Intended for healthcare professionals

Editor's Choice

Several horsemen of the apocalypse

BMJ 2008; 337 doi: (Published 21 August 2008) Cite this as: BMJ 2008;337:a1365
  1. Tony Delamothe, deputy editor, BMJ
  1. tdelamothe{at}

    The eradication of smallpox was meant to be the harbinger of future triumphs over infectious diseases. But it’s looking more and more like a one-off. Polio was meant to have followed smallpox by 2000, but this deadline has been shifted forward several times.

    Similarly, tuberculosis refuses to go away. As a recent Lancet review reminds us, a third of the world is infected with Mycobacterium tuberculosis, and two million people die from tuberculosis every year, even though the BCG vaccine has been available for more than 75 years. For reasons unknown, this vaccine doesn’t seem to “work” in much of the world. The causative organism always keeps a few jumps ahead of our attempts to stamp it out. The emergence of extensively drug resistant tuberculosis on the heels of multidrug resistant tuberculosis is scary for the whole world, with South Africa currently on the front line of the battle (doi: 10.1136/bmj.a1385).

    Two articles in this week’s journal and an interview available on focus on malaria, another infection with a dispiriting recent history. As Geoff Watts tells us in his profile of Brian Greenwood, malaria kills one million people annually—most of them African children (doi: 10.1136/bmj.a1267). Professor Greenwood, who has just won the Hideyo Noguchi prize for medical research in Africa, is best known for showing the benefits of mosquito nets impregnated with insecticide in preventing infections. He thinks that, for most parts of Africa, eliminating malaria—that is, preventing its transmission—is a more realistic goal than eradication. He favours “squeezing the map”—starting at the edges of the malaria belt and moving inwards.

    Greenwood’s research unit is a beneficiary of the Bill and Melinda Gates Foundation, which has challenged partners to adopt the goal of eradication. Drawing on lessons from the first global malaria eradication programme (1955-69), Jo Lines and colleagues have a gloomy response: even time limited elimination remains unfeasible with existing tools (doi: 10.1136/bmj.a869). Instead of eradicating or eliminating malaria, they favour the more modest goal of reducing the burden of disease—firstly, by prioritising universal coverage of a few interventions. They’re no fans of “shrinking the map” if that entails diverting resources from high burden areas to places were elimination seems realistic.

    On you can hear Deborah Cohen interviewed about how Ethiopia has emerged as a beacon of hope among African countries battling malaria. With an annual health spending of $7 per capita, it’s highly dependent on outside aid to sustain its antimalaria programmes. What happens when the Global Fund’s support ends in a few years is already worrying health workers.

    For a little light relief, you might seek out Theodore Dalrymple’s dissection of John Buchan’s last book, Sick Heart River (doi: 10.1136/bmj.a1354). Published posthumously in 1941, it concerns a man whose diagnosis of fatal tuberculosis leads him on a voyage of self discovery to Canada’s frozen wastes. Buchan was governor general of Canada at the time and a martyr to peptic ulcer. Dalrymple describes him eking out “his bland poached eggs at elaborate state dinners while everyone around him gorged themselves.” Buchan’s doctors weren’t to know that peptic ulcer had an infective basis.

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