HOSTILITIES AGAINST MALARIA

Author: Konstantin Markov

Editor's Note: We tried gradually to build a story about the campaign against Malaria in Bulgaria. Already in an earlier issue of our booklist we presented some introductory notes — cf. "Striburni, L. Epidemiological and Biological Studies on Malaria in Belomorie and Makedonia. Sofia: 1946". This major effort of the bulgarian government — which is the first mass public health campaign in Bulgaria, per se — involved enormous material and financial resource for the interwar period 1920-1939. The hostilities against Malaria are presented here as they are included in two unpublished reports to the League of Nations, Health Organization. Official reporter is Dr. Konstantin Markoff, Inspector General for Malaria; meanwhile, the material is distributed in two equivalent copies in english and french /L'Etude du Paludisme en Bulgarie/. The figure of this public health activist stay misty in the whole narrative and entirely in the Directorate of Public Health. As good as it is, from the scanty material we have at hand and we could infer some important landmark points in his carrier: 1) with Prof. Bruno Galli Valerio, Lausanne, 1913; 2) with Prof. S. S. Abramov, Berlin, 1922; 3) with Prof. Muhlens at the Tropical Institute in Hamburg, 1923 and Dr. Sfarcic at the Anti-malarial Institute in Trogar (Dalmatzia), 1923. The vanguard role of this scholar is evident and we should continue our updates on the topic, ditto.

ORGANIZATION OF THE CAMPAIGN AGAINST MALARIA IN BULGARIA

Organization of the Malaria Service

A special law was passed in Bulgaria on April 16th, 1919 dealing with the campaign against malaria. The law established a Malaria Inspectorate to be attached to the Department of Public Health, consisting of three persons: a malaria medical expert (i.e., the principal malaria inspector), a hydrological engineer and a zoologist. All questions relating to malaria are decided by the Malaria Inspectorate; the most important questions are decided by the Supreme Medical Council.

The whole of Bulgaria is divided into malaria districts, each of which comprises forty to sixty villages. Each district is controlled by a malaria medical inspector. Attached to him are a microscope and a laboratory assistant. In each village declared to be infected with malaria there is a person, who distributes quinine to the sick and take specimens of their blood.

The Malaria Inspectorate  controls a fund for the campaign against malaria constituted by:

(a) Annual State subsidies of 500,000 levas;

(b) Five per cent of the regular revenue of communes declared to be infected with malaria;

(c) Ten per cent of the revenue of departments where malaria is epidemic;

(d) The revenue obtained from the sale or leasing of premises rendered malaria free by the Inspectorate.

At the beginning of April the fund for the campaign against malaria amounted to 7,000,000 levas.

Quinine Monopoly

In order to provide the population with cheap quinine of good quality, the Bulgarian State has established a quinine monopoly. Part of the quinine is sold by private chemists and a further quantity is distributed free to the population in the malaria districts by the hospitals. Bulgaria consumes about 6,000 kilograms  of quinine a. year and spends from fifteen to twenty million levas for this purpose.

The campaign against malaria in Bulgaria consists in the curative and preventive use of quinine and the improvement of the land. The curative and preventive use of quinine is carried out in accordance with various ordinances and with the regulations of the quinine monopoly.

Under Article 35 of the law concerning the campaign against malaria, persons suffering from the disease are treated free of charge in districts declared by the Supreme Medical Council to be infected with malaria. In districts with a malaria morbidity of less than 10% the Malaria Inspectorate does not intervene. The preventive use of quinine is employed, especially in the case of railway workers and the personnel of State undertakings.

Up to now the most important work in draining of the land etc. has been carried out by the Malaria Inspectorate. The minor operations are carried out by the administrative authorities on the advice of the Malaria Inspectors.

The Inspectorate undertakes the destruction of mosquitoes and their larvae by other preventive means such as the mechanical protection of inhabited dwellings, oiling of stagnant water, fumigation, etc.

The Inspectorate undertakes anti-malaria propaganda among the population by means of lectures, pamphlets, etc. It gives rewards to persons who have shown zeal in the work of the malaria service.

Malaria in Bulgaria in 1922

In 1922 the campaign against malaria was carried on in 11 malaria districts: Vidin, Varna, Burgas, Plovdiv, Lom, Svichtov, Aitos, Jambol, Pazardjik, Gorna-Djoumaia and the Railway District. There are 495 villages in Bulgaria declared to be infected.

The geographical distribution of the malaria districts is as follows:

1) In the Danube basin, 3 districts: Vidin, Lom, and Svichtov

2) In the Black Sea basin, 3 districts: Varna, Burgas, and Aitos;

3) In the Maritza basin, 3 districts: Jambol, Plovdiv, and Pazardjik;

4) In the Struma basin, the malaria district of Gorna Djoumaia.

The number of persons treated for malaria in the 11 malaria districts by the organs of the Malaria Inspectorates is as follows:

The mortality from malaria is slight in Bulgaria, 203 persons (0.4%) died. in the Burgas district, 58 persons (0.09%) in the Varna district and 0.10% in the Aitos and Gorna-Djoumaia districts. Among a population of 363,763 persons 334 died from malaria or 0.09%.

The spleenic index among school children at Gorna Djoumaia is 50%, at Pazardjik 47.2%, at Vidin 36.8%, and at Varna 38.6%, while the average spleenic index for the whole of the malaria districts is 37%.

The malaria morbidity during the different months of the year is as follows:

The results of the microscopic examination of the blood of persons suffering from the disease in 1922 is as follows:

It is proposed to make the following innovations in the Budget for the financial year 1924-25:

1) The establishment of two more malaria districts, viz. Russe and Harmanli, each comprising 60 to 70 villages;

2) The establishment of a malaria institute at Burgas;

3) The supply of means of propaganda, magic lanterns, cinematographs and microscopes and, in general, an increase in propaganda during the period in question.

(Signed)

April 30th, 1924.

***

SECOND REPORT ON MALARIA IN BULGARIA IN 1922

In accordance with the special law on malaria, the Inspectorate of Malaria in the Public Health Department is responsible for the study and prevention of malaria in Bulgaria.

The work is carried on in certain regions which, under Article 3 of the law, are declared infected by the Supreme Medical Council, acting on the advice of the Inspectorate. There is no systematic campaign in areas not declared infected, and malaria patients in these areas are treated by the district, hospital or municipal doctors.

Consequently, the present statement is based on reports from the malaria Inspectors and district medical officers. In 1922 the Inspectorate for Malaria carried on operations in 11 malarial districts, namely: 1) Vidin, 2) Varna, 3) Burgas, 4) Philippopolis (Plovdiv), 5) Lom, 6) Svichtov, 7) Aitos, 8) Jambol, 9) Pazardjik 10) Gorna Djoimaia, 11) the Railway system.

The work of the Inspectorate has more than doubled since 1921; its operations then only extended to five malaria districts, while in 1922 there were eleven such districts in its charge.

We may notice here that certain malarial districts are extremely large and include numerous villages which are often as far as 70 kilometers apart. For instance, the district of Vidin comprises 65 villages, that of Burgas 65, that of Plovdiv 76 and that of Jambol 65. The large number of the villages and the great distances between them make supervision by a single Inspector impossible. Better conditions of work are essential; either the larger districts must be divided into two, or more Inspectors must be appointed and provided with State means of transport, so as to be able to visit their districts more frequently.

The following table shows that in 1922 the Inspectorate carried on operations in 495 malaria localities, of which 219 were highly malarial, 211 less highly malarial and 65 only slightly malarial. In addition, eight new districts have been declared malarial, so that the Inspectorate has had to double its work.

It need not be pointed out that, as the number of malaria districts increases, the Inspectorate is unable, in spite of all its efforts to extend its work as the case requires. Moreover, according to information received from the Inspectors, there will shortly be about 90 more villages (i.e., 11 malaria districts) to be taken over, which, however, can only be done gradually for the reasons set out above.

A glance at the map of Bulgaria will show that the country may, from the point of view of malaria, be divided into four basins:

1) The basin of the Danube, which comprises the malaria districts of Vidin, Lom and. Svichtov.

2) The basin of the littoral of the Black Sea, which includes the malaria districts of Varna, Aitos and Burgas.

3) The basin of the Maritza comprising the districts of Jambol, Plovdiv, and Pazardjik.

4) The basin of the Struma which includes the district of Gorna Djoumaia.

Each basin has its own topographical characteristics.

1. The basin of the Danube

The Bulgarian bank of the Danube, which is one of the Kingdom’s natural geographical frontiers, is higher than the Roumanian bank opposite. In accordance with certain well-known natural laws, the Bulgarian bank is slowly crumbling and forming accumulations on the Roumanian side, so that the Danube is at several points deserting its bed, creating here and there islands and marshes which gradually become separated from the river itself. Moreover, the tributaries of the Danube in its lower reaches, and especially at the delta, silt up with sand, so that, when the river rises in the spring, there are particularly high floods in the delta.

The marshes along the river’s course are therefore created both by the river leaving its former bed and by the silting of sand at the mouths of its tributaries.

The villages in the malaria districts of the Danube basin may be divided into two classes: those situated actually on the banks of the Danube and its tributaries and those built at higher altitudes or on the cliffs. Malaria is more prevalent in the former than in the latter.

2. The basin of the littoral of the Black Sea

The main topographical features of the Black Sea basin are the lakes and enormous marshes which have existed for thousands of years and have been formed by the sea itself and by the silting of sand in the mouths of the rivers.

Owing to the vicinity of the sea, the measures taken to combat malaria consist here, as in many other districts, in converting the fresh water marshes into salt marshes.

3. The basin of the Maritza

The basin of the Maritza comprises the whole of Thrace. It is traversed by the various tributaries of that river, which is in some places a broad and shallow stream. Several centuries ago Thrace was a well cultivated, well wooded, and thickly populated country. Under Turkish rule the cultivation of this rich area was neglected, with the consequent formation of marshes and the appearance of malaria.

A special factor which should be mentioned as encouraging the development of malaria is the cultivation of rice. There is no law in Bulgaria on this subject, although more than one bill has been proposed. The Turkish laws contained no special sanitary regulations for the cultivation of rice. The Turks, nevertheless, recognized that the rice fields were a danger to health, as rice was only allowed to be cultivated at a distance of 1 to 3 kilometers from towns and large villages. Moreover, all work had to stop from seven o'clock in the evening onwards, and laborers were forbidden to spent the night in the rice fields.

According to some writers (Djounkowski and certain Italian authorities), the cultivation of rice is not responsible for an increase of malaria. The facts, however, disprove that theory and show that malaria is much more prevalent and takes on far more virulent forms in places where rice is cultivated. This, further, is confirmed by Professor Konsoulof, who is the best authority on the effects of the cultivation of rice on the breeding of mosquitoes in Thrace. The divergence between these two theories would appear to be due to the different ways of cultivating and obtaining rice in different countries. In Italy, for instance, the irrigation system is founded on modern technical principles. It is carried on by means of inclined water courses which allow the water to drain off rapidly, and do not give it time to remain long in one place and so allow of the development of miasma, infection, noxious weeds, etc. This operation is repeated every 7 or 8 days.

The Bulgarian system is exactly the opposite. In summer the rice fields become vast foul marshes which harbor all kinds of insects and become extremely favorable breeding places for mosquitoes. The many dams constructed for irrigating kitchen gardens and for turning mill wheels throughout the plains crossed by the Maritza also foster the propagation of malaria on a vast scale.

4. The basin of the Struma

The same conditions prevail in the basin of the Struma. Here again we find the most primitive conditions — rice fields, tobacco plantations, grass lands, mill dams, etc. Malaria prevails in a virulent form.

The question of irrigation in the Bulgaria plains crossed by the larger rivers, has frequently been investigated by the Ministry of Agriculture, which has published a full and detailed report on the subject. Its instructions, however, have never yet been put into practice and no decision has yet been taken. (See summary of the Irrigation Bill from 1915).

There are also in the basins mentioned above several small swamps which are situated near inhabited localities and brick-kilns, and formed by old springs, wells etc., while the roads and railways are all bordered by ditches and puddles.

The inhabitants of these places have the objectionable habit of digging ditches round their fields, courtyards, meadows, garden and vineyards. In the spring these ditches are filled with stagnant water, which is a factor producing malaria. In a word, apart from the marshes, many inhabited localities are surrounded by quantities of small swamps and ditches which are a breeding place for mosquitoes.

These small swamps and ditches, which constitute the most serious danger of all, are entirely neglected by the people, and this is why the efforts to stamp out Malaria must, first of all, be concentrated upon these. A single example will suffice to show how dangerous a small swamp is.

In British India the natives use reeds to construct their houses and fences. After number of showers of rain the British discovered that, although the top ends of these reeds contained only a tiny quantity of water, they nevertheless contained the larvae of the anopheles. To obviate this danger, the British Authorities issued orders that reeds used for the construction of fences and buildings must be cut exactly at the joint, so that there should be no hollows which would enable even the most insignificant amount of water to enter the reed. Infringements of this order were made punishable by death.

According to the meteorological information received from district Inspectors, 1922 was not, generally speaking, a favorable year for the breeding of mosquitoes. The spring was protracted, cold and wet, it was followed by a drought, which dried up the many swamps and stagnant waters, so that in most districts the mosquitoes bred only twice. Old mosquitoes appeared first about April 1st and even as late as as May (at Burgas) and the first new mosquitoes were not observed in most places until June or July. In the district of Vidin, however, they made their appearance as early as April. The second generation was hatched towards the end of August and September. By October the weather became cold and dry.

What kind of mosquito was predominant in 1922? The reply to this question from all Inspectors was unanimous; the predominant type was the Anopheles Maculiponnia. The Culex was noticed only by the Inspector of the district of Pazardjik. Another type was prevalent in the rice fields in the plains of Plovdiv and Pazardjik, namely, the Myzorphynchus Pseudopictus. We have not yet had news of the third species, the Anophales Superpictus, which was noticed by Professor Djounkowski among the tributaries of the River Tcherna. Its presence, however, may he assumed also among the tributaries of the Struma.

It has been noticed that the Anopheles lives in places inhabited by man and animals, as these constitute its principal supply of food. The Anopheles is a blood-sucker, while the Culex is a vegetarian. Only the female of the Anopheles sucks blood and she prefers dark corners away from noise and wind. She usually flies near human habitations, her distance being not more than one and half kilometers and she keeps about two to three meters above the ground. She is rarely seen flying more than ten meters high. These mosquitoes specially haunt the small swamps. At Plovdiv in 1922 their eggs were found in the various household water receptacles, e.g. tanks, tubs, cisterns, etc. In winter they hide in warm stables and cellars. At Burgas they usually hibernate in the town drains. Egg-laying takes about two to three days and the larva requires twenty to twenty-five days to develop. Between two and four generations are hatched in the warmer months.

No measures were taken in any of the villages in 1922 for the extermination of old mosquitoes: instructions, however, have been given this year.

Staffing

The prosecution of the malaria campaign in the affected areas depends entirely on the special staff appointed for this purposes. Under the law for the prevention of malaria we have three classes of staff, namely: (1) The superior staff, (2) The second-grade officials, and (3) Sub-ordinate staff.

The superior staff includes doctors, engineers and zoologists.

The second-grade comprises analysts, superintendents and nursing staff.

The sub-ordinate class includes the quinine dispensers.

The work for the prevention of malaria is seriously affected by the shortage of staff in the first two grades. In 1922 there were only two permanent District Inspectors out of the seven provided for in the budget. The same was the case with the analysts, of whom there were only four and they were not properly trained for the work. There is no difficulty in obtaining candidates for the post of quinine dispenser, as the work does not demand special qualifications.

Owing to the very low salaries paid to doctors and analysts and owing particularly to the lack of means of transport for the former, these posts which, moreover, require special training and a certain professional enthusiasm, do not prove at all attractive. As the Government saves on the salaries of these officials, we may anticipate that for some time we shall have no permanent District Inspectors or analysts, and moreover, those who at present occupy these posts are not likely to show much enthusiasm. As the dispensing of quinine provides the worker with a small additional income there will always be plenty of candidates for these posts. We regret, however, to have to state that dishonesty is far too frequent among the dispensers, many of whom appropriate the quinine which is distributed gratis and sell it for their own profit.

The Inspectorate constantly urges the District Inspectors to restrict the quantity distributed and to exercise a strict supervision over the dispensers as the drug is extremely costly. Proceedings against dispensers were taken on two occasions in 1922.

The Inspectorate staff was composed as follows in 1922:

The above table shows that in 1922 the Inspectorate had 2 permanent District Inspectors and 9 acting Inspectors (namely, provincial, district and railway medical officers), 4 analysts assisted by 7 temporary analysts and 435 dispensers. 108 of the dispensers were qualified hospital attendants; 91 were clerks — tax-collectors, mayors and other clerks; 66 school-masters and priests, while 69 belonged to other professions.

With but few exceptions the work done by this staff cannot be called satisfactory. The permanent staff carried out their duties well, but the work was badly done in places where these posts were held by temporary employees. Some of them do nothing and do not take the slightest trouble; they only care about the pay. There are even some who have not made a single visit to all the villages under their charge.

The Inspector at Vidin is the only Inspector who has carried out 18 visits in 72 days and visited each village two or three times during the season. This slackness is due to low rates of pay and deficient transport. In view of these shortcomings the Inspectorate has made a proposal to the Public Health Department that the District Inspectors should be properly paid and should, more especially, be given means of transport; these are the only conditions in which it would be possible to obtain a permanent staff ready to carry out its work with industry and enthusiasm.

When visiting their districts, the Inspectors inspect the work done by the dispensers and, in co-operation with the majors, recommend certain sanitary measures to the people. The Inspector at Vidin has earned special distinction, as he has persuaded the mayors to have notices end placards posted up to inform the people that it is forbidden to dig ditches, that quinine is distributed gratis in malarial areas, etc.

Lectures too were frequently given in the villages. 30 lectures were given in the district of Lom, for instance, not including 216 meetings attended by schoolmasters, priests and mayors. The Inspector of Vidin has given lectures in that town attended by schoolmasters and students and accompanied with practical demonstrations by means of an aquarium and exhibits of the petroleum treatment of stagnant water.

Sanitary improvements have been carried out in various villages on the recommendation of inspectors. Many inspectors made spleen examinations of school children. For example, 7000 children in 57 villages were inspected in the Vidin district; 1529 in that of Lom; 210 in that of Burgas; 4218 in that of Pazardjik; 1838 children were inspected at Gorna Djoumaia, etc. The Inspector in each case personally took a specimen of blood for analysis. The analysts have worked very satisfactorily, especially at Vidin and Burgas.

The work done by the dispensers, however, has been carried out in a very different manner. Everything depends on the individual dispenser. Some of them are conscientious, but others are altogether worthless. All Inspectors agree that, with rare exceptions, it is hospital attendants who are responsible for the misuse of quinine. The inspector of Vidin detected 20 cases. The same observations have been made by the District Inspectors of Plovdiv and Varna. Only the Inspector of Lom states that he is satisfied with the work done by his staff.

The Malaria Inspectorate believes that until hospital attendants discontinue treating patients and devote their time entirely to preventive measures which they are paid to carry out, the misuse of quinine will continue, owing to the temptations it offers.

Incidence of Malaria

It is no easy matter to investigate the incidence of malaria. It is impossible at the moment to give figures, although the District Inspectors have been asked for them. A thorough enquiry will require years of study and we must wait until the Inspectorate has a permanent staff and, again, until that staff is trained and has obtained the necessary experience.

Spleen examination is not really an efficacious method of detecting the spread of malaria. Not all persons attacked by the disease show enlargement of the spleen, which is mainly found in patients who have had more than one attack or in those suffering from one of the virulent forms of the disease. Accordingly, the Inspectorate in its Circular Note № 11 526 of October 7th 1922, prescribed that District Inspectors should in future base their conclusions on the results obtained by blood analysis.

Let us now consider Table I below, which shows the number of malaria cases successfully treated in each district:

Unfortunately the table is neither complete nor accurate, as the District Inspectors were not informed in good time — namely at the beginning of the season — that they would be asked for these particulars. The figures given should therefore be regarded as purely relative. It will be seen that more malaria cases were examined in the district of Vidin than anywhere else. The next largest number examined was at Svichtov, next Varna, and so on. The highest percentage of malaria cases occurred at Varna (22.6%); the next in order are Aitos, Svichtov, Vidin, etc. In brief, out of the total population of 363,763 in these districts — 37,858 malaria patients, i.e. approximately 10% were examined. Those, however, are not of course the exact number of malaria cases or of patients examined and treated by the Inspectors, as many patients did not apply for treatment.

The spread of the disease depends upon various factors: the situation of the villages (plain or hills), climate (rains, cold weather, winds, hot weather, droughts), successful treatment of patients, prophylaxis by use of quinine, etc.

As it was said, malaria was less general than usual in 1922 mainly owing to the weather, namely, a rainy and cold spring and a hot and dry summer, so that there were relatively few mosquitoes. Further, the people are beginning to treat themselves with quinine. The health measures taken in the villages of Kroumovo, Turkmen, Jakesli, Vajakeli and Madara appreciably assisted the decrease of malaria in those areas. The access of sea water to Lake Athanaskeui and the excavation of a big canal between the marshes of Varna and Deven will improve health conditions in about seven or eight villages with a consequent reduction in malaria. Although small, these results will encourage the Government to continue the campaign. The fight was begun in Italy in 1878, and tangible results were only obtained after 50 years.

Mortality

Generally speaking, deaths from malaria are rare. The disease, however, greatly undermines the patient health, and he often dies as a result of some other disease which need not have been fatal. However that may be, our information shows that the largest number of deaths from malaria occur in the districts of Burgas, namely 203 — 0.46%; the next largest is in the district of Varna, 58 deaths — 0.09%; Aitos and Gorna Djoumaia — 0.10%, and so forth. There were 334 deaths out of a total population of 363 763 inhabitants — i.e., 0.09%. These figures however must be accepted with reserve.

The enlargement of the spleen (Index Koch') is an incidental feature of the disease, but in several cases constitutes proof of malaria. Unfortunately, we have not received from all Inspectors information regarding the state of the spleen in school children:

The data given in Table II show that there was a higher percentage, namely 50%, of school children suffering from enlargement of the spleen in the district of Gorna Djoumaia than in any other district. The next in order are Pazardjik 47.2%, Varna 38.6%, Vidin 36.8% and so on. Out of 26,663 school children examined 8,839 — i.e., 37% were found to suffer from enlarged spleen.

Main features of Malaria

Malaria was less virulent than usual in the last year. The most prevalent form was the tertian, while about the quarter of the cases suffered from the tropical or other combined forms.

This is made plain in Table III:

The largest number of cases were recorded in the hottest months, i.e. August and September. It should be noted that tertian fever was prevalent at the beginning of the summer and towards the end of the autumn, i.e., during the cooler months, and the tropical variety during the hot months.

A glance at Table IV will confirm this fact:

The death rate, however, followed a different curve attaining its highest point in August, September and October. Cases of malaria rarely occur in the winter, and then are generally cases of relapse. Most new cases occur in the summer.

The most frequent complications are gastro-enteritis, epistaxis, etc. Some patients developed idiosyncrasies in consequence of the use of quinine. Cerebral complications are rare. No cases of this kind have been observed except by the Inspectors of Vidin and Burgas. The cure of such cases depends on the manner in which they are treated.

Malaria spares no one and one attack of the disease does not confer immunity. Frequent relapses result in complications — enlargement of the spleen, pernicious anemia, etc. Cases of immunity are rare. Experiments made on patients with serum injections show that it is impossible to obtain immunity by artificial means. It has been noticed that old people who have suffered from malaria are less predisposed to the disease than children.

Prophylaxis

Reliable statistical data are essential for the establishment of effective scientific prophylaxis and prophylactic measures are absolutely indispensable, quite apart from the treatment of the disease itself. Prophylactic measures against malaria may be divided into two classes: (a) palliative, (b) radical measures.

The following are regarded as palliatives — quinine, treatment of stagnant water with petroleum and protection against mosquitoes by the use of wire gauze windows, etc.

Radical measures are those taken for the purpose of curing patients suffering from the disease. There is, of course, and it is accordingly advisable first to apply the former and thus to reduce the necessity for the latter.

We have now reached a high standard of knowledge of the proper treatment of malaria, and whole areas have been cleared of the disease in Italy, while swampy districts have been turned into prosperous towns and villages.

The following are the prophylactic measures taken by the Inspectorate. The District Inspector of Burgas has had wire gauze windows placed in the mineral baths and in dwelling houses near the Athanaskeui salt lake. The Inspector of Vidin has distributed such windows to all military posts on the Danube, and the Inspector at Plovdiv has distributed them to the owners of certain dwelling houses and to the School of Agriculture at Sadova. In all, 400 square metres of wire gauze have been distributed.

The effective use of wire gauze as a protection against mosquitoes demands a certain standard of education, and, accordingly, it should only be distributed to villagers who have been instructed in its use. It is also employed in some of the public administrative buildings in Burgas and Vidin and in the Railway stations at Jassen, Nirvitza, Dupnitza, Simetli, Sarambey and Philipovo, where the windows have been protected with wire gauze for the last 10 years. Further, 200 mosquito masks were distributed by the Inspectorate of the Railway district to workmen, who, however, refused to wear them on the ground that they were uncomfortable to work with.

Treatment of stagnant water with petroleum

Under the present conditions, this method of protection is only a palliative, and a costly one at that. The measure was, however, carried out by the District Inspector of Vidin in 1922.

The town is surrounded by marshes covering an area of 70 hectares. The marshes form at the beginning of the spring towards May: portion of them dry up during the hot season, but others persist throughout the Summer. Some of them are broad and deep and are not, consequently favorable breeding grounds for mosquitoes. Others, however, provide a perfect breeding ground for the insect. In the town itself there are many ponds and ditches which are particularly suitable for the development of mosquito larvae. Accordingly all stagnant water where larvae were found was treated with petroleum. Last year's mosquitoes laid their first eggs between May 2nd and 6th, their second on May 27th, their third on June 17th, their fourth on July 11th, their fifth on August 2nd, their sixth on August 15th and their seventh on September 18th.

Overall 2,000 liters of petroleum were used. Examination of the water on the day following treatment showed that all. larvae had been destroyed. It should be noted that not all the mashes surrounding Vidin are favorable to the development of mosquitoes; this is the case with marshes which are more than 60 centimeters deep and exposed to the wind and cold. Shallow ditches and puddles protected against the wind are full of larvae, and are their favorite haunt. Only 1/15 or 1/20 of the 70 hectares under water are suitable for the breeding of mosquitoes, and, accordingly only this fraction was treated with petroleum; moreover, a portion of the marsh dries up in summer.

An interesting observation was made on one occasion at Vidin, on the day following treatment with petroleum. The surface film of the water was covered with dead mosquitoes. This is due to the fact that Bulgarian petroleum is coarse and contains a large number of glutinous oleaginous substances which evaporate slowly, so that the old mosquitoes, arriving to lay their eggs at night, stuck on the surface of the water and were unable to fly away.

According to a report forwarded by the Inspector of Vidin, treatment with petroleum is far from easy, as it necessitates a permanent staff and other requirements, e.g. vehicles, boats, pumps, etc. None of these were available last year and should, accordingly, be provided.

This treatment was also carried out in the neighborhood of the mineral baths at Burgas, where 100 liters of petroleum were employed; at Polatovo where 50 liters were used and at the Lew' factory near Plevna, where 100 liters were used, etc.

Use of quinine

Owing to the shortage and high cost of the drug, quinine has only been used for prophylactic purpose among the conscript laborers working at Guenichevo and Wolen Tchiflik, and among certain grades of railway employees in some of the villages in the Burgas district.

It is, of course, undeniable that the prosecution of the malaria campaign by the prophylactic use of quinine can only be successful if applied in all malaria areas. Unfortunately, however, the Inspectorate is unable to do this owing to the extremely high price of quinine and the difficulty in obtaining it.

Further, the preventive dozing with quinine cannot be carried out in winter, as the dispensers are discharged during that season. This fact, of course, is favorable to the plasmodia development and the infection of mosquitoes for the next seasons, and the source of infection remains untouched.

The distribution and taking of quinine in the presence of the dispenser, which is prescribed by our regulations, is an easy and simple matter. As the people, however, are not yet familiar with the exact effect of quinine and the importance of this measure, few patients carry out the prescriptions for treatment contained in Order № 932 to the end. As soon as the patient feels better, he stops going to the dispenser and waits until he suffers a new paroxysm.

Moreover, a villager finds it difficult to go two or three times a day to the dispenser to take quinine, as in the summer all country people go out to the fields and sometimes remain there for three or four days at a time. The dispenser, again, cannot spend his time waiting in one village merely in order to dispense quinine. This is more especially the case with medical attendants, who are required to go round all villages in turn. In these circumstances the dispensers should be authorized to give patients a supply for two or three days.

The following are the methods of taking quinine as a prophylactic. The Inspector at Vidin has adopted the subsequent system:

A blood specimen is taken at the beginning of the cure and a second specimen 7 days after the last dose of quinine. If the second analysis shows plasmodia in the blood, the cure is continued in the same manner.

The Inspector at Varna has strictly complied with the instructions contained in Order № 932 of August 2nd, 1920. The Inspector at Plovdiv gives quinine for 5 days and takes a blood specimen. After 3 days' interval he takes a second blood specimen and according to the result shown by the analysis continues the quinine treatment until the desired effect is obtained, sometimes for as long as 6 weeks. Few patients, however, are willing to follow this method to the end.

The methods employed by the other Inspectors are much the same.

The following amounts of quinine ere dispensed in 1922:

Notwithstanding the most careful economy, the Inspectorate requires annually about 700 kgs. of quinine, and even then quinine is not distributed for preventive purposes. If this were done, the amount required would be from 1200-1500 kgs. Naturally, the Inspectorate decided that a preventive distribution was impossible, in view of the present high price of the drug. The average consumption of quinine per patient at Vidin was 4 grams, at Lom Dorn 5.77 grs., at Svichtov 2.80 grs. and at Varna between 5 and 10 grams.

Measures other than the cure

The most logical method of combating malaria is to render an infected area healthy. To this purpose the Inspectorate’s main efforts should. be directed. Once the infected areas are made healthy the rest will follow as a matter of course. It is by attacking the source of the infection that the worst malaria districts in Italy have been rendered healthy once and or all.

The work undertaken for the improvement of sanitary conditions in in Bulgaria in 1922 may be divided into two classes: major and minor works. The former were begun in 1921. Some have already been finished, while others are in course of completion. By major sanitary improvements we mean the turning of the marsh at Athanaskeui into a salt marsh by draining the sweet waters into the sea through a canal; the draining of the marsh at Jakesli (already concluded), the linking of the lake of Varna to the lake of Deven by a canal, which has resulted in the draining of about 1,500 hectares; the construction of a canal 3 kms., 600 m. long near the village of Madara, thus draining 40-50 hectares; the draining of the lake at Kroumova (223 hectares) and finally the draining of the marsh at Turkmen in the Province of Plovdiv. The above major works are the continuation of those begun in 1922.

Minor sanitary improvements are of great practical value and it is to be hoped that they will one day be adopted as regular prophylactic measures.

As already stated, even the smallest puddles may become breeding places for mosquitoes. All District Inspectors state in their annual reports that they have given the necessary instructions for filling them up. At Vidin, for instance 254,000 sq. meters have been filled in, including two large swamps in the centre of the town, the waters of which have been drained into the Danube by canals. The inhabitants of this town unfortunately have the mischievous habit of digging round their gardens ditches, which become full of larvae, etc.

Small ponds, totaling 12,000 sq. meters in area, have been filled in the malarial district of Lom.

Numbers of straight water courses have been made and many small swamps drained in the district of Burgas. A swamp has been drained in the middle of the village of Athanaskeui, and another at Anchialos, both of which were used by buffaloes for wallowing. A canal was extended to a length of 800 m. so as to reach the village of Souvatile. A dam constructed to make a pond for use as a watering place for animals was demolished at the village of Lidjakeui. The bed of the mineral baths was put in order. A marsh was drained at the village of Diolovo. Plans were made for the canalization of the river Lidjene, etc.

By turning the marsh at Athanaskeui into a salt marsh, the government has farmed out a contract for five million kgs. of salt, and by the extension of the canal to the village of Souvatile it has obtained 15 hectares of arable land. Those are the immediate results of the works carried out in the Burgas district.

In the Plovdiv district a canal 518 m. long was dug near the village of Katounsko Konare; the canal which runs for 1,000 m. along the Plovdiv-Sadova road was cleaned out and another canal 3,120 m. long was cleaned out near the village of Katounsko Konare. Much other similar work has bean completed, with the result that most of the ponds and marshes at the side of the Plovdiv-Sadova road and 30 hectares near the village of Golobradovo, and 95.7 hectares near the village of Turkmen have been drained; these tracts are now ready for cultivation.

Being anxious to obtain data for the investigation of the progress of malaria, and accurate statistics on this subject, the Inspectorate instructed the District inspectors to make more frequent analyses of the blood of patients and school children, and to base their figures upon blood analyses, and not upon spleen examinations.

The data for 1920 are given in the following Table:

This table shows that 40,000 analyses were made during the malarial season; a quarter of these showed positive results and three quarters — negative results. Some 1/4 (5,246) of the positive analyses showed tertian fever and 1/3 (1,770) tropical fever, the ratio of tertian to tropical fever being 3 to 1. The largest number of analyses were made in the districts of Burgas and Vidin. Far purposes of comparison, we give the analyses made in 1921, — viz. 9,209 analyses with tertian 830, tropical 737,  combined forms 332, and the remainder nil.

The fact that the malaria position was more satisfactory in 1922 must be attributed: (1) to the weather conditions prevailing in the summer, and (2) to the work accomplished by the staff. There are, of course, still many difficulties, e.g. financial stringency, defective education, etc., which will contrive to impede the success of the malaria campaign.

We must again emphasize here that, as the campaign is at present only in its initial stage, it would be premature to expect immediate concrete results from the Inspectorate, which is still devoting every effort to discovering the most effective methods. Even the law for the prevention of malaria requires modification, as it is imperfect and contain certain inconsistencies. We do not possess adequate statistical data to determine exactly what places in Bulgaria are malarial, and several districts have still to be included in the list. Government circles in Bulgaria are not fully aware to the seriousness of the disease, and hesitate to allocate adequate sums for the prosecution of the campaign.

Malarial towns and villages should be re-grouped into malaria zones according to the prevalence of the disease The first classification was carried out so hurriedly that information supplied by the Inspectors whose instructions are more definite and who have gained experience — viz., no longer tallies with that furnished by the Inspectors who were earlier in the field. The Inspectorate proposes to study this question in a practical spirit and will then carry out the necessary changes.

The new districts to be declared malarial are the following:

Malaria campaign on the railways

Out of a total of 90,000 railway employees the following numbers were found to be suffering from malaria: (1) in 1920 — 15,361 employees; (2) in 1921 — 9,261 employees and, (3) in 1922 — 5,424 employees.

The above cases are distributed among the following districts:

Most of the cases occurred in July, August and September. The largest numbers were notified at the following stations: Zlatisa Mahala, Levski, Karjali, Bobocevo, Kocarinovo, Harmanli, Sarambey, Philippopolis and Orizovo.

In agreement with the Inspectorate, the Inspector for the railway system employed quinine as a prophylactic in the following districts:

The following are the data for patients examined in 1921 and 1922:

If we assume that these data wore obtained, by the same method and. by the same persons in both years, it will be seen that there were more cases of malaria and more deaths in 1922 than in 1921. The data refer to four provinces only, as in 1921 only 4 areas had been declared malarial.

As the medical officers of these provinces were unable to supply more detailed. reports on malaria, this work being carried out by the District Inspectors, we have confined ourselves to extracting the bare figures from their reports for purposes of comparison.

It will be impossible to supply more accurate comparative data, either regarding the incidence of malaria or mortality from this disease until next year.

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References: More information on League of Nations, Health Organization's Malaria Commission could be found in the WHOLIS database,

Copyright © 2008 by the author.