1- In public health, focusing on behavioral change instead of structural change is like haggling over pennies. I've posted about public health lessons from #HIV history in addressing #COVID19, but we can also learn from #malaria history, which I recently learned about.

2 - Until the 1930s, malaria was much more common in the US south, mostly affecting people living in poverty. Malaria went from 3.7 deaths per 100k in 1933 to 1.1 in 1940. How'd they do that?

3 - Malaria cases declined in the 1930s. In the 1940s, weather conditions + WW2 troops indicated a spike might happen, but it didn't. The US underwent major infrastructure changes, draining 500,000+ acres of mosquito breeding sites. This was led by the public health services.

4- A 2nd big influence was a cohesive state/local health department infrastructure, who led the drainage. This didn't just happen out of nowhere: Congress passed an act in 1935. Further, more houses had screens, another structural change. This is oversimplified, ofc.

5 - The main contributors to US' malaria decline weren't personal behaviors or even meds, but structural changes & a large-scale coordinated response w/ federal + state HD working together. Structural factors facilitate the changes you want people to make.

6 - Money, infrastructure, coordination, & prevention. We aren't going to end a pandemic w/ behaviors. Effective PH response can't depend on humans behaving perfectly. Nor do we depend solely on vax/meds. What are the drainages we need to build? Why are we haggling over pennies?

7 - Sources: Sledge & Mohler, AJPH 2013. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4007881/. NPR, 2017. https://www.npr.org/sections/goatsandsoda/2017/04/24/525405956/malaria-wiped-out-in-u-s-but-still-plagues-u-s-hospitals