Malaria: The hundred-year story behind the bite

By Kumudini Hettiarachchi

Why did the mighty ancient Raja Rata kingdoms fall? Was it due to foreign invasions or did the kings up and leave their cities, along with the people because a tiny insect was wreaking havoc, spreading disease and death? Did malaria cause the abandonment of the Raja Rata?

The answers, of course, lie buried in the sands of time, but two doctors in more recent times have taken up the task of not only documenting the scourge of malaria but also detailing the “organized” control efforts in Sri Lanka.

As Sri Lanka stands on the threshold of eliminating malaria in three years, 2015, and celebrated ‘World Malaria Day’ on April 25, the efforts of these doctors- turned-authors have yielded a slim but comprehensive book titled ‘100 years of Malaria control efforts in Sri Lanka – 1911-2011’.

The duo are Dr. Punsiri Fernando and Dr. Supriya Warusavithana who have been heavily involved in malaria control work and know through experience how many people worked long and hard to get Sri Lanka to this status. That’s why they have dedicated their labours to “all those who have contributed to malaria control in Sri Lanka from the grassroot level of the implementation of the control programme to the policy-making level”.

Both come with the right credentials to document malaria control activity. Dr. Fernando has been in the malaria arena for 30 years reaching the peak of his career as the Director of the Anti-Malaria Campaign (AMC) from 1992 to 2003. Dr. Warusavithana who has seen wards full of shivering malarial patients, had been moved especially by the plight of expectant mothers while working as a Medical Officer of Health at Anuradhapura and ending her government service as a Consultant Community Physician at the AMC. Even though she now works for the World Health Organization (WHO), her passion for malaria control has not waned and she handles technical assistance for Communicable Disease Control Programmes including vector-borne diseases.

The book brings to the fore what most people have forgotten about malaria and its control and some of the major players in this field. How many would remember that “celebrated personalities” such as Sir Ronald Ross (1857-1932) who first discovered that the carrier of malaria was a mosquito and George MacDonald (1903-1967) who analyzed the 1934-35 epidemic that swept the country and created the famous MacDonald’s Formula were both engaged in malarial control work here. Sir Allen Perry who published a report on malaria fever in the low country as a sessional paper had also carried out the first spleen survey in the country in 1908.

The two doctors take us back down the misty corridors of time… indicate the differing views of when malaria began. A map published by the Dutch in 1638 is proof that the Southern Province had been depopulated and deserted by “fever sickness” and the North Central Province was marked as an area “depopulated by sickness”.

This leaves the reader wondering whether history was repeating itself with regard to the fate that befell the Raja Rata during the ancient kings, also in Dutch times. Major milestones in the battle against the parasites Plasmodium vivax, Plasmodium malariae and Plasmodium falciparum passed onto Sri Lankans by the female Anopheles mosquito are dealt with comprehensively in the book. They include the inauguration of the first AMC centre in 1911 at Kurunegala; the establishment of Anopheles culicifacies as the vector of malaria; the appointment of a malariologist before the launching of colonization schemes in the North Central Province; DDT (Dichlorodiphenyl trichloroethane) era; the first malaria eradication attempt way back in 1958-63; and the launch of malaria mobile clinics in more recent times.

However, a short explanation on ‘What is malaria’ would have enhanced the book to non-medical readers. The hurdles and negatives have also been put in black and white without being glossed over, as these are as important as the positives. They include the two malaria epidemics which left a trail of death and disease.

The book creates a terrible image of the great malaria epidemic of 1934-35 with its beginnings at Alawwa on the left bank of the Maha Oya with official figures indicating 80,000 dead within seven months but general literature quoting as many as 125,000 dead and 2.5-3.5 million episodes of malaria.
It also deals with how by the early ’60s it became a “forgotten disease” and medical students studied about malaria without seeing a single patient.

The country was holding onto a foolish sense of complacency, with a resurgence of the disease, this time with Anopheles vivax biting with a vengeance in new development projects and chena (slash-and-burn) cultivations.

The second epidemic swept the country in 1967-68, virulent as ever though the deaths were not as bad as in the great epidemic. A name which comes into focus is the then Paediatrician at Anuradhapura, Dr. Kamalika Abeyaratne, who is no more, showing a Professor from England more than 100 cases.
“Entire villages had been abandoned with the victims shivering in their huts,” documents the book, recreating the tragedy of malaria.

The writers have also not let the country forget the dangers as recently as 1984 when in Sri Lanka chloroquine-resistant P. falciparum strains were detected and the strategy adopted to combat them.
Setting the ground situation, “both operational and technical factors” that contributed to the malaria epidemic of 1986/87, the doctor-authors point out the control measures implemented including the input of the USAID Project and the promotion of insecticide-impregnated mosquito nets.

They dub as a “very important milestone” the decentralization of malaria control activities between 1989-2000 in the strictly “vertical” AMC. While pointing out that many beneficial effects ensued, one disadvantage had been the budgetary problems in the early stages.

The contributions of agencies such as the WHO (including the roll-back initiative) and the IDA/World Bank (which included the malaria mobile clinics in the form of four-wheel driven double cabs) are dealt with at length along with the conflict situation’s impact on malaria and also the GFATM Round 1 Project 2003-8, Round 4 2005-9 and the ongoing Round 8 from 2009-14.

The factors which have enabled Sri Lanka to be on the threshold of vanquishing this old foe, according to the two doctors, include a strong political commitment, strategic technical contribution, enhanced parasitological surveillance through mobile clinics, timely introduction of new tools for malaria control, multi-sectoral support and a well-committed staff at all levels.

The lessons learnt from malaria could very well be used against the threat that Sri Lanka is facing from dengue. The time may be right to take a leaf out of this book to prevent, face, control and someday eliminate the menace of dengue.

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