magic bullets are bad and silver bullets are hard to come by (agenda for approaching resistance to malaria treatments)

i have previously discussed the bizarre origin of ‘magic bullets’ as a phrase used positively and aspirationally in public health – as well as the folly it represents: relying on a single approach to a public health problem rather than doing multiple, hopefully coordinated, activities.*

my feeling is that something silver-bullety is going on right now in discussions about addressing malaria treatment and parasite resistance to that treatment.

there is a big push — both to wisely spend malaria-treatment resources and to stave off parasite resistance to ACTs (artemisinin-based combination therapies, the current WHO-recommended first-line treatment for uncomplicated malaria**) — towards using rapid diagnostic testing (RDTs); further, towards coming up with incentives for people to choose a treatment commensurate with those test results (and to incentivize drug vendors to encourage clients to choose treatments that correspond with the diagnosis).***

diagnosis is awesome. those issues need attention. but

there are other big components in effectively treating malaria and fighting resistance that seem to be getting too little attention because they lack a fancy acronym and cool technology aspect? because they are unsexy? and/or because they are hard to do and measure?

in any case, counterfeiting and improper dosing and usage of ACTs are also important issues and i just don’t hear them getting the same buzz.

first, whether it is the public sector or the private sector that ultimately delivers the drug to an end-user, ‘health systems strengthening’ needs to include increasing government (or private?) monitoring, testing, and regulatory — pharmaco-vigilance — capacity to test drugs and check prices at port and mid-way through the supply chain, not just with the front-line workers. companies like sproxil offer one way to approach this problem, though monitoring and regulation seems like the sort of thing you might want a state to be able to do.

second, just because good drugs get to front-line workers, it doesn’t mean the end user is getting the right drug for his/her body weight. but that’s actualized access: affordable, available, acceptable, adaptable, AND USED. there’s evidence that workers with even limited training can make the right decisions about diagnosis and weight-class (including here and here).

but there is not a lot of evidence that most front-line workers possess this information, say, via regular government trainings. certainly my experience in northern ghana suggests that many vendors do not know about weight classes for drugs (preferring, if anything, to assign treatment by age) these private vendors are a major interface with the population seeking treatment for fever.

i recently heard someone promote pediatric formulations – syrups or enemas – to help guide vendors and users toward the right dosing decision even without understanding weight-classes (‘syrups are for kids’ is a relatively easy message). this seemed like very sage advice from shunmay yeung.

third, even though ACTs are only a 3-day (6-time) course of meds, people don’t finish them for all kinds of reasons.**** i was surprised at this problem when i first started looking at malaria after much more work on behavior around TB and chronic diseases – it seemed like such a short treatment course! but, it turns out a lot of people (including ex-pats!!! looking at you, JoT) don’t finish their malaria treatment course: like, 30% of people, in some endemic countries. there have been efforts at addressing this, for example here and again here, using follow-up text messaging. but, again, this just doesn’t seem prominent on the malaria agenda.

the last mile isn’t just getting affordable drugs into remote areas: it’s about getting good, affordable, and appropriate drugs in the right amounts into the bodies of the people who need and want them.

i have become quite fond of the ‘silver buckshot‘ metaphor to use in place of ‘silver bullets.’ in this case, treating malaria and protecting the effectiveness of malaria treatments requires looking at diagnosis, pharmaco-vigilance, and appropriate dosing and use. (and that’s without opening the prevention can of worms!)

keeping this bigger, balanced, and un-acronymed package of items on the malaria treatment agenda is difficult — but i hope it can be done.

*recognizing, of course, the problems with ‘planning’ and ‘coordination’ without allowing for ‘searching’ in terms of design and implementation.

**”it’s complicated” may be less-than-ideal as a relationship status on facebook — but it is definitely no good as a status update on your malaria.

***also, there is the tricky follow-up question of what to do if someone tests negative for malaria (moreover, what else to do if someone tests positive for malaria, given the potential for co-morbidities; these are topics for another time).

****too many pills, feeling better, saving the pills for the next illness, feeling nausiated from the pills, and so on


i am not sure that means what you think it means (origins of metaphors in development, german folk-stories edition)

thanks to having professors who are curious about the origins and use of phrases, i have recently had the occasion to consider two phrases in common use — and likely mis-use. these would be hilarious mid-understandings as the basis of a sit-com or, as here, folklore. as the basis of policy, not so much.

1. magic bullets.

to be sure, i learned about this one because i went to see the black rider, not because i can claim a love of german opera or a deep understanding of german folklore, though both would be good life goals. the underlying story of ‘magic bullets’ – from the German freischuetz (marksman) folk-narrative – is a faustian bargain in which someone needing to prove hunting prowess takes n special bullets from a stranger, n-1 of which will do what the bargainer needs and 1 of which is under the control of the devil. oops.

why ehrlich would choose ‘magic bullet’ to represent the quest of his research, i am not quite sure. in the end, magic bullets may be a fairly apt metaphor for much that we actually do in public health (and development — targeted, purposive actions in one area with unintended consequences in another) but as a description of what we are trying to do, it seems less desirable.

silver bullets (from ancient Greek mythology) seem the slightly more appropriate aspirational metaphor (also good for killing werewolves); however, maybe this whole confusion with the unintended consequences and deal-with-the-devil thing is a good reason to drop the idea of looking for single causes &/or solutions?

or else, we need to have charlie daniels’s fiddle skills involved in a whole lot more of our work.

2. pulling oneself up by one’s bootstraps.

bootstraps are those loops on the back of your boots that help you pull them on. using them to pull yourself up, on the other hand, is apparently physically impossible (“for a force to accelerate an object it must come from outside it. you can’t pull yourself up by your own bootstraps. anyone who says you can is literally wrong.”).

which is why it made for such a hilarious story as originally told — it’s an adynaton (new word of the day!).  the original version came in one of two forms. either from tales of davy crockett who, along with other feats, was said to have pulled himself over a fence by his bootstraps or from the german tales of baron muenchhausen‘s adventures, who described how he fell into a swamp and lifted himself out by pulling on either his ponytail or his bootstraps. if you watch ‘house’ or are just otherwise savvy, you’ll recognize that his name also serves as the  basis of the disease of fictitious disorders.

there may well be counterparts to these stories in other literary traditions — i’d be happy to hear about them!!!

(the end of one of the referenced posts also reviews daily show’s coverage of candidates out-bootstrapping one another (not an actual over-the-fence, out-of-the-swamp competition, although that would be amazing and i would like to suggest it in place of one of the debates). surely it owes something to monty python’s four yorkshiremen sketch, which culiminates with, “right. i had to get up in the morning at ten o’clock at night, half an hour before i went to bed, eat a lump of cold poison, work twenty-nine hours a day down mill, and pay the mill owner for permission to come to work, and when we got home, our dad would kill us, and dance about on our graves singing ‘hallelujah.'”)

(thanks to guenther fink & josh salomon for raising these issues, as well as the magic of wikipedia)