WEBVTT

00:01.660 --> 00:06.120
Prof: What I want to do
this morning is first of all

00:06.115 --> 00:10.645
begin by recapitulating a couple
of points that we made last

00:10.648 --> 00:11.338
time.

00:11.340 --> 00:17.270
You'll recognize our friend
here, having her blood feast,

00:17.270 --> 00:21.840
and last time we talked about
the importance of malaria in

00:21.836 --> 00:26.406
human history for a little bit,
from ancient times to the

00:26.413 --> 00:30.583
contemporary world,
and we tried to suggest that

00:30.580 --> 00:35.520
malaria continues to impose an
extraordinary burden of

00:35.522 --> 00:40.782
suffering and death,
along with those consequences

00:40.780 --> 00:44.530
that follow in its train:
poverty,

00:44.530 --> 00:49.090
low productivity,
illiteracy, a low level of

00:49.091 --> 00:52.981
political,
social and education

00:52.978 --> 00:54.858
participation.

00:54.860 --> 00:57.490
We also talked,
as you'll remember,

00:57.494 --> 01:01.684
about the transmission of the
disease, with the complex

01:01.677 --> 01:06.247
lifecycle of plasmodia and
Anopheles mosquitoes.

01:06.250 --> 01:11.120
We talked about the effect of
the disease on the human body of

01:11.123 --> 01:15.363
the patient and symptoms that
result from malaria,

01:15.360 --> 01:20.150
and we tried to deal also with
the great years of discovery at

01:20.153 --> 01:24.103
the end of the 1890s,
between 1898 and 1901,

01:24.099 --> 01:28.969
when the great mysteries of
this disease were largely

01:28.965 --> 01:32.425
unraveled in two different
places.

01:32.430 --> 01:35.800
First in India,
with the collaboration of

01:35.797 --> 01:40.957
Ronald Ross and Patrick Manson,
they demonstrated the mosquito

01:40.961 --> 01:45.181
transmission of malaria with
regard to avian malaria--

01:45.180 --> 01:47.560
that is, among birds.

01:47.560 --> 01:52.440
And then the other place,
even more importantly,

01:52.440 --> 01:56.240
was Italy, where Giovanni
Battista Grassi and other

01:56.239 --> 02:00.189
scientists of what was called
the Italian School,

02:00.188 --> 02:04.578
or the Rome School,
proved the mosquito theory of

02:04.575 --> 02:07.495
transmission for human beings.

02:07.500 --> 02:12.680
I hope that in that discussion,
it was apparent to all of you

02:12.675 --> 02:18.105
that malaria is by far the most
complex of all the diseases that

02:18.110 --> 02:23.510
we've studied,
or will study, in our course.

02:23.508 --> 02:28.618
And that point is important and
underlies the fact that we spent

02:28.616 --> 02:33.476
a lot of time talking about the
complexity of the disease.

02:33.479 --> 02:37.919
It's important because it helps
us to understand a great deal of

02:37.922 --> 02:38.912
the history.

02:38.910 --> 02:43.720
One point is that if we
understand that,

02:43.720 --> 02:48.570
we're in a position to
understand also why research on

02:48.571 --> 02:54.061
malaria generated such intense
intellectual excitement in the

02:54.063 --> 02:54.983
1890s.

02:54.979 --> 02:59.769
It was then that malariology
because the centerpiece for the

02:59.772 --> 03:03.512
new medical discipline of
tropical medicine.

03:03.508 --> 03:08.828
Here was one of the world's
oldest and most important public

03:08.829 --> 03:12.799
health problems,
and suddenly it was yielding

03:12.796 --> 03:14.236
its secrets.

03:14.240 --> 03:18.810
There was a tremendous
excitement intellectually,

03:18.805 --> 03:23.745
and malariology attracted some
of the world's leading

03:23.750 --> 03:27.840
scientists and public health
officials.

03:27.840 --> 03:33.100
We also wanted to talk about
the complexity of malaria,

03:33.098 --> 03:38.558
because a second reason is that
it helps us to understand why

03:38.563 --> 03:43.483
the public health strategies
that we've examined so far

03:43.483 --> 03:47.403
haven't worked in dealing with
malaria.

03:47.400 --> 03:49.390
If we think,
for example,

03:49.389 --> 03:54.529
what are the main public health
strategies that we've discussed

03:54.532 --> 03:57.522
so far--one was plague measures.

03:57.520 --> 04:02.040
You know the drill by now:
sanitary cordons,

04:02.040 --> 04:04.670
quarantines,
isolation.

04:04.669 --> 04:08.289
These, however,
prove to be powerless against a

04:08.294 --> 04:12.794
disease that's borne by vectors
as efficient and mobile as

04:12.787 --> 04:15.307
Anopheles mosquitoes.

04:15.310 --> 04:20.770
In high malarial endemicity
areas, mosquitoes are infinitely

04:20.766 --> 04:23.816
numerous and infinitely mobile.

04:23.819 --> 04:27.559
Plague measures would be no
help at all.

04:27.560 --> 04:32.450
We can understand also why
another form of public health

04:32.446 --> 04:33.686
was useless.

04:33.690 --> 04:36.820
The sanitary movement was
irrelevant.

04:36.819 --> 04:39.769
Malaria is not like cholera.

04:39.769 --> 04:46.049
It's not a disease of filth or
the bacteria that thrive in it.

04:46.050 --> 04:50.850
Places that are immaculately
clean can be lethally infested

04:50.848 --> 04:55.068
with mosquitoes and the
plasmodia that they bear.

04:55.069 --> 04:58.789
Furthermore,
malaria is a disease of rural

04:58.788 --> 05:02.418
areas, primarily,
and urban cleanups were

05:02.415 --> 05:06.855
therefore largely irrelevant in
combating it.

05:06.860 --> 05:11.770
So, a second strategy of public
health that we've confronted so

05:11.769 --> 05:15.649
far was powerless in dealing
with this disease.

05:15.649 --> 05:20.239
Another public health strategy
that we've examined was the

05:20.242 --> 05:24.492
strategy of vaccination,
and we've seen that pioneered

05:24.492 --> 05:28.322
by Edward Jenner,
and developed much more by

05:28.315 --> 05:29.735
Louis Pasteur.

05:29.740 --> 05:34.420
And this too,
thus far, has proved unavailing

05:34.420 --> 05:37.080
with regard to malaria.

05:37.079 --> 05:40.979
Let's think for a moment about
vaccines,

05:40.980 --> 05:44.620
and I'd like to argue that
they're effective primarily

05:44.624 --> 05:49.014
under certain conditions,
that they aren't universal

05:49.007 --> 05:51.557
panaceas for all diseases.

05:51.560 --> 05:55.200
They're helpful primarily,
first of all,

05:55.197 --> 06:00.887
in combating diseases against
which the body develops a robust

06:00.887 --> 06:02.937
acquired immunity.

06:02.939 --> 06:06.839
Smallpox is a perfect example.

06:06.838 --> 06:11.728
A patient who has once suffered
from smallpox,

06:11.733 --> 06:16.953
but then recovers,
is then immune for the rest of

06:16.954 --> 06:19.134
his or her life.

06:19.129 --> 06:24.289
And, so, the strategy for
vaccination is to produce

06:24.293 --> 06:29.973
artificially the same effective
immune response that was

06:29.973 --> 06:35.243
generated by the naturally
occurring infection.

06:35.240 --> 06:40.350
The strategy then is to
reproduce what nature does on

06:40.346 --> 06:41.326
her own.

06:41.329 --> 06:46.499
But in malaria,
the immune response of the body

06:46.497 --> 06:50.197
is limited,
and it takes multiple

06:50.202 --> 06:55.692
infections and recovery there
from to acquire a partial

06:55.689 --> 06:59.479
immunity,
and that immunity even then is

06:59.478 --> 07:00.548
short-lived.

07:00.550 --> 07:02.470
It's partial and short-lived.

07:02.470 --> 07:07.660
If you have painfully acquired
an immunity from malaria and

07:07.661 --> 07:11.691
then you move away from the
malarial area,

07:11.689 --> 07:17.409
in a couple of years your
immunity fades away,

07:17.410 --> 07:21.900
and if you return to the
malaria area you're susceptible

07:21.901 --> 07:23.291
all over again.

07:23.290 --> 07:28.720
So, this is one factor that
makes vaccine development so

07:28.723 --> 07:30.603
very complicated.

07:30.600 --> 07:36.430
Another point about vaccine
development is that vaccines

07:36.434 --> 07:42.164
haven't so far been developed
against a pathogen with a

07:42.161 --> 07:47.361
lifecycle as complex as that of
a plasmodium.

07:47.360 --> 07:53.430
In targeting a virus or
bacterium, a vaccine is always

07:53.425 --> 07:59.715
dealing quite simply with the
virus or the bacterium.

07:59.720 --> 08:03.430
But the point about studying
about--one of the points about

08:03.427 --> 08:07.257
investigating the lifecycle of
the plasmodium is that they're

08:07.264 --> 08:08.164
different.

08:08.160 --> 08:13.520
They go through a series of
complicated life stages.

08:13.519 --> 08:16.749
Sometimes they're sporozoites.

08:16.750 --> 08:19.000
Sometimes they're merozoites.

08:19.000 --> 08:22.180
Sometimes they're gametocytes.

08:22.180 --> 08:27.260
And the problem with a vaccine
is that in order to be viable,

08:27.259 --> 08:31.999
it has to be effective against
all of those phases in the

08:32.000 --> 08:34.710
lifecycle of the plasmodium.

08:34.710 --> 08:40.770
And then also another feature,
as I said, is that malaria is

08:40.774 --> 08:43.144
not a single disease.

08:43.139 --> 08:47.759
It's a family of four different
parasitic diseases,

08:47.759 --> 08:51.209
and the vaccine has to be
effective against not simply

08:51.212 --> 08:54.912
one,
but against numerous,

08:54.914 --> 08:59.864
therefore, species of parasite.

08:59.860 --> 09:05.180
Now, I don't want to argue that
therefore the development of a

09:05.179 --> 09:08.669
vaccine against malaria is
impossible.

09:08.668 --> 09:12.468
In fact, as we're speaking,
scientists are hard at work

09:12.470 --> 09:15.570
trying to develop such a
vaccine, and indeed,

09:15.567 --> 09:17.747
they have come up with one.

09:17.750 --> 09:22.460
You read some rather silly
things in the press.

09:22.460 --> 09:28.150
The vaccine developers came up
with a vaccine in the last few

09:28.153 --> 09:32.523
years that's about
thirty-percent effective.

09:32.519 --> 09:36.459
I remember reading in places
like the New York Times

09:36.455 --> 09:40.585
that malaria would therefore be
eradicated globally in five to

09:40.594 --> 09:41.684
seven years.

09:41.678 --> 09:44.588
This is a sort of rather silly
prediction,

09:44.590 --> 09:47.680
and even the people--I know
because I've talked to them--

09:47.678 --> 09:52.488
who are developing the vaccine
have no such illusion about its

09:52.491 --> 09:53.361
efficacy.

09:53.360 --> 09:56.930
They're thrilled because it's
thirty-percent effective,

09:56.934 --> 10:00.714
but that means that it's
seventy-percent not effective.

10:00.710 --> 10:05.080
Well, in order to understand
the evolution of public health

10:05.077 --> 10:09.447
strategies against malaria and
the problem facing the world

10:09.447 --> 10:12.457
today in dealing with this
disease,

10:12.460 --> 10:17.350
then we need to know that the
very complexity of malaria has

10:17.352 --> 10:22.332
led to a wide array of different
strategies to combat it,

10:22.330 --> 10:28.320
as well as to an ongoing debate
on which course is likely to be

10:28.317 --> 10:29.957
most effective.

10:29.960 --> 10:34.490
And as yet there's no consensus
in the international health

10:34.490 --> 10:38.630
community on the best and most
effective strategy,

10:38.629 --> 10:42.179
despite the fact that since the
turn of the twentieth century,

10:42.178 --> 10:45.008
at the least,
malaria is a disease,

10:45.009 --> 10:48.539
paradoxically,
that has such extraordinary

10:48.539 --> 10:51.639
ravages on the global
population,

10:51.639 --> 10:56.759
and yet, paradoxically,
it's a disease that's both

10:56.761 --> 10:59.691
treatable and preventable.

10:59.690 --> 11:03.440
There is an amazing paradox.

11:03.440 --> 11:06.730
This morning,
then, I want to talk about not

11:06.730 --> 11:09.740
the effects,
the nature of the plasmodium,

11:09.739 --> 11:14.719
the nature of mosquitoes,
the lifecycle or symptomatology

11:14.716 --> 11:18.476
of malaria,
but I'd like to look instead at

11:18.475 --> 11:22.025
the disease from the societal
point of view,

11:22.028 --> 11:27.428
and in particular on efforts to
development a successful

11:27.432 --> 11:29.792
antimalarial strategy.

11:29.788 --> 11:34.448
But developing a strategy or
thinking about the proper

11:34.452 --> 11:39.472
strategy against malaria is
easier if we think of a number

11:39.466 --> 11:44.566
of ways in which this disease
might be characterized,

11:44.570 --> 11:49.360
the ways in which it has been
seen by leading scientists,

11:49.360 --> 11:53.760
physician, and public health
officials who've dealt with it.

11:53.759 --> 11:57.949
So, I'm wondering if we could
think of malaria--we might ask a

11:57.950 --> 12:00.080
number of questions about it.

12:00.080 --> 12:05.460
How should we describe this
disease?

12:05.460 --> 12:11.570
Is it a disease of poverty,
and what's the evidence for

12:11.567 --> 12:12.357
that?

12:12.360 --> 12:16.030
That would entail dealing
with--and in a particular way

12:16.033 --> 12:18.893
that might be different from
other ways.

12:18.889 --> 12:24.129
One of the leading world
malariologists in the early

12:24.134 --> 12:29.794
twentieth century defined
malaria as a house disease.

12:29.788 --> 12:33.238
In other words,
it's primarily defined by poor

12:33.241 --> 12:37.611
housing conditions in which
people are crowded in order to

12:37.614 --> 12:40.534
work in agricultural
occupations,

12:40.529 --> 12:45.029
and those houses are porous to
insects,

12:45.029 --> 12:47.559
and it's in the house that the
disease is transmitted,

12:47.558 --> 12:52.478
and both mosquitoes and human
beings are infected.

12:52.480 --> 12:58.060
Or should we see it instead as
an occupational disease?

12:58.058 --> 13:02.708
We've talked about the
relationship of malaria to

13:02.706 --> 13:06.586
agriculture,
and it's quite clear that

13:06.587 --> 13:12.317
certain forms of agricultural
production create and generate

13:12.320 --> 13:16.400
high risk for those who practice
them,

13:16.399 --> 13:21.139
and malaria is contracted
overwhelmingly by people who

13:21.142 --> 13:24.902
work in fields under certain
conditions.

13:24.899 --> 13:28.219
Another way of thinking about
it is,

13:28.220 --> 13:31.470
in that case,
one way of attacking a malaria

13:31.465 --> 13:35.765
then would be to have occupation
improve the conditions of

13:35.768 --> 13:37.778
farming,
of agriculture,

13:37.783 --> 13:41.093
to regulate rice fields and all
the rest of it.

13:41.090 --> 13:45.230
That would be what you would
do, perhaps, if you define it as

13:45.226 --> 13:47.016
an occupational disease.

13:47.019 --> 13:51.359
Should we think of it instead
as an environmental disease,

13:51.364 --> 13:55.634
that it's a disease that
flourishes where the environment

13:55.633 --> 13:57.313
has been degraded?

13:57.308 --> 13:59.458
Where there's been
deforestation,

13:59.458 --> 14:00.398
for example.

14:00.399 --> 14:07.819
Where the hydrology of rivers
has been undermined.

14:07.820 --> 14:12.310
Where there's flooding of
places where there are swamps

14:12.309 --> 14:14.139
and impounded water.

14:14.139 --> 14:16.449
In that case,
the way of dealing with

14:16.452 --> 14:18.142
malaria,
you might think,

14:18.139 --> 14:21.189
might be to have land drainage,
reclamation,

14:21.190 --> 14:26.240
environmental sanitation--
quite a different strategy for

14:26.235 --> 14:28.595
dealing with the disease.

14:28.600 --> 14:32.340
What should we call this
particular disease?

14:32.340 --> 14:38.660
Is it an endemic disease,
or is it an epidemic disease?

14:38.658 --> 14:42.958
And here I think that malaria
is one of those diseases that

14:42.961 --> 14:46.821
we're studying in our course
that's actually both.

14:46.820 --> 14:52.880
That is to say,
in a particular locality,

14:52.884 --> 14:56.984
it is an endemic disease.

14:56.980 --> 14:59.800
For example,
if you were to go to the

14:59.799 --> 15:04.499
tropical areas of Africa today,
malaria is present throughout

15:04.500 --> 15:05.520
the year.

15:05.519 --> 15:09.849
It's highly, even hyper endemic.

15:09.850 --> 15:16.380
But it's also capable of being
an epidemic disease.

15:16.379 --> 15:18.179
First of all,
that's easiest to see,

15:18.178 --> 15:22.448
perhaps, it temperate zones
where malaria has also been

15:22.451 --> 15:26.141
prevalent,
because then it's seasonal and

15:26.144 --> 15:29.614
you have the winter when the
disease--

15:29.610 --> 15:33.020
it's too cold for the
plasmodium to be transmitted,

15:33.019 --> 15:36.119
but you have an annual summer
epidemic.

15:36.120 --> 15:39.120
But in addition,
under certain conditions we

15:39.120 --> 15:43.310
would say that the epidemic is
intensified in conditions,

15:43.308 --> 15:47.358
for example,
of years of exceptionally heavy

15:47.363 --> 15:48.403
rainfall.

15:48.399 --> 15:53.519
Or, say, in tropical Africa,
it becomes an epidemic disease

15:53.518 --> 15:57.488
when something happens to the
environment,

15:57.490 --> 16:02.620
where there are complex
emergencies or famines that

16:02.620 --> 16:06.830
cause people to move in large
numbers--

16:06.830 --> 16:12.620
who lack immunity to move to
areas where the disease is

16:12.621 --> 16:13.911
prevalent.

16:13.908 --> 16:18.778
So, malaria can cause
extraordinarily intense

16:18.784 --> 16:24.774
epidemics against a background
of being also an endemic

16:24.769 --> 16:26.099
disease.

16:26.100 --> 16:30.250
I would like to argue,
and I will be arguing that part

16:30.245 --> 16:33.995
of the complexity of malaria--
and if I were asked the

16:34.004 --> 16:36.954
question--although you may want
to disagree with me,

16:36.950 --> 16:40.410
because people are still
arguing about how one defines a

16:40.413 --> 16:42.683
malaria and how one deals with
it.

16:42.678 --> 16:46.938
But I'd like to suggest that
perhaps it's all of those.

16:46.940 --> 16:48.930
It's a disease of poverty.

16:48.928 --> 16:52.518
This is part of its complexity,
its biological,

16:52.523 --> 16:55.573
social, and environmental
complexity.

16:55.570 --> 16:57.760
It is a disease of poverty.

16:57.759 --> 17:00.139
It's also a house disease.

17:00.139 --> 17:02.309
It's an occupational disease.

17:02.309 --> 17:04.099
It's an environmental disease.

17:04.099 --> 17:05.609
It's an endemic disease.

17:05.608 --> 17:09.078
And it's an epidemic disease as
well.

17:09.078 --> 17:14.888
Well, what are the kinds of
strategies that have been

17:14.894 --> 17:19.484
deployed against this dreadful
disease?

17:19.480 --> 17:25.840
One was since we now know that
it's transmitted by vectors,

17:25.838 --> 17:29.268
Ronald Ross,
who was one of the people who

17:29.272 --> 17:35.412
won the Nobel Prize,
in fact for establishing that

17:35.407 --> 17:39.787
very idea,
developed very question the

17:39.787 --> 17:45.647
idea then if it's a disease
that's transmitted by vectors,

17:45.650 --> 17:49.960
perhaps the right course for
dealing with malaria is vector

17:49.964 --> 17:50.714
control.

17:50.710 --> 17:54.470
Kill mosquitoes by
insecticides,

17:54.469 --> 18:00.289
or remove their breeding
grounds by environmental

18:00.288 --> 18:05.118
sanitation,
by dealing with an unregulated

18:05.122 --> 18:09.982
hydrology of an area,
by land drainage,

18:09.978 --> 18:14.478
by removing uncovered water.

18:14.480 --> 18:20.250
A different strategy would be
to deal with not the mosquito

18:20.251 --> 18:22.841
but with the plasmodium.

18:22.838 --> 18:26.678
And so there have been--and
here I've talked about the

18:26.679 --> 18:32.829
Italian School of malariology,
and Giovanni Battista Grassi

18:32.833 --> 18:41.163
had the idea that you would be
able to eradicate malaria by the

18:41.164 --> 18:47.574
use of antiplasmodial--
that is, quinine--one the first

18:47.566 --> 18:49.906
effective magic bullets.

18:49.910 --> 18:55.240
He thought the idea was that if
we know what causes malaria and

18:55.244 --> 18:58.864
there is an effective treatment
for it,

18:58.858 --> 19:02.068
if you can use it
prophylactically to prevent

19:02.073 --> 19:06.023
people from being infected for a
number of seasons in a

19:06.016 --> 19:10.596
particular geographical area,
or if you can destroy the

19:10.604 --> 19:15.324
plasmodia in the bloodstreams of
all of the sufferers,

19:15.318 --> 19:20.558
then you can prevent mosquitoes
from being infected for the

19:20.563 --> 19:22.103
following year.

19:22.098 --> 19:27.048
And if you do that for several
seasons, then you could break

19:27.047 --> 19:31.237
the cycle of transmission and
eradicate malaria.

19:31.240 --> 19:35.990
Both of the people who
discovered the mosquito theory

19:35.987 --> 19:41.097
of transmission very quickly
came to the idea of malarial

19:41.098 --> 19:42.558
eradication.

19:42.558 --> 19:47.088
Ross did so,
and Grassi immediately thought

19:47.086 --> 19:50.856
that malaria had what he
called--

19:50.858 --> 19:55.088
it was the "colossus with
feet of clay"--

19:55.088 --> 20:00.568
and that quinine would be the
instrument that would enable the

20:00.565 --> 20:02.715
world to eradicate it.

20:02.720 --> 20:06.310
But if you think of it as a
disease of poverty,

20:06.308 --> 20:11.638
you might think instead--and a
disease of housing,

20:11.640 --> 20:16.360
and an occupation disease--then
you might think of a different

20:16.356 --> 20:20.746
strategy of social uplift,
that what you need to do to

20:20.750 --> 20:25.530
deal with malaria is to practice
social medicine to deal with

20:25.534 --> 20:30.474
poor diet,
poor wages, child labor--those

20:30.471 --> 20:38.121
whole series of complex factors
that create the substratum in

20:38.115 --> 20:41.295
which malaria thrives.

20:41.298 --> 20:46.368
And then there is another
strategy which is quite commonly

20:46.373 --> 20:47.533
thought of.

20:47.529 --> 20:52.019
It has not made much progress,
at least to date,

20:52.019 --> 20:55.709
though who knows,
maybe it will in the future,

20:55.710 --> 21:00.040
and that's the
Jenner/Pasteurian strategy of

21:00.040 --> 21:05.480
hoping to develop an effective
antimalarial vaccine.

21:05.480 --> 21:10.070
So vaccine development is one
of the great hopes in the

21:10.066 --> 21:15.316
antimalarial struggle,
and enormous amounts of

21:15.316 --> 21:23.876
resources are being invested in
antimalarial vaccine development

21:23.880 --> 21:25.920
as we speak.

21:25.920 --> 21:29.870
Well, I want to give an example
of a particular place.

21:29.868 --> 21:33.478
It's the one you're reading
about this week,

21:33.476 --> 21:38.336
which was the impact of malaria
on a particular country.

21:38.338 --> 21:42.538
And I've chosen Italy for
particular reasons.

21:42.538 --> 21:47.988
One is that Italy had a special
relationship to malaria.

21:47.990 --> 21:53.790
It was the only Western
European country where it wasn't

21:53.788 --> 21:58.638
a colonial issue,
but rather the most important

21:58.638 --> 22:02.328
domestic public health problem.

22:02.328 --> 22:09.518
It was also the international
center of malariology from about

22:09.515 --> 22:13.515
1900 until the Second World War.

22:13.519 --> 22:16.839
In other words,
we've talked about the hegemony

22:16.836 --> 22:21.016
of powers in international
medicine in the early nineteenth

22:21.017 --> 22:24.907
century down the middle of the
nineteenth century.

22:24.910 --> 22:30.750
In the smaller domain of
malariology, Italy was the

22:30.752 --> 22:36.832
center of the action from 1900
until World War II.

22:36.828 --> 22:41.798
This is the place where people
went to be trained in

22:41.804 --> 22:43.174
malariology.

22:43.170 --> 22:47.360
People traveled--physicians
from all over the world--

22:47.358 --> 22:52.198
to study with those people who
were called the Rome School,

22:52.200 --> 22:55.180
or the Italian School of
malariology--

22:55.180 --> 22:58.320
Giovanni Battista Grassi most
prominent.

22:58.318 --> 23:01.378
But other names were extremely
prominent also,

23:01.378 --> 23:04.298
like Angelo Celli,
and we could list a whole

23:04.301 --> 23:05.731
series of others.

23:05.730 --> 23:10.840
And it was Italians primarily
who were responsible for

23:10.836 --> 23:14.496
unraveling the mysteries of
malaria.

23:14.500 --> 23:17.910
And finally,
Italy was a place that did

23:17.909 --> 23:20.779
something quite extraordinary.

23:20.778 --> 23:27.748
It was the first place to have
a successful strategy of

23:27.746 --> 23:31.226
antimalarial campaigning.

23:31.230 --> 23:36.360
In other words,
a campaign began in 1900 and

23:36.362 --> 23:42.332
was successful in a eradicating
malaria by 1962.

23:42.328 --> 23:48.898
The last indigenous case of
malaria in Italy was in Sicily

23:48.896 --> 23:50.046
in 1962.

23:50.048 --> 23:53.348
So, this means that Italy has
lessons,

23:53.348 --> 23:58.028
and there are not many places
where there have been campaigns

23:58.028 --> 24:01.998
that have succeeded
intentionally in eradicating the

24:02.003 --> 24:02.943
disease.

24:02.940 --> 24:09.180
This leads to a message of
hope--what can be accomplished

24:09.178 --> 24:12.898
by doing it,
and it also means that I think

24:12.901 --> 24:17.141
it's useful to look at the this
successful campaign in order to

24:17.140 --> 24:21.240
draw lessons from it,
but to beware also of the

24:21.243 --> 24:25.293
misuse of history,
because a lot of what I think

24:25.289 --> 24:29.109
are the wrong lessons have also
been drawn from it.

24:29.108 --> 24:32.088
Well, in any case,
let's look just very,

24:32.093 --> 24:35.233
very quickly at the Italian
experience.

24:35.230 --> 24:37.790
As you know,
Italy was united in the middle

24:37.785 --> 24:41.985
of the nineteenth century,
and by the 1880s the new

24:41.994 --> 24:48.014
liberal regime became aware of
the prevalence of the disease

24:48.008 --> 24:52.568
throughout the country,
and this is the map that

24:52.565 --> 24:56.925
was--it's not the best map
artistically or even in terms of

24:56.926 --> 25:00.466
clarity,
or I would even say in terms of

25:00.468 --> 25:02.918
accuracy;
and, so, you're wondering why

25:02.924 --> 25:06.034
do I show you this map of
malaria in Italy when there are

25:06.026 --> 25:09.566
actually better maps that are
more colorful and all the rest?

25:09.568 --> 25:13.168
But for historians,
this is the important one,

25:13.170 --> 25:17.900
because this is the one that
shook Italians up and convinced

25:17.900 --> 25:22.310
them of the enormity of the
problem in their country.

25:22.308 --> 25:26.128
One of the things that's quite
clear, even in looking at this

25:26.126 --> 25:29.686
map, is that malaria was present
everywhere virtually.

25:29.690 --> 25:33.150
There are areas that are
yellow, pink,

25:33.153 --> 25:38.493
and red of prominence or
extreme prominence of malaria.

25:38.490 --> 25:43.430
And it was the case also that
after unification,

25:43.430 --> 25:46.490
instead of the
problem--unification seen as a

25:46.489 --> 25:50.449
foundational moment for this new
regime that's supposed to

25:50.452 --> 25:53.872
deliver civilization,
economic betterment,

25:53.869 --> 25:56.689
progress, and also public
health--

25:56.690 --> 26:00.100
but instead,
the years at the end of the

26:00.104 --> 26:04.224
nineteenth century see the
malarial problem,

26:04.220 --> 26:07.710
already intense, getting worse.

26:07.710 --> 26:12.820
Worse because of things like
deforestation of the Apennines.

26:12.818 --> 26:18.578
The railroad era actually had a
devastating impact,

26:18.578 --> 26:22.668
because it led to the demand
for trees to make the railroad

26:22.673 --> 26:25.643
ties and the stations and all
the rest,

26:25.640 --> 26:30.660
and therefore led to massive
deforestation and deregulation

26:30.660 --> 26:34.470
of the hydrology of the entire
peninsula,

26:34.470 --> 26:37.880
which was turned topsy-turvy.

26:37.880 --> 26:44.040
It was also a time then of
economic difficulties and

26:44.035 --> 26:49.465
crises, and malaria feeds on
human misfortune,

26:49.465 --> 26:55.375
and it did so in the late
nineteenth century.

26:55.380 --> 26:58.120
Well, in any case,
Italy also provided--

26:58.118 --> 27:01.178
we've talked about malaria as a
housing disease--

27:01.180 --> 27:05.800
I thought I'd just show you a
representative type of peasant

27:05.798 --> 27:09.638
housing,
even down through the 1930s and

27:09.644 --> 27:11.934
'40s,
and when you live in places

27:11.925 --> 27:13.945
like this,
in a malarial area,

27:13.948 --> 27:17.458
you're highly vulnerable
because this is almost like

27:17.460 --> 27:18.700
being outdoors.

27:18.700 --> 27:22.130
In fact, it's probably worse in
terms of mosquitoes.

27:22.130 --> 27:27.150
It's entirely vulnerable and
open to flying insects,

27:27.150 --> 27:31.510
and having numerous people
sleeping in conditions like this

27:31.505 --> 27:35.105
helps to promote the disease and
transmission.

27:35.108 --> 27:40.508
Similarly, we talked about it
being an occupational disease.

27:40.509 --> 27:45.239
It wasn't by chance that Italy
is also a place of rice fields,

27:45.240 --> 27:49.590
and rice fields are actually
wonderful places for mosquitoes,

27:49.588 --> 27:53.498
and the rice workers were among
those people who were most

27:53.499 --> 27:57.609
vulnerable,
and became symbolic as the

27:57.608 --> 28:00.758
victims of the plasmodia.

28:00.759 --> 28:05.239
So, in any case then,
there was an epidemic and

28:05.242 --> 28:08.072
endemic condition in Italy.

28:08.068 --> 28:12.708
And Italy showed all of those
terrible consequences of malaria

28:12.712 --> 28:17.282
that we've been talking about:
absenteeism in agriculture;

28:17.278 --> 28:22.098
waste--whole areas that weren't
cultivated because they were so

28:22.095 --> 28:26.905
dangerous, and those who did
work on them sickened and died;

28:26.910 --> 28:31.440
an area of low productivity,
of illiteracy;

28:31.440 --> 28:34.620
the underdevelopment of civil
society;

28:34.619 --> 28:39.509
low participation in politics;
mass emigration.

28:39.509 --> 28:43.159
And I would argue indeed that
one of the features of Italy is

28:43.162 --> 28:45.782
that we've talked about North
and South,

28:45.779 --> 28:50.359
and I talked about agriculture
being a determinant of malaria,

28:50.358 --> 28:54.938
and that the global North had
advanced forms of agriculture

28:54.941 --> 28:58.971
that were intensive and not
conducive to malaria;

28:58.970 --> 29:01.710
and the South,
the global South,

29:01.710 --> 29:03.390
had the opposite.

29:03.390 --> 29:09.160
Well, this was reproduced in a
microcosm in Italy in that the

29:09.163 --> 29:14.363
North of Italy was much less
vulnerable to malaria,

29:14.358 --> 29:19.458
and the form of malaria was the
milder vivax malaria,

29:19.460 --> 29:24.210
while the South of Italy was
riddled with malaria,

29:24.210 --> 29:28.220
and it was malaria that
predominantly falciparum;

29:28.220 --> 29:34.040
that is, the most devastating
and lethal form of the disease.

29:34.038 --> 29:41.728
Well, there was a time of great
scientific discoveries that

29:41.726 --> 29:44.506
we've talked about.

29:44.509 --> 29:47.889
Oh, this is a famous picture,
just to show you.

29:47.890 --> 29:51.010
This is a painting called
"Malaria,"

29:51.010 --> 29:53.220
and as you see,
it's sort of like a

29:53.220 --> 29:56.140
piet�,
or a deposition from the cross,

29:56.138 --> 29:59.188
and I think it conveys,
in a moving,

29:59.192 --> 30:04.072
emotional way,
the reaction of a society to

30:04.067 --> 30:07.897
intense malarial transmission.

30:07.900 --> 30:12.980
This is the prime minister at
the turn of the century until

30:12.978 --> 30:17.088
the First World War,
under whom the antimalarial

30:17.093 --> 30:19.373
campaign gets started.

30:19.368 --> 30:22.068
And this is Giovanni Battista
Grassi--

30:22.068 --> 30:25.968
I tried to show him last
time--who was the person who

30:25.971 --> 30:30.101
proves the mosquito transmission
among human beings,

30:30.098 --> 30:35.068
the leading representative of
the Rome School of malariology,

30:35.068 --> 30:38.838
and his work was--we've talked
about institutions--

30:38.838 --> 30:41.408
this is the Santo Spirito
Hospital,

30:41.410 --> 30:44.800
where he conducted his
research, because there were an

30:44.800 --> 30:47.660
enormous,
almost unending supply,

30:47.664 --> 30:49.674
of malarial patients.

30:49.670 --> 30:53.750
And it was here that he first
successfully infected human

30:53.753 --> 30:57.113
beings with malaria with a
number of scientific

30:57.108 --> 31:00.078
experiments,
that you might consider

31:00.076 --> 31:03.076
ethically problematic,
but in any case,

31:03.076 --> 31:07.186
there weren't rules about such
things at the turn of the

31:07.189 --> 31:08.759
twentieth century.

31:08.759 --> 31:13.769
Well, the pillars of the
eradication program--the pillar

31:13.771 --> 31:17.601
of it was initially going to be
quinine.

31:17.598 --> 31:23.158
And so Italy passed a series of
quinine laws from 1900 to 1907,

31:23.156 --> 31:27.366
with support from the liberal
prime minister.

31:27.368 --> 31:31.078
And the idea was that you could
kill the plasmodia,

31:31.077 --> 31:33.377
break the cycle of
transmission,

31:33.375 --> 31:35.595
and eradicate the disease.

31:35.598 --> 31:39.278
Grassi thought it would be
merely a matter of a few years.

31:39.279 --> 31:45.409
In fact, it then turned out to
be impossible to eradicate the

31:45.405 --> 31:51.325
disease so easily that people
were not used to contact with

31:51.327 --> 31:52.857
physicians.

31:52.858 --> 31:56.258
There wasn't access,
in other words,

31:56.259 --> 31:58.009
to medical care.

31:58.009 --> 32:01.529
Distributing quinine was
tremendously problematic.

32:01.528 --> 32:05.848
It also has to be followed
according to a very complex

32:05.852 --> 32:08.552
regimen,
and it has to be followed for

32:08.549 --> 32:11.719
months at a time,
and you can't get people to do

32:11.720 --> 32:14.440
that unless they understand the
disease.

32:14.440 --> 32:18.790
And, so, actually to have an
effective antimalarial program,

32:18.788 --> 32:22.948
turned out you have also to
deal with poverty and with

32:22.950 --> 32:26.570
illiteracy,
which are the allies of the

32:26.573 --> 32:28.913
mosquito and of malaria.

32:28.910 --> 32:33.910
And so it was important to
teach people the discipline of

32:33.913 --> 32:38.033
quinine and the reasons for it
so very quickly,

32:38.025 --> 32:41.685
and also health access was
important.

32:41.690 --> 32:47.720
And, so, new parts of the
program turned out to be rural

32:47.723 --> 32:49.703
health stations.

32:49.700 --> 32:55.620
It's expanding now beyond
quinine to include rural health

32:55.619 --> 32:59.849
stations, education and rural
schools.

32:59.848 --> 33:03.538
In other words,
a whole panoply of things that

33:03.535 --> 33:07.625
we might call social medicine,
improved housing.

33:07.630 --> 33:12.190
Actually, Celli argues that
trade unions were a powerful

33:12.189 --> 33:17.329
antimalarial tool because they
helped deliver better wages,

33:17.328 --> 33:20.098
and with that,
better diet and better

33:20.096 --> 33:23.206
clothing,
and child labor laws--and we

33:23.211 --> 33:27.051
know that children are
particularly susceptible to

33:27.049 --> 33:29.469
malaria--
and the regulation of

33:29.471 --> 33:32.791
occupations that were
particularly dangerous,

33:32.789 --> 33:36.119
such as working in rice fields.

33:36.118 --> 33:38.168
Well, the results of the
liberal program,

33:38.170 --> 33:43.260
which has expanded well beyond
distributing quinine--

33:43.259 --> 33:46.609
in other words,
it starts with the vision of a

33:46.611 --> 33:50.781
magic bullet and moves very
quickly to a whole panoply of

33:50.782 --> 33:53.862
things that we might,
for shorthand,

33:53.862 --> 33:57.782
call social uplift,
with having to do with access

33:57.778 --> 34:00.968
to medical care,
improved housing,

34:00.969 --> 34:03.629
civil liberties,
education,

34:03.630 --> 34:07.050
and all of those sorts of
measures.

34:07.048 --> 34:09.058
The results of the liberal
program,

34:09.059 --> 34:12.939
by the eve of the First World
War, were a massive decline in

34:12.943 --> 34:16.343
mortality,
at least, but still the

34:16.338 --> 34:19.428
persistence of the disease.

34:19.429 --> 34:24.029
And then comes World War I,
which was an extraordinary

34:24.030 --> 34:25.940
setback for malaria.

34:25.940 --> 34:31.010
And I've talked about the way
that malaria is a disease that

34:31.007 --> 34:37.087
thrives on human misfortune,
and there is no misfortune that

34:37.088 --> 34:40.618
is better for malaria than war.

34:40.619 --> 34:46.049
I thought I would show you a
few paintings of the First World

34:46.045 --> 34:51.105
War to show you the kinds of
conditions that led in Italy

34:51.110 --> 34:55.170
that destroyed,
almost, the first fifteen,

34:55.172 --> 34:58.642
sixteen years of antimalarial
efforts,

34:58.639 --> 35:04.099
and created this huge explosion
of epidemic malaria during the

35:04.099 --> 35:05.709
First World War.

35:05.710 --> 35:10.690
And this is a famous
painter--Sartorio is his name--

35:10.690 --> 35:13.750
who was a combatant in the
First World War,

35:13.750 --> 35:17.980
but then was wounded,
and returned to the front as a

35:17.978 --> 35:21.328
painter--
rather, as a photographer--and

35:21.331 --> 35:25.571
he took photographs of the
conditions at the fighting

35:25.565 --> 35:28.925
front,
and then he did paintings from

35:28.932 --> 35:30.382
his photographs.

35:30.380 --> 35:33.550
And these are some of the most
impressive, I think,

35:33.547 --> 35:36.397
moving pictures of the sorts of
conditions.

35:36.400 --> 35:40.350
You can see exactly how
mosquitoes would thrive in

35:40.351 --> 35:42.451
conditions of this sort.

35:42.449 --> 35:44.679
This is not dead soldiers.

35:44.679 --> 35:48.069
These are soldiers bivouacking
after a battle,

35:48.070 --> 35:51.860
and I think you can imagine
them being from non-malarial

35:51.864 --> 35:56.564
areas and not having resistance,
and you can see that they are a

35:56.563 --> 36:00.253
wonderful feast for
Anopheles mosquitoes,

36:00.250 --> 36:04.160
and the soldiers from
non-malarial areas fell sick and

36:04.161 --> 36:06.231
died in enormous measures.

36:06.230 --> 36:10.470
We've talked about malaria as a
housing disease.

36:10.469 --> 36:14.879
Well, also the destruction of
housing renders people

36:14.876 --> 36:18.046
vulnerable;
if you have to move into tents

36:18.050 --> 36:20.580
or into the open fields to
bivouac,

36:20.579 --> 36:24.859
to move from area to area,
from cities to the rural areas

36:24.855 --> 36:28.905
and all the rest of it,
you become extraordinarily

36:28.905 --> 36:29.855
vulnerable.

36:29.860 --> 36:33.560
And, so, the destruction of
housing and the housing stock

36:33.561 --> 36:35.281
was extremely important.

36:35.280 --> 36:40.000
So, there was this tremendous
upsurge of malaria during the

36:40.003 --> 36:41.473
First World War.

36:41.469 --> 36:46.819
After the First World War,
in 1922, we have a new regime,

36:46.815 --> 36:51.965
and this was the fascist regime
of Benito Mussolini.

36:51.969 --> 36:55.609
We won't talk about the
conditions that brought

36:55.608 --> 36:59.848
Mussolini to power,
but we now have a totalitarian,

36:59.851 --> 37:03.611
one-party dictatorship--
the end of elections,

37:03.606 --> 37:08.226
police repression,
violence, the secret police,

37:08.226 --> 37:13.836
and a foreign policy of
expansion to restore an empire

37:13.842 --> 37:19.462
and to pursue broad European and
African conquest.

37:19.460 --> 37:25.070
By the end of the 1920s,
Mussolini is fully in power,

37:25.070 --> 37:28.860
and he institutes some
antimalarial measures that

37:28.864 --> 37:32.694
became extremely famous,
and he's often thought as a

37:32.693 --> 37:36.143
hero of the antimalarial
movement because of what he did

37:36.143 --> 37:39.323
in this area--
the Pontine Marshes--which is

37:39.322 --> 37:42.512
just outside of Rome,
and you'll be reading about

37:42.505 --> 37:42.835
that.

37:42.840 --> 37:46.640
This was done,
however, for political purposes

37:46.643 --> 37:51.093
more than for medical ones,
because the point about the

37:51.094 --> 37:55.494
Pontine Marshes was that only a
couple of thousand people lived

37:55.492 --> 37:59.162
there in 1930,
and this became the height of

37:59.159 --> 38:02.209
the regime's antimalarial
measures,

38:02.210 --> 38:07.780
which were to drain the swamps,
to build new housing,

38:07.780 --> 38:10.130
and to settle the land.

38:10.130 --> 38:14.260
But it doesn't actually
confront malaria in the parts of

38:14.257 --> 38:18.457
Italy where the most numerous
people were getting ill and

38:18.458 --> 38:19.208
dying.

38:19.210 --> 38:25.050
It was an enormous propaganda
effort to demonstrate,

38:25.050 --> 38:28.050
more than health,
the power of the regime:

38:28.047 --> 38:32.287
that Mussolini could succeed
where liberals had failed,

38:32.289 --> 38:34.049
where the popes had failed.

38:34.050 --> 38:39.790
The sorts of measures that were
undertaken, this is the kinds of

38:39.793 --> 38:44.263
conditions that he found--the
swamp conditions.

38:44.260 --> 38:46.780
I guess I'm overdoing it,
but I'm showing you there was

38:46.775 --> 38:49.335
plenty of water and there were
plenty of mosquitoes,

38:49.340 --> 38:54.020
and it was estimated that you
had an eighty percent chance of

38:54.021 --> 38:58.861
contracting malaria if you spent
a single night in this area in

38:58.860 --> 39:01.740
the summer,
before the drainage of the

39:01.737 --> 39:02.237
swamps.

39:02.239 --> 39:07.199
Well, this is the construction
of something modestly called the

39:07.204 --> 39:10.574
Mussolini Canal,
and we'll see also it went

39:10.567 --> 39:13.447
pumping stations,
land drainage;

39:13.449 --> 39:15.849
you see canals being
constructed;

39:15.849 --> 39:20.859
water being raised to be
harmlessly diverted to the sea

39:20.864 --> 39:24.244
went with it as well;
the distribution of

39:24.235 --> 39:27.355
quinine--I'm showing quinine
being distributed;

39:27.360 --> 39:31.170
education and literacy,
and the teaching about the

39:31.168 --> 39:34.818
mosquito theory of
transmission--all of that was

39:34.820 --> 39:35.910
important.

39:35.909 --> 39:40.379
We see fascist Boy Scouts
learning about larvae and their

39:40.382 --> 39:44.532
collection, and taking that
information home to their

39:44.534 --> 39:47.334
families, was part of the idea.

39:47.329 --> 39:49.739
Here they're doing the same
thing.

39:49.739 --> 39:51.829
There were sanatoria.

39:51.829 --> 39:55.499
And you see the improved
housing.

39:55.500 --> 39:57.020
These are sturdy houses.

39:57.018 --> 40:00.158
They have screened windows and
all the rest of it.

40:00.159 --> 40:02.089
You see screens going up.

40:02.090 --> 40:06.670
So, this was really a huge,
huge project.

40:06.670 --> 40:12.140
It also included things that
weren't so--the building of new

40:12.135 --> 40:12.965
cities.

40:12.969 --> 40:16.689
Suddenly an area that was a
swamp, you see modern cities

40:16.686 --> 40:17.426
going up.

40:17.429 --> 40:20.199
The display of power is
enormous.

40:20.199 --> 40:26.129
This was really an idea that
had as much to do with the power

40:26.126 --> 40:29.876
of the regime as with public
health.

40:29.880 --> 40:33.710
I'm not saying that it's my
view that fascism is in fact bad

40:33.706 --> 40:36.426
for your health rather than good
for it.

40:36.429 --> 40:40.929
Here are some of the propaganda
pictures of the first peasant of

40:40.925 --> 40:43.985
Italy here, among his smiling,
happy crowds,

40:43.992 --> 40:45.922
and all the rest of it.

40:45.920 --> 40:48.420
So, this was used in that way.

40:48.420 --> 40:53.190
Well then, part of fascism,
however, you can't understand

40:53.188 --> 40:57.358
it without its impetus to
expansion and to war.

40:57.360 --> 41:02.640
And the Second World War,
again, led to a major

41:02.643 --> 41:09.253
destruction and to devastation,
repeating even a worse scale

41:09.251 --> 41:13.691
what had happened during the
First World War.

41:13.690 --> 41:15.300
So, I won't talk about that.

41:15.300 --> 41:20.790
I won't talk either this
morning about a war crime that I

41:20.793 --> 41:25.413
do discuss in the book,
that will see the use of

41:25.405 --> 41:29.815
malaria as an instrument of
bioterrorism.

41:29.820 --> 41:34.660
But my theme this morning is
what are the tools for dealing

41:34.664 --> 41:38.014
with malaria,
and the lessons that can be

41:38.007 --> 41:39.007
learned.

41:39.010 --> 41:42.820
And, so, I'd like to look
then--with the downfall of

41:42.822 --> 41:47.092
fascism and another terrible
upsurge of malaria during the

41:47.085 --> 41:51.445
Second World War,
there is a campaign to

41:51.449 --> 41:57.509
eradicate malaria that gets
underway 1945-1946,

41:57.510 --> 42:00.740
and succeeds by 1962.

42:00.739 --> 42:04.559
And it's done with Allied
cooperation,

42:04.559 --> 42:10.379
the leadership of the
Rockefeller Foundation and money

42:10.375 --> 42:15.625
from this country,
and it involves the idea of a

42:15.630 --> 42:20.110
powerful new weapon to destroy
mosquitoes--

42:20.110 --> 42:22.000
a technological weapon.

42:22.000 --> 42:28.070
DDT was discovered during the
war and is now used as an

42:28.065 --> 42:34.465
instrument, a powerful
insecticide, to destroy malaria.

42:34.469 --> 42:40.029
And this is thought,
in fact, to be--and becomes--a

42:40.032 --> 42:42.482
premise, if we like.

42:42.480 --> 42:48.580
The lesson is drawn that
malaria was eradicated in Italy

42:48.577 --> 42:54.057
after the use of DDT,
and so DDT is thought to be the

42:54.056 --> 42:57.506
cause of the destruction of
malaria,

42:57.510 --> 42:59.520
the successful campaign.

42:59.518 --> 43:04.358
And this becomes the premise
for an international campaign,

43:04.360 --> 43:08.540
a global campaign,
of the World Health

43:08.539 --> 43:14.869
Organization from 1955 until
1969 to use DDT worldwide to

43:14.867 --> 43:18.367
eradicate malaria globally.

43:18.369 --> 43:22.199
I want to argue that this is in
fact misleading,

43:22.195 --> 43:26.835
because the wrong lessons were
drawn from what happened in

43:26.835 --> 43:27.645
Italy.

43:27.650 --> 43:31.740
In actual fact,
the eradication after World War

43:31.742 --> 43:37.082
II was possible in part because
it marked not only the use of

43:37.079 --> 43:40.219
DDT,
but it also meant a massive

43:40.215 --> 43:44.105
investment of American aid to
provide food,

43:44.110 --> 43:47.670
clothing, housing and
employment, that becomes,

43:47.670 --> 43:51.720
first, UNRA,
and then the Marshall Aid Plan.

43:51.719 --> 43:56.419
And so there is an enormous
campaign to improve housing and

43:56.423 --> 43:58.293
conditions of people.

43:58.289 --> 44:01.379
In other words,
there's a massive social

44:01.378 --> 44:05.258
uplift, if we like,
that's going along at the same

44:05.260 --> 44:07.400
time as the use of DDT.

44:07.400 --> 44:10.890
At the same time,
you have the reestablishment of

44:10.893 --> 44:14.463
healthcare services and rural
health stations,

44:14.460 --> 44:20.060
and the massive distribution of
quinine and artificial quinines

44:20.059 --> 44:24.829
developed during the war--
Atabrine and chloroquine.

44:24.829 --> 44:30.379
So, it's not a simple,
unidimensional program that

44:30.382 --> 44:31.632
succeeds.

44:31.630 --> 44:37.530
By 1962, Italy becomes
malaria-free,

44:37.530 --> 44:41.320
and I think that's one of the
factors that led to the

44:41.324 --> 44:44.174
possibility of the economic
miracle,

44:44.170 --> 44:47.790
and Italy's becoming after,
by our day,

44:47.789 --> 44:50.269
the world's seventh industrial
power.

44:50.268 --> 44:55.158
So, there's an amazing measure
of hope of what can be done.

44:55.159 --> 45:01.249
When you eradicate malaria,
you unleash productivity and

45:01.248 --> 45:02.798
development.

45:02.800 --> 45:07.390
But in addition,
this example then becomes the

45:07.385 --> 45:13.395
basis of the post World War II
program of global eradication

45:13.396 --> 45:18.996
that believed that it would be
possible simply to have a

45:19.001 --> 45:22.971
panacea,
a technological intervention

45:22.971 --> 45:26.841
with DDT,
and this is an experiment that

45:26.835 --> 45:32.065
by 1969 collapses in failure,
and I would like to argue that

45:32.065 --> 45:36.215
this ought to lead us to
enormous questions about today's

45:36.217 --> 45:40.517
antimalarial program of the
World Health Organization,

45:40.518 --> 45:44.638
Roll Back Malaria,
and very often it's thought

45:44.635 --> 45:50.125
that the development of using
some sort of magic bullet would

45:50.126 --> 45:51.586
be adequate.

45:51.590 --> 45:55.230
I want to argue that this was
partly based on a

45:55.233 --> 45:58.563
misunderstanding of the Italian
lesson,

45:58.559 --> 46:01.659
and I think we're dealing with,
in our own world,

46:01.659 --> 46:04.429
the consequences of that in the
form,

46:04.429 --> 46:10.579
now, of either DDT- or
insecticide-treated bed nets as

46:10.581 --> 46:14.761
being the most useful
instruments;

46:14.760 --> 46:20.370
and I think the campaign is
having enormous difficulties,

46:20.367 --> 46:25.567
and I think we need to think
about how we define this

46:25.574 --> 46:31.374
disease--what is its substratum;
what conditions promote it;

46:31.369 --> 46:36.929
and what kinds of strategies
are effective in combating it.

46:36.929 --> 46:38.499
So, thank you.

46:38.500 --> 46:44.000