*Disclaimer: This blog takes a very simplistic stance on the very complex topic of malaria endemicity. I would like to personally apologize to any public health professionals who may be reading this. Also, with a sample size of 1, a more appropriate title would be: “Why It Could Be Seen As a Good Thing That Dennis Had Malaria Last Week.” But that title isn’t as catchy.
It can be the very definition of growing pains. And something that can be tricky to explain to those who don’t deal with it every day; so let me have a go at it:
In areas of high malaria transmission, individuals are bitten by infected (vector) mosquitoes on a constant basis. This is an enormous problem for children and pregnant women, but by adulthood, an acquired immunity is developed whereby the malaria parasite (usually Plasmodium falciparum) is always in the bloodstream, and each additional exposure to the vector (aka: mosquito bite) rarely results in an episode of clinical malaria. This scenario is euphemistically termed “stable malaria”.
In areas of lower transmission, individuals are bitten by infected mosquitoes less often, and the amount of malaria parasite in the blood stream fluxuates. This is a somewhat better situation for children and pregnant women; however, immunity is not acquired in adulthood, at least not as consistently, and each new vector exposure leads to an episode of clinical malaria more often. This scenario is called “unstable malaria”.
Now, it may seem like both scenarios have their pros and cons, and one is not necessarily better than the other, but lower transmission is certainly better than higher. (Think of which one is better for the women and children, sort of like a Titanic/life boats situation…They are more important and get saved first.) And the end goal of all malaria programs is eradication: the elusive E word. In order for that to happen, areas of high malaria transmission will have to become areas of lower transmission before they can become malaria-free areas. Alas, for my friend Dennis, these growing pains can be literal pains indeed. (Though he seems to be smiling now.)
A somewhat related “growing pains” type of situation worth mentioning is one from the field of HIV/AIDS that my old CGD colleague, Mead Over, an expert in AIDS economics, deals with on a daily basis. It has to do with the difference between incidence and prevalence, and the fact that, counterintuitively, higher HIV prevalence rates can undoubtedly be a good thing. Incidence refers to the amount of people newly diagnosed with a disease over a certain period of time; a lower number here is almost always better**. Prevalence, on the other hand, refers to the number of people currently living with the disease. And for HIV/AIDS, the main goal right now is increased access to ART (antiretroviral therapy). Thanks to the great advancements in these HIV drugs, people are now able to live much longer lives with the disease. And higher prevalence rates – more people living with the disease – means more people not dying from it. Seems straightforward enough, but it still causes headaches for Mead and other AIDS experts dealing with policymakers doling out the money.
**Higher incidence rates can also be a somewhat good thing if great strides have been made in the number of people being tested for a disease. Obviously, it is not a good thing that more people have the disease, but it is better that the higher burden is now known by public health professionals. This happened recently when the HIV/TB co-infection rate jumped from 1-in-8 to 1-in-4 almost overnight.
Let me explain. The Pharmaceutical Society employs a driver who runs errands (picking up checks, delivering letters, etc.) all day all over greater Accra, because the national postal service takes up to 4 or 5 days, and I suppose this is considered more efficient and cost effective. His name is Charles, and he is a short guy (maybe 5’5) with short hair, a little goatee and big, wide eyes. I am to go with him because I need to make a few stops myself (U.S. embassy and National Malaria Control Program), so we leave the office around 11am. What I didn’t know is that the combination of multiple errands to run all over town and Accra traffic means that I am spending the next 5 hours with him. It is 5 hours of a great education.
I buckle up, he flips on the radio and we’re off. Charles is very affable, and it is clear after a few stops that he knows many people all over town. By Ghanaian standards he is a very good driver (aka: extra crazy). The only stop sign I see all day is blown by us, as Charles waves to the taxi that honks, swears and slams on its breaks to avoid hitting my front passenger side door. Traffic is bad, even in the middle of the day, and hundreds of people are employed by hawking goods to the cars stopped in the gridlock. Even when traffic is moving, they do not leave the middle of the road, and I have a fleeting thought about correlation vs. causation. Men and women of all ages carry baskets of wares atop their heads, selling everything from bags of water and nuts to neckties and paintings.
Charles' radio station of choice blasts a mix of international and local rap and R&B in between commercials for hair care products and PSAs about making sure to wear a condom when you have sex with your girlfriends (but not your wife). It is a nice change of pace form the music that Dennis plays in his car (only Gospel). The radio station is very into international entertainment news as well, and I soon learn who Alicia Keys is in the studio with and when Shakira’s new single is dropping. As I hear a string of Eminem, the Ying Yang twins, that “Blame It on the Alcohol” song (I think it’s Jamie Foxx) and “Sexy Can I”, a thought occurs to me: Have donors ever considered paying popular artists to sing about their issues of concern? Can the World Bank pay Rihanna to sing about how sexy it is when people wear condoms? Can USAID pay Jay-Z to talk about how only true ballers adhere to their entire regimen of TB drugs? (Two related thoughts: Like movie stars that endorse foreign products overseas, Westerners don’t even have to know about it. Also, Ghana is an English-speaking former British Commonwealth, so it occurs to me that this type of campaign would probably be less effective for its Francophone neighbors, but I still think there might be something there…)
It is now the middle of the afternoon, and school children in their brightly-colored matching uniforms and backpacks can be seen walking next to the goats on the side of the road, as we make our way in the traffic. I contemplate a sign above a nearby shop declaring “Herbalist - HIV Has a Natural Cure!” and continue to notice the school children. Without having to turn my head, I am able to see the color-coded kids walking away from me and other ones walking towards me with a basket of fruit and a bag of soccer balls, respectively. What is the difference between those children on the side of the road and those in the middle of it? Between those carrying backpacks instead of balancing an open box of jewelry on their heads. These depressing thoughts stay with me for a bit, but a few miles down the road I see something that improves my mood. It is a billboard from the Ministry of Health promoting HIV prevention that states: “Abstain, Be Faithful, OR Wear a Condom Every time!”, and I am overjoyed that the Ghanaian government has taken the sensible approach of giving their citizens options…I guess that was too much to ask for from the Bush Administration.
