Tag: Malaria

We Know How Cerebral Malaria Kills Children — But Do We Know How to Save Them?

Donated medical devices are not the solution, part 58

Donated medical devices are not the solution, part 58 – ultrasounds in Kisoro, Uganda (photo: me, 2013)

We now know how cerebral malaria kills children. But do we know how to save them? An otherwise-fantastic NPR story suggests a solution that is, unfortunately, exactly wrong for the scope and scale of the problem: donated medical devices.

And the problem of cerebral malaria is a massive problem. Malaria is a wicked disease, causing an estimated 584,000 deaths in 2013 – 78% of which were children under five. Plasmodium falciparum, one of the five malaria species known to infect humans, is the most common and the most deadly, in part because it can end up in the microvasculature of the brain, causing what is known as cerebral malaria.

Cerebral malaria is particularly deadly for children, but until now, researchers didn’t really know why. A new study in the New England Journal of Medicine indicates that cerebral malaria kills them by, effectively, suffocating them:

Our study design addressed the sources of this uncertainty, and the findings suggest that brain swelling and the likely increase in intracranial pressure that is associated with brain swelling are strong predictors of death in Malawian children with cerebral malaria.

Basically, brain swelling kinks the brain stem, shutting off the autonomic nervous system; the patient no longer breathes independently, and, without assisted breathing through a mechanical ventilator, dies. (Now is a good time to mention that I have no clinical background, so, grain of salt…)

The NPR story highlights a potential solution:

One possibility is to try putting the child on a ventilator, John says. “Then, during a period when brain swelling might affect the child’s ability to breath, you could breath for them,” he says. Then take the child off the ventilator when the brain swelling goes down.

Many clinics in Africa don’t have ventilators or physicians trained to use them, John says. “It’s going to be very hard to implement that across Africa. But I would love to see ventilators tested.”

And if a malaria ward in Malawi can get a million-dollar MRI machine, surely somebody could donate life-saving ventilators.

Emphasis mine. This framing – donation as solution – is the absolute wrong way to think about the problem, for three reasons.

First, medical device donations fail. Predictably. All the time. I am a broken record on this subject.

Even if donated medical devices functioned as they are supposed to, this is too big a problem to solve with second-hand donations. Every mid-sized hospital that can support one (more on that in a minute) should have a ventilator, and it’s wrong to think that a second-hand donations market could support that demand.

And lastly, donated ventilators aren’t built for low-resource hospitals; they’re built for hospitals with consistent electricity, highly-trained clinical staff, and a support ecosystem with trained biomedical engineers and spare parts immediately available. None of this can be assumed for the vast majority of hospitals that would see cerebral malaria patients in low-resource regions.

The solution, then, is not a second-hand donation; it’s a ventilator designed for the environments in which it will be used in. Here I’m a broken record as well.

It is wonderful that we now know, clinically, what it takes to save the lives of children with cerebral malaria. But donated ventilators aren’t up to the task.

Saturday Links

*”Is it possible?” is really three separate questions: 1) Is it theoretically possible? (the answer is probably yes); 2) Is it feasible? (the answer is much less clear); 3) Is it the right way to expend limited global health resources? (again, even less clear)

Monday Links

  • The United States is going to destroy six tons of illegal ivory, which it hopes will discourage elephant and rhino poaching. I’m skeptical – I don’t get the feeling that ivory buyers really care what the United States does with its ivory – but haven’t seen studies analyzing supply-and-demand after these types of events (in the 80s, Kenya did the same thing)
  • One man’s quest to develop a malaria vaccine, which has so far culminated in the most successful vaccine to date – theoretically. Logistically, rolling out multiple rounds of intravenous vaccine to children in low-resource settings is a mess
  • Mass drug administration – like giving praziquantel to kids in schistosomiasis-endemic regions – is a powerful public health strategy. This article goes in depth about mass drug administration with respect to lymphatic filariasis, the parasite best known for causing elephantitis  
  • I think Sendhil Mullainathan gets it a bit wrong in his latest article on obesity. One study he references (which I wrote about here) looks at gut bacteria and how it affects weight, irrespective of total calories consumed. It finds that mice with “thin” gut bacteria will gain less weight on an equivalent diet as mice with “thick” gut bacteria – but that, with the right diet (heavy in fruits and vegetables), the thin gut bacteria would actually overtake the thick gut bacteria  in an obese mouse after a fecal transplant, which causes it to lose weight. Importantly, this takeover never happened in obese mice that continued to eat an “unhealthy” diet high in saturated fat. To me, this bolsters the case for viewing obesity as something that can be profoundly affected by behavioral changes (and, indeed, behavioral economics), and even provides a roadmap for better health

Monday Links

  • “Dual-use” scientific research – like the research that brought the world both atomic energy and atomic weapons – meets biotechnology and genomics, and the implications are pretty terrifying. Pandora’s Box is already open, so how should the scientific community respond? This excellent ForeignAffairs article offers some suggestions
  • Why does malaria still infect 300 million people – and kill 500,000 people, mostly children – every year? It’s a parasite that has been successfully eradicated from much of the world, but still haunts sub-Saharan Africa. Sonia Shah argues that it still exists because a) poverty; and b)  because it’s just not that big of a deal to many living in sub-Saharan Africa. The former point is incontrovertible (I wrote about research detailing the link here); the latter will probably get some criticism, but I think she makes a strongly-argued point
  • Besides being generally excellent, this article highlights one of the truly repugnant ways that drug companies incent physicians to use their pharmaceuticals: writing a check for the physician. It also provides insight into how drug companies price pharmaceuticals for patients that are basically price-inelastic: charging as much as possible until there is an outcry for cheaper prices
  • That this method of teaching – basically, hands-off facilitating – could be called “radical” is both very accurate and very sad. The science is firm enough now that teachers who don’t innovate and start “radicalizing” their teaching methods are doing a disservice to their pupils – as are the regulations that take away such freedom from teachers. It’s a great article that you should take the time to read

Study Links Poverty to Higher Rates of Malaria in Kids

(Via SciDevNet)


In regions afflicted with malaria, the poorest kids are twice as likely to contract malaria than their slightly less-poor neighbors

[KAMPALAExtremely poor children are about twice as likely to contract malaria in endemic regions as their least poor counterparts, according to a review.

Malaria experts have long considered the disease to be affected by socioeconomic factors, so researchers from Sudan and the United Kingdom searched the literature to assess whether socioeconomic status is linked to risk of malaria among children up to 15 years old in endemic countries.

Our objective was to stimulate the thinking about socioeconomic development as a malaria intervention, says Steve Lindsay, study coauthor and a disease ecologist atDurham University, United Kingdom.

Lindsay and colleagues searched 4,696 studies published from 1 January 1980 to 12 July 2011 and found 15 studies with statistical data linking malaria risk and socioeconomic development — defined to include household assets, household income or parent’s occupation.

One study was conducted in Yemen and the rest focused on countries in Sub-Saharan Africa: Burkina Faso, Equatorial Guinea, Ethiopia, the Gambia, Ghana, Kenya, Malawi,Rwanda, Tanzania and Uganda.

The researchers  used meta-analysis, a type of study which uses statistical methods to combine and analyse results of individual studies, to establish the overall relationship.

Even in poor communities, there was a stark divide between the poorest and the least poor, according to the study published in The Lancet last month (14 September).

“Poorest children were twice more likely to be at risk of malaria than those that were least poor, ” Lindsay tells SciDev.Net.

 Lindsay says the study has significant implications for malaria policy in Sub-Saharan Africa, as it helps explain the protective effect of development and how it could be used to control malaria.

He adds that they highlighted housing because its improvements could reduce the likelihood of mosquitoes entering homes at night.

Chris Cotter, a malaria researcher with the Global Health Group at the US-based University of California San Francisco, thinks that a focus on socioeconomic development is a positive shift as long as it compliments other current interventions.

“This is a wise step so long as it appropriately balances the need for proven, life-saving interventions such as bed nets, effective drugs and residual spraying with broader economic development,” he tells SciDev.Net. “Countries that have successfully eliminated malaria have struck this balance in the past.”

Lindsay hopes that the research will help governments and aid donors view malaria eradication in a different light. “I think it’s just thinking outside the health box, which is really important in looking for new approaches,” he says.

Link to full paper in The Lancet

*Free registration is required to view this article.

Thursday Links

(There are more links than usual because I’ve been too busy working and editing pieces to write new ones. Exciting things coming up though!)

  • A genius Mongolian 15-year old kid aces a MIT Massively Open Online Course (MOOC) on Circuits and Electronics, and is now a MIT student. Wonderful story. I’m in favor of using MOOCs – I think they’re fantastic, and have taken a number of them – but I don’t think this one tale should assuage the fears of MOOC skeptics. Remember: this kid is a genius, and would almost certainly have found success with or without the MOOC; the true hope of MOOCs is that they’ll level the playing field for the masses (and make higher education cheaper in the process)
  • This is a fun, informative look at the use of tablets – and “screens” more generally – in education. The author is refreshingly frank about her biases, and makes it clear that the tablet isn’t a panacea in and of itself; how it’s used is much more important than that it is being used. The company Amplify, a News Corporation offshoot helmed by former NYC Public School Chancellor Joel Klein, is featured prominently; it uses a few neat tricks to make the tablets theoretically excellent engines for learning
  • “Eighty to 90 percent of people who use crack and methamphetamine don’t get addicted,” according to Dr. Carl Hart, a neuroscientist/psychologist profiled in this article. That’s astounding. He makes a persuasive case that crack addiction is more psychological and sociological than biological (i.e., for some poor, unemployed people, the hit of crack is better than their other options, but others with better options, the hit of crack isn’t better). Also, he used conditional cash transfers in an experiment! Adding his book, High Price, to my reading list
  • Malaria is, in important ways, a social disease, even within the same poor community: “Our findings suggest that low socioeconomic status is associated with roughly doubled odds of clinical malaria or parasitaemia in children compared with higher socioeconomic status, within a locality.”
  • Nice use of smartphone technology in Pakistan: ensuring workers are actually doing their job in preventing dengue fever
  • Can’t wait to read Sendhil Mullainathan’s and Eldar Shafir’s book, Scarcity, when I make it home for Christmas. You should read it. Until then, here’s Cass Sunstein’s review in the New York Review of Books; it’s quite good

Sunday Links

  • Big, big news: a malaria vaccine provided 100% protection in a few cases, and will be trialed in Tanzania. As the article notes, there are a lot of logistical hurdles to scale it, but it’s an excellent foundation for building a reliable, scalable malaria vaccine in the future
  • Typically-cogent piece by Aaron Carroll at The Incidental Economist on rationing in American health care. The idea that we don’t ration currently (see: poor, uninsured) would be silly if it wasn’t so destructive
  • A really long, really interesting profile of Hedy Lamarr, an American actress who quietly laid the groundwork for WiFi and Bluetooth
  • Urban farming in Kibera, Nairobi’s largest slum


Thursday Links

  • This is spot on, so far as it goes, but the author would do well to remember that, just like there are good surgeons and bad surgeons, there are goo consultants and bad consultants
  • Nitric oxide is being tested as a treatment for cerebral malaria in Mbarara. Evidently, it’s a vasodilator, which allows blood to get where it needs to go in the brain after the plasmodium parasite causes encephalitis. This wouldn’t cure malaria – it can’t kill plasmodium falcipiarum – but, if effective, would give time for antimalarials to work, and potentially can curb some of the long-term neurological problems that result from cerebral malaria
  • Uwe Reinhardt’s never-to-be-enacted proposal, the “Rugged Individualist Health Plan” – allow individuals the option not to purchase health insurance. But if they opt out, they can never enter the health exchanges, receive subsidies, or have community-rated insurance.
  • “N—–s ain’t gonna vote where I live. If they did, they’d control the government. They ain’t gonna go to school with my kids. And when a n—–s gets close to mentioning sex with a white woman, he’s tired o’ livin’. I’m likely to kill him. Me and my folks fought for this country, and we got some rights. I stood there in that shed and listened to that n—–sthrow that poison at me, and I just made up my mind” – from an account of how Emmett Till was murdered in Mississippi that should leave you feel a little ill

Sunday Links

  • I really, really hope this patch that “makes humans invisible to mosquitoes” works as well at the founder says it does. But I’m very, very skeptical that it does. He touts backing from the Bill & Melinda Gates Foundation, and one of their major initiatives is to reduce malaria; if this patch worked, they’d continue pouring money into it and wouldn’t need a crowdfunding campaign
  • Toyota Kaizen experts donate time and expertise to a New York Food Bank. This is one of the absolute best ways to give back: do what you’re uniquely good at. Organizations like CatchAFire  are doing a great job pairing expertise with need (incidentally, I talked about this exact idea one day with a co-worker while I was in consulting – glad to see it working)
  • Part of Peter Buffett’s argument in this op-ed seems to be: stop donating, and let things get bad enough for revolution. I’ve tested out this argument before, but I don’t buy it; too many people would needlessly suffer or die in the short term, and it’s unclear if the type of revolution he’s looking for would ever be able to occur
  • Totally agree with the conclusion of this article in (of all places) Christianity Today: often, money spent on short-term international trips is misspent, and people should just stay at home and donate it. But the premises the author uses to get there – including “there are kids in Knoxville, Tennessee that can’t swim” – are remarkably off base

Monday Links

  • This article on eastern DRC is absolutely required reading for understanding the situation there; it’s length – 10,000 words or so – is in indication of just how complex the situation is
  • Can – and should – we eradicate malaria? The Lancet’s new Global Health Journal takes up the argument, and makes the case that we can and we should. I don’t know about the former – it seems to me that diseases with animal reservoirs and zoonotic transmission (i.e., monkey malaria that can subsequently infect humans) make it a very difficult task
  • Relatedly – if we can eradicate some species of mosquitoes, should we? The author of this Nature article says yes, and I tend to agree with her. It seems that there will certainly be some ecological consequences of doing so, but that it’s worth the potential cost – especially in areas where mosquitoes are, more or less, aliens
  • Longform New Yorker article on Lyme Disease is worth a read. The author seems to side with the patient community which believes that current treatment is ineffective, though that community seems to be just this side of crazy (some members told the author that Lyme Disease was created by the government, for example)
  • I would work at Goldman Sachs just to play in this New York City-wide “midnight madness” puzzle contest