CIVIL DEFENSE PERSPECTIVES
July 1998 (vol. 14, #5) 1601 N Tucson Blvd #9, Tucson AZ 85716 c 1998 Physicians for Civil Defense
WAR ON MALARIA: A LOSING STRATEGY
In a classic science fiction novel, Ender's Game by Orson Scott Card, insect-like aliens have attacked the earth twice, and the survival of humanity is in doubt. Ultimately, the war is won only when a young general violates the prime rule set by the world government: He attacks and destroys the enemy's planet.
After many triumphs in the struggle against infectious disease, humanity is losing ground to the microbes as they learn to dodge our Magic Bullets. The biggest killer-malaria-is again on the rampage and could soon be finding its way back to prominence even in the United States. This is partly due to the ingenious defenses of the malaria parasite, especially the most virulent type (Plasmodium falciparum). But it is largely due to a global strategy that is tantamount to surrender.
The World Health Organization (WHO) has announced a new ``Roll-Back Malaria'' campaign. The objective is explicitly ``not another attempt to eradicate the disease.'' Rather, the aim is to halve malaria-associated mortality by 2010 and again by 2015. Apparently, the warriors will be content if only two children are dying of malaria per minute (instead of four), and one person is dying every 24 seconds (instead of every 12). And what of the 500 million cases of sickness?
Common sense and basic epidemiology should tell us that even if we reach the goal of reducing an infectious disease by half, exactly nothing will be accomplished in the long run except possibly the cultivation of more resistant organisms. Two possible approaches are reasonable: confining an epidemic within a certain population or geographic area, or eradicating the disease altogether. These have apparently been ruled out.
The strategy will not be ``fragmented.'' It will ``revolutionize malaria control and set the stage for more integrated health action in other priority areas such as tuberculosis and safe motherhood.'' There will be ``better ways of regulating... practitioners,'' and the ``health sector will be called to account for ways in which scarce resources and efforts are used'' (Science 280:2067-8, 1998). In other words, there will be tight intergovernmental controls. It will be very difficult for any renegades to try something that is not on the unified agenda.
From the outset, the campaign (officially, the Multilateral Initiative on Malaria or MIM) is designed to be a Thirty Years War, with the first shots to be fired after the year 2000.
``We are in no hurry, we want to get it right,'' said Richard Feachem, director for health, nutrition, and population at the World Bank. Infrastructure comes first: formal partnerships with research bodies, new funding as from the World Bank, and political support from African heads of government. New tools, with an emphasis on a vaccine and new drugs, are needed.
A new vaccine ``showing some promise'' was announced in 1994: but its efficacy was only 30% (Insight 12/12/94). The prospects are hardly more encouraging than for an AIDS vaccine. For one thing, natural immunity to the disease is very poor. Even those who recover can become reinfected many times, developing only partial resistance over a period of years.
New drugs are desperately needed. The mainstay of treatment, chloroquine, is now virtually useless against P. falciparum except in a small area that includes Mexico, Central America, and part of the Middle East. There is a growing problem of resistance to pyrimethamine and sulfadoxine (Fansidar) in Southeast Asia, Africa, and the Amazon region, and resistance to mefloquine has developed in Cambodia and Thailand. Chloroquine-resistant P. vivax has been reported in Indonesia, Papua New Guinea, and other areas.
``If drug resistance in P. falciparum continues to increase at the current rate, malaria may become untreatable in parts of Southeast Asia by the beginning of the next millennium'' (N Engl J Med 335:800-806, 1996).
Some effective drugs (including artesunate, artemether, and halofantrine) are not available in many countries, including the United States, because of licensure requirements. Few drugs are on the horizon. The risk and regulatory climate is such that private investment in research and development can only be justified when large profit margins are expected in the event of success. Most of the demand for antimalarials is currently in the part of the world too poor to buy them.
The US Executive Branch is ``speaking with a single voice, affirming our self-interested responsibility for global health through national security,'' as it continues to downsize the military, where most research on ``exotic diseases'' is centered (Joshua Lederberg, JAMA 276:417-419, 1996). And lifting regulatory impediments is not part of the message.
US policy as initiated by the National Technology Council, chaired by Al Gore, is based on dubious assumptions about the cause of emerging infectious diseases: population growth, travel, and ``Nature's revenge'' for our ``intrusion into forests, irrigation projects, and climate change'' (ibid.). The goals and methods emphasize global surveillance, sensitizing professionals to look out for exotic diseases, an interagency task force, a legal basis for enforcement of cooperation by professionals and agencies, and providing information and guidance (ibid.)
The clear implication is that the ``process of learning from past successes and failures'' will avoid the central question: when malaria was on the verge of extinction, what happened?
Past campaigns zeroed in, not on the malaria parasite, and not on the infected patients, but on the vector: the mosquito. The incidence of malaria was cut almost to zero in many areas with one cheap, simple intervention: spraying houses with DDT.
Curing the patient once was not enough; he would probably return home and quickly be reinfected by the very mosquitoes that had gotten their load of parasites from his own blood.
It is stated that mosquito resistance was the reason for discontinuing or deemphasizing vector control. The fact is that many countries are banning or restricting the use of DDT because of continuous pressures from groups like the International Pesticide Action Network (Emerging Infectious Diseases, July-Sept, 1997).
``We are now facing the unprecedented event of eliminating, without meaningful debate, the most cost-effective chemical we have for the prevention of malaria. The health of hundreds of millions of persons in malaria-endemic countries should be given greater consideration before proceeding further with the present course of action.''
Could the global unified campaign against malaria have an outcome equivalent to protecting an alien enemy's planet?
DDT and Breast Cancer
Feminists and environmentalists were both disappointed by the news that DDT has not been proved to cause breast cancer.
``I just find it very difficult to believe,'' said Geri Barish of East Meadow, New York, president of One In Nine: The Long Island Breast Cancer Action Coalition. In fact, she told The New York Times (10/30/97) that she ``could not accept'' the absence of a link between breast cancer and pesticides in her locality (J Women's Health 7:7-8, 1998).
The study in question used blood samples of 32,286 women obtained in 1989 or 1990 as part of the Nurses' Health Study. Levels of DDE (a metabolite of DDT) and PCBs were measured in 240 patients who were diagnosed as having breast cancer before June, 1992, and 236 matched controls. The median level of DDE was 12% lower in the cancer patients (4.71 vs. 5.35 parts per billion, P=0.14). The level of PCBs was also slightly lower in the cancer patients (4.49 vs. 4.68 ppb). Researchers stated that ``exposure to high levels of both DDE and PCBs was associated with a nonsignificantly lower risk of breast cancer (relative risk for women in the highest quintiles of both DDE and PCBs as compared with women in the lowest, 0.43; 95% confidence interval, 0.13 to 1.44).'' The conclusion was that ``our data do not support the hypothesis that exposure to DDT and PCBs increases the risk of breast cancer'' (Hunter DJ et al: N Engl J Med 337(18):1253-8, 1997).
DDT had been banned for nearly 20 years in the U.S. by the time the blood samples for the above study had been taken. Another study, performed in Mexico (where DDT is still used for malaria control), revealed that blood levels were more than 100 times higher, but there was still no statistically significant difference in the blood levels between breast cancer patients (526 ± 676 ppb) and controls (505 ± 567 ppb) (Lopez-Carrillo et al, Cancer Research 57:3728-32, 1997).
A multi-center European study showed a statistically significant trend for lower DDE levels in adipose tissue in breast cancer patients. ``The odds ratio of breast cancer, adjusted for age and centre, for the highest versus the lowest fourth of DDE distribution was 0.73 (95% confidence interval 0.44 to 1.21) and decreased to 0.48 (0.25 to 0.95, P for trend 0.02) after adjustment for body mass index, age at first birth, and current alcohol drinking.'' While these numbers could suggest a chemical hormesis effect (i.e. a protective effect of low-dose exposure), the authors concluded that ``the lower DDE concentrations among women with breast cancer may be secondary to disease inception. This study does not support the hypothesis that DDE increases risk of breast cancer in postmenopausal women in Europe (van't Veer et al, BMJ 315(7100):81-85, 1997.
Of course, DDT could actually increase breast cancer rates substantially in African women by making it possible for them to live long enough to develop this disease.
The reason for banning DDT in the US-and the pressure to expand rather than lift the ban-had nothing to do with genuine fears of carcinogenesis or ``endocrine disruption,'' as the following excerpt from the Congressional Record shows.
Barry Goldwater on DDT
The late Senator Barry Goldwater asked for unanimous consent to print the entire statement of J. Gordon Edwards on ``The Infamous Ruckelshaus DDT Decision'' in the July 24, 1972, Congressional Record-Senate, S11545-6:
``The recent Ruckelshaus decision regarding DDT restrictions is an abject capitulation to professional environmental extremists and a tremendous defeat for science and mankind. Most concerned persons are mindful of the waste of holding seven months of federal `hearings' on DDT and then ignoring or rejecting all evidence which did not support the preconceived decision of this EPA administrator....
``The `substitutes' recommended by Mr. Ruckelshaus to replace DDT will needlessly destroy thousands of honeybee colonies and millions of birds and mammals...which would NOT be injured by DDT applications....
``Hundreds of farm workers have already been killed and hundreds of thousands made ill by those chemicals, but the EPA and the EDF (Environmental Defense Fund) do not object. Dr. Charles F. Wurster, Chairman of the Scientists Advisory Council of the EDF stated that `...the organophosphate acts locally and only kills farm workers and most of them are Mexicans and Negroes' and that `People are the cause of all the problems. We have too many of them. We need to get rid of some of them and this is as good a way as any.'
``The ultimate goals of the EDF have been explained as far back as 1969, in Bioscience 19:809, by one of their leading spokesmen...`If the environmentalists win on DDT, they will achieve...a level of authority that they never had before.'
``For seven months the EPA hearings exposed the insincerity of the anti-DDT cultists...Under oath, there were a great many confessions of citing false information and deliberately omitting or altering significant data. The `authorities' repeatedly feigned ignorance of extremely significant details which are well-known to most scientists ... such as the annual Audubon Society bird counts and the results of the Hawk Mountain sanctuary counts of migrating hawks....''
[The complete statement is available on request. Lectures by J. Gordon Edwards to DDP are available on CD-ROM and audiotape.]
The Beat Goes On
Scientists continue to look for indirect ways in which DDT might cause cancer, years after being banned (despite lack of evidence that it does), as by activating the human estrogen receptor (Primary Care and Breast Cancer 17(8):14-15, 1997).
Journalist Fred Lebrun celebrates the 25th anniversary of the DDT ban (``Chemicals, the gifts that keep giving,'' Times Union, Albany, NY, 9/19/97). He applauds Rachel Carson's Silent Spring and deplores the fact that it took ten years after her lament for dying songbirds to get a federal DDT ban. Now the songbirds are still flying to South America, where there is still DDT, and some may not come back.
Propagandists are getting children to draw signs showing how ugly the state of Arizona would become if it accepted a load of DDT-contaminated mud from a Superfund site (see cover of Everyone's Backyard, Summer 1997). [The DDT-laced mud is not for sale.] This issue features an article on ``environmental racism''-with no mention of malaria in Africa.
Mamadou Kasse, medical editor of Senegal's largest newspaper, Le Soleil, said that ``malaria keeps Africa down, and down is where the rest of the world wants us to be. If this was a disease of the West, it would be gone'' (Ellen Ruppel Shell, Resurgence of a Deadly Disease,'' Atlantic Monthly August, 1997, pp. 45-60).