director himself.
Much thoughtless matter has been written on this point.
For instance, it has been stated that because quinine has proved
so beneficial in Italy, it is also the appropriate measure for all
malarious countries. But the success of quinine there does
not prove that mosquito reduction might not have been equally
successful, possibly even at the same cost. I do not say that
this is the case, but it might be so. Moreover, the conditions
in Italy and elsewhere may be extremely different. Italy
possesses a temperate climate which admits of mosquito-breed-
ing only during a few months of the year, so that there is
plenty of time for the treatment of old cases during the non-
malarious months. Italy is also a highly civilised country
with an intelligent white population, amongst whom there are
numbers of medical men who speak their own language, and
who add to their practice by the treatment of cases of malaria.
Lastly, in Italy malaria occurs principally in rural areas, that
is just where quinine is rationally called for. What more
natural than prevention by treatment in it. But in many other
countries the.se conditions do not obtain ; malaria abounds in
towns ; the population is ignorant and often stupid ; there are
very few qualified medical men ; infections occur nearly all
the year round ; and the cost of maintaining medical men and
312 PREVENTION [Sect.
dispensers for quinine distribution may, in urban areas, far
exceed that, not only of Anopheline reduction, but of mosquito
reduction in general. We really must not apply rules suitable
for one country to all other countries. We have to consider
each case on its own merits.
Protection is a measure for individuals, mosquito reduction
for local governments and municipalities, guided by their sani-
tary departments, and prevention by treatment for doctors. It
is not to be wondered at that the last named are so fond of
the last measure ; they are acquainted with drug giving, but
often not acquainted with public health matters, drainage and
general municipal polity. They naturally tend to select quinine,
and often very wisely so. In many cases, however, it would
have been a wiser policy to have adopted the larger measure
from the first.
Up to the present we have considered each measure separ-
ately ; but in many cases, probably in nearly all, it may be
better to adopt a combination of several measures partially
carried out. In fact, practically it nearly always comes to
this. As previously stated, the complete adoption of any one
measure is generally impossible ; we cannot remove every
mosquito, nor can we treat every case. Possibly a partial
mosquito reduction combined with a partial case reduction
will produce the same amount of malaria reduction at much
less cost. In other words, we remove what breeding waters
we can remove without great expense, and we treat as many
of the infected persons as possible. At the same time we
urge protection upon the populace and adopt various methods
under different local conditions. The proper policy is not the
protection policy, nor the mosquito reduction policy, nor the
quinine policy, but an opportunist policy which uses any
weapon it can. It is sometimes stated that this opportunist
policy will cost more than the specialised policy ; but this does
not follow at all. Ultimately we have to frame our measures
according to local feasibility.
4o] FIRST STEPS 313
40. Conduct of the Campaign. ā Up to the present most of
the anti-malaria campaigns have been due to the intelHgence
and energy of individuals ; but it must be the desire of all ā
and certainly this book has been written in the hope of it ā
that similar work should now be attempted in every civilised
malarious country. This has not hitherto been done, because
often neither governments nor health departments have known
how to commence and to organise their efforts. I propose now
to make some suggestions on the point. They are based upon
the scheme proposed by me for Mauritius, after careful con-
sultation with the capable medical profession of that colony.
They are tentative suggestions, and alterations of detail may
be required under other conditions, and even in Mauritius ;
but I hope that, with such alterations, the general scheme will
prove applicable to most malarious countries, especially in the
tropics.
(i). First steps. ā Whether the campaign is to be a large or
a small one, the authorities must begin by educating not the
public, but themselves, regarding the simple but often ignored
axioms of section 38. The following points must also be
remembered : ā
{a) In most places the campaign can never cease ā the
disease can seldom be extirpated once and for ever,
until civilisation has reached a much higher state.
We should be prepared for the fact that malaria
reduction must become a permanent part of the
general sanitary campaign.
{J}) Unless the work is to be a pretence it cannot be
attempted without expense. Perhaps the ideals of
the third and fourth axioms cannot be reached ā but
they must be remembered. Rarely can we destroy
so redoubtable an enemy without some goldshed.
But every penny spent is likely to save pounds
both to Government and to the public. Moreover,
though the war may never cease, the cost of it is
314 PREVENTION [Sect.
likely to diminish with good administration, and
especially with success.
(c) Public instruction must always be given, but, except
perhaps in very civilised states, it is not likely to
be entirely effective by itself. The individual may
take quinine, use nets, or prevent breeding in his
premises, but he cannot force his neighbours to do
so, nor can he clear the surrounding country or
drain the marshes. Only the better educated classes
are likely to attend to sanitary advice. The great
public is an infant for which everything must be
done by the nurse. The poor are too poor, the
idle too idle, the busy too busy, to concern them-
selves much with sanitary injunctions. Neverthe-
less, instruction costs the state little and may
occasionally reach the small percentage of the wise.
(d) Sanitation is a form of war. It requires not only
money and effort, but also thought, organisation
and discipline.
(2). Appointment of a directory. ā This being the case the
first thing to do is to appoint a commandant. For a small
campaign in a town or district, the proposer of it, whether he
be an administrative, sanitary or medical officer, had better
appoint himself (without salary) and then proceed to collect
what army he can in the form of sanitary inspectors, medical
assistants and even policemen. He can then begin to ask for
funds. But this is personal effort ; and for larger areas Govern-
ment should appoint a special officer in the Sanitary Department.
His pay and status must depend upon the area to be dealt
with. He should be thoroughly acquainted with the subject
and also with general sanitary administration ā a medical man,
or possibly an entomologist or engineer, or for very large areas
an administrative officer.
For entire countries I advocate the construction at once of
a Malaria Bureau as part of the general Sanitary Department ā
4o] DIRECTORY 315
that is, a director with a trained "malariologist," an entomologist,
a sanitary engineer, and a statistician as subordinates, and a
suitable office. The bureau will collect information and co-
ordinate efiforts throughout the country, will carry out inspec-
tions, give advice, examine results, and publish reports.
Those who have no acquaintance with public affairs may
think that this is an extravagant suggestion. In 1904 I mooted
the idea for India through the Secretary of State. In that
country malaria has been officially estimated to cause about
1,000,000 deaths annually. Government spends enormous sums
on plague, which has a smaller mortality and much smaller
morbidity ; but a mere cipher on malaria. My suggestion was
not accepted, and not even a director was appointed. Hence
the efforts made there have been, in my opinion, too discon-
tinuous for success (section 59), and much of the money spent
has possibly been wasted.
The head of the Sanitary Department must often himself
direct the anti-malaria work. He will do well to begin at once
by collecting a permanent special staff. This will cost money ;
but it will save much more which is otherwise likely to be
wasted on inexperienced efforts. Public work is permanently
successful only if directed by officials who are permanently
interested in its success. Local enthusiasts perform great
services in originating campaigns, but they alone cannot
maintain them for ever.
General anti-malaria work is now sure to be commenced in
most civilised countries, and it is high time that governments
should prepare for this by providing the necessary adminis-
trative nucleus.
(3). Anti-malaria Leagues, under the presidency of high
officials, consisting of numbers of medical men and influential
persons, with a central office and local branches, should be
started at once ā have been, in fact, already started in many
places. They serve to interest the public, to disarm opposition,
and to enlist active allies. To them should be entrusted the
3i6 PREVENTION [Sect.
dissemination of information regarding the disease by the well-
known methods of placards, pamphlets, postcards and lectures.
Personally, I think it wise not to demand a general subscription
for membership, as this tends to limit the list, but to ask for
donations from Government and wealthy individuals in order
to pay for the printing and other small expenses of the League.
Unfortunately, there is a distinct danger that the Government,
as soon as the League has been formed, will attempt to shift
responsibility on to it. It is not often that the League will be
able to do the whole work. Its duty lies principally in arousing
public attention as regards protective measures and quinine.
It can seldom undertake extensive mosquito reduction or much
quinine distribution. Lastly, as soon as the novelty wears off,
the efforts of the League may tend to slacken.
(4). Legislation. ā The next thing required is to reconsider
the local Government and municipal sanitary regulations in
order to take power to deal with mosquitos and other details.
This is largely a lawyer's matter, as most regulations are so
framed that they may be interpreted in various ways. The
Government will do well, therefore, to call together a committee
to consider the subject thoroughly. Certain clauses are given
as examples in section 64. It is easy to overrate the import-
ance of legislation in the campaign. The experienced health
officer depends upon it as little as possible ; but it is, never-
theless, occasionally useful to control objectors and other foolish
people. Thus, in Egypt my brothers found it better to ignore
such persons rather than waste time over compulsion, and my
experience has always been the same. The trouble and expense
of bringing recalcitrants to book is greater than what is incurred
in doing the work by departmental agency. The wise health
officer seeks to trouble the public as little as possible, and the
amateur one as much as possible. Laws protecting indentured
coolies should be carefully revised in the same sense, though
this is seldom necessary. All this costs nothing, but requires
considerable time to effect in consequence of the unavoidable and
4o] THE MALARIA SURVEY 317
often unnecessary discussions which arise. I apprehend that
these discussions will now become shorter, because every colony
is adopting the required legislation. See especially R. Boyce's
book [1910] and sections 59 and 64.
A serious difficulty in the way of all sanitary improvement
lies in the inadequacy of punishment often given by legislators
for sanitary contraventions. These are too small to be deterrent.
Endless petitions are allowed ; and the time of the Sanitary
Department, which should be spent on useful work, is used
up in attending courts and writing up cases ā a simple waste
of public funds. This is not freedom but licence. It is a
very low form of civilisation in which individuals are allowed
to abuse the freedom which civilisation has given them by
poisoning or infecting their neighbours. If those who make
and administer the laws were called upon to sit by the side
of dying patients, as medical men too often are, and to watch
the effects of the bereavements that follow, they would not so
often treat these serious offences as jests or as petty failings.
The success of the work at Panama has been largely due to
the stringent discipline exerted ; and the public themselves
have become thankful for it. Sanitary discipline is like that
of the sick-room, against which only the most foolish patient
rebels ā to his own cost. I would, therefore, strongly advise
the Government which determines upon a general war against
malaria to tighten up the reins in this matter.
(5). The pj'eliminary malaria survey. ā The necessity for
repeated measurements of malaria is quite obvious. Without
them we cannot {a) make any estimate of the expense which
might theoretically be incurred for prevention by axioms 3
and 4, and {b) determine the exact effect of the measures which
are taken. Thus, the authorities will not feel the necessity for
the demands made on them, nor the value of the work done,
and the whole campaign may tend to collapse. This happened
in 1899 in Sierra Leone, where the authorities disliked a malaria
survey because they feared that it would alarm the public.
3i8 PREVENTION [Sect.
Hence, while the League is being formed, the Director will
do well to spend some months in making his preliminary-
measurements according to the principles given in sections 31
and 32. Maps being obtained, the local total death-rates for
as many years as possible should be carefully scrutinised and
compared with the attendances for malaria at hospitals and dis-
pensaries ā the results being entered in the maps and registers.
This will cost nothing, but will yield information regarding
both local distribution and general prevalence which will be
invaluable for testing the success of future measures.
At the same time the measures proposed in next sub-section
to be adopted in schools, including registration of enlarged
spleen, should be commenced.
It is now also advisable to make, if possible, a general
" spleen census," That this can be done on a large scale at
little expense has been proved in Mauritius and Ceylon,
where 31,022 and 92,258 children respectively were examined
(section 22). Of course, the work cannot be done entirely by
the Director himself. Orders should be issued to Government
medical officers to undertake it, each for his own district, and
the help of all medical men, of trustworthy assistants and dis-
pensers, and of large employers of labour should be solicited.
Travelling expenses must occasionally be paid, and I think
that fees ought to be allowed under certain circumstances, as
the gratuitous services of medical men are too often demanded
as it is. The Director should set the example by examining as
many children as possible, and he must, of course, register
all the results.
The season during which the spleen census is taken is
important. In the middle of the malaria season the figures
are probably very variable ; so that it would be better to select
a time before or after that season. I advise between one and
two months before the commencement of the season, or a
period within about one month after the end of it ā in the
hope of obtaining the minimum and maximum spleen indices
y
4o] MEASURES IN SCHOOLS 319
respectively. In fact, for the first year I advise that the census
be taken twice, namely, at the periods mentioned. Of course,
it is not necessary or possible that all the children should be
examined on the same day, but I think that the work ought
to be done within about one month.
(6). Measures in schools. ā From this point the actual campaign
commences, and the first principle requiring attention is that
the cheapest measures should first be set in train. The Director
will be able to do much at little cost with various public
institutions according to the principles laid down in section 37.
Schools, if they exist, furnish an admirable opportunity for
large-scale work. In most countries the schools are either
maintained entirely by Government or are given what are
called "grants in aid," or at least licences. This enables
Government to maintain a close control over the health of the
children, and the Director to use the schools for his great
purpose. Two uses can be made of them, {a) by the treatment
of children with fever or enlarged spleen, and {b) for the
repeated measurement of malaria. Both measures are especi-
ally suitable for children since they are the principal homes
of the parasites. I advise as follows : ā
(i). That every school be visited once a quarter by a
suitable medical officer (who may, if necessary, be
paid for the work).
(2). That at this examination the medical officer shall select
all children with enlarged spleen, or with fever at
the time of his visit, and should enter their names
in a register kept by the schoolmaster.
(3). That at the same time the medical officer shall advise
the schoolmaster as to the treatment to be given to
the child during the next three months.
(4). After the inspection the medical officer should report
to the Malaria Director the number of children
found to show signs of malaria, and the latter
should incorporate the facts in his statistics.
320 PREVENTION [Sect.
(5). At the next inspection the medical officer should
observe the number of newly-infected children and
those who have become cured, and should again
report the facts to the Malaria Director.
(6). The schoolmaster should give the medicine to the
children as ordered by the medical inspector.
(7). Quinine may also be advised for the children who are
not suffering from fever or enlargement of the spleen,
but no compulsion should be used to force them to
take it.
(8). The Medical Department should supply quinine in
freshly-made pills or tablets, in appropriate doses,
to each school. This may be done gratuitously for
the schools of the poor, but I think that payment
should be demanded in some cases. Different
doses should be put up in different canisters, and
sweets may be allowed for small children.
(9). The medical inspector may stop the drug, if in his
opinion it disagrees with a child.
I do not advise here as to the amount of the drug, which
I think had better be left to the medical officer. A useful plan
is for the schoolmaster to give the medicine when the child
first comes to school in the morning. It may not be considered
advisable to dose the children every day during the whole three
months, though this may perhaps be done at certain times.
Perhaps the first fortnight of each month ought to suffice, at
least for a trial. During the malaria season the drug may be
given more continuously, and during the non-malarious season,
less so.
(7). Measures on estates, factories, etc. ā There are generally
large numbers of children in connection with the above, and
these may be managed in exactly the same manner as children
in schools. Estates often have their own medical officers, who
should be directed to keep the registers, to give the quinine,
and to report every quarter to the Malaria Director. The
4o] MEASURES ON THE ESTATES 321
latter will thus possess an excellent standing record of the
state of health upon each estate or factory.
In addition to this adults on estates and factories must also
be continuously treated if they are sick. The defect has
generally been that they are given doses only for a day or two,
thus necessitating their frequent presence at the dispensary,
a thing which causes endless trouble both to dispensers and to
patients. It is much better to give sufficient quinine to last
for a week, or fortnight, or more, according to section 36.
Whether quinine should be used for prophylactic purposes
depends upon the severity of the local endemicity, the possi-
bility of reducing Anophelines, and the judgment of the
Director (see especially section 57).
Whether quinine is to be supplied gratis to plantations, etc.,
depends upon the local labour regulations.
(8). Other quinine distribution. ā I suggest the following
steps in accordance with section 36 : ā
(i) A number oi quinine dispensers, who are duly qualified
dispensers, should be appointed under the Malaria
Director.
(2) Each dispenser should be stationed at a convenient
centre within an area allotted to him, and should
spend the whole of his time in house-to-house
distribution of quinine to those who he thinks
require it.
(3) He should be provided with a small portable case, to
be carried by himself, containing a day's supply of
quinine in the form of pills or tablets, put up in
canisters of different doses.
(4) He should be provided with a uniform, or at least an
official badge, and a written authority stating his
duties.
(5) Every day he should visit a number of houses allotted
to him,
(6) On coming to a house he should offer the quinine
X
322 PREVENTION [Sect.
gratis to all persons who suffer from fever or
enlargement of the spleen. He must not demand
nor take any payment whatever, either for medicine
or for his advice.
(7) He may give the drug to any person who demands it,
in doses sufficient for a week or a fortnight, if he
thinks that that person is infected or is in imminent
danger of becoming infected.
(8) He may also examine children for enlargement of the
spleen, if permitted to do so by the occupiers of the
houses, and shall keep a record of the number in
which he finds this symptom.
(9) The quinine dispensers should be well instructed in
their duties, and in a knowledge of malaria in
general. They should furnish a report every month
to the Malaria Director.
(10) The Malaria Director will be well advised to send
these men most frequently to the most intensely
infected areas, and utilise them also, if necessary,
for providing vermifuges and sulphur ointment to
the very poor. The cost of this will be but small
and the advantage great.
In addition to the quinine dispensers, I advised in my
report [1908] that a change should be made as regards the
distributing of quinine to out -door patients of hospitals and
dispensaries. It is quite insufficient to give patients only a few
doses for a few days. Enough should be given for a fortnight
or more.
In Mauritius we found that one dispenser could visit 200
houses a week, and giveaway about 3-3 lbs. (about 1,200 grammes)
of quinine to about 650 sick, or nearly 3 grammes to each.
I must again remark that to be really useful the drug must
simply be poured out in unlimited quantities. A certain amount
may be sold, but stinginess in this particular tends merely to
defeat the main object in view. Government quinine may
4o] MOUSTIQUIERS 323
be distinguished by a certain colour, as done in India ;
authorities should guard against the possibility of their quinine
being subsequently retailed to purchasers or even exported ;
but too many precautions will have the effect only of ruining
the whole scheme, the object of which is wide distribution, for
the sake of saving a few pounds. The cost of collecting money
for small sales, and of sending in reports of exact amounts
distributed, really exceeds the cost of wastage, unless this is
allowed entirely without any limit. Government must, I fear,
face a certain loss from leakage, but this should be looked upon
as an unavoidable part of the general cost of the campaign.
(9). Appointment and instruction of vioustiquiers. ā We now
turn to mosquito reduction. The first necessity, an absolute
one, is for the Director to have a number of subordinates well
trained in a knowledge of mosquitos. In Mauritius we called
these men moustiquiers. They were paid about 25 rupees
a month, and were mostly of Indian extraction. The men
should be carefully selected for intelligence and reliability by
the Director himself, and should be formed into a class to be
trained by him personally. It will be found that they learn
their work in a surprisingly short time, and generally take
great interest in it. Each man should be taught how to catch
adult mosquitos, and how to find larvae in all possible breeding-
places ; also how to fill up holes in trees and rocks, and to
direct the gangs of workmen required for clearing pools and