Table 7 Malaria control in China
China has had the longest running successful public health initiative focused on malaria of any country in the world. Starting gradually in 1950, systematically organized with a National Malaria Control Programme in 1955, and continuing to the present day, this adaptive, multiple-intervention, locally tuned effort at malaria suppression warrants in-depth examination and much more attention in contemporary discourse than it is receiving. Using 1949 as a starting point for baseline statistics, there were more than 30 million malaria cases in the country, and the mortality rate was approximately 1% per annum. Malaria was epidemic in 70–80% of all counties in the country, and represented 61.8% of the total recorded cases of acute infectious diseases in China in 1949. By the year 2000, there were 1.202 billion people living in areas where malaria incidence was less than 0.1 per thousand, and no county in the country reported an incidence above 10 cases per thousand. When the national control programme was initiated in 1955, it relied on primary health care networks as an organizational base, and made extensive use of community participation to respond to local needs. An intensive educational programme was put in place that featured advertising of integrated sets of interventions, giving balanced emphasis to both prevention and curative medicine. This balance has persisted to the present day. Indeed, successful suppression of malaria in the diverse Chinese ecosystems owes much to this holistic philosophy. Of special note is a particularly innovative use of intermittent irrigation for malaria control in Chinese ricefields, which was put into place in the 1970s, tuned to the local ecology of terraced ricefield systems The guiding framework for malaria control in China is the adaptive tuning of multiple interventions guided by performance-based ratings carried out over time. An additional form of monitoring also needs to be included here; namely, assessment of drug resistance. Not surprisingly, this phenomenon was, and continues to be, a challenging feature of antimalarial drug distribution in China. However, a research programme focused on drug resistance and the development of new drugs was initiated in response to this problem and plays an important role in the current version of the national programme. A central feature of the Chinese programme is that local ecology drove the choice of site-specific interventions. There was no imposition of general international guidelines about what interventions to emphasize globally. The only notion of scaling up that was brought into consideration was simply coverage of at-risk communities using tools appropriate to the local ecosystem. You could hardly have the intermittent irrigation strategy, so suitable for terraced rice fields, put into play in non-rice growing regions of China. A second key feature of this national programme is the organizational and communication infrastructure that facilitated a steady flow of information and local evaluations back and forth from the national programme to the village and district levels. The entire organizational structure of this programme provides an important role model for any country that is trying to implement a national malaria control effort. |