The Long Struggle Against Malaria in Tropical Africa by James L. A. Webb, Jr. (review)

There is a new enthusiasm for the eradication of malaria, initiated by Bill and Melinda Gates at a Malaria Forum held in Seattle in October 2007, and the Bill and Melinda Gates Foundation now directs a substantial proportion of its resources for malaria research and control toward achieving this objective. It is hard to argue against the notion that getting rid of all human malaria parasites (eradication) must be the ultimate goal for malaria control for otherwise the parasite will almost inevitably bounce back with devastating consequences. However, it is salutatory to be reminded from time to time how difficult it will be to achieve eradication. Frank Snowden has documented the challenges faced in achieving elimination of malaria in Italy,¹ a program of sustained effort that took over fifty years. In this new book, James L. A. Webb, Jr., describes how parallel efforts undertaken in tropical Africa have yet to achieve similar success.

The first two chapters of this book discuss the little that is known about malaria in tropical Africa before the arrival of the Europeans and the devastating effects of the infection on the latter, especially on the coast of West Africa, “the white man’s grave.” Although some of the early European travellers took quinine, it was not until Ronald Ross’s discovery of the mode of transmission of malaria in 1897 that better targeted control programs could be attempted. Ross visited Freetown in 1899 and initiated a program of mosquito control that was temporarily successful but, like many subsequent programs, it was not sustained. In chapter 3, Webb describes the many malaria control programs that were undertaken in tropical Africa from the time of Ross’s visit up to the start of the first malaria eradication campaign in 1955. Many of these, which used chemoprevention and/or mosquito control, were at least partially successful, but a key message that emerges from the history of this period is the lack of continuity in effort; temporary success was often achieved but almost invariable followed by declining interest and a return to the status quo or even worse.

It was recognized from early on that a successful malaria control program in children, which saved many young lives, might impair the immunity that they acquired as a result of by repeated infections, rendering them susceptible to severe disease in later life if a control program was wound up, as was so often the case. The risk of achieving protection in early childhood at the cost of increasing susceptibility to severe disease in later life, sometimes termed “rebound malaria,” was hotly debated at a famous malaria conference held in Kampala, Uganda, in 1950, and it is an issue that is still very relevant today as vaccines and other effective interventions are developed. The story of why the first malaria eradication failed has been well told previously,² and, sensibly, Webb does not go over this ground again in any detail.

The second half of the book deals with the years of neglect of malaria from the end of the eradication programme in 1969 until a re-awakening of interest in the infection around 1997. I would like to have learnt more about the author’s thoughts on why malaria was so neglected during this period and what was responsible for the resurgence of interest around 1997 after a 30-year gap. Chapter 6 deals, rather briefly, with some of the recent encouraging developments in malaria control, including success in developing new drugs, insecticides, and vaccines, tools that are needed urgently in the face of increasing threats from drug and insecticide resistance. An area that could have been given more attention is that of funding for malaria control and how and why this has varied so much over time. Recent success in malaria control in Africa has been achieved largely through an increase in funding, allowing scaling up of tools...