topnaman | Malaria blog

Sometimes I hate advocates. Anything which smacks of “my disease is more important than yours” is a great way for me to stop listening. Nicholas Kristoff’s blog post on pneumonia importantly highlights the large disease burden and the relatively scant public attention. However, the solution is not to have a world pneumonia day. Nor do we need to justify schistosomiasis control with tenuous evidence on its association with HIV prevalence. I understand what Hotez et al. are trying to accomplish since the latter is a hot issue, but I wonder whether we will be undermined by such messaging in the long run. As a friend of mine said, “Treat schisto to treat schisto.  Anything else is icing on the cake.”

We need to move beyond unilateral thinking and organize around broader public health platforms. Unfortunately, this is not as tangible as a single topic, and it doesn’t make a good bumper sticker.

How do we do it?

a

So this is what I’ve been writing about. Courtesy of Wordle.

Everyone likes to talk about DDT and malaria, and a friend of mine asked me to post about the topic. No way! I am not walking into that mess.

Suffice to say, I am frustrated with both sides of the debate. My personal views probably lie closest to those eloquently expressed here.

I really have to hand it to Paul Chinnock and his team at Tropika. Paul has turned the site into what I think is the best source of groundbreaking and offbeat  malaria news on the web (the site covers tropical diseases in general). I like his editorial input as well - he’s not afraid delve into substantive comments or share doubts and criticism. However, changing the comment system to not require a log-in would be my one suggestion for them. Here are some of my recent favorites from Tropika:

• MalERA - The malaria eradication research agenda - it’s arranged according to programmatic areas with all relevant documents made available, lists upcoming events, and has a forum to provide feedback! Well thought, transparent and progressive, I’m impressed.
• Every day is Malaria Day - a gem of an article. With a brilliant tongue-in-cheek first paragraph lamenting single disease and the stifling positivity of today’s adovacy, Paul goes on to guard against magic bullets, creating false hopes, and the consequences of failure.
• Gates, Lancet, priority setting in global health - a random hodgepodge of topics but noteworthy for not only mentioning that Ranbaxy plans to move forward with an antimalarial trial (which many news sources carried) but pointing out that Medicines for Malaria Ventures pulled out of that project after previous results.
• Sharing experiences in vivax control - a) its news on vivax b) I simply did not see this conference covered anywhere else
• China and malaria elimination in the Solomons - a fascinating story about an scaled up malaria control effort and the controvery it has generated. The tone of the discussion (in the original news source, not the Tropika article) is disturbing and I hope to write more about this soon.

Note: I’m sorry posts have been sparse but this will likely continue with USMLE exams and work in India coming up

Today is World Malaria Day.

Many more people are aware of this fact in 2009 with the increase in advocacy, particularly  in the Western world. Some would say malaria is now “hip”. For others, that’s as much a cause for concern as it is for celebration. In any case I’ll certainly take a minute today to reflect on how far we’ve come, and where we’ll go.

Today, the Affordable Medicines Facility for Malaria (AMFm) was unveiled in Norway (great NY Times piece) with an initial $225 million. The subsidy program aims to increase the availability of affordable artemisinin combination therapies (ACT) - the recommended first line treatments for malaria - through private drug shops. Many people in some countries self-treat with antimalarials bought from these private shops since they can be closer to their home, don’t have long queues, etc. ACTs are rarely bought because of their higher prices so the idea is to make them inexpensive and reduce the incentive to buy otherwise cheaper, but less efficacious, antimalarials.

The article suggests that “For a poor farmer in Cameroon or a poor market woman in Ghana, the difference between 20 cents and $8 is huge” which is true but fails to mention that in many countries ACTs are available free of charge through public and private health facilities. ACTs are already subsidized through national control programs though the extent of their reach could be expanded. I must admit I have my doubts about this plan. First, as Dr. Bernard Nahlen notes in the Times article, there’s scant evidence for a scale-up of this approach. The deputy director of the President’s Malaria Initiative (a solid CDC EIS alumnus - random aside I think CDC involvement is a key reason for PMI’s to date success) is justified in his skepticism. The bulk of data are basic case studies from a few Clinton Foundation pilot projects. Second, even if more rigorous evaluations demonstrate some impact, is it really a desirable way forward?

We need more delivery channels and increasing the availability of ACTs is critical, but it should be done as a component of improving overall case management. The idea of encouraging  indiscriminate pill-popping (even if it is the current scenario) with better drugs probably does not align with most countries health priorities. Additionally, there are also the inherent risks of missing other etiologies of fever and increasing drug pressure. On the other hand, cheap ACTs in drug kiosks may be able to provide quick wins in areas which have seen little progress, but countries should think carefully before embarking on this road. It may be an OK stop gap to stave off some morbidity and mortality in places with non-existent health systems but could sabotage development in the long run.

A follow-up comment I posted on Science magazine’s blog which I think adds some more information:

Going the private route is not new. Global Fund drugs get distributed through private channels in many countries whether it is NGOs or partnerships with industries that have medical facilities. What is newer is the use of drug kiosks but even Cambodia for a few years has been marketing ACTs through private shops - with questionable impact. We’ll see how this effort progresses but it is not likely to help build health systems.

My brother is amazing. For his senior design project as a biomedical engineer, he is developing an inexpensive platform for the diagnosis of infectious diseases (covered by the News & Observer). Pavak sought out technical and business development experts, put together a great team of students, and spent countless hours building an imaging cytometer - a device which can count cells in an automated fashion. By labeling cells of interest with a specific dye, its possible to detect and measure the presence of a specific organism. They are starting with an assay to detect tuberculosis, but the next step may be a malaria test. To be fair, the technology isn’t appropriate for all situations and there are many hurdles before the idea can even make it to the field. But for a group of undergraduate students its a tour de force demonstrating initiative, creativity, and engineering ability.

An addendum: how do we create the right environments to encourage and support students to take such risks?

“Pool-filling could control malaria” an article at AllAfrica.com says.

True, but so could swatting enough mosquitoes with your hands. The existence of an intervention does not mean its viable. Media communication of science research or public health news (previously discussed here) is consistently poor. To be fair, the environmental control of malaria can be an appropriate tool.  Historically, Brazil, Italy, Panama and a few other countries have used it with good success. Why did it work there? First, reducing mosquito density will have little effect on transmission in highly endemic areas, but these countries had the right ecotype. Second, environmental control is labor intensive and requires strong management, both of which were provided through military-style campaigns.

Last February, I wrote my first post on the influence of the Gates Foundation in malaria. I started the blog primarily with the intention of improving my writing skills. I also hoped the process would help me better develop, organize, and communicate my thoughts related to malaria. Sometimes writing regularly has been hard, especially in the midst of exams and travels. But it has always been fun - finishing a post (still a slow affair) is exquisitely satisfying. If you read this blog, thank you. If you leave comments, thanks double - I really want to foster more discussion. Here are some year one stats:

• 1,518 unique visitors
• from 79 countries
• 45 posts, 11,157 words
• Top 3 posts:

1. Cellscope
2. Eradication vs control
3. GSK ends lapdap

Yes, it’s true - Bill Gates released a jar full of mosquitoes on the audience during his talk at the 2009 TED conference (some funny remarks in the comments here). He said, “Not only poor people should experience this.” Sure releasing mosquitoes is an unorthodox presentation tactic which gets your attention, but the idea, even as joke, seems rather inelegant - not unlike the Davos Refugee Run. Apparently, a Gates Foundation spokesperson found it necessary to clarify that the mosquitoes were not carrying malaria. I honestly wonder what species the mosquitoes were (only the Anopheles  species carry malaria), where Gates got them (it is fairly cold right now), and if the mosquitoes actually bit anyone (only female mosquitoes take blood meals and maybe he released all males)?