FHED L. SOPER FA SprER
4104 Fosemary Street
Ghevy Chase 1, ‘Maryiana

MEMURANDUM ON TRIP To AFRICA
AND GENEVA, JCTUBER Jlet to DSCFKSER 10, 1959

Left veshington 4:30 P.M, October 3lst. Arrived in Brasseville
abeut 11100 o'clock, November 2nd, proceeding to Leopoldville for sleep-
ing accommodatiang.

Attended the Nalaria Eradication Technical Meeting from Novem
ber 3rd to 6th, inclusive, and the Symposium on veaticides in the same
locale from the 9th to the 13th of November.

Left Brassaville 2:),0 P.M., Wovember 15th, sleeping the night
at Douala in the Cameroons.

November 16th, proceeded to Accra, the capita! of Ghana, where
I was met by or. L. Charles, the official consultant to the (hana
Gevernment on malaria.

un November 17th, traveled by ear from Accra to Ho, where the
world Health Grganisation has a new station for malaria investigation.

wa November Lith, traveled by car with Dr. Charles tc Kumasi,
proceeding by car cnward to Tamale, and by traveling after dark, arrived
in Bolgatunga at 8:00 o'clock in the evening.

Remained in Bolgatunga the nights of the 19th, 20th, and 2lst,
returning by car on Sunday the 22nd to Tamale, and continuing by Ghana
Airwaya plane to Accra, arriving at 4:00 P.. Speng the night of the
22nd in Acera, and flew on Nowsmber 23rd to Robertsfield, Liberia.

November 2hth, 25th, 26th in Monrovia. November 27th to Kpain
with Dr. saehburn and Mr. Pardes.

Remained in Kpain until Lecember lat, returning to Munrovia
with Dr. Gatuso. December 2nd, ird, and kth spent in Monrovia, proceeding
on December 5th to Harbel, spending the night with the Liberian Institute.
Pleasant day on December 7th at the Institute, proceeding on lecamber 7th
te Lisbon by way of Pan American Airways Flight 153, arriving Lisbon
25200 o'clock.

“ecember 8th left Lisbon by Swissair at 7:hS A.tie, arriving
Geneva 12:00 ?.Me

Left Geneva ‘eceaber cecember lith, arriving in washington
J‘ecember 12th.

The above itinerary cowera roughly two weeks in bragzaville,
one week in Ghana, two weeks in Liberia, and one week traveling to and
from Geneva.

Overall impressions of the situation in «frica:

i. The situation technically with regard to the possibility
Ce; of ey, fh baticgs tle, Shag? Co, ba. Me

ae
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of malaria eradication in africa aeems to be clearer than it was some
months ago.

Dr. Melonald, the Chairman of the Malaria Heeting in Brazzaville,
called attention on the first day of the meeting to the statement on
pages 13 and 1h ef Docunent AFRO/MAL/S that malaria in Africa camot be
eradicated ty insecticides alone, and asked far a discussion on this
point. After the week's discuagion, Ur. MeDonald brought up this same
question again and went from delegate to delegate without being te get
any clear-cut negation of the possibility of eradicating malaria by
insecticides. There were statements to the effect that 14 would be dif-
Acult, it would be expengive, and that problems of personnel end of
transportation would be sost difficult of selution, but no one was able
te bring up any definite reason for not doing the job.

although there may be different situations existing in the var
ious parts of Gentral Africa, it appears fron studying the report of
Dr. Livides of the world Heelth urganisation on some work done at Yaounde
in the Cameroons, and of Ur. Guttuso of the world Health Organization in
Liberia, that a careful aystematic application of DDT to all buildings
anc shelters in which human beings sleep will prevent malaria transaissicon
in the areas of west Africa where the principal vectors are Anopheles
gambiae and Anopheles funsstus.

in the case of the Cameroons, the local authorities had reported
failure to stop tranasiasion with insecticide, but on careful questioning,
the Chief of the Service admitted that his men had struck whanever he had
insiated on their getting away fran the WéFGdr highways and spraying the
rice kitchens and shelters on the isolated farus.

in Liberia uhere the orld iiealth Organization has ceen operating
since 1953, the early yeare were marked by failure to stop transnisaion,
but since April 1958, when Dr. duttuso arrived and insisted aet—eky on
thorough spraying of the entire interior of all of the houses in the villages
and of all isolated sheltere on farms, there has been no difficulty in
stopping transmission. This result was foreshadowed by the repert of
De. Giglioli, which wes prepared in July of 1957 after two and a halt years
in the interior of Liberia. Dr. Giglioli, m entumologist, insisted in
this report that the use of insecticide in the villages stopped the breed-
ing of both gambiae and funestus in and around the villages and that neither
of these two mosquitoes Were Tound in @ high forest until after the errival
of settlers and was then limited to the area imsediately around the indi-
vidual farms. Or. diglioli from the beginning refused to ecoept the idea
of exbphily, and stsetesclearly in his report that if malaria was continu-
ing in the sprayed villages, it was a case of malaria without anophelign.

2q The problem of resistance to insecticides seems to be of
less importance in Africa than was previously stated and feared. Although
there is definite resistance to dieldrin in osrtain parts of dest Africa,
thia insecticide is being used in Zanzibar aad certain areas of iast
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Africa without any appearance of resistance. Hesistance to “OT
has not appeared in vest Africa in areas with dieldrin resistance.
(Some previous reports of such resistance were apparently based
on imperfect tests.)

_jde A> the Meeting in frazgaville there were some corments
and discussion on the importance or lack of importance of malaria
to the African population. Dr. Pringle from Tanganyile referred
to studies which had been mde there attempting to differentiate
between the physical staims of children with and without nalaria
in the same areas. Omring a week in Ghane and two weeks in Liberia
in which I travelled much in the interior of >oth of these countries
I inquired at each dispensary and hospitel where we stopped regarding
the importance of malarie in the life of the adult African. All
of those doing clinical wrk were unanimous in inalsting thet
although malariae is not. primarily a disabling disease of the adult
African it is an important facter in the course of other diseases
end in preventing the adult Afriesn from being a regular and willing
worker. Repeatedly I heard the etetement that treatment of malaria
was considered to be an integral part of the treatment of dysentery
and practically any other infection that the individual might have
when he cane to the dispensary or hospital,

le The political development towards indppendence and the
creation of additional African states had not proceeded nearly as far
last Hovember as it has at the present tim. At the meetings in
aragzaville ani everywhere we went in weet Africa there was s more
acute sense of ispending chamge than one could possibly feal from
a distance of several thousand miles in the United States. One
eannot avoid the impression that the development cf new nations is
going to create ae situation in which the United States will be called
upon te consider asaistame to Africa in s way and on a scale which
was not possible during the colonial period. It is obvious that
to those who are familiar with malaria in tropical areas particularly
in Africa that the proper utilisation of techrical assistance funds
in all fields — agriculture, education, indwetry, trensportation —
and in other health flelds, is dependent upon the control of malaria,
In Africa where the ever present Anopheles gambiae and & funestu:
are such tremendous veotors of nalart a, the solution of the probiion
can hardly be a local one. It is obvious that malaria programs in
Africa should begin covering a very large area aid mst be ready to
expami at the periphery even beyond national boundries if they are
to succeed and permanently protect the populations concerned.
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_5e The situation in Liberia merits special comment because
of the existence of two milaria services there, the one an ICA
sponsored project, the other under the auspkces of the world Heal th
Organization and af the recent proposal that these services should
be amalgamated. The United States became involved in mlarta con:rol
in Liberia early in World War II when a considerable number of U. 8.
personnel were stationed in Liberia especially at Robertafield. In
1953 the World Health Organization began a pllot study of the prevention
of malaria in the forested areas of West ‘frica through a fleld,at
Kpain, Since this unit was an emerimental unit it was established
with WHC control of operstions and an entirely different type of
administration from that of the ICA and the Sovernment of Liberia
Malaria program.

The small country of Liberia with a population of not more
then one million people cannot be justified in maintaining two
malaria services. The proposal was wade some months ago that the
ICA and “HO programs should be fused, The initiative in this
proposal came from the USCH, (I had an opportunity to discuss
this proposal with Mr. Sabeock, the Chief of USOM in Liberia and
With Dr, James Ward, ICA Public Health Officer, stationed at
Monrovia before leaving “ashington.)

Dr. Me A. C. Dowling and an administrative officer of the
Regional Office of the World Health Organisation for Africa visited
Monrovia in September end made a proposal which might serve as the
basle far negotiating ICA/WHO collaboration in malaria eradiention
in Liberia,

Advantage was taken of the presence of many interested
parties in Brazzaville on November 7 to have a discussion of the
ijberiian problem. Present at this meeting vere Drs. Bruce-Chwatt,
He A. Ce Dowling, Malaria Consultant in the Regional Office,

Dr. Guituse, the WHO Chief of Cperetions in Liberia, Dr. Washburn,
the newly sppointed Entomologist to ICA in Liberia and myself.

Pointe which came uwxler special discussion at this meeting
were 1) the necesalty or not of using larvicides in Monrovia ad
if so what larvicides should be used, 2) the appropriateness of
using malaria eradication funds for controlling pest mosquitoes,
3) the capacity of Dr. Guttuso and his World Heel th Organization
group to take over the responsibility for all of Liberla and
4) the advisability or not of having USA and WHO teehmical staff
working together on Liberia projects alnce there are important
differences in conditions of employment.
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Ktrefused te make any commitments until after visiting Liberia.

After vialting the WHO fLleld operations in Kpain and the ICA
activities in and around Monrovia ant discussing the situation with
the Minister of Health, and learning something of the administrative
irregularities tolerated in this country, I found it dfMoult to
believe that there is my future for ean ICA/GOL Malaria Eradication
Program as now organised. likewise, I believe there would be no
futmmre for a WHO controlled pro. ram operating here under the same
conditions that ICA hes been farced to operate. Ths one absolute
necessity here for success is an administration outside of all
political control and financial intervention of the Liberian
Government. Independence of action and financing might conceivably
be arranced if it were possible to establish Liberla as a demonstration
national eradication area in which an extensive program would be
established covering the etire country with the expectation that
once this has been done arrangements could be made for continuing
expmesion until the entire ara from Mauretania and Senegal to
Nigeria has been covered.

The WHO proposal provided for something moch less than
an attempt to cover Liberla and was limited to an extenaion of the
WHO area in the interior directly out to the coast, teking in
Henrovia and probsbly three quarters of the population cf the
country, hile it ia true that actual development in Liberia might
be slew and extension to the coast as suggested by WHO may well be
the logical next step, nevertheless the planning and the programming
and the financing should be, from the beginning, on the bahis of a
national program

The Malaria ‘radication Program in Liberia can be
recommended only under certein very favorable conditions. ith the
intense transmission of malaria which occurs in uncontrolled areas
and with the constant movement of population in thia pert of the
world, eradication to be succesaful met start on a fairly large
scale end must be ready and able to expand, It is to be hoped that
the program for the eradication of malaria in Liberia can be set up
asa demnstration national eradicction program to be given special
financing and spesial staffing as a demonstration aml training area
for eradication programs in other parts of West Africa. (By West
Africa, in this report, one moans particularly that part of vest
Africa lying South of the Sahara and North of the Gulf of Guinea
extending from Mauretania to the Camerouna.) ‘The entire Liberian
program should be considered as a pilet project and at the sane
time as an intcrnational training area for other parts of west Africa,
The program should be presented te and discussed by the Regional
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Committee of the “orld Health Organization from the standpoint of
a regional effort in which all of the countries of this part of
Africe have a definite stake. Other countries should be advised
from the beginning that as this progran becomes succeseaful it will
be essential to extend ite operation in every directian.

It showld be repeated that this program should not
be undertaken on a minimal budget but that arrengements should
be made to get adequate Government, “HO, UNICEF and ICA Minancing
in accord with the importance of this program for the rest of the
area.

ve On arrival in Geneva I had an opportunity to talk
ower the situation in iiberia with Dr. Bruce Chilatt and later with
Drs. Alvarade and Kaul. During this latter discuesion I made the
following suggestions:

1.) Early action should be taken now to avoid the
developadnt of an expansion of the ICA/OCL procrem which might
jeopardize the development of an eradication pregran.

2.) Assume that the WHO project with Dr. Guttusc
is going to continue to be successful.

3.) The plan of operations for Liberia should be on
a courtry wide basis including obvious districts of Guinea where
the population is contiguous with thet of Liberia; these districts
are already being used ty Suttuso for certain studies of insecticides.

4.) Reoommend aghinet attempting to fuse the ICA/GCL
and WHO Malaria Programs since these programs are orgenised on an
entirely UAffermt besis and have no similarity either in standard
for personml, payroll ner operational procedure. Recommend rather
that «HO extend its procram to cover the camtry with the present
IcA/GOL Staff baing made available to the dovernnent for pest
mosquitoes and insect control.

Se) Insist om national procram. planed in such a way
that there should be no interference whatever from the Mintster of
Health,

6e) Set up the Liberian project -s a pilot mlaria
eradication program for the region of Africa insisting that it is
of more than national interest ani therefore mst not be subject
to rational political pressures,

7.) Recommend that this project be approved as a
regional procram of the World Health Organization only if the
Idberlan Governmentacquiesces in the conditions and financing needed,
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8.) The negotiations for this type of program should be made
with no less an authority than the President of the Kepublic. The
Fresident should be convinced that this is the greatest prestige building
program in Africa since professional people from other countries will be
brought here to learn how to administer eradication programs.

9.) Plan from the beginning ths strategy ef future work in vest
Africa looking for other points to start in cleaning up the area between
the Jenezal and Camsrouns as soon as the Liberian project is well organized
and beginning to show results.

10.) Make arrangements as soon as possible to avoid the necessity
of iCA building up the staff which would cause complications later,

During the discussion of these proposals with the WHO grou;,
Dr. Kaul stated 1t as his opinion that it would not be right to try to
run an eradication program without having the Government of Liberia in
charge of the operation with »lhC acting as an advisor. 1 peinted out
that the pilot project now in Liberia is being run by Dr. Gattuso. To
this Dr. Kaul replied that the present program is a pilot project and I
come back insisting that tie eradication program itself haa to be considered as
a pllet project if this job is going to get done under Liberian conditions.

6 A record should be made in this report of the fact that
Dr. MeDonald as Chairman of the Meeting in Brazzaville specifically requested
me to discuss the question ef dosage and cycle of application of insecticides.
fhis I meticulously refuse tc do since I was not thorouchly familiar at
the time with the attitude of the ICA on this point. Dr. Dowling proceeds
to prasent the WHO program b¢ two grams per square metor twice a year.

Z- Im the discussion of malaria eradication in Africa 1 point
out to several persons that the use ef residual insecticides inside houses
may not be the cheapest and most efficient way of getting rid of malaria
in some of the desert and semimarid areas, 1 call attention to the fact
that in the eradication of Anopheles gambiae from Brugil it was found in
Cumbe, a small area which had been reserved fer atudy of the biology of
gambiae, Shat complete eradic:.tion of the species had been possible in a
three weeks period when all] of the petential breeding places were dusted with
Faris green, The empty pail method of application of Faris green makes the
operator so moblle that work can be done en a mich more economical basis than
was poesible when it was considered necessary to have powder pump gun@ for
the appliestion of Paris green in cust.
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§. With regard to surveillance Dr, aeDenald the Chairman and
Dr. Bruce-Kwatt did not oppose thy idea of using surveiliance to indicate
the places where malaria eradication is continuing. They both admigy that under
African conditions the attempt to find and treat all parasite carriers would
ba & wost difficult underteking. The documents of this conference then are
contrary to those of other conferences in that surveillance is recognized as
a search for places where transmission is continuing rather than a search for
all. of the individual cases.

4 Gne of the curious observations in Africa on my recent trip wis
the strangs reluctance of many people to scknowledge or ad: iff the importance,
the unique importance, of mlaria in this continent. ime of the severe]
discuasions as to the propriety of coneentrating on the single problem, malaria,
until this preblem is done in, rather than considering it just as one of many
problems to be tackled sinultansously, was with Dr. Nelson from Kenya, who is
now doing research work, but was previously in public health administration.
The following quotation is from my diary of “ovember 6, 1959:

"Yesterday Dr. Pringle who is doing investigations in Tanganyika
expressed some doubts as to the economical feasibility of sradicating
malaria frem Africa although he clearly states his conviction of the
technical feasibility ef eradication in sast Africa. At the big party
given by the French Gevernment last evening, this comment of Fringle's
cama wp for discussion with Dr. Nelson who used to be a public health
adviser put is now doing researeh. sAglson raised the old question of
whether with all.of the heclth problems which exist, it is justifiable
to concantrate large amounts of monsy and numerous personnel on a single
disease especially when it cannot be clearly shown that this single disease
is the most important health problem or oven that thie disease je an
important cause of death. Nelson insists on taiking as a public heaith
administrator and net as a Malariolegist. i take the tims, even in the
heat and humidity of the steaming throng of blacks and whites to axplain:

"1,) That Xam not a milariologist.

"2,.) That as Director of the PASB and Regional Director of “HO,
I had general responsibilities for all health conditions in the Americas.

"3,) ‘That the general attack on all disease which “elson would seem
to appreve pre<-supposes the existence of well-trained health workers.

"h.) That such well-trained health workers to work in rural Africa
will not be available for at least another generation.

5.) That the first line of attack on many other problems such
as undernutrition, tbe and aven sducation is through the elimination of

malaria,
    

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" 6.) That the funds for malaria eradication do not come
necessarily ‘rom the ceneral health funds but can be often largely
raised for the special purpose of malaria eradication,

" 7.) That it is not possible to get coordinated action of a
large number of countries on general health programmes for a region but
that it 1a possible to -et interest in a general attack on a specific
problen,

" 8.) That the world attack on malaria igs setting a precedent for
other diseases, for animal diseases » for plant diseases and insect and
animal and plant pests, as well as for international cooperation in
widely-diversified fields,

" 9.) That the idea that mlaria is a patriotic disease that does
not kill cans is as creat a myth as was the reputed patrictism of
yellow fever in Brazil. (Dr. Nelson had said that studies made by a
pair of docters in East Africa had failed to show greet physiological
1m PecewweT among children after malaria had been eliminated without
ever indicating at what period after eliminstion of malaria the
statement had been mades when I asked about the in mt mortality
rate Nelson replied thet it is 300/1000 in first 12 months of life
but that this high mortality could not be attributed te malaria since
all of the children who died from whatever cause hav¢ parasites in
the Ubod-amdplivel!!!) Of course I repeat once more for Nelson the
story of viacerotomy in NE Brazil,

"10.) I finish by telling Neleon that there is no question but
that the history of Africa in the next generation can still be vitally
affected by what is done in this generation in the elimination of malaria."
/é
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A ‘the Report of the Entomologist, 1955 to 1957, by Me Se Ce
Giglioli, of July 10, 1957 prepared at Kpain, Liberia was found by
Dr. “red L. Soper lying on Or. Guttuso's library shelf at Kpain. This
document was conaidered to be of such importance that it was taken to
Honrovia and copied at the USM headquarters.

Since Pr. Soper had heard no mention of Giglioli's studies
in Liberia during the mmy discussions of Anopheles ganbiae and & fimestus
activities in Africa at Brazzavilic, Dr. Soper made a request for this report
on arrival in Geneva et the “orld Health Organisation's malaris headquarters.
The report was found there in the files, but Li'tle attention had been paid
te this r@ort apparently because of the adverse coments of Or. “ulueta,
dated October 3, 1957, Zulueta criticised the wrk of “iglioli because
Giglicli hed establiahed too large a number of capture stations to permit
freqent vidits. “ulueta also criticised Giglioli for not having mide
tests on Anopheles mosquitoes for msceptibility tc dieldrin. The fact
thet dieldrin resistance was observed in this area very shortly after the
termination of Gigliclits stubies probebly accounts for the discrediting
of Giglioli's otner observations which are believed by Dr. Soper to be of
primary importance. '

Giglicli explained in his report the lack of susceptibility
tests in his area due to the scarcity of ancpheles in the treated areas;
Giglioli simply did not find adult mosquitoes in the sprayed villazes amd
althouvh the numbers of anopheles found in isolated shelters and rice
kitchens were sufficlent to explain the convenient transmiasion of malaria
they were not present in numbers permitiing statistics] stuties on resistance.

The important ccntribution of Uglioli was m the distribution
of gamblae aid funestus which he could not find in uninhabited forest ar-as
ami which he could not find in swayed villages.

fme dusportant note is to be found in “uluete's letter, however,
which does have, I believe, considerable application to the situation in
Africa during recent years. To quote “ulueta "I am always surprised to
find in among meleria projects how mich attention is paid to the behavior
of mosquitees and how much entomelggical research is carried out, whereas
the actual spraying wrk md particularly complete coverage b spmying
becomse of very secondary importance and of this I think liberia affords
a good example. I would like to see research experiments and research
of how to gain the goodwill of the farmer's &iving (working) far away in
the forest, and how to spray their hute in time." (Zulueta fails to point
out that it was Girlioli the entomologist studying the behavior of mosquitoes
whe critieli zed most severely the contre] service at Knain which was not
getting out end spraying the rural farm shelters. )
if
5 ~

4 iresent statue of DOT in Africa, Considering other reports on
the use 6 win Arles, the Follow tate from AFRO/MAL/L«15 of
October 23, 1959, review of the Malaria Proeran in the African region by

Me A. Cy Dowling is of interests Pave S. DBT "in spite of its many
disadvantages (for example irritent affect, lower initial toxiclty to
anopheles) continues to give excellent results when properly acplied.

in Liberia, where the conditions “or residual spraying are extremely
difficult the concentr:tion of total coverae md an efficient application
has resulted in the apparent interruption af transaission over s Wide area we.
A thorouch applicetion of 307 alone in the absence of any associated
chemoprophylaxis, has produced the most encoura.“in; results,”

Also in relation t DOT vermis argus, we find on Page 75 "The
use of drugs in the malarta provrams in the African reyion. Mass chemo«
proph;laxis as an auxiliary to residual spraying hea been tried out ina
nurber of territories within the African reglonaes. The results have been
on the whole, disappointing largel- due to the “act that a total coverare
of the population with the drug has net been achieved; in those areas where
100 per cent coverage of the inhabitants has bem obtained the results have
been universall-- excellent. Such conditions cannot often be obtoined ant
it would appear therefore that mass chemoprophylaxis showld onl- be
reserved for areas where it. has been conclusively shown that residval
spraying with total CWerage cannot, interrupt trmemisstion b itself,

It is not considered that this conelusive evidence has been demonstrated
eS PRELO
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a
lg The visit to Ghana was a most interesting one largely

because of Dr. Charlus and his facilitating oy trip to Ho and to

Bolgatonga in the Nerthern part of the country. I meat the chief

ef the UCGM Hission, Mr. A.F, 4oMt and “rs, Pinder, and ir. Simpson.

Mr, Simpson particularly asked regarding my impression of the salaria

situation in Ghana and what might be done about it by IGA. I found

Mr. Moffat very such interested and convinced that malaria is one of

the imspertant problems of this part of Africa. (Ialse had an opportunity

to discuss walaria with fr, Moffat at the home of Hr. ou. Neal in Monrovia

some days later.)

The efferts at malaria control in Uhana leading up to eradication
are supposed to begin in 1960 but there seems to be woefully little preparation.
The “orld Health Organisation has a station at Ho where soma work is being
dons on entomelogy and on therapeutics of cases and arrangenents have been sade
for a stuiy on the use of drugs and salt in the Northern part of Ghana beginning
in Fabruary. it is teo airly to give any results from either of these study
BPeBSe