Tuesday, September 29, 2009


It’s somewhat remarkable that I’ve been sitting here in Mali blogging about matters of public health and I’ve managed to go 15 months without addressing the subject of malaria.

For starters, malaria is caused by a parasite called Plasmodium, the most common and dangerous being the Plasmodium falciparum which is carried by female Anopheles mosquitoes.

The Anopheles mosquito is merely a carrier of the parasite and likes to drink fresh mammalian blood just as the tamer mosquito species of North America, but when an Anopheles carrying the Plasmodium parasite feasts on human blood, some Plasmodia backwash through its proboscis into the human blood stream.

Young Plasmodia parasites spend a brief stage in the liver and then mature in the red blood cells where they trade gametes and conduct sexual reproduction. When the red blood cells have become so full with Plasmodia spawn the cellular membranes burst, sending a massive release of new parasites into the blood stream where they in turn effect more red blood cells. Once the population of Plasmodia proportional to the volume of blood reaches a certain tipping point,the human carrier experiences severe fevers and chills in a cyclical manner as each new batch of parasites is released. Unless the human carrier receives proper treatment, the parasite population will continue to expand exponentially, potentially causing the victim to experience delirium, kidney failure, culminating in a coma or death.

Part of the reason why this Water Sanitation Extension Agent hasn’t been able to do much about malaria is that – whereas diarrhea can be comprehensively diminished with the establishment of proper toilets, wells and hygiene practices – the only way to completely eliminate malaria is to completely eliminate water. In the tropics, where there is any body of water from a lake to a puddle that is not flowing at a swift clip, there are almost certainly Anopheles mosquitoes. In any desertous region without any standing water, there aren’t many mosquitoes and there isn’t much malaria – but there also aren’t very many people. So long as human beings are going to cultivate rice paddies and build settlements along rivers and lakes and anywhere that is at all fertile enough to make a living from the land, we are going to have to deal with malaria.

A better reason why I haven’t concentrated my attention on the greatest preventable cause of mortality in Mali and all of Africa is that it’s already received plenty from international development agencies and NGOs. Here in Sanadougou the local maternity distributes mosquito nets to every expecting mother and teaches her how to properly tie it above her infant’s bed and to come and treat it again every year. The community health organization conducts extensive formations on malaria prevention, teaching a mostly illiterate and ignorant audience how to monitor their children and when they display symptoms of malaria to bring them to the CSCOM to receive quinine injections. And PMI: The President's Malaria Initiative – one of the actually admirable legacies of the presidency of George W. Bush – pays for the “Mosquito Killing Wagon”; a truckload of men who drive around to people’s homes and bodies of standing water to spray insecticide, hopefully reducing the mosquito population.

Though my latrine and soak pit construction campaign is primarily meant to curb diarrhea, dysentery and cholera, containing people’s raw sewage underground does carry a secondary benefit of reducing the bodies of standing water. If this campaign ever reaches a critical mass and entirely rids certain neighborhoods of wastewater puddles – which during dry and hot seasons serve as the only bodies of standing water – the village of Sanadougou might experience a significant dip in seasonal mosquito populations and the incidence of malaria.

During rainy season, however, any anti-malarial externalities of Operation Sphincter Plug are nonexistent. There are little sprinkles now and then throughout the year, but the months of June, July, August and September are known as “rainy season” for a reason. When the monsoons come every week or so the thunder on my tin roof makes it sound like a battle’s a-raging outside, the sheets of rain will come down so thick and so strong that they sting my eyes if I dare venture to peer out of my rain jacket hood. Hours later when the storm has calmed to a drizzle, the streets will be so full of storm waters that a mighty creek will have formed, carving a gulley to the floodplains downhill. For days afterwards the landscape will stay pocked with large gaping puddles which render some roads impassable.

During rainy season – no matter how much insecticide America disseminates – there will always be standing water and there will always still be mosquitoes. To be honest, I’m not sure if the spraying of insecticide even does all that much good, because if it’s toxic enough to render a puddle infertile for mosquito breeding, then it can’t be that great for the health of humans when it inevitably percolates down into the groundwater and infiltrates into people’s wells from which they’re going to drink it straight.

Also thanks to the intervention of the international development agency/NGO complex, every woman who walks out of Sanadougou’s maternity with a newborn baby also leaves with a mosquito net. If she has twins, then she leaves with two. If she has many more children, over the years she will still have at least one mosquito net per child – free of charge. Lack of access to mosquito nets is not at all the problem, and one couldn’t say that the women aren’t adequately educated.

Nevertheless, a rather odd thing happens with those mosquito nets. In all fairness, some women diligently act upon la matron’s instructions and string them above their babies. But the vast majority of women put the nets up the first few weeks after childbirth (if even) – and for whatever reason they grow tired of the habit. And eventually Malian women shove these perfectly good mosquito nets away in some corner where they will be nibbled by mice and termites. And this is a better-than-average case scenario; a significant number of women never open their free mosquito nets at all and just hoard them, never to be used.

It is really amazing how in this village where there is truly a mosquito net fairly allocated for many children born over the past 5 years, hardly anyone ever sleeps under a mosquito net. I’ve inquired far and wide why this might be. Economic studies have shown that people who receive mosquito nets for free are significantly less likely to actually utilize their mosquito nets than those people who pay for them in full, or even those who receive heavily subsidized nets and have to pay at least some of the cost. Perhaps the problem is that those who don’t pay for their mosquito net don’t realize its full value – William Easterly writes of women who cut up free bed nets to make lace trimmings for their dresses and wedding veils.

I ask the doctors, the teachers, my host brothers why Sanadougoukaw don’t put up their mosquito nets. They unanimously reply: “People are lazy!”

Thus despite the good efforts of PMI, UNICEF, Oxfam, Save the Children, WorldVision, malaria is still endemic. One could say that the worldwide NGO axis isn’t doing enough and that they should shower Africa with more aid, but it really wouldn’t be fair to blame the continued incidence of malaria on any miserliness of the globetrotting humanitarian-industrial complex. Asides from physically tucking all 800 million sub-Saharan Africans into their mosquito nets each night, I really cannot think of anything more that we the West can do.

One fair argument to make against the distribution of free mosquito nets to new mothers is that it creates some perverse incentives. Everyone I’ve ever spoken to about the subject wants a mosquito net, and there are perfectly good mosquito nets available in every market and many sizable butigis – but the fact that mosquito nets are being given out for free to someone makes it seem foolish for anyone to spend their own money on this basic consumer item. Adults contract malaria and die of it too. And even in my relatively wealthy host family where the parents are beyond their reproductive age and their kids are in their late teens and 20s, they are reluctant to spend money on something that can be gotten for free.

I’m extremely skeptical about distributing free mosquito nets to all people regardless of age, or even distribution at a subsidized price. The standard model sold in markets like Sanadougou’s go for 2,500 francs (~$6). Yes, Mali is a poor country. But a packet of tea costs 200 francs, a kilo of sugar costs 450 francs, a full pack of cigarettes costs 2,000 francs, and a full motorcycle gas tank costs 2,000 francs – 3,000 if it’s a Yamaha. In a small town like this, phone cards are sold for denominations of 1,000 or 2,000 francs. 2,500 francs for a potentially life-saving device is not so unaffordable to explain why so few people here sleep under mosquito nets

One day, after coming down with malaria, my host brother Jafete angrily demanded that I buy him a mosquito net.

“Every time I leave town I pay you good money to water my garden and feed my animals. What’ve you been spending it on?”

“Gasoline, phone credit, cigarettes, tea and sugar.”

“This conversation is over.”

Even if every single person in Mali had a mosquito net and they diligently tied it and slept under it every night, that still wouldn’t solve the problem. Mosquitoes are active so long as the sun is down – and they bite during dinnertime, when people are sitting around at night listening to the radio, and when they wake up before dawn to pray. If you roll over in your sleep and your foot is leaning against the net, mosquitoes can bite through the holes.

At the onset of rainy season, as the proud owner of lemon trees I received a steady stream of visitors who wanted to cut some lemon leaves. According to traditional Bambara folklore, a brew of lemon leaves with certain tree barks into a strong tea serves to protect the drinker from malaria. I saw no harm in it and said yes to all. The lemon leaves are just an old wives’ tale, but there apparently are some bona fide anti-malarial properties to the tree bark – after all, quinine is derived from the bark of the cinchona tree, which was used as a similar remedy by the Quechua people of Peru and Bolivia.

Back in the olden days of Western colonialism, European outposts in Africa went no further than the coasts because those battalions which ventured any sizable distance inland were decimated by malaria. But present day Western neocolonialists like Peace Corps Volunteers can live and work in land-locked Mali only because over the past two centuries modern science has developed a number of dependably effective malaria prophylaxises which inhibit the reproduction of Plasmodia. I most likely have malaria Plasmodia in my bloodstream right now, but the fact that I took my prophylaxis contains their levels to such a minimal number that they can hardly reproduce - and one would not say that I "have malaria".

Even then, a lot PCVs still come down with malaria because the prophylaxis isn’t a cure-all. Even Mefloquine - the first choice prescription for all PCVs - is only effective 95 percent of the time. And every so often there have been Volunteers who intentionally don’t take their prophylaxis because they actually want to contract malaria in order to “fully experience” what it’s like to live as a Third World peasant – last year a Volunteer was brought comatose to the Dakar PC Medical Unit. Official policy states that a Volunteer found not taking their prescribed malaria prophylaxis gets “administratively separated” i.e. sent home.

Since I’ve been diligently sleeping in my mosquito net tent and taking my Mefloquine prophylaxis, I have yet to contract malaria. However, it must be noted that this particular malaria prophylaxis has some significant side effects. Night after night Mefloquine was giving me these extremely vivid, realistic, dark and violent nightmares; a recurring theme involved various permutations of hungry West African night adders, green mambas, crocodiles, musket-wielding cannibals and me armed with only a machete. To refer to these dreams as merely “nightmares” wouldn’t be doing them justice – Mefloquine dreams are so lifelike that it is rather difficult to differentiate between what has really happened in my waking life and what has only happened in my head, and so my memory would store them like actual life experiences and really fuck with my subconsciousness.

Once in the wee hours of the morning I dreamt that my next-door neighbor was chasing me through the woods shooting above my head and just barely missing – and by some luck I managed to ambush him, get a good swipe with my machete just above the shoulder and proceed to hack him to pieces. An hour later I woke up in a pool of sweat, and had hardly rubbed the gunk out of my eyes when I went out to fill my bucket at the water pump - and there my neighbor was, friendly as always, greeting “I ni sogoma!” I struck pallid with terror and curtly raced home without returning his greeting.

Generally speaking, the psychological side effects of Mefloquine were causing me to be become unfoundedly anxious, paranoid even. I could discern a profound change in my general personality - I was bugging out over things that never happened. My reaction to the cheap prophylaxis had gotten so bad that I was engaging in conversation with my cat. I explained these symptoms to my psychiatrist father, who diagnosed via Skype that my malaria prophylaxis was most likely throwing my neurochemistry out of whack; in extreme cases, Mefloquine has been known to trigger full-blow psychosis and manic behavior.

I explained these disturbing side-effects to Dr. Camara. As though I don't already have enough crazy shit to worry about in this country, I could do without the crazy shit that really isn't. For the same reason why they distribute oranges at Hampshire College's acid-soaked Halloween fete, I wanted to change my medication so that these macabre dreams would end.

The next drug of choice is Doxycyclin - which does just as good a job at curbing Plasmodia multiplication as Mefloquine, and falls in the same price range. But in a number of cases - such as my own - Doxycyclin causes whatever matter the user has consumed as their most recent meal to transform into a high-speed projectile.

The only other anti-malarial prophylaxis which the Peace Corps can prescribe is Malarone. Malarone inhibits Plasmodia just as much if not slightly better than Mefloquine or Doxycycline - only it does not carry the negative side effects. The only reason why Malarone isn't the first choice is that it's so prohibitively expensive at $8 per pill per day. It also causes vivid dreams, but they are for the most part wonderful lucid dreams. Now my slumber is full of flying over moutains and doggies and kitties and frolicking amidst blueberry bushes with long lost friends, and when I wake up I can peacefully engage in amateur Freudian analysis and personal introspection.

And I'm as safe as safe can be from malaria.

The same can't be said for everyone else in Sanadougou. There's no way that even the wealthiest people in this village could ever afford to pay $8 a day for top-of-the-line malaria prophylaxis, let alone lesser quality substitutes. The only economically feasible things that your average Malian can do to protect themselves from malaria would be to sleep under a mosquito net and continue drinking lemon leaf-tree bark tee - and most aren't even doing that.

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