Salta/Jujuy, 20 May 2019 (PAHO)—“Has the boy ever had chucho?” asked Felipe Sanchez, a health worked in Salvador Mazza, Salta, to a boy’s mother who lay sick in her arms one day in 1987. “Chucho” is still a popular name for malaria even today.
The boy’s mother told Sanchez that she had taken her son to several hospitals, but that the fever had persisted. Even though he had only been working as a health worker for a short time, Sanchez recognized the symptoms. The local outbreak of malaria that year had “been impressive,” he recalled. The child tested positive and the health worker provided the medicine necessary to begin treatment. “The mother remained grateful all her life,” said Sanchez, almost 30 years later from a hospital room in Salvador Mazza.
Jobs like Sanchez’s, in the community, were the ones that enabled Argentina to receive its malaria free country certification from the World Health Organization (WHO) this week, becoming the second country in the Region of the Americas to receive this certification in the last 45 years.
Following decades of hard work reducing cases of this disease, in 1970, Argentina began its own journey towards malaria elimination, directing its efforts to the north of the country (Salta, Jujuy and Misiones) where the disease burden had always been greater.
Keys to the country’s success included high-coverage of indoor residual spraying, microscopic diagnosis, initiating case studies in order to find out where infections were in-progress, treatment of cases, active malaria surveillance, and collaboration between border countries.
Between 2000 and 2011, Argentina worked with Bolivia on its side of the border to spray more than 22,000 homes with insecticides, and to diagnose and treat cases. During this period, the number of indigenous cases of malaria in Argentina dropped from 440 to zero. Argentina recorded its last indigenous case in 2010, but the journey towards elimination had begun much earlier.
Paterson, a pioneer
Carlos Miguel Ripoll, physician and Health Director of Jujuy, says that it was “thanks to malaria” that he was born in Argentina. His maternal grandfather had brought his brother, who was very sick with malaria, from Spain, “but he died before they arrived and my grandfather stayed in Jujuy,” he explained, while walking through a ward of the “Dr. Guillermo Paterson” hospital in San Pedro, Jujuy.
Paterson was Scottish and the first in Argentina to identify the parasite that causes malaria at the beginning of the 20th Century. He discovered it using a microscope illuminated only by an oil burner and carried out much of his research at La Esperanza sugar mill, where Ripoll’s great-uncle worked.
In Argentina, malaria presented in two different ways. In the northwestern area it was an endemic disease caused by the Anopheles mosquito, which was present during the hottest, rainiest months. This is a mosquito that requires a shallow, well-aerated stream of water, as well as the sun, to provide a green algae upon which its larva feed.
In the northeastern part of the country, however, the malaria outbreak occurred when mosquitos arrived after river flooding in Paraguay and Brazil. This led to the development of estuaries, which provided the insect with the ideal environment to reproduce. “This remained until 1931 when Dr. Carlos Alberto Alvarado, was put in charge of malaria control,” recalled Carlos.
Alvarado and the primary care model
Ripoll is a student of Alvarado, who developed the Policy Spotlight Plan, which focused on building infrastructure to ensure better flows of water in order to prevent the growth of mosquito larvae.
“A circle was drawn in a target area and the temperature, humidity and flight range of the female Anopheles, which transmits malaria, and can fly more than a kilometer, was determined,” said Ripoll. A circle was then made in the target perimeter, another a kilometer from there, and a third a kilometer from the previous one. “When that inner zone was clear, the focus progressed to the next circle. Over the course of two or three years, there was around a 60% decrease in cases, without having to apply insecticides,” added the doctor.
After the Second World War, Argentina began using Dichloro Diphenyl Trichloroethane (DDT), also managed by Alvarado. Its use led to a reduction in the time taken to reduce cases from the five years initially planned by authorities, to just two. Malaria was “practically enclosed in just a few small zones.” The last cases in Jujuy were seen in 2005,” explained Ripoll.
In 1966, following his retirement from WHO where he was global head of malaria, Alvarado returned to Jujuy where, as Minister of Health, he presented the Rural Health Plan, which created the role of health worker. This would be someone who lived in the community, of the same color, ethnicity and culture of the population in which they worked. The health worker would also be responsible for diffusing health prevention and promotion messages and should have a good pair of legs to walk on and a big heart to do good with.
The key role of the health worker
The health worker was responsible for ensuring that public health services reached the most remote and vulnerable populations. They were responsible for ensuring daily contact with local populations and for finding out if they had recently been ill. They also took blood samples and analyzed them in the same place. If a case of malaria was suspected, they reported it to the hospital and to the brigades, which quickly sprayed the house.
Between September and March each year, initiatives were carried out to monitor the disease in the northwest and northeast of Argentina. “This was exhausting due to the intense heat, humidity and rain,” said Mario Zaidenberg, Head of the National Malaria Program for 24 years, until his retirement in 2017.
Zaidenberg was one of the pioneers of the ArBol plan, put into effect in 1996 by the governments of Argentina and Bolivia to tackle malaria in the face of an increase in cases.
The legacy of the brigades
Horacio Rodriguez, head of the National Vector Control Base in Salta believes that due to the conditions in which operations were carried out, divine intervention probably played its part. “When there was nowhere to sleep, we slept outside. There were areas that we couldn’t reach by van so we went on horseback or mule. We walked on the edge of precipices, with our feet absolutely soaked,” he said.
The work of the brigades seems to pass from generation to generation. In the city of Oran, Antonio Rodriguez is proud that his son, Cristian Andres, has joined the fumigator brigade. “When I was a child, I watched my father leave home for days or months. Then I slowly began to understand what his work was about,” said the young man.
Once the elimination certificate has been achieved, Zaidenberg states that the challenge will be to ensure that training professionals in the detection of the disease is maintained. “It gives me great joy to get to this stage. It would not have been possible without the commitment of all those people living in hidden places, who were responsible for detecting patients with malaria,” he concluded.