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Something’s Bugging Me

11 Feb 11
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The statistics are enough to take your breath away, if you are so inclined to worry about such things.

This year, malaria will strike as many as half a billion people. At least one million of them will die, with most of those deaths coming from children younger than five. And the vast majority of those children live in Africa.

I’ve been thinking about this a lot lately. Right now we’re living in a country where malaria is present. While it is not a problem in Indonesia’s cities, including Bandung where we live, malaria is an issue in other parts of the country. Over Christmas we all traveled to Bali, an island where they claimed to have gotten rid of malaria. But a few stubborn cases led us to take precautions anyway, including a prophylactic course of doxycycline, an antibiotic. So malaria has been on my mind.

Over the past year or so I’ve traveled twice to southern Africa, spending a few weeks in Zambia and Malawi. These countries represent Ground Zero in the fight against the disease. In Zambia, almost 20% of the country’s babies die from malaria before reaching their 5th birthday. And these are the official statistics. While they may be accurate, I have reason for doubt.

The Zambian government’s record with other health statistics, most notably HIV infections, is not a good one. The government reports an HIV infection rate of around 12% of the country’s population. But if you talk to AIDS workers on the ground, as I have, they will tell you that the real figure is much higher. The infection rate in Mfuwe where I visited, near South Luwangwa National Park, is reported to be as high as 45%. So given legitimate questions about the AIDS statistics, I wonder just how accurate those malaria statistics are.

While there are four species of parasites that regularly transmit malaria to humans, Plasmodium falciparum is by far the most deadly. It is this parasite that can attack the brain, and it accounts for the vast number of deaths from malaria worldwide.

Getting malaria and surviving it can grant a minor level of immunity. Millions of people in Zambia and Malawi have contracted malaria many times over their lives. One person I was working with in Zambia exhibited malaria symptoms at both training sessions, which were held months apart. Another station manager left the first training session early because they had come down with malaria.

So because of this repeated exposure, older kids and adults are often less susceptible to Plasmodium falciparum (although it can, and does, still kill adults as well). This is one reason why so many of the deaths come from young children.

Another reason is healthcare. Medicines are available that can reduce the chances of being infected – just as we did in Bali, I took doxycycline while in Africa for my own protection – but these medicines are not generally available to the poor. And once they have contracted the deadly form of malaria, gaining access to medicines that could save their life is almost impossible. Clinics with such medicines are sometimes days away by foot, which is the only way many people can travel in the rural regions of the country. For a disease that can kill quickly, sometimes less than a day after major symptoms occur, time is the enemy.

Malaria is a tropical disease, which means much of the developed world is not affected by it, so it’s primarily a disease of the poor.

Many things can be done to reduce malarial infections. The anopheles mosquito which transmits the disease (only the anopheles is a carrier) breeds in standing water, so removing old tires, buckets and other places where water can collect can quickly lower infection rates. New research is also being done on novel techniques to reduce mosquito habitat.

Scientists are even working on a virus that can kill older mosquitoes, because they are more likely to carry the disease. The reason for this particular approach is a realization that simply wiping out mosquitos may upset a delicate ecological balance by removing a food source vital to some other animal. Allowing them to breed and killing those that can transmit disease would remove this ecological cascade problem.

There is of course another way to drastically reduce the rates of malaria. The two step process is both inexpensive and effective.

The most critical part is the use of mosquito netting while sleeping. Several groups in Africa now sell nets treated with an insecticide for less than $5, a cost often subsidized even further by non-governmental organizations (NGOs). The anopheles mosquito comes out at dusk, so the use of these nets while sleeping, coupled with a periodic coating of bedroom walls with an insecticide solution that kills mosquitos where they rest during the day, has been proven to make people much safer.

And yet in many places, including Zambia and Malawi, the nets are not being used by enough people.

There are many reasons why, but I was fascinated by a story told to me by a journalist from Malawi while we were doing a training in the Zambian town of Chipata. During one discussion he casually mentioned that men in his country won’t use the mosquito nets. When I asked why, he said the nets made the men impotent.

This I had to understand.

In Zambia and Malawi, as well as many other traditional societies, having children is a sign of virility in men. So an inability to have children can have major repercussions.

As Joseph told the story, when couples slept without nets a mosquito bite might wake them up, so they could then have ‘relations’ (his words, not mine). This way they have children, and his manhood is established. However, if they sleep under a mosquito net and are not bitten, they sleep through the night, do not have ‘relations,’ and therefore do not have children. So nets make them impotent. This means the men do not want to use the nets, and somehow this translates to the children as well – no nets for anyone.

I’m fascinated by such stories. As a journalist, I think a lot about how cultural beliefs and biases affect the transmission and acceptance of information. While we may find the story of alleged impotence to be quaint, similar examples can be found in the United States, particularly when it comes to the acceptance of the overwhelming level of evidence concerning climate change. Many people cling to an outlier study that may claim to disprove some basic tenet of climate knowledge, simply because if they were to believe the real evidence in front of them it would challenge some element of their personal belief system. In other words, what we believe and our sense of who we are often trumps actual facts. Just think about the scientists burned at the stake in our not so distant past for being heretics.

One element of the netting strategy that has some people concerned is the use of DDT. While there are other insecticides that can kill mosquitoes, DDT remains king. Its residual effect means spraying can be more infrequent. And when used appropriately, a very small solution is all that is required to drastically limit exposure to anything other than mosquitoes. (It appears to be unclear how DDT works to control mosquitoes, however. While some think the insecticide kills the insects, at least one study indicates the synthetic chemical actually chases the mosquitoes away, rather than kills them)

The massive over-use of DDT in the 50s and 60s, and the release of Rachel Carson’s book Silent Spring, has led many people to believe that the use of any DDT is wrong, and they are troubled by its resurgent use in malarial control. And who can blame them? Those videos of kids playing in the DDT fog trailing insecticide spray trucks in the U.S. still give me the creeps. But most if not all international health groups now understand the power of this chemical, when used appropriately, to drastically change the lives of so many people.

So why am I writing this now? I’m planning several trips. In March the kids and I will visit Thailand, where malaria is present (although again, not in Bangkok, a major city, where we will be staying). I will also be traveling to Kuching, in the Malaysian portion of Borneo called Sarawak. And in April we hope to drive around western Java when my cousin visits, taking a boat to Krakatau and visiting a national park where the rare one-horned Rhino lives. I suspect we will take malaria medication for that one, and also when Beth visits and we go to see some world heritage sites on southern Java.

We’ll likely take doxycycline again, and while you can still become infected with malaria while taking the medication, the odds are much lower. We’ve been back from Bali for more than a month now, and so far everyone is okay.

But across Indonesia, some kids without the same access to medication and health care will die soon from malaria. And that’s something I’ve been thinking about a lot lately.

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