DDT (from its trivial name, Dichloro-Diphenyl-Trichloroethane) is one of the best known synthetic pesticides. It is a chemical with a long, unique, and controversial history.
First synthesized in 1874, DDT's insecticidal properties were not discovered until 1939. In the second half of World War II, it was used with great effect among both military and civilian populations to control mosquitoes spreading malaria and lice transmitting typhus, resulting in dramatic reductions in the incidence of both diseases. The Swiss chemist Paul Hermann Müller of Geigy Pharmaceutical was awarded the Nobel Prize in Physiology or Medicine in 1948 "for his discovery of the high efficiency of DDT as a contact poison against several arthropods." After the war, DDT was made available for use as an agricultural insecticide, and soon its production and use skyrocketed.
In 1962, Silent Spring by American biologist Rachel Carson was published. The book catalogued the environmental impacts of the indiscriminate spraying of DDT in the US and questioned the logic of releasing large amounts of chemicals into the environment without fully understanding their effects on ecology or human health. The book suggested that DDT and other pesticides may cause cancer and that their agricultural use was a threat to wildlife, particularly birds. Its publication was one of the signature events in the birth of the environmental movement. Silent Spring resulted in a large public outcry that eventually led to most uses of DDT being banned in the US in 1972. DDT was subsequently banned for agricultural use worldwide under the Stockholm Convention, but its limited use in disease vector control continues to this day in certain parts of the world and remains controversial.
Commercial DDT is actually a mixture of several closely related compounds. The major component (77%) is the p,p isomer which is pictured at the top of this article. The o,p' isomer (pictured to the right) is also present in significant amounts (15%). Dichlorodiphenyldichloroethylene (DDE) and dichlorodiphenyldichloroethane (DDD) make up the balance. DDE and DDD are also the major metabolites and breakdown products of DDT in the environment. The term "total DDT" is often used to refer to the sum of all DDT related compounds (p, p-DDT, o, p-DDT, DDE, and DDD) in a sample.
Currently about 1,000 tonnes of DDT are used annually worldwide in disease and insect vector control. India and China are the only countries still producing and exporting it.
First synthesized in 1874 by Othmar Zeidler, DDT's insecticidal properties were not discovered until 1939 by the Swiss scientist Paul Hermann Müller, who was awarded the 1948 Nobel Prize in Physiology and Medicine for his efforts.
DDT played a small role in the final elimination of malaria in Europe and North America, as malaria had already been eliminated from much of the developed world before the advent of DDT through the use of a range of public health measures and generally increasing health and living standards. One CDC physician involved in the United States' DDT spraying campaign said of the effort that "we kicked a dying dog. But in countries without these advances, it was critical in their eradication of the disease.
In 1955, the World Health Organization commenced a program to eradicate malaria worldwide, relying largely on DDT. The program was initially highly successful, eliminating the disease in "Taiwan, much of the Caribbean, the Balkans, parts of northern Africa, the northern region of Australia, and a large swath of the South Pacific" and dramatically reducing mortality in Sri Lanka and India. However resistance soon emerged in many insect populations as a consequence of widespread agricultural use of DDT. In many areas, early victories against malaria were partially or completely reversed, and in some cases rates of transmission even increased. The program was successful in eliminating malaria only in areas with "high socio-economic status, well-organized healthcare systems, and relatively less intensive or seasonal malaria transmission".
DDT was less effective in tropical regions due to the continuous life cycle of mosquitoes and poor infrastructure. It was not pursued at all in sub-Saharan Africa due to these perceived difficulties, with the result that mortality rates in the area were never reduced to the same dramatic extent, and now constitute the bulk of malarial deaths worldwide, especially following the resurgence of the disease as a result of microbe resistance to drug treatments and the spread of the deadly malarial variant caused by Plasmodium falciparum. The goal of eradication was abandoned in 1969, and attention was focused on controlling and treating the disease. Spraying programs (especially using DDT) were curtailed due to concerns over safety and environmental effects, as well as problems in administrative, managerial and financial implementation, but mostly because mosquitoes were developing resistance to DDT. Efforts were shifted from spraying to the use of bednets impregnated with insecticides and other interventions.
Silent Spring was a best seller, and public reaction to it launched the modern environmental movement in the United States. The year after it appeared, President Kennedy ordered his Science Advisory Committee to investigate Carson's claims. The report the committee issued "add[ed] up to a fairly thorough-going vindication of Rachel Carson’s Silent Spring thesis," in the words of the journal Science, and recommended a phaseout of "persistent toxic pesticides". DDT became a prime target of the growing anti-chemical and anti-pesticide movements, and in 1967 a group of scientists and lawyers founded the Environmental Defense Fund (EDF) with the specific goal of winning a ban on DDT. Victor Yannacone, Charles Wurster, Art Cooley and others associated with inception of EDF had all witnessed bird kills or declines in bird populations and suspected that DDT was the cause. In their campaign against the chemical, EDF petitioned the government for a ban and filed a series of lawsuits. Around this time, toxicologist David Peakall was measuring DDE levels in the eggs of peregrine falcons and California condors and finding that increased levels corresponded with thinner shells.
In response to an EDF suit, the U.S. District Court of Appeals in 1971 ordered the EPA to begin the de-registration procedure for DDT. After an initial six-month review process, William Ruckelshaus, the Agency's first Administrator rejected an immediate suspension of DDT's registration, citing studies from the EPA's internal staff stating that DDT was not an imminent danger to human health and wildlife. However, the findings of these staff members were criticized, as they were performed mostly by economic entomologists inherited from the United States Department of Agriculture, whom many environmentalists felt were biased towards agribusiness and tended to minimize concerns about human health and wildlife. The decision not to ban thus created public controversy.
The EPA then held seven months of hearings in 1971-1972, with scientists giving evidence both for and against the use of DDT. In the summer of 1972, Ruckelshaus announced the cancellation of most uses of DDT—an exemption allowed for public health uses under some conditions. Despite the ban on its domestic use, DDT continued to be produced in the US for foreign markets until as late as 1985, when over 300 tonnes were exported. Immediately after the cancellation was announced, both EDF and the DDT manufactures filed suit against the EPA, with the industry seeking to overturn the ban, and EDF seeking a comprehensive ban. The cases were consolidated, and in 1973 the U.S. Court of Appeals for the District of Columbia ruled that the EPA had acted properly in banning DDT.
The U.S. DDT ban took place amid a climate of growing public mistrust of industry, with the Surgeon General issuing a report on smoking in 1964, the Cuyahoga River catching fire in 1969, the fiasco surrounding the use of diethylstilbestrol (DES), and the well-publicized decline in the bald eagle population.
The Stockholm Convention, ratified in 2001 and effective as of 17 May 2004, outlawed several persistent organic pollutants, and restricted the use of DDT to vector control. The Convention was signed by 98 countries and is endorsed by most environmental groups. Recognizing that a total elimination of DDT use in many malaria-prone countries is currently unfeasible because there are few affordable or effective alternatives, the public health use of DDT was exempted from the ban until alternatives are developed. The Malaria Foundation International states:
The outcome of the treaty is arguably better than the status quo going into the negotiations…For the first time, there is now an insecticide which is restricted to vector control only, meaning that the selection of resistant mosquitoes will be slower than before.
Despite the worldwide ban on agricultural use of DDT, some farmers in India still use it in crop production.
About 1,000 tonnes of DDT per year is still used today in some countries where malaria is a serious health problem. In this context, DDT is applied to the inside walls of homes to kill or repel mosquitos entering the home. This intervention, called indoor residual spraying (IRS), greatly reduces environmental damage compared to the earlier widespread use of DDT in agriculture. It also reduces the risk of resistance to DDT. This use only requires a small fraction of that previously used in agriculture; for example, the amount of DDT that might have been used on 100 acres (0.4 km²) of cotton during a typical growing season in the U.S. is estimated to be enough to treat roughly 1,700 homes.
DDT, DDE, and DDD magnify through the food chain, with apex predators such as raptors having a higher concentration of the chemicals than other animals sharing the same environment. They are stored mainly in body fat. In the United States, human blood and fat tissue samples collected in the early 1970s showed detectable levels in all samples. A study conducted in the late 1970s after the U.S. DDT ban found that blood levels were declining, but DDT or metabolites were still found in a high proportion of samples. Biomonitoring conducted by the Centers for Disease Control as recently as 2002 shows that more than half of subjects tested had detectable levels of DDT or metabolites in their blood, and of the 700+ milk samples tested by the USDA in 2005, 85% had detectable levels of DDE.
DDT is a toxicant across a range of phyla. DDT was a major reason for the decline of the bald eagle in North America in the 1950s and 1960s as well as the brown pelican and the peregrine falcon. DDT and its breakdown products are toxic to embryos and disrupts calcium absorption, thereby impairing eggshell quality. Studies in the 1960s and 1970s failed to find a mechanism for the hypothesized thinning. However, more recent studies in the 1990s and 2000s have laid the blame at the feet of DDE. Some studies have shown that although DDE levels have fallen dramatically, eggshell thickness remains 10–12 percent thinner than before DDT was first used. DDT is also highly toxic to aquatic life, including crayfish, daphnids, sea shrimp and many species of fish. DDT may be moderately toxic to some amphibian species, especially in the larval stages.
In contrast to studies which measured DDT or DDE late in life, a recent study was able to assess DDT exposure early in life and track the breast cancer status of the women later in life. This study found a strong association between exposure to the p, p-isomer of DDT early in life and breast cancer later in life. Exposure to the o, p'-isomer was negatively correlated with breast cancer (i.e. a protective effect was observed), and no association was observed for DDE. Unlike previous studies, this was prospective cohort study in which blood samples were collected from young mothers in the 1960s while DDT was still in use, and their breast cancer status was then monitored. In addition to suggesting that exposure to the p, p-isomer of DDT is the more significant risk factor of breast cancer, the study also suggests that the timing of exposure is critical. For the subset of women born more than 14 years prior to the introduction of DDT into US agriculture, there was no association between DDT levels and breast cancer. However, for women born more recently—and thus exposed earlier in life—the most p, p-DDT exposed third had a fivefold increase in breast cancer incidence over the least exposed third, after correcting for the protective effect of o, p-DDT.
Spraying DDT is but one of many public health interventions that have historically been used to control malaria, and one of many still in use today. Before the advent of DDT, aggressive campaigns to eliminate mosquito breeding grounds by drainage or poisoning with Paris green or pyrethrum were used, sometimes successfully, to fight the disease. In many parts of the world, rising standards of living resulted in the elimination of malaria as a collateral benefit of the introduction of window screens and improved sanitation. Today, a variety of interventions are used, and usually many are used simultaneously. These include the use of antimalarial drugs to prevent or treat malaria infections; improvements in public health infrastructure to quickly diagnose, sequester, and treat infected individuals; the distribution of bednets and other methods intended to keep mosquitos from biting humans; and vector control strategies. These include larvaciding with appropriate insecticides, ecological controls such as draining mosquito breeding grounds or introducing fish to eat larva, and indoor residual spraying (IRS) with DDT or other insecticides. IRS involves the treatment of all interior walls and ceilings with insecticides, and is particularly effective against mosquitoes, since many species will rest on an indoor wall before or after feeding. The contemporary DDT debate revolves around how much of a role the chemical should play in the mix of malaria control strategies.
Once the mainstay of anti-malaria campaigns, as of 2006 only 13 countries were still using DDT, including India and some southern African states. The WHO's anti-malaria campaign in the 1950s and 1960s relied heavily on the chemical and initially the results were promising, though short lived. Experts tie the resurgence of malaria to numerous factors, including poor leadership and management of malaria control programs, a chronic lack of funds in the countries worst hit by malaria, and the resistance of the malaria parasite itself to the drugs traditionally used to treat the illness. According to Richard Tren, "Malaria surged through Africa in the 1990s, fueled by resistance to chloroquine and other historically effective drugs. Resistance of mosquitoes to DDT has also been a factor, which was exacerbated by the often unrestricted use of DDT in agriculture. This, coupled with the awareness that DDT may be harmful both to humans and the environment led governments to restrict or curtail the use of DDT in vector control.
Today, DDT is still included in the WHO's list of insecticides recommended for IRS. Since the appointment of Arata Kochi as head of its anti-malaria division, WHO's policy has shifted from recommending IRS only in areas of seasonal or episodic transmission of malaria, to also advocating it in areas of continuous, intense transmission. The WHO remains, however, "very much concerned with health consequences from use of DDT" and it has reaffirmed its commitment to eventually phasing it out. South Africa is one country that continues to use DDT under WHO guidelines. In 1996, the country switched to alternative insecticides and malaria incidence increased dramatically. Returning to DDT and introducing new drugs brought malaria back under control.
According to DDT advocate Donald Roberts, malaria cases increased in South America after countries in that continent stopped using DDT. Other mosquito-borne diseases are also on the rise. Roger Bate claims that until the 1970s, DDT was used to eradicate the Aedes aegypti mosquito from most tropical regions of the Americas. The reinvasion of Aedes aegypti since has brought devastating outbreaks of dengue fever, dengue hemorrhagic fever, and a renewed threat of urban yellow fever.
Resistance was noted early in spray campaigns, with Paul Russell, a former head of the Allied Anti-Malaria campaign, observing in 1956 that eradication programs had to be wary of relying on DDT for too long as "resistance has appeared [after] six or seven years." DDT has lost much of its effectiveness in many parts of the world including Sri Lanka, Pakistan, Turkey and Central America, and it has largely been replaced by organophosphate or carbamate insecticides, e.g. malathion or bendiocarb.
In many parts of India, DDT has largely lost its effectiveness. Agricultural uses were banned in 1989, and its use for anti-malarial purposes has been declining. Its use in urban areas has been halted completely. Nevertheless, DDT is still manufactured and used in the country, and one study had concluded that "DDT is still a viable insecticide in indoor residual spraying owing to its effectivity in well supervised spray operation and high excito-repellency factor."
Studies of malaria-vector mosquitoes in KwaZulu-Natal Province, South Africa found susceptibility to 4% DDT (the WHO susceptibility standard), in 63% of the samples, compared to the average of 86.5% in the same species caught in the open. The authors concluded that "Finding DDT resistance in the vector An. arabiensis, close to the area where we previously reported pyrethroid-resistance in the vector An. funestus Giles, indicates an urgent need to develop a strategy of insecticide resistance management for the malaria control programmes of southern Africa."
It has been argued that DDT can still be effective against resistant mosquitos, and that the avoidance of DDT-sprayed walls by mosquitoes is an additional benefit of the chemical. For example, a 2007 study reported that DDT-resistant mosquitoes still avoided DDT-treated huts. The researchers argued that DDT was the best pesticide for use in IRS (even though it did not afford the most protection from mosquitos out of the three test chemicals) because the others pesticides worked primarily by killing or irritating mosquitoes—modes of action the authors presume mosquitoes will develop resistance to. Others have argued that the avoidance of DDT sprayed walls by mosquitoes is detrimental to the actual eradication of the disease. Unlike other insecticides such as pyrethroids, DDT requires a long period of contact before mosquitoes pick up a lethal dose; however its irritant property makes them fly off before this occurs. "For these reasons, when comparisons have been made, better malaria control has generally been achieved with pyrethroids than with DDT." In India, with its outdoor sleeping habits and frequent night duties, "the excito-repellent effect of DDT, often reported useful in other countries, actually promotes outdoor transmission.
In addition, DDT is not suitable for this type of spraying in Western-style plastered or painted walls, only traditional dwellings with unpainted walls made of mud, sticks, dung, thatch, clay, or cement.As rural areas of South Africa become more prosperous, there is a shift towards Western style housing, leaving fewer homes suitable for DDT spraying, and necessitating the use of alternative insecticides.
Other villagers object to DDT spraying because it does not kill cockroaches or bedbugs; rather, it excites such pests making them more active, so that often use of another insecticide is additionally required. Pyrethroids such as deltamethrin and lambdacyhalothrin, on the other hand, are more acceptable to residents because they kill these nuisance insects as well as mosquitoes. DDT has also been known to kill beneficial insects, such as wasps that kill caterpillars that, unchecked, destroy thatched roofs.
As a result, says Dr. Avertino Barreto, chief of infectious disease control in Mozambique, resistance to DDT spraying is \"homegrown\", not due to \"pressure from environmentalists\". \"They only want us to use DDT on poor, rural black people,\" he says. \"So whoever suggests DDT use, I say, 'Fine, I'll start spraying in your house first.' \"
Evidence for exposure to DDT is seen in South Africa, where in contrast to areas where DDT use has ceased (even where it was used heavily), in areas where DDT is currently in use ostensibly in small amounts for malaria prevention only, DDT levels in men and women were significantly higher than the allowable daily intake. Breast milk from regions where DDT is used for malaria control contains enough DDT to greatly exceed the allowable daily intake of breast feeding infants. These levels have been associated with neurological abnormalities in babies ingesting relatively large quantities of DDT in their milk although toxicity via this mode of intake has not been proved.
Some researchers have suggested that the negative health effects of exposure to DDT might outweigh the health benefits afforded by anti-malarial properties. For example, scientists with the US National Institute of Environmental Health Sciences argued in The Lancet that \"Although DDT is generally not toxic to human beings and was banned mainly for ecological reasons, subsequent research has shown that exposure to DDT at amounts that would be needed in malaria control might cause preterm birth and early weaning, abrogating the benefit of reducing infant mortality from malaria...DDT might be useful in controlling malaria, but the evidence of its adverse effects on human health needs appropriate research on whether it achieves a favourable balance of risk versus benefit.\"
These arguments have been called \"outrageous\" by former WHO scientist Socrates Litsios, and May Berenbaum, a professor of entomology at the University of Illinois at Urbana-Champaign, says that \"to blame environmentalists who oppose DDT for more deaths than Hitler is worse than irresponsible. In May 2008 article in Prospect, John Quiggin and Tim Lambert write that \"the most striking feature of the claim against Carson is the ease with which it can be refuted.\"
Criticisms of a "ban" on DDT often specifically reference the 1972 US ban (with the implication that this constituted a worldwide ban), ignoring the fact that DDT has not been banned for public health use in most areas of the world where malaria is endemic. Reference is also often made to Rachel Carson's Silent Spring even though she never pushed for a ban on DDT. In fact, she devoted a page of the book to consideration of the relationship between DDT and malarial mosquitoes, with cognizance of the evolution of resistance in the mosquito, concluding:
It is more sensible in some cases to take a small amount of damage in preference to having none for a time but paying for it in the long run by losing the very means of fighting [is the advice given in Holland by Dr Briejer in his capacity as director of the Plant Protection Service]. Practical advice should be "Spray as little as you possibly can" rather than "Spray to the limit of your capacity."
According to Amir Attaran, many environmental groups fought against the public health exception of DDT in the 2001 Stockholm Convention, over the objections of third world governments and many malaria researchers. In an opinion piece in Nature Medicine he strongly objected to what would have been a de facto ban and stated: "Environmentalists in rich, developed countries gain nothing from DDT, and thus small risks felt at home loom larger than health benefits for the poor tropics. More than 200 environmental groups, including Greenpeace, Physicians for Social Responsibility and the World Wildlife Fund, actively condemn DDT...
It has also been argued that donor governments and agencies have refused to fund DDT spraying, or made aid contingent upon the non-use of DDT. According a report in the British Medical Journal, use of DDT in Mozambique "was stopped several decades ago, because 80% of the country's health budget came from donor funds, and donors refused to allow the use of DDT. The pro-DDT advocacy group Africa Fighting Malaria (AFM) maintains that USAID and some other international donor organizations have refused to fund public health DDT programs. Roger Bate of AFM asserts that "many countries have been coming under pressure from international health and environment agencies to give up DDT or face losing aid grants: Belize and Bolivia are on record admitting they gave in to pressure on this issue from [USAID].
However, according to the USAID website, "USAID has never had a 'policy' as such either 'for' or 'against' DDT for IRS. The real change in the past two years [2006/07] has been a new interest and emphasis on the use of IRS in general—with DDT or any other insecticide—as an effective malaria prevention strategy in tropical Africa. USAID's Kent R. Hill states that the agency has been misrepresented: "USAID strongly supports spraying as a preventative measure for malaria and will support the use of DDT when it is scientifically sound and warranted. The agency's website explains that in many cases alternative malaria control measures were judged to be more cost-effective that DDT spraying, and so were funded instead.
Organophosphate or carbamate insecticides, e.g. malathion or bendiocarb, are considerably more expensive than DDT, and malathion requires more frequent respraying. Pyrethroids such as deltamethrin and lambdacyhalothrin are also more expensive than DDT, but due to their much greater coverage per unit weight, the net cost per house is about the same.
There are some insecticide alternatives to DDT, including methoxychlor and pyrethroids. The environmental and health effects of alternatives are also under scrutiny. Under the Stockholm Convention, these are issues to be addressed when investigating and promoting alternative chemicals. A recent study has found that DDT as well as pyrethroid residues, such as permethrin and deltamethrin, were present in breast milk from a malaria controlled area in South Africa. The DDT was derived from malaria control, but the pattern of pyrethoid pollution indicated exposure via agricultural use, where mothers frequently work in cotton fields, as well as from domestic use of insecticide dusts in vegetable gardens.
The relative effectiveness of IRS (with DDT or alternative insecticides) versus other malaria control techniques (e.g. bednets or prompt access to anti-malarial drugs) varies greatly and is highly dependent on local conditions.
A study by the World Health Organization released in January 2008 found that mass distribution of insecticide-treated mosquito nets and artemisinin based drugs cut malaria deaths in half in Rwanda and Ethiopia, countries with very high malaria burdens. IRS with DDT was determined to not have played an important role in the reduction of mortality.
Vietnam is an example of a country that has seen a continued decline in malaria cases after switching in 1991 from a poorly funded DDT-based campaign to a program based on prompt treatment, bednets, and the use of pyrethroid group insecticides. Deaths from malaria dropped by 97%.
In Mexico, the use of a range of effective and affordable chemical and non-chemical strategies against malaria has been so successful that the Mexican DDT manufacturing plant ceased production voluntarily, due to lack of demand. Furthermore, while the increased numbers of malaria victims since DDT usage fell out of favor would, at first glance, suggest a 1:1 correlation, many other factors are known to have contributed to the rise in cases.
A review of fourteen studies on the subject in sub-Saharan Africa, covering insecticide-treated nets, residual spraying, chemoprophylaxis for children, chemoprophylaxis or intermittent treatment for pregnant women, a hypothetical vaccine, and changing the first line drug for treatment, found decision making limited by the gross lack of information on the costs and effects of many interventions, the very small number of cost-effectiveness analyses available, the lack of evidence on the costs and effects of packages of measures, and the problems in generalizing or comparing studies that relate to specific settings and use different methodologies and outcome measures. The two cost-effectiveness estimates of DDT residual spraying examined were not found to provide an accurate estimate of the cost-effectiveness of DDT spraying; furthermore, the resulting estimates may not be good predictors of cost-effectiveness in current programmes.
However, a study in Thailand found the cost per malaria case prevented of DDT spraying ($1.87 US) to be 21% greater than the cost per case prevented of lambdacyhalothrin-treated nets ($1.54 US), at very least casting some doubt on the unexamined assumption that DDT was the most cost-effective measure to use in all cases. The director of Mexico's malaria control program finds similar results, declaring that it is 25% cheaper for Mexico to spray a house with synthetic pyrethroids than with DDT. However, another study in South Africa found generally lower costs for DDT spraying than for impregnated nets.
A more comprehensive approach to measuring cost-effectiveness or efficacy of malarial control would not only measure the cost in dollars of the project, as well as the number of people saved, but would also take into account the negative aspects of insecticide use on human health and ecological damage. One preliminary study regarding the effect of DDT found that it is likely the detriment to human health approaches or exceeds the beneficial reductions in malarial cases, except perhaps in malarial epidemic situations. It is similar to the earlier mentioned study regarding estimated theoretical infant mortality caused by DDT and subject to the criticism also mentioned earlier.
A study in the Solomon Islands found that "although impregnated bed nets cannot entirely replace DDT spraying without substantial increase in incidence, their use permits reduced DDT spraying.
A comparison of four successful programs against malaria in Brazil, India, Eritrea, and Vietnam does not endorse any single strategy but instead states "Common success factors included conducive country conditions, a targeted technical approach using a package of effective tools, data-driven decision-making, active leadership at all levels of government, involvement of communities, decentralized implementation and control of finances, skilled technical and managerial capacity at national and sub-national levels, hands-on technical and programmatic support from partner agencies, and sufficient and flexible financing.
DDT resistant mosquitoes have generally proved susceptible to pyrethroids. Thus far, pyrethroid resistance in Anopheles has not been a major problem.
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