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The facts, treatments, and ethical issues surrounding the banning of DDT
DDT vs Malaria
The facts, treatments, and ethical issues
surrounding the banning of DDT
Michael O’Driscoll
MPH 560: Public Health Ethics
Professor: Dr. Vicki Boye
Concordia University
February 21, 2015
The facts, treatments, and ethical issues surrounding the banning of DDT
Any infection, disease, affliction, illness, or condition that affects a large number of
people is worth examining – and finding solutions to conquer it. This is, of course, the goal of
public health.
What makes this journey challenging, however, is that only one human disease
(smallpox) has ever been eradicated (Pfizer Global Pharmaceuticals, 2006). Bacteria mutate or
become more resistant, new virus strains emerge, conflicting arguments are presented, and the
ensuing debates (especially in light of social media and online news venues) bring to the
forefront ethical and moral issues which can make people fearful and mistrusting of any
intervention or examining current actions.
Malaria is such a condition. Believed to be largely eradicated in the United States by the
end of 1951, when dichlorodiphenyltrichloroethane (DDT) proved effective, the World Health
Organization (WHO) submitted at the World Health Assembly in 1955 and ambitious proposal
for the elimination of Malaria worldwide (malaria.com, n.d.). In 1972 the United States banned
DDT after claiming it was a carcinogen and caused the chemical to build up in human body fatty
tissues (EPA, n.d.). Subsequently, the chemical was banned for agricultural use worldwide under
the Stockholm Conventions and other countries began to stop using DDT as a pesticide to
control mosquito populations (Ovuorie, July 2013).
According to the World Health Organization, Malaria is caused by a parasite called
Plasmodium, which is transmitted via the bites of infected mosquitos. The parasites multiply in
the liver of the human host and then infect their red blood cells. If not treated, Malaria can
become life-threatening by disrupting the blood supply to vital organs. In many parts of the
world, the parasites have developed resistance to many of Malaria medicines. There were an
The facts, treatments, and ethical issues surrounding the banning of DDT
estimated 627,000 malaria deaths worldwide in 2012 and 77% of those are children under 5
years of age; there were an estimated 207 million cases of Malaria in 2012 and 80% occur in
sub-Saharan Africa. Between 2000 and 2012, estimated mortality rates decreased by 42%
worldwide and 49% in the African region and the estimated incidence of Malaria fell by 25%
globally and 31% in the Africa (WHO, n.d.). Many of the African nations are using DDT as part
of their integrated pest management program to reduce the mosquito population which has led to
the significant decrease in Malaria rates.
These biostatistics and the controversy surrounding the use of a known carcinogen—
DDT--to control mosquito populations and prevent Malaria is worthy of examining and
analyzing the ethical and moral aspects of the decisions by leaders in affected countries to use
the chemical, reducing morbidity and mortality from Malaria.
The Epidemiology of Malaria
A highly contagious disease, Malaria parasites are transmitted via the bite of a female
Anopheles spp mosquito. In humans, the parasite grow and multiply first in the liver cells and
then in the red cells of the blood. In the blood, successive broods of parasites grow inside the red
cells and destroy them, releasing daughter parasites than continue the cycle by invading other red
cells. The blood stage parasites are those that cause the symptoms of Malaria. After 10-18 days,
the parasites are able to be transmitted to another human by the Anopheles mosquito (CDC, n.d.).
When it first presents, Malaria can be indicated by a variety of symptoms such as, fever,
chills, sweats, nausea and vomiting, body aches, and a general malaise (CDC, n.d.). Such mild
symptoms are often tolerated or misdiagnosed. Indeed, those infected can defend these
symptoms as allergies, influenza, or simply a common cold. Advanced symptoms can include
The facts, treatments, and ethical issues surrounding the banning of DDT
acute kidney failure, cardiovascular collapse, severe anemia, seizures, coma, and death. Left
untreated or undiagnosed, Malaria can spread quickly in regions with high populations of
mosquitos and cause severe pain and suffering in a community. Currently, the WHO estimates
that an estimated 80% of Malaria deaths occur in just 14 countries and together, the Democratic
Republic of the Congo and Nigeria account for over 40% of the estimated total Malaria deaths
globally (WHO, n.d.).
Dichlorodiphenyltrichloroethane
Better known as DDT, dichlorodiphenyltrichloroethane is an organochlorine insecticide
that was used freely around the world for insect control. Historically, DDT was used in the U.S.
to eradicate Malaria with excellent results. Organochlorine pesticides are nerve toxins that when
ingested or introduced into the human body, can cause convulsions and death, but their acute
toxicity to humans is low (Maxwell, 2009). Because DDT accumulates in the body, exposure is
cumulative, and increases over time, however, the data is somewhat unclear about its long-term
damage to human health and has been difficult to prove.
Furthermore, data shows that when the amount of DDT used is significantly reduced,
Malaria increases exponentially. For example, data from 1993 to 1995 in South American
countries showed a sharp increase of Malaria in countries that decreased their usage of DDT and
a 61% decrease in Malaria rates in the one country that increased its use of DDT –Ecuador
(Roberts, Laughlin, Hsheih, and Legters, 1997).
The primary concern with DDT continues to be the length of time it can remain in our
environment, up to 15 years, and the adverse effects seen in wildlife (ATSDR, 2011). DDT can
build up in the fatty tissues of animals and cause long-term exposure damage including,
neurological, liver, or reproductive impairment.
The facts, treatments, and ethical issues surrounding the banning of DDT
Human Rights:
The Universal Declaration of Human Rights contains 30 articles listing the political, civil,
economic, and cultural rights entitled to all human beings. For the purposes of my discussion I
will refer specifically to Article 25 of the declaration, which states, “everyone has the right to a
standard of living adequate for the health and well-being of himself and of his family, including
food, clothing, housing and medical care” (United Nations, 1948: p.76). These basic human
rights are understood to be universal, with equal weight given to all women, men, youth, and
children; and, without discrimination.
Health and human rights were not necessarily linked together when the universal
declaration of human rights was presented to the world. In fact, Mann et al. assert that with few
exceptions, discussions about health have rarely included human rights (Mann et al., 1994). In
particular, Mann conceptualized the linking of human rights and public health offering a
differing perspective and new framework for interventions at the international level (Mann,
2006). The challenge of applying human rights in response to health problems such as infectious
diseases like Malaria, is defining precisely what constitutes a health problem that rises to the
level of violating recognized human rights. For example, pertussis (whooping cough) was
believed to be largely eradicated in the 1950’s when a vaccine proved effective, it has recently
seen a large increase in the prevalence rates around the world. Since 1990, Pertussis has claimed
an estimated 400,000 lives globally each year and caused hundreds of thousands more to suffer
its consequences (Tan, et al., 2005). Would this rise to the level of violating human rights by not
acting on finding a solution to pertussis? If we use Mann’s framework for human rights, public
health action to limit human death and suffering must be considered and resources allocated to
reduce Pertussis in the human population; the same should apply to Malaria.
The facts, treatments, and ethical issues surrounding the banning of DDT
Ethical Considerations:
There are distinct differences between clinical and public health practice. Each area is
guided by a set of values (individual morals + social norms) that influences the way in which
transactions are carried out. These become ethical “standards” that may change over time. While
the development and application of values may be different, the application, i.e., deciding what is
right versus what is wrong, is usually the same. Medical ethics applies to the relationship
between two individuals, e.g., physician-patient. And, public health ethics are applied within a
population-based context, e.g., the relationship between public health professionals and society.
For example, medical ethics would encompass the treatment of individuals with Malaria while
public health ethics would contain guidelines on eliminating the cause of the disease in the
community, i.e. abatement of mosquitoes and their breeding grounds.
By using another public health framework developed by Nancy Kass, there are six
primary questions designed to help public health professionals consider the ethics implications of
proposed interventions, policy proposals, research initiative, and programs (Kass, 2001). The six
questions are: 1) What are the public health goals of the proposed program? 2) How effective is
the program in achieving its stated goals? 3) What are the potential burdens of the program?
4) Can burdens be minimized or are there alternative approaches? 5) Is the program implemented
fairly? And, 6) How can the burdens of the program be fairly balanced?
Making sound ethical decisions and utilizing a set of ethical principles is essential when
considering on a course of action in a population which can have an enormous impact on the
lives of millions of people, such as, banning or severely limiting the distribution of DDT as an
insecticide to aid poor countries in their struggles against malaria.
The facts, treatments, and ethical issues surrounding the banning of DDT
The concern over DDT stems from the way it stays in the environment. As an
organochlorine pesticide, it is persistent. When absorbed by an animal, it is lipophilic, meaning it
concentrates in the fatty tissues and as the pesticide moves up the food chain, it biomagnifies.
Ultimately, DDT becomes a toxic at higher levels in the food chain, which was the premise of
the book Silent Spring (Maxwell, 2009). There existed slim scientific evidence that the
biomaginfication of the organochlorine chemical in bald eagles caused the shells of the eagles’
eggs to weaken and crack, and the birds were not able to breed successfully (Maxwell, 2009).
After DDT was banned in the United States during the 1970’s, other countries followed and
Malaria saw resurgence around the world, especially in the endemic areas of Africa where
millions of people continue to become infected and die from the disease. The question I am
attempting to answer by using the six primary questions posed by Kass in her framework is,
“what is worse, Malaria or DDT?”
The World Health Organization acknowledges that Malaria is one of the world’s most
deadly diseases that kill about 880,000 people, mostly children in sub-Saharan Africa annually
(WHO, n.d.). Yet, methods and chemicals to control Malaria continue to be elusive and a subject
of controversy. Currently, DDT is classified as one of 21 “Persistent Organic Pollutants by the
UN Environmental Program which over 150 nations have agreed to ban production of those
chemicals (MercoPress, 2009) making this product unavailable to the third world countries that
struggle with Malaria.
Certainly, by following the selected framework by Kass, we can apply her six primary
questions to assist in determining if limiting the supply of DDT to the poorer nations where
Malaria is endemic might be considered unethical: (1) the public health goal of any chemical
application program is to reduce prevalence of Malaria and deaths associated with the disease;
The facts, treatments, and ethical issues surrounding the banning of DDT
manufacturing and providing DDT for mosquito abatement programs must be considered part of
a prevention program; (2) program effectiveness can be measured by annual data collected by the
WHO; (3) potential burdens are the environmental issues associated with DDT, cost of the
chemical and training applicators; (4) burdens can be minimized by educating and training
people in the use of DDT and supplementing chemical applications with other less damaging
approaches such as using environmentally safe larvacide and mosquito netting around beds. In
addition, by requesting developed nations provide the funding and resources to needier countries,
and allowing the WHO to monitor outcomes and progress can also reduce the burdens to the
poor countries; (5) to implement a mosquito abatement program with DDT fairly, other nations
should provide resources to the poorer nations and the WHO should work with the local
governments to make sure the resources are spread evenly; (6) an appropriate Malaria reduction
program can be fairly balanced by using a combination of DDT and other prevention methods
such as bed netting and treating standing water with larvacide.
Discussion:
The question of DDT’s risks and benefits as an all-or-nothing proposition which fails to
examine the complicated environmental, public health, medical, socioeconomic, and wide range
of geographic locations is a failure on both sides of the argument to determine an ethical solution
to save millions of lives. Science has not been successful in finding a replacement chemical to
replace DDT effectiveness. The UN and WHO recommends the following prevention techniques
to reduce malaria: 1) sleeping under a mosquito net; 2) the use of skin repellent and mosquito
coils, 3) hanging mesh screening or cloth nets implanted with approved insecticides over doors
and windows, and 4) educating people about how to eliminate standing water in ditches to
destroy mosquito breeding grounds. While these techniques may be helpful, they alone are not
The facts, treatments, and ethical issues surrounding the banning of DDT
nearly enough to control malaria in the endemic nations. In fact, one of the biggest ethical
challenges the developed countries must overcome is the fact that most of the world’s wealthiest
nations who are part of the UN are malaria fee and it’s easy for the leaders in those nations to
ban DDT while many of the poorer, undeveloped countries have little input. Thus, it would
appear that ethical questions continue to exist with this issue and restrictions are being placed on
countries, which do not have the resources to implement more costly mosquito abatement
programs in lieu of DDT. Safer alternatives should be tested first and if successful, DDT should
be reduced, especially in many African countries and parts of Central America where Malaria is
endemic and hardest hit by the disease.
DDT is a fat loving, halogenated compound that has been found to persist in the
environment, can accumulate in body tissues, and has been found to biomagnify in the food
chain (Maxwell, 2009). Because DDT accumulates in the environment and body and, even if
acute human toxicity is low, DDT is still a chemical, which can cause harm and needs to be
managed appropriately. In low doses, DDT can still effectively kill mosquitos reducing the risk
of contracting Malaria and minimize risk to the environment and human beings.
Millions of people contract Malaria each year and hundreds of thousands of those die;
and, most are from very poor sub-Sahara African and South American countries. Ethically, I
believe it is incumbent upon the world leaders of the wealthier nations to develop and support a
Malaria reduction prevention program in those undeveloped countries. By following the public
health ethics framework outlined by Nancy Kass, a solution that meets those six guidelines can
be found to protect both the environment and reduce Malaria.
The facts, treatments, and ethical issues surrounding the banning of DDT
References:
Agency for Toxic Substances and Disease Registry. (September 2002). ToxFAQs for DDT, DDE,
and DDD. Retrieved January 29, 2015 from
http://www.atsdr.cdc.gov/toxfaqs/tf.asp?id=80&tid=20
Centers for Disease Control and Prevention. (n.d.) Malaria Biology. Retrieved January 25, 2015
from http://www.cdc.gov/malaria/about/biology/index.html
Environmental Protection Agency. (n.d.). DDT. Retrieved January 29, 2015 from
http://www.epa.gov/pbt/pubs/ddt.htm
Kass, N. (2001) An ethics framework for public health. American Journal of Public Health,
91(11), 1776-1782
Malaria.com. (n.d.) The history of malaria. Retrieved January 20, 2015 from
http://www.malaria.com/overview/malaria-history
Mann, J. (November 2006). Health and Human Rights. American Journal of Public Health,
96(11), 1940.
Mann, J., Gostin, L., Gruskin, S., Brennan, T., Lazzarinin, Z., & Fineberg, H. (1994). Health and
Human Rights Abstract. Health and Human Rights, 1(1), 6-23.
Maxwell, N. (2009). Understanding environmental health. Sudbury, Massachusetts: Jones and
Bartlett Publishers.
MercoPress. (May 11, 2009). Environment program agreement to ban nine persistent organic
pollutants. Retrieved February 2, 2015 from http://en.mercopress.com/2009/05/11/unenvironment-program-agreement-to-ban-nine-persistent-organic-pollutants
Pfizer Global Pharmaceuticals (2006). Milestones in Public Health, New York, NY. Pfizer Inc.
Roberts, D., Laughlin, L., Hsheih, P., and Legters, L. (1997). DDT, global strategies, and a
malaria control crisis in South America. Emerging Infectious Diseases, 3(3), 295-302.
The facts, treatments, and ethical issues surrounding the banning of DDT
Ovuorie, T. (July 2013). African countries adopt controversial deadly chemical, DDT, for
malaria treatment. Retrieved January 22, 2015 from
http://www.premiumtimesng.com/news/141150-african-countries-adopt-controversialdeadly-chemical-ddt-for-malaria-treatment.html
Tan, T., Trindade, E., & Skowronski, D. (May 2005). Epidemiology of Pertusis. The Pediatric
Infectious Disease Journal, 24(5), S10-S18.
United Nations. (n.d.). Universal Declaration of Human Rights. Retrieved January 30, 2015 from
http://www.ohchr.org/EN/UDHR/Pages/Introduction.aspx
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http://www.who.int/topics/malaria/en/