RoW Joined, us in Geneva on February 1, for initial conversations

with the World Health Orgenisation staff. We left Geneva on February 5
arriving in Delhi (India) on the evening of the 6th. Departure from pefnit ol:
on llth by way of Calcutta to Hongkong where we arrived on the 12th. Wey. ff
went to Taipeh on the 1th and on the 16th started south returning to
Taipeh on the 19th and proceeding to Manila on the 20th. From Manila to Siavy
Ceylon on February 25th, with February 27 and 28th devoted to a trip to the

dry areas of the north-eastern part of the island. March 1, to Madras; . meh

 
     
   

March 2 to Bangalore; March lth to lith, station-wagon ¢gur of Mysore Gh
state and Goonoor., March lth, Bangalore to Delhi. This week has been fi f
devoted largely to the Third Asian Malaria Congress which is also referred ‘
to as the First Asian Malaria Eradication Congress, since the previous two —_

Congresses were devoted to malaria control,

In Taiwan, Ceylon and Mysore State (India), we ha i
not only to discuss the situation with the tec Bete resrowe poi e nity
the eradication programs but also were able to get to the field and see the
terrain and visualise the problems encowmtered,. In the Philippines, we had
to depend on conversations at headquarters and at the malaria institute bu
had the advantage of access to the ICA staff impressions.

One finds that there is a typical pattern emerging in each of the
comtries visited. kalaria has been eatly reduced and probably t ie ion
stepped im large groups of population £ the most accessible ereak ene its

population is living and working in the traditional stable manner. The
fadivre to get malaria eradication is apparently largely due to a failure
to adapt the administrative procedures of the eradication service to

certain unstable elements of the population and especially to the peripheral
population living in scattered habitations often times in foot-hills or

in mountainous areas.

Ni re
Tn-none_of the 0c eb Se ste did the responsible authorities

attribute failure to the development of resistance to insecticides by vector
mosquitos nor to a failure 6¢ malaria to disappear within a reasonable period
of time once transmission had been interrupted. in other words, one can

say that the failure of malaria to disappear completely from these countries
has been due to the failure to adapt the administrative methods for the
application of insecticides to scattered houses in difficult terrain, to

the temporary habitations of seasonal agricultural workers and to the
shelters of squatters in areas under development.

There seems to be no evidence in the comtries we visited that
failure to eradicate has been due to error of the initial premise, that
malaria would disappear when transmission had been interrupted by residual
insecticides, Where accessible population groups have been properly
covered malaria has either disappeared or dropped to almost zero. Failure
has been due to administrative difficulties rather than to technical onese
There has been difficulty in some areas ainding e houses; in
other areas in finding new houses immediately after construction and in
many areas there has been inadequate checking and supervision of the worke

Certain of the cleaned areas are large enough to justify the
conclusion that the residual insecticides can stop tranémission and that
in the absence of transuission, malaria itself disappears, within a
neasonatile tine. Wh
(28-Hay 1965, mnc)

The failure of eradication programs to eradicate has led to greatly

increased interest in searching out and treating persons with malaria,
not for the purpose of revealing the areas where transmission has con-
tinued in spite of residual insecticides so that administrative or
technical defects can be corrected, but in the hope of using therapy
to remove the final seedbed of parasites from the human population.
This switch from an attack on the malaria parasite in the mosquito with
residual insecticides to a campaign against the plasmodia in the human
host based on searching out and treating all infected persons, may well
be disastrous in its effect on the eradication program,

While it has been anticipated that a small percentage of the
malaria problem would have to be taken care of with methods other
than residual insecticiding, the real premise on which the program
was founded is that malaria transmission can, in most malarious areas
of the world, be interrupted and that such interruption will be fol-
lowed after a suitable period by spontaneous disappearance of the
infection in the human population of the area worked.

Unconsciously, almost, many workers have changed their working
premise; they now seem to say that residual insecticide will get rid
of the bulk of the infection in the easily accessible population but
that the final roots of infection in the peripheral population must
be eradicated with drugs.
Bs } m . B43 ek Ba & t
i spn vB ey YOR Fike be be

2 alr

~ 1G Nant 17S?

/969 cel = 19 Mans

FEBRUARY 3RDs

Dr. Bruce Chwatt: Original plans in India did not include the
hypo-endemic areas but only the areas in which there was a very serious
problem (one delsy was caused by insistence of Indian Government that
vehicles should be tyred by Dunlop tyres manufactured in India. Cars
arrived and remained for over-a year without tyres). As late as 1956, _
some of the states were still trying to do spraying with voluntary teams.
BC says thet he was fighting for regional organization within the country;
REW says he planned five regional organizations in 19523 BC confirms
the fact that poor work in India gives good results. BC believes that
with good administration, there is no doubt regarding the final eradication
of malaria, East Pakistan probably has more a. sundaicus than Bengal;
otherwise problems mey be very largely the same. West Pakistan is doing
nothing as yet. Nepal is working and has three WHO teams. India-Nepal
border has special attention from the Nepal side, In Pakistan, everyone
including PFR thought they were getting some good reaction only to be
disappointed. (Discussion of Afridi and Jafar situations83)

Discussion with Dr. Weeks and BC. Problem of As» stephensi,
urban malaria vector has not been properly worked with. Filariasis
problem is tremendous and we are not in a position to do anything about
it since the vector species becomes rapidly resistant to insecticides.
BC suggests that we visit Malaya to help convince authorities of possi-
bilities of eradication. TisteNex two organizations trying to do the
Same thing; clash between ICA and Manila office of WHO.

Third Asian Malaria Conference; 16th to 21st of March = Delhi
Ministers invited for first three days; BC is preparing report om
malaria eradication in USSR: behind in drugs, in insecticides etc
but they are getting results. No campressed air sprayers. Ground
is prepared for eradication and are now having only 3,500 cases per
year. Controls of individuals who have had malaria are tremendous;
surveillance is almost perfect in USSRe (RBW tells of old surveillance
in the Japanese malarious areas under the empire with the malaria
control work hooked up with police force: people either came in for
treatment or the officers went out and brought them ins; but this all
failed during World-War II and in the absence of quinine supplies,
Formosa became very highly malarious.) RBW tells of one area in
India where, following the building of a dam, malaria became so bad
that the area was rapidly depopulated: in contrast to this, BC
tells of hyperendemic areas in Sarawak where the only obvious effects
of malaria are early iliness and increased death-rate among infants.

20 malariologist 1951)
O entanologists
350 engineers ) 1956) USSR

2,000 of 3,500 cases are in Asian areas; claim they will have eradication
of malaria within another two yearse

Sal S- erm, Rot Fob jt Chel

B brrnnt Athe 4 row u
Y- 10 Th 1 Carr 14 Dax fo (hy
TAIPEH = FEBRUARY Wh:

Met by Dr. & Mrs, C. He Yen, Dr. Robert L. Cherry, Dr.
Fennington, Miss E. Brackett, Stephen H. U. (Namru II), Dr. C.T.
Ch'en, et ale

Dr, C. Te Chien is now head of the Malaria surveillance
service:

‘Reports—= 1956 : over OO cases
1957 + over 00 cases
1958 s over 600 cases

But 1958 is first year of new surveillance programe

We got rooms in the Jade Phoenix Wing of the Grand Hoteles
Learn Dr. Oliver NicCoy now Head of the China Medical Board is in
towne Capte (Dre) Robert Ae Phillips is head of Namru Ile

Reception at Home of Robert Leslie Cherry ICA; Haralsons,
Neufeldts Pennington, Brackett, Oliver McCoy, Dr. & Mrs. C. He Yen,
General Fang, Nurse fran WHO (Scott), C. T. Ch'en.

Dinner at Grand Dregon Restaurant in Grand Hotel: Dr, &
Mrs. C. He Yen, Sopers, Watson, McCoy, Stephen H. U., Pennington,
C.T.Ch'ene One dish after the other ending with soup. Then
immediately everyone went hamee

TATEPH =~ SUNDAY, FEBRUARY 15:

Capt.e Robert Allen Phillips of Namru II calls and takes me
to see his installation in a lerge brick building which was previously
the nurses' residence; it seems that a committee consisting of RAP,
James Shannon and three or four others looked over the situation here
in 195 and decided this was a place the navy should have a research
centre. amru II which was originally Tan River's unit with head-
quarters first at the RI and later in Guam was reactivated for service
here. At present, there are seven professional staff from the Navy,
a group of eight professionals fram civilian life and places for a
number of local personse Balance include clinical, various parasito=
logical and bacteriological research of all kinds with a number of
fellowships open to natives of the countries of Asiatic origin. RAP
says, he has been able to make very satisfactory arrangements with the
local Government for working space and conditions for handling such
eases in hospital as Namru may want to study; everything is clear
except where this 411 ties in with the local medical training and with
the future development of the area. Return and spend the afternoon
and evening at the hotel getting some much-needed rest and getting
ready to travel with reduced baggage to the south of the island.
-10-

FEBRUARY 16 -— MONDAY:

Dre Robert Cherry of ICA furnishes one car and with the
other of the malaria service, Drs. RBW, Ce T. Ch'en, Juliet and
I leave the city of Taipeh about 9. 45 aw. after spending sometime at
the foreign affairs headquarters trying to get permits for leaving
the country for Juliet and RBWe The day was spent visiting two
health centres where we asked about the number of malaria slides
taken and examined last year in the areas representing to give almost
amillion population. In the first group of 450,000 population
only one positive slide and that fran a person infected in a know
focus of malaria, The only focus found in this NW part of the
island is among some of the aborginees where some six positive
slides were found among the population of 7,500 people. These
7,500 people are having their homes sprayed every months and are
getting monthly treatment for malaria in an all out attempt to
end this focus, In the late afternoon, we stop at the new
capitel of the province of Taiwan and call on the Governor whom
RBW had known as a military person some years agoe At Taichung,
where we have lunch and where we later visit the office of Dr.
C. H. Yen, Dr. Kuo his assistant seems delighted to see me again
and tells me how much I simplified his small-pox problem by
suggesting thet he should undertake to vaccinate one-third of his
population every year instead of all of it every third year’
This controls small-pox adequetely and gives him an even budgetary
distribution of funds each year as well as steady employment for
his staff. To a little hotel on the hill to sperd the night.

In discussion with RBW as what should be done by RF or
other interested parties, I point out that there are two sides
to each eradication problem and that many things should be tried
on a large scale before being undertaken on a world basis, It
would seem that there is need for an eradication centre or group
to study and develop information needed for future eradication
programs before the world finds itself hooked with other programs
in the way it has to become committed to eradication of malariae

Taiwan was visited in 1955 in November when the rice was
being or had been harvested; on this trip in February, one is
surprised to see so much of the land flooded getting ready for the
planting of rice. Near Taipeh, the planting has not yet started
but as we come south, we find first a little planting going on and
by the end of the day came to areas where the wheat is almost ready
for harvest and most of the rice has been planted. We also came
into areas of corn and sugar cultivation. All of the agriculture
is in small fields and carried out in such a way as to require the
utmost in hand labour. ICA car lent by R, Cherry was released at
Taichung with documents signed and with # 20.00 tip.
cHAO -Chow

-ll-
FEBRUARY 173

Leave the hotel on the hill above at 09.00 as planned and
spend the day until sometime after 15,00 in reaching the headquarters
of the RF malaria program beginning in 19h6, C.T. Ch'en digs up
an old board with Robert Briggs Watson's name on ite The front
door still has a sign declaring it to be the residence of the WHO
malaria team (RBW examines screens of copper he put on twelve
years ago and indicates he and Carter made “with their hands" various
improvements such as the plumbing which had been non-existent. To
RBW's surprise, there is now a hot water heater for the bath).

This building is typical Japanese with sliding paper doors and was
originally built as the residence of one or two of the priests who
were attached to the nearby temple. The electric lights and the
electric fans in the bedrooms give a modern touch to it; but this was
fairly primitive at the time Wetson and Carter took overe Later

J.» H. Paul was here for a time and eventually the Pletsch family all
lived here. May be this isolated building surrounded by rice-fields
gave Mrs. FP. the desire to live in the USA and bring her daughters up
there rather than take them to Mexico when Don moved down some three
years agoe Lunch was teken *t a restaurent which makes an attempt

at European dishes and serves food with knife and fork rather than
chop-sticks. The combined men's and women's toilets soon dis-
illuisioned Juliet *s to the extent of adoption of the western notionSe

FEBRUARY 18 ~- WEDNESDAY:

368 township health stations; 22 county health centres;
150 towmship health stations have trained microscopists but only
27 special stations are receiving slides from the surveillance
services (1) Surveillance section is in charge cf Assistant
Director; as 110 full-time slide collectors and 02 pert-time blood
collectors who put in two to ten days per month, (2) Epidemology
section; follow-up each month for 12 months of all cases or foci
found. If negative for 12 months, it is considered of no more
importance. (3) Laboratory section as 50 microscopists working
here at Chou Chou. Now, people examine 80,000 slides a month here
and another 20,000 at outlying stations. (lh) Military malaria
liason section is responsible for surveillance among troops since
civilians cannot come into the military installations. Twenty~seven
doctors and technicians from the military service are now attached
for work with the institute. Three cases found in military
personnel last year; these were among recruits. (5) Entomology
section: 2 entomologists, 8 assistants and 1? junior technicians.
(WHO furnishes money for 170 persons for the program here, 10 of the
12 technicians for entanology being WHOMMESA.) (6) Engineering
sections Over all training and logistics, book-keeping etce (All
DOT used is now made on the island). (7) Administrative section
(8) Parasitology sections Filzeriasis studies also carries outs
-12-

TOTAL BUDGET:
Prove Govte 2,500,000
Local Govt. 800, 000
ICA 960,000
ICA (12 vehicles,
100,000 DDT) 2,520,000 $ 70,000 USA
WHO 2,020,000

( $ 30,000 USA) 1,080,000

5,080,000 @ 3,608 to 1 USA
110 full-time slide takers for between 1,000 and 3,000 population for
which each is responsible; (a) for visiting once a month and bleeding
of persons having fever during previous month (the same is true for
schools) children less than 2h months of age are bled every three
months and everyone is supposed to be bled ‘tR at least once a yeare
These men were put on the job last July but only in September did they
became fully effectivee Same 60,000 blood slides were examined by
the end of January 1959 with the finding of three foci not known beforee
The supervision of the slide takers seems to be inadequate by our
standards; as also it seems there has been inadequate supervision of
the DDT spraying. CTC admits that some of the continuing foci of
infection are in areas with scattered houses; an independent survey
made by the engineers showed thet the occurance of cases could be
correl#ted with failure of spraying or even with failure in finding
certain housese In the laboratory building, we find some 50 girls

and men at microscopes; each is allowed to examine only 60 to 65 daily,
so this lab can do possibly 65 to 70 thousand per month. 11 slides
come to Chauchaw and after preparation about 20 per cent are sent to
other labs for exam. (False positives with parasites of Ple Innui
(monkey malaria) are inserted from time to time.)

RBW is not happy over the return to the Japanese method of
staining which RBW believes will cause a number of positives to be
missed by masking by shells of RBC.

SPRAY 7 men 1 foreman
| with pumps
2 helpers

Tomship - Head-foreman for 3 to 5 spray squads.
County Supervisor -= may have upto 32 head foreman

Spraying covers 2 months period -—= County supervisors are full-time
only immediately before, during and after spraying period. Over-
lapping etc. -- Feriod ranges from March to October, Period
determined by convenience of labour staff rether than epidemologye
~DB-

Supervisor is not responsible to Malaria Institute, Townships
are charged for work done on a percapita basis.

Now TAMRI is fully responsible for work done in active foci
of which there are four. In the principal focus of 9,000 people,
there are 16 workers; (a) monthly survey with blood samples (b) semi-~
monthly single dose treatment of everyone whether infected or not (c)
treatment of confirmed cases. (The house spraying is done by other
personnel which comes in from outside),

FEBRUARY 18: CHOU-CHOW SUMMARY:

From the discussion today, it becomes apparent that the man
in charge of the malaria work believe there are only about125, 000
people living in dangerous areas and another 125,000 in potentially
dangerous areas; these areas are all in the foot-hills and mountains
where housing is poor and of a type which does not retain DDT, where
populations tend to be temporary, where houses are scattered and
easily missed by the spray crews, where climbing causes shoes to wear out
faster and where supervision is most difficulte Only four foci areas
ere now known amd CTC does not expect many more foci to be found. He
finds it hard to explain why he is now using treatment while still re-
cognising thet 95% of the island was Successfully cleared of malaria
without Rae

The entomologist is not happy with my suggestion that he is
discovering a new type of malaria transmission, namely, transmission
without vectors and vaguely talks of possibility of A. maculatus,

RBW mentions at first possibility of ae leucosphyros which is a vector
elsewhere but gives up this idea when he learns that malaria has dis~
appeared from areas where he previously found A.§,

At the end of the afternoon, Robert indicates his belief that
the difficulties here have been administrative rather than technical
and I find myself giving a lecture on the need for supervision and more
supervision until the Director of the Services who must take the res-
ponsibility of signing the monthly reports can be certain that the work
at the end of the line, that is in the houses, has been donée CTC has
no answer to my query as to what will be responsible for the disappearance
of malaria when it disappears under the impact of DDT every four months
and Ryevery two weeks but tends to defend his action by saying that many
of the malariologists of the world are now favouring the double attack on
malaria, I indicate this is a sign of weakness and lack of faith in
their own administrative services,

FEBRUARY 193

All day on the train back to Taipeh.

During the day, I leernt fran Dr. Ch'en that Dr, George MacDonald
is to come to Taiwan in February 1960 for six weeks to look over and
evaluate the surveillence programe GM's visit will be preceded by a

two month's survey by Dr, Isseres, entomologist, of the WHO. Also learn
Isserex and McDonald were out last yeare
FEBRUARY 203

Visited the medical defence center; rs. Chow and Fang show a
very well-equipped plant for training doctors, nurses, and other medical
groups needed in the armye (Maximum number of entrance students in
medicine is 80 chosen from some 700 applicants; only about 5 of these
80 ever become doctors). Lunch with Miss E, Brackett; called on
Robts. L. Cherrye

N. W. Air to Manila; met by Calbourne, Dy, Hargreaves, Etchavez,
Lipton, Turnbill and Prof. Chow.

FEBRUARY 218

Sit the morning out with Colbourne and Chow discussing malaria
situation in the P.I. Ejercito had a stroke about a month ago and in
any case is out of the picture soon because of retirement; health
section in hands of Menezes? is at about the same age; so, young blood
has to take over soone Colgbourne has had experience in West Africa
and in Borneo before coming here as regional consultant for WHO; knows
Bruce-Chwatt and is apparently trying to copy BC's beard Malaria in
Pele; four situations, (a) no malaria, (b) malarious areas now free
because of program, (ce) malarious areas still dirty inspite of program and
(d) malarious areas which have never been worked because of difficulty
of accesSe

Resistence of authorities to continuing budgets after malaria
has been greatly reduced is apparent; why spend on non-existent malaria
when there is so much to be done for fileriasis? Insecticidal resistance
hes not been found to be of importance here, Notes on notes furnished
by Duck Egg Chow: Pre DDT situation; (a) normally two million cases
with up to 20, deaths, during World-war II over ),,000,000 cases
amnuallye (b) Economic losses from $ 100,000,000 to $ 750,000,000 pesos
annually (c) Endemicity not high, spleen rates of over 50% annually in
the Province of Falawan, little malaria in long-settled and heavily
cultivated areas, more in areas of mixed conditions and high in foothills
and newly settled undulating areas. (d) normally not found above
700 meters. (e) 33 species anopheles; A, minimu flavirostrig is main
vector; A, mangyanus secondary vector and A, maculatus and A.
balabcensis are potential vectors (f) &. mine flave, Slow moving waters ;
streams, seepages and rivers with grassy edges; peak during September
to December lesser peak June to July; resting places more outdoors than
indoors; outside 91.5%, indoors 8343 feeds mostly on domestic buffalo;
comes to houses mostly between 10 pame and 2 aeme3 leave 5 to 6 acme
(g) A, mangyanus important vector in newly opened jungle areas; never
met in long settled areas. (h) Plasmodias normally prewar picture (1928)
75e5% vivax26% falciparum and 0.5 malariae, During the World-war II,
falciparum predaninated but post world-war IT, vivakbecame 71.2%,
fale 28.5% and malaria less than 1%, (i) Discontinuation survey
Sept. 1957 March 1958 of areas sprayed for four consecutive years;
507,000 bloods from individuals, children one to four years and fever
cases (of these 2,472 had been examined by June 30, 1958, 760
falciperum (71%), 236 vivad (23%), 10 malariae (1%). The falciparum
infections were distributed throughout the reporting field units with
high prevalence in those areas immediately adjacent to resettlements
(3) Epidemiology moderately unstable; peak years 1925, 1930, 1938 and

 
~15 =

World-War II 192-173 zoophilic anopheles causes need for high density

for transmission. (k) Epidemiological survey and investigation: (1)
"Non=malerious areas" 14 million of 22.5 million believed to be in non-
malerious ereas need survey to be sure. (2) "Continuation areas" three
million live in areas where residuel spreving has gone on for to 5

years in spite of which some maleria transmission still occurs; teams of
epidemiologist, one entomollgist and two technicians have been recommended
by George McDonald. (Epidemologist and Entomologist are to have six

months fellowship of ICA tio study elsewhere during 1959 and then return to
plan and train for the P.I.)3 duties of teams are to (2a) determine origin
of malaria cases as sporadic, imported, induced or introduced. (2b) To
determine if total coverage has been carried out; (2c) Bgoassay of residual
effect of insecticides (2d) Insecticide susceptibility tests with local
anopheles (2e) Observe survival rate of captured mosquitoes from sprayed
houses (2f) Bionomics of vectors (2g) Cultural characteristics of population
which might interfere with action of insecticide (2h) To determine secondary
vectors if present (21) Bo recomend counter-measures to get final eradication
(3) “Discontinuation areas'ts as "inaccessible" areas become accessible they
should be surveyed to determine where they are malarious or non-malariouse
Selah Chow has spokendé!

 

FEBRUARY 23 -— MANILLA:

Morning visited the WHO and to the Malaria Service where we find
Dr. Villanueva acting for Dr. Ejercito who had a stroke some weeks agoe

Afternoon meeting with Drs. Dy. John McDowell, Etchave2%, Foulsen
--llansen and Prof. Chow. Dy gives summary of developments on malaria
control here. The first reel post-war control was in 1952 with Dr.
Sambesivamof WHO on Mindanao; this pilot project wes highly successfulx
Philipines with ICA was written and signed in March 1956, four months
after my visit here at the end of 1955. George McDonald was here and
made recommendations for surveillance program after about a month in the
country but efter Feter Issaris had made a several month's survey.
MacDonald and Issaris were working together and are especially McDowell
emphasizes the question of settlements in the forests: both the official
resettlement and those under individual interests working on the problems
of surveillance and disappearing malariae The recommendations made by
M and Is*have been followed very closely "and that is why they are so
expensive" (words of F.Dy). Surveillance is used wherever discontinuation
of spraying occurs. Present plans call for a report on the situation
here with a final plan of eradication to be prepared and agreed upon by
the Government, WHO, ICA, and UNICEF.

Dye believes that while malaria incidence has been greatly reduced
in the cities and towns that there is still some transmission in certain
arease Dy does not believe that DDT has been a failure but is rather in=
clined to believe that failures are in large part due to failure of
administratione McDowell believes that problems are chiefly those of
resettlement and aborginal tribese
-16-

1953 survey of spleens indicated 1,200,000 households involved;
195), 1955 the same figures; 1956, with eradication program 1,1)00,000;
then 1957, 1,490,000. This was fourth spraying for 1,200,000 houses.
(Of 1,200,000, 1,060,000 houses could be excluded from spraying is@e
there were almost 200,000 houses which were thought to be in areas with
continued tramsmission occuring). At intervels during 1957, a survey
was made of fever cases, of individuals and small children; on three
surveys of 1/3 of houses each time, there were 20,000 slides taken
which gave 0./)2% positives.

Mesa surveillence began July 1958. Only 328,000 of 600,000
houses in crosshatched «reas were sprayed (see map 1.3. This year,
about 126,000 houses are being sprayed. It is believed that 600,000
houses should be spreyed until 1962. Thirty relarie units each with
a doctor es leader: official government surveys; with some three or
four sub-units in certain areas. Doctor, meleriologist, one engineer,
one or two foreman and technicians for each sectore

$  3,460,000.00 US
$ 14,600,000.00 Pesos = of what has been counterpart
($ 1,850,000 .00 funds =<— rest from Government
MCD emphaises the question of settlement in the theories; both the

final resettlement and those under individual initiadeardx
FEBRUARY 26TH «~ COLOMBO:

Discussion in office of Dr. Visfwalingham who bs taken over
from Dre Gunaratna who died a few months agoe 1934-35, 50,000 deaths
in less than six months; more than 70,000 for the 12 month period.

V gives us his Report on Activities of the Anti-Malarial Campaigns,
A x ak

Ceylon of 15.1.1959. In the intermediate home surveillance is

t . #
wep a Aa Q
more related to persons of «!’"’". rather than,cases of malariae

fee “4

A in’ the Hyperendemic zone,

ieee doing surveillence of houses in A. @ulidifacies areas. In other Wt Ws

-

areas, what I am suggesting is to concentrate on insecticide rather than

I raised the question of doing the same

”

on treatment . (Dre Weckramsingh and Dr. Weerasooriya, doctors in the

 

malaria services in Colombo >
more cases reported for 1959 thn we had anticipated but all are charged es

4

maueh againsk infection from the dry zonee

The morning was devoted to visits with DKV to Dr. Visfvalingam,
the Director of Malaria Suexeys Service, Dre Kahawita, the Director of
Health and tum ‘Gn the Minister of Heaith Madame V (7). We learnt that
the WHO is financing a study here of ways and means of surveillance using
a population of 100,000 people in the dry zone far a period of two years.
The Planops has just been signed; some of the microscopists are already
here. Tere are to be 1) men in the field collecting bloods from fever
cases in some areas at intervels of two weeks, in other areas at intervels

of four weeks, in others at six weeks and in still others at intervels of

eight weeks, In addition to this a certain population will be able to

: Wo\ @ Yy wwe — ak Le
4
compietely so as to give an idea of what is actually happening in the blood
without reference to the production of me fever, There are to be eleven
micropists to examine the estimated 600 slides taken daily, After visiting
Dr. Kahawita, we call ga on the Minister and (1) insistéd that she should

come to Delhi for the Malaria Conference in March and (2) talk about the
necessity of spending enough money to get rid of malaria once and for all

time in Ceylon (3) emphasise the fact that the easy part of the job has been
done but that malaria will continue until the €henas and the outlying areas

are taken care of (The minister seems surprised that there is any difficulty
in’ countering the houses since it is tne obligation of every village headman and
every forest ranger to know all of the houses in his areaf and all of the
island has been assigned to one or the other of these officers) »/£o the Indian

Embassy for reentry visa; of course three pictures are required of RBW and

JSS before we can get clearance to travel, This takes most of the afternoon.
FEFRUARY 273

Colombo to Polanoruwhe in Dr. Visfwalingam's Consul (English Ford)

With the DKV, RBW and the owner driving the car. A stop was made at Kurunegala to
make arrangements for the housing of the micropists (10 or 11) who are to work
here for WHO, witty Some pictures taken heres On to Polonaruhwe where we decided to
spend the night. I drive on up with the 2 V's to make arrangenents for office

and living quarters for the group of field workers WHO are to take bloods for the
WHO study. At the end of the line, we met the inspector responsible for vigilence
in this area. In answer to a direct question, he says it should be possible for
an inspector living and working in a district to know about all of the chenas and

plantations and wood cutters and other jinvadors of the forest areas§}j{
FEBRUARY 28:

- Got pictures of two spraying units, one with a little jeep and one with
a weaponcarrier with more men and more pumps. His pumps are of the Kgapsack xi
shoulder type with the over the shoulder low-pressure lever pump handle, ‘The
nozzles are a conical type which are net really not satisfactory for DDT spraying) -
Also got a picture of an elongated jeep modified for carrying pumps as well as
men. We visited a chena area in a rather wild forest where the workers! tefuge is
a nest ina tree about 30 feet from the ground, DKV completes arrangenents
for housing af field workers of WHO in this outlying area, The question which
constantly comes to my mind is why im not spend more time hunting Aouses and chenas
that has / 2 ‘nore surveillance of missed houses rather than trying to find and
treat every infected caseg? Todate, the premise hy DDT sprembcibocthe sprayed
in the houses will resuit in the interruption of transmission has not been proven
false and yet we see an enormous drive to find cases; so these cases can be
treated as well as their contacts. Should cases not rather be searched for in
order to find where transmission is occuring? I believe, a fundamental study
should be made here of the basis of eradication: can eradication be tas by

hunting out and treating cases or must it be done by interrupting transmission?

4
. : fo. og,
plive heals

During the trip, we got a good administration of a one-man administration with the
Director looking after freryminute detail, I tried to point out some of the
‘ te TW

defects in the method of coverage by arrastaa but got just exactly nowhere]

Arrived back at the Galle Face hotel in Colombo at about 18.30 O' clock,
MARCH 13 CEYLON — COLOMBO:

Spent the morning packing and paying the hotel bills the latter

took more time than the former, Afternoon plane to Madras where we are
met by a driver and car from the Shell O41 Company. To the Connemera
hotel for the night.e (Mosquito nets used by JSS for the first time in

many years; these ere essential because of filariasis in Madras).
MARCH 2:

Indien Airways to Bangalore (DC3). Very good chance to see
Deccan plateau with some pictures teken. (We are met in Banzalore by
Drs. Chandrasekeriya , now retired from position of Director of Health
of Mysore State, H. Shama Sastry, Y'rector of Malaria Sradication for

Let ia TB os Cj
the state,. panethan who remembers me from thé 1950 talk en-the—eeeasion
at JHU when he was a fellow, and fhodtc Dr. K. R. Venkatesan, all old
PR LALKYKA | -

friends of RBW cad by er Make, a Farsee friend of RBW who is said to be

more British than are the British themselves.

Later at the Hotel we met Dr. Junglewalla, the Director of the
All India Institute at Calcutta. We also met Dr. Yestee Rodda, the
Director of Health and called on the Minister of Health of the State,
4
4

“ 4 who is a physician, not with PH training but who seems to

know pretty well what is going on.

The trip to Poona seems to be more difficult than anticipated
; 1 ate MO,
with the result that plans sre changed to Ae Mysore State, leaving Foona for
em i\
another occastons (akeyr

Receive “ote on the progress of the Working of National Malaria
~ Do
Sradication Program in Mysore" from Dr. Shama Shastrye

Outdoor dinner at the Victoria hotel with all of the ke doctors

oO
named above and half a dozen mores 4s scussion rese to eradication of

[oe LoS be gis
malaria, bet) ste and to planned parenthood.

. BeTel pet
Juliet takes her first step on the downward path as 4 -bettte-not-

chewer $
MARCH 3RD:

Day in Bengslore; morning with Dr. Shama Sastry; at 3.30

to the Health Depertment and at 6.30 to dinner with Lal Kaka the Parsee,
: : “ . ms m, } —= - (
jusshe boa oat pereertkas Keie You fin? Sk mn ty Ws ( S$ ane yes Nae K

itu wegen)

MARCH TH:
Leave Bangalore at 9.90 crock! lunch on sandwiches and drive

on to Shimoga where we visitg@ the laboratory for virus studies and

where I am asked to sign the first card for a mouse group injection.

Anderson and Trapido are in the area at the moment and we should see

them this afternoon or tomorrows
Photo taken with the following persons present: JSS, RBW,H

Malaria in Shimoga — Discuss maleria situation here which is

said to indicate that all cases found have been infected outside the
ae: of _—
rere Cy?
area, We drive to Jog Falls where the falls have (Ftew 900! from top

to bottom; the face of the cliff is said to be the nesting place for
PIG Eon’s
hundreds if not thousands of rock proce gens which make difficult
Mier cQ_
Ss es khoumgh ki they ex cane in at night because of the speed of

kek ‘their flight and“ Sharpness of their drop over the falls on arrival.
Juliet sleeps on top of the coverlet because the sheets are
not unused; otherwise the service is satisfactory and the food

acceptable though different fram week oF three doctors who sit at
Larry Re

the table with us and eat sotoradesuae diet with their hands. Anderson
(Chas) and Trapido (H) came in just before 21.30 and we make talk until
after 00.30 in the morninge HT recounts his 1952 experience in Sardinia
where he and T. Aitkin sperd- the summer studying he labranchiae in a

small valley 1; kilometers lon: where ele had been found almost three years
after spreving h:d been stopped. The Roy showed that one AW
was found on the average for each 100 (pa. no adults were found

at any time even though houses and all possible shelters were searched
- {
gt bee eth

and traps of all kinds with various kinds of mormal baits were employed.

It seems difficult to imegine whet was heppening since according to
cane -
wnat is known of the behaviour of the species, the. does not

rode 2 oA,
met except in the presence of a swam oflaswa ¢ In the absence of all

evidence of adults in the area a few larva continued to be found

during the summer season. On the other hand, Ae hispaniola which had
es _.
beer found du¥ing kam the first12,000,000 Kube mit made for larva by

(ake a

Erlaas is now a predaninant species among( tw on the island. HT

 

points out that someone has termed the impact of DDT on certain species

CL
of insects #6 equal for its effect has-net on the development of genetic
PC Aa +
ipreeess to the Pleistocene kimk geogological age HT points out a

species may be expected volta up end disappear under a certain type
attack
of Rakk woich is adapted to its habits in the periphery on its range

where a rel- tively poor strein mey be xg present: H. Ts kk believes on

the other hend thet the Species et its original centre of distribution
¢

UL.
may be much more complex genetically and able to develop resistence and

OTE LY Av
other for surviviee wnich cannot occur at the perip herye / Anderson
Wa AE &
says vaccination against KF disease has not beenjof valuete-beof

but wititirem hopeSto get some figures which may be indicative of its
value during the present yeare The RF group have offered this year
Rs» 3 for a dead monkey, Rse 6 tor “Sick monkey and Rs, 10 for monkeys
from which they isolate virus. The take and secondary health
centres cievertin We, of this a fur have made it possible to
rear bane people are sick and tes information thetrould otherwise have
been impossible. KFD xm continues to occur in the area where it occured
in 1957 and 1958 but hes spread to new areas in 1958-593 apparently
the disease is not so mew and the xxxrkem virus is more difficult to iso-
lete in the 1957 areas but the virus is still theree KFD apperently

¢ avd, £h8
infects enlarge _mimoopot ee animals and birds ‘and monkeyf
don't seem to have any Mec ection in maintaining the viruse Its
importance is due to the fact that it is susceptible and its death is

Aww? v

noticeable. Cattle in the ‘Semeinfected areas have positive bloods
fx bitte ork

bitiseb outside the known areas £6r% na@gative gem bloods. Both man
and the monkeyf seenf’ to be accidents and not an important factor in the

were of KFD. HT says this may be the first time thé virus has
been in this area and that it may have came from Malaya but that the story
is kak complicated by xeasmm recent evidence of doe ces 4 in
Sweden, xXrk Ireland, Pnerencgere © Checkgslovakia where there are no
monkeys tes where the disease boar apparently long been present without

LOr—nnr
ene ae pecognided. HT believes on the besis of studies here
MARCH 8, SUNDAY —- VISIT TO COORG == TOWN OF MERCARA : DR. AYEPA

}

This is the state from which the best warriors come probably
because of the mixture of Arabic people. There is a large immigration
of labour for the plantations during the crop season. Malaria control
began in 19:7. Transmission is period just before and just after the
monsoone In other words, transmission occurs when there is some water
but not the large amounts which come at the peak of the monsoon, in
1956, the national committee suggested that the time had come to stop
sprayinge This was done and during 1957 and until May 1958, no cases
were found. Then there were clearly an increasing number of cases
found in the tribes. Immigration labour is blamed. Cases have all
occured in southern area among tribes of aborignals. This is an
apparent example of a reinfection of an area thought to be clean but
on discussion, Dre Ayepa comes out with the statement that he believes
the work was never properly done in the aborginal tribes. One-third
of the state has been put under spraying againe Cases have been found
among population groups of about 20,000; spraying has been started
again among 0,000 people. Total population of Coorg 2,30,000.

‘From the investigations conducted so far, it is know that the in-
fections are confined to tribal people and labour populations with
evidence of spread to locals", (Tribes 30, Labourers 20, Local popula =
tion 8). Cases have occured in Srimangalu and Gonicoppal circles.

In the group of 60 random slides taken from tribes, 16 positives were
found who gave no story of infection nor of fever.
MARCH 93

Morning at the palace. In the afternoon to K.R. Nagar. Previously
1
highly Hypereddemic area, Malaria associated with irrigation and A. fiuriatilis.
Doctor here gives a categorical yes when asked if he believes that malaria has
been eradicated here, No local cases for three years and only one case of any
kind found last year; this case was in an engineer who had been out of the
Cen PiwerL

district on leave, Here 4 to be a stable population without forests

and without damigravihe labourgt,
Bondipur last night. Morning trip in the forest to see
and film animals after which I rode the elephant to the tune by ten
RS. Drive with Dr. Bhombore and HSS to Coonoor where after a bath
and lunch we came to Malaria headquarters at the Pasteur Institute
of South India which dates from 1907. Office here is one of the
six original offices for the malaria survice, Three states here,
Serala, Mysore and Madras. Dr. Bhombore gives us a table of data,
(which see). B says he came here in December 58; has a French
parasitologist and an American entomologist with one foreign
technician who are beginning to study mosquitos and parasites in
dry area towns where spraying has never taken place for a check
program of WHO. (RBW and I have somewhat the same impression we
had on encountering at Mysore the Indian doctor from South Africa
who has been in India aimost a year without doing anything at all),
=2a

RBW asks Bhombore and HSS what reaction could be expected to
the suggestion in a combined program for India — for the three states
of Mysore, Madras and Kerala, Then to the Hotel for tea and further
discussion. (I point out to RBW that what he has seen here explains
why I am not enthusiastic regarding the possibilities of getting program
of WHO financed by RF). At the Hampton Hotel, we have tea and get
HSS's ideas of what more he needs to put on an ideal program of* sur»
veillance in the present state of Mysore. Among other things, there
comes the request for 400 jeeps and microscopes and slides and personnel
to the extend of about $ 66,000 USA annually, All of the requirements
except the jeeps might conceivably be gotten but 400 jeeps are just not
going to be found in addition to what he has. I cannot forebear bring=
ing up once more the cost of surveillance as being planned here and in
certain other parts of the world and point out that I have considerable
faith in sampling and in continued negativity where one is sure the
work has been donee I believe, we should have faith in our ability to
find malaria and also should have faith in the ability of the organization
to blot out any reinfections which may occur without the necessity of
sampling of blood from all fever cases every two weeks§ HSS discusses
once more the failure in Coorg and insists that it was not ready after
eight years of spraying under the National Malaria Institute since the
work was never properly supervised and checked. It was interesting in
Coorg to note that only in the southern part of their range were the
aboriginees continuing to have malaria, This indicates that the work
in the other area was better than in the south. When RBW asks HSS
about the future of the men to be hired now and the 00 vehicles (jeeps)
which are not to be needed after eradication is over, he is told that
they can be used in other programs of eradication in the state, I came
up with the suggestion that there should be a pool of materials and men
formed to work from state to state in India wntil the entire country is
free of malariaj

MARCH 11s

Had a nice cool night at the Hampton Hotel which is at an
altitude which makes for delightful climate at this time of the yeare
(Paul Russell lived here at Coonoor for some time while in India).

Drse HSS and Bhombore drive with us to Mysore where we dine with a
number of doctors as the guests of Dr. Chetti, the Indian from South
Africa who is with the World Health Organization and who speaks out very
freely regarding conditions in Africa as against conditions in India,

C is third generation, that is the second born in Africas; his grandfather
was indentured for two years and then given the choice of repatriation or
a chance to remain in South Africa with a small piece of land, He re=
mained, got into business for himself and the family has prospered, In
spite of the racial difficulties in Africa, C says Indian worker in
Africa is much better off than anyone of similar position here. (I am
surprised that C speaks so freely in front of the Indian doctors with
whom he must work during the coming months and years, especially since

no one had asked his opinion on the points he discussed.) (Photo of
Indian doctors at the lunch taken in front of the Hotel just before we
left.) Stop at Mandya where the school for malaria workers was in=
augurated with RF help some years ago. Dre. S. Rao, the present
Director was trained at Harvard and was never trained as a malariologiste
-3-

The school is spread out in small separate buildings over a large plot
which mekes for high initial cost on construction, then difficult
administration end consequent disorder. The present Director took over
from HSS; he talks rapidly about many minor difficulties which he has
not solved himself but which he seems to think Dre Watson, as representa-
tive of the RF should solve for hime RBW does not get interested in
helping him but points out that all of his problems should have local or
at least ICA or WHO solutionse (Photo of group including Dr. Watson
on steps of main building). Stop at health centre where RF Fellow is
in charge; picture taken of this Fellow with the signs of the health-
centre and of the Government Family Planning centre; also with the

sign with his namee During the day RBW asks me about the fiasco of
our Brazilian joint effort of 1957: I give no added details other than
to assure RBW again that what I did was done in good faith and that I
was greatly surprised when I learnt of President Rusk's reaction to the
Situation. RBW says he received a two page cable from President Rusk
stating that the RF would not, repeat would not become engaged in the
administration of the program in Brazil under any circumstancese RBW
enlightens me with information that his cable was shown to Davee the

day after its receipt and that it was on the basis of this cable that
UNICEF decided not to have any part in the Brazilian malaria eradication
service] Arrive in West End Hotel in Bangalore at 18.15 —- completing
just eight days on the rosd without stopping; a most interesting trip
in which we have travelled some over a thousand milese

MARCH 12 = 133

In Bangalore — official visits to HSS and to Director of Health.
MARCH Uj:

Fly to Delhi with transfer in Hyderabad to the Janpath Hotel.
MARCH 15-SUNDAY:

le Met Dr. Woods, once with the PASB along the border between USA
and Mexico whom I had not seen since 1945 at the Typhus meeting in Mexico
City Wis now with ICA in Indonesiae

20 Meeting with B.A. Rao, HSS, RBW & FLS

RBW outlines our trip and our objectives and asks if there is
anything RF can do to help in India. BA says WHO has studies in three
areas in India and another in Ceylon and at first seems to think that
this is sufficiente BAR and FLS have long discussion of place of
surveillance in malaria eradication: Points at Varia NCE (1) BAR
does not feel the need of surveillance as a check on results of spraying
operationse (2) BAR uses surveillance only to find and root out
final infections; FLS would use to find where transmission is still
occuring (3) BAR says there is still 5% of positive in the Punjab
three years after a big epidemic whereas FLS shows figures for
~~

&e gambiae infected area of Brazil for 1939-041, namely 6505, 968
and O.5%~ (hk) BAR still believes in infant parasite rate as in-
dex pf stoppage of transmission although it has been found wanting in
Taiwan, Ceylon and elsewhere.e (5) BAR says that RF if going to
work in India should do so in agreement with the National Goverment
rather than with states or with WHO.

36 Learnt fran MFARID (a) that malaria in lower Egypt showed an
increase near Cairo in 1958 and hence is now getting some attention
(b) that there is some malaria in Fayum area but that the oases of the
Western Desert are apparently free although A. sergenti did, after an
absence of three years, reappear in Dahkla apparently reintroduced
from another Oasise (c) That Jafar is still Director of Health in
Pakistan and just as determined as ever not to do anything about
malaria but that the Minister of Health may have different idease

CAA is to stop there after the conference to discuss matters by special
intervention of the Minister since Jafar would not have recognized

the convenience of CAA's visite

MARCH 16:

Inauguration of the Third Asian Malaria Conference which C.
Mani refers to as the First Asian Malaria Eradication Conference since
the previous two conferences were for the Control of Malaria ( To hear
CM state publicly that Malaria eradication is within our grasp is an
important index of progress)e Prime Minister Nehru opens the Conference
with some remarks on the effect of Malaria on the course of history and a
statement that malaria is worse than many diseases which kill outright
since those who are not killed are all too often enslaved.

Indonesia sent a letter to CM against representation of
Netherlands here. CM refuses to read the letter saying that this is
not a meeting of Governments but of participents and that there is no
reason to bring political problems to a technical meetinge Soeparno
insists and does read the letter himself. The representative of
Netherlands (Metselaar) replies that Netherlands is sovereign there.
In his talk, the Minister of Health Sri D. P. Karmarkar says that if
we are to take credit for malaria control, we must also take blame for
the malaria which still exists (Ideas if good do spread!).

Afternoon meeting. The Minister of Health of Malaya in the
chairs at the top table Don Johnson, CAA, Colbourne and the two
rapporteurs. The meeting had hardly begun when DKW told the chairman
to ask me to talk which I did to the extreme of giving something of
the history of eradication and what happened in Aa eradications

Then some words from Don Johnson, Mr. Davis of UNICEF and
CAA. The representative of Indonesia (Soeparno) says that he has
difficulties in getting his government to accept the idea that ICA
can give guarantees only year by year and not for the full course of
the eleven year program. I got dragged in again by Don Johnson to
help tell what will happen with regard to US aid. JI said Indonesia's
problem of getting funds from USA will be solved by what happens in
Indonesia rather than by anything anyone can do in the USA.
=f =

After the meeting CAA tells me I may be named honorary Presi~
dent of the VOP's. My answer is that in 1939, I received a telegram
from Maneco and Bruce Wilson signed "2 other VOP's", The Allens and
Peg Balfour came by and took us to the party at Patiala housej An
outdoor party in the grounds with the moon overhead, since at this time
of the year, it is possible to plan without the risk of raine Telked
with the Minister of Health of Nepal and got a very good impression of
his orientation regarding malaria eradication. Talked with Dr,

Barket Narain of Indis who seems to be incharge of the organization of
integrated Health Services throught the country: Narain defends the
policy of thinning out centres responsible for 60,000 persons or twice
as many as can be taken care of. Narain says his hand is forced by the
development of integrated community services in which health is only
one element.

MARCH 17, 1959:

Malaria Boards Afghanistan, Burma, Indonesia, India (J. Singh),
Viet-Nan, Je Singh tells what is happening in Indias; B. A. Rao is
Director of the Malaria eradication program but is not the Director of
the Institute where S. P. Ramakrishnan holds authority. JS says
everything is working well, a statement which is denied by RBW. Health
Minister of India and DK both discussed the ideal and the practical types
of organization ranging from military vertical service to fully integrated
services with details all carried out by regular health servicese

MARCH 18:

_ Lunched at the Gymkhana Club as guests of Secretary V. Ks Be
Pillaiy The Minister of Health, Dr. John C, Hume, Mr. Howard Houston
is head of US TCM, Dr. Mani and 20 other people were there. The
Minister seems to be a very intelligent if ruthless individual. Spend
the afternoon visiting the All India Institute of Medical Sciences with
Dr. Lucien Gregg and B. B. Dikshit. In the late afternoon, visited the
Indian Council of Medical Research, of which Dr. C. G. Pandit is the
Director, Interesting discussion regarding plans for eradication of
small~pox in Indias also discussion on problems of cholera and plague.
Apparently the problem of cholera is very definitely related to the East
and West Bengal areas as endemic centres, Pandit is responsible for the
publication of a paper suggesting the possibility of Hilsa fish taking
part in maintaining cholera vibrios for human consumptione We missed
the party given by the Minister of Health because of a failure to get the
invitation which was posted addressed to the RF without any indication
even of the city. The morning today was spent visiting the Malaria
Institute where Dr. B. Aw Rao gave a talk on the institute and on the
program for eradication of malaria following which we visited various
sections. One of the interesting thing going on here is the genetic
work in which an attempt is being made to link a spread-wing mutation
with gene responsible for resistence to insecticidese
MARCH 19:

Lunched at the Ashoka Hotel with Minister Sambantham from
Malaya and Dr. Ding The Minister asked Drs. Watson and Soper to
cammert on plans for a pilot project in his country. Between us we
suggest that the pilet project is too small (only 5,0000) people
especially so since it has no defensible borders on two sides. We
suggest thet the idea of a small pilot project with areas of all five
factors is not a sound one since in Venezuela, there have been found
two almost contiguous areas in which a. acuasalig behaves in different
manners; in one area DDT gives good results, in the other area it has
failedjj I insist that the pilot area is Malaya and that whatever
work starts on a smal] area that area should immediately be considered
as a training area for the rest of the country. (Later in discussions
with Dr. Colbaurn, I learned thet he had accepted the pilot project
progrem for Malaya as most he could get since Dr. Reid of the Institute
has been opposed to any all-out attempt to eradicate malaria in Malaya.
C says he would welcome a visit of mine to Malaya if I could put on
pressure to get faster action on building up a national program.
(While we were talking to the Minister, he indicated that it would be
very difficult to get Malaya begin its eradication program in the pocket
next to Thailend border since Thailand has failed to collaborate with
Malaya in the suppression of communist activities which have continued
as long as they heve largely because of the open border areas through
which they have opereted), Later in the day, I have a chance to talk
with Reid who says that his opposition to an all out campaign of eradi~
cation is based on studies in which he participeted some years ago in
which four areas were taken having operations of about 1,000 people each.
One area was treated with drugs, one with DDT,one with BHC and one was
left as atrial. From a malaria rate of 30% in each piece, the rate
dropped in three years to 3% in the DDT area and only 2.5% in the drug
treated areas Mr. Reid was entomologist who has been at the institute
a number of years and is now serving as Director, but expects to retire
next year as part of the nationalization of Malayan institutionse

Have discussion with RBW and draw up the following notes of our
conclusions as we are talkinge

(A) Many areas in Taiwan, in the Philippines, in Ceylon and in
Mysore have been cleaned of malaria (in spite of the statement of CAA
that real eradication has been recorded only in those areas such as
Sardinia, and sections of Venuzuela and British Guiana from which the
principal factor has been eradicated).

(B) No country or state has been entirely cleaned but in each
area, the authorities attribute the difficulties to the problems of
population distribution and population movement (immigration, chena
farming, aberginees etc.

(c) No evidence in the countries we have visited of difficulties
due to false promise: Where all houses have been sprayed properly,
melaria hes disappeared; no evidence of resistence as an important
factor in the areas visited. Failure has been dve to administrative
difficulties rather than technical ones; finding and spraying houses.
=o 7 =

(D} Certain of the cleaned areas are large enough to justify the
promise that the residual insecticide itself stop transmission and that
in the absence of transmission, malaria does disappears

(BE) RBW and FLS believe that tail end cleaning is to be solved by
improved administration rather than by hunting out and treating all
residual cases of malarial

(F) The proposal to switch from insecticide to drug therapy at the
end of the trial is proving expensive beyond reasone

(G) What is happening in malaria is typical of epidemiology of
communicable diseases under attack (also disease features): initial
eradication easy but hard core of final cleaning up is difficult be-
cause attempt is being made to use single technique for all conditionse
It must be remeanbered that the problems which are difficult are in best
in temporary conditions which occur only once but are a routine part

of the life of the areas being worked. Therefore, plans must be made
to meet the problems which ere encountered without recourse to routine

therapye

(4) The solution of the problem of final step eradication is
important not only for malaria, but for every disease in which eradi-=
cation is to be attempted. Froblem is indicated by acceptance of
term "epidemiology of disappearing malaria" and the introduction of
tem "epidemiology of a retreating disease"ard the “epidemiology of
evanescent disease". Important elso for animel and plant diseases.

(I) Importance and urgency of problem is increased by DG report
in 1960 document presentstion.

(J) See no advantage in funds now to WHO unless they could be tied
to a program to be carried with personnel selected by the RF and with
RF shaping the details of the program (since WHO has already two pro-
grams with MacDonald Betol, RF should work independently).

({K) Believe RF to build staff to work on epidemiology of dis-
appearing diseases (cite RF 1 First eradication program (YF)

2 No Aa YF since 193k.
World committed to maleria eradication. We cannot see it faill!

wait A
wr RBW leaves on BOAC Brittania at 20.15 F.M. Farewells at
the air-port.

Long telk until after mid-night with Don Johnson: Don
realises thet Congress has been misled regarding period required for
maleria eradication. (1959-60 is supposed to be the peak yeard!)

The headquarters steff on melsria consists of only three people,

Rao, Roy Dritz, Don Johnson, and an assistant, all three of whom

shsre a single secretary. This staff is supposed to be over seeing

the spending of 30-35 million a year and prepare budgets and documents
and meintein reletionships with International organizations etc. etce for
programs which are spread round the world. Herold Hinmen is coming

to DC to become one of the three regionel chairman, Pease and Curtis
being the other two.
(19 May 1965, mnc)

BPIDEMIOLOGY OF DISAPPEARING DISEASE
OF RETREATING DISEASE

New Delhi
March 20, 1959

Malaria Notes

Many areas cleans no country and no state entirely clean) no evidence
of failure because of technical difficultyy resistance not imp.

Areas cleaned are large enough to validate premise that
Interruption of Transmission Results in Eradication.

Difficulties are due to failure to do complete job with adequate check-
ings administrative rather than technicals failure to get eradica-
tion is resulting in switching horses at the end of the trail;
so-called evaluation is in many areas a disguised attempt to do by
finding and treating residual malaria cases what has not been accom-
plished by insecticides!

Curves of incidence everywhere show large rapid reduction in malaria
cases followed by flattening of curve at a low level. This is the
typical "control" curve seen by health workers in so many diseases
in so many places in the past six or seven decades. (Eradication
curve breaks sharply and continues downward without undue flattening--
Flattening of curve means unsolved problems; either administrative
or peripheral, (Hidden breeding of A. aegypti.))

Malaria workers are projecting their work for unnecessarily long periods
of time--in Taiwan a study of the data shows that this job can be
done rapidly from here on out.

Obvious that evaluationists and therapists have taken over

a. WHO document EBS9 called for 75 per cent of spraying costs.
b. McDonald's influence Taiwan, P.I., Ceylon, India.
c. Mysore State, e.g., 1 man for 10,000 populations monthly visits.
d. In Ceylon I finally suggest surveillance for houses rather
than cases.

Question: Should search for cases be used to reveal where transmission
is occurring so proper correction of insecticidal work can be made
or to identify all infective cases to permit elimination of infection
by treatment?

Concept of eradication is valid for some diseases ami as time goes on,
with improvement in techniques and with additional experience in
coordinating activities of neighboring states, will become a most
important tool (not only for attack on human diseases and disease
vectors but also on those of animals and plants!).
2

Epidemiology of Disappearing Disease

There should be a group devoted to study of possibilities of eradica-
tion and especially to study of Epidemiology of a Disappearing
Disease.

The area closest to eradication is probably Taiwan.

(P.S. Above notes prepared before visit to Poona (Bombay State) where
T. R. Rao admitted an outbreak of tens of thousands of cases last
year due to anopheline resistance to DIELDRIN. (65 per cent of
120,000 people estimated incidence at Tanta.)

Both RBW ani myzelf have been reluctant to accept the system of surveil-
lance requiring the visit of an inspector to each house every two
weeks which is being introduced in several countries. Such close
surveillance is justified by its proponents as a means of finding
of residual infection which is then to be eliminated by treatment.
(In the Americas, we have advocated using drugs as a bait to facilitate
surveillance but have considered surveillance as a tool for finding
where transmission continues in order to correct the defect in insec-
ticidal application making such transmission possible rather than as
a means of finding all infected cases for the purposes of a radical
cure.

It is surprising that the same workers who have undertaken malaria
eradication only because of the introduction of residual insecticides
are willing towards the end of the campaign and while admitting that
the premise on which the campaign was initially based is valid are
whiddang to switch about and treat infected persons. This switeh
requires the development of an entirely new organization and a very
expensive one.

File: Malaria, Asia
Diary —
Daily
(21 April 1965, mne)

FLS DIARY NOTES ON TRIP TO MYSORE, BOMBAY, THAILAND

h + 11 March
22 March - 13 April
19-59
_

Wednesday, 1) March

Drive from Bangalore to Jog Falls where the night was spent.

Evening discussion with H. Trapido: Trapido believes, on the
basis of studies here, that the Russians are wrong about trans-
ovarian transmission in the vector; here the ticks do not seem to
carry the virus over from one generation to the next.

At the present time numerous cases are being found in humans
as well as in monkeys. Tomorrow we shall see some cases in the
hospital, on the basis of promises from HT tonight.

It becomes clear during the discussion that there has been some
jealousy between the RF workers and the local people with one of the
local workers insisting that he had mouse groups inoculated with the
virus from KFD cases when the RF group came, but that Dr. Worth
refused to do any typing or studying of the virus whichwas soon
lost. HT said that the RF group arrived here directly, inoculated
animals and got material on Wednesday which went to Poona on Thurs-
day, was inoculated in animals there on Friday and gave isolation
of virus as early as Monday of the following week. Their visit to
Bangalore was on Friday, and the Indian doctor in question did not
show animals nor ask for help on typing any material he had.

Thursday, 5 March

Inspection of Shaiavathi Valley Hydro-#lectric Project and
from there to Sagar where KFD cases were seen. Visit to the Medical
Officer of Health and lunch at Shimoga. Shimoga to Tarikere to
Pammangandi where we spent the night.

The problem of labor on the Bhadra Reservoir Project is compli-
cated by the system of sub-contracts for the individual bits of work
to be done on this project. The sub-contractor hires and fires
labor at will with no overall control for the 26,000 people working
on the project. The present schedule calls for all houses to be
visited at least once each month by the inspector looking for fever
cases. Fever cases found are treated with the object of, and I
quote: "The treatment is aimed at radically curing all malaria
cases." "The number of cases has been reduced to a minimum during
the latter months of 1958. This reduction has been mainly due to
the prevention of relapses by the treatment of malaria cases with
8 aminoquinolines which eradicate the malaria infection in most of
the cases by destroying the tissue parasite."
The following table gives the summary of past experience:

 

 

1953 195u 1955 1956 1957 1958
Population by year 26,320 26,320 51,857 36,232 25,097 21,859

Treated cases by
year 726 1,277 1,260 2,410 6,009 1,810

Cases per/1000
per year 27 hg aly 66 20 82

Jog Falls, Mysore State, India

 

After taking some more pictures of our Indian friends together
with the doctors from the RF we started back over the same trail we
came in on last evening but stopped at construction project for a dam
which has some 26,000 employees and is expected to last 10 years
before completion. ‘Some cases of malaria are being found among
workers from other regions but no cases have been found here during
the past five years, 2-1/2 of which have been without routine spray-
ing and under surveillance. It would seem that we have here a defi-
nite answer to those who say drugs are needed to finish the final
residual cases of malaria in an area!!!

We stopped at Sagar (data on the malaria situation) and for a
visit to the hospital where we see cases of KFD diseases.

Later in the morning and during the lunch hour (without lunch)
we had an excellent opportunity to see and study at close range the
conditions under which KFD occurs. There was a trip interruption
due to a natural degeneration of old rubber in tires.

Friday, 6 March

left Pemmnagundi to Shikmagalur and on to Belur where we visited
the upstairs office of the Medical Officer of Health and had lunch.
After visiting the temple in Belur we go to Mudigere, visited the
office of the Medical Officer of Health, and on to Sakleshpur where
the night was spent at the home of Mr. H. Radicliffe (Otherwise we
might have stayed at the Manjanadab Club.), one of RBW's tiger hunting
friends where beautiful large tiger skins were in a separate display
on walls and floors throughout the villa. when the temple at Belur
was visited some pictures were taken. This temple is in active use
at the present time and is indeed a wonderful example of stone work
both inside and out.

Saturday, 7 March

Visited the field station at Sakleshpur and went cn to Puttur
for lunch and to visit the malaria unit. Left Puttur for Mercana in
Coorg where the night was spent. Regarding the malaria surveillance
work in the Coorg District, spraying was interrupted on 7 January 1957
after instructions of the Expert Committee composed of DKV, BA Rao,
and IM Puri. This Committee visited the Coorg District in June 1956,
The little report containing this information should be attached to
the diary notes as a very interesting documant. (This completes the
dictation from notes, now available on the trip to Asia, in 1959.)

Sunday, 8 March

Visited the Health Office at Mercara and went on to Gonikoppal.
After lunch drove to Mysore and on to Krish Raj Sagar and spent the
night .

Monday, 9 March
K. R. Sagar to Mysore and on to K. R. Magar and back to Mysore.

Tuesday, 10 March

Mysore to Coonoor, and spent the night.

Wednesday, li March

Coonoor to Mysore. Lunch at Mysore as the suest of the Indian
doctor from South Africa. itn route Mysore to Bangalore, visited Mandya
where there is a malaria investigation with a Malaria Training Center.
This was the original site of the Training Center set up by RBW some
years ago. Also stopped at a health center where there is a family
planning unit established before returning to the hotel in Bangalore.

Saturday, 1) March
To Delhi.

Sunday, 15 March
B. A. Rao.

16-21 March
Malaria

Sunday, 22 March

In Delhi; a rather hot Sunday at that. The day was spent in the
writing room of the Ashoka Hotel, trying to summarize the impressions
of the past few weeks for Dr. Bugher.

Monday, 23 March

Dinner at the home of, Prof. and Mrs. Dikshit with Dr. and Mrs.
Pandit, Dr. and Mrs. John Hume, Dr. and Mrs. Roy Allen, and Dr. and
Mrs. Lucien Varig.
Tuesday, 2: March

The first holiday of the Holi celebration, All day at the hotel
writing reports for the trip and finishing a letter to Dr. Bugher.
The Holi festival in India is one that is not universal but it is
very much celebrated in north India. It is characterized particularly
by the throwing of dyed, scented water on one's friends and the better
the friendship the deeper the dye and the more certainty of its delivery.

Wednesday, 25 March

Fly to Bombay with Mrs. Balfour and Don Johnson. At the Santa
Cruz airport, Bombay, we are met by Dr. T. Ramachandra Rao who reports
that H, Trapido is not sending his car which has had an accident but
has asked him to bring us all up the hill. A very interesting but hot
and tiring trip up the Ghat, arriving in Poona about the middle of the
afternoon. Go to the home of Dr. T for the night.

Dinner is late, awaiting the arrival of Dr. C. Pandit. Those at
dinner, besides the Sopers and the Trapidos, were Dr. Pandit, Dr. and
Mrs. Anderson, and Dr. Ruth Meyer.

The evening discussions were related to various subjects, with
special emphasis on the possibility of eradication of smallpox in
India. Dr. Pandit said that he has been made responsible for present~
ing a plan for national eradication. The plan he is submitting pro-~
vides, first, for pilot project in a number of states to get a basis
for estimating costs of the organization required, then for early
preparation of adequate stocks of vaccine and a budget sufficient to
vaccinate everyone in India in one year. (I had previously discussed
with Dr. Pandit the possibility of organizing smallpox eradication by
carefully doing the vaccination of about one-fifth of the population
for one year so the entire population would be covered within a period
of 5 years. I am willing to admit freely that Pandit's method is bet-
ter if the money can be gotten for putting on the type of organization
that can do the job in a single year.) I would prefer to see provision
made for a continuing recognition of the problem of smallpox for a period
of 10 years with an adequate budget for covering a fifth of the popula-
tion each year rather than attempt to get the funds with which to do
vaccination of everyone in a year. Pandit's plan calls for 12 million
dollars costs the first year.

During the course of this discussion with T. R. Rao today, I
learned that D. K. Viswanathan was impressed with tales of eradication
during the Tropical Diseases Congress in Washington in 198, and on
his return to India attempted the eradication of Anopheles culicifacies
in a considerable area without success.

 

Poona is a city of some 500,000 people, about 2,000 feet above sea
level, with only 29 or 30 inches of rain annually. The climate is hot
at this time of the year and the air conditioned bedroom at the Trapido
home was indeed a treat.
To the Medical Research Center where Harold Trapido showed the
crowded conditions under which everyone is working, and then gave me
the story of how the laboratory became busy with the KFD and Japanese
encephalitis B and West Nile viruses. Trapido said that just two
years ago, Dr. T. 2. Rao went down through the Shimoga area with the
malaria group, namely Martin Young, Jack Henderson, and Bruce-Chwatt
who were here looking into the malaria situation in India for ICA.

In Shimoga T. R. Rao was told by the local health authorities some-
thing about a disease of humans which was not malaria, and about a
disease which was killing monkeys. T. R. Rao told Trapido about the
information on March 23, Saturday, and on Monday Trapido and Dr. Worth
were on their way down to Mysore State. They arrived at Sagar on Tues-
day, saw their first sick monkeys on Wednesday, and by Monday night
had word from the Laboratory in Poona that mice were coming down with
some virus disease. The rest of the story is mostly in the published
reports, but suffice it to say that in less than three weeks the KFD
disease had been worked up much faster than is known to have occurred
in the case of any other disease.

Called at T. R. Rao's headquarters and find him indeed in very
crowded conditions. An attempt is being made to train men in micros-
copical work on a veranda and it is quite obvious that he has never
been properly installed following a fire which did some damage a few
years ago to the Malaria Headquarters. It is difficult to believe
that a malaria eradication program responsible for a population of
some 50,000,000 people can efficiently operate under the conditions at
the Poona Headquarters. T. R. Rao has no adequate assistant and is
unable to delegate authority for even the most minor financial trans-
actions.

March 27

We travelled last evening by train from Poona to Bombay and spent
the night at the airport hotel. This morning we took the early morning
plane to Aurangabad from Bombay.

Met by Dr. G. N. Joshi who took us to his home to meet his wife
and three boys. Mrs. Joshi and the elder son went with us this after-
noon to the Ellora Cave. Dr. T. R. Rao arrived during the day from
Poona by car, with Don Johnson, which resulted in contimed discussion
of malaria during the evening and during a considerable part of March 28,
We all spend the night at the Indian Airway Hotel.

March 28

Sixty-four miles drive to the Ajanti Cave and back to Aurangabad
where we take the five o'clock plane for Bombay. In Bombay we leave
Don Johnson and take the evening plane back to Delhi.

During the day T. R. Rao insisted on repeating the entire story of
what happened in Kanara where he believed the anthropophilic A. fluviatilis
was exterminated, leaving only a zoophilic strain. Dr. Rao agrees that
eradication is possible and says that it will be gotten although he
recognizes fully the difficulties of administering a service as large
as his without a man to help at the top.

During the day T.R. gives some details of a serious outbreak of
malaria in his State last year, which he attributed to the development
of resistance to dieldrin on the part of the vector. TR estimates that
65 per cent of some 125,000 people were ill. (This forms quite a
reservoir of infection which will again require some three years to
disappear, under best conditions. )

March 29

To Jaipur and Amber by plane. Visit the ruins at the Rhambad
Palace Hotel after lunch, where we join the Humes and the Troi Johnsons.
(Much of the day spent with George Kindred of Scarsdale, New York, with
whom we shared expenses.)

March 30

Learned that the trip to Nepal cannot be made through failure to
get plane reservations. Dr. and Mrs. Leroy Allen had dinner with us
at the Ashoka,

March 31

Learned at last that the secretary whose services were made avail-
able to me by the Rockefeller Foundation office here is of no value
whatever. More time is taken in correcting his mistakes and in reading
his own shorthand than it would have taken me to do the work myself.

April 5. To Kashmiri.
April 6. To Delhi.
April 7. To Benares.

April 8. To Calcutta.

April 9. To Bangkok.

Arrived at Hotel Erawan about 0215 after a very long day, beginning
with a 0600 start from Clark Hotel in Benares to see the famed and famous
River Ganges; its early morning bathers, its begging pilgrims, its pro-
fessional vagrants, its cremation, its one dead animal carcass--probably
a cow with a vulture and crow busily riding downstream, and the fantastic
buildings along the River which has a difference of water level of many
meters from one season of the year to another. The flight from Benares
to Calcutta was by India Airlines Corporation; the trip from Calcutta to
Bangkok was by Pan American Airways.
On arrival at Bangkok the inspector of the immigration at the air-
port asked for three photographs of FLS and another three of JSS. (He
seemed surprised when I asked him when he wanted the photographs. On
his reply that he wanted them now, I asked him where his photographer
was and assured him that I am trying to comply with any and all require-
ments of his government by visiting the Embassy in Delhi, where I had
been informed that with the passports JSS and I hold there would be no
requirement whatever. The answer to this was that I was given 15 days
to get out of the country. )

At the Erawan Hotel we find a partially air-conditioned room which
is mich better than the outside temperature, even at three o'clock in
the morning. And so to bed and later finishing breakfast at 10 a.m.

Melvin &. Griffith sends a car for me; fortunately, the USOM is
now in air-conditioned buildings and the hour spent with Griffith,
Dr. Charles Richards, Dr. Harold Brown, and Dr. Joseph M. Butler, Jdr.,
was pleasant in spite of the outside heat, which was quite noticeable
during the lunch hour since the USOM lunch room is not air-conditioned.

Dr. Richards has been out only 13 months and is now recovering
from an attack of infectious hepatitis. Hichard is not married, is
from the University of Nebraska, and is involved in the long continued
efforts of the USOM to get a medical school started in Chiengmai in the
northern part of the country.

R. is convinced that two years is only too short a period for over-
seas staff to be posted in a country.

Dr. Harold Brown of the Veterans Bureau is finishing a tour of two
years and returns to the United States next week. HB says he has had a
great experience here, the family has liked it, and everything is nice
except for two things: (1) the period is too short to follow programs
through to a conclusion, (2) he is sure that both he and his family will
have some problem of adjustment to life in the United States,

With Dr. Griffith visit Dr. Utai, now the Director of the Malaria
Service. Utai says the continuation of transmission in part of Thailand
has been due to the failure to follow up in the rest of Thailand with
the techniques and with the same relative number of men as was used by
the WHO Demonstration Team in 1949. In the Demonstration Area, sixty
men were used for a population of 60,000, but in the country program
the work had been done with five men for 100,000 population. Unfortu-
nately, the difficulties of the service are coming after most of the
malaria has disappeared, and at the low tide of human interest.

I raised the question of the function of surveillance. Should it
be the means of finding cases to treat as the final step of the eradi-
cation program, or should it be a tool for getting information as to
where control measures have been poorly used?

Dr, Utai says Thailand today is a problem of the people in the
forest.
Dr. Utai says the Rockefeller Foundation could be of great value
if it would come in and help prove that diseases other than malaria
are important as causes of febrile illmess and death. Thailand needs
help in the study of virus diseases, not only for their own sakes
but to get them out of the malaria statistics.

Utai says governments are not working together on anything but
the easy Mekong Valley parts of the program. Wherever it is difficult
other countries are not following through.

Opposition comes in some areas to the anti-malaria work from the
lecal quacks and others who derive their living from fever cases and
who do not want to lose their income,

In discussing places with similar treatment but different results,
MEG mentions a place called Phra Buddha Phat, where the same type of
work was done as in Hang Dong and Sarapee but where results were not
so satisfactory and so conclusive.

During the talks with MEG I learned that the picture of progress
with the control of malaria here has been the picture of communicable
disease control rather than the curve of eradication. The eradication
curve is one of geometrical regression and does not flatten out inter-
minably. MEG says that everything seemed to go very well during the
first five years of operation; the sixth year's results showed no
improvement over the fifth year's, and the seventh year's results were
no better than the sixth year's results.

I point out that the speed of eradication is surprisingly fast
when eradication is really occurring and suggest that Drs. Utai and
Griffith should study the results of the best programs in Thailand
and take these as the standard for the norm of eradication. Utai and
MEG agree that the best results were in Chiengmai but especially in
the district of Sarapee and Hang Dong. A study from the results from
Sarapee and Hang Dong shows that the second year after the program
started, that is, during the third year, very little malaria occurred.
This means that after two years of spraying practically no malaria
should be found and none at all after three years under ideal Thailand
conditions! Whenever malaria fails to disappear the malaria cases
should be thoroughly investigated and the reason for the failure ascer-
tained and action taken to correct the cause of failure. I insist that
the curve of eradication is always downwards. Geometrical regression
can and should be just as steep downwards as the curve of geometrical
progression.

April 10

Call on Under-Secretary Dr. T. Bin and the Director of Health,
Dr. Kandthorn; also visited the office of Dr. Fitzmaurice before
calling on Dr. Ayerkwait, retired Director of the Malaria Services,
who makes arrangements for us to go to the country tomorrow.

lunch at a Chinese restaurant as guest of Dr. Stengh, the head
of the new School of Medicine, who gives the party to eight people
for Dr. Harold Brown. Those present include Dr. Griffiths, Dr.
Richards, the Professor of Biology and the Professor of Chemistry
in the new School (too much food for all but very good).

Meet Engs. Wood (tall boy from Texas) and Robertson who used
to be at Massachusetts and is now finishing his first two years in
Thailand and expects to come back for another tour.

Late afternoon "tea" with Miss Virginia Arnold of the Rockefeller
Foundation and Mrs. Hassenpflug, the Director of the Nursing School of
UCLA who is traveling at RF expense and who has her husband, a real
estate operator in Los Angeles, with her. Mrs. H. tells a delightful
story of their going to a Japanese Inn in Kyoto some weeks ago, when
it was supposed to be closed, and of having first one hot water bottle
for two beds and then the next night two hot water bottles for one bed.

In the evening with Dr. Kandthorn, the DG for Health, to the out-
door reception given by the Medical Association for the recent graduated
doctors who received their diplomas. It is a shock to hear "Hail, Hail,
the Gang's All Here" immediately after the National Anthem and just
after the toast to the King and Queen. (We get a chance to meet a
number of professors and others of interest, and a Miss Anderson from
So. Africa who used to work for WHO in Africa on nutrition, is now
here on loan from WHO to FAO. Miss Anderson says that in Thailand
they remove the vitamins from the rice, and then enrich it umer govern-
ment subsidy; Thailand is one of the best fed countries in Asia, since
it is a food exporting country.)

We do not partake of the dinner for the recent graduates but are
taken by Dr. K. to the Golden Dragon where. we have a very excellent
Chinese dinner in company with Dr. Young, a nutritionist, and another
colleague who was quite voluble during the early part of the evening
but eventually passed out at the table.

April 11

Drs. Melvin &, Griffith and Ayurakit, who has been working on
malaria for many years, came for us at 0725 for a drive to Phrabuddhaphat
where one of the malaria training stations is located, the other being
at Chiengmai in the north. The road is relatively good but the drive
still takes almost three hours from Bangkok.

As one drives through the country outside Bangkok one is reminded
of Guayaquil and the lowlands of Ecuador by the type of houses built
up on piles, and of the Netherlands by the absolute flat nature of the
land which is so like the polders from which the seawater has been pumped.

We are told that there is evidence of the rising of the land where
Bangkok is now located during the past few thousands of years.

Arrived at the Malaria Training Center which is also the Center for
Malaria Operations in this area; Dr. Ayurakit brings out his reports for
LO

the surveillance work which is the only work now being carried out in
this area.

The report form is a very simple one, providing for a complete
census by family groups or by groups of persons living in the same
house. Names of each individual are written out and the indication
of sex is by name only. Actual ages of each individual are given,
together with an indication of history of fever during the previous
seven days or even for a longer period. When such history of fever
is present a slide is taken, and drugs given, and duly registered in
this form. The final diagnosis, when positive, is also entered.

Among the first 1 slides taken, on the record which by chance I
see, l: positives were found of which one was falciparum infection.

The positive had occurred in slides taken on the 2nd or 3rd of
March, and had been examined almost immediately, that is, within one
or two days, but no further information was available regarding this
slide nor regarding the people from whom they had come.

On checking up on actual use of the forms, it is found that the
census form is the only record available; the field operator prepares
this form and submits it to the laboratory, together with slides of
fever cases found. The laboratory makes its examination and enters
on the census form the results of each positive slide and sometimes
enters, and sometimes not, the negative results. There is no indica~
tion of the date of the examination of the slide nor who made it.
Also, there is no record of the laboratory number of the slide itself.

When I expressed surprise that no follow-up field investi gation
has been made on the positives found, MEG explains that there is no
provision for any further investigation because of a lack of men and
money; that the present study which is designed to visit each house
every season (that is three times a year) is really for survey purposes
only, and that only in 1961 will there be any follow-up if present plans
go through!! (In other words, all the work done this year and next is
for the purpose of finding out where cases are occurring, without
attempting to determine whether the cases have been found of local
origin or have been imported!! When I began to put on pressure regard-
ing the use of the census forms, Dr. G. asks Dr. A. about the use of the
new card form which has been adopted and is to serve for presentation
of material for the big IBM analysis of the surveillance data.
1l

April ll, Thailand

Notations of material for the big IBM analysis of the surveil-
lance survey MEG is planning and which he told me about at his office:

Ayurakit indicates that they are beginning to use the card and
are taking off the data from the census forms and entering on the cards
as fast as possible,

MEG explains to A. that this is not what was intended but thet the
card has been designed as the only record to be kept. Dr. A. explains
that this is not possible since the men in the field are not able to
remember all of the data from individual houses in order to fill out
the card which is essentially a summary form itself. (A. reports almost
word for word a criticism I made of the card when I saw it in the office
yesterday.)

I take time to discuss the matter of forms for the present opera-
tion and call attention to the necessity of deciding, before preparing
forms, first, what is the unit of interest in the study, and, second,
what are the items of interest regarding that unit.

Once a unit has been determined, all data regarding that unit
should be placed on a single horizontal line with different units fol-
lowing each other, line by line. Hach item of interest is given a
certain position in the horizontal line in such a way that summation
may be made rapidly by vertical addition.

With regard to the actual problem, I suggest that the unit of
interest is the house, as the place where transmission occurs and is
the unit of spraying. The house also is fixed geographically and can
always be found. So, in the present study, although individuals are
being studied, we are interested in the individual only as one of a
family group living in a certain house. Therefore, a single line should
be given to each house (which should be identified by some number) and
by the name of the head of the household. The number of persons in the
family group, as well as the ages of persons in this group, can be regis-
tered by setting up a classification called ages-by-groups (MEG suggests
groups O-1, 1 to 2, 2 tol, 5 to 9, 10 to 14, and 15 and over. I propose
a separate space for each age group and a space for the total number of
people registered. This makes it possible to get data for summaries
without the laborious procedure of working over reports in which all
ages are listed together. The forms should have then the other items
which are given in the present census form regarding fever and any treat-
ment given.)

Once an individual is found to have had or to have fever, he becomes
a unit of special interest and merits further listing which for convenience
and for copying data together may well be made on the back of the census
forms itself.

The forms for registering these persons who have had fever and who
may be of special interest later should be done in such a way as to
12

reflect this possible future interest; that is, certain basic
epidemiologic data should be collected at the time the slide is
prepared regarding the time of residence in the place where fever has
occurred and the indication of the place from which the individual
has come.

There will be then on the form prepared in the field all of the
information required for the summary cards now being proposed as well
as some additional information of value when positives are found.

I insist once more with MEG that basic data must be registered
at the time by the field worker and that all summaries must be from
written records. The original record must not be itself a summary.

MEG has been here for seven years and is asking to be sent back after
his next leave. (This leave is due in the fall but MEG has asked for
a delay in order, I suspect, to be here while WHO is making its survey
of conditions. )

On one of the reports I saw three or four positives had been found
in the same family but no attempt was made to find out anything about
whether this family came from outside the district where the infections
were reported or not. MEG is placidly spending money and time to get a
survey of how mich malaria is occurring in the country with no provision
being made for doing anything about the malaria found nor for finding
cut whether the malaria found is local or imported,

After the foregoing discussion, we go to the field for a couple of
hours in the area where malaria has not been found to be transmitted
for some years and from large parts of which Anopheles minimus has appa-
rently disappeared. We get as far as the dam where there is very little
water because of the failure of the rain during the past two years.
(Near the dam I take some pictures of a long dragon and some of the
hills in the distance.)

This area is in the beginning of the foothills and is an area in
which before the control of malaria it was impossible for the people to
live and work. (Last year this previously heavily malarious area is
reported to have exported 35,000,000 bahts of agricultural products.

. In any case there are now 10,000 families living in the area.)

After lunch we visit the footprint of Buddha and a small and not
too clean cave with a large, fat, smiling Buddha.

And so back to Bangkok where we attend a dinner given by the teach-
ing staff with whom he has been working for Dr. and Mrs. Harold Brown of
Utah, who are returning to Salt Lake City next week after two years here.

In glancing over the paper "Malaria Eradication in Thailand" one
comes across some words of high significance in relation to the criticism
I have placed in today's notes: "The ICA assisted projects aims towards
developing and implementing the anti-malaria campaign and reducing malaria
13

to a point from which eradication is assured! (The exclamation point
is mine! FLS). It is expected that the project can phase out in 1962
with malaria largely eliminated and a continuing program established

on the regular Thai Government budget to complete eradication by 1965."
(But eradication curve does not flattens; if ICA and Government together
cannot get eradication in 11 years, how expect the Government alone to
do so in three more years???)

Further notes on this paper:

l. Statement is made that surveillance is bi-monthly whereas
MEG says that it is three times a year.

2. Surveillance may be instituted after one, two, or three spray-
ings but is always used after fourth spraying with additional spraying
limited to proven foci of transmission.

3. Program includes large-scale program in malaria treatment with
drugs distributed through hospitals, health centers, and field units to
treat over five million cases (but fails to indicate whether these five
million cases represent the entire program since 1951 or is current
annual treatment).

lh. Learn that Thailand is member of anti-malaria Coordination
Board representing six countries including also Burma, Cambodia, Laos,
Malaya, and Vietnam. (This Board may be useful but it has not been
sufficient to get Malaya off the ground and even thinking of anything
more than a pilot project of 50,000 people and that far from the
Thailand border.)

» 5. In Thailand spraying is substituted by surveillance "when the
annual technical surveys show reduction of the malaria problem below a
critical level." (I presume this critical level may be in essence the
same as the threshold concept in the eradication of yellow fever years
ago when it was noted that yellow fever did not continue in a city

after the A. aegypti index had been down to 5 per cent or below.)

One cannot but be disappointed in reading that the "malaria death
rate in 1957 was thus only 18 per cent of the rate during the five years
preceding 1950 when spraying began...the spraying campaign began in
areas of less than 100,000 population and did not reach all malarious
areas until 1957...the above results were achieved with 57 per cent of
the campaign completed." The annual number of deaths from malaria
beginning with 1950 has been 35,819, 34,225, 29,115, 21,51, 16,173,
1,520, 13076, and 10,577 for 1957. This drop is by lysis rather than
by crisis, and this reduction may be due in part to drug distribution
rather than actual control of malaria. The percentage declines year
by year have been from 1950 to 1951, .53 to 1952, 11.9; to 1953, 26.3;
to, 1954, 23.23 to 1955, 11.9; to 1956, 10.0; to 1957, 10.9.

The following costs are reported: 1951 to 1958 7,351,000 dollars;
1959 to 1962 3,464,000 dollars; 1963 to 1965 750,000 dollars; total
11,565,000 dollars. Of this amount the Government will have contributed
1

2,938,000 dollars; counterpart funds, 3,733,000 dollars; and the USA/
ICA 1,894,000 dollars; all of the costs after 1962 are for the account
of the Thai Government!

The following statement is sc extraordinary that it merits full
presentation in these notes: "The above plan will accomplish through
three steps to the end point of eradication: 1. a house spraying
campaign reaching the homes of over 12,000,000 people in-the major
malarious areas, averaging three to four annual spraying of each home
to destroy malaria-carrying mosquitoes and stop malaria transmission;
2. a surveillance program reaching the homes of the same people in
the same areas at bi-monthly intervals, for three years, following the
house-spraying campaign, to search out and treat the remaining malaria
ecases3; 3. a reconnaissance program in minor malarious areas (all areas
in Thailand other than major malarious areas) reaching houses of an
additional 12,000,000 people at bi-monthly intervals for one year to
search out and eliminate any hidden foci of malaria transmission."

In looking over the report on birth and death in Hang Dong and
Sarapee districts of Chiengmai received from Dr. Utai it is seen that
in so far as deaths are concerned, the behavior was according to plans:
work started in Hang Dong in 1950 with 232 deaths from malaria, three
years later, in 1953, none were reported. In Sarapee district the
death dropped from 213 in 1950 to 7 in 1953 and 3 in 195h after which
there were none.

A conclusion from the past two-month trip might well be that we
had not underestimated the difficulties of eradication, but that we
had underestimated the difficulty of selling the true concept of eradi-
cation and of getting administrative orientation to carry it out.

April 12
Late afternoon tea at hotel downtcwn on River Bank,
April 13

Call at the USOM and have final talk with MEG on malaria. Griffith
reports that he has difficulties which cannot be put in the reports;
that the present Director General of Health cannot understand why malaria
should not be part of the general health service in each commnity; that
the Civil Service of the country requires that everyone working at a
supervisory level in the malaria service should have at least two years
of special preparation (that means that the "Guarda-Chefe" in charge of
four inspectors has to have two years training as a malariologist before
appointment. I point out that this tends to negate the very basis of
eradication which is that relatively undertrained personnel can carry
out the technical procedures required for eradication after very short
periods of training; there is no need for the man who is supervising
spraying to know how to examine blood slides, and so forth.); that in
the Malaria Coordinated Board which represents six countries, representa-
tives of some countries come with instructions to give a picture of the
15

situation in their countries different from what actually exists;
that all introduction of new forms and new ideas encounter
resistance, etc. etc.

MEG says he feels that there is a definite need for some outside
agency to make an overall survey of what is happening to malaria eradi-
cation with a presentation of the report in such a way as to make it
apparent that the countries are in all this together and that a war
against the malaria parasite cannot be won unless it is carried out
as a war should be with some central control. MiG has suggested to
ICA the appointment of a Regional Malaria Adviser for South Hast Asia
since this area represents a number of countries which have common
problems which require simultaneous solution.

MEG reports that Dr. Ayerkwait told him some years ago that pre-
viously--that is before 1951--there were many more monkeys at a monkey
temple than at that time, and that the reduction in the number of
animals had been due to a disease which had killed large numbers of
the primates. I called attention to the importance of monkey deaths
as an index of what may be happening in the human population, and sug-
gest communication with laboratories should he ever get further stories
of monkey mortality, which may come through the malaria surveillance
service,

Learned that Miss Jones, who lives near Ellicott City, Maryland,
is the Assistant to Sam Keeny in the UNICEF Repional Office in Bangkok.