The Tomorrow of Malaria

The Tomorrow of Malaria is, in large part, the chronicle of yesterday's malaria wars - a hundred years' conflict fought as much between malariologists as against the parasite. This is the centenary of Ronald Ross's discovery of the transmission of bird malaria through the mosquito. The super-sensitive, single-minded Ross went to his grave still holding the firm conviction that malaria could be eradicated if only weak-willed governments would commit themselves to exploit his discovery and attack the anopheline in their watery lairs.

On the other side were those who considered malaria to be a social disease. Malaria would disappear only when the economic life of the subjugated populations improved. Good housing, good nutrition, good health and education services, and modern agricultural practices were the best antimalarials. The anopheline without the parasite was only another biting nuisance. Economic betterment was advanced as the cause of the disappearance of malaria from northern Europe and England - where more than 10,000 cases had been admitted to London's St Thomas's Hospital alone between 1860 and 1870, followed by a rapid decline to four or five cases each year by 1925.

Schismatics soon arose on each side. The technocrats divided into the chemical-therapy camp led by the German bacteriologist Robert Koch, who believed malaria should be drugged into submission, and the vector-control camp led by the Englishmen Malcolm Watson and L. W, Hackett and the Americans Fred Soper and Paul Russell, who maintained the Rossian stand of selective anopheline control. The sociocrats split into the active-betterment camp and a 'do nothing' camp which maintained, on the basis of prevailing immunological fact and theory, that holoendemic malaria led to a benign state in adults. The unfortunate wastage of the young was a necessary, worthwhile cost in the community's journey to functional immunity. Those technocrat-sociocrat wars were fought in the 'bow and arrow' era of malariology, Quinine was the only therapeutic drug, and pyrethrum and Paris green the only insecticides. Then the Second World War ended, the pesticide DDT was rediscovered and the World Health Organization (WHO) embarked on its global crusade to eradicate malaria.

Socrates Litsios. the WHO insider and sometimes apostate, has written a slim, fascinating book. Its greatest strength is its account of the WHO malaria eradication campaign beginning in 1955 and ultimately failing in 1969. Litsios recounts how the vector technocrats, now armed with DDT, took over WHO. In 1953, the psychiatrist Brock Chisholm, campaigning for re-election as director general, had remarked: "one cultural anthropologist is worth more than 100 malaria teams". The malariologists campaigned on the promise of malaria eradication. Chisholm lost and was replaced by the Brazilian malariologist Marcolino Candau. For the new WHO. nothing less than global eradication of malaria would do - impure thoughts of 'control' could lead to excommunication. A strict, universal formula for DDT, application and surveillance was imposed on all national programmes. A timetable to eradication was promised.

In his book, Litsios rarely makes a direct comment or expresses an opinion. But his description of events and selection of citations speak for his sentiments. In this way, he condemns WHO for being too inflexible; for imposing a universal prescription when each setting required a programme to accommodate its vectors, its parasites and its human population's culture, behaviour and economy. Litsios faults WHO for not realizing that the massive reservoir of malaria, sub-Saharan Africa, was undoable. Nor did they appreciate the political-economic pressures on the new governments then emerging from colonial paternalism that would distract from the national malaria campaign.

The final chapter, "The Tomorrow of Today", is the sobering account of malaria's current annual toll - 300 million cases with 2 million deaths, DDT is gone. Cheap, effective chemo-therapeutics and prophylactics are gone. Multi-insecticide and multi-drug resistance are here, Steady-state, benign (for adults) holoendemic malaria has been replaced, in many settings, by unstable hyperendemicity - functional immunity impaired by the ad hoc chemotherapy distributed from the primary health centres. It is déjà vu all over again as the technocrat-sociocrat wars continue. The molecular technocrats now offer the unfulfilled, over-hyped, crime-tainted promise of a vaccine. Non-molecular technocrats offer bed nets dipped in permethrin. In one of his few displays of direct feeling, Litsios, in this final chapter, reveals himself to be the humane socio-crat: "The aim should be to improve the quality of life, with regard to human dignity, the realization of people's potentials, and the achievement of a decent standard of living. This implies a radical revision of established practices."

This is a fine, powerful little book. I would make all molecular-malaria graduate students read it before they clone their first gene or make their first hybridoma. Come to that, I would insist that their mentors read it too.

Robert S. Desowitz is in the Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA.

Published in Nature, Vol 383 September 1996

The tomorrow of malaria by Socrates Litsios provides a short and immensely readable overview of the past, present and future of malaria. With its stimulating and provocative title, we are instantly reminded that, while malaria has been with us for thousands of years, the disease remains and will remain a critical global problem for future generations. The aims of the book are clearly laid out in the introduction. The author shows that by drawing on an historical perspective and by looking back at the successes and failures of campaigns to central and eradicate malaria in the past we will more readily understand the current and future situations. In particular, Litsios emphasizes that the rich epidemiological studies and the development of ideas on "malaria as a disease" in the pre-DDT era must not be forgotten, for, as he states, "it is of great importance to keep alive the excitement of the malaria story, an aim to which this publication is dedicated".

The author successfully meets this aim. The design of the book itself is simple and attractive and immediately offers both the specialist and non-specialist reader a fascinating insight into the debates as well as the problems and politics that have thwarted attempts over the centuries to eradicate and control malaria. The book is divided into three parts: 'The yesterday of malaria', 'The today of malaria', and 'The tomorrow of malaria'. In the historical part, the ancient history of the disease receives a brief mention and it is the history of its control in different parts of the world during the twentieth century, following the discoveries by Charles Louis Alphonse Laveran, Patrick Manson, Ronald Ross, Giovanni Grassi and others of the plasmodium parasites and the mosquito cycle, that dominates this section. Litsios's fascinating accounts of the researches, ideas, disputes and frustrations of five key malariologists, Paul Russell, Louis Hackett, C Percy James, Sir Malcolm Watson and Nicholas Swellengrebel, are especially illuminating. The second section explores the DDT era of malaria control and eradication. Revealing comments are taken from official reports as well as from the unpublished diaries of a number of leading players in the main malaria conferences and debates, allowing the reader to be drawn into the realities and complexities of malaria central efforts in the 1950s and 1960s. The final part of the book offers a valuable opportunity to understand how and why global politics have shaped the present and future malaria situation. It also includes a short discussion of the various strategies and scientific tools which are currently being adopted or developed in the hope of controlling the global threat of malaria. The book ends on a note of caution. Malaria is interwoven into the fabric of life in a complex way and, as Litsios demonstrates, there will be no easy answers to solving the very critical issue of the "tomorrow of malaria".

The book is published at a time when we shall shortly be "celebrating" the centenary of the discovery of the mosquito transmission of malaria and the golden jubilee of the World Health Organisation's attempts at global eradication of the disease. It is a timely reminder that, in spite of important scientific discoveries and global campaigns, human endeavors have not solved the tomorrow of malaria. This is an excellent introductory text and highly recommended for all those who are concerned with the past, present and future of malaria and its wider implications.

Mary J Dobson, Wellcome Unit, Oxford
Published in Medical History, 41, July 1997.

This small light blue paperback, unassuming in appearance, is a surprisingly potent and captivating account of malaria history and programmes aimed at malaria eradication or control. It is replete with tidbits of information, whether for the historian, scientist, public health specialist, or politician, and is a fine starting point for further study of this field. Key players and stories are featured as Litsios painstakingly brings forth the viewpoints and decisions that have driven malaria programmes from one decade to the next. Meanwhile, his underlying wish is that a greater understanding and appreciation of the past will be realized and bring new hope for the people of tomorrow.

This book provides glimpses into the thinking of the times since the malaria parasite was first discovered by Charles L. A. Laveran in 1880, through landmark meetings including the League of Nation's Conference on Rural Hygiene (Bandoeng, 1937) and a series of World Health Organization (WHO) Expert Committee Meetings that convened between 1946 and 1986. This is a whirlwind tour of the malaria situation and challenges faced by several generations. Litsios frequently recaptures quotes from the past and cleverly employs irony to bring attention to major decisions which seemed to have been made with a disregard for available knowledge, with irrational thinking, or with political motivations. This style makes for amusing reading, but, importantly, it succeeds in bringing emphasis to elements of the history of malaria that ought to be revisited, and nudges current generations to critically assess the logic behind important decisions today.

Strategic plans for malaria control shifted dramatically from a broad public health and social approach prior to World War II, where malaria research in areas such as immunity and epidemiology were also deemed relevant, to the WHO's militant-like eradication campaign between 1955 and 1969, where DDT elimination of Anopheline mosquitoes became the dominant goal. Now, with reference to the changing politics of the post Cold War Era, Litsios conveys the message that it is an opportune time to tackle malaria with renewed recognition of knowledge and studies from the past, and where "human development" is also a focus. With this in mind, he carefully scrutinizes directions taken especially by the WHO as the world's leader of malaria eradication and control programmes for almost 50 years. His critical analysis points to conflicting viewpoints that have existed with regards to philosophical approaches, strategic planning, and methodologies. Litsios points out examples where knowledge of the times was overlooked as the WHO's global eradication campaign was designed and implemented; in some cases a sense of urgency overruled practicality; or, Cold War politics dictated its direction. Later, Litsios discusses one of the WHO's current focuses as a primary supporter and patent holder of the widely publicized candidate malaria vaccine known as Spf66. Litsios notes that once the results are available for the latest in a series of large scale trials - conducted in Thailand - that the future of this vaccine candidate "will be reviewed and decided upon." The reader is thus brought up-to-date as the world currently waits at another major crossroads to see in which direction the WHO will decide to proceed.

Litsios' critical accounts are meant to be instructive. He takes his readers through periods of high hopes, confidence, despair, and wonder, as history shows that massive efforts have helped little to avenge malaria - the "King of Diseases," which, as he notes, it was dubbed long ago in ancient Indian literature. The Tomorrow of Malaria is very timely as the 100th anniversary of the August 1897 discovery in Secunderabad, India of malaria in mosquitoes approaches. The past 100 years of discovery, both scientific and personal, are leading to a special period of reflection. Socrates Litsios, who is currently a Senior Scientist with the WHO Division of Control of Tropical Diseases, writes with a sense of optimism as he refers to the WHO's current Global Malaria Control Strategy, a product of the Ministerial Conference on Malaria (Amsterdam, 1992), and the end of neglect noting that this plan is "beginning to yield tangible results." He has hope in "the tomorrow of malaria" as he beckons his readers to be knowledgeable, logical, and responsible when deciding upon the present and future of malaria.

I especially recommend this penetrating little book to anyone working in any area of malaria research or control. This literary work may very well mark a reemergence of malaria scholars and help these fields flourish with accomplished malariologists.

Mary R. Galinski
Department of Medical and Molecular Parasitology
New York University School of Medicine
New York, NY 10010, USA

Published in Parasitology Today [PT 13 (2), 83-84, 1997]

"The Tomorrow of malaria" explores the history of malaria. with the aim of helping the reader to understand why malaria is still a major public health problem today and why its control in the coming decades will most likely be tied up with how poverty, environmental degradation and abuse of natural resources are successfully addressed" (p. 9). Thus Socrates Litsios sums up the scope and purpose of this concise but valuable history of malaria. Litsios has written an engaging internalist history of malaria control theory, highlighting the two principal doctrines of malaria control - namely, killing the parasite with medicine or killing the mosquito during some phase of its life cycle - and the personalities who fought for them.

In 1955 the World Health Organization (WHO) declared a program of all-out malaria eradication; in 1969 the same organization admitted the failure of this campaign. Litsios's account, with its global perspective and insider's knowledge of the WHO, deftly traces the history of malaria control in the twentieth century, illuminating the WHO disaster and the frustrating years since. This book is required reading for all who would understand the history of malaria during the past century and for those who plan the malaria campaigns during the next.

Margaret Humphreys

Published in the Journal of the History of Medicine.

This is a little gem of a pocket bock (29 X 16 cm). Gems can be flawed but the author's account of the philosophy of malaria central through the ages is mostly free of errors; Anopheles funestus is wrongly spelt in some places (pp. 41, 77, 106 and 107) and An. nuneztovari is incorrectly written on page 85.

The author, having served with the World Health Organization since 1967, is in a good position to describe the past and present, often conflicting, philosophies of malaria eradication and central. The insights and opinions, often prejudiced, of the prime actors on the malaria stage, such as Paul Russell, Louis Hackett, Malcolm Watson, Percy James, Nicholas Swellengrebel and Arnoldo Gabaldon, and the conflicts that arose among them, are well documented. Much attention is given to the differences between malaria central and the era, doomed to be short, of malaria eradication based on house-spraying with DDT. Malariologists remained divided as to whether preventing malaria could be achieved through killing mosquitoes or by drug treatment and socio-economic progress.
The author has written a popular account of malaria-central strategies, from yesterday to tomorrow, that can be understood by non-specialists. This little bock, however, should have a broad readership, encompassing malariologists and others engaged in malaria control or research, because it illustrates how past experiences in disease control can be relevant to modern concepts and ideologies of control.
In summary, this is a good read, albeit a rather expensive one.
M. W. Service
Published in Annals of Tropical Med.&Para. Vol 91 #2, March 1997