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What the world needs now is.April 11, 2004
By TINA ROSENBERG
The year 2000 was a time of plague for the South African town of Ndumo, on the border of Mozambique. That March, while the world was focused onAIDS, more than 7,000 people came to the local health clinic with malaria. The South African Defense Force was called in, and soldiers set up tents outsidethe clinic to treat the sick. At the district hospital 30 miles away in Mosvold, the wards filled with patients suffering with the headache, weakness and feverof malaria -- 2,303 patients that month. ''I thought we were going to get buried in malaria,' said Hervey Vaughan Williams, the hospital's medical manager.
Today, malaria has all but vanished in Ndumo. In March 2003, the clinic treated nine malaria cases; Mosvold Hospital, only three.
As malaria surges once again in Africa, victories are few. But South Africa is beating the disease with a simple remedy: spraying the inside walls of houses inaffected regions once a year. Several insecticides can be used, but South Africa has chosen the most effective one. It lasts twice as long as the alternatives. Itrepels mosquitoes in addition to killing them, which delays the onset of pesticide-resistance. It costs a quarter as much as the next cheapest insecticide. It isDDT.
KwaZulu-Natal, the province of South Africa where Ndumo and Mosvold are located, sprayed with DDT until 1996, then stopped, in part under pressurefrom other nations, and switched to another insecticide. But mosquitoes proved to be resistant to the new insecticide, and malaria cases soared. Since DDTwas brought back in 2000, malaria is once again under control. To South Africans, DDT is their best defense against a killer disease.
To Americans, DDT is simply a killer. Ask Americans over 40 to name the most dangerous chemical they know, and chances are that they will say DDT.
Dichloro-diphenyl-trichloroethane was banned in the United States in 1972. The chemical was once sprayed in huge quantities over cities and fields ofcotton and other crops. Its persistence in the ecosystem, where it builds up to kill birds and fish, has become a symbol of the dangers of playing God withnature, an icon of human arrogance. Countries throughout the world have signed a treaty promising to phase out its use.
Yet what really merits outrage about DDT today is not that South Africa still uses it, as do about five other countries for routine malaria control and about 10more for emergencies. It is that dozens more do not. Malaria is a disease Westerners no longer have to think about. Independent malariologists believe it killstwo million people a year, mainly children under 5 and 90 percent of them in Africa. Until it was overtaken by AIDS in 1999, it was Africa's leading killer.
One in 20 African children dies of malaria, and many of those who survive are brain-damaged. Each year, 300 to 500 million people worldwide get malaria.
During the rainy season in some parts of Africa, entire villages of people lie in bed, shivering with fever, too weak to stand or eat. Many spend a good part ofthe year incapacitated, which cripples African economies. A commission of the World Health Organization found that malaria alone shrinks the economy incountries where it is most endemic by 20 percent over 15 years. There is currently no vaccine. While travelers to malarial regions can take prophylacticmedicines, these drugs are too toxic for long-term use for residents.
Yet DDT, the very insecticide that eradicated malaria in developed nations, has been essentially deactivated as a malaria-control tool today. The paradox isthat sprayed in tiny quantities inside houses -- the only way anyone proposes to use it today -- DDT is most likely not harmful to people or the environment.
Certainly, the possible harm from DDT is vastly outweighed by its ability to save children's lives.
o one concerned about the environmental damage of DDT set out to kill African children. But various factors, chiefly the persistence of DDT's toxic imagein the West and the disproportionate weight that American decisions carry worldwide, have conspired to make it essentially unavailable to most malarialnations. With the exception of South Africa and a few others, African countries depend heavily on donors to pay for malaria control. But at the moment,there is only one country in the world getting donor money to finance the use of DDT: Eritrea, which gets money for its program from the World Bank withthe understanding that it will look for alternatives. Major donors, including the United States Agency for International Development, or Usaid, have notfinanced any use of DDT, and global health institutions like W.H.O. and its malaria program, Roll Back Malaria, actively discourage countries from using it.
Part of the reason for DDT's marginalization is that its delivery method, house spraying, doesn't work everywhere. Insecticide sprayed inside houses repelsmosquitoes -- and kills those that do make it indoors and perch on walls -- for several months. Since most mosquitoes bite at night, when people are likely tobe indoors, the spray reduces the number of times people are bitten. If around 80 percent of houses are covered, spraying protects everyone, as the bites thattake place will be from mosquitoes less likely to have bitten an infected person. But house spraying is only effective against mosquitoes that bite indoors --not all do. It also requires a government capable of organizing, training and equipping sprayers, which is beyond the reach of some countries.
Even when spraying is possible, though, developed nations don't want to pay for it. Instead, the malaria establishment in developed nations promotes the useof insecticide-treated nets that people can buy to hang over their beds. Treated bed nets are indeed a useful tool for controlling malaria. But they havesignificant limitations, and one reason malaria has surged is that they have essentially become the only tool promoted by Western donors. ''I cannot envisionthe possibility of rolling back malaria without the power of DDT,'' said Renato Gusm-o, who headed antimalaria programs at the Pan American HealthOrganization, or P.A.H.O., the branch of W.H.O. that covers the Americas. ''Impregnated bed nets are an auxiliary. In tropical Africa, if you don't use DDT, The other reason DDT has fallen into disuse is wealthy countries' fear of a double standard. ''For us to be buying and using in another country something wedon't allow in our own country raises the specter of preferential treatment,' said E. Anne Peterson, the assistant administrator for global health at Usaid. ''Wecertainly have to think about 'What would the American people think and want?' and 'What would Africans think if we're going to do to them what wewouldn't do to our own people?' ' Given the malignant history of American companies employing dangerous drugs and pesticides overseas that they would not or could not use at home, it isunderstandable why Washington officials say it would be hypocritical to finance DDT in poor nations. But children sick with malaria might perceive a moredeadly hypocrisy in our failure to do so: America and Europe used DDT irresponsibly to wipe out malaria. Once we discovered it was harming theecosystem, we made even its safe use impossible for far poorer and sicker nations.
Today, westerners with no memory of malaria often assume it has always been only a tropical disease. But malaria was once found as far north as Bostonand Montreal. Oliver Cromwell died of malaria, and Shakespeare alludes to it (as ''ague' ) in eight plays. Malaria no longer afflicts the United States, Canadaand Northern Europe in part because of changes in living habits -- the shift to cities, better sanitation, window screens. But another major reason was DDT,sprayed from airplanes over American cities and towns while children played outside.
In Southern Europe, Latin America and Asia, DDT played an even more prominent role in controlling malaria. A malaria-eradication campaign with DDTbegan nearly worldwide in the 1950's. When it started, India was losing 800,000 people every year to malaria. By the late 1960's, deaths in India wereapproaching zero. In Sri Lanka, then called Ceylon, 2.8 million cases of malaria per year fell to 17. In 1970, the National Academy of Sciences wrote in areport that ''to only a few chemicals does man owe as great a debt as to DDT' and credited the insecticide, perhaps with some exaggeration, with saving halfa billion lives.
From the 1940's to the late 1960's, indoor house spraying with DDT was tested all over Africa. It was least effective in the lowland savannas of West Africa,but even partly successful programs provided considerable health improvements. And in other parts of Africa, DDT reduced the infant mortality rate by halfand in some places wiped out malaria completely.
Still, DDT was falling out of favor even before the 1962 publication of ''Silent Spring,'' Rachel Carson's book that described the dumping of DDT and otherpesticides on American towns and farms and detailed the destruction they caused. DDT had not been sold as a way to control malaria but to eradicate it, sothe world would never have to think about malaria again. But eradication failed -- it is now considered biologically impossible -- and because DDT had notlived up to its billing, disillusion set in. At the same time, DDT's indiscriminate use was provoking the development of resistance among mosquitoes, andmany countries were shifting to decentralized health systems, which meant they were no longer able to organize nationwide house spraying.
The move away from DDT in the 60's and 70's led to a resurgence of malaria in various countries -- Sri Lanka, Madagascar, Swaziland, South Africa andBelize, to cite a few; those countries that then returned to DDT saw their epidemics controlled. In Mexico in the 1980's, malaria cases rose and fell with thequantity of DDT sprayed. Donald Roberts, a professor at the Uniformed Services University of the Health Sciences in Bethesda, Md., has argued that whenLatin America stopped using DDT in the 1980's, malaria immediately rose, leading to more than a million extra cases a year. The one country that continuedto beat malaria was Ecuador, the one country that kept using DDT.
In the few countries where it is used today, DDT is no longer sprayed from airplanes, and no country admits to using it as an insecticide for crops -- althoughthere are probably cases where it is diverted for agricultural use. Its only legitimate use is inside houses. Roberts said that the quantities used for housespraying are so small that Guyana, to take one example, could protect every single citizen of its malarious zones with the same amount of DDT once used tospray 1,000 acres of cotton. ''The negative environmental effects of DDT use that led to its banning were due to massive, widespread agricultural use,' says afact sheet published by Usaid (no fan of the chemical). ''Spraying limited amounts of DDT inside houses is considered unlikely to have major negativeenvironmental impact.' What about DDT's impact on the people inside the houses? The most serious evidence of DDT's harm to humans are a few studies showing that higher levelsof DDE (the form DDT takes when it metabolizes) in a mother's blood is associated with premature birth and shorter duration of breast-feeding. But otherstudies have found no such associations. There was suspicion that DDT causes breast cancer, but study after study has found no connection. In general,DDT is feared for its effect on the environment, not on humans. It has been used on such a huge scale over the last 50 years that it is reasonable to think thatif it had any serious effect on human health, we would know it by now.
Rereading ''Silent Spring,'' I was again impressed by the book's many virtues. It was serialized in The New Yorker in June 1962 and published in book formthat September -- a time when Americans were living in the golden glow of postwar progress and science was revered. ''Silent Spring' for the first timecaused Americans to question the scientists and officials who had been assuring them that no harm would result from the rain of pesticides falling on theirfarms, parks and backyards. Carson detailed how DDT travels up the food chain in greater and greater concentrations, how robins died when they ateearthworms exposed to DDT, how DDT doomed eagle young to an early death, how salmon died because DDT had killed the stream insects they ate, howfiddler crabs collapsed in convulsions in tidal marshes sprayed with DDT.
' Silent Spring' changed the relationship many Americans had with their government and introduced the concept of ecology and the interconnectedness ofsystems into the national debate. Rachel Carson started the environmental movement. Few books have done more to change the world.
But this time around, I was also struck by something that did not occur to me when I first read the book in the early 1980's. In her 297 pages, Rachel Carsonnever mentioned the fact that by the time she was writing, DDT was responsible for saving tens of millions of lives, perhaps hundreds of millions.
DDT killed bald eagles because of its persistence in the environment. ''Silent Spring' is now killing African children because of its persistence in the public mind. Public opinion is so firm on DDT that even officials who know it can be employed safely dare not recommend its use. ''The significant issue is whetheror not it can be used even in ways that are probably not causing environmental, animal or human damage when there is a general feeling by the public andenvironmental community that this is a nasty product,' said David Brandling-Bennett, the former deputy director of P.A.H.O. Anne Peterson, the Usaidofficial, explained that part of the reason her agency doesn't finance DDT is that doing so would require a battle for public opinion. ''You'd have to explain toeverybody why this is really O.K. and safe every time you do it,'' she said -- so you go with the alternative that everyone is comfortable with.
' Why it can't be dealt with rationally, as you'd deal with any other insecticide, I don't know,'' said Janet Hemingway, director of the Liverpool School ofTropical Medicine. ''People get upset about DDT and merrily go and recommend an insecticide that is much more toxic.' Because the ban on DDT became the midwife to the environmental movement, the debate about it, even today, is bizarrely polarized. Most environmentalgroups don't object to DDT where it is used appropriately and is necessary to fight malaria. But liberals still tend to consider it a symbol of the Frankensteineffects of unbridled faith in technology. For conservatives, whose Web sites foam at the mouth about the hypocrisy of environmentalists, DDT continues torepresent the victory of overzealous regulators and Luddites who misread and distort science.
So far, conservatives have not been able to budge Usaid, even though they have managed to remake the agency's overseas AIDS programs to promoteabstinence and discredit condom use. But malaria is not part of the public debate as AIDS is, and DDT does not have the same cultural urgency for thereligious right that abstinence does.
William Ruckelshaus, the head of the newly created Environmental Protection Agency, banned DDT in 1972. It remains one of the most controversialdecisions the E.P.A. has ever taken. Ruckelshaus was under a storm of pressure to ban DDT. But Judge Edmund Sweeney, who ran the E.P.A.'s hearings onDDT, concluded that DDT was not hazardous to humans and could be used in ways that did not harm wildlife. Ruckelshaus banned it anyway, for all butemergencies.
Ruckelshaus made the right decision -- for the United States. At the time, DDT was mainly sprayed on crops, mostly cotton, a use far riskier than indoorhouse spraying. There was no malaria in the United States -- in part thanks to DDT -- so there were no public health benefits from its use. ''But if I were adecision maker in Sri Lanka, where the benefits from use outweigh the risks, I would decide differently,'' Ruckleshaus told me recently. ''It's not up to us tobalance risks and benefits for other people. There's arrogance in the idea that everybody's going to do what we do. We're not making these decisions for therest of the world, are we?' n fact, we are -- the central reason that African nations who need DDT do not use it today. Washington is the major donor to W.H.O. and Roll Back Malaria,and most of the rest of the financing for those groups comes from Europe, where DDT is also banned. There is no law that says if America cannot use DDTthen neither can Mozambique, but that's how it works. The ban in America and other wealthy countries has, first of all, turned poor nations' agriculturalsectors against DDT for economic reasons. A shipment of Zimbabwean tobacco, for example, was blocked from entering the United States market because itcontained traces of DDT, turning Zimbabwe's powerful tobacco farmers into an effective anti-DDT lobby. From a health point of view, of course, Americanoutrage would have been more appropriate if traces of tobacco had been found in their DDT than the other way around.
Then there are chemical companies. ''I get asked all the time -- are you being paid by chemical companies?' said Thomas DeGregori, a professor ofeconomics at the University of Houston and an advocate for DDT. The question is amusing, because the corporate interests in this issue are actually on theother side. DDT is no longer on patent, and it is known to be made only in India and China -- and the price has soared since the rich-country ban putmanufacturers out of business, making it harder for poor countries to buy. Janet Hemingway of the Liverpool School, who advises African governments, saidthat she and the officials she works with are often lobbied by chemical companies selling more expensive insecticides, telling her about DDT's evils. ''Clearly,they'd like to see DDT banned -- it cuts into their markets,' she said.
But more important to DDT's demise has been pressure from the international malaria establishment. Sometimes it is direct. Mexico gave up DDT, forexample, because the North American Free Trade Agreement obligated it to. Donald Roberts, who was working in Belize in the early 1990's, said that Usaidtold the country to stop using DDT or it would lose foreign assistance. (Belize did, and malaria rates soared.) In May 2001, 91 countries and the European Community signed a treaty in Stockholm on 12 persistent organic pollutants, the ''dirty dozen.'' It banned nineoutright. For DDT, the treaty allowed its use in indoor spraying for public health purposes, but called for its gradual phase-out. DDT's exemption, which hadbeen opposed by environmental groups but supported by malariologists, did allow countries dependent on DDT to continue to use it for the present. ButStockholm's guiding principle -- phase it out -- is one more factor that discourages donors from financing DDT.
Brian Sharp, who is leading South Africa's house-spraying program, said that some international research agencies will not finance studies in any wayassociated with DDT. Roll Back Malaria sees its mosquito-control strategy as promoting bed nets, period. Its 2003 Africa report hardly mentions housespraying. The Global Fund to Fight AIDS, Tuberculosis and Malaria -- which uses guidelines set by W.H.O. -- currently finances no DDT. Vinand Nantulya,senior adviser to the fund's executive director, said that the fund might theoretically supply DDT to a country that requests it -- but none have. This is nosurprise: these countries work closely with W.H.O. and advisers from Usaid to formulate their proposals to the Global Fund, and they are unlikely to ask forthings that stand a low chance of approval. Many African scientists and health officials report being told by donors, ''You'll have trouble getting money forthis' or ''Donors believe this has unacceptable environmental effects.' The balance of power is so tilted toward the donors in these relationships that poorcountries will go quite far out of their way to not offend. DDT is controversial; better not to ask.
In 1999, the Pan American Health Organization recommended that Ecuador use DDT to control malaria in the wake of El Nino. The World Bank said no. Ina document explaining its decision, the bank said, ''Because of the controversial issues surrounding DDT, the World Bank's malaria team discourages thehabitual use of DDT for malaria control.' Renato Gusm-o of P.A.H.O. said that the bank's environmental group told him it was fighting for the elimination ofDDT and could not allow the bank to finance DDT while advocating a ban.
In many countries, decisions about DDT are made by environmental ministries, with little input from health officials. When Colombia banned DDT in theearly 1990's, for example, ''people in public health found out when they read about it in the newspaper,'' Gusm-o said. Malaria cases more than doubled. The1980's and 1990's also saw the rise of environmental units within the health institutions and donors like the World Bank. These watchdog units were muchneeded and in general have been a crucial tool to protect the environment. But they look at only the risks, not the benefits. Walter Vergara, the World Bankofficial who headed the unit that dismissed DDT in Ecuador, defended the decision to me: ''DDT has an awful impact on the biosystem and is beingeliminated by the world community. There are alternatives. We're not the only species on the planet.' Said David Brandling-Bennett, the former deputy director: ''My experience at P.A.H.O. was that the malaria community eventually gave in to heavypressure from environmental groups, including within the organization. There was a fairly heavy debate in P.A.H.O. a few years back about whether weshould use DDT where it is effective. But the overwhelming perception of DDT as the nastiest kid on the block just made it very difficult to argue forcontinuing. Really, the malaria community retreated.'' When Lee Jong-Wook became head of W.H.O. last year, he wrote an article for The Lancet, the British medical journal, setting out his vision. Lee wroteabout AIDS, about SARS, about strengthening public health systems. He did not mention malaria.
Probably the worst thing that ever happened to malaria in poor nations was its eradication in rich ones. That has made one of Africa's leading killersshockingly invisible. '' Silent Spring' had a clear message about things at home Americans could see and touch and feel,'' said Brooks B. Yeager, vicepresident of the Global Threats Program for the World Wildlife Fund. ''Americans who live on the Carolina coast know the brown pelicans have come back'since DDT spraying was halted. ''Malaria is a long way away. You have to read about it or see in person its devastation, and not many Americans have theopportunity to do it.'' Lawrence Barat, the World Bank's adviser on malaria control, said, ''When I tell people I work on malaria, sometimes I get, 'Gee, I didn't know it stillexisted.''' One of the most depressing aspects of talking about malaria is that you get to hear the phrase ''the powerful AIDS lobby,'' a term no one but a malariologistwould use. AIDS in the third world is still criminally underfinanced, but at least it gets some money and a lot of attention. Malaria gets AIDS's dregs. AIDSwas a sudden plague, very visible in its choice of victims, and it has a vocal constituency in rich countries. Even in Africa, malaria gets nowhere near theattention of AIDS. It has always been around, and it kills not middle-class adults but rural 4-year-olds, who don't have much of a lobby.
Malaria's status can be read in the aid figures. By the 1990's, it was almost completely ignored, and Africa's malaria-control programs disintegrated. In somecountries, the entire federal antimalaria program employed only two or three people. When developed nations got together to begin Roll Back Malaria in1998, they pledged money to meet its goal of cutting the death toll from malaria in half by 2010, but have then proceeded to donate peanuts. In 2000,according to Amir Attaran, a Massachusetts-based fellow of the Royal Institute for International Affairs, the 23 richest countries in the world plus the WorldBank together provided $100 million to fight malaria -- less than a tenth of the annual sum necessary to meet Roll Back Malaria's goals.
The AIDS epidemic has begun to excite a broader interest in third-world diseases, and malaria has benefited, especially from the establishment of the GlobalFund, which has approved $499 million for malaria -- although it has only actually disbursed a tenth of that amount. Usaid, which in 1998 gave just $12million to fight malaria, now gives $80 million a year, a notable advance.
But money is still very short. One illustration of donor stinginess is the fact that the world today employs malaria cures that don't work. As resistant strains ofmalaria have evolved, chloroquine, the most popular remedy, fails up to 80 percent of the time, and a newer treatment, Fansidar, is not much better and isgetting worse. They are still in use because they are cheap; chloroquine costs only pennies per dose, a cost most African families can handle themselves.
New, effective drugs are available, but they cost a minimum of 40 cents for a child's treatment and $1.50 for an adult's, which means that Africangovernments -- and therefore donors -- will have to pay. Only a handful of Africa's 42 malaria-endemic countries have switched; one is South Africa, wherethe new drugs have been partly responsible for the country's recent success. Those prices may not seem like much to cure malaria, especially whencontrasted with the hundreds of dollars a year for life needed to treat AIDS. But 40 cents a child is apparently too much for donors to provide.
The lack of political interest in malaria has been a very important factor in the decline of house spraying and rise of bed nets. Bed nets follow the fashion indevelopment assistance today: bypass the government and work through private sector, nongovernmental groups and with the affected people themselves.
People can buy nets in a store for $2 to $10, or their subsidized or even free distribution can be integrated into other health programs, like vaccination days.
Bed nets are an exciting and important form of mosquito control. But they have major drawbacks. Even a few dollars is still too much money. Peoplesurveyed in rural Africa about what they would like to buy listed a bed net as only the sixth product on their wish list. The first three were a bicycle, a radioand, most heartbreakingly, a plastic bucket. The price is also kept artificially high because most countries, shamefully, still tax bed nets. And until nets withlong-lasting insecticide can be widely distributed, bed nets need regular retreatment. It is insecticide that protects, not the net, and the insecticide wears offwithout people knowing it.
Both bed nets and house spraying can be effective, and studies comparing costs differ on which is cheaper. For the world malaria establishment, however,one huge difference is that with house spraying, the central government -- and therefore donors -- bear the cost. Financing repeated rounds of spraying,donors argue, is not sustainable. ''But 'sustainable' is what you choose to sustain,'' Amir Attaran fumed. ''Nobody demands my garbage collection inCambridge, Mass., be sustainable. The garbageman comes once a week, and it is accepted that society pays for that.'' Mozambique is now doing house spraying successfully and cheaply without a national army of sprayers and a fleet of S.U.V.'s. Mozambique hires a fewpeople in each community and gives them two weeks of training and the materials they need. Those sprayers then walk from house to house, spraying eachone twice a year. ''It helps save on transport costs, and the fact that sprayers come from the community makes it a lot more credible in terms of peopleaccepting what is done in their households,'' said Jotham Mthembu, KwaZulu-Natal's malaria control program manager, who also advises the program in neighboring Mozambique. Mozambique, because it depends on Western donors, uses a more expensive insecticide. But if it used DDT, it could protectpeople for $1.70 per person per year.
There are other ways to control mosquitoes. Parts of India, for example, are having success stocking mosquito-breeding ponds with guppies, who eatmosquito larvae. But India's ingenious strategy would not work in Africa, where mosquitoes breed in cattle hoofprints during the rainy season.
Malaria must be more than simply a line item in the health budget. Malaria kills tourism and foreign investment. It greatly reduces human intelligence andproductivity and lessens agricultural yields. Against these costs, a nation's business sectors and economic ministries should willingly join the fight -- anddonors must begin to think of malaria control as an unusually cost-effective antipoverty program.
South Africa's success is inspiring another look at DDT around the continent. Uganda, Kenya and other places are now examining whether it could work intheir nations. If it could, donors should encourage it. DDT is a victim of its success, having so thoroughly eliminated malaria in wealthy nations that weforget why we once needed it. But malaria kills Africans today. Those worried about the arrogance of playing God should realize that we have forged aninstrument of salvation, and we choose to hide it under our robes.
Tina Rosenberg writes editorials for The New York Times. Her last article for the magazine was about global corruption.
An article on April 11 about DDT and its effectiveness in controlling malaria in developing countries misstated the position of an international healthorganization on it. The Global Fund to Fight AIDS, Tuberculosis and Malaria indeed plans to finance some DDT spraying, in Somalia.
ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, Apr. 2002, p. 1080–10850066-4804/02/$04.00ϩ0 DOI: 10.1128/AAC.46.4.1080–1085.2002Copyright © 2002, American Society for Microbiology. All Rights Reserved. Oxazolidinone Antibiotics Target the P Site onHiroyuki Aoki,1 Lizhu Ke,1 Susan M. Poppe,2 Toni J. Poel,3 Elizabeth A. Weaver,3Robert C. Gadwood,3 Richard C. Thomas,3 Dean L. Shinabarger,2 and M.