Malaria control in South Africa and neighbouring countries

Jasson Urbach | 02 Mar 2011
Health Policy Unit
For a decade, the number of recorded cases of malaria in South Africa's Limpopo province averaged 413 over the festive period. Over November/December 2010, this number increased to 488.

Malaria is a complex disease and myriad factors could be responsible for this increase. Two easily identifiable causes are weather conditions and, more importantly, people. Individuals, returning from malaria endemic areas in neighbouring countries, bring the parasite into SA and swell the numbers attending our clinics, especially after the festive season. Seasonal increases that occur every year, and the larger than normal increase over this last festive season, demonstrate just how difficult it is to control malaria and how important it is to remain ever vigilant.

South Africa is a world leader in malaria control. We have good scientists who base our malaria control policies on sound scientific evidence. They receive strong political support and SA's relative wealth allows the government to pay for the best interventions for our circumstances. SA, with Botswana, Namibia and Swaziland, is committed to eliminating all local transmission of malaria.

SA's highly effective malaria control programme combines the best available drug therapy for those infected with the malaria parasites, along with the judicious use of proven insecticides that are sprayed in tiny amounts on the inside walls of houses. This method of control provides the one-two punch necessary to break the transmission cycle and knock out the disease.

Theoretically malaria control sounds relatively easy. The disease is both preventable and curable but numerous factors make the control of it difficult. With so many variables, it is extremely difficult to develop a formula or an early warning system to alert us when malaria cases are likely to go up.

Fortunately, for us, the vast majority of South Africans will never experience the debilitating effects of malaria since it is generally limited to the far North Eastern corners of the country where the Limpopo, Mpumalanga and KwaZulu-Natal provinces border with neighbouring countries.

Recognising the fact that malaria does not respect political borders, the SA Ministry of Health (MoH) has entered into cross border initiatives with our neighbours. The most successful cross border malaria control programme has been the Lubombo Spatial Development Initiative (LSDI), a tri-lateral agreement between the governments of Mozambique, SA and Swaziland which receives substantial input from SA's Medical Research Council (MRC). Since its inception in 1998, the LSDI has reduced the incidence of malaria on the border between SA and Swaziland from more than 25 per cent to less than 2 per cent. In Maputo province, the parasite prevalence was over 60 per cent in 1999, but is now well below 5 per cent.

In order to continue the success of our regional malaria control initiatives, concerted efforts need to be made to fund malaria control properly and ensure that the tools required are available.

This includes securing stocks of the insecticides used in our control programmes.

One of the insecticides instrumental in the successes recorded in suppressing the parasite in our region is DDT. Regrettably, DDT is also a chemical that environmentalists love to hate. But there can be no disputing the extraordinary impact that DDT has had, and continues to have in disease control programmes in SA and around the world. Communities have grown and prospered thanks to the remarkable degree to which DDT saves lives, contrary to the expectations of critics who argue that it is harmful to humans. It is an indisputable fact that since DDT was first used over 60 years ago there is no evidence that would comply with the most basic epidemiologic criteria to prove cause and effect to show that DDT environmental exposure is harmful to humans. The insecticide was used intensively and extensively across many developed countries with advanced health care systems starting in the mid-1940's. After almost 30 years of use they stopped. It has now been approximately 40 years since the use of DDT was discontinued in developed countries and during all this time environmental scientists have conducted thousands of investigations at great financial cost and vast numbers of papers have been published. Despite millions of dollars spent on research, scientists still cannot identify any harm.

In fact the International Agency for Research on Cancer (IARC), classifies DDT as a possible carcinogen. While this statement may not be definitive, DDT shares the classification with a number of common household consumables, such as peanut butter, beer and coffee. More importantly, the World Health Organisation (WHO) continues to advocate for the controlled use of DDT for public health purposes and states, "the improvement in health resulting from malaria campaigns using DDT has broken the vicious circle of poverty and disease resulting in ample economic benefits" such as increased productivity of workers, lower rates of morbidity and the use of previously unoccupied areas that were ravaged by the parasite.

SA's leadership in malaria control is a beacon of light that other African countries strive to emulate. The DoH should be applauded for the work it does while having to contend with conditions that make malaria control an extremely complex issue.

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