topnaman | Malaria blog

The Malaria Blog is retiring. Writing posts was a blast while it lasted but the times change. The blog helped focus what I was already reading into meaningful output, connected me to many kind strangers, and provided a platform to share some of my own views. Five years later, none of these matter anymore. My audience is different, my interests are broader, and I use different platforms for disseminating ideas. The public nature of blogs, generally a boon for many reasons, was always a source of some slight discomfort. The ideal of quiet service, acting (or writing) without fanfare, is appealing and seems incompatible with the medium. Perhaps it is not, but I need to try other means now. I’m grateful to everyone who read and commented.

PS the site will be archived here.

• The mosquito menace in Chennai (the city’s response might be scarier)
• J Kevin Baird picks apart a historical fallacy in what might be the most important review of the year
• Malaria, swine flu, and understanding the political economy of control programmes in endemic countries
• Is an elimination agenda increasing inequity (previously discussed here) and why so much funding for Equatorial Guinea (here)? Some evidence on the need for donor re-allocation from GFATM and WHO

I’d like to turn to the subject of being critical. I have no desire to pour rain on the good intentions of others. Yet many of my posts take on a critical tone and some are even snarky. But they are always accompanied with a certain guilt. Critical thought has a place. It’s a perspective missing in much public debate. The web especially tends towards an echo chamber.  Why does this happen? Lots of reasons: we live in an era of concerted marketing, an inability to respond critically (especially for heavily technical areas), the lack of confidence to publicly express criticism, social desirability which suppresses it, and so on. The problem may be worse within communities working on humanitarian matters where normative stances tend to be similar. Additionally, the dominance of soft money, a limited set of funders, and frequent career jumps edges us towards caution. I’m reminded of a scene from a TV show (edited some for brevity and mostly for foul language):

If only half of you at the district attorney’s office didn’t want to be judges, didn’t want to be partners in some downtown law firm… If half of you had the balls to follow through, you know what would happen? A guy like that would be indicted, tried and convicted… But no, everybody stays friends. Everybody gets paid. And everybody’s got a future.

– The Wire

But thinking critically and expressing it are different matters. The former is desirable and essential. The second of questionable utility and perhaps taste. I came across this somewhere:

Attacking bad books is not only a waste of time but also bad for the character. If I find a book really bad, the only interest I can derive from writing about it has to come from myself, from such display of intelligence, wit and malice as I can contrive. One cannot review a bad book without showing off.

– W. H. Auden, “Reading,” The Dyer’s Hand, And Other Essays

I’ve heard it another way – it’s easier to clever than it is to be kind. What’s the alternative to critical expression then? I don’t think there is any per se but I’m trying, struggling, to apply two points. First, being generous with one’s criticism. Second, thinking appreciatively. These are not unrelated. The former allows us to retain the benefits of the critical approach and in fact, enhances it by upholding a higher standard. The latter makes sure we don’t get overwhelmed by it. I won’t elaborate more because the links are excellent. Another term ‘steelmanning‘ (hat tip: Andrew).

Disease burden estimates are contentious as I’ve previously discussed on the blog (here and here) and in print (here, here, and here). So I won’t say much but share some surprising new comments. They are surprising not for their content (which we’ve already said) but because they are from the Global Burden of Disease group, which includes the authors of the controversial malaria estimates, and they are published in the Lancet, which published and actively promoted these estimates.

We now joke to each other how we used to get away with murder in the past doing burden studies. We tended to make lots of not so replicable ad-hoc decisions and few people knew what we were doing anyway.

We have also had some experiences of disease experts taking on roles of advocates with aim to ‘boost the numbers’ rather than being ‘impassionate’ scientific advisers.

Countries should develop sufficient capability to independently assess the merits of different methodologies and interpretation of findings: simply because WHO has issued estimates of disease burden does not make them correct.

Let’s see if these get noticed. I should add that I admire the openness of the article and the intent to change business-as-usual expressed there within (thanks Matt for the link).

Heterogeneity exists in the risk of malaria – both between different areas and between individuals in the same area. The old maxim states “malaria is a local and focal disease”. Targeting malaria control interventions (nets, spraying, etc) is thus, a time-honored activity. Countries which undertook malaria eradication efforts have stratified populations at-risk for intervention delivery since  in the 1950s-60s.

In recent years a spate of papers (here, here, and a policy piece here) have emerged on the idea of hotspots and ‘hitting them’ for high-impact control. What do these papers add? These studies quantified the heterogeneity in risk at the individual and household levels and their change with time. Another innovation in measuring the concentration of transmission was the use of serological in addition to parasitological data – although the two studies conflicted on which serological measurement was better. Finally, the papers recommend individual or household-level targeting of certain control interventions (vaccines, mass drug administration, specific vector control activities) at certain times based on annual surveys. What do these studies miss? First, as with many studies, particularly those conducted or focused in sub-Saharan Africa (all of the above), they suffer from a lack of historical perspective. Enamored with the idea of novelty, the authors fail to acknowledge decades of experience in ‘hitting hotspots’ using different data and different units of selection elsewhere in the world. Second, these studies do not assess, deductively or empirically, the direct and indirect costs of targeting. What are the training, delivery, coverage gaps and leakage implications of using serological data compared to parasitological data or of using household level stratification compared to village or area stratification? Without the comparative and programme perspectives such key questions remain unasked.

Using and improving targeting is an important area of work in malaria control. But the detection of these hotspots therefore, does not necessarily lead to their use in control work. Long-standing, sophisticated malaria control programmes face considerable difficulty in targeting activities using much coarser criteria. Conclusions and recommendations should follow from study results. This is a basic principle of scientific writing, and possibly, the most violated due to well-meaning intentions to ‘do something’ along with the less noble imperative to overstate one’s work. Academic research and publication will always favor the new over the credible, future possibilities over present realities. This is not necessarily a bad thing. We need to aim high and we need to look ahead. Programme managers and other practical consumers of the literature should be prudent in the promotion of such work. What worries me is the academic-donor nexus which prevents this caution and brings in varying degrees of distraction.

Innovative vector control as reported in The Hindu (thanks Anup Anvikar) using a locomotive to spray larvicide along train tracks through the city of Delhi. As we see malaria transmission decline from improved control efforts, the remaining foci will increasingly be limited to specific ecotypes. Examples include urban and forest malaria, which have proved refractory, and we will need strategies specific to their peculiarities.

A few years ago Dr Steve Phillips, the medical director for global issues at ExxonMobil, spoke at my university about their work on malaria. Vaguely I recalled some company controversies in the same regions where Exxon promotes their charitable work. So I asked the good doctor if he felt his no doubt good intentions were sometimes limited by broader corporate policy. The reply invoked the resource curse as if it was a supernatural phenomenon ! Unsatisfied, I bore into the (many see here, here, and here) articles published on Exxon’s involvement with human rights, governance, environmental challenges, and particularly their relationship with the brutal dictator of Equatorial Guinea.

What emerged led me to question whether we (the public health community) may have conflicted interests. Do we accept support generated by business practices which may harm health more than the good work enabled by that support?  Deciding to write about the issue was difficult. On one hand there was little recognition of the possibility of conflicts of interest in this case which could be worthwhile to promote. On the other hand I was wading into the realm of ethics, for which I am poorly equipped, and the energy and focus may be better applied towards the smaller, more practical problems which constitute my routine work. Ultimately, I think it was just the challenge of doing something new which led to its recent publication in the Journal of Public Health Policy (unfortunately not open access). Accompanying the article is a kind commentary by the public health ethicist Sheldon Krimsky which concisely summarizes the key problem and the trade-offs inherent in addressing it.

PS pre-print version available here

Not what you clinicians are thinking (i.e. the suspension). My drink of choice has long been tonic water for it’s antimalarial components. This might be the new favorite (hat tip: Priyanka) once I find the cinchona needed.

Ramachandra Guha, whose writing has brought me much profit, described the three tests for science in a country such as India formulated by the British-born Indian architect Laurie Baker: 1) is it eco-friendly? 2) is it non-violent? 3) is it poverty-reducing? This vision of science complements the notion of the method as a means of greater service promulgated by others. It eschews the public persona and elicits, instead, quiet determination. It is fundamentally outcome oriented and that too with the long-view. In this age of accomplishment evaluated on the timescale of press releases and serious matters adorned with glossy sentimentality, I wonder how we can build such an ethos in our own research community? At the risk of non-attribution (for I cannot find the source), we must recall that true dharma requires the unification of knowledge with action.

The New England Journal of Medicine recently reported phase III trial results for artesunate + pyronaridine and tucked away in the acknowledgments I noticed this:

We thank Naomi Richardson (Magenta Communications) for developing the first draft of the manuscript and for editorial assistance.

I wondered, why? On one hand, for a well-defined type of study such as a phase III randomized controlled trial the writing can be fairly formulaic and easy to outsource. The data analysis was also conducted by another corporation. As an industry-sponsored study, no doubt the funders wanted a quick, and efficient process once the trial was complete. The additional cost of these services (anyone know how much?) which I suspect are expensive may not be much compared to the entire study budget. Still, it is somehow disappointing to me to see a paper which was not analyzed or written by the scientists who conducted the work. Is the process not important and what are we losing to the CRO culture which dominates these days? By all accounts (number of previous publications), Dr Ronnatrai Rueangweerayut who is the first-author, could have benefited from the writing experience. How else will we build scientific capacity?