Comment: Winning the war on Dengue

The news that dengue is hitting the Maldives hard has reached the Netherlands, along with other parts of the world from which your beautiful country attracts large numbers of tourists.

That Maldivian children are dying of dengue is distressing and of course a horrific experience for the families affected, but there will surely be broader ramifications for the country. The blame culture that followed these deaths, fuelled by emotional debates in the press is affecting your country badly. Negative press will influence the tourism sector and may have a major economic impact.

When the Indian Ocean island La Reunion was struck by an outbreak of Chikungunya virus – also transmitted by dengue mosquitoes – in 2005/6, it suffered losses of tourism income amounting to €225 million (US$325 million). The French government had to inject €76 million to keep the tourism industry alive. With 1.2 million tourists per year, surely the Maldives cannot afford to wait for such a thing to happen.

So how can the war against dengue be won and can it be done quickly? In my opinion this is possible by doing just one thing well: learning from the past.

In the absence of a vaccine and specific medicines, the sole option to contain or eliminate dengue is through controlling the mosquito that transmits it. It is this option where many countries are failing miserably. Whereas in the middle of the last century, the responsibility for mosquito control remained in strong government hands and was rigorously organised and meticulously executed, a gradual shift of responsibility to the general population in recent decades has yielded disastrous outcomes.

Community awareness and engagement in controlling potential mosquito breeding sites has at best been partially effective, but remains hopeless in most countries with endemic dengue. The result at present: 2,5 billion people at risk, and an estimated 100 million cases of infection per year. These numbers keep growing steadily.

By 1947, the same mosquito that is causing havoc in the Maldives today had invaded 11 million square kilometres of Central and South America. The Pan-American Sanitary Bureau then took the decision to eliminate it. By 1962, these efforts had succeeded in 21 countries, an area encompassing 8.5 million square kilometres. I repeat, 8.5 million square kilometres. Compare that to the size of Male’, or even the Maldives at large, and one wonders why we have forgotten past successes and not simply repeated these.

Back then, these huge successes were based on intensive campaigns to search for breeding sites and either remove or treat them with insecticides to kill mosquito larvae. Large teams of inspectors moved from house to house, and all they did was that. Clean up trash and kill mosquito larvae. These teams were well organised, well funded, well trained, motivated, and well paid.  Much of that has changed, and with the shift of responsibility away from governments, so has the capacity and know-how to deal with outbreaks waned.

Pro-activism to control dengue mosquitoes is gone. Instead, waiting for things to go wrong and then act has become the norm for policy. Why is that?

First, it’s a money issue, and the lack of willingness of governments to put money on the table when prevention is the issue. Politicians like to solve problems that are visible but shy away from spending money on something that may strike one day. Further complicating chronic underfunding are five other factors that contribute to the failure of dengue vector control programmes.

These factors are:

• The desire to find easy solutions

• Degradation of technical and managerial skills

• The increasing scope of the problem

• The shortness of human memory

• Expectation of failure

I emphasize that the most important factor in achieving successful control of dengue mosquitoes is a programme led by a high calibre administration and staffed by well-trained, supervised and motivated personnel. Most countries suffering from dengue lack precisely these things and call upon experts from the World Health Organization (WHO) when disaster strikes. Beyond the WHO’s advisory role, which mostly emphasizes strategies based on community participation of which we know that they don’t really work, there isn’t much it can do.

When the experts fly home, you remain with the problem and responsibility to execute their well-meant advice. They will not do it for you. Setting up a high-level response team is certainly a good thing, but meetings do not control epidemics.

What is needed are highly competent control staffs that know how to systematically cover areas and reduce vector breeding; staff that go out into the country and are capable of containing transmission of the virus and to prevent further misery. Although this should be done in a military style, this is not the same as mobilising the military as is now being done in the Maldives.

We have taken a different approach to the persistent problem of dengue by building on the hugely successful campaigns of the past, and augmenting the old strategies with the latest scientific knowledge and modern tools. The successes of the past were accomplished without computers, mobile telephony, satellite imagery, modern monitoring and surveillance tools, and so on.

We have these now, and should use them to the full. Not just to control outbreaks, but solve the problem permanently, in a sustainable and green manner.

We are discussing this approach with various islands in the Caribbean at present, and consider the Maldives as another great example of where dengue mosquitoes can be eliminated for good.

Now you are facing bad press, political turmoil, and deaths. A public-private partnership holds the key towards avoiding this from happening every few years, and if given an opportunity we are ready to lend a helping hand with our team that holds some of the world’s leading mosquito and dengue experts.

Maldivians should not worry about keeping their kids from going to school. Instead, the country should be planning a dengue mosquito elimination campaign. Good for the public, good for tourism.

Prof. Dr. Bart G.J Knols of the University of Amsterdam is a medical entomologist and CEO of the private firm Soper Strategies, which aims to provide comprehensive mosquito-borne disease elimination programmes.

(http://www.soperstrategies.com)

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