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CSU 82/2009: MALARIA ELIMINATION IN SARDINIA, 1945-1950

Wednesday, 23rd of December 2009

CSU 82/2009: MALARIA ELIMINATION IN SARDINIA, 1945-1950

 This year’s series of updates ends with an historical glimpse at the early
 days of malaria eradication, also available at
 http://www.cdc.gov/eid/content/15/9/1460.htm  The title notwithstanding,
 Emerging Infectious Diseases runs many articles of interest to a broad
 audience of readers.
 This year, remarkably, we have a rare December conjunction of Muharram,
 Hanukkah, and Christmas. Best wishes to all who are celebrating.
 Good reading.
 BD
 Please see below, by topic, the updates covered in calendar 2009. What have
 I omitted?
 
 
 |-------------------------------------------------------------------------+-------|
 |TOPICS |TOTAL |
 |-------------------------------------------------------------------------+-------|
 |MEASLES |23 |
 |-------------------------------------------------------------------------+-------|
 |MALE CIRCUMCISION AND HIV PREVENTION |13 |
 |-------------------------------------------------------------------------+-------|
 |DISEASE ERADICATION |9` |
 |-------------------------------------------------------------------------+-------|
 |MALARIA |9 |
 |-------------------------------------------------------------------------+-------|
 |POLIO |7 |
 |-------------------------------------------------------------------------+-------|
 |VACCINATION AND EPI |7 |
 |-------------------------------------------------------------------------+-------|
 |INFANT,  CHILD AND YOUTH MORTALITY |4 |
 |-------------------------------------------------------------------------+-------|
 |HUMAN PAPILLOMAVIRUS VACCINATION |4 |
 |-------------------------------------------------------------------------+-------|
 |BIRTH  SPACING |4 |
 |-------------------------------------------------------------------------+-------|
 |SMOKING |3 |
 |-------------------------------------------------------------------------+-------|
 |RUBELLA VACCINATION, DEWORMING, SCHISTOSOMIASIS, H1N1 VACCINATION, HAND |2 |
 |WASHING IMPACT, PNEUMOCOCCAL DISEASE AND VACCINATION, ORAL CHOLERA |EACH |
 |VACCINATION | |
 |-------------------------------------------------------------------------+-------|
 |MDGs IN BANGLADESH, HEALTH IN CUBA, FILARIASIS, FUNDING FOR NEGLECTED |1 |
 |TROPICAL DISEASES, IMCI, EQUITY, GLOBAL INITIATIVES AND HEALTH SYSTEMS, |EACH |
 |PEPFAR EVALUATION, SELECTIVE ABORTION, SOUTH AFRICAN HEALTH POLICIES, | |
 |LEPROSY, MNTE, CHAGAS,  YELLOW FEVER, PELLAGRA, VITAMIN A, HIV RISK, | |
 |KOCH’S POSTULATES, TB, CHOLERA, AFRICA’S DEMOGRAPHIC TRANSITION | |
 |-------------------------------------------------------------------------+-------|
 
 
 
 
 
 Volume 15, Number 9–September 2009
 Historical Review
 Program to Eradicate Malaria in Sardinia, 1946–1950
 Eugenia Tognotti
 Author affiliation: University of Sassari, Sardinia, Italy
 Suggested citation for this article
 Abstract
 During 1946–1950, the Rockefeller Foundation conducted a large-scale
 experiment in Sardinia to test the feasibility of indigenous vector species
 eradication. The interruption of malaria transmission did not require
 vector eradication, but with a goal of developing a new strategy to fight
 malaria, the choice was made to wage a rapid attack with a powerful new
 chemical. Costing millions of dollars, 267 metric tons of DDT were spread
 over the island. Although malaria was eliminated, the main objective,
 complete eradication of the vector, was not achieved. Despite its being
 considered almost eradicated in the mid-1940s, malaria 60 years later is
 still a major public health problem throughout the world, and its
 eradication is back on the global health agenda.
 In 1944, Sardinia was used as a test site for eradicating native
 malaria-carrying mosquitoes (1). During that year, the insecticide DDT
 (dichloro-diphenyl-trichloroethane) was sprayed inside houses to annihilate
 mosquitoes in Castel Volturno (2). During that spring, another trial was
 conducted in the Tiber Delta and Pontine marshes, where breeding sites of
 Anopheles labranchiae, the most common, abundant, and widely distributed
 vector in the Mediterranean basin, had increased dramatically after German
 troops strategically flooded a large area to hinder the movement of the
 Allied Armed Forces (3). In the face of a potential malaria outbreak, the
 Allied Malaria Control Commission studied the effect of the DDT spray, in
 the absence of other control measures, on anopheline density.
 The operations in central Italy were under the direction of Paul F. Russell
 and Fred Soper, officers of the Rockefeller Foundation. Russell was a
 veteran of malaria-control campaigns and a graduate of the Harvard School
 of Public Health Soper was a public health administrator and epidemiologist
 who during 1939 and 1941 (4) had directed successful eradication campaigns
 of an invading vector, A. gambiae, in Brazil and Egypt. Attempting to
 eradicate the indigenous well-adapted mosquito species A. labranchiae was
 more difficult than attempting to eradicate an invading vector. Both
 believed that the miraculous effectiveness of DDT (5) opened up a dazzling
 new era for the study of malaria: DDT was highly effective against the
 parasite-carrying mosquitoes and interrupted the transmission of the
 malaria parasite. In addition DDT was inexpensive, considered safe, and
 easy to use.
 In this climate of optimism, the Italian malariologist Alberto Missiroli
 convinced civil authorities in Italy to conduct a massive malaria control
 program. The United Nations Relief and Rehabilitation Administration
 (UNRRA) provided funds (6). The idea of large-scale eradication work in
 Sardinia took shape in a series of meetings involving Missiroli, the
 director of UNRRA for Italy, and Soper, who was a staunch advocate of the
 vector-eradication approach to malaria control.
 In a July 1945 letter from Italy (7), Soper informed George H. Strode,
 scientific director of the International Health Division (IHD), that
 Missiroli was "very insistent that the first work" begin in Sardinia. He
 also reported on meetings with Colonel Reekie of the UNRRA. They had
 undertaken a rapid reconnaissance flight over Sardinia, and in conclusion
 Soper stated:
 …from available information and what little I had seen it appeared that
 anopheles eradication in Sardinia might be entirely feasible if the
 materials, transportation, money, and authority could be made available.
 Last-minute decisions left little time for planning. In their haste, the
 Rockefeller Foundation staff underestimated the difficulties of the
 project. In addition, the rush to conclude the agreement with government
 representatives in Italy and with the High Commissioner for Sardinia led to
 a lack of clarity about the goal of the campaign (8). The aims of the IHD
 were entirely scientific, as was clearly explained in a letter from Strode
 to the UNRRA director in 1946: "The only reason that I was interested in
 the proposal was the fact that we were to attempt an eradication program
 among the indigenous species of anophelene" (9).
 However, the public health authorities in Italy were interested in
 implementing a full-scale public health program and were willing to invest
 heavily in this endeavor and use their recovery funds. They were unlikely
 to have devoted so much interest to support a purely scientific experiment.
 This ambiguity dragged on for 2 years. Ultimately, the project became a
 public health campaign against malaria. A change in the goal enabled the
 Regional Agency for the Anti-Anopheles Struggle in Sardinia (ERLAAS) team
 to convince the increasingly reluctant High Commissioners for Hygiene and
 Health to divert funds from the scant health budget toward the campaign.
 The story of the "Sardinian Project" (Technical Appendix, note 1 [ 91 KB, 3
 pages]), the greatest antimalaria effort in Europe since the discovery of
 the cycle of transmission of the disease, needs to be reexamined in the
 light of the recent debate about the new global malaria eradication
 strategy (10). This article, based on firsthand sources such as letters,
 memoranda, and diaries (8), concentrates on the objectives, errors,
 results, and final implications of the campaign.
 Sardinia, a Malaria-Endemic Island
 Malaria is believed to have been introduced to Sardinia by infected workers
 imported from North Africa after the Carthaginian conquest of Sardinia in
 502 bc. The disease became endemic to this region during the medieval
 period (11), but since the classical ages, Sardinia had been tarred with
 the reputation as an "unhealthy island" (12) (Technical Appendix, note 2 [
 91 KB, 3 pages]). In the last decade of the nineteenth century, the average
 number of deaths caused by malaria on this island oscillated between 2,000
 and 2,200 per year (in 1901, the island had a population of 795,793) (13).
 Sardinia kept the unfortunate primacy of being the most malaria-ridden
 region in Italy (Table 1) because of the high prevalence of Plasmodium
 falciparum and its associated high mortality rates. Rates were particularly
 high for children <5 years of age in highly malaria-endemic areas.
 Economic and demographic development (14) was dramatically inhibited.
 Malaria infested the plains, which constituted the most fertile and least
 populated areas. The productivity of those affected with chronic disease
 was low, and they were unable to work during fever attacks (15). A decline
 in the mortality rate began after advanced antimalarial legislation
 (1900–1907) provided free quinine, which attacks malaria parasites in the
 bloodstream. In the 1920s and 1930s, the fascist regime carried out an
 indirect battle for eradication through its great land reclamation project,
 which used modern technology on a large scale for drainage and sanitation (
 16). The centralized "Italian way" produced a decline in malaria mortality
 rates, but rates also declined as a result of greater access to medical
 services by the rural population, the main reservoir of malaria in the
 past. Over 40 years, mortality rates declined from an average of 2,000
 during 1890–1900 to 138 in 1939 and 88 in 1940. The decline in illness and
 death from malaria was interrupted only by the 2 world wars: in 1946,
 74,600 malaria cases and 169 deaths were reported (17).
 At that time, malaria was still endemic to Sardinia. In 1947, an ERLAAS
 survey showed an overall spleen index (a measure of splenomegaly) of ≈21%;
 in many low-lying places, the index approached 100% (18). The effect of
 malaria on public health and economic growth was still severe; according to
 contemporary analyses, the vicious circle of poverty and disease could be
 broken only by eliminating malaria. Sardinia, therefore, appeared to be the
 ideal site. It was an island. In addition, the weakness of local power
 represented an additional advantage for a project that verged on being a
 military occupation of the territory.
 However, there were enormous organizational and logistical problems. One
 was the sheer size of the island: 9,294 square miles, with mountainous
 massifs and ravines. Another was the fast-flowing streams that carried
 water into low-lying areas in the springtime, forming stagnant pools (19).
 The island was virtually devoid of internal communication systems, and the
 inhabitants lived almost exclusively in villages. Few local people had
 technical expertise, and it was not easy to recruit and train people as
 disinfectors, larva scouts, and sprayers or to find suitable staff to
 perform supply, transport, and administrative services. However, these
 obstacles did not hinder the IHD decision to implement the program. They
 feared that the ongoing crisis in UNRRA and the unstable political balance
 in Italy might ultimately impede their efforts.
 On October 2, 1945, the Rockefeller Foundation formally agreed to
 collaborate in the project. A few weeks later, UNRRA allocated an initial
 sum of US $400,000 and approved the plan, in agreement with the Italian
 government and the Rockefeller Foundation. In April 1946, the IHD founded
 the special agency ERLAAS to implement the program. The first director was
 John Austin Kerr, and the medical entomologist was Thomas Aitken. The
 island was divided into divisions, sections, and sectors of 2.8 square
 miles, the basic geographic unit for antilarval spraying. The entomologic
 service headquarters were set up in Cagliari, and the chief executive
 officers operated from there. Workers on the ground were responsible for
 day-to-day operations in their specific localities and were crucial to the
 entire operation. The organization followed military principles of
 hierarchy and discipline. Scouts for larvae and pupae were given rewards
 for good work and penalized for sloppy performance.
 Difficulties of the Antimalaria Campaign
 Problems emerged even before the Sardinian Project began. Aitken's
 entomologic survey indicated that 3 principal species of Anopheles
 mosquitoes were in Sardinia: A. labranchiae, A. algeriensis, and A.
 claviger. Unlike tropical malaria-carrying mosquitoes that thrive close to
 villages, A. labranchiae "breeded usually in open water, but is often found
 in marshes and mountain streams" (20). According to some estimates, the
 number of water sites was somewhere between 1,000,000 and 1,200,000.
 
 
 |-------------------|
 | Figure 1 |
 |-------------------|
 | |
 |-------------------|
 |Figure 1. Donkeys |
 |used to transport |
 |equipment and |
 |larvicide in hilly |
 |territory, |
 |Sardinia, |
 |1948–1950. |
 |Photograph by |
 |Wolfgang |
 |Suschitzky. |
 |Reprinted with |
 |permission from |
 |Istituto |
 |Etnografico della |
 |Sardegna. |
 |-------------------|
 | |
 |-------------------|
 | Figure 2 |
 |-------------------|
 | |
 |-------------------|
 |Figure 2. Poster by|
 |the Regional Agency|
 |for the |
 |Anti-Anopheles |
 |Struggle in |
 |Sardinia. |
 |Photograph by |
 |Wolfgang |
 |Suschitzky. |
 |Reprinted with |
 |permission from |
 |Istituto |
 |Etnografico della |
 |Sardegna. |
 |-------------------|
 | |
 |-------------------|
 | Figure 3 |
 |-------------------|
 | |
 |-------------------|
 |Figure 3. |
 |Larviciding. |
 |Photograph by |
 |Wolfgang |
 |Suschitzky. |
 |Reprinted with |
 |permission from |
 |Istituto |
 |Etnografico della |
 |Sardegna. |
 |-------------------|
 | |
 |-------------------|
 | Figure 4 |
 |-------------------|
 | |
 |-------------------|
 |Figure 4. Aerial |
 |spraying of DDT in |
 |Sardinia, 1948. |
 |Photograph by |
 |Wolfgang |
 |Suschitzky. |
 |Reprinted with |
 |permission from |
 |Istituto |
 |Etnografico della |
 |Sardegna. |
 |-------------------|
 
 
 During their investigation, the entomologists faced the alarming fact that
 making a sharp distinction between the breeding places of A. labranchiae
 mosquitoes and those of other species was impossible. As a result, larva
 control was extremely difficult. The topography and the altitude of the
 various breeding sites meant that operations took longer and were more
 costly than forecast. Mules and donkeys (Figure 1) rather than jeeps had to
 be used to transport equipment. By mid-1946, it was already clear that
 eradication of the indigenous vector would be far more difficult than
 eradication of invaders such as A. gambiae mosquitoes in Brazil. Complaints
 in this regard made by superintendent Kerr to IHD headquarters were not
 well received. As well, their eagerness to achieve their objective
 encouraged them to overlook alarming information about the potential
 toxicity of DDT (Technical Appendix, note 3 [ 91 KB, 3 pages]), of which
 Fred Soper was aware as he insinuated in a letter, suggesting that there
 were "contraindications to the use of DDT as a larvicide as planned." At a
 meeting of agricultural entomologists in Riverside, California, USA, he had
 heard alarming news of rather high concentrations of DDT being found in
 animal milk. These were not "carefully studied observations," but he
 advised, "Caution may be indicated" (21).
 In the summer of 1946, Kerr began warning about the need to study potential
 reinfestation after the campaign, stating that "a period of at least one
 full year" was needed for extensive ecological field studies (22). About
 Kerr's insistence, Soper wrote ironically to Strode that, "It is indeed to
 be regretted that the word 'ecology' was ever invented, or having been
 invented came to [Kerr's] attention" (23). In October 1946, the second
 ERLAAS Advisory Committee approved a new plan that included indoor residual
 spraying, trial larviciding, and all-out larviciding of the entire island.
 Despite the optimism of IHD leaders, Kerr's misgivings increased. According
 to an account by the parasitologist O.R. McCoy, who visited Sardinia for
 the IHD, substantial problems had arisen as a result of Kerr's conviction
 that eradication was impossible. Kerr's concerns, and the tremendous
 difficulties of the eradication program, threatened to delay the operations
 by a whole year, at the risk of losing UNRRA funding. Hostility toward the
 organization increased. The aid to Eastern European countries was seen as a
 dangerous instrument that was facilitating the consolidation of communist
 governments. McCoy wrote, "Since additional funds depend upon UNRRA's
 recommendation it is essential that the budget for another year of work be
 approved." And, "The stake is too great," McCoy emphasized, "It was made
 very clear that the next few months during which UNRRA is still functioning
 are critical as far as ERLAAS is concerned."
 Budget problems were becoming increasingly challenging, partly because of
 fluctuations in the value of the lira. Field experience had shown that the
 campaign would have to take longer than expected. Again, the Italian
 government reluctantly provided additional funds that permitted the program
 to continue. By June 1947, ≈85% of all villages and towns in Sardinia had
 been completely sprayed with DDT. The operations consisted of a single
 spraying of every room in every house, all outhouses, and isolated
 buildings in the countryside, including the ancient nuraghi (stone
 dwellings centered on a main tower or fortress) (24).
 Effects of Early Cold War Tensions
 Additional problems were created by the tensions of the Cold War
 (continuing state of conflict, tension, and competition after World War II)
 (25). On July 2, 1947, the Sardinian edition of l'Unità, a newspaper that
 served as the mouthpiece of the Communist Party, wrote that ERLAAS was
 creating a neo-fascist organization in Sardinia, with a hierarchical,
 almost military, structure that had 600 vehicles and cells (organized
 groups) in the villages. This information appeared in the International
 Herald Tribune on July 21, 1947. In the following months, communists began
 promoting disruption of the execution of the Marshall Plan by means of open
 confrontation with local governments. This situation prompted the IHD to
 transform the original objective and proceed more swiftly. "The eyes of the
 world were upon the Anopheles eradication," and it was of prime importance
 to move forward at all costs before a crisis ensued (26). However, Kerr's
 conviction that the eradication of A. labranchiae mosquitoes was not
 feasible (27) was problematic. Finally, in a dramatic letter to Strode, the
 superintendent commented "I do not have either the mental or physical
 stamina for this task, which I am convinced is certain to fail." The
 frantic correspondence among the chief executives indicated that they
 feared that the campaign was destined for failure, while they were
 intending to present positive results at the first meeting of the World
 Health Organization Expert Committee on Insecticides, which would take
 place in Cagliari in May 1948. In September 1947, the following dramatic
 scenario played out, including a letter from Bauer to Strode:
 It would be a tragedy if the project was abandoned now without a thorough
 trial. It would open us to all sort of criticism, especially in view of the
 fact that a large sum of money which did not belong to us in the first
 place has already been spent; Italian communists would jump on this
 occasion (28).
 The ultimate decision was that Kerr should be replaced. Under the new
 superintendent, John Logan, the operations continued with the planned
 residual spraying against adult mosquitoes. A quarantine service was set
 up, and ships and planes arriving in Sardinia were inspected (29).
 Political tensions grew as the elections of April 1948 approached. The US
 government intervened in Italy to prevent the Communists and the Socialists
 from winning election funding. The Truman administration declared that no
 further help from the European Recovery Program (Marshall Plan) would be
 given to the country if the Communist party won the elections (Technical
 Appendix, note 4 [ 91 KB, 3 pages]).
 Communist press attacks on the Rockefeller Foundation increased. Some
 newspapers wrote that the ERLAAS vehicles were secretly armed and equipped
 to "take over" Sardinia. A radio report from northern Italy claimed that
 ERLAAS was paving the way for the transformation of the island into an
 enormous US air base (30). Furthermore, antagonism to the larviciding was
 growing, and legal actions for damages were pending.
 Overall, ERLAAS operations were welcomed by the people of Sardinia. The
 inhabitants of the rural areas appreciated the abatement of mosquitoes and
 houseflies. Exhortations to the disinfectors appeared in verse on rocks and
 house walls. The few criticisms of the campaign concerned the "violence of
 the method."
 In 1948, a sociologist a report on communism in Sardinia concluded that
 "the popular Front deputies at Rome could cause some outcry over the
 allocation of government controlled funds for equipment" (31). At this
 time, the staff of the Sardinian Project did not speak of "an eradication
 program among indigenous species of anophelines" but of "a large project
 which is one of the most important public health in the world today" (32).
 Various leaflets were used to demonstrate the beneficial effects of the
 campaign. One showed "before" and "after" images of Sardinia; "before"
 pictured a frowning sun and a giant mosquito, and "after" featured a
 smiling sun and an island free of mosquitoes, wiped out by a jet of DDT (
 Figure 2).
 At the end of 1948, the campaign entered its final phase. In the summer of
 1948, the last offensive against Anopheles larvae (Figure 3) was launched
 as sort of a "Normandy Landing" with an army of 30,000 men. Foci were
 cleaned with long-handled billhooks, vegetation was cut back, 100,000 acres
 of swampland were drained, and tons of insecticide were spread over the
 island by aircraft and helicopters (Figure 4). At the height of the
 campaign, the weekly amount of pure DDT spread was about 3,250 kg.
 Approximately 110 km2 of water had been treated with a dose of 30 mg/m2 (33
 ). At the end of that year, the management of ERLAAS announced that the
 number of breeding places of Labranchiae mosquitoes had been drastically
 reduced. The presumed reduction was 99.93%. The remaining positive foci
 were mainly in isolated areas (34). In 1950, for the first time in the
 history of Sardinia, no new cases of the disease were reported on the
 island (Table 2).
 The first large-scale attempt to rid a malaria-endemic area of indigenous
 mosquitoes had not succeeded, but it did free Sardinia from malaria.
 Emphasizing this outcome enabled the hierarchy of the IHD to maintain the
 concept of eradication, which prevailed in 1955 in the Eighth World Health
 Assembly, and they voted to adopt DDT as a primary tool in the fight
 against malaria (35).
 IHD leaders slowly created a story of success (36). Writing to Missiroli,
 Paul Russell exalted the fact that "the local health authorities could
 forever keep it under control, while the first large areas previously
 infested with the disease could be reclaimed and cultivated." He also
 emphasized the scientific results:
 If the ERLAAS proves that it is not feasible to attempt complete
 eradication of a tenacious indigenous species like A. labranchiae as a
 measure of malaria control, such an answer will be of great value to the
 scientific world, because on all sides we hear the cry "eradicate the
 mosquito" (37).
 Conclusions
 During the campaign, under the pressure of various factors, the initial
 ambitious purpose had changed: Sardinia, at the end, was free from the
 disease, not from the vectors that remained. However, vector breeding
 places were drastically reduced by 99.93%.
 The widespread use of DDT was not required, considering the potential
 negative effect on the environment and on persons. To interrupt malaria
 transmission, indoor DDT spraying, as already demonstrated in peninsular
 areas where the chemical was sprayed in small amounts on the house walls,
 would have been sufficient.
 At the 60th anniversary of the end of the campaign, a risk-to-benefit
 assessment was possible. It is an established fact that the eradication of
 malaria contributed powerfully to the subsequent socioeconomic development
 and public health of the island.
 With respect to the possible long-term effects of DDT, a team of Sardinian
 researchers recently conducted studies to determine whether DDT has
 negatively affected the health of the human population of the island. On
 the basis of statistics on births and stillbirths in the prewar and postwar
 years (1945–1954), widespread use of DDT apparently did not affect
 stillbirth rates, infant mortality rates, or the male:female ratio of
 newborns (38). With regard to the potential carcinogenicity of DDT, the
 results of the most recent follow-up study of deaths among 4,552 male
 workers exposed to DDT demonstrated little evidence of a link between
 occupational DDT exposure and death from any of the cancers previously
 associated with exposure to this chemical (e.g., pancreatic cancer) (39).
 The researchers of this study argued that expansion of the cohort and
 collection of information are needed to clarify these findings. No studies
 of the environmental effects have been conducted.
 The lessons learned from the Rockefeller Foundation antimalarial campaign
 in Sardinia have contemporary relevance in discussions of DDT-based malaria
 control strategies around the world. Nevertheless, although DDT played an
 important role in the liberation of the island from malaria, it was not
 sufficient alone to accomplish the task. The benefits of this enormous
 expenditure of funds were cast-iron (inflexible) organization, exceptional
 technical and scientific expertise, and continuity in mosquito control
 efforts maintained by the regional government for decades after conclusion
 of the campaign. Geographic isolation also played a role. Furthermore, the
 support of UNRRA and of the Italian High Commissioner for Health, as well
 as the ability and experience of the Rockefeller Foundation staff,
 neutralized the considerable obstacles of lack of technical resources,
 expertise, and infrastructure on the ground. An additional factor was the
 favorable attitude of the local community, which had grown accustomed for
 decades to fighting malaria with quinine and with land reclamation projects
 that reduced the mosquito habitat.
 In conclusion, the Rockefeller Foundation antimalarial campaign in Sardinia
 was an important step in the development of malaria control policies in the
 20th century. It displays the various approaches to the control of malaria
 and contributes important lessons for the ongoing debate over possible
 solutions to the terrible problem of malaria and the difficult challenge of
 eliminating it from the modern world (40).
 Dr Tognotti is associate professor and professor of history of medicine and
 human sciences at the University of Sassari Medical School in Italy. Her
 research interests are the history of malaria in ancient and modern Italy
 and infectious diseases of the past, such as syphilis, cholera, and the
 1918 influenza pandemic.
 References
 1.     Stapleton DH. Lessons of history? The anti-malaria strategies
 of the International Health Board and the Rockefeller Foundation from
 the 1920s to the era of DDT. Public Health Rep. 2004;119:206–15.
 2.     Soper Fred L, Knipe FW, Casini G, Riehl Louis A, Rubino A.
 Reduction of Anopheles density effected by the preseason spraying of
 building interiors with DDT in kerosene, at Castel Volturno, Italy,
 in 1944–1945 and in the Tiber Delta in 1945. Am J Trop Med Hyg.
 1947;27:177–200.
 3.     Snowden F. The conquest of malaria: Italy, 1900–1962. New
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 4.     Packard RM, Gadelha P. A land filled with mosquitoes: Fred
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 5.     Missiroli A. Anopheles control in the Mediterranean area. In:
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 6.     Gladwell M. Fred Soper and the Global Malaria Eradication
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 7.     Rockefeller Foundation Archives. Letter. 1945 Jul 28; series
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 8.     Rockefeller Foundation Archives. Committee meeting minutes;
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 9.     Rockefeller Foundation Archives. Letter from GH Strode to WA
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 10.   Feachem R, Sabot O. A new global malaria eradication strategy?
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 11.   Sallares R, Bouwman A, Anderung C. The spread of malaria to
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 12.   Brown PJ. Malaria in Nuragic, Punic, and Roman Sardinia: some
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 archeology. Ann Arbor (MI): University of Michigan Press; 1984. p.
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