So Torres, an Argentine immigrant who works in food service in the Chicago suburbs, launched his own investigation. Now, he is convinced that his son did indeed kill himself. But he blames Lariam, a drug taken by tourists, Peace Corps volunteers and troops to prevent malaria. An Army psychiatrists report also suggests the medication was a factor in Torres' suicide.

Controversy swirled around Lariam in 2004 after a UPI-CNN investigation linked it to the suicides of six Special Forces soldiers, including three murder-suicides at North Carolina's Fort Bragg in the summer of 2002.

... The Food and Drug Administration's Web site warns of anxiety, hallucinations and other side effects, and says: "Some patients taking Lariam think about killing themselves, and there have been rare reports of suicides. We do not know if Lariam was responsible for these suicides."

The Pentagon launched an investigation into the drug in 2004, but it is still regularly prescribed for troops in Afghanistan, Iraq and other regions.

Now, Torres, 53, is asking for congressional hearings and is demanding a moratorium on Lariam pending more investigation and stricter oversight of the drugs used by troops.

via Washington Post:  Family Blames Soldiers Suicide on Anti-Malaria Drug

Editor : J Langhorne

Publisher : Springer (2005)

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Kami akan segera mengirimkan pesanan anda ke email anda, setelah anda mentransfer biaya pengiriman ke no  rekening 0028890784 (Bank BNI) . Untuk  mempermudah kami dalam mengidentifikasi pesanan anda, kami anjurkan anda untuk mentransfer dalam jumlah yang unik, contohnya Rp. 50.300,-

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Salam

Edo

Following on the heels of the impromptu Malaria/DDT carnival earlier in the week, take a look at these posts:

• From My Garden - A Kiwi Gardener's Green Blog, a note that the bees have gone missing in New Zealand, too, and some conjecture on why.
• From :the flash advancer, an announcement of pending publication of a study showing links between pesticide exposure and neurological disease.
  

  This new research shows that farmers who used agricultural insecticides experienced increased neurological symptoms, even when they were no longer using the products. Data from 18,782 North Carolina and Iowa farmers linked use of insecticides, including organophosphates and organochlorines, to reports of reoccurring headaches, fatigue, insomnia, dizziness, nausea, hand tremors, numbness and other neurological symptoms. Some of the insecticides addressed by the study are still on the market, but some, including DDT, have been banned or restricted.

  These findings will be available online in April, and published in the June issue of Environmental Health Perspectives. The research is part of the ongoing Agricultural Health Study funded by the National Institute of Environmental Health Sciences and the National Cancer Institute, two of the National Institutes of Health, and the Environmental Protection Agency.

• From Dear Thyroid, a meditation on continuing remission of thyroid cancer.  The author wonders whether running through DDT sprays as a child contributed to the thyroid cancer.  Interesting thought -- thyroid cancers are almost common among downwind victims of the fallout from U.S. atmospheric atom bomb tests, but I am unaware of links to DDT.  I've asked the author for more information.
• From Sociolingo's Africa, the press release from Africa Fighting Malaria (AFM) complaining about European Union regulations of pesticides, claiming that such regulations make availability of pesticides difficult for malaria fighters in Africa.  AFM is Roger Tren's organization, Tren being one of the foremost frothers against Rachel Carson and rational restrictions on DDT use.  The petition seems to make no sense, other than offering an opportunity for a press release against environmentalists.  Again, I've asked the blogger for more details, if any.

Kind of like thinking about how the mortgage crisis will be a potential area for disenfranchisement due to the confusion of change of address as a voter.  Sorry, I still happen to think it's total bullshit that when "we" decided to overhaul the voting system in this country we just made it easier to rig and not easier for people to actually vote.

Today during the computer class a fourth grader walked up to me and said, "There's a dead mesquito by my keyboard" and I'm not sure where it came from, but I went with my gut response which was, "Well, for the love of god, don't eat it."  Sometimes you say shit like that and kids realize it's a joke and other times you get responses akin to, "that's a good point, I shouldn't eat that."  Either way, it's sometimes shocking that I still have a job.

Good thing I keep quinine next to my sharpened number two pencils.

In 2000 the noted lateral thinker Edward de Bono advised the U.K Foreign Office committee that the Arab-Israeli conflict might be due, in part, to low levels of zinc found in people who eat unleavened bread, known side-effect of which is aggression. He suggested shipping out jars of Marmite to compensate.

In a New Year's Eve episode of Mr. Bean, the titular character serves "Twiglets" (Marmite-flavoured pretzel-like snacks) to his friends. These "snacks", however, are actually twigs taken from a tree outside Bean's window and dipped in Marmite.

In August 2006 as part of the launch of squeezy marmite celebrity chef Gary Rhodes created a dessert consisting of Coffee Ice Cream topped with Chocolate Sauce with a dash of marmite. It was served for one week only in his London restaurant — since this it has been reported that a handful of ice cream bars in some parts of the UK are now offering this topping. (One that does is close to the Marmite factory in Burton-On-Trent).

Some suggest that the consumption of Marmite can ward off mosquitos, the reasoning being that the skin gives off a scent, unnoticeable to humans, but which mosquitoes find unappealing, or that the vitamin B content wards off the flying pests. British travelers to tropical locations sometimes take Marmite with them to eat during the trip, although it has been shown that the B vitamin complex does not repel mosquitoes. The root of this belief might have been its use during the 1934–5 Malaria Epidemic in Sri Lanka:

“ The two things given to each patient were a bottle of the standard quinine mixture and Marmite rolled into the form of vederala's pills. The latter was said to have been the idea of the late Dr. Mary Ratnam and to have been more effective than the quinine itself, such was the degree of starvation among the peasantry. The Suriya Mal workers were amazed to see how this little Marmite revived them and put some life back into them. ”
—George Jan Lerski, [1]
 

Despite its strong and acquired taste, it is reported to be a very common staple amongst British sufferers of SED.

Paddington Bear features in the Marmite UK TV advertisement (broadcast on 13 September 2007); in which he tries a Marmite and cheese sandwich instead of his traditional marmalade sandwich.

For many years NZ Marmite containers had an advisory on the back label saying "Too much spoils the flavour".

In the 1996 film, The English Patient, Katherine Clifton (played by Kristin Scott Thomas) includes Marmite among her favourite things: "Water—fish in it—and hedgehogs—I love hedgehogs. Marmite—I'm addicted, and baths, but not with other people! Islands—and your handwriting. I could go on all day."

In The Vicar of Dibley, Letitia Cropley serves a Marmite cake on Frank's birthday.

In T.C. Boyle's short-story "The Miracle at Ballinspittle" Nuala Nolan eats nothing but Marmite and soda-water as part of a Lenten fast.

And Pontrhydfendigaid Primary School in Cardiganshire banned it!

Principais Substâncias: Cucurbitina

Nome Cientifico: Citrullus lanatus

Utilidades: Serve como hipotensora, abaixa a pressão. Produz efeitos magníficos contra doenças renais e febre intestinal. Usa-se também em Ácido Úrico, Alergia, Anúria, Arroto, Artrite, Azia, Ascite ou Barriga Dagua, Bexiga, Cálculos, Cirrose, Erisipela, Gonorréia, Gota, Herpes, Hiperstensão, Impotência, Malária, Menorragia ou Fluxo Menstrual Excessiva, Obseidade, Reumatismo, Urétra.

Forma de Uso: Sucos, saladas, cremes e sorvetes, tinturas.

Fotos:

9/10/2008  CIENCIA

Revelado el genoma del parásito de la 'malaria olvidada'

Descargar ( revelado-el-genoma-del-parasito-de-la-malaria-olvidada.pdf  )

1. • El 'Plasmodium vivax' afecta a 300 millones de personas al año aunque no es mortal

MÁS INFORMACIÓN

• El desarrollo de una proteína fluorescente se lleva un Nobel

OCTAVI PLANELLS
BARCELONA

El genoma de otro ser vivo ha quedado al descubierto. Se trata del Plasmodium vivax, un parásito que causa una variante de malaria menos virulenta que la que origina el Plasmodium falciparum. Pese a no ser mortal, la infección por este organismo afecta cada año a unos 300 millones de personas y, además de los problemas de salud que ello conlleva, constituye un importante sumidero económico en países como Papúa-Nueva Guinea, la India y Brasil. Por ello, los expertos definen al parásito como "el gran olvidado". En el trabajo, publicado hoy en la revista Nature, han participado Hernando del Portillo y Carmen Fernández-Becerra, del Centre d'Investigació en Salut Internacional de Barcelona (CRESIB).
Los expertos saben ahora que el Plasmodium vivax posee unos 5.500 genes, pero aún desconocen la función de la mitad. "Esperábamos hallar más diferencias entre ambas especies", confesó ayer Del Portillo. Las disparidades genéticas reflejan los distintos mecanismos de infección de los dos parásitos. El Plasmodium falciparum pasa a la sangre tras penetrar en el hígado. En cambio, según Del Portillo, "el Plasmodium vivax permanece latente en el órgano durante días, meses o incluso años". Es al retomar su actividad cuando causa los problemas de recaídas clínicas.

MÁS FONDOS
Entre otros objetivos, los científicos andan ahora tras la búsqueda de dianas con las que diseñar nuevos fármacos. Aunque también esperan encontrar más fondos para que su trabajo no esté limitado. "Por ahora estamos haciendo un copy y paste de los trabajos realizados con el parásito más virulento", explicó Del Portillo. "Tenemos que innovar --añadió el científico--, y para ello debemos disponer de una buena financiación".

Full Prescription: Better Malaria Treatment for More People, MSF's Experience

Zopas echter stuurde iemand me een bericht uit Senegal met volgende mededelling : "Dé behandeling is volgens de who handleiding gewoon vier keer per jaar een curatieve behandeling volgen met malarone, of je nu ziek bent of niet, zo dood je alle parasieten en slik je minder pillen dan continu preventief vooral met kleine kinderen is het onverantwoord om te wachten tot de aanval komt." .

Conclusie : sowieso preventief Malarone voor de hele familie en dan een nieuwe kuur binnen drie maand.

Toch is het wellicht raadzaam nog eens te informeren bij prof. Van Gompel van het ITG, de nummer 1 zoals collega's hem noemen. Met die man spreken is immers altijd een feest voor het oor.

Een twee factor van verwarring : er is een nieuwmalariamedicijn op de markt:

Eenvoudig in gebruik, goedkoop en niet gepatenteerd

© AZG

ASAQ is een nieuwe geneesmiddel tegen paludisme. Het is eenvoudig in gebruik, goedkoop en niet beschermd door een patent. Het bevat in één enkele tablet artesunaat en amodiaquine. Deze behandeling is het resultaat van onderzoek dat werd gevoerd in partnership tussen DNDi (Drugs for Neglected Diseases initiative) en Sanofi-Aventis. Het toont aan dat een nieuw geneesmiddel rechtstreeks in het openbare domein kan worden gebracht voor een zo ruim mogelijke toegang in arme landen.

zie ook : de site van Artsen zonder Grenzen (AZG)

This Week's Topics: Malaria, Obesity, Mediterranean Diet, and Abortion

Complied By Danielle Alvarez, beat blogger

Malaria

On Wednesday, Sept. 24th, the United Nations held a meeting on the Millennium Development Goals. One important topic on the agenda was a discussion on the world’s fight against the blight of malaria in Africa. The disease continues to kill nearly 3,000 children each day. It seems unlikely; we have nearly wiped out Malaria in our own country with existing technologies and anti-malarial drugs. Unfortunately for many people in Africa, even a simple mosquito net that would  significantly reduce the rapid spread of the disease is out of reach. You can help. There are many organizations working together to defeat malaria. Click here for one in New York. With just $10 you can make a difference.

Obesity

Obesity is a well-known and widespread problem in the United States; over 74% of people ages 15 and up, are considered overweight. But this isn’t only a problem in the U.S., nearly half of our neighbors in Mexico have growing waistlines, and the rate of diseases that have been associated with obesity continues to rise. Vamos Por Un Million de Kilos (or Let’s Lose a Million Kilos) is the country’s new program to help the Mexican citizens become healthier and lose the excess weight. According to USA Today, it is the rise of the middle class and the cheaper caloric-Mexican food that has led to the country’s devastating weight gain. Through government-funded education, new and improved fitness facilities, and an encouraging campaign for the consumption of more fruits and vegetables they hope to “nip this sucker in the butt” before it gets out of hand. Hopefully the U.S. will use Mexico as an example in our  own weight loss initiatives.

The Mediterranean Diet

The Mediterranean diet that has  been applauded for contributing to longer life spans and happy hearts is on the decline… in the last place you’d guess: the Mediterranean. A daily regimen focused on a high intake of nuts, fruits, vegetables, and olives seems to have lost its popularity. Unfortunately, the replacement diet is not nearly as healthy and features processed foods and fast-food chains. This change is especially apparent in children,  who are now a whopping two-thirds are overweight. Health experts and leaders are frantically trying to save their nutritional traditions, an aspect they consider an “intangible piece of cultural heritage.” You too can make the effort in a few easy steps provided by Mayo Clinic:

Eat a generous amount of fruits and vegetables

Consume healthy fats such as olive oil and canola oil

Eat small portions of nuts

Drink red wine, in moderation, for some

Consume very little red meat

Eat fish on a regular basis

Abortion

American women have long since had the right to have abortions despite threats of restriction since the 1820. A new anti-abortion movement, however, has moved to Russia, as the debate continues. The use of contraceptives remains unpopular as many Russian women continue to rely on abortion as their method birth control. As a result, led by the government, the discussion has evolved into that of a moral issue for a country that claims to have of world’s highest abortion rights. What’s your stance on the issue?

Danielle Alvarez is a junior magazine journalism and modern foreign language dual major. She has previously interned at Cookie magazine in the summer of 2008 and has been spending this past year stuyding abroad. She is in Santiago, Chile after being Cuenca, Ecuador this summer and plans to end her world travel in Strasbourg, France next Spring. Look out for her global health news alerts every Wednesday from "Around the World."

Her e-mail is dealvare@syr.edu.

My news searches today turned up a number of items of interest in DDT and fighting malaria -- enough to merit another summary post, IMHO.  Here goes.

First, Tim Lambert at Deltoid sets straight the history of the policy of the World Health Organization (WHO) with regard to DDT use, and whether WHO caved in to pressures from environmentalists to completely ban DDT, as Roger Bate had earlier, erroneously said.  Tim has a number of well-researched, well-reasoned posts on DDT and health; people researching the issue should be sure to visit the archives of his blog.  But for today, make sure you read "Roger Bates' false history."

This Friday the Hawk Mountain Sanctuary presents an award to Tom Cade, the Boise, Idaho guy credited with doing much to save the endangered peregrine falcon. You can read about it in the Allentown, Pennsylvania, Morning Call.

Cade played a major role in reviving the nearly extinct peregrine falcon in the 1970s. As a graduate student, he studied how a pesticide contributed to their sharp population decline. He eventually founded a conservation group, The Peregrine Fund, which reintroduced captivity-bred birds to the wild.

. . . The falcon's revival is widely considered one of the most successful recoveries of an endangered species. The species teetered on the brink of extinction in 1970, when as few as 39 known pairs of nesting falcons existed. A 2003 survey puts the number of nesting pairs at more than 3,100.

On Thursday Cade will receive the Sarkis Acopian Award for Distinguished Achievement in Raptor Conservation.  According to The Morning Call, "The award is given infrequently by Hawk Mountain officials and is named after the Kempton-area bird sanctuary's primary benefactor, a late philanthropist who studied engineering at Lafayette College."

Also, see this story about the recovery of peregrines in Canada, from the Sudbury Star.

Bug Girl tells the story of a new documentary on the Michigan State University professor who documented the deaths of songbirds made famous in Rachel Carson's book, Silent Spring. Dr. George J. Wallace's work became the subject of an article in Environmental Journalism in 2005.  Students and faculty at MSU's Knight Center for Environmental Journalism produced the movie, "Dying to Be Heard."  Be sure to check out the comments at Bug Girl, for more information.

International health care expert César Chelala argues that the "War Against Malaria Can Be Won, Without DDT" at the on-line Epoch Times. Chelala reports on a project in Mexico -- where DDT use has never stopped since 1946 -- a project now extended to other places in Central America, demonstrating that the tried and true methods of preventing mosquitoes from breeding and avoiding contact work well to fight malaria.  Plus, he says, it's cheaper than using DDT.  Doubt that it could work?  Chelala points out that the Panama Canal could not be dug without controlling mosquito-borne illnesses, and the Canal was opened in 1914, 25 years before DDT was demonstrated to be deadly to insects, more than 30 years before widespread deployment of DDT.

Early detection and treatment is critical to eliminate the parasite carriers. An important aspect of this project has been the collaboration of voluntary community health workers who are taught to make an early diagnosis in situ and to administer complete courses of treatment not only to those affected but also to the patients’ immediate contacts.

The project was carried out in specific pilot areas called “demonstration areas” which had been selected due to their high levels of malaria transmission. In those areas, the number of malaria cases fell 63% from 2004 to 2007. In several demonstration areas I visited in Honduras and Mexico as a consultant for the Pan American Health Organization malaria had practically been eliminated. Plans are underway to expand the project to other regions where malaria remains a serious threat.

One of the advantages of not using DDT (besides avoiding its toxic effects) is the enormous savings realized from discontinuing its routine use. These savings can now be put to good use with other diseases.

You might also want to view Chelala's description of solutions for public health crises in Africa, at The Globalist.

Chelala's cool, clear and accurate reporting sadly contrasts with the hysteric and wrong reporting at Newsbusters and other polemical outlets on the web, seemingly bent on perpetration of the hoax that DDT is harmless and Rachel Carson was wrong.

Liz Rothchild's one-woman play about Rachel Carson, "Another Kind of Silence," got good reviews upon opening at the Warehouse Theatre, in Croydon, England.

Meanwhile, from Uganda comes news that DDT spraying failed to reduce malaria in spraying done in that nation. Proponents expected a sharp and steep decline in malaria, but numbers are not greatly reduced.  Even after taking account for the legal difficulties of spraying, after conservative businessmen sought an injunction to stop DDT use, the results do not speak well for DDT's effectiveness.

Contrary to expectations, data collected by health departments in Apac and Oyam districts, which record the highest malaria incidence in the world, do not reflect significant improvements since DDT spraying ended prematurely. From May to July 2008, which is the period immediately following the spraying, between 400 and 600 clinical malaria cases per 100,000 of the population were reported per week in Oyam; and 600 to 800 such cases in Apac for the same period. These are almost exactly the same as the number of cases reported between January and April 2008.

Getting news out of Africa is not always easy.  Reading reports from Ugandan papers, it becomes clear that reporting standards differ greatly from the U.S. to Uganda.  Still, the saga from Uganda demonstrates that DDT is no panacea.  Uganda is a nation that had not used DDT extensively prior to the mid-1960s.  Resistance to use now comes from tobacco and cotton interests who speciously claim that potential DDT contamination of crops would result in the European Union banning vital Ugandan exports.  The legal issues all alone assume Shakespearean tragedy dimensions.  Or, perhaps more accurately, we could call the story Kafkaesque.

See also:

• "Bukenya roots for indoor spraying" (Uganda's vice president)
• "Uganda, UK in joint anti-malaria campaign"
• "Government must focus on malaria prevention" (editorial)
• "Will DDT save northern Uganda," from Ethiopian Review

Happily, we have evidence that younger people show concern about DDT pollution, in a story about the stuff in Teen Ink magazine.

A study in the UK finds DDT present in colostrum, the vital pre-milk substance newly-lactating mothers create for their babies, as well as in later breast milk.

Bed bugs continue their own surge on Americans, and knee-jerk writers editorialize for the return of DDT, completely unaware that bed bugs are among those critters most resistant to DDT, and unaware that there are other, more effective solutions.

James McWilliams writes in The Texas Observer that most of us are ecological illiterates, which makes control of pollution more difficult, in a review of a new book, The Gulf Stream. Canny readers will recognize McWilliams as the author of the recently-published book, American Pests: Our Losing War on Insects from Colonial Times to DDT.

• The Gulf Stream: Tiny Plankton, Giant Bluefish, and the Amazing Story of the Powerful River in the Atlantic; by Stan Ulanski, University of North Carolina Press, 232 pages, $28.00

Sandra Steingraber will lecture on November 11 in Philadelphia on "The Many Faces of DDT," part of a series of lectures sponsored by the Chemical Heritage Foundation, "Molecules That Matter."  Steingraber is the author of Living Downstream:  An ecologist looks at cancer and the environment.

Canada's Leader-Post reports that Chinese food processors have been caught using DDT in food to reduce insect infestations.  The cycle starts all over again.

Time for this carnival's midway to shut down for the night.  Don't let the bed bugs bite.

After purchasing over 300 € (£230) worth of medication, I feel ready to leave. Also because I can't afford anymore expenses... This week I bought a travel towel that dries super quickly, a thin-but -warm fleece, long light cotton trousers that unzip into shorts, and my malarial tablets. I have been pondering whether to get some, but my super cool doctor decided for me. He says it's worth the money, especially in the Northern parts of Thailand at the end of the wet season (October). I couldn't agree more.

Here is now the official list of the contents of my backpack. I will keep you updated on what I use, send back, regret packing or obviously forgot. I have visited a lot of blogs, websites and forums over the last few months, to see what others were packing, so my list is now added to the mumble-jumble of the web and I hope it can help others planning trips like mine.

- 1 pair of jeans (old and rugged, ready to be left somewhere - I am told they can be annoying as they don't dry fast enough! I love my jeans, so I'll just see how it goes and dump them somewhere if not practical),
- 1 pair of light cotton trousers (that double up into shorts and make me look like an 1920s explorer)
- 1 fleece (for the flight, because it's always freezing on planes and I don't want to be cold during the night in Northern Thailand)
- 2 tshirts, 2 vest tops, 1 long-sleeved tshirt,
- 1 pair of shorts (for sleeping or sports),
- Enough underwear,
- Shoes: hiking, bright yellow trainers (yep, they're coming with me), plastic flip-flops (that I can shower with if necessary),
- 1 pair of long-haul flight support tights (actually, still debating whether they're worth the hassle. I actually won't be flying all that much, and they'll just end up being bulky. My vein-doctor says they are also handy during long bus, train or car rides),
- the oldest bikini in the world (desperately need to get a new one, after mine got badly discolorated due to an overenthusiastic pool owner scared of a potential algal bloom in his beloved swimming puddle),
- First Aid Kit (with anti-malarial for 2 months (approximately worth an arm and a leg), anti-diarrhoeal medication - for Dehli Belly and its local equivalent -, anti-constipation (for the extreme rice intake), antispamodics, antibiotics, mosquitoe repellent, motion sickness medication and everything needed for small cuts, bleeds and scratches)
- Toiletries: travel towel, toothbrush (with cover, thanks for the tip Harry), toothpaste, comb, mooncup, soap, small bottle shampoo (because I won't need much), razor, Nivea all-over moisturizer (to smell like my Grandma), nail scissors, tweezers, earplugs,
- Random: photocopies of travel documents (actually it's all electronic, so can't lose them!), passport, driving license, CV (plus electronic copy of the above sent to myself by email), ziploc bags of varying sizes, small pocket knife, toothpicks, duct tape, charger for camera, digital alarm clock, ipod USB charger, 2 blank DVDs for burning photos, combination lock,
- Bolivian handbag my brother got me from his travels (actually a camera bag in disguise) with SLR camera and its protective scarf, change purse, ipod full of great music with new sturdy headphones,
- money belt: passport, cash, credit cards, SD cards.

So I think I'm ready. I haven't packed my trusted backpack yet, but it doesn't look like much when spread out on my bed at my parents' house. Hopefully it should weigh less than 10kg, and ideally about 8kg. I had gone to India with 7kg at the beginning of the year, but I don't think I'll manage to beat that.

For now, I just need to make sure I get some sleep tonight, and play it cool, real cool.

DATE AND VENUE
Date  : Friday – Saturday : 21st and 22nd November 2008
Place : Horison Hotel, Bandung

THEMES (SEE TENTATIVE SCHEDULE FOR DETAIL INFORMATION)
1. Health promotion and HIV-prevention
2. Clinical presentation and treatment of HIV/AIDS
3. Tuberculosis and HIV
4. HIV-services in prison, methadone services and community
5. Occupational risks related to HIV/AIDS
6. Economic and public health aspects of HIV
7. Sexually transmitted diseases; prevention and care
8. Dengue fever update on new diagnostics and management
9. Avian influenza
10. Bacterial sepsis
11. Fungal infections
12. Malaria management update

Speakers from:
1. Medical Faculty Universitas Padjadjaran, Hassan Sadikin Hospital
2. Universitas Padjadjaran, Hasan Sadikin Hospital
3. University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta
4. University of Nijmegen, Netherlands
5. University of Maastricht, Belgium
7. IMPACT - (Integrated Prevention, Control and Treatment of HIV/AIDS West-Java)
8. Litnagkes Depkes RI/ US.Neval Medical Research Unit II
9. Komite Penanggulangan AIDS Nasional & Provinsi Jawa Barat
10. SEA-ICRN (South East Asia - Influenza Clinical Reserch Network)
11. Ministry of Heath

CONTACT DETAILS
Contact person : Nonon Saribanon, Siti Wulandari
Telephone         : 022-2037893, 022-70820078
Fax                    : 022-2037893
Email                 : bandungideas@yahoo.com
web site             : http://www.bandungideas.co.cc
Address              : Tropical Infectious Disease Unit
                             Departement of Internal Medicine, Faculty of Medicine,
                             Padjadjaran University, Hasan Sadikin Hospital
                             Jl. Pasirkaliki 190 Bandung

REGISTRATION FEE
                               Before 1 Nov 2008       After 1 Nov 2008
Specialist                  :  Rp. 600.000,-                Rp. 700.000,-
General Practitioners : Rp. 400.000,-                 Rp. 500.000,-

Transfer to:
Bank Mandiri KCP Bdg RS. Hasan Sadikin
a.n. Primal Sudjana, dr (Kas)
No. Rekening : 132.000007161.4

Download Invitation and SCHEDULE here

What a shame that millions are afflicted by malaria when all that is required is the use of a mosquito net to keep the bloody insects at bay.  Nobody has taught or had to teach this roadside vendor this elementary message.

Mosquito mats and other creams have been found to be harmful in the long term.  And a recent study found that the mosquito repellants are no longer effective.  

WHO has been spending millions of dollars for providing inseticide impregnated nets mainly in Africa.  And it has been shown that when used properly and every day, it can drastically cut the number of malaria cases.

In 1973 the use of DDT was banned in the USA mainly, I think, because of its supposed harmful effects on birds, especially the Bald Eagle. I have not researched the scientific evidence on this matter, but there is one fact I do know. In the early 1970s there were less than 30 nesting pairs of Bald Eagles in Oregon, and now there are around 500. This is a fantastic story of recovery. Was the banning of DDT an integral part of this recovery? Many think so. And there are those out there that think not.

It could be that DDT has the potential to control and might eradicate malaria. The Bill and Melinda Gates Foundation has committed large amounts of funds to develop drugs and other things to control malaria. Maybe they should fund a new study on DDT to once and for all find its scientific properties, good and bad.



In a related matter, the Pine River Superfund Site in St. Louis, Michigan, is a location where DDT and other chemicals were manufactured. The Velsicol Chemical plant on the Pine River (formerly called Michigan Chemical) is in the process of being cleaned up. Like many superfund sites, the extreme pollution took many years to accumulate.

In the picture the former plant is in the left center. Across the river, to the north, are cofferdams that have been put in place so the bottom of the river can be accessed and dirt removed. That’s were there is lots of contaminated soil.

Here is a link to one of the many web sites on this superfund location.

In many ways the book is not closed on DDT. And as a final note, I can’t help but offer another link. This one of some Junk Journalism from Fox News. Here’s the link. The header is “Junk Science, Rethinking DDT.” The issue will not be settled by the junk that comes from Fox News. It can be settled by a modern scientific study. Malaria is such a widespread disease that we should give it our best effort to bring it under control.

The BBC, though, is not bound by such a ruling and continues to pump out the untruths that have been so thoroughly discredited. Now climate change propaganda has found its way into history articles. Not content with governments and the media disseminating propaganda to manipulate and control the future, we have to suffer the distortion of the past as well. In this month's BBC History magazine there is an article about 'the scientists who predicted climate change'. This is a very topical issue, and could have been a very interesting article had it not come off the rails and become a train wreck in the first few lines.

We are to understand that the article was penned by Dr Paul Parsons,

a former editor of award-winning science and technology magazine Focus. His latest bookThe Science of Doctor Who, was long-listed for the 2007 Royal Society Prize for Science Books

We're not told that Parsons is a BBC journalist, or that the magazine Focus, of which he was editor, is a BBC publication that heavily promoted his book in 2006, and no doubt made him plenty of dosh into the bargain. Parsons has a DPhil in cosmology, and is the author of the BBC book 'The Big Bang: The Birth of our Universe'. That great bastion of bigoted atheism, the Royal Society, describes Parsons as 'a lifelong worshipper of Doctor Who', and he is hailed by the BBC as an 'expert' on Doctor Who (a science fiction television programme). In my judgment, he's too far into the fiction to be able to determine what is truth from a scientific perspective.

In his article in the BBC History magazine, he has barely got started when he comes out with this howler:

Climatologists now warn that extreme weather events...are set to get ever more common as we start to feel the effects of global climate change.

There are other signs too...Malaria has been reported in Nairobi, Kenya, as the city's high altitude becomes warm enough for mosquitoes carrying the disease to survive there.

It seems that Parsons has lifted this straight out of Gore's An Inconvenient Truth, a piece of propaganda worthy of the Third Reich. Don't tell a fib, because no-one will believe you. Tell a whopper because no-one would believe that anyone would lie to that extent, so the lie will prevail. Such was Goebbels' doctrine.

Anyone reading this text by Parsons would (because they are being told this by a scientist) be expected to believe that 1) malaria was not known in Nairobi before, 2) Nairobi's climate is warming, 3) malaria is related to warm climate, and 4) this is a sign of climate change.

All four propositions are false. No true scientist could possibly believe this rubbish, but as the Nazi propagandist wrote,

It is not propaganda's task to be intelligent, its task is to lead to success.

Yet even in 2001, that political body, the Intergovernmental Panel on Climate Change (IPCC), stated

there are insufficient historical data on malaria distribution and activity to determine the role of warming, if any, in the recent resurgence of malaria in the highlands of Kenya... (emphasis mine)

Perhaps the most detailed relevant study was by Small, Goetz and Hay published in 2003 in the Proceedings of the National Academy of Sciences, Climatic suitability for malaria transmission in Africa, 1911-1995, which stated

The majority of areas with variable transmission potential showed no evidence of trends in climatic suitability...Climate warming, expressed as a systematic temperature increase over the 85-year period, does not appear to be responsible for an increase in malaria suitability over any region of Africa...These results suggest research on the links between climate change and the recent resurgence of malaria across Africa would best be served through...closer examination of the role of nonclimatic influences, such as the rise of drug resistance.

One of the world's leading experts in malaria, Paul Reiter at the Pasteur Institute, sums up the evidence against Gore's claim

Gore's claim is deceitful on four counts. Nairobi was dangerously infested when it was founded; it was founded for a railway, not for health reasons; it is now fairly clear of malaria; and it has not become warmer.

What has been seen in East Africa is a resurgence of malaria. Under British colonial rule, action was taken against malaria - draining swamps, destroying breeding grounds and spraying with pyrethrins, DDT and malathion, anti-malarial city planning etc. This is all documented in the literature:

Diary of an African Journey, 1914 by Henry Rider Haggard:

Typhoid is rife (there is no drainage in Nairobi) and notwithstanding the altitude there is a good deal of malaria...

A City of Farmers: Informal Urban Agriculture in the Open Spaces of Nairobi, Kenya by Donald B. Freeman, describing the situation in the 1920s:

Further tracts of open apace in the city were provided by the vigorous anti-malarial activities of the colonial administration. Twelve foot minimum-width way-leaves along the banks of all streams and drainage lines were left free of buildings to permit spraying of mosquito larvae and clearing of dense brush that harboured adult mosquitoes. The Nairobi swamp and other low-lying areas were drained and canalized.

Bulletin of Hygiene, 1926:

Nairobi was divided into 18 areas in each of which the breeding of mosquitoes were mapped, together with notes of the varieties taken.

Diseases of the Tropics, by George Cheever Shattuck, 1951:

Autochthonous falcaparum malaria is common in Nairobi (Kenya) where it is transmitted by A. gambiae at altitudes up to 5700 feet (1900 metres)

International Nursing Review, 1969

A little over 20 years ago plague was well-known in Nairobi, and malaria was prevalent.

Paul Reiter has an interesting note:

My colleagues have looked carefully at climate and malaria records kept by the management staff of nearby highland tea estates, and published their findings in Nature.

They found no evidence of long-term climatic change and noted that epidemics of malaria were frequent until the 1950s, when DDT appeared. Malaria's return in the past 20 years has been due to many factors - the effective ban on DDT, deforestation, migration from highly malarious areas, drug and insecticide resistance and above all, poverty.

Enough. We have demonstrated that Al Gore's assertions about malaria in An Inconvenient Truth are pure deception. But Gore is a politician and not a scientist. Shame on Paul Parsons, a scientist, who is embracing, repeating and propagating such fantasies.

Etter mer enn en uke med høy feber av ukjent årsak (eller FUÅ som jeg husker det stod på et kompendium vi fikk en gang) valgte den smågale legen fra Ukraina med skumle isblå øyne å sende meg på sykehus. Søster (I Uganda er jo fremdeles sykepleiere sykesøstere og blir kun kalt søster) var helt enig, og spurte meg om jeg var forkjølet siden det rant fra nesen min. Det var jeg jo ikke, kun fullstendig motløs over at det jeg trodde skulle bli et spennende opphold og en engasjerende jobb var blitt redusert til febertåke og nå også innleggelse. Fjorårets lille opphold på Haukeland sykehus spøkte i bakhodet mitt, og jeg visste ikke hva jeg skulle forvente av et sykehus i Kampala. ”Dette er et av Kampalas beste sykehus” sa legen, og forsikret meg om at på dette sykehuset kom legen veldig fort, i motsetning til det andre av de gode sykehusene, der man visstnok kunne risikere å vente lenge på legen. Jeg tenkte en liten tanke på alle pasientene mine som måtte vente i timesvis da jeg var turnuslege alene på vkat, og tenkte at ventingen var vel ikke viktigst, men heller teknologi og kunnskap.

Og da jeg kom til hospitalet, som var nabo til boligen til den norske ambassadøren, måtte jeg faktisk ikke vente så lenge. Men i den lille tiden jeg rakk å vente, fikk jeg med meg at en ”søster” foretok en blodtrykkskontroll av en pasient – inne på undersøkelsesrommet der jeg ventet! Ikke mye taushetsplikt og konfidensialitet, akkurat. Og da legen kom målte han blodtrykket mitt også, i tillegg til temperaturen, men ingenting annet. Så ble jeg sendt på rommet med beskjed om at overlegen skulle komme snart.

Dette må være første, og sannsynligvis blir det eneste, gang jeg har bodd på VIP-rom. Men det var faktisk det de kalte det. VIP-rommet var et enerom, men med to senger i tillegg til et nattbord. Jeg hadde et eget bittelite bad, og utgang til en slags liten balkong. Jeg landet på den ene sengen, og syns livet var ganske kjipt. Vet ikke hvor lenge jeg lå der, og siden ingen kom inn var det ingen å spørre om hva som skulle skje. At den ene bryteren på veggen egentlig var en ringeklokke med en sinnsyk lyd fant jeg først ut av senere.

Overlegen kom til slutt. Han virket ganske oppegående og undersøkte meg litt mer enn den forrige legen. Men utrolig nok satte ingen et stetoskop over hjerte og lunger under hele oppholdet. Det ble tatt blodprøver og en ultralyd. Utpå ettermiddagen kom overlegen og forklarte at de ikke kunne utelukke malaria, og at det var for farlig å vente med behandling i tilfelle det skulle være malaria. Så han ville gi meg kinin. Jeg var for sliten, oppgitt og lei til å i det hele tatt tvile på hans vurdering.

I mange afrikanske land er dette et greit regnestykke:

Feber = malaria, inntil det motsatte er bevist

At det var så å si umulig at jeg kunne ha malaria ble ikke tatt med i regnestykket. Så etter at to søstre hadde strevd med å sette veneflon, tape den grundig fast og få intravenøst-settet til å passe sammen i nesten en time, satt jeg med kinin intravenøst og gulvet hadde flekker med både blod og kinin. Ingen informasjon om bivirkninger eller at bivirkningene ville være mildere hvis jeg fikk i meg godt med væske. Ingen væske intravenøst, og jeg fikk ikke

Utover dagen strømmet det på med besøk. Bekymrete kollegaer kom med vann, mat, blader, vifte, bøker, sjokolade og alt mulig. Jeg hadde mitt første møte med sjefen min, som hadde vært bortreist, iført pysjamasbukse, en t-skjorte med en geit på, tannkosten i munnen og et kinindrypp i armen. Håret var fett og jeg luktet sikkert vondt. Lenket som jeg var til kinin-helvetet hadde jeg jo ikke fått dusjet. Men en geskjeftig sjef på besøk er alltid greit. Hun fikk laben til å ta flere prøver og en dame fra den norske ambassaden var plutselig på plass.

Feberen gikk ned, og da kininen endelig var ferdig følte jeg meg bedre enn på lenge. Jeg begynte å komme mer til meg selv, og etter lange diskusjoner med legekollegaer var jeg jo selv helt overbevist om at jeg ikke kunne ha malaria.

De av dere som har lest bloggen fast vet at jeg fikk rett. Da jeg møtte til kontroll noen dager senere var jeg feberfri da jeg slengte nye prøvesvar foran ham og sa: ”Nå har jeg stilt min egen diagnose, og det var ikke malaria”. At overlegen på et av Kampalas beste sykehus ikke ville stilt riktig diagnose fikk jeg bekreftet da han så prøvesvarene mine. Han syns det var så eksotisk og uvanlig at han ville skrive en kasuistikk til et lokalt legetidsskrift.

Sånn. Det var det som egentlig skjedde på hospitalet. Men for å ikke gjøre denne teksten for lang har jeg utelatt en del komiske episoder. De får komme i de neste episodene. Som den interaktive bloggen dette jo er, kan interesserte lesere få velge mellom følgende temaer:

- måltidsritualer for VIP-gjester

- hvordan få tak i en sykepleier?

- hvor mye sykebesøk kan man få etter en uke i Uganda?

- kleskode på hospitalet

Do Rwandy przyjechałem z pewnym nastawieniem co tu mogę spotkać, które bardzo szybko zostało zweryfikowane. Wdziałem jednak w Waszych komentarzach, że także macie jakiś swój obraz tego kraju.

Co więcej kilka rzeczy, które wymyśliłem sobie po przyjechaniu też już w ciągu dwóch miesięcy się zmieniło. Wyprostujmy więc nieco obraz tego kraju.

Komary i malaria wiszą w powietrzu

Tak to mnie więcej wyobrażałem sobie przed przyjazdem. Chmary komarów, leżący na ulicach ludzie dogorywający na malarię (jak opisywał to Kapuściński), zwłaszcza, że Rwanda jest jednym z krajów najbardziej zagrożonych pod tym względem. Nikt nie wychodzi o „szarej" godzinie z domu i każdy nad łóżkiem ma moskitierę.

To najbardziej pozytywne rozczarowanie chyba :) Komary widuję w liczbie jednej sztuki na kilka dni. Ponoć w czasie pory deszczowej powinno być ich zatrzęsienie, ale od kiedy się zaczęła, nic się nie zmieniło.

Miałem zamiar ze strachu stosować wieloliniową obronę przed malarią: pryskanie się repelentami, zażywanie codziennie malarone, spanie pod moskitierą i siatki ochronne w oknach.

Siatki mam (nieco dziurawe, ale znośne), biorę też malarone. Pod moskitierą spałem tylko w hostelu przez dwa pierwsze dni i potem w szpitalu. W domu jej nie mam.

Pierwszego dnia całkowicie spryskałem się repelentem, a później przez dwa tygodnie, tylko jak słyszałem brzęczenie komara w pokoju. Teraz jak słysze brzęczenie co najwyżej nakrywam się szczelniej kołdrą i zasypiam.

Paul mówi, że na malarię choruje średnio raz na dwa lata i mówi, że to straszne cholerstwo, którego nikomu nie życzy. Innocent mówi, że nigdy nie chorował.

Jestem jedynym białym w całym Nyamata

Też nieprawda, ale już o tym pisałem :) Na początku miałem takie wrażenie, ale do dziś poznałem już bardzo dużo ludzi z całego świata, a często widze też i białych nieznajomych. Wszyscy tu są z pomocą rozwojową podobnie jak ja.

Jestem spalony na raka

Jeden raz mnie lekko piekła skóra jak poszedłem na dłuższy spacer. Jest słonecznie, ale jakoś udaje mi się uniknąć poparzeń. Jak pisałem chmury tworzą tu coś w rodzaju filtra przeciwsłonecznego, przez co jest jasno, ale nie upalnie (ale bywają i dni bz chmur). Bardzo mnie zdziwiło odczucie termiczne. Któregoś dnia gdy zakładałem, że jest idealna temperatura 21 stopni, wszedłem na stronę z prognozą pogody i bardzo się zdziwiłem widząc, że brakuje tylko jednego stopnia do trzydziestu. W Polsce nie dałoby się żyć w takich warunkach, a tu było naprawdę super.

Większość mieszkańców Rwandy to katolicy

Tu też zdziwiewnie. Wikipedia i CIA twierdzą, że katolicy to ponad połowa wierzących, ale widocznie nie mają aktualnych danych (dane CIA są z roku 2001). Przez całe dwa miesiące pobytu spotkałem tylko jedną katoliczkę (Pacifique, dziewczyna Paula). Zdecydowana większość to protestanci różnych wyznań (adwentyści, ewangeliści, kościół odnowienia i założona w Rwandzie Zion Temple). W ostatni dzień Ramadanu zauważyłem sporo muzułmanów (ale i poza tym dniem bywają widoczni).

Rwandyjczycy dzielą się na Tutsi i Hutu

Już nie. Dominuje opinia, że byli podzielieni prze ludobójstwem, sztucznie przez kolonizatorów. Obecnie wszyscy nazywają się Rwandyjczykami i oficjalnie nikt nie zwraca uwagę na to kto kim kiedyś był. Podejrzewam jednak, że to tylko trochę fasada: każdy dobrze wie kto był Hutu, a kto Tutsi, ale nikt nie chce wracać do podziałów pamiętając jak to się skończyło. Zresztą jak wspominałem jest to nielegalne. Można pytać, owszem, kto kim jest, ale nie wolno nikogo z tego powodu dyskryminować. Ludzie jednak mówią żebym nie pytał, bo to może ich drażnić, więc nie pytam. Nie wiem kto kim jest, jedynie się domyślam na podstawie opowiadanych przez nich historii rodzinnych. Na przykład Robert mówi, że jego rodzina przed ludbójstwem mudziała wraz ze swoimi krowami uciec do Ugandy - typowa historia Tutsi.

Rwandyjczycy są niebezpieczni

Bo jakby niby inaczej miało być w kraju, w którym każdy albo zabił kogoś by żyć, albo zginął?

Tymczasem jest tak, że zdecydowanie bardziej boję się chodzić po ulicach w dzień w Polsce niż w Rwandzie po zmierzchu. I wcale tu nie przesadzam. Wiele razy opisywałem przyjazność Rwandyjczyków i chęć pomagania. Bardzo, bardzo pozytywni ludzie. Przed przyjazdem mama wszyła mi od wewnętrznej strony spodni ukryte kieszonki na pieniądze. W ogóle z nich nie korzystam.

Po przyjechaniu wymieniłem kilkaset dolarów na franki i od razu porażka: dostałem tak dużo banknotów (objętościowo była to cegłówka), że nie zmieściłbym ich do żadnej kieszeni. Wrzuciłem je więc do plecaka.

Po ulicach chodzę z aparatem w ręku, laptopa zostawiam na widoku. Jak pisałem, nie wierzę by Nyamata byli złodzieje (ale ponoć w Kigali trzeba na siebie czasem uważać).

Gdzie więc ci wszyscy mordercy? Nie żyją, w więzieniach lub uciekli za granicę. Rwanda przez ludobójstwo to baradzo młody kraj. Niemal wszyscy których znam w 1994 roku mieli zaledwie kilka lat i są teraz sierotami. Te ostatnie jest smutne, jak sobie pomyślę, że mając 4 lata sttracili oboje rodziców.

Na pobliskich sawannach pasą się lwy i antylopy

Na pobliskich zawannach nic się nie pasie. Lwy, bawoły, antylopy i żyrafy ponoć są tylko w Parku Akagera (do którego zdradzę, że być może pojadę w najbliższy weekend!).

Od końca września cały czas leje

W Rwandzie są dwie pory deszczowe: wiosną i jesienią. Przy czym ta pierwsza nazywana jest porą deszczów długich, a ta druga - krótkich. I tak jest w istocie. Deszcz pada średnio co półtorej dnia i trwa około piętnastu minut. Przeważnie wieczorami lub w nocy. Deszcze są różne, od cichych i delikatnych, aż po naprawdę superanckie nawałnice, w czasie których nic poza deszczem nie słychać. Raz się zdarzyło, że w czasie szkolenia taki spadł i musieliśmy przerwać zajęcia, bo nawet gdy krzyczałem nikt mnie nie słyszał (duży w tym udział ma fakt, że wszystkie budynki pokryte są falistą blachą na dachach, która działa jak bęben). Deszczom czasem towarzyszą burze, a nawet grad.

Po deszczu rynsztoki są nieco wezbrane wodą, ale krótko. Za to jak pada, to zawsze zalewa nam przez nieszczelne okna telecentrum.

The main thesis of the MSF report, entitled "FULL PRESCRIPTION: BETTER MALARIA TREATMENT FOR MORE PEOPLE, MSF’S EXPERIENCE" is that providing free treatment leads to better uptake of interventions, increased wellness, and reduction in mortality-- especially among children.  This was determined by comparison to data from the normal system of formal treatment centers ("formal structures" or public health units) at which a low flat fee was being charged.  A critical component of project success in all three countries however, was the use of informally trained village workers to deliver malaria interventions in the villages. The report presents, but fails to highlight the contribution of this service distribution strategy.  

The reasons for low use of medical services (even subsidised, low cost) are well known in the W. African context, and the report itself identifies:

Quantities of drugs supplied are often calculated based on the actual use of services rather than on real morbidity figures. But the use of public services is usually extremely low and does not correspond to the real medical needs of the population.


Limited use of health services is a general problem in many poor sub-Saharan communities. The authorities in Sierra Leone found that only 12% of children suspected of having malaria were using health services within the 24 hours of the onset of fever.


In Mali, patients on average visit health services fewer than 0.3 times per year; financial obstacles often prevent them from seeking care. Part of the stocks of ACTs [Artemisin-based Combination Treatment] may not be used before their expiry dates11, not because people are not sick, but because the existing clinics are little used by the population.

The implication is that people are poor and/or have higher priorities for their spending than even low cost malaria treatment for their children.  The idea, heavily emphasised in the report, that just removing financial barriers leads to increased uptake of services is nevertheless misleading.  In a section entitled "No cash, no care"  MSF points out that financial barriers of this kind are a widespread problem in  "resource poor settings"-- even though the success the MSF programs being described was clearly dependent on local human resources!  We can further examine this contradictory theme of resource poverty in the context of the report itself. 

In all three cases described, care was extended to the communities by training local village inhabitants--described as having"no specific health background"  to diagnose cases (using the latest rapid diagnostic technologies); dispense ACT drugs; and refer cases to the central clinics-- three critical functions for the success service delivery that would normally be provided by workers in the formal systems.  For Sierra Leone the report says:

At the end of 2007, in addition to the support provided to the health structures, 107 malaria village workers were selected and trained in villages where people struggled to reach health care centres (further than three kilometres away from the formal structures). The village workers had no specific health background but received training to perform RDTs [Rapid Diagnostic Tests]. They tested children under five with fever and pregnant women, and dispensed free ACTs to patients who needed it and explained how to take the treatment. Patients with negative RDT results and with severe malaria are referred to the health centres.

The low impact of formal health structures is not just a cost issue.  We can understand this if we look at related statistics from another study in the same Sierra Leone context which showed that 70% of births within 3 miles of a free Public Health Unit (clinic) were at-home supervised by a Traditional Birth Attendant (TBA; indigenous midwives). It is a common observation that community preferences impact the effectiveness of healthcare services above and beyond ease of access.   

In a recent presentation I made at the OptAIDS/WHAM Workshop I explored the proposition that greater public health impacts could be achieved per unit investment if the existing systems of Traditional Medicine Practitioners (TMPs) were co-opted. In Sierra Leone, limited data collected during TMP registration by the Sierra Leone Traditional Healers Association (SLENTHA) indicates that there are many more TMPs per capita than allopathic trained health workers, and that they are more widely distributed among rural populations. By giving TMPs access to even rudimentary training, technologies, and processes as described for the MSF projects, significant impact could be achieved at lower cost and in a more sustainable way. The MSF states unequivocally that in Mali:

Community based activities through malaria village workers increased coverage and access to prompt treatment for children affected by malaria. The experience also showed that the use of RDTs by malaria village workers, when trained and supervised, is possible and efficient.

Thus even though it is only tangentially discussed in the report, the importance of the community's perception of health care service providers, living in their midst, is potentially more of a contributing factor than removal of financial barriers. Indeed, little discussion of the relative cost of the compared strategies is presented even though it is clear that even a little bit of empowerment of local agents had a significant and immediate impact:

Many more children and pregnant women can be promptly treated for simple malaria by having the community select the malaria village workers - which gives them legitimacy -  [my emphasis] and by procuring the tools and ensuring appropriate training and supervision.

Results from the projects also show that at the community level, systematic use of rapid diagnostic tests is possible and that the community approach is an effective way to increase the number of patients treated. For instance, in Chad, the malaria village workers could cure one episode of malaria per child per year in 2007.

It is difficult to quantify the contribution of TM to healthcare in African countries because TM data is rarely if ever explicitly incorporated into surveys of public health.  A starting point for better provision of healthcare in Sierra Leone and other African countries would be to simply accept the fact that the national health status of a country is the outcome of both formal allopathic healthcare systems (typically dating back to colonial times, and supplemented by INGOs like MSF), and indigenous Traditional Medicine systems (which typically supply up to 80% of primary care yet receive no inputs).  For the Sierra Leone case, I have previously attempted to quantify relative impacts of national healthcare structures versus indigenous Traditional Medicine with the limited data that is availabe about numbers and distribution of TMPs.  A somewhat outdated 2002 survey estimated that there are 15,290 people per doctor and 7560 per trained nurse working in the country's formal national healthcare system.  Contrast this with data from a recent WHO training course on HIV prevention in which 280 TMPs came forward and registered for training in just two of the country's 143 rural chiefdoms Based on these numbers, one can tentatively estimate that there may be of the order of 20,000 TMPs in Sierra Leone versus about 5000 western trained medical workers!  I am pleased that MSF and other agencies are finally paying attention to this valuable resource, investing in it, and providing it with modern technologies. There is a significant and culturally committed resource to be tapped. 

In Sierra Leone, TMPs are given legitimacy by both cultural preference, and formal licensure by the Paramount Chiefs in each Chiefdom.  Nevertheless, this indigenous resource is usually ignored or even actively put down by the "formal" healthcare system, or NGO agencies.  Up until very recently it received zero investment or support by the national government except (inadvertently) through the preservation of natural forest resources on which it depends.  Sierra Leone recently established a National Policy on Traditional Medicine that at least on paper, creates a Governmental budget line to support Traditional Medicine.  MSF and other agencies could help by advocating for greater formalization of this indigenous resource in concordance with these policy pronouncements and collecting and sharing the kind of data presented in this report.

In conclusion, I highlight this report because it offers important insight and supporting evidence that giving basic training and putting modern technologies in the hands of indigenous healthcare workers, chosen by local communities, can have a significant positive impact on the success of malaria interventions. 

You can read the MSF report here:

FULL PRESCRIPTION: BETTER MALARIA TREATMENT FOR MORE PEOPLE, MSF’S EXPERIENCE

My Powerpoint presentation is accesible here:

Can Investment in African Traditional Medicine Systems Yield Better Public Health Returns Than Allopathic Healthcare Systems?

Malaria prophylaxis is the prevention of Malaria. Malaria is thought to be one of the oldest infectious diseases, evolving around 10,000 years ago. The development of new antimalarial drugs spurred the World Health Organization in 1955 to attempt a global Malaria eradication program. This was successful in much of Brazil, the US and Egypt but ultimately failed elsewhere. Efforts to control Malaria are still continuing. 

As there is no vaccine available for protection against Malaria despite decades of research, there is a need for an alternative method that offers a fairly reliable protection against Malaria. And as Malaria can be severe in the non-immune, all visitors from non-malarious area to a malarious area should be protected. Antimalarial drugs offer protection against clinical attacks of Malaria.

The risk of contracting Malaria depends on the region visited, the length of stay, time of visit, type of activity, protection against mosquito bites, compliance with chemoprophylaxis etc. 

Risk for Travelers

Risk can differ substantially even for persons who travel or reside temporarily in the same general areas within a country. For example, travelers staying in air-conditioned hotels may be at lower risk than backpackers or adventure travelers.

Basic Prevention

The ABCD of Malaria prevention are:

A. Awareness of risk;
B. Bite prevention – Travelers to Malarious areas are advised to wear long clothes that cover as much of the skin as possible. Exposed parts of the body should be treated with insect repellent. When sleeping, insecticide-impregnated bed nets should be used. 
C. Chemoprophylaxis
D. Rapid Diagnosis and Treatment

Suppressive Prophylaxis

Chloroquine, Proguanil, Mefloquine and Doxycycline are suppressive prophylactics. This means that they are only effective at killing the Malaria parasite once it has entered the erythrocytic stage (blood stage) of its life cycle, and therefore have no effect until the liver stage is complete. That is why these prophylactics must be continued to be taken for four weeks after leaving the area of risk. 

Causal Prophylaxis

Causal prophylactics target not only the blood stages of Malaria, but the initial liver stage as well. This means that the user can stop taking the drug seven days after leaving the area of risk. Malarone and Primaquine are the only causal prophylactics in current use.

Chemoprophylaxis

Chemoprophylaxis is the strategy that uses medications before, during, and after the exposure period to prevent the disease caused by Malaria parasites. The aims of Malaria treatment in broad terms are to alleviate symptoms, to prevent relapses and to prevent further transmission of the parasite. There are approximately 14 antimalarials that are advised for use in the prevention and treatment of uncomplicated Malaria.

Drug Regimens

The following regimens are recommended by the WHO, UK HPA and CDC:

1. Chloroquine 300 to 310 mg once weekly, and Proguanil 200 mg once daily (started one week before travel, and continued for four weeks after returning);
2. Doxycycline 100 mg once daily (started on day before travel, and continued for four weeks after returning);
3. Mefloquine 228 to 250 mg once a week (started two-and-a-half weeks before travel, and continued for four weeks after returning);
4. Malarone (Atavaquone + Proguanil) 1 tablet daily (started one day before travel, and continued for one week after returning).

Doses depend on what is available (eg in the US, Mefloquine tablets contain 228 mg base, but in the UK they contain 250 mg base). The data is constantly changing and no general advice is possible. Doses given above are appropriate for adults and children over 12 years of age. 

Chloroquine, Mefloquine are safe in pregnancy, Doxycycline is not. 

While chemoprophylaxis in pregnancy appears efficacious, a major question remains – which agents are safest for both the woman and the fetus? Some drugs routinely used in non-pregnant individuals should not be offered to pregnant women because of known direct effects on the fetus. Doxycycline is teratogenic, and Primaquine poses a significant of fatal intravascular hemolysis in G6PD deficient fetuses. Other drugs, such as Atovaquone / Proguanil and Artesunate, are not well studied in pregnancy, and therefore are not recommended for use unless other options are not available. 

Given these reaction profiles, Chloroquine or Mefloquine are usually the best choice with their superior safety and efficacy.

*Chloroquine is widely used because it is inexpensive and well tolerated, with only pruritus, mouth ulcers and gastrointestinal upset as the most common adverse effects. Persons who experience uncomfortable side effects after taking Chloroquine may tolerate the drug better by taking it with meals.

*Mefloquine is usually well tolerated, but can cause dose-related neuropsychiatric effects; it is contraindicate in those with a history of epilepsy or psychiatric disease.

The World Health Organization (WHO) recommends Chloroquine as first-line prophylaxis in pregnancy (plus Proguanil if the region exhibits emerging Chloroquine resistance). In areas with proven Chloroquine resistance, Mefloquine is the drug of choice. 

The Centers for Disease Control and Prevention (CDC) also advises use of Chloroquine (or Mefloquine in regions with Chloroquine resistance). The CDC discourages the use of Atovaquone/Proguanil, Doxycycline, and Primaquine, due to known adverse fetal effects or inadequate experience in pregnancy. 

Chemoprophylaxis Regimen: Malaria chemoprophylaxis with Mefloquine or Chloroquine should begin 1-2 weeks before travel to malarious areas. Beginning the drug before travel allows the antimalarial agent to be in the blood before the traveler is exposed to malaria parasites. In addition to assuring adequate blood levels of the drug, this regimen allows for evaluation of any potential side effects. Chemoprophylaxis should continue during the stay in Malarious area and for 1-4 weeks after departure from the area. Chemoprophylaxis can be started earlier if there are particular concerns about tolerating one of the medications. Starting the medication 3-4 weeks in advance allows potential adverse events to occur before travel. If unacceptable side effects develop, there would be time to change the medication before the traveler’s departure.

Antimalarials and Pregnancy: CDC Recommendations
Travel during Pregnancy to Areas without Chloroquine-Resistant P falciparum: Pregnant women traveling to areas where chloroquine-resistant P falciparum has not been reported may take chloroquine prophylaxis. Chloroquine has not been found to have any harmful effects on the fetus when used in the recommended doses for Malaria prophylaxis; therefore, pregnancy is not a contraindication for Malaria prophylaxis with chloroquine phosphate or hydroxychloroquine sulfate.
Travel during Pregnancy to Areas with Chloroquine-Resistant P falciparum: Mefloquine is currently the only medication recommended for malaria chemoprophylaxis during pregnancy. A review of Mefloquine use in pregnancy from clinical trials and reports of inadvertent use of Mefloquine during pregnancy suggest that its use at prophylactic doses during the second and third trimesters of pregnancy is not associated with adverse fetal or pregnancy outcomes. More limited data suggest it is also safe to use during the first trimester.

Because of insufficient data regarding the use during pregnancy, atovaquone/proguanil is not currently recommended for the prevention of Malaria in pregnant women. Doxycycline is contraindicated for Malaria prophylaxis during pregnancy because of the risk of adverse effects of tetracycline, a related drug, on the fetus, which include discoloration and dysplasia of the teeth and inhibition of bone growth. Primaquine should not be used during pregnancy because the drug may be passed transplacentally to a glucose-6-phosphate dehydrogenase (G6PD)-deficient fetus and cause hemolytic anemia in utero. 
How to protect yourself

Know the Facts
Persons who are traveling to malaria risk areas can almost always prevent this potentially deadly disease if they correctly take an effective antimalarial drug and follow measures to prevent mosquito bites.

Know the Symptoms
Despite these protective measures, travelers may become infected with malaria. Malaria symptoms can include:
• fever
• chills
• headache
• flu-like symptoms
• muscle aches 
• fatigue
• low blood cell counts (anemia) 
• yellowing of the skin and whites of the eye (jaundice)

When Symptoms Appear, Seek Immediate Medical Attention
Malaria is always a serious disease and may be a deadly illness. Travelers who become ill with a fever or flu-like illness either while traveling in a malaria-risk area or after returning home (for up to 1 year) should seek immediate medical attention and should tell the physician their travel history.

Personal Protection Measures
It must be remembered that no chemoprophylaxis regime provides 100% protection. Therefore it is essential to prevent mosquito bites as well as to comply with chemoprophylaxis. Anopheles mosquitoes bite at nights, with peak biting between 10pm and 4am and Malaria transmission occurs at these hours. Travelers must take personal protective measures against mosquito bites at nights. 

• Remaining in well-screened areas after dusk, using mosquito nets, and wearing clothes that cover most of the body are some simple but effective measures. 
• In addition, mosquito repellents like N,N diethylmetatoluamide (DEET) can be used. It is better to have a pyrethrum-containing space spray to use in living and sleeping areas during evening and night hours. Travelers should take a flying insect spray on their trip to help clear rooms of mosquitoes. In the United States, permethrin (Permanone) is available as a liquid or spray. Overseas, either permethrin or another insecticide, deltamethrin, is available and may be sprayed on bed nets and clothing for additional protection against mosquitoes. 
• Protect infants (especially infants under 2 months of age not wearing insect repellent) by using a carrier draped with mosquito netting with an elastic edge for a tight fit. 
• Clothing, shoes, and camping gear, can also be treated with permethrin. Treated clothing can be repeatedly washed and still repel insects. Some commercial products (clothing) are now available in the United States that have been pretreated with permethrin. 
• It is advisable to quickly report any febrile illness and disclose your travel histories to your healthcare providers.
Know the Signs and Symptoms of Malaria

You can still get malaria despite taking an antimalarial drug and using protection against mosquito bites. Taking an antimalarial drug greatly reduces your chances of getting malaria. Symptoms are very flu-like and can include fever, shaking chills, headache, muscle aches, and tiredness. Nausea, vomiting, and diarrhea may also occur.

Malaria symptoms will occur at least six to nine days after being bitten by an infected mosquito. Therefore, fever in the first week of travel in a malaria-risk area is unlikely to be malaria; however, ill travelers should still seek immediate medical care and any fever should be promptly evaluated.

Recommendations for travelers to malaria endemic areas
All travelers to malaria-endemic areas are at risk of contracting Malaria and being non-immune, P falciparum infection in these individuals can become severe. Therefore, all travelers to Malaria endemic areas are advised to use an appropriate chemoprophylaxis and personal protection measures to prevent Malaria. However, it should be remembered that, regardless of methods employed, Malaria can still be contracted. Symptoms can develop as early as 8 days after initial exposure in a Malarious area and as late as several months after departure from a Malarious area. Malaria is easily treatable early in the course of the disease but delay in treatment can lead to serious or even fatal consequences. Therefore, individuals who develop symptoms of malaria should seek prompt medical help, including blood smear (or QBC test) for malaria.

Dr Sulbha Arora MD DNB
Scientific Director
Deccan Fertility Clinic and Keyhole Surgery Center

I met someone recently who told me she's had malaria 4 times in the last few years. She wondered out loud whether or not once you have it, you always have it. I was surprised she hadn't looked it up but maybe she didn't want to know. I looked it up and the medical verdict (although I am not a doctor) is that proper drug treatment should kill the parasites entirely. Some of these bugs hide in the liver undetected and come out when the coast is clear and this may be the source of the idea that once bitten you're done for. If you're not sure, check with your doctor or Wikipedia or both.  

As I write it's almost 5 PM and about 40 degrees centigrade outside. This is normal. I was told yesterday that there were three days last January (during the "hot season") where it went up to 60. rm

The story from The Observer in Kampala, via All-Africa.com news, provides some of the details, but little analysis to be debated.  Is the failure of the program due to partial implementation, since implementation was resisted by businesses and cotton farmers?  Or is DDT simply ineffective?  It's nearly impossible to tell from data available so far.

Below the fold, the story in its entirety.

Uganda: Health - DDT Experiment Fails Its First Test

The Weekly Observer (Kampala)

1 October 2008
Posted to the web 2 October 2008

Devapriyo Das

The fallout of the DDT indoor-residual spraying programme is slowly being registered. Worryingly, public health data for Lango show that, week-for-week, reported malaria cases are higher this year, than they were in 2007.

Contrary to expectations, data collected by health departments in Apac and Oyam districts, which record the highest malaria incidence in the world, do not reflect significant improvements since DDT spraying ended prematurely. From May to July 2008, which is the period immediately following the spraying, between 400 and 600 clinical malaria cases per 100,000 of the population were reported per week in Oyam; and 600 to 800 such cases in Apac for the same period. These are almost exactly the same as the number of cases reported between January and April 2008.

Again, there were 2,403 reported malaria cases in Apac in the last week of July 2008, which is the lowest number since the spraying; but only fractionally lower than the 2,422 reported cases in the first week of February this year. While case numbers have gradually declined since end of June, they have risen again from the middle of August.

A possible explanation for figures being higher this year is that data collected from local health centres and hospitals was often incomplete in 2007, as opposed to being almost complete in 2008. Yet, a comparison of the same fourth week of May in both 2007 and 2008, where reporting was 81% and 100% complete, respectively, shows 4,328 cases of malaria this year compared to 2,626 last year. Others argue that the ongoing rainy season has boosted mosquito numbers.

DDT failure

DDT spraying was supposed to have prompted an immediate and dramatic reduction in malaria incidence. This has not happened. Instead, Bernard Opio of Atana parish, Apac Sub-county, has found his health deteriorating since his house was sprayed, without his consent and in his absence.

"It was two days after, I started feeling some cough. Actually, since then up to now, my cough has not been healing properly. I thought maybe as they had sprayed it would reduce the rate of malaria as they were talking, [but] the mosquitoes are still there. They're coming into the house."

Members of the farmers' group Ocan Mwole in Aboke Sub-county consented to have their houses sprayed with DDT in April 2008. They complained of stomach problems, headaches, flu and red eyes shortly afterwards, while noticing no tangible reduction in the number of mosquitoes in their homes.

These are symptoms to be expected of most chemical fumigations, but people were not informed of them beforehand.

According to Ellady Muyambi, General Secretary of Uganda Network for Toxic Free Malaria Control (UNETMAC), "most effects are long term". He explained that when they spray DDT in someone's house it bio-accumulates. It breaks down into smaller particles and those are either inhaled or taken by air currents. "Within two years, people experience health effects", he said.

Giving a litany of physiological damage thought to be linked to DDT exposure, from reduced production of breast-milk in mothers, reduced IQ in children, congenital deformities, to low sperm-count in men, he claims that for Apac and Oyam, the "damage is done".

Irregularities in the spraying process, "one reason why the High Court listened to us," Muyambi continues, "was because the Ministry of Health tried to convince the court that it will follow the guidelines put forward by the Stockholm Convention, WHO and National Environmental Agency (NEMA)." These guidelines state that the Ministry of Health should sensitise people where it's going to spray, at least three months before the exercise. That was not done."

Politicisation

Muyambi alleges that "most sprayers were not fully trained to accommodate the programme". He adds that Research Triangle Institute (RTI), the organisation contracted by the Malaria Control Programme to carry out IRS, was unfit for the job. He accuses them of poorly training sprayers who ended up applying excessive DDT on walls. He also charges that they under-paid the locally recruited sprayers in addition to threatening residents that they would be denied access to public health services if they did not agree to have their houses sprayed.

"They politicised the whole programme," Muyambi says, alleging also that those who refused to have their houses sprayed were accused of being members of opposition political parties.

While this correspondent found it difficult to corroborate every aspect of Muyambi's observations with facts on the ground, proof does exist to show instances of shoddy implementation.

John Bosco Amunyu of Barodillo parish, Cegere Sub-county, was a Team Leader in charge of five spray operators and one washer (who washed overalls, boots, etc. after the spraying). He says they had enough training - 12 sessions over 21 days - but that they were underpaid and never got formal contracts.

They were reportedly told that "payment for a day would be Shs 15,000. "We got very little. It was 2,500 per day," says Amunyu. As team leader he was getting Shs 6,000. Later, after they went on strike, this was raised to Shs 7,000.

When contacted, RTI referred any queries about the IRS exercise to the Malaria Control Programme. According to one of the sprayers, John Edward Ruma of Inomo Sub-county, the whole exercise which was to take three months, was condensed into about one month. He feels this affected the sensitisation of local communities.

Barren men?

"Many places we went, women said chemicals were going to destroy the power of their men. In Abongomola, they said we should not spray their houses, because the women said it would make their husbands barren," says Ruma.

Since house spraying was optional, sprayers were instructed to move away from those who refused.

Sprayers acknowledge they had to meet their spraying quotas, i.e. 20 households per day, for which they were issued four to five sachets of DDT, which would need to be mixed with water. What is less clear is whether they dumped DDT into anthills, as some monitors allege, since they could not actually meet their targets. Spray operators deny having witnessed any of their co-workers throwing away DDT, and confirm that used and unused sachets were brought back to their head office for accountability at the end of each day.

Ultimately, total coverage of households in Apac did not happen, and the court injunction meant that Apac Town Council itself remains largely unsprayed. Besides, people were not told about how to manage their household waste after spraying had occurred.

According to Muyambi, NEMA requires the Ministry of Health to provide containers to every household sprayed in which to put the dust when cleaning their houses.

The idea was for monitors to collect the dust and test whether there was contamination. But this was reportedly not done. Sprayers Ruma and Amunyu confirm that neither they nor their teams got such containers.

Off to Kanungu

Dr. John Bosco Rwakimari insists that the Malaria Control Programme which he heads, emphasised that people must witness sprayers putting chemical into their spray tanks, adding that "every sprayer is given a code number. Every house he goes and sprays, if he sprays water - as some people claim that they pocketed DDT and sprayed water- we have bio-assess techniques to test the walls."

He defends RTI saying, "those detractors of DDT IRS say that Ministry of Health can't manage to do this, because they have no capacity. So, we said we will hire the services of a consultant, an expert already used to doing IRS in other countries: RTI has been in Mozambique, South Africa, Angola." Whatever the reasons, it's clear that the process was not flawless. Perhaps more worryingly, the Lira-based Lango Organic Farmers Promotion, a collective of regional organic producers, recently announced it would split from its members in Apac and Oyam for fear of having their products rejected by association with DDT-sprayed areas.

Both Muyambi and Dr. Rwakimari concur that DDT is less harmful and more effective than several other chemical alternatives. The latter even points to a sinister conspiracy by pharmaceutical companies, who sell billions of dollars worth of anti-malarial drugs in Africa every year, and malign DDT for fear of losing this vast market.

However, the bottom-line for Muyambi is, "we observed DDT was used in the wrong manner. Our country has no capacity to use it, so now we're opting for other alternatives. And the court has agreed."

Dr. Rwakimari counters by saying it was "quite unfortunate that the court had to do this. We are working around the clock with the Attorney General's office to make sure that this court handles the case as soon as possible, so that we should not fail to implement our programme."

On politicisation of the programme, Dr. Rwakimari conceded that some politicians had taken to telling their constituents that 'the government is going to kill you because you're in the opposition'! Majority of people in Lango supported the opposition at the last elections in 2006.

To avoid this dangerous misunderstanding, Rwakimari said, DDT spraying is now spreading to Kabale, Rukungiri and Kanungu areas, a stronghold of the ruling party.

In fact, despite the injunction, the IRS programme resumed in Kanungu this August.