BACKGROUND: The debate regarding dichlorodiphenyltrichloroethane (DDT) in malaria prevention and human health is polarized and can be classified into three positions: anti-DDT, centrist-DDT, pro-DDT.

OBJECTIVE: We attempted to arrive at a synthesis by matching a series of questions on the use of DDT for indoor residual spraying (IRS) with literature and insights, and to identify options and opportunities.

DISCUSSION: Overall, community health is significantly improved through all available malaria control measures, which include IRS with DDT. Is DDT "good"? Yes, because it has saved many lives. Is DDT safe as used in IRS? Recent publications have increasingly raised concerns about the health implications of DDT. Therefore, an unqualified statement that DDT used in IRS is safe is untenable. Are inhabitants and applicators exposed? Yes, and to high levels. Should DDT be used? The fact that DDT is "good" because it saves lives, and "not safe" because it has health and environmental consequences, raises ethical issues. The evidence of adverse human health effects due to DDT is mounting. However, under certain circumstances, malaria control using DDT cannot yet be halted. Therefore, the continued use of DDT poses a paradox recognized by a centrist-DDT position. At the very least, it is now time to invoke precaution. Precautionary actions could include use and exposure reduction.

CONCLUSIONS: There are situations where DDT will provide the best achievable health benefit, but maintaining that DDT is safe ignores the cumulative indications of many studies. In such situations, addressing the paradox from a centrist-DDT position and invoking precaution will help design choices for healthier lives.

Key WORDS: effects, health, indoor residual spraying, malaria vector management, precaution. Environ Health Perspect 119:744-747 (2011). doi:10.1289/ehp.l002127 [Online 18 January 2011]

Recent publications and correspondence regarding human health implications of dichlorodiphenyltrichloroethane (DDT) in this journal (e.g., Blair et al. 2009; Burton 2009; Tren and Roberts 2010; van den Berg 2009) are evidence of a continuing debate on a subject pertinent to millions of people in three continents and some islands. The debate is polarized and could be characterized by three viewpoints that are at odds over fundamental and pragmatic issues:

* The anti-DDT viewpoint wants to eliminate any production and use of DDT because of environmental and health concerns. We could find no current outright anti-DDT activities except news from a court case in Uganda against the use of DDT for malaria control (Lewis 2008).

* The centrist-DDT point of view adopts an approach that pragmatically accepts the current need for DDT to combat malaria transmission using indoor residual spraying (IRS) but at the same time recognizes the risks inherent in using a toxic chemical in the immediate residential environment of millions of people. The continued use of DDT is strongly qualified by an urgent call from the Stockholm Convention for alternative chemicals, products, and strategies. This call inherently implies the eventual termination of DDT used in IRS for malaria control (Steiner 2009).

* The pro-DDT viewpoint considers DDT safe to use in IRS when applied correctly and promotes DDT to be used as IRS in malaria control where it is still effective. Even if eventually human health effects are found to be caused by DDT, these effects would be far less than those caused by malaria (Africa Fighting Malaria 2010; Roberts et al. 1997). This is a simplistic outlay of the current gradient of the debate--there will undoubtedly be other ways of characterizing it--but, in broad terms, these statements reflect different views of common considerations.

Objectives

Our objective in this commentary was to match a series of questions on the use of DDT in IRS with the literature, experiences, and insights that may not be published in scientific articles or that may not always be recognized when considering the health implications. …