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Combating Malaria in Ethiopia: The Early Public Health Initiatives of USAID

After thirteen months of combating the novel coronavirus pandemic through periods of quarantine, mask mandates, and social distancing, all adults in the United States are now eligible for the COVID-19 vaccine that continues to become more widely available with each passing day. Whether it be Pfizer, Moderna, or Johnson & Johnson, vaccines have been a hot topic of conversation; and getting them into the arms of Americans has proved to be a positive turning point in the return to normalcy and curbing the devastation of the pandemic. However, the COVID-19 vaccine is not the only vaccine that has recently made headlines.

Malaria Mosquito (2015) | Pixabay
Malaria Mosquito (2015) | Pixabay

A new malaria vaccine has shown promise in preliminary trials that proved to be 77 percent effective in a group of 450 children. While the research and trials must continue on to further stages, this breakthrough is monumental in the fight against malaria, a disease that kills 400,000 people a year, mostly children.

Although it seems that we are just now experiencing signs of promise regarding malaria and the production of an effective vaccine, the United States has spent decades providing resources for research and malaria control for struggling communities and nations, especially in Africa where nearly 95 percent of malaria deaths occur. According to USAID [United States Agency for International Development], American leadership has helped prevent more than 1.5 billion malaria cases and saved the lives of over 7.5 million individuals since 2000. However, USAID’s efforts in the fight to curtail malaria are by no means a novelty of the last two decades. USAID deployed various methods to fight malaria as early as the 1950s, including contributions and funding for a potential vaccine that, unfortunately, did not prove successful, but led to key findings and developments.

A pioneer in international health programs, Dr. Julius S. Prince had firsthand experience with the disease gripping Africa and the early initiatives USAID had underway to help these people in developing countries. Acting as the chief of the Public Health Division, Prince served as the leader to USAID’s [International Cooperation Administration at the time] Ethiopia Mission. In this “Moment” in U.S. diplomatic history, Prince describes the malaria epidemic that brought devastation to Ethiopia in 1958 and the public health programs, projects, and evaluations undertaken by USAID in collaboration with the Gondar Public Health College and Training Center in the early fight against the disease.

Julius S. Prince’s interview was conducted by W. Haven North on January 24, 1994.
Read Julius S. Prince’s full oral history HERE.

Drafted by Jacqueline Chianca

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Excerpts:

“As far as I can tell, this was the first enunciation of the basic concept involved in the establishment of a training program.”

The Foundation for Health Programs in Africa:
PRINCE: [Dr. Henry R. O’Brien] was at that time the Commissioner of Health for the Pennsylvania State Health Department. He came to Ethiopia at the request of the Ethiopian Government and traveled quite widely around the country, meeting the relevant officials and field medical personnel available. As a result, he was able to make an overall recommendation for the development of health services in the country, which included the establishment of “a demonstration health department and field training school for medical assistants to be set up in one of the provinces, with cooperative support in supplying both staff and equipment from the Ministry of Public Health, U.S. Technical Cooperation Administration [USAID’s predecessor], and WHO.” As far as I can tell, this was the first enunciation of the basic concept involved in the establishment of a training program epitomized by that which was organized in and around the Gondar Public Health College and Training Center.

Q: First, in what context…?

PRINCE: In the context of the establishment of a school for the training of paramedical personnel to fill a gap that was created by the lack of “fully qualified health personnel,” i.e, of physicians.

Training programs were considered essential to meet the long range objectives of health programs, namely, the development of health services in a given country. And the training of several categories of health workers was felt to be necessary for this purpose. In addition, while the training of paramedical and auxiliary health workers is going on, it was concluded that the training of teachers in these disciplines should be carried out concurrently and that these projects should be designed in such a way that the host country can take them over as rapidly as possible.

“I believed that we have to be concerned about the health of people in other countries because everything is related to everything else.”

An Interest in International Health Problems:
PRINCE: I should add that I had been interested in international health problems, especially since my work overseas in World War II and the research at Harvard and Chautauqua County simply reinforced that interest. In addition, I was completely “converted” to the belief that we are not, as [George] Santayana said, “an island” and similarly, I believed that we have to be concerned about the health of people in other countries because everything is related to everything else. So that is the philosophical reason why I wanted to do this kind of work. But as well, there was the technical one in trying to see if my ideas on evaluating impact of development programs were sound. So it wasn’t long before I was on my way to Ethiopia.

“And never having had any experience with malaria epidemics, I was astonished.”

           
Malaria Patient, Nyangaton, Ethiopia (2014) Rod Waddington | Wikimedia Commons
Malaria Patient, Nyangaton, Ethiopia (2014) Rod Waddington | Wikimedia Commons

Setting the Scene and Getting to Work:
PRINCE: Arriving in Ethiopia, I wasn’t allowed to have any time to think about Gondar [Public Health College and Training Center] because the minute I got off the airplane in Addis Ababa my staff was there and said, “Dr. Prince, come on, we’ve got to get to work with the Ministry. Ethiopia is in the grip of a terrible malaria epidemic.” And never having had any experience with malaria epidemics, I was astonished. The reasons why such things apparently exist are set forth in a paper which Russell Fontaine and Abdallah Najjar and I wrote in 1961, in which we pointed out the epidemic’s likely relationship to the peculiar ecology of the country and lack of malaria immunity among the relatively high altitude inhabitants who were usually not exposed to the disease.

Basically, it had to do with the altitude and meteorological conditions necessary for mosquitoes to breed under certain conditions. But in 1958 things were just right, we suspected, in terms of temperature, humidity, rainfall and the like, for mosquitoes to breed in locations even well above 5,000 foot altitude.

Well, we went directly to the Ministry of Health that morning and joined the planning already underway. And the only thing to do was rapidly to get as much chloroquine tablet medication as possible into the country and distribute it for emergency treatment of all individuals found to be febrile as widely as one could over the affected areas and also do that as rapidly as possible; for time was of the essence. It was mainly a logistics problem; and that is what the Ministry of Health undertook. From the Mission we sent cables to the U.S, U.K., and Kenya to try and obtain chloroquine tablets in sufficient amounts and in the shortest possible time to deal with this enormous pandemic.

“I doubt that many health workers have any idea how significant the work that was done in [Ethiopia] was.”

Sowing Seeds of Progress:
But generally speaking, I doubt that many health workers have any idea how significant the work that was done in [Ethiopia] was in the development of an approach to recommended health policies and strategies in much of Africa. But the truth of the matter is that none of these ideas were particularly prevalent in Africa and, in fact, were mostly nonexistent in those days, in the very beginning of 1952 when the Gondar project got underway. But there was concern about the situation and consequently it became a “fertile field” in which to suggest innovative concepts of public health practice. Little did I know, even then, how relevant that was and how important it would be to try to sow these seeds of progress!

“The whole program for improving health services delivery in that country, and what AID has done elsewhere, showed us that what we really need to do to get in motion in these countries, is to train top level professionals with a global interdisciplinary view.”

Lessons Learned:
It seems to me that the projects in Ethiopia in health and agriculture showed us that we had to put a lot more emphasis on providing opportunities for institutions of higher education in the U.S. to work with the developing country institutions of higher education in the third world to help them achieve the kind of objectives in training and policy innovations as well as to avail themselves—the U.S. institutions I mean specifically—of lessons to be learned from experiential and training programs in the third world countries where they have established relationships with the mentioned institutions of higher education.

And I think that this is a lesson that needs to be taken to heart in terms of what we are trying to do in helping people around the world, especially in developing countries, to improve their own welfare. Clearly, it seems to me that the [Demonstration and Evaluation] project in Ethiopia, as well as the whole program for improving health services delivery in that country and what AID has done elsewhere, showed us that what we really need to do to get in motion in these countries, is to train top level professionals with a global interdisciplinary view of things so that they in turn may teach in top level professional schools and, as appropriate, in paraprofessional schools, because they can have such a profound influence on their students’ thinking. And their students could then “carry the ball” worldwide as appropriate, and may well become leading officials and innovative thinkers and policy makers in their own countries.

TABLE OF CONTENTS HIGHLIGHTS

Education
BA Yale University 1928–1932
MD Columbia Universityad’s College of Physicians and Surgeons 1934–1938
MPH Columbia University School of Public Health 1947–1948
Dr. PH Harvard University 1952–1953
Joined the United States Agency for International Development 1958
Gondar, Ethiopia—Chief of the Public Health Division 1958–1967
Tunis, Tunisia—USAID Population Study 1967
Accra, Ghana—Director of the AFR Regional Population Officer 1967–1973