going viral in delhi / is diagnosis a luxury (delhi summer illness 2)

In this post, i continue to try to make research and observational hay out of my own illness in Delhi (starting here). As a quick re-cap, there was a week of severe, arthritic joint pain and weakness, which started to let us slightly right when the rash and fever kicked in. Those were mercifully short-lived but the joint pain has continued for over a month.

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When you shuffle (quite literally since my feet weren’t keen on bending and my hips weren’t into a long stride-length anyway) into a doc’s cabin in Delhi and the first words out of your mouth are ‘joint pain’ and it is dengue and chikungunya season, these are the immediate suspects (also here for news of outbreak). One of the doctors i saw  was happy to diagnose me by sight and actually, actively encouraged me not to bother with the (pcr) bloodtest, since (he was a bit of an overconfident ass and) the test is expensive (about INR 5000 or roughly US$ 75 — definitely out of reach for a lot of patients). An earlier doctor had prescribed a cheaper test, which is more sensitive to the stage of the illness (IgM).

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At this point, i have had the two different chikungunya tests, a dengue test, a malaria test, & a parvovirus b19 test, all of which have come back negative. If malaria had been positive, of course, it would have indicated a very different treatment course than any of the viruses. And it’s good to know if you have dengue rather than a different virus because it is possible you may need a transfusion. But at the patient-level, all the rest of these viruses have a similar ‘treatment’ protocol – fluids, rest & painkillers (plus, as it always seems in Delhi, an antacid to pair with the painkiller).

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There perhaps isn’t much reason, then, to explore which specific virus ails you unless you, like me, find comfort in having a named illness rather than a collection of symptoms that could be named ‘a viral fever.’ (Update 9 Oct 2016: unknown viral fevers in Delhi.)

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And anecdotally, some folks in Delhi seem comfortable just saying that they have ‘a viral’ or ‘a viral fever’  or, intriguingly, that they are going to get tested for dengue to see ‘whether it’s dengue or a viral fever.’ (See also the name of the disease and the work of many anthropologists on this kind of non-specificity vis-a-vis underlying causes.) People also don’t seem a lot of stock in the tests — colleagues and at least one of the doctors i have seen feel like i probably had/have chikungunya, blood work .

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Which raises the question of why i have sought so many different diagnostics (yes, insurance covers it) and why a person might do so more generally. For me, i have both a desire to have a name for my diseases and also a suspicion that a virus doesn’t explain the full story of what has been an extended summer of illnesses rather than a single episode. But for a regular patient paying out-of-pocket, beyond sorting illnesses with different treatment protocols (so, parsing malaria from dengue), being able to pin a particular name to the cause of feeling unwell may not be that important — or, indeed, may be a luxury.

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From a public health perspective, though, lack of clear diagnosis means no numbers to report upward, to understand how illness patterns are changing (including with zika looming on India’s doorstep), when there is a legitimate outbreak, etc. i say that without a complete understanding of how my test results in a private, corporate hospital (some of which were sent to a private path lab in Bombay) make it into any sort of public health statistics at all. The current numbers being reported in Delhi and the surrounds certainly seem too low relative to what doctors off-handedly say they are seeing.

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All of this raises a few questions:

  • During an outbreak, should people satisfied with a diagnosis not based on blood-work (if it looks and walks like chikungunya, it probably is)? Is this sufficiently successful to make up for time and money saved?
  • If diagnosis (sorting between viruses, say) has more public than private benefit (since your treatment won’t change and having ‘a viral fever’ seems satisfactory), should diagnostics be subsidized? How, for whom, etc?
  • Can anyone explain to me whether and how test results from the private sector of clinics and diagnostic centers make it to official numbers? What would need to be done to improve reporting and merging of results into city- or state-wide stats?

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  • Would i be more satisfied with a diagnosis of an unnamed virus in the States? Possibly — it’s certainly happened when down with non-specific ‘flu‘ symptoms that rule out the need to treat with antibiotics. But why am i more comfortable with this?
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fresh fruit, folk flu, confessions, cold season, & conclusions

the main gist here is that it is not fun to have an illness with no name, no clear prognosis, and, insofar as someone thinks it is necessary, no clear, commensurate-to-symptoms treatment plan. the need to restate this grew out of recent discussions around malaria diagnosis and treatment of malaria and the broader range of illnesses that can cause malaria-like symptoms.

the introduction of diagnostics into the SOP of addressing malaria results from the change in WHO policy away from presumptively treating all fever with malaria medication. using malaria meds as the answer to all fevers has led to over-use of malaria meds, lowering the mojo of their api. and, the likelihood of mistreating a fever as malaria is rising as underlying malaria epidemiology changes. as such, this seemed like good moment to reflect on other common understandings of the causes of symptoms and how they should be treated, as well as the desire for some treatment that matches the symptoms. i focus on a few US/UK examples, especially as we move into cold season.

the first confession is the nearly obscene number of times i have watched this sketch, in which john cleese teaches his students to defend themselves against fresh fruit, which he sees as the weapon of choice of most criminals as well as the root of most illnesses (or the cure for illnesses, including flu, depending on which version you watch).  cleese fears fresh fruit – far more than point-ed sticks – and therefore proposes it as the cause of  any problem with nebulous threat, as well as enacting fairly disproportionate treatments given the threat.

the second confession is how much i didn’t care for the article i am about to summarize. at the time, as one of the first reads in my first medical anthropology class in undergrad, it seemed awfully mundane in the face of a selection of many more romantic and exotic articles about places i had not yet been and diseases which i had not yet heard of, let alone had. but, i have ended up returning to it many times – more than some of those other articles. this is mccombie’s piece on ‘folk flu and viral syndrome.’ the article is quite amusing, interesting, and worth reading in full. mccombie describes that in the southwestern US, at least, people use ‘flu’ as a catch-all for feeling crappy, including covering a probable hangover. this ‘folk flu’ and misinterpretations of ‘flu-like symptoms’ can be a real impediment to appropriately treating the actual cause of the symptoms. similarly, better understandings of ‘folk malaria’ and how to convince people that their symptoms are caused by something else would be useful (some research has, of course, been done on this, including by mccombie; i’d suggest that additional qualitative work would be quite helpful). the second half of mccombie’s article covers the same type of catch-all for non-specific, undiagnosed problems by providers, who label a problem as ‘a virus’ when ‘they aren’t sure’ what is wrong with you. it’s better than being told that you are imagining things, of course, but not all that much.

the third confession is that i am/was an airborne junkie at the first sign of illness, especially in the face of symptoms with no clear bacterial or otherwise medicate-able diagnosis with something more than fluids and rest. this craving extends to using echinacea lollipops (found only in the US, i presume?), terrible zinc tablets that make one vomit, etc – almost anything (not mint) to feel like i am being proactive. if there ever were a place where it makes sense to try to introduce placebos as an actual treatment option, the ‘treatment’ of non-life-threatening viruses that make you feel generally crappy must  be it. it would limit the temptation to mis-treat with powerful drugs whose powers we all benefit from preserving. (see @danariely on the excellent placebo qualities of airborne for guidance on the way forward.)

so, fourth confession, i wish we could introduce placebos as an actual treatment option, for ‘flu’ and ‘malaria.’ if you’ve watched the birdcage (the robin williams & nathan lane version), you’ll know the value of ‘pirin’ tablets. as for the ethics of this and the providers’ ability to keep the secret, that’s for another debate.

but the initial point holds. people want a named diagnosis that makes sense, that has some sort of prognosis, and that has a treatment that fits our conception of the problem. so, we may not be able to do placebos but we also probably don’t need to release a tiger to tackle a man wielding a banana or loganberries, threatening though that can seem. once a tiger’s (antimalarial, antibiotic) out, it’s kinda out. you need to give people a comforting way to feel proactive without calling down the thunder.