Showing Malaria a Red Card

David McCormick

The World Cup is in full swing and although the only remaining African team was knocked out by the most blatant display of poor sportsmanship I think I’ve ever seen, it’s still the most popular event on TV and one of the main topics of conservation here in Blantyre. For many Malawians, the World Cup may be the only TV event that they  have seen in a few months and they may not see another TV event for a while (“exciting” is not a word I’d use to describe the regularly scheduled programming on Malawi’s only TV station).  Public health officials are taking full advantage of this situation and a constant feature of the broadcasts is a small band of text at the bottom of the screen encouraging the viewers to use the mosquito nets and visit the health clinics if they suspect that they or a family member might have malaria.  To drive the point home, the half-time analysts usually wear shirts with the local “Roll Back Malaria” logo.

Malaria is a major problem in Malawi – it’s not uncommon for a child to suffer from the disease 4-5 times in a single year and it is one of the leading causes of mortality in children under 5.  Although there are some effective preventive measures and treatments available, people must visit a clinic before they take advantage of them.  Visiting a clinic can be expensive – the visit itself is free, but the wait can be as long as 8 hours to see a doctor, and if you have to wait that long that means missing out on a day of work.

One small problem with this campaign is that the notices are only in English.  Although all Malawians learn English in school, it’s certainly possible that these messages would reach more people if they were also presented in Chichewa, the dominant native language. Other than this small quibble, I think it’s great that officials are using the World Cup as an opportunity to bring important public health messages to as many people as possible.

The View from my Window

David McCormick

I’ll be spending my summer internship in Blantyre, Malawi, where I’ll be working on a few projects.  My office is in the Malaria Alert Centre, which is conveniently located next to the central hospital (where one of my advisers works) and also houses the Blantyre Malaria Project, with whom I’m collaborating on a project that is trying to develop a diagnostic algorithm to differentiate pediatric patients with bacterial meningitis from those with cerebral malaria.  Both diseases have very similar symptoms and a high mortality rate, but unfortunately they both require different treatments.

Complicating the situation, many health care centers (and even some district hospitals) in Malawi don’t have the resources that they need to perform even basic lab work (in some cases they are unable to determine hematocrit or blood glucose), so this algorithm would ideally be based on 4-5 clinical observations that don’t require sophisticated equipment.  While I’m in Malawi I’ll also be collaborating on a project to determine the burden of cancer in Malawi – we take it for granted in the US that we know how many cancer cases occur each year, and what the most common types of cancer are, but that information has not been systematically collected for Malawi, which makes it difficult to allocate health care resources to where they are needed.

The View from my Window.

I share my office with two other researchers – an MD/PhD studying cerebral malaria, and a post-doc working on a device to measure the size of a hole that red blood cells infected with malaria can pass through.  We have a fourth seat in our office which visiting researchers and professors will often use when they need a place to sit and work.  It’s a humble office on the second floor that is well-supplied with tea, coke, and various snacks (including the tasty but unfortunately named “Salticrax” cracker).  The office looks out over fields and the noise from people working will drift in (it’s the cooler dry season and our windows stay open during the day), the MAC insectory, where they raise mosquitoes (and the reason we have to close our windows when it gets dark), and across to the Malawi Liverpool Wellcome Trust.  Combined, it’s a nice view of both average life in Malawi and sophisticated research institutions, highlighting the need for research on infectious disease and the hope that research here will one day lead to better care.

International Travel Doctor Visit

Carrie Rheingans

Since I’m going abroad for a social work internship this summer, I needed to make a travel health appointment to make sure I have all the vaccinations and immunizations I need to stay as healthy as possible while I’m traveling. I had my appointment last week (my third in five years…) and got my first-ever anti-malarial medication prescription.

As a current student, I have access to the services at the University Health Service (UHS). They have a travel & immunology clinic, and it can get pretty busy during certain times of the year (before spring break and summer break). They ask you to take an online basic travel health training in order to make an appointment. It doesn’t take long and is a good review of water and food safety, sun and bug issues, and what to do in a health emergency.

It’s best to go prepared to the appointment and know exactly where you’re going in your travels. Malarial areas can get pretty trick in some places, so it’s best to know what cities or villages you’re going to if possible. The appointment is pretty quick and includes a review of health issues in the locations where you’re traveling and some immunizations and prescriptions as necessary. My favorite part is getting ciprofloxacin to treat diarrheal illness. It’s helped me out in the past! UHS can also dispense many of the prescriptions right there in their pharmacy.

There’s a price list on the travel health page for planning for what immunizations you might need. If you don’t have insurance coverage for some of the requirements, it’s easy to go to the Washtenaw County health department as well.

Malaria in Michigan?

David McCormick

When you think about malaria, chances are high that the United States is not the first country that comes to mind.  However, malaria was endemic in the US until the late 1940′s, and the high prevalence of malaria in the Southeastern US is one of the main reasons why the CDC headquarters is located in Atlanta.

Malaria has a long history in the US.  Until 1880 it was thought that malaria was caused by bad air (“malaria” comes from the Medieval Italian for “bad air”) and it wasn’t until 1898 that Sir Ronald Ross of Britain proved that malaria is transmitted by mosquitos.  Our capital was built on a swamp (truly a wonder of modern urban planning) and in the summer was notorious for diseases including malaria and yellow fever.

It’s easy to forget that until as recently as a century ago, much of the US was still a developing country – industrial manufacturing was low and most people lived in small towns and worked on family farms.  The population density was low in many regions and low-lying fields were good farmland and ideal breeding grounds for the mosquitoes that carried malaria when they flooded.  Malaria was such a problem in the US that the US Census of 1870 released a map showing areas in the US where deaths from malaria were high (see below).

A Census Map Showing the Proportionate Mortality of Malaria in the US in 1870

The map is courtesy of the US Library of Congress and can be found in its original context here.

Michigan’s reputation as a hotbed of malaria was well known, as the following quote from the Bulletin of the Medical and Surgical Sanitorium (Battle Creek, Michigan, 1892) shows:

But what about Michigan malaria? Unfortunately for the reputation of Michigan as a healthful State, the idea got abroad many years ago that the principal feature of its climate was malaria. Going to Michigan was considered almost synonymous with going to have a fit of the ague. It was not supposed to be possible for a person to visit Michigan or even to pass through the State without having the chills.

Apart from being a mere historical curiosity, the high prevalence of malaria in Michigan served as a barrier to development – the rural regions of Central Michigan stand in sharp contrast to the well-developed Southeast and are a legacy of peoples’ hesitancy to venture further inland.

So how did we eradicate malaria in the United States?  Public health.  Even before it was known that malaria was transmitted by mosquitoes, people would clear swamps to reduce the incidence – a classic example of how you can solve a health problem without knowing the exact cause of disease if you understand the risk factors.  Once we figured out that mosquitoes were the culprit, much of the eradication effort focused on their elimination.  Common practices included land improvement, removal of mosquito breeding sites, and heavy insecticide use.  DDT was the most commonly used insecticide, and its use in the 1940′s to eliminate malaria lead to severe environmental consequences (for more, see Silent Spring). A very nice (and brief) history can be found here.