Le Infezioni in Medicina, n. 2, 309-319, 2022

doi: 10.53854/liim-3002-19

INFECTIONS IN THE HISTORY OF MEDICINE

Epidemiological evolution and historical anti-malarial control initiatives in Colombia, 1848-2019

Julio Cesar Padilla-Rodríguez1, Mario J. Olivera2, María Cristina Padilla-Herrera1

1Staff and Health SAS, Bogotá, D.C., Colombia;

2Grupo de Parasitología, Instituto Nacional de Salud, Bogotá, D.C., Colombia

Article received 14 May 2021, accepted 18 April 2022

Corresponding author

Mario J Olivera

E-mail: molivera@ins.gov.co

SummaRY

The evolution of epidemiological transmission and the control measures implemented in Colombia have been the result of complex global and regional economic and political processes that occurred at different historical moments, since the dawn of the country’s republican life. The development of economic activities for the production, exploitation and export of agricultural products, minerals and raw materials demanded in the international market, favored the necessary conditions for the emergence, expansion, resurgence and persistence of the endemic epidemic of malaria in the different stages studied. A common and fundamental element in the different defined historical moments was the importance given to malaria as an economic problem due to the negative externalities it imposed on the labor force. In addition, due to the role it played as a barrier that limited the exploitation of natural resources and raw materials of interest; as well as the impact that it caused to the flow and commercial exchange.

The previous situation was framed with the growth, consolidation and geostrategic expansion of the United States, as the main commercial partner of the region, and its interest in the exploitation of resources and raw materials, cheap labor, the need to create new markets, which coincided with the goals of modernization and economic strengthening of Colombia. Taking into account different relevant milestones that occurred in the 1848-2019 period, the following stages were defined:

1) Epidemiological emergence and re-emergence of tropical fevers in places of economic exploitation, 1848-1899;

2) Emergence of a new paradigm, control in enclaves of economic interest, ports and cities, 1900-1949;

3) Control to eradication, intensified control-eradication, prevention and control, 1950-1999;

4) Prevention, control and elimination of malaria, 2000-2019.

Historically, antimalarial control initiatives in the country have been directed, restricted and prioritized in places of political and economic importance. The technical-scientific intervention measures implemented in the different stages studied have been uncritically replicated without adapting to the epidemiological scenarios existing in the country. Finally, the antimalarial control measures implemented in Colombia have been imported and adopted from international health initiatives as a result of commitments and obligations acquired in the global commercial context.

Keywords: malaria, plasmodium, control, history, Colombia.

INTRODUCTION

Malaria is one of the most serious public health problems in the world. It has been considered a problem of economic and social efficiency due to the burden it has imposed on the workforce and the obstacle it has represented to the exploitation and commercialization of natural resources and raw materials in tropical regions. Rising production costs, workforce disability losses, high costs for care, and reduced profit margins have traditionally been the main concern [1, 2]. For this reason, the policies and strategic initiatives that have been proposed to intervene in the problem during different stages studied have obeyed the need to protect economic investment in economic enclaves and facilitate commercial exchange [3, 4]. One of the gaps in knowledge on the subject is about the behavior and evolution of the epidemiological transmission of malaria and the measures that have been used in different historical moments to intervene in the problem in this country. Due to these considerations, in this paper, we intend to answer the following questions: what has been the behavior of malaria? and what anti-malarial control initiatives have been applied to the problem from the mid-19th century to the present day in Colombia?

Magnitude and historical importance of malaria in Colombia

An approximation of the magnitude and historical importance that malaria has represented in our country can be made through the accumulated burden of cases and the economic cost that malaria has imposed on institutions and society at different times. According to official data, in the period 1937-2019, an accumulated 6,279,679 cases of malaria were registered in Colombia, corresponding to an average of 75,659 cases per year (Figure 1). A total of 80.5% (5,057,265) of the cases were reported in the 1950-1999 period. In the 1960-1969 decade, there was the lowest absolute number of cases at 208,720, which corresponds to the eradication period of malaria in the country (Table 1). In turn, the nineties registered 1,567,332 cases, the largest number recorded in the second half of the 20th century. Approximately 65% of the malaria infections registered throughout the study period were caused by Plasmodium vivax, except in the sixties when Plasmodium falciparum predominated. Similarly, in the different ecoepidemiological regions, P. vivax predominated, except for the Pacific region where P. falciparum infections predominated.

Figure 1 - Distribution of malaria cases, Annual Parasite Index, stages and initiatives in the fight against malaria in Colombia,
1937-2019.

At the end of the thirties, a study estimated that 3,600,000 cases and 18,000 deaths from malaria occurred in Colombia within an at-risk population of 8.5 million inhabitants and that the disease had cost the state approximately US $11.8 million at the time, assuming that there was an average of four malaria episodes a year in the affected population [5]. An estimate of the losses caused by malaria in Colombia before the start of the control campaigns, carried out between 1942-1951, based on a valuation of 4,059 lives lost annually (average of 10 years) were valued at about US $9,639,393; losses due to disability and work stoppage were approximately US $3,989,697. In addition, during the preparatory phase of the Malaria Eradication Campaign (MEC), it was estimated that the economic impact produced by the disease was about US $30 million annually [6].

In a report by the Director of the National Malaria Eradication Service (NMES) in 1968, it was estimated that for the period 1958-1960, the accumulated losses caused by malaria were US $45,272,616. However, in 1961 were the losses calculated at US $12,932,889; in this period, investment in a malaria program of US $12,149,578 avoided losses of US $32,339,727. Likewise, in the period of 1961-1964, an investment of US $19,894,103 avoided damages worth US $76,289,280; that is, for the period 1958-1964, the antimalarial campaign produced, due to deaths and incapacity not caused in accordance with the situation found in 1965, profits of 340%. Another example of anti-malarial performance is given by the banana region of Uraba, where, when the NMES work began, production was estimated at US $189,985 per year; to date, the region produces US $20,000,000 per year by export from local points [7]. Likewise, in the 1960s, the estimated costs for work disability caused by malaria in the country were US $8,683,627 [8]. At the end of 1979, the economic investment made to the NMES had reached the sum of US $13,109,005 and the cost for incapacity of US $14,452,765 [9]. Likewise, in 1978, it was established that the institutional spending of the malaria program, during 1958-1979, reached the sum of US $3,710,825, of which 75% consisted of contributions from the national government [10].

From 1980-1989, the costs of incapacity to work were estimated to have reached approximately US $72,335,774 in the country. In 1988, the total year cost of direct and indirect work disability and school absenteeism was estimated at more than US $100 million [11]. Recently, in the last decade, the institutional costs to guarantee the operation of departmental and district programs for the prevention and control of malaria and other vector-borne diseases varied between US $8,514,409 and US $10,110,861 annually [12].

First stage: epidemiological emergence and reemergence of tropical fevers in geographical settings of economic exploitation 1848-1899

During the development of this stage, the relationship between the exploitation of agricultural products for export and the emergence of epidemic communicable diseases, which spread to adjacent populations along the Magdalena river, began to be seen in national territories and the province of Panama [13, 14]. This was caused by the interaction of susceptible populations exposed to environmental risks, resulting from the interaction on the environment, infecting carriers, and the existence of efficient vectors in these receptive sites (Figure 2). A tobacco boom was experienced in the period from 1848 to 1875 [15, 16]. Likewise, between 1860 and 1882, there was an increase in the international demand for cinchona, which caused the “cinchona fever” that hit and ravaged the unexplored jungles of Magdalena and those of the southeastern Colombian territory during that historical period in the country. There were three great quintessential booms or bonanzas of very short duration: 1849-1852, 1867-1873 and 1877 [17, 18]. The situation described led to the displacement of peasants from various temperate and cold neighborhood regions who migrated in search of job opportunities to the warm and fertile regions of the Upper Magdalena, where the economic activity of the moment was concentrated and intensified (Figure 2). The exploitation of cinchona was a line that influenced the appearance of emerging and reemerging epidemic outbreaks of tropical fevers in the national territory [19].

Figure 2 - Epidemics of tropical fevers in Colombia, 1848-1899.

Some medical authorities of the time maintained that the malarial endemic, with its epidemic recrudescence, was the most prevalent febrile pathology in most neighboring towns and along the Magdalena river. In these areas, the existence of three malarial areas was established.

However, while it was not specified whether they were of endemic transmission or of recent spread and geographical extension, it was known that they had had an upward march along the river’s route [14]. A reemerging epidemic wave, presumably of malaria, was registered in Ambalema, which spread to the town of Guaduas from 1856-1857. Subsequently, epidemics of tropical fevers began to be registered along the routes of the Magdalena, Patia, Cauca rivers and other regions where the economic exploitation of natural resources was developing (Figure 2). Additionally, during the frequent regional warlike confrontations that occurred in the second half of the 19th century, there were intermittent tropical fever outbreaks and malarial remitter [20].

From 1848-1855, important outbreaks of tropical fevers were recorded in the province of Panama due to the passage and massive influx of immigrants from various parts of the world, attracted by the gold rush in San Francisco, California. Construction of a railway was performed, which crossed the Isthmus of Panama, between 1850 and 1855, and malaria and yellow fever took the lives of many workers brought in for the work; it is said that each installed sleeper cost a life, with more than 9,000 victims [21, 22].

Construction of the railroad aroused interest in building an inter-oceanic canal in Panama. In the 1880s, French builders attempted to construct this canal, following the route of the Chagres river. In this attempt, they suffered enormous loss of life and economic losses from yellow fever and malaria. It is estimated that in nine years, there were more than 20,000 deaths among workers brought in for the work, which was one of the fundamental causes of the failure of this project, postponing expectations for a canal [23, 24]. This coincides with the ignorance that prevailed at that time about the transmission mechanisms of these diseases.

In Colombia, under the constitution of 1886, the Central Board of Hygiene was created and placed in charge of the problems related to epidemic diseases and maritime health in ports and adopting and following the provisions of international sanitary conventions. However, a series of political, financial, institutional, and geographical accessibility limitations prevented the development and consolidation of a solid structure and adequate health policies for this purpose [25, 26].

Second stage: Emergence of a new paradigm, control in enclaves of economic interest, ports and cities 1900-1949

During the vertiginous rise, geostrategic positioning and expansion of the United States, the country showed a greater interest in the exploitation and commercialization of natural resources and raw materials, such as oil, gold mining, coffee and bananas in most tropical countries and the need to create and expand new markets for their products in the region. A concern shared by the current rulers, institutional actors, political leaders and the national bourgeoisie, during the first decades of the 20th century, was the need to promote the economic boom and modernization of the country to achieve its insertion into the world economy [27, 28]. The United States had already promoted the independence of the province of Panama.

National governments adopt and include sanitary provisions in national legislation, and it is beginning to be applied to avoid the imposition of quarantine measures on national ships as they passed through the Panama Canal. In the country, there was a precarious institutional capacity and underdevelopment of the health infrastructure at all levels; there was scarce availability of financial and budgetary resources for this purpose [29]. In the first decade of the 20th century, reports of possible outbreaks of malaria appeared in areas such as the Eastern Plains, Tolima, Valle del Cauca and some areas of mining exploitation on the Pacific Coast of the country and the Banana Zone (Magdalena) by the United Fruit Company [30].

The outbreak of the First World War between the powers of the time, occurred between 1914-1918. Malaria was one of the communicable events that most affected the military population and that hindered the availability of quinine in the international market [31]. The Rockefeller Foundation highlights the economic importance of malaria, among all tropical diseases. From that moment on, this pronouncement would become a fundamental part of the discourse that would justify the policies and initiatives in the global fight against malaria [32].

During the construction of the Antioquia railroad, a program was implemented that contemplated the use of mandatory prophylactic quinine among workers, sanitation measures in the camps, and the protection of houses with metal mesh [33]. Mandatory sanitation and mosquito control campaigns of sanitary importance were ordered in the primary sea and river ports of the Republic of Colombia [34].

In the 1920s, the US $25 million received for compensation from Panama was finally used for the construction of roads, railways, and telegraphs to improve the connection in those low and warm areas of economic interest, receptive with potential transmission of malaria [35]. Around that time, the exploitation and refining of crude oil began in the department of Santander, by North American companies such as the Standard Oil Company and the Gulf oil Company, closely related to the interests of the Rockefeller Foundation, which produced an increase in the vulnerability and receptivity that favors the emergence of diseases such as malaria [36].

Due to the frequent appearance of this type of outbreak in the region, it was evident the need to perform the first geographical studies to determine the distribution of the risk of malaria transmission and the characterization of the existing malaria foci in Colombia, which were carried out between 1927- 1929 [37]. At the end of the decade, an important world milestone was the great economic depression in the United States, which affected trade relations but made it possible to carry out technical cooperation agreements between governments of the Americas region and private philanthropic entities [38]. Malaria was considered a rural health problem and, above all, represented a major economic obstacle to the exploitation and commercialization of natural resources [39].

A Commission for Malaria Studies, in 1932, showed that the Magdalena Valley regions were malarious, some of very low intensity and others not endemic [40]. Concerns are raised about the health situation in the main mining enclaves and the need arises to carry out preliminary environmental studies before starting the exploration for gold and platinum. The health section of the ministry would be responsible for directing health campaigns, such as malaria, in rural areas and port health [41]. Starting in 1937, the organization and operation of the official and systematic reporting of the statistics of the communicable diseases of mandatory notification in the country was consolidated. In the period 1937-1939, 97,165 cases of malaria were registered in the country (Table 2). This decade closed with the outbreak of the Second World War.

In December 1941, the United States entered World War II, which led to closer relations with the 21 republics of Latin America to guarantee hemispheric security and provide technical assistance to improve health and sanitation in the region. Cooperation agreements are established with the Office of Inter-American Affairs of the US Department of State, among which a plan is defined for the implementation of health and sanitation activities in the region [42, 43]. The Inter-American Cooperative Public Health Service was created, which would function as an intermediary between the Inter-American Affairs Office and the Ministry of Labor, Hygiene, and Social Welfare to carry out these actions. In the Inter-American Cooperative Public Health Service, a Malariology Campaign was established to carry out surveillance and anti-malarial control along the Magdalena River to Barranquilla; campaigns against malaria in Tumaco and Buenaventura and were complemented by the services offered by the Sogamore ship in the Pacific [44].

Alliances were made with the largest mining transnational companies, such as Frontino Gold Mine and Pato Mines, for the evaluation of the sanitary situation, studies and surveys to perform antimalarial control [45]. At the request of the union, the risk of malaria transmission in rice production sites is evaluated [46]. During the development of World War II, the National Institute of Hygiene “Samper Martínez” to supply the low availability of antimalarial drugs caused by the war, increased the production of quinine and Totaquina to meet the demand for these drugs in the country [47]. In mid-1945, in the international context, World War II ended in favor of the allies, led by the United States of America, the new world power. In Colombia in 1947, the Malariology Division replaced the Malariology Campaign. This unit will carry out engineering works and experimental vector control projects with the new synthetic insecticide Dichlorodiphenyltrichloroethane (DDT), in some ports and cities of the country [48]. In 1948, a definitive international milestone was the crea­tion of the World Health Organization (WHO), an entity that would play an important role in the eradication campaigns of the time. It would oversee managing international policies for prevention, promotion, and intervention at a global level in health. In the previous year, Pan American Health Organization (PAHO) was restored in the region [49]. The health agencies registered in the 1940s an accumulated 461,742 cases of mala­ria and some 43,509 deaths from this cause in the country (Table 1).

Third stage. Control to eradication, intensified control-eradication, and prevention-control, 1950-1999

Outbreaks of political violence between liberals and conservatives reemerged and intensified in most of the national territory until the early 1960s. In addition, the government promotes the colonization of national territories [50]. Until 1956, malaria control activities were carried out by the Malariology Division and technically conduc­ted by the Inter-American Cooperative Service of Public Health. These were carried out through operational zones, complemented by campaigns in areas such as the Pacific [51]. In the mid-1950s, Colombia adopted the MEC. The preparatory phase of MEC was carried out between 1952 and 1956. The NMES, replaced the Malariology Division. In October 1958, this phase began with 100% coverage of the malarial area with DDT [52]. A cumulative 716,992 cases of malaria were registered in the 1950s, with an average of 71,670 cases per year and a median annual parasite index (API) of 11.5 per 1,000 inhabitants. In 1959, the first evalua­tion of the MEC was carried out, and that year, a reduction of more than 90% of the malaria endemic was recorded in relation to the average for the decade, but the goal of eradicating malaria in the country was not achieved (Figure 1).

In the sixties, social problems, moderate econo­mic growth, currency devaluation, price inflation, and the high cost of living were accentuated. The Eradication Plan was developed amid interruptions and setbacks [53]. A total of 208,720 cases of malaria were registered, with an annual average of 20,872 cases, registering a reduction of 57% of the endemic average in relation to what was registered in the 1950s. The median API was 2.7 per 1,000 inhabitants. Additionally, health agencies reported 11,266 deaths from this cause in that period, corresponding to 1,127 annual cases, and a 6% fatality rate, with a 47% reduction in relation to what was observed in the previous decade. There was a significant reduction in the malaria endemic, but this level of control was only maintained until the middle of the decade. It is the period with the lowest levels of incidence of the disease achieved in the country. (Table 1).

During the decade of 1970-1979, there was an intensification of rural colonization in the territories of Orinoquia and Amazonia. The planting of illicit marijuana crops and an increase in drug trafficking activity in the Caribbean and Orinoquia regions, which caused a greater population displacement, began to become evident. In addition, there was a gradual growth and dominance of insurgent groups in these rural regions of the country. The NMES becomes the Directorate of Direct Campaigns, maintaining its administrative autonomy and assigned functions. The MES adopts the new anti-malarial strategy promoted by PAHO [54].

At the end of the 1970-1979 period, a total of 412,515 cases were reported, which represented an increase in the malaria endemic by 140.5% relative to the sixties, a median API of 4.8 per 1,000. Additionally, epidemic outbreaks occurred in 1973, 1977 and 1979, which registered an unusual increase of 54.8 and 36% in relation to the average for this period (41,252 cases) (Figure 1). In addition, 7,388 deaths were reported from this cause, corresponding to 739 annual deaths, with a 65.6% reduction in this event compared to the previous period. The median fatality rate observed was 1.9% (Table 1).

During the eighties, malaria showed a worsening of transmission in the national territory due to the intensification of social, political, and economic contradictions in the country. It spreads and they continue to apply control measures intermittently [55]. 792,565 cases of malaria were registered, with an annual average of 79,256, and a median API of 10.2 per 1,000 inhabitants. In relation to the casuistry of the previous decade, an increase of 92% was registered. Epidemics are registered in 1983 and the endemic level rises from 1986 to the end of the decade. Mortality from malaria in the period showed an accumulated in the period of 4,038 deaths and that represent an average of 404 annual cases, lethality 0.6%. There was an 83% reduction in deaths from malaria in the seventies (Table 1).

In the nineties, there was an environment of political crisis, ideological pluralism, economic and social crisis, foreign debt, guerrillas, and drug trafficking, paramilitarism, terrorism and other problems. Political changes are presented such as a new constitution, administrative decentralization, the popular election of mayors, a new General System of Social Security in Health, and national transfers, among others [56]. The Special Administrative Unit for Direct Campaigns was created, which retains the assigned functions and imposes the task of decentralizing and deconcentrating the program for the prevention and control of malaria and vector-borne diseases at the sub-national level. In mid-1994, the country adopted and adapted the technical elements of the World Malaria Control Strategy in the National Malaria Prevention and Control Plan. Likewise, a strategic plan was defined, where the recommendation to decentralize the management of existing vertical campaigns to horizontal programs was made from the local level; the integration of malaria control into the health services and the delegation of responsibilities and resources was initiated to be used more appropriately by those who are directly in contact with the problem [57]. True to its tradition, the country welcomes and adapts the Roll Back Malaria initiative at the end of the decade. Historically, in this decade, the largest casuistry was recorded in the entire period studied, 1,567,332 cases. An increase of 97% was observed in relation to the behavior observed in the previous decade. 1,445 deaths from malaria were recorded and a sustained decrease was maintained (Table 1).

Fourth stage: prevention-control and elimination 2000-2019

In this stage, the spread of coca-growing areas and illegal mining proliferate and increase in the main sources of active transmission, which increases the malaria potential due to the migration of susceptible and parasite carriers to the receptive areas. In addition, little political commitment and weak local response capacity persist. Projects are carried out with international financing [58]. During the first decade of the 21st century, a cumulative 1,401,106 cases of malaria were registered. Although a reduction of close to 9% was observed in relation to the last decade of the 20th century during 2002, a major malaria epidemic was registered in the country followed by a downward trend in the endemic. The deaths were 322 accumulated (Table 1).

In the period 2010-2019, the National Public Health Plan 2012-2021 was defined, a demonstration project on malaria financed with international funds is implemented, and the commitment to eliminate malaria is adopted [59]. A sustained reduction of the malaria endemic of 48% was observed, in relation to what was registered in the previous decade and a decrease in mortality of approximately 50%. However, a pattern of important seasonal outbreaks was observed in the Pacific, Orinoquia and Amazon regions due to migration problems.

CONCLUSIONS

The epidemiological evolution of malaria as observed since the beginning of republican life in Colombia has been determined by the contradictions and interactions resulting from certain economic, political, social, military, and cultural development of capitalist forms of production that occurred during this period at the national, regional and global levels. During the processes of economic exploitation of natural resources and raw materials such as tobacco, cinchona, indigo, rubber, gold and platinum mining and oil, among others, in receptive regions of interest in the national territory where environmental interactions and negative social conditions have been evidenced by the abrupt and sudden appearance of emerging, expansive, reemerging epidemic outbreaks until the current endemic malaria epidemic transmission was maintained. Additionally, the opening of roads, the construction of railways and the initial attempt at building the Panama Canal also contributed to the situation. More recently, the intensification of armed social conflicts, violence and the spread and intensification of illicit crops have made an important contribution to the persistence of endemic malaria epidemic transmission in the country.

Its importance as a problem stems from its role as one of the greatest obstacles to the processes of economic exploitation of natural resources and raw materials in the tropics, affecting at different times economic efficiency, production costs and the reduction of margins of gain. Based on the level of scientific knowledge on the subject, the technological development achieved, and the experiences acquired in specific situations in colonial settings and sites of political and economic interest, contributed to structuring the different paradigms of the fight against malaria.

In our country, the strategic anti-malarial control initiatives implemented in different historical moments have been the result of technical cooperation agreements established with the International Health Organization, the Rockefeller Foundation, and the Office of Inter-American Affairs of the United States, who imported, organized, directed, and transferred public health issues, such as malaria, during the first half of the 20th century. There has been little impact on the behavior of malaria morbidity in the country throughout the period studied.

However, the maintenance of a marked reduction in mortality from this cause is noteworthy due to the improvement in accessibility to health services that has led to the strengthening of the strategy of early diagnosis, timely treatment, and follow-up of cases. Finally, the determinants that have influenced and explained the persistence of the endemic epidemic transmission of the disease include the growing inequity and social inequality, the worsening and intensification of armed social conflict, corruption, the expansion of illicit crops, drug trafficking and illegal mining. Others include the low leadership of the health sector; there is very little commitment from the institutional or social actors involved at the subnational and local levels. Furthermore, the institutional capacity for the technical and operational management of regular and contingency prevention and control programs at the subnational and municipal levels is very weak or nonexistent. The contingency, technocratic and traditional empirical approach persists and has generated strong and ingrained paternalism to the actions carried out by the health sector and a low perception of risk and responsibilities for the problem in the population, institutions, and potentially allied sectors.

Perspectives

Institutional and social managers need to understand the complexity, dynamics, and multidimensionality of the problem, according to specific situations. In this way, a comprehensive, dynamic, and flexible, multidisciplinary, cross-sectoral approach could be adapted, with the participation of the institutional and social actors involved in the problem, national and international strategic partners, establishing an integrated management strategy as a reference framework under the leadership of the health sector.

It is necessary to prioritize and promote, as soon as possible, a process of sustained institutional development to optimize and strengthen the technical, administrative, and operational management capacity at the subnational and local levels. This is essential to be able to have a solid technical and operational response capacity that guarantees the sustained development of health promotion, prevention, epidemiological intelligence activities and the comprehensive clinical approach to cases within the framework of a regular program. In addition, it is essential to improve the capacity for timely detection and control of contingencies produced by malaria epidemics at the subnational and local levels through solid epidemiological intelligence and to improve the supervision, monitoring and evaluation of actions and promote applied research on malaria. In addition, mechanisms must be implemented that guarantee the commitment and permanent political support of the municipalities and optimize international technical support and cooperation according to the country’s needs.

Financial support

The authors received no financial support for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that there is no conflict of interest.

Acknowledgments

The authors would like to thank the knowledge management, research and innovation network in malaria.

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