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Bart Knols

Managing Director, In2Care BV

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Join now: What is really needed to have a world without malaria? Live Conversation with Bart Knols

More than 800 million people currently live in parts of the world where they used to run the risk of contracting malaria. Its disappearance in more than 70 countries shows us one thing: it can be done...

The question then arises why we fail to repeat these successes in major parts of the tropics, notably sub-Saharan Africa. Although we have seen a decline in deaths starting in 2005, we're still looking at anywhere between 0.7 - 1.2 million deaths per year.

In this debate, we have the opportunity to discuss the 'why' of this problem, but also the 'how' and 'what' regarding possible solutions. I would encourage you to come forward with innovative and creative ideas that may provide new insight.

Thank you for participating.

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    Jun 12 2012: Bart, Sorry this is my very first TED discussion so I’m new to this... with your experience do you feel there is a gap between the medical profession- namely nursing in regards to entomological control? I know many medical professionals are working on malaria eradication efforts, but I was curious if you feel that ancillary health care support is critical to program success?
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      Jun 12 2012: Beyond any doubt. Malaria elimination is not just about killing mosquitoes. Any country that succeeded in eliminating malaria had proper health care support in place. Success means staging an integrated programme with proper diagnosis, proper treatment (with drugs that still work), with mosquito control, etc. This has been difficult to set up in many developing countries.
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    Jun 12 2012: > the economic crisis is affecting malaria control negatively
    > Last year there were 60 cases of malaria in Greece...

    ...which seems to prove the point. What stuns me the most, in problems like this, is the disproportion between the cost of solutions and the cost of not implementing them. The entire world could be freed from Malaria with less then 1% of Greece public debt, then we all could start to rip the low-hanging fruits of having healthy and productive people. Yet (we collectively behave like) we don't care...
    Thanks for your answers, Bart!
    Michele
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      Jun 12 2012: Such a nice comment - I could not agree more with you. Malaria is costing Africa some 12 billion $ per year...so think about the return on investment once you would get rid of it...it would be massive. But what that means is that you have to cough up the money to run such a campaign first...and that is where the world sets its mind on other priorities (like fighting wars...how much are we spending on that each year?).
  • Jun 12 2012: Alexandra Taylor - New York, USA

    While, eradication of Malaria is the main goal of many organizations and individuals in the fight against Malaria, there is a need to control the spread of Malaria now. The most cost effective and efficient way is through the use of long-lasting insecticide-treated bed nets.

    Do you believe we will eradicate Malaria by the UN Millennium Development Goal of 2015?
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      Jun 12 2012: Regretfully, my answer is no. It is estimated that between 655 k and 1.2 m people die of malaria each year. There is no way we will bring this number down to zero (which is the MDG for malaria by 2015).

      I do not think that bednets are the panacea to curb the problem - they do save lives, but they are a temporary and unsustainable solution...
  • Jun 12 2012: London PhD student

    From trawling the literature I have found only a couple of studies where an increase in insecticide resistance in mosquitoes has been correlated to an increase in malaria, and even these studies, in my opinion, aren't hugely convincing due to the many confounding factors involved. I found this very surprising seeing that resistance in the mosquito vector has been around for over 50 years.

    So my question is, is resistance really a problem?

    possible reasons for why it might not be a problem:

    1. Resistant mosquitoes might not be as good vectors as "normal" mosquitoes
    2. A few studies have shown resistance in the mosquito decreases with age, so maybe they become sensitive before they can transmit malaria?

    Or is it just a very difficult thing to prove (needing good malaria and resistance surveillance over a long time period)?
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      Jun 12 2012: All good and valid points, Adam. Resistance has been one of the reasons why the WHO abandoned the global malaria eradication campaign that ran between 1955-1969. Resistance today, especially against the pyrethroids used on nets, is becoming more widespread. Although it is argued that resistant mosquitoes are still being exo-repelled (don't come into the house), it is a matter of time before even this effect wanes. And if you are no longer repelling or killing vectors, you don't stand a chance of malaria elmination (even if they become less competent).
      • Jun 12 2012: Do you know of, and if so what is your opinion on, potentially using mosquito parasites (such as entomopathic fungi and microsporidia) to make resistant mosquitoes sensitive to insecticide?
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          Jun 12 2012: Yes they do - in fact, we have been researching this ourselves. Check for the name 'Farenhorst M' on pubmed and you will find her publications on this topic...
      • Jun 12 2012: Yes I've read it, thanks. Sorry I didn't make it clear but I'm also working on something similar.

        Before the time runs out I'd like to say thanks for setting this up its been very interesting.
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    Jun 12 2012: Bart -
    Can you tell us a little more about why it's been so difficult to eradicate, and what the unintended consequences are?
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      Jun 12 2012: Eradication has been complicated by a number of factors, notably:
      - resistance of mosquitoes to insecticides
      - resistance of malaria parasites to drugs
      - lack of funding
      - insufficient support for setting up appropriate health infrastructure in developing countries
      - not enough well-trained public health specialists in many endemic countries

      A long list...showing how difficult it can be to eliminate a disease nobody needs to die of...
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      Jun 12 2012: As for unintended consequences...failure to eradicate means that evolution catches up with us. Prolonged efforts to control rather than eliminate means that you give the players in the system (notably the mosquito vector and the parasite) all the time to evolve, mutate, and become resistant.

      The result is that we have to go back to the bench once more to find new drugs and/or insecticides...
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        Jun 12 2012: (I am from the US, NYC, btw.)

        Such a difficult situation. Admittedly, I know little about this problem but want to understand it better. It's my hope others more educated than I will join the conversation - since I am only able to ask the most elementary questions. :)

        What companies are most committed to finding answers, Bart?
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          Jun 12 2012: No problem - even basic questions are good. Malaria control (note the word control as there are very few companies engaged in this commercially) is mostly funded through large NGOs (think of UNICEF, World Bank, Global Fund for HIV/AIDS, TB and malaria, and so on.

          But you raise an interesting point, as I believe there is a lot of scope to 'commercialise' malaria control (if not elimination).
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          Jun 12 2012: The US President's Malaria Initiative (PMI) is run through USAID, and they outsource activities (notably house spraying with insecticides) to a commercial firm. They have done so in at least 15 African countries to date.
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          Jun 12 2012: In terms of finding new drugs and insecticides, commercial entities are engaged (pharmaceutical companies as well as pest control companies) and there are public private partnerships to drive this endeavour (e.g. the Medicines for Malaria Venture (MMV), or the IVCC (Innovative Vector Control Consortium).
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        Jun 12 2012: This stuns me. International companies dedicated to developing eradication methods for every weed and insect under the sun are not directing a significant effort into eradicating malaria?

        I also live in Idaho - on a ranch - when not in NYC, and the money we (farmers and ranchers)receive simply to participate in weed eradication is embarrassing.
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          Jun 12 2012: The amount of money spent on pet drugs in the US far exceeds the research and control budget for malaria...
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          Jun 12 2012: As a company developing insecticides, you should know that it takes a decade on average and 1 b$ to bring a new insecticide to the market. Obviously there is much more business in agriculture than in public health, so the public health insecticides we use today have mostly come from the agricultural field...
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        Jun 12 2012: What are the health risks to house spraying? How is this handled in underdeveloped countries?

        When training, I like to tell the story about the cats in Borneo...through the song by Alan Atkisson :)
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          Jun 12 2012: Yes - the cat story from Borneo. DDT spraying and its pros and cons are still being debated in sicentific circles. Fact is that it is used on a large scale because it is cheap and persistent. But widespread resistance means that we will sooner or later stop using it anyway...
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      Jun 12 2012: Another major reason why it is hard to eradicate malaria is that in many countries it is virtually impossible to set up a campaign due to civil war or civil unrest, making it hard for programmes to be implemented...
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        Jun 12 2012: Yes, this is a real problem. Have there been any specific approaches that have been effective in the face of this unrest?
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          Jun 12 2012: If anything, then insecticide-treated bednets may find there way into communities, even when exposed to such stress. In DR Congo bednets have reached far-out corners of the country now. However, even though these will save lives, this is not about elimination which requires a lot more...
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    Jun 12 2012: Dear all,

    We are nearing the end of this conversation. Many things were discussed (repellents, insecticides, public health systems, funding, wars, refugees) that were all of interest to me, so I thank you very much for sharing your thoughts with me.

    It shows that getting rid of malaria is not an easy thing...but maybe doable in the long run. Let's keep up the fight!

    Should you wish to talk more, you can reach me via the contact page on my website: www.bartknols.com

    Warmest regards, and thanks once again,
    Bart
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    Jun 12 2012: You have a wonderful speaking style, Bart. Thanks for sharing your knowledge and vision.
  • Jun 12 2012: Hi, Mr. Knols,
    In respect of the mosquito net, I am just wondering if it's possible for the researcher to find some way to make the net from materials which could be found in the place in need. If people living there could be taught to make nets from surrounding materials with their own hands (although these net might not be as good as products made through industrial process,) we might help them not only to prevent malaria but also help them to improve financial conditions.
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      Jun 12 2012: This may be difficult...but an interesting thought nevertheless. Nets need to have a certain mesh size (normally 156 holes per square inch) to make sure that mosquitoes do not penetrate through them. If people have to make there own nets it has to be done according to these specfications in order to have a meaningful effect. Having said that, there is a local bednet manufacturer in Tanzania (A-Z textiles) that is providing jobs for hundreds (if not thousands) of Tanzanians in the Arusha region. So yes, malaria control can create jobs in developing countries also.
      • Jun 12 2012: Thank you for the reply. If we could apply some (lasting and not harmful to human) substance that mosquitoes hate on the net, could we make the number of holes smaller? If the answer is yes, then that might make the manufacturing process easier. :-)
  • Jun 12 2012: Jonathan from Florida, USA.
    What, if any, computer and information technologies are used in the fight against malaria? Are there many opportunities for this sort of technology, whether it be internet, mobile, or whatever, to make any kind of significant contribution, e.g. in tracking the disease, informing and coordinating populations, somehow aiding scientists, or anything at all?
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      Jun 12 2012: Yes there is a lot that being used in malaria control these days. GIS, remote sensing technology, satellite imagery, mobile telephony, and so on. On Zanzibar mobile phones are used to report cases and take quick action, mobile telephone usage is used to track where people move (between infested and uninfested regions for instance), so yea, quite a bit of that...
  • Jun 12 2012: What is the latest on the genetically modified malaria resistant mosquitoes? How's that debate going? How close is an integrated (successful) pest management strategy?
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    Jun 12 2012: Good Morning,

    I'm jumping in a bit late. It seems to me that water is part of the problem and solution. Living in tropical Mexico we deal with mosquitoes, dengue fever and small malaria outbreaks. Knowing/educating on how to store H2O and clear/clean stagnant water is important; if not the solution. We are finding that the pesticides used for killing the mosquitoes are harming bee and other insect populations which in turn is effecting pollination, bird population etc.

    Not sure that this was at all helpful but am interested in the topic and solutions that are sustainable.
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      Jun 12 2012: Water storage is not so much an issue when we talk about malaria than dengue. Malaria mosquitoes breed in standing water at ground level (in pools, hoofprints etc) although there are some exceptions (like Indian malaria mosquitoes breeding in water tanks). Water storage therefore is particularly important to stop breeding of dengue mosquitoes, not so much for malaria mosquitoes.
  • Jun 12 2012: Hi. Writing from mosquito infested Bombay.

    How does an individual take steps to keep their environment safe in the absence of larger initiatives? Any natural long term remedies such as growing plants of a certain type that can keep these little monsters away?
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      Jun 12 2012: Repellent plants do exist, but give only partial protection. There isn't much one can do if you are alone in a village or town and there is no programme - your back to bednets, use of window screens, etc.
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    Jun 12 2012: Vietnam

    When I was little, my family gets a free mosquito net from a government program of malaria prevention. Just that one time, I don't remember anything further.
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      Jun 12 2012: Excellent point - it is all about sustainability. Over the last few years more than 200 million nets have been distrubuted in sub-Saharan Africa. Who will hand out the next net when the current ones lose their activity (3 years from now)?
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    Jun 12 2012: Hello Bart,
    The digging of the panama canal had a problem with mosquito´s too back then the answer was detroying all possible breeding groud in the vincinity. It did end the mosquito plague.
    The fact that pets which are simularly protected did not end the existence of the flea does raise a question.
    Is it the goal to end human to human infection?
    Kind regards.
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      Jun 12 2012: Human malaria is caused by 5 different parasite species, of which only one has a reservoir in monkeys (Plasmodium knowlesi). That means that the other four are only found in humans or mosquitoes. Suppressing or eliminating mosquito populations the means eliminating malaria....
  • Jun 12 2012: I forgot to mention that I personally do not use pesticides/insecticides unless absolutely necessary ... I try to use natural (eco) methods
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      Jun 12 2012: Green is often better and often more sustainable. Were you aware that in Africa somwhere between 4 and 5 million kg of DDT are sprayed each year, though this pesticide was banned in the USA in 1972 and shortly afterwards in Europe?
      • Jun 12 2012: Wow, I was NOT aware of this, and I imagine that most people think that DDT was banned worldwide and is not used anymore! Certainly that would be true of Americans.

        If DDT is in fact not a net positive (and I assume it is not?) then to the extent that it is being used in countries that have significant tourism or significant investment by the World Bank/IMF etc, outside pressure to ban it could be an idea
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    Jun 12 2012: Here's Michele from Milano, Italy.
    How dependent malaria prevention is from economic trends?
    Did the economic crisis worsen the problem, over the last few years?
    Thanks for your reply!
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      Jun 12 2012: Good point, Michelle. Unfortunately the global economic crisis has had an impact on malaria control efforts. Globally, we need 6 b$ to make a real difference, but last year we 'only' had 1,6 b$. The economic downturn has also led to governments spending less on global initiatives (like the Global Fund) that has seen much less money coming in to disburse for control efforts. So yes, the economic crisis is affecting malaria control negatively...
  • Will H

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    Jun 12 2012: I've always wondered what the mosquito's place is in the ecosystem. Who would miss them if they went away?
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      Jun 12 2012: They do play a role in nature, especially as larvae (as food for fish, amphibians etc). But it is not about eliminating mosquitoes, it is all about eliminating the parasite...
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      Jun 12 2012: Mosquitoes can also play a role in pollination (mainly the males), but the extent to which this is important remains largely unknown.
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    Jun 12 2012: Hello everyone,

    Welcome to this live conversation on malaria. A few ‘rules’ to guide our discussion:

    - Even if you are not a malaria professional, please contribute
    - No question is a silly question. No comment is a silly comment. True innovation thrives on people throwing around ideas (that may sound silly at first)
    - Sharing ideas and possible solutions is what we aim for. Let’s make it an ‘open innovation’ event
    - Please remain polite and don’t use abusive language

    If all goes well than I intend to write a blog about this conversation on MalariaWorld (www.malariaworld.org), the world’s largest free platform for malaria professionals (with more than 7500 subscribers in >140 countries).

    I am keen to know where you are based, so when posting a comment or question, please start with your country the first time you contribute. In my case this would be ‘Netherlands: ….’.

    Thanks – let’s get started.
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    Jun 12 2012: I study bed bugs. We don’t see disease transmission with those per say, but elimination and eradication issues are probably similar in certain ways.
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    Jun 12 2012: Whoo. How would I solve malaria? Very difficult question. In certain circumstances I don’t believe it’s yet possible honestly. Your comments on civil unrest, political pander, education, awareness, misuse and pesticide/ medicine abuses all confound the problem. Poverty is also the greatest barrier as with any public health disease. Funding issues, resource allocation etc... I think it is very possible, but true eradication is very difficult in areas with all of those barriers in place.
  • Jun 12 2012: What about incense based on citronella etc? Can these be effective?
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    Jun 12 2012: One more thing... what are your thoughts on malaria reports creeping up northwardly? I know we have the vectors in the US (I’m an American living in Belgium) but yet malaria was eradicated years ago from our southern coastline if my memory of past med entomology coursework is correct... it’s been a while though so correct me if I’m wrong. Do you think Europe and US will see malaria resurgence? If so any thoughts on the reasoning?
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      Jun 12 2012: Well, we have had quite a few cases in Greece last year, and Spain saw local malaria transmission for the first tie in 50 years. Globalisation and perhaps climate change will influence malaria - yet I do not see this happening soon. The US has had some 60 small outbreaks in the last 50 years, and all of these were eliiminated...
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    Jun 12 2012: Yes Bart, you do have a great speaking/ writing style. I’ve benefited from this question response session.
  • Jun 12 2012: Hmm. What about burning incense like citronella etc? Effective?
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      Jun 12 2012: To some extent...if people sit close to it it may offer some level of protection. But as a full means to protect yourself against contracting malaria...No.
  • Jun 12 2012: I see a lot of stories in the malaria news about supporting refugee camps with bed nets and malaria drugs. Conflict and migration are big issues when trying to combat malaria. Besides targetting camps, are there other ways to target the at risk populations? It seems so hopeless!
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      Jun 12 2012: In a refugee situation, all you can do is use nets and take care of patients. This is indeed a major problem as population displacement also means that people get exposed to new genotypes of the parasite in the areas they migrate to, against they have not built up any immunity. Malaria therefore strikes such refugees extra hard.

      As for targeting populations in peaceful settings, I believe that we should carefully look at areas that have seasonal transmission (sahel zone, horn of Africa) and double wham malaria with mosquito control and use of drugs that kill transmissible stages of the parasite. All evidence is there that this can work...but nobody os doing this right now...
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    Jun 12 2012: What are your thoughts on genetically modifying mosquitos for sterility? Is it too daunting of a geographical spread to work? This was a huge discussion in our program. I know there is a man who recently succeeded in infecting mosquitoes with Wolbachia to combat Dengue though the results of success are not in yet. I imagine there are others working on those forms of control as well. One invention I believe is often overlooked is that of the window screen. I know the feasibility of use in Africa may not be realistic, but perhaps some of those simpler techniques- items based off of human behavior rather than insect behavior (or in conjunction with) would be beneficial.
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      Jun 12 2012: House improvement is definitely a major step forward (making houses less prone to mosquito invasion). Remember that porches in the USA had a major contribution to malaria control.

      As for GM mosquitoes: we'll have to see. It is too early to gauge their potential, and I'd like to give it the benefit of the doubt. As for sterile malaria mosquitoes, the IAEA is developing this (I worked there) but the problem is that in most of Africa there are at least 2-3 species of mosquito transmitting malaria. So setting up a programme to release steriles will be very costly...
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    Jun 12 2012: I forgot to say... I’m in Belgium.
  • Jun 12 2012: My understanding is that the crane fly (known as Skeeter eaters here in the US) are beneficial because they eat mosquito larvae. For photos of the crane fly, see http://en.wikipedia.org/wiki/Skeeter_eater.

    Would releasing crane flies be a worthwhile control method? Just as ladybugs are released to eat aphids?
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      Jun 12 2012: Interesting - biological control using predators might be worthwhile, but the continent of Africa is vast, you need to distribute those predators, and the introduction of predators not native to a certain country is not always without problems (...Australia)...
  • Jun 12 2012: What has been the most significant on-the-ground programme that you have seen in Afirca to eradicate malaria? Is there a country or community that stands out for its continued efforts and why?
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      Jun 12 2012: Egypt eliminated its malaria problem between 1943 and 1945, during WWII. It was run along the Nile with a huge number of people treating breeding sites with insecticide (Paris green) and spraying houses with DDT. Chloroquine was used to treat patients - it worked and the country has remained free of malaria since.
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        Jun 12 2012: What were the human health consequences from this action? Long or short term?
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          Jun 12 2012: That Egypt has been free of the malaria scourge for all the decades...in terms of the impact of the action itself, well, the generation that lived than is no longer with us... But remember that DDT was used on an enormous scale in the US in the 1950s, and we have not seen a massive increase in cancer or other ailments because of that...