Malaria on a Military Peacekeeping Operation: A Case Study with No Cases

Military Medicine, Mar 2005 by Houston, David J K, Tuck, Jeremy J H

Background: Malaria continues to be a disease of importance to travelers and the military is no exception. Individual protection measures based on advice, bite avoidance, chemoprophylaxis, and diagnosis are advocated for protection against the disease. However, the military has an additional strand to malaria protection-the chain of command. Aim: To describe the experience of a British military deployment where the Force Commander took a proactive approach to malaria protection. Results: In 512 person-weeks of exposure in a theater with high rates of transmission of malaria, with an enduring threat of asymmetric military action and with a proactive approach by the chain of command to the implementation of malaria protection policy, no malaria cases developed. Conclusion: The chain of command can have a significant impact on compliance with malaria protection measures, which might reduce incidence of the disease in the deployed population.

Introduction

Malaria remains a disease of importance for travelers, with the degree of risk related to the destination and activity. In the year 2000, it was reported that there were in excess of 2,000 cases of malaria reported in the United Kingdom. On average, there are nine deaths per year, but the trend appears to be going up and the majority of those affected are tourists or United Kingdom residents visiting friends and relatives domiciled overseas.1

Malaria also remains a disease of military importance and military populations have been exposed to the disease throughout the world. In the last decade of the 20th century and the first years of the 21st century, the medical press has regularly published descriptions of the malarial experiences of deployed forces.2-8 The outbreak among United Kingdom troops in Sierra Leone in 2000 generated attack rates of 10% in certain groups,9 and attack rates in excess of 40% have been reported in the popular media concerning the deployment of U.S. troops to Liberia in 2003.10

The United Kingdom continues to deploy personnel to malarial areas and, in the middle of 2003, as part of a United Nationsmandated, multinational deployment, an engineer group was deployed to the northeastern part of the Democratic Republic of the Congo (DRoC). Although local entomological inoculation data are not available, the border area with Tanzania to the south of the operational area sees a wide range of entomological inoculation rates,11 and this whole region is regarded as highly endemic for malaria.

From the outset, the Joint Force Commander took a robust and proactive approach to the prevention of malaria, ensuring that his subordinate commanders understood that it was their responsibility to maintain compliance with existing malarial protection policy. The force returned to the United Kingdom after 6 weeks in the operational area.

The aim of this case study was to describe the experience of a British military deployment where the Force Commander took a proactive approach to malaria protection, showing how a proactive commander might influence compliance with malaria protection policy in a high-risk area.

United Kingdom Malaria Protection Policy

Protection of visitors to malarial countries is an important aspect of travel medicine and the United Kingdom Advisory Committee on Malaria Protection publishes guidelines for the prevention of malaria in travelers from the United Kingdom.12 Force malaria protection policy is based on these guidelines. In summary, they describe an A, B, C, and D approach to malarial protection where A is awareness, B is bite avoidance, C is chemoprophylaxis, and D is diagnosis (early and accurate and closely linked to early and aggressive curative therapy).

Evidence has been published that appears to demonstrate that the greater the number of protection measures used, the greater the level of protection.13 However, there is additional evidence to suggest that the message is not getting through to the target population and that among travelers, civil14-17 and military (A.R. Menzies, personal communication), levels of knowledge, attitudes, and practices concerning malaria protection are chronically poor.

There is an additional strand to malaria protection that is peculiar to the military: the role of the chain of command in integrating malaria protection measures into plans and encouraging compliance. In the British military, this is articulated in official policy disseminated by the Surgeon General.18

It has been observed in the past that the chain of command can directly affect the level of compliance in a force. Commanders with an indifferent or hostile attitude to malaria protection have presided over large outbreaks among their troops, whereas those with a more proactive approach saw dramatic improvements in malaria attack rates.19 During the Burma Campaign of World War II, General Slim acknowledged the role of the chain of command in ensuring compliance with malarial protection measures such as wearing appropriate clothing and taking chemoprophylaxis. General Slim applied pressure to his commanders and achieved a notable success in getting officers to understand their role in the protection of troops. He wrote: "good doctors are useless without good discipline. More than half the battle against disease is fought not by doctors but by the regimental officers. It is they who see that the daily dose of mepacrine is taken, that shorts are never worn, that shirts are put on and sleeves turned down before sunset . . . . I, therefore, had surprise checks of whole units, every man being examined. If the overall result was less than 95% positive, I sacked the commanding officer. I only had to sack three; by then the rest had got my meaning."20 In taking these actions, he reduced the daily admission rate for malaria and other communicable diseases from 12 per 1,000 per day in 1943 to 1 per 1,000 per day in 1945.20