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.

AMFm evaluation: joint post with victoria fan

check it out: http://blogs.cgdev.org/globalhealth/2012/09/what-the-pre-post-evaluation-of-amfm-can-tell-us.php

Aside

happy malaria day!

turns out, control means you are supposed to keep working at something (that includes funding it): http://www.bmj.com/content/344/bmj.e2935

if it doesn’t kill them, it makes them stronger (III) / why would you do things that way? (II)

well, this is bad and annoying.

bad: malaria resistance to ACTs is being increasingly reported in Thailand.

annoying: the article’s narrator & interviewee go on to say that immediate steps need to be taken.

then, instead of listing some possible steps, they highlight that maybe a malaria vaccine is on the horizon.

1. what should we do now? use rapid-diagnostic testing? encourage proper use (dose-completion) of ACTs? encourage prevention with bednets?

2. what do we think is that actual probability of having a viable malaria vaccine in three years? if so, how likely is its protective immunity likely to last for an inoculated person?

3. why are we so, so, so jazzed about a malaria vaccine when malaria elimination & eradication in the past has been very much about environmental management? is sanitation not sexy enough? do we not think that governments in malarious countries can and should be providing drainage, sewage, and other services that reduce malaria breeding habitats?

from The Making of a Tropical Disease (Packard)

In the end, the book males a simple point. Malaria policy needs to be informed by history. The history of malaria tells us that malaria cannot be understood or eliminated independently of changes in the societal forces that drive it. This is not to argue that past and current malaria control efforts have had no effect on reducing the burden of malaria. Nor do I believe that malaria cannot be controlled before social and economic impediments to health are completely removed. Rather I argue that the array of biological weapons mobilized in the war against malaria needs to be joined with efforts to understand and improve the social and economic conditions that drive the epidemiology of the disease (xviii).

from The Fever (Shah)

The uncomfortable truth is that ending malaria over the long-term will require difficult social and economic adjustments in African communities, just as it has elsewhere. Infrastructure will have to improve. Settlement patterns and housing styles will have to change. Education and healthcare systems will have to be built. Antimalaria activists know this. But it is not possible for them alone to transform Africa’s economies and cultures. The best they can do is offer partial, short-term solutions. That is, in the meantime, they can blanket the continent with treated nets and better drugs… After all, the perfect need not be the enemy of the good. The question is how the short-term solutions impact the long-term ones. Usually, something good today doesn’t reduce the probability of something better tomorrow. But in malaria, it can (237).

The conflict over short-term solutions and long-term sustainability has yet to be adequately resolved. The US antimalarial program, government malariologist Thomas Ritchie says, ‘is pouring obscene amounts of money’ into quick fixes against African malaria, but is spending little on supporting local antimalaria leadership or building antimalarial infrastructure. Plenty of African clinicians, scientists, and community leaders are dedicated to taming malaria, Ritchie says, but when the world’s richest country decides to help, ‘they give these people nothing, not a cent!’ (238).

The conflict plays out in heated debates at international malaria meetings. At one, an official from the Nigerian MoH became engrossed in a long argument with a representative from Sanofi-Aventis, which was at the time the sole purveyor of WHO-recommended ACT drugs. Finally she turned to me. ‘Write it in your paper,’ she commanded. ‘We need to build African capacity to make treated nets and ACTs. That is the only way we can solve malaria. They don’t want to do technology transfer,’ she said, motioning to the drug company rep. ‘They just want us to buy, buy, buy’ (238).

Although it publicly recognizes the need to build infrastructure in endemic countries, RBM has also stated that tackling the disease cannot be the responsibility of local governments. ‘If malaria control is left to governments to plan and execute,’ RBM wrote, ‘malaria will not be controlled.’ This is, of course, exactly backward. It is the only way malaria will be controlled. Malaria-endemic societies have proven this over and over again, from when the Italians distributed quinine to their populace – and built the schools and clinics and roads they needed in order to do it – to when Malawi banned the sale of chloroquine and rid the country of chloroquine-resistant parasites… ‘You can do a lot of good with bed nets, with spraying,’ says malariologist Tom McCutchan, ‘but in the end, you have got to give power to the people who are at risk’ (239).