Battleship: West Africa

These days are not the greatest for West African nations. Every day it seems like one more of Ghana’s neighbors falls victim to another political fiasco, torpedoed by the powers that be. It makes me understand and appreciate a nation like Ghana even more, which really does seem to rise above the fray and stand out as a beacon of democracy for the rest of the region.

I suppose this recent bout of turmoil started with Nigeria: the most populous African nation, and less than 300 miles East of Ghana. At the end of November 2009, the Nigerian president, Umaru Yar’Adua, conspicuously disappeared. At first it was sort of like, “Hey, has anyone seen the President?” The Nigerian government was silent and the media became restless. For a few days it was sort of a running joke over here, like those old advertising campaigns: “It’s 10pm, do you know where your president is?” or, like the dairy farmers asked: “Got president?” But after a while it became clear, like when a parent discovers that their teenager is not at the friend’s house who was supposed to be having a sleep-over, that something was going on. The game was up, and the silent treatment would no longer work.

As it happened, the government revealed that President Yar’Adua was receiving medical treatment for a heart condition in Saudi Arabia, but the extent of the condition was still kept very close to the vest. As his departure lengthened from weeks to months, rumors of his impending demise and the “power vacuum” in Nigeria strengthened. Compounding the problem, the strongest militant/rebel group, the Movement for the Emancipation of the Niger Delta (MEND), ended its 3 month cease-fire with threats of all-out assault on the oil and gas industry. After more than two months away, the president finally made the formal transfer of power to the vice president, Goodluck Jonathan (I can’t make this stuff up), mitigating the “power vacuum.” President Yar’Adua flew back to Nigeria earlier this week, and surprise surprise, the vice president isn’t so keen on relinquishing his new powers.

Meanwhile, the president of Ghana’s next door neighbor to the West, Ivory Coast, has deemed it necessary to dissolve the country’s parliament and electoral commission, after accusing the latter of fraud. Elected in 2000 for a 5-year term, Ivorian President Laurent Gbagbo has now postponed elections for the sixth time. The latest issue is over the electoral commission trying to add some 400,000 names to the definitive electoral role. In the last month, presidential supporters have been trying to use the courts to remove thousands from the electoral role, whom they deem to be foreigners, and this latest move is no different. According to president Gbagbo, these people are foreigners, and this amounts to fraud. According to the opposition party, these people are from ethnic groups in the north of the country who are unlikely to support Gbagbo. In 2002, the rebel group, New Forces, seized power in the north of the country and formed a power sharing government with Gbagbo, which has been in power ever since. Ex-rebel leader and current Prime Minister, Guillame Soro, has been asked to form a new government. New elections have not been scheduled yet.

If East and West weren’t enough, just last week, Ghana’s neighbor to the North (and East), Niger, experienced a coup when a military junta kidnapped the president and seized power. To the junta’s credit, they say all they want to do is oust a tyrant and hold elections, and they have done nothing to make anyone believe otherwise. To the African Union (AU), however, a coup is still a coup, and they have suspended Niger and threatened sanctions. An article in The Economist on this development points out that despite the AU’s harsh denunciation of the coup, the body has done very little to address the worrying trend of African heads of state abolishing term limits, which Niger’s president Mamadou Tandja did at the end of last year, following in the footsteps of nations like Uganda, Algeria, Chad and Cameroon. It is a major factor that led to the coup in the first place, and a reason why the majority of people in Niger seem to be in favor of it. As a member of ECOWAS (the Economic Community of West African States) stated, paraphrasing JFK: "When you make peaceful change impossible, you make violent change inevitable."

For Ghana, its political problems are almost laughably small in comparison. In fact, I did laugh out loud when watching news coverage of the most recent episode. The quick version of the story goes like this: The house of one of Ghana’s ex-presidents, J.J. Rawlings, burned down. All I will say here is that Ghanaians of all political leanings seem to have a soft spot for this guy (who is “very charismatic” according to Dennis), and his story of multiple coups and democracy in Ghana is really very interesting. But anyways, his house burned down and the public was pretty distraught, calling for the current administration in power (Rawling’s own party, the National Democratic Congress (NDC)) to help him and his family in some way. Meanwhile, a member of the opposition New Patriotic Party (NPP), Mr. Nana Darkwa, went on radio and said that he had evidence that Rawlings had burned his house down himself, inferring that he would capitalize on the insurance and the help the current administration would surely provide. The guy was then arrested and thrown in prison, on what charges, I am not sure. The NPP was obviously furious, and the news coverage I laughed at was showing the NPP members, noses in the air, holding a walk-out of a parliamentary session in protest. I could only be reminded of the trial scene in “Animal House,” and was just disappointed that the NPP members weren’t also humming the national anthem as they departed.

Now, I know that this is not all that funny, and regardless of his so-called evidence (which turned out to be bogus), it is a serious case of freedom of speech and individual liberties, but I can’t really help the connections my mind makes sometimes. Ghana’s democracy is still very nascent, relatively, and they are learning that you can’t just throw someone in jail because he/she said something derogatory about your friend on the radio. I’m not a lawyer, but I’m pretty sure a lawsuit has to filed with legitimate charges brought forth against the accused (in this case maybe slander or defamation), and a free and fair trial has to be held before you can throw someone in jail. In this vein, you’ll be happy to know that Mr. Darkwa has since been released on bail, and the charges will most likely be dropped…baby steps.

Like I said, Ghana is learning, but its democratic institutions seem to be strong, and its problems are laughably small compared to some of its aforementioned neighbors. I know that to compare the political troubles of West African states to a game of battleship is to trivialize them. But again, I can’t really help the connections my mind makes, and recently, it sort of feels that way. Our fellow ships are being torpedoed all around us, and we’ve cleverly hidden our vessel along the bottom row of the board. Who will be the next victim and how long will we remain unscathed? These are the unanswerable questions being discussed at the water cooler, while everyone crosses their fingers that the next number called isn’t ours.

Lunch of Champions

I have already told you about my typical Ghanaian breakfast (Hausa Cocoa and Kose). Since then, I have also established my lunch option of choice: grilled plantain and fried yam. There are two women who set up shop next to each other on the roadside about ½ a mile from our office and cook them both for the lunch rush: one specializes in grilling the plantain over a charcoal grill and sells it with little bags of peanuts (called groundnuts here), while the other fries the yams in a big vat of vegetable oil and sells it with red or black pepper sauce for dipping. The latter also fries whole tilapia, but I stick with the yams. As I am a very good repeat customer, coming back anywhere from 2-4 times a week, and surely the only white person who tries to greet them in their native tongue, they always have big smiles and waves for me when they see me coming up the road on my midday stroll.

There isn’t really a standard time when the food is ready, so sometimes I get there and they are just getting going. The grilled plantain is pretty standard. Very similar to banana, she simply peels the fruit and then just throws it on the open-face grill. I watch eagerly, her hands jetting in and out of the heat as she turns the plantain with nimble fingers. When they are good and done (brown and crispy on the outside, hot and soft on the inside), she stacks them in a pile on a corner of the grill away from the most intense heat but still staying warm. I select two good ones just in time to hear the sizzle as the first of the yams are thrust into a large vat of oil on the ground about 10 yards away. As the yam slices settle at the bottom of the basin, I watch the translucent surface bubbling over with intense escaping heat and can’t help but think of Harry Potter (never far from my thoughts). It reminds me of a cauldron in Snape’s dungeon during Potions lessons. It’s not long before the yams are being fished out of the oil with a long black spatula, ready to take their place next to the tilapia in a glass display case on top of the wooden table that faces the road and the customers.

my two lunch-time buddies, grilling plantains at front

yams frying in the vat of oil

I should say that yams in Africa are quite different than what we know as yams – the orange-fleshed sweet potato – in the U.S. The best way that I can describe African yam is to say that it is almost identical to yuca, a dish native to Latin America, which you may have encountered at Caribbean or South American restaurants in the U.S. (There is a Cuban restaurant in Arlington, VA I used to frequent that serves yuca with a terrifically spicy green sauce.) Like yuca, the fleshy, edible part of an African yam is much denser and starchier than potatoes. A full yam is large and tubular, usually over two feet in length and weighing about 10 pounds. Its skin is much rougher than a potato, almost more like tree bark. African yam is almost always prepared by peeling off the skin and cutting it into smaller pieces to be boiled or fried. The end result of the fried yams is that they resemble very large steak fries. Dip them in spicy black pepper sauce and pair them with plantain hot off the grill and you’ve got a nice little lunch. Not only are the yams and plantain delicious, but they are really cheap, too. I can get more than I can (or should) eat for the equivalent of about $1.

table-top glass case with fried yams top left and fried tilapia top right

a typical road-side produce stand: unripe plantains front left, ripe plantains right, yams center left and bananas far left

I have discovered that if I want to eat and live like a Ghanaian, then it is generally very affordable to do so. On the other hand, the second that I have “Western” cravings that require addressing, I better be ready to pay for it, because everything is imported. American/European food is usually at least twice as expensive as it should be, while toiletries can simply be laughably expensive. Last week, I went into a western shop to see how much my shampoo (Head and Shoulders) costs in Ghana. I walked back to the hair care section and found my shampoo in the middle of the shelf next to other standard fare. If you just took a snapshot of the products on the shelf, you could have been anywhere in America, but as soon as you look under those products to see the price labels, you realize that you are definitely not. For a standard bottle (not like a huge Costco bulk size), it was about $15. I just laughed audibly, thought about asking one of the workers if anyone actually buys this stuff for this price, thought better of it, and walked out the door. Luckily I have some people visiting me in the coming weeks who will be kind enough to indulge me a shopping list!

PS: If anyone was wondering, Everton just got through beating Chelsea and Manchester United (the two top teams in the league) in back-to-back matches. It's more of less the equivalent of sweeping the Yankees and Red Sox in back to back series. On top of that, Landon Donovan is tearing it up, especially considering that many of the defenders he's played against in recent weeks are first stringers for the English national team that he and Team USA will face in the first game of the World Cup. Everton have not lost a league match in months, as they continue their climb up the ranks of the Premier league. Since I declared my fandom, the have gone from 11th place to 8th. And the fans love Donovan; unfortunately, it seems like he will be headed back to the LA Galaxy when his loan is over, but many are saying that he will be signed permanently next year.

Theory and Reality: A Natural Experiment

Yes, another blog about malaria…deal with it. ***DISCLAIMER***This entry became longer than intended, so please know that going in. There is, however, a story involved, so hopefully it won’t seem as long as it is.

In my previous Malaria 101 posting, I spoke of how Ghana’s new “Strategic Plan for Malaria Control” calls for moving from a presumptive clinical diagnosis to a diagnosis based on laboratory testing or rapid diagnostic test (RDT). In theory, this has tremendous potential to reduce costs for patients and the overall health system; to decrease the likelihood of drug resistance emerging, thereby preserving the efficacy of artemisinin-base combination therapies (ACTs); and to improve the health outcomes for the public by treating patients for the disease that is actually ailing them. That is in theory; in practice (aka: in reality) is another story entirely. To illustrate this, I will detail a natural experiment I was lucky enough to conduct some weeks ago. But first, a little bit more explanation of the malaria diagnostic situation.

When ACTs first came on the scene 5-10 years ago, the malaria community was so happy that there was a highly efficacious, well-tolerated alternative to chloroquine and SP (the two antimalarials in wide use at the time, to which plasmodium falciparum had developed high resistance profiles in several countries), that it’s number one priority became increasing access to ACTs as quickly as possible. In this regard, many countries (including Ghana) made ACTs available over the counter, instead of needing a prescription, and the WHO recommended clinical diagnosis in high burden areas, especially for children under 5. So basically, for the last 5-10 years, if you felt feverish or sick in Ghana, you could pop into your local pharmacy or licensed chemical seller shop*, they could take a look at you, declare that in their opinion it seemed likely that you had malaria, give you a regimen of ACT, transaction completed and you were out the door: not much different than buying advil. But ACTs are not advil. Ibuprofen (advil) fights inflammation. ACTs are anti-infectives that fight living microbes that put up a fight because they don’t want to die. The other issue is price, and the main catch with ACTs is that they are significantly more expensive than chloroquine and SP. Many people can only afford these alternatives, which are actively discouraged by the government but still widely available in the private sector. Alternatively, if a person demands ACT but cannot afford a full regimen, irresponsible drug dispensers have been known to provide less-than-complete doses.

Fast forward to 2010 where several developments have caused the global malaria community and Ghana’s Ministry of Health (MoH) to rethink their treatment strategy. First, there is a growing body of evidence that malaria is being significantly over-diagnosed and, consequently, ACTs over-prescribed. In Ghana, those numbers look something like this: around 90% of patients presenting with fever at both public and private sector health facilities were diagnosed with malaria, whereas the percentage of those febrile patients that actually had malaria (confirmed through laboratory tests) was more around 50%. This is alarming not only because of the vast, unnecessary use of ACTs and other antimalarials, but also because so many sick people are not being treated for the illnesses they have. Second, the first documented cases of resistance to ACTs have been documented along the Thai-Cambodian border. This is troubling both because that is the same hotspot where chloroquine resistance first appeared in the 1950s (before spreading to the rest of the world) and because there is no new antimalarial drug in the pipeline to replace ACTs if they significantly lose efficacy. Third, there is promising evidence of reduced malaria transmission rates in some countries (including Ghana). While this is a very exciting development, it also means that the over-diagnosis that stems from equating all fevers with malaria is even more pronounced. The fourth and final development is the emergence of RDTs on the scene. RDTs for malaria are pretty awesome; they are very easy to administer (a little finger prick, a drop of buffer and voila), they are quick (results in 15 minutes), they are relatively affordable (less than $1) and they are very accurate** (sensitivity and specificity in the high 90th percentiles).

So, faced with these 4 developments, some pioneering countries have decided to change their treatment guidelines. But, as is so often the case, the difference between theory on paper and realities in practice may be massive. The MoH has not rolled this new program out yet, but a little natural experiment I was able to conduct highlights some of the practical issues it might be facing in the private sector. And the story goes like this:

I should first say that one of my number one priorities upon landing in Accra was to secure some RDTs for myself. It took me about a week, but I was eventually able to procure some from the MoH. I had to buy an entire box (30 tests), but like a good boy scout, I was prepared. I kept them under my bed at home.

One day at work, John, PSGH’s good-natured accountant and Jonas, its hard-working on-site handyman, declared that they weren’t feeling very well, and both thought (or in their own words, knew) that they had malaria. Jonas was feverish and achy all over. John, while not feverish, was also achy and had a badly sore throat with bitterness in the back of his mouth: a symptom, he said, that was unique to his bouts of malaria. Rosslyn, PSGH’s head of public health (and a pharmacist like Dennis), immediately took a slip of paper and began writing down some ACTs she recommended, so that Jonas could run out and buy them. Sensing the opportunity, I jumped in and asked if we couldn’t first use RDTs to make sure that they actually had malaria. For a split second you could hear a pin drop, but then they all decided to humor me. I offered to go home with Charles (PSGH's driver) immediately and grab them, but it was already late in the day and John and Jonas both decided that they were fine waiting until first thing in the morning. I felt bad, like I was the reason for them not being treated today, like I was the white man rationing the medication for the Africans. John, always quick with a sarcastic barb, grinned and said, “We will take the test, but I fear we are wasting them, since I have no doubt that it is malaria.” Jonas nodded his agreement. Again, I offered to go home to grab the tests, so we could do them now, but John, seeing the anxiety on my face and sensing the tension, put his arm around my shoulder and said “No worries. Tomorrow, we will see.”

John, PSGH's sly, slick-dressed accountant

Jonas, PSGH's always-smiling handman, with his typical headphones

Tomorrow came quickly, and I was sure to bring the box of RDTs to the office. Jonas was already hard at work when Dennis and I arrived, but we decided to wait for John to do the test. Waiting anxiously for John’s arrival, I opened the box to look through its contents. It was filled with lots of little, individual packages neatly arranged in a space-saving manner. The box contained: single-use sterilized lancets (miniature plastic swords), single-use alcohol swabs, single-use pipettes, the bottle of buffer and the test cards. While it was a little confusing staring at all those little packages, when John arrived, Rosslyn took over - she had actually attended a MoH training session to learn how to correctly administer it – and it was pretty logical. You wipe the tip of the index finger with the alcohol swap, do a little finger prick with the lancet, get a few drops of blood with the pipette, drop two or three into one of the little basins on the card, squeeze two drops of the buffer into the other, and wait 15 minutes for results.

box of malaria RDTs and contents, from left: test card and pipette, buffer, alcohol swap, and sterilized lancet

We administered the tests in Rosslyn’s office, which I currently share with her. Jonas excitedly granted his finger to Rosslyn and watched the proceedings. John, on the other hand, had a decidedly all-knowing air about him, as if this was a meaningless perfunctory task which would only confirm what he had known all along. The “patients” left the room for the interim, as I snuck furtive glances at their test cards on Rosslyn’s desk. RDT results are displayed with 2 clearly-defined lines that would either appear or not on the face of the card. If the “control” line appeared, it meant that you had conducted the test correctly; if it did not, you had to do it over. If the other line appeared, a case of malaria was confirmed. Pretty simple: two lines = yes, one line = no. After a few minutes, the control lines on both of the tests appeared (good), and Rosslyn and I waited anxiously (I saw her sneaking glances, too) for the others. 15 minutes passed, 20 minutes passed, for good measure, we waited a full 30 minutes, but no second line appeared on either test.

RDT card showing negative result, on left are the two basins where the buffer and blood are dropped

When Rosslyn left her office to break the (good) news to them, their immediate response was to question the quality and validity of the test: “Are you sure this thing works?!?” “I’m sure I have it!” Rosslyn successfully parried those concerns by assuring them that the RDT is very accurate and a false negative is extremely rare. The next question, which Rosslyn so eloquently posed to me upon re-entering her office, was more troubling: “OK, now what?” In theory, the answer to the “OK, now what?” question is that the person should now go to the hospital for more tests to determine the identity of the bug that is actually ailing him/her. But I don’t have to reiterate what is wrong with theory. In reality, John had already started taking SP the day before, and Jonas did not want to wait in line at the hospital for more tests, so he did nothing and ended up feeling better in a few days. From a public health standpoint, this little 2-person experiment can provide a lot of insight into challenges facing this new diagnostic policy, especially in the private sector:

1) The public’s perception of what is and is not malaria is incorrect. This might be the consequence of too much of a good thing, where donors, government ministries, NGOs and others have put so much stress on combating malaria that the general public perceives the problem to be worse than it is. Every Ghanaian has grown up knowing and fearing malaria since birth, so when in doubt, they err on the side of malaria. It’s a common sense approach that anyone would do, but it is a real problem that is both very tough to fix and getting bigger, as malaria transmission rates go down.

2) Getting patients and practitioners to use and trust the validity of the RDTs will be a big hurdle. This was evidenced by John and Jonas’ initial reaction to their test results. In the public sector, this is not so much of an issue, but when patients have to actually pay for the RDT with their hard-earned money (instead of just finding a shop that will give them antimalarials without taking an RDT), this is a major challenge. There is also a growing body of evidence showing pharmacists and others dispensing anti-malarials anyways, even in the presence of a negative RDT result. It is not just patients who need to work on their trust issues.

3) Issue 2 in compounded by the profit motive of practitioners. As we know all too well in America, when healthcare is provided by parties with a profit motive, the incentives affecting behavior do not always align with those actions necessary for optimal individual or public health outcomes. Pharmacists in Ghana make good money dispensing anti-malarial drugs. This new policy calls for testing all possible malaria patients with an RDT, and that a good chunk of them (who they would have dispensed anti-malarial drugs to in the past) will come back negative. A negative result will mean that you can either give them something OTC (most likely with a lot smaller profit margin than an ACT) or tell them to go to a hospital for more tests (no further monies coming into your shop). How likely is it that pharmacists and other, less-trained dispensers will turn sick patients away because they need to have more tests done? How likely is it that the patient will actually go wait at the hospital for those tests, when the reason they came into the pharmacy in the first place might have been to avoid those same lines?

4) What did John and Jonas do? John chose to incorrectly self-medicate, while Jonas chose to do nothing. Leaving alone the fact that John managed to procure an antimalarial (SP) which is not supposed to be available anymore outside public hospital (and only used for pregnant women), how likely is it that patients with a negative RDT result will self-medicate, or go from shop to shop until they find one that will give an anti-malarial without conducting an RDT first? The policy is only as strong as its weakest link. And Jonas did nothing. Whether because he did not want to miss work, did not want to wait at the public hospital, could not afford a private clinic, or any other one of myriad reasons, is this outcome any better than anti-malarial over-prescription?

5) This entry is becoming much too long, so the final lesson that can be learned from my little experiment is that laboratory capacity will become even more important when this policy is rolled-out. Two RDTs = two negative results = two more patients that should then go get further testing done. The number of trained laboratory technicians capable of conducting the requisite amount of tests is already much too low in all developing countries. Microscopy takes time, culturing samples takes time, and these health workers are already spread too thinly. Some tests take days or weeks for results: days or weeks in which the patient is still sick. If we really expect patients to obediently wait it out, the MoH should couple this policy roll-out with adequate increased investments in laboratory capacity. Is that happening? All signs on the ground point to no.

So what is my part in all this? I’m trying to secure funding for PSGH to go all over the country and run training programs for all of its member pharmacists in this new policy prior to roll-out. I think that’s enough malaria talk for today. We’re really getting into the weeds on some of this stuff, and I know you’re all very excited! My next couple extries won't be malaria-related at all, so I'll give you all a break for a bit, I promise!

* In Ghana, licensed chemical sellers are able to dispense only over the counter products (including anti-malarials). They are not trained pharmacists and, so, cannot dispense prescription drugs, but they outnumber pharmacists almost 10 to 1.

** There are dozens of malaria RDTs currently marketed worldwide, all with variable quality. Thankfully, the WHO and others partners have begun conducting lot tests to determine the quality of each. The brand I procured from the MoH received very high marks for quality from the WHO lot tests.

Football and More Football

For those of you who were worried about my ability to watch the Super Bowl this past weekend, fear not; I was successful in finding a place. There is a local sports bar called Champs, which is a favorite among expats for its nightly specials (Tuesday is ½ price kebobs, Wednesday is wing night, Thursday is trivia, Friday is karaoke, Saturday is an all-you-can drink special, Sunday is movie night, etc.), its plethora of flat screen TVs, and its satellite subscriptions showing any sporting event around the world that you would ever want to see. You can see why it is slowly becoming my go-to spot. The first night I hung out there was actually on New Year’s Eve, and I haven’t looked back. Champs happily stayed open until 3am to cater for all the rowdy Americans wanting to see the big game, myself amongst them.

sign outside Champs

the back of the Champs menu outlining the daily specials

In other football news, you will all be happy to know that I have decided to become a full-fledged supporter of the English Premier League team Everton. (That's a soccer team; or, as the rest of the world calls it: football.) I spent the first few months here just happily enjoying all the games (matches) allegiance-free, but something was definitely missing. It was really easy for me to tease Dennis when his team, Chelsea, lost, or to give Desmond a hard time when his team, Manchester United, did. But they couldn’t give it back to me, because I did not support a team. This situation was pretty unfair to them. And since I have already resigned myself to probably not being able to watch a single White Sox game all season, it was also necessary for me to find another team to root for.

And so, I had the task of picking a team. For those of you who don’t know, there are 20 teams in the English Premier League. Every season, the bottom 2 or 3 teams get relegated to the second division for the next season, while the top 2 or 3 teams in the second division get bumped up into the Premiership. I didn’t go through a long process like ESPN writer Bill Simmons did when he picked a team (Tottenham Hotspur) to support back in 2006, but I had already watched enough games to know which teams were fun to watch. While Simmons based his pick on things like the owner, jersey color, and team nickname, my criteria were a little less defined. I had already narrowed it down to half a dozen potential teams back in December, and then Everton announced that they were picking up USA captain Landon Donovan on loan from the LA Galaxy. Everton was already in my top six, because I liked the coach, fans (a lot like White Sox fans), style of play and general vibe I got from their club. Not to mention their goalie, Tim Howard, is also the starting goalie on the USA national team. (For some reason, all the Premiership teams with Americans on them had made my cut.) When Donovan came in January, I anxiously watched his first few games to see how he would fit in, and he delivered in a big way. What sealed the deal for me is that their center midfielder is this tall, lanky Belgian guy named Fellaini who sports the biggest afro I have ever seen. And so it is, that I am now an Everton fan.

This is how I roll now.

The reason I mention my Everton fandom here is because I was headed to Champs on Saturday to both watch their match against archrivals Liverpool and see if they would be showing the Super Bowl the next day. While Everton unfortunately lost their game, I learned that not only would they be staying open late to show the Super Bowl, but also that Sunday night is movie night and they would be showing (a bootlegged copy of) “Up in the Air,” a movie that I really wanted to see.

When Sunday night rolled around, I made my way over to Champs for the Super Bowl and what was my first of probably many movie nights there. Sitting in fairly comfy booths with all the lights off, we watched George Clooney, projected on a good sized screen, as he fired hundreds of employees he did not employ for the next two hours. Watching a movie in a sports bar, I have to say, was quite interesting.

3 quick pros and cons:

pros:
1.) the movie was free
2.) no commercials beforehand
3.) the movie was free

cons:
1.) a few times some guys playing pool in the back room would yell and you would miss lines
2.) no previews
3.) no popcorn

Either way, the movie was pretty entertaining, and when the lights came back on, it was game time.

About an hour before kickoff, the place was filling up, and I could no longer have the booth to myself. Fortunately, a very nice couple from Atlanta sat next to me. The woman, Ashowa, had grown up in Ghana, but been in the US for most of her life and was back visiting her mother for a few weeks. About that same time, a half-dozen teenage-looking kids (I swear one girl looked like she was 13, but they were probably in some sort study abroad or exchange program.) rolled in and took the table right in front of the projection screen. Another of their group was a skinny blonde girl with a pony tail wearing a Drew Brees jersey. She quickly made sure that everyone in the bar knew she was from NOLA and led the first of about 4 dozen WHO DAT chants. I was pulling for the Saints because of two good college friends who are from NOLA and love their Saints, but honestly, this girl was so annoying (and completely wasted even before The Who stepped on stage) that I almost changed allegiances. But then I remembered Dave and Chelsey and continued rooting for the Saints.

projection screen and other TVs; loud blonde girl on the right

Ashowa, her husband and I endured the endless pregame babble from the Chris Berman, Mike Ditka and the other monkeys who never fail to look like blind people helped them in their wardrobe selections. They finally gave their picks for who was going to win, but astonishingly, none of these “experts” predicted a double-digit Saints victory or for the Colts to score less than 20 points….and Robert Meachem certainly did not have a big game, as one of them boldly stated. After the completely unnecessary God Bless America (was Rupert Murdock running the show?), it was time for the National Anthem, the coin toss and kickoff!

another view of the great Champs ambiance

All in all, it was more than I could have asked for. I got to watch the Super Bowl live at a really fun bar and have a comfy place to sit in front of several big TVs, not to mention that is was a really good game and my team won. The main/only drawback to my Ghanaian Super Bowl experience was the lack of commercials: something I look forward to almost as much as the game itself. The bar got the game on a direct ESPN feed, so all we had for 4 hours were commercials about ESPN 360 and ESPN Deportes. And the only "This is Sports Center” commercial (which are consistently hilarious) aired was the one where Drew Brees is driving a big Mardi Gras float and can’t get it through the main gates at ESPN, which we saw no less than 12 times.

When the game was finally over, the rowdy, now-drunk, blond girl led her last WHO DAT cheer and almost fell backward into the projection screen after an overly-enthusiastic jump. Looking at my watch, I saw that it was past 3am. I bid adieu to the nice couple from Atlanta and followed the crowd outside. I flagged down a cab, and quickly made my way home, where I was able to sleep almost a full 3.5 hours before my 6:59 alarm reminded me that it was Monday morning: time for work.

More Than You Ever Wanted to Know About Malaria

As promised, here is another work-related blog. I have tried to keep the acronyms to a minimum but found it very difficult. The good news for me is that my work life is starting to get interesting. The bad news for all of you is that my upcoming blogs will invariably have a lot more to do with malaria (control) and a lot less to do with goats and beaches. But seriously, some of this stuff is really interesting (at least to me), and I will try my best to convey it in a way that you will also, hopefully, find it more than soporific. Now, the readership of this blog certainly has varying levels of knowledge about malaria. In an effort to get everyone on the same page, I will do a general overview of the disease and the main interventions currently in use to control it. Once that is taken care of, I can get into the interesting stuff in future entries and keep the explanations to a minimum. For those of you know all of this stuff, bear with me.

Malaria is an infectious parasitic disease endemic to most tropical and sub-tropical countries in the Americas, Asia and Africa. In humans, it is caused by 5 species of a parasite of the genus Plasmodium – falciparum, vivax, ovale, malariae and knowlesi – with falciparum by far the most deadly, as well as the predominant species in sub-Saharan Africa. The parasite is transmitted to humans via a mosquito bite, specifically the female Anopheles mosquito. Once inside humans, the parasites migrate to the liver and begin multiplying inside liver cells. After an incubation period, usually 6-15 days, these cells rupture and the parasites escape into the blood stream and infect red blood cells: killing those and infecting new ones. The most common clinical symptoms of malaria include sustained fever, shivering chills, joint and muscle pain, headache, vomiting, fatigue and dry cough. Severe malaria cases can lead to coma and death. Less common is a malarial infection of the brain, known as cerebral malaria, which can cause permanent cognitive impairments and brain damage, with children being much more vulnerable.

Annually, there are believed to be between 300-500 million cases of malaria each year, killing between 1 and 3 million people: 90% of these deaths occurring in sub-Saharan Africa and the vast majority killing children under 5. Adults die much less often from the disease, especially in endemic areas with "stable malaria" transmission, which I explained in a previous blog. (The large range of disease burden estimates is inherent in high-transmission, resource-poor countries with many constraints to adequate diagnosis. This will be discussed further in future entries, so stay tuned. I know you’re on the edge of your seat.) Malaria is the number one cause of death of children in Africa, and among adults, the lost productivity due to illness is estimated to be 1.3% of GDP. In some high-burden areas, it is estimated that malaria consumes up to ¼ of all household income.

Currently, there are 4 main interventions used to prevent and treat malaria in endemic areas. The first is using insecticide-treated bed nets (referred to as ITNs, LLINs, or other acronyms) to prevent the mosquitoes from biting humans, thereby preventing the transmission of the disease. The rationale behind this is that the Anopheles mosquito likes to bite at night. So, if people can cover their sleeping areas, this can prevent transmission. The current nets last 5 years; after that the insecticide wears off, and they become less effective. Many countries give nets out to pregnant women and children (the most vulnerable population) in the public sector hospitals and clinics for free. Prices vary greatly in the private sector, but in Ghana, you can pick one up in a pharmacy for about $7-$10. Bed nets have been shown to be an extremely cost-effective intervention, and they are now a major part of most national malaria control programs. There are also some NGOs and charities specializing in bed nets that you might have heard of across the pond, most notably Nothing But Nets, which partners with the NBA, and Malaria No More, which runs a very successful program with American Idol called "Idol Gives Back."

The second intervention is called Indoor Residual Spraying (IRS), and it involves going door to door to spray the inside walls of residences with insecticide (yes, sometimes even DDT). The rationale here is that the Anopheles mosquito, in addition to liking to bite at night, also prefers to hang out on the inside walls of homes. If we can make it so that they die every time they land on the wall, then that is one less malaria-carrying mosquito. The IRS only has a 6 month duration and can be fairly expensive, but it has still been shown to be another very cost-effective prevention intervention.

The third tried and true intervention is called Intermittent Preventative Therapy (IPT) during pregnancy. This is where pregnant women are able to take a drug during pregnancy to protect themselves and prevent mother-to-child transmission of malaria. In Ghana, the drug used is called sulfadoxine-pyrimethamine (SP, for short), and is, ideally, given 3 times at different intervals during the 9 month gestation. As children and pregnant women are the most vulnerable populations for malaria infection, this makes inherent sense and has been shown to be very effective.

The final intervention, and the one that I am most involved with in my current capacity, is increasing access to the most effective drugs available: artemisinin-based combination therapies (ACTs). Artemisinin is a drug derived from the plant Artemisia annua, or Chinese wormwood, whose antimalarial properties have been known to Chinese traditional herbalists for centuries. In the last 5-10 years, using ACTs has become the WHO (World Health Organization)-recommended treatment for uncomplicated malaria in all endemic countries due to their high efficacy and tolerability. Unacceptable levels of drug resistance have developed to all of the previous first-line antimalarial treatments, including chloroquine, SP, and artemisinin monotherapy, but using artemisinin in combination (as with ACTs) helps prevent the emergence of resistance, since 2 different drugs with 2 different mechanisms of action are attacking the parasite at once. The challenge with increasing access to ACTs is two-fold: first, over half of all malaria cases are treated in the private sector (mostly in pharmacies and community drug seller shops), and second, the natural extraction of artemisinin is costly, which means that ACTs are quite a bit more expensive than the aforementioned alternatives and out of reach for most people. A lot of this taking place in the private sector means less government control, and in resource-poor developing countries, this means that even though effective treatments are on the shelves, much less effective ones are often given (or a fraction of a regimen of ACT is given), which continues to drive drug resistance.

(Worth mentioning here is an exciting donor-funded project being piloted in 9 countries (including Ghana) called the Affordable Medicines Facility – malaria (AMFm), which will highly subsidize the purchase price of ACTs, hopefully making them as cheap as, if not cheaper than, all other alternatives for the end-user. Much more on this to come in future blogs.)

These challenges are also compounded by the difficulties of adequately diagnosing malaria, where the vast majority of diagnoses (especially in the private sector) are presumptive and symptomatic (euphemistically called clinical diagnosis) rather than confirmed with laboratory tests. This practice is actually recommended by WHO in most high-burden countries, especially for children under 5. However, as the main symptom of malaria is fever, it has becoming common practice to equate all fevers with malaria and treat accordingly. And, not surprisingly, more and more studies have concluded that there is vast over-diagnosis of malaria and over-prescription of antimalarials happening. Combined with this growing evidence base of over-diagnosis, studies showing decreasing transmission rates in some countries (thanks to the interventions above), as well as the development of accurate rapid diagnostic tests (RDTs), have made it feasible to take action in some countries. And Ghana is one of those countries. The 2009 Strategic Plan from Ghana’s National Malaria Control Program (NMCP) calls for moving from clinical diagnosis to laboratory or RDT-confirmed diagnosis. While this is an exciting paradigm shift, indeed, it is one thing to have it on paper, and another thing entirely to roll it out in practice (especially in the private sector).

So there you have it: Malaria 101 brought to you by Scott(y). Don’t say I never gave you anything. As you can see, there are several cost-effective proven interventions in the arsenal, which makes malaria control a very dynamic field to be in. However, challenges remain, especially in relation to leveraging the full potential of the private sector (“leveraging” is business speak for “using to the fullest”), which is why working with pharmacists is an exciting place to be. There will be much more on malaria to come, and you have been adequately warned, so try to contain your enthusiasm. And, to answer your question: no, there is not a vaccine (yet). The farthest one along in the pipeline is British pharmaceutical giant GlaxoSmithKline’s (GSK) RTS,S candidate. It is in phase III clinical trials, but it is at least 3 years away and will most likely only be partially effective (30-60%).

I know that I used the word gestation is this post, so I hope it wasn't too much like a science lesson. And I apologize about the lack of pictures. I’m tired of acronyms, aren’t you?