists in situ we can revive the strategy over a large area. Go in, and don’t come out until prevalence is 0.

    @Iris. Thanks - read your blog about the MDGs in Philippines. Same story applies as above.

    @Bill (2). There were probably more females that made it across. The original population that was discovered by Shannon numbered a few THOUSAND specimens, so it is likely that there were more gravids on board that also kept the genepool more diverse…


  • Christophe BOETE on 28th May 2010:

    @Bart

    Very Interesting post! Good food for thought!

    I just quote your reference about the infectious rate

    “...in terms of vector competence, Soper mentioned the data collected by Davis:

    “Dissection of gambiae collected in houses in the epidemic zone showed a truly astounding rate of Infection. Davis found 52 or 30.2 per cent glands with sporozoites and 108 or 62.8 per cent midguts with oocysts, in 172 dissections. Thirteen of the 102 infected midguts had more than 100 oocysts each, one stomach had some 600 oocysts, and another 400.”


    These rates are really amazing. This means that the parasite did really well with the mosquito and that this latter one was not ‘suffering’ too much from infection (tolerance vs resistance?)...  This seems just like a ‘non-natural’ combination between the vector and its parasite compared to the usual rates observed in Africa between An. arabiensis and P. falciparum…


  • Bart Knols on 28th May 2010:

    @Christophe. The infection rates observed in the African mosquitoes infected with Brazilian Plasmodium were more like the rates observed in typical lab studies where e.g. stephensi is infected with a rodent malaria.

    I guess that the co-evolution between the two in Brazil had only just started, that would eventually have selected for mosquito genotypes that would sustain 1-2 oocysts, more like that observed in Africa today…

    The point is, it did extremely well in Brazil.


  • inge on 28th May 2010:

    Thanks, Bart, for this interesting blog. Malaria has been eradicated in Europe & America and I wonder if it is not ‘an easy way out’ to assume that it is not possible in other parts of the world. I am interested in reading more about the ‘Soper way’. Could you explain a bit about this strategy?  Where would you start? How to organize this? How about local politics?
    Would local communities be involved and would they benefit besides the health benefit? etc.


  • Bart Knols on 28th May 2010:

    @Inge. These are critical questions, thanks. Let me try to answer them:

    - The elimination of malaria from the USA and Europe was caused by a multitude of factors, including general development, improved health infrastructure, etc., but also because of a rigorous anti-malaria campaign. ‘Community involvement’ was minimal, and essentially based on compliance.

    - The Soper strategy in Brazil focused on the deliniation of boundaries and grids, and assigning grid blocks to larval inspectors (picture above). These had to locate all (I repeat all) standing water that was suitable for mosquito breeding, and treat it with larvicide. The men working in the field, would have two flags (picture above), one which they would plant along the roadside, the other where they were working. Supervisors could thus easily find them and inspect their work. There were always 2 teams: one consisting of larval control staff, the other to monitor mosquitoes (and assess the overall effect of the campaign).

    - Where to start. First it will be essential to seek out a place where it can be done (I mentioned Zanzibar, but Pemba island could be another example). Sudan anywhere north of Khartoum would be perfect, southern Mauritania, all northern malarious parts of Sahelian countries). Next, ensure that accessibility is guaranteed. With this I mean that all parts of the areas should be accessible for larval control measures. If this cannot be guaranteed, forget it. This then also means another critical issue needs to be resolved: can and will communities provide access. If not, look for another place. If communities provide consent, the work can proceed. Next, organise the training of a large number of young and driven people. In terrain reconnaissance, in the use of biological larvicides, in the treatment of water, in identifying larvae, and so on. Next, determine that the biopesticides planned for use are still working and that there is no resistance. Next, do not interfere with other ongoing measures (indoor spraying, bednets etc). These measures already in place should continue, and will only help. Then get started with systematic coverage of the terrain, the actual campaign. Continue until the monitoring people do no longer find traces of mosquitoes. When mosquitoes have disappeared, start using serology as an indicator of success (any child born after the campaign ends should not have antibodies to mosquito saliva). This is a quick summary - the whole operation will of course be more complex.

    - Local politics need to buy into the campaign. If they don’t, look for another place. This is vital, again in terms of access to breeding sites. Leadership is vital: the people working in the field need the right support from above, need to know that they are looked after well, and stand a chance of becoming heroes. Bill used the word ‘ruthless’ when it came to Soper. ‘Strict, fair, meticulate, but determined’ may be better. As Manuel says, these are the individuals that need to stand up to lead such campaigns…


  • Bill Jobin on 28th May 2010:

    Bart,
    I am still skeptical that a foreign mosquito was well adapted to Brazil. Almost by definition it must have been more acclimated to Africa.  There are many ecological factors that were probably overlooked, such as predators, new mosq diseases, etc.

    Secondly I prefer the Swiss cheese strategy, where you have multiple control methods, each overlapping.  Thin slices of Gruyere can be placed over each other slightly turned, so the holes do not coincide.  Thus a few slices gives you full coverage.  On a national or large scale program you need the multiple coverages.

    If the larviciding doesn’t work in one town, you cover it with indoor spraying, or drainage or land levelling or screens.

    Soper was ruthless.  He had his spraymen on assigned routes with the hour and minute they were supposed to be at each site.  One day there was an explosion from a gas leak at a factory at one of the sites.  He looked up the schedule and determined that his sprayman should have been at the site of the explosion, precisely when it happened.

    When the man turned up for work the next morning, Soper fired him.


  • Bart Knols on 30th May 2010:

    @Bill.

    - So we agree that nobody really knows how well arabiensis did in Brazil. For a species that invades 54 thousand sq km in 8 yrs I would say that the circumstances were not bad, but alas, nobody knows.

    - I am also a strong advocate of multiple approaches. The point is very simple: Soper’s strategy in Brazil worked with larviciding ONLY. That means if we embed this strategy in a background of ongoing IRS or nets, that this should work even better, right?

    - Yes, Soper was ruthless. But so is the disease malaria. The point is simple: you can’t eliminate an infectious disease like malaria with half-hearted approaches. Unless you’re ruthless, you will always loose the game…


  • Daniel Bridges on 31st May 2010:

    Bart,

    Very interesting post. Couldn’t agree more with you on the need for multiple approaches. Its similar to combination therapy - no single therapy / eradication method is going to be 100% perfect, (although Soper showed this isn’t an absolute). Nevertheless by combining multiple strategies the chances of resistance arising are massively reduced.

    What worries me about whether a pan-African eradication programme will be successful is how can one ensure that it is carried through to completion? What I mean is that as rates of malaria fall, inevitably other public health priorities may threaten continuation of the strategy. Without 100% adherence, the strategy will fail and doom another generation to believe that malaria is uneradicatable. Or perhaps I have missed the point and you advocate a country by country approach?


  • Marit on 31st May 2010:

    @ Bill & Derek: adaptive or not, mosquitoes are just insects and will just die if you target them with a working product. As a biologist I am also intrigued with how adaptive anophelines are, but that doesn’t mean we can’t kill them.

    Why do we (especially researchers) not let much more difficult questions, such as how to make refractory mosquitoes or how to make vaccines, stop us while we do see the question of how to successfully implement control tools as a uncrossable hurdle?
    If we really want to get rid of malaria, we need people to actually go out and do that.

    The main issue clearly is how to organise effective camppaigns (continent-wide). And with that the main problem is that someone will have to take that responsability.


  • Kija Ng'habi on 31st May 2010:

    Hi Bart,
    Thanks for an interesting post. I think Soper’s approach need to be revived for malaria control in Africa and i am very optimistic that this will do better in Our settings especially with the ongoing efforts to scale up other interventions such as ITNs. Because adults are becoming much more labile while evading and undermine available interventions, targeting the less motile larval would maximise malaria control efforts and success.  Like Derek’s example of unsung success for school children, if the bulk of young unemployed men get trained, given all necessary gears and paid they can do as better as the Soper’s army approach. For better results, the approach should involve locals, who have much knowledge of the area eg at village level.  However ruthless remains important for it to be successful. Resources need to be made available and Soper’s approach have to be revived and put into Action in Africa to build more on the success in malaria control.


  • Bart Knols on 31st May 2010:

    @Daniel. Multi-pronged approaches will be essential - for sure. The idea of a continent-wide elimination campaign is not realistic at present. A Soper campaign cannot be executed in areas which are not safe, full of landmines, and other hurdles that make access impossible.

    However, there are major chunks of the continent where the Soper approach could start immediately. Particularly the parts where transmission is not intense and only seasonal would be highly prone to this form of attack. Think of countries like Eritrea, (northern) Sudan, Mali, etc. And of course all the malarious islands around the continent (with the exception at this stage of Madagascar, simply because of its sheer size).

    So yes, bit by bit, country by country, rather than an immediate continent-wide assault.


  • Bart Knols on 31st May 2010:

    @Marit. The saying introduced by Prof. Novak is that larvae comply with the CIA: they are Concentrated, Immobile, and Accessible. Unlike adult mosquitoes.

    I would not (see comment to Daniel) propose a continent-wide campaign, this is not realistic and impossible to resource. Rather I would like to bring a team of people together to start identifying a few places in Africa where Soper’s strategy may be revived. And see how successful it can be.

    Perhaps I should take it on me to get such a group of interested people together…

    @Kija. Many thanks for your comment. And yes, I agree, the more local people can be involved in such a campaign, the more likely it will be that the result is successful elimination of vectors and malaria. That’s why I would propose to set up a team of citizens of Zanzibar to run the campaign rather than an outside group.

    @All. I have invited WHO representatives and members of the Malaria Elimination Group to respond to this article. Curious to see how they will respond to the article and your comments.


  • Johan Knols on 01st June 2010:

    Interesting. We now see that we have two millennium development goals that contradict each other.
    MDG 6 aims to combat malaria and MDG 7 is aiming to reduce biodiversity loss.
    Now what?


  • Bart Knols on 01st June 2010:

    @Johan. The removal of an invasive species from new territory, in this case Brazil, is not considered a loss of biodiversity, so the two MDG’s don’t bite each other in this case.

    But seriously, you have worked in Botswana for so long, wouldn’t the Soper strategy work out there? It’s only the northern part of the country that has malaria anyway…


  • Mark Q. Benedict on 01st June 2010:

    One can argue about adaptation of An. arabiensis to Brazil and the variety of methods that could be used to eliminate it from regions of Africa, but the fact remains: An. arabiensis was eliminated from a large region of Brazil and Ae. aegypti from larger areas. The latter is arguably a much more difficult target: persistent and cryptic.

    Current control efforts presage endless distribution of bednets and IRS, diagnostics and drug administration. The activity associated with these is greater than the long-term impact. They will accomplish malaria elimination - at best - only where they are most intensively implemented indefinitely. Who will fund these regional efforts when malaria is eliminated? What will protect the non-immune population?

    Bart is correct: Area-wide elimination of vectors followed by consistent surveillance and elimination of reintroductions would provide benefits that can never be achieved by the personal protection approaches that are in vogue.

    Many have commented that Africa-wide elimination of malaria vectors is not possible. I agree that this is true for political and economic reasons. Countries and regions in which these are favorable can however conduct area-wide programs to solve their own problems.

    A global effort for malaria elimination is not necessary to conduct a regional one, and vectors are more easily destroyed and detected than parasites. What is needed is vision and courage.


  • Uli on 01st June 2010:

    Thanks, Bart. Another fascinating post! Not much to add, just that I would love to see more larviciding projects in Africa, and the manpower needed could lead to exciting new local employment & empowerment options too. I agree that many people on the continent would love this opportunity - male and female. Potentially many new anopheles specialists in the making…such a project would also be a great chance to learn more about the local habitats of the different anopheles species. I also love the idea of targeting areas, where this approach seems particularily fruitful. (The south of Madgascar might well be such an area btw.)

    But I remain sceptical of eradication/elimination on a broad scale; and importantly I have doubts about its merits as a concept (!) in policy, I would argue that we need to stop seeing a strategy only as valuable when it promises elimination/eradication. Might seem like linguistic wordplay to some, but funding tends to be tied to such promises…. So ‘yes’ to larviciding, ‘no’ to pushing eradication as the first and foremost, overall strategy with regards to malaria.


  • Bart Knols on 01st June 2010:

    @Mark. Ref your first comment: As long as nobody has tried the Soper approach in all seriousness in a part of Africa where the chance of success is high, we can indeed debate for a long time about the pros and cons. Fact remains: nobody knows for sure if it can or cannot succeed.

    Second comment: all in agreement. Nobody will deny that current efforts are good, most will agree that the current tools are not the panacea for elimination. So area-wide tactics will sooner or later have to come into play anyway.

    I have not suggested that continent-wide elimination is feasible at this stage in history, but agree entirely that major chunks of the continent can be freed this way.

    Courage from whom? Who should take the lead in this?

    @Uli. First para - we have the same thoughts, thanks. Second para: I am not sure if you are aware of the elimination of New World Screwworm from the entire North America, Mexico and Central America, down to Panama. It is a great example of what bald approaches can deliver. As mentioned to Mark, it is not realistic to talk about a continent-wide campaign, but it is possible in many parts.

    What’s needed is a proof-of-principle. Start in northern Mali and attempt, using Soper’s approach, to push the boundary of malaria southwards. It won’t be hard to convince donors if you show that this works.

    We will only know it if we do it.


  • patrick sampao on 02nd June 2010:

    If Fred Soper’s strategy was to be executed in Africa today, a toddler who isnt old enough to read now will one day come across an article, titled “The man who saved Africa.”
    I agree with you that we are better placed to wage and win a war against malaria than Soper did. The weopons we have today are way more advanced than his. However there is one integral thing we are missing today in Africa that Soper had in abundance, government support.
    I have participated in measles and polio eradication campaigns in Kenya, these campaigns receive overwhelming support, during this period every government ministry gives a vehicle and a couple of volunteers for a week to support the campaign. If the current trends of these diseases is anything to go by, measles and polio will soon be history in this East African country.
    If African leaders dedicated just a little bit of their time and government resources to malaria eradication as the Kenya government does with measles and polio, it would even take a shorter time than it took Brazil to wipe malaria out once and for all.


  • Bart Knols on 02nd June 2010:

    @Patrick. You raise a point of MASSIVE importance. Soper was lucky in that he had direct support from president Vargas, which ensured that he had access to each and every place where he and his men wanted to go. It would not work otherwise.

    You will need access, otherwise you’re just wasting funds and will gain temporary control at best.

    However, your comments about polio and measles do show that rigorous campaigns are possible - if we can do it for these diseases, then why not for malaria?


  • Bill Jobin on 02nd June 2010:

    Bart,
    Adding a carefully executed larviciding program to the current narrow strategies of WHO and PMI is an excellent way to broaden the attack against malaria.  This fits with my Second Law for malaria control which I explain in the new Blue Nile Monograph One - “A realistic strategy for fighting malaria in Africa”.  When we add other means of larval control such as the classic ditching and filling, and the revival of fish recently explored by Matias and Adrias, we are getting off our chemical dependency too.  Geographically I agree that Mali - and also southeastern Africa - are ideal places to start because of their stability and proven competence in malaria matters.  Congratulations on your strategic thinking, and this includes everyone on this blog.  Can we get these ideas to Tim Zeimer somehow?  He is the head of PMI at USAID Washington and has the flexibility that WHO lost long ago.  But we need to convince him of the value of additional weapons in his current strategy.  I have tried, but he has not heard me.
    Bill


  • Bart Knols on 02nd June 2010:

    @Bill. Thanks for additional input. It seems from what you now write that you would consider a Soper add-on campaign a worthwhile endeavour - again, if we don’t try we’ll never know.

    I would also appreciate receiving views from Dr. Ziemer. Besides people from WHO (which I have invited but remain silent) we need more input and keep this discussion going. If they don’t believe it can work, than it would be good to at least know WHY they think so.

    I have found Dr. Ziemer’s contact details and will send him a polite request to have a look at this article and the comments underneath it.


  • Osvaldo on 02nd June 2010:

    Nice post. This was an inspiring accomplishment.
    However it is necessary to remember that approximately 500,000 cases of malaria still occur annually in Brazil. One battle was won. There is much more to be done before we can say Brazil won the war against malaria.


  • Bart Knols on 02nd June 2010:

    @Osvaldo. You’re absolutely right. The impression should not be there that Soper’s campaign removed malaria from Brazil. It removed the African malaria mosquito from it.

    But then, could a campaign in a similar style, against indigenous malaria mosquito species be equally effective? Today, in Brazil anno 2010? Curious to see how you feel about that…


  • Bart Knols on 04th June 2010:

    @all. A very interesting article, showing that it can be done. Read the abstract: On the military training facility of Tekong Island, Singapore, a comprehensive vector-borne disease control program was started in end-2006 to reduce mosquito populations and negate the need for anti-malaria chemoprophylaxis. The program was based on 1) preventing importation of malaria through screening of visitors, 2) preventing human-to-mosquito transmission through early case detection and mosquito control, 3) preventing mosquito-to-human transmission through personal protection, and 4) contingency plans. Systematic environmental works were performed to reduce breeding sites, and insecticide use targeted both adult mosquitoes and larvae. Mosquito populations declined from 103 mosquitoes per sampling site in January 2007 to 6 per site by March 2007 (P < 0.001). The proportion of positive ovitraps declined from 93% in January 2007–2% in March 2007 (P < 0.001). There were no malaria cases on the island despite chemoprophylaxis termination, showing that comprehensive combination vector-control strategies were effective in reducing the risk of malaria.

    Ref: http://www.ajtmh.org/cgi/content/abstract/82/6/1024?etoc


  • Osvaldo on 04th June 2010:

    Bart
    I quick answer to your question, posted on June 2nd, is no, I do not think a campaign in a similar style, against indigenous malaria mosquito species would be equally effective.
    It would be impossible to identify, map and treat all or most anopheline breeding sites in the Amazon (3,179,715 sq mi). But similar campaigns would be very effective if targeted to preventing urban malaria in cities such as Manaus and Porto Velho.


  • Bart Knols on 04th June 2010:

    @Osvaldo. I have to agree fully with you here. The scale you’re looking at is something that cannot be targeted in the medium if not long term and other approaches will be needed.

    As this discussion is progressing, I have, however, not seen any obstacle why the approach cannot work in smaller areas, island (think of Indonesia and the Philippines), major parts of the Sahelian zone in Africa, and some complete countries (e.g. Eritrea, Zanzibar and Pemba, Mauritania, Mali, Burkina Faso, Niger, northern Sudan).

    I am still hopeful that key people invited for their views from WHO and PMI are willing to shed their light on this, let’s hope they come forward. Thanks for your comments.


  • Anton Cruysheer on 06th June 2010:

    Hi@Bart,
    something big is happening here…
    but now it’s time someone will throw the stone in the lake as a startingpoint for the one goal: a malaria free world! Maybe you know someone who will take the lead, but I don’t see why you can’t be this person: The Malariaman! I’m convinced this project needs a face, just one person (like Soper), not (only) an organization - that’s in a publicity point of view not convincing for the majority of people to believe in the main goal: this really needs to be a person, a role model. Everyone needs their heroes, so does Malaria.
    To really make the difference you will have to act like other ‘heroes’, like Ghandi. Just one man among 100 million who wanted the British to leave his country and he succeeded. The lessons to be learned from this example that could benefit the malaria objective is in my opinion:
    1. one man, one mission
    2. act as you speak (most people, organizations, just talk a lot wasting precious time)
    3. you can’t kill all the bugs by yourself, so with the main goal in sight you have to act what’s in your reach; keep it small! Target at one Island, one region at the time, one by one, never stop, just go!
    4. when you want change, you’ll get negative reactions. That’s a fact, you will step on every toe in the world, but just keep your focus, never negotiate, just keep on going (Ghandi was put in jail over and over again, but he just kept on going)
    5. Ghandi was no fool, he was a strategist using a lot of people, friends on one hand to work for him and on the other hand used the public opinion like no one ever did before in his time. This will need major propaganda, and I mean MAJOR!
    6. You have shown that you believe in this solution (with Soper as an example), than don’t wast time talking about why this way work. You don’t want to waste time and energy on a battle against other malariaprograms. This will be a never ending story, their are just too many governments, too many organizations and you will end up talking about it, defending it instead of doing it (see nr. 2 above). The only thing you need to do is express your believe in your solution. You are convinced! You are not believing when you need to defend your program (than you are in battle and you can only loose). Of course, you don’t need to be arrogant, just tell the world that YOU believe in this; you WILL get malaria out of the world. And every step, every Island that’s liberated is the propaganda you need for your story.
    Well, I don’t want to make this too long, you get the point: GO FOR IT!!!  (I believe in you!)


  • Bart Knols on 07th June 2010:

    @Anton. Woow, this is a challenging comment - the most challenging so far I have to admit. However, the message is also very straightforward: we (I) have to move forward and do it somewhere, do it very well, and succeed. It is likely that only THAT will be convincing to the many stakeholders involved in the malaria field. Anything else will be an upstream battle, as you rightly point out…

    I will certainly keep updating this blog, when steps (albeit small) are taken in this direction. Thanks for prodding me into decisive action on this.


  • Bart Knols on 14th June 2010:

    I’m happy to inform you that the Malaria Policy Centre in Washington has picked up this story and publicised it: http://www.malariapolicycenter.org/blog/?p=1943

    Let’s hope more will come out of this!


  • Bart Knols on 13th July 2010:

    @tushar - thanks, appreciated.


  • Bart Knols on 25th July 2010:

    @Ashwani - Thanks for your kind words. Indeed, although great successes from the past have been forgotten, it is our duty to bring them to the foreground once more. It will, as you point out, be challenging to convert those that are sceptic and don’t believe in the possibilities to eliminate malaria. But one step at the time, we pursue this and hope to convince those that pull the strings to have a go at campaigns based on historical successes…


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