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Links I liked, November 18, 2014

I liked so many things I read today that, rather than clutter social media, I’ll make note of them right here:

“Falling” by William McPherson – By far, the most depressing thing I have read in a while. McPherson is a Pulitzer winning writer and former editor at the Washington Post who chose a life of curiosity and is now paying the ultimate price. It’s awful that the brightest people have to be punished for thoroughly embracing life. So many people I know are going to go this way, it is possible that I might, too.

In India, Growth Breeds Waste NYT – Documenting India’s mounting problem of what to do with its waste. Europe went through their urbanization pains centuries ago. Unfortunately, developing countries are rising to the challenge fast enough. The problem, of course, is that elites are sheltered from the problems of waste and weak and corrupt government structures disallow people from demanding that their countries clean up. International environmentalists need to focus less on screaming about corporate polluting (though it is important) and need to start making demands for more boring things, like managing waste on a local level.

Stop calling me ‘the Ebola nurse’ – Kaci Hickox – This lady was a hero. She never had ebola, but was still illegally interned for having it because a few Americans don’t understand science. Anybody who supported her detainment should just stop speaking to me now. It was shocking how readily Americans were willing to lock people up simply because they were scared and even more shocking where the calls for her “arrest” came from. I give up. People like Hickox put their money where their mouths are. She did what most humans wouldn’t do and she was vilified for it. Unforgivable.

Ten Things that Anthropologists Can Do to Fight the West African Ebola Epidemic I think it should be required that every field research project include an anthropologist.

Q Fever Is Underestimated in the United States: A Comparison of Fatal Q Fever Cases from Two National Reporting Systems People are dying of Q, but much of it isn’t recorded.

Today is Jonas Salk’s 100th birthday

100 years ago today, Jonas Salk was born. As the creator of the inactivated polio vaccine, he not only changed the course of human history, he also ushered changed the field of public health forever. We can count the polio vaccines and the elimination of smallpox as probably the two great success of public health.

In its mildest form, polio causes a mild bout of diarrhea. In its worst form, the virus migrates to the spine, impedes development and causes debilitating long term paralysis. My grandfather was struck with the disease and had one of his legs stunted and weakened (though he managed to serve in WWII anyway as a Marine). A carpenter who worked for me a while back died due to long term respiratory complications from a childhood polio infection.

Polio is mostly foreign to anyone born in my generation. We were nearly all vaccinated, and the high levels of vaccination have destroyed opportunities for the virus to persist in the environment, protecting everyone, even those who don’t get the vaccine.

Unfortunately, though Salk’s achievements were great, medical care and attention to polio was hardly equitable and tainted by the racism of the time.

During the 1930s the systematic neglect of Black polio victims had become publicly visible and politically embarrassing. Most conspicuously, the polio rehabilitation center in Warm Springs, Ga, which Roosevelt, himself a polio survivor, had founded, accepted only White patients. This policy, reflecting the ubiquitous norm of race-segregated health facilities, was sustained by a persuasive scientific argument about polio itself. Blacks, medical experts insisted, were not susceptible to this disease, and therefore research and treatment efforts that focused on Black patients were neither medically necessary nor fiscally justified.[1]

It is likely true that African Americans experienced a lower burden of disease than white children. We now know that polio’s worst effect arise from the lack of acquired immunity to the disease. Repeated infections from infancy, most importantly during the first six months, when babies still have maternal antibodies to fight for them. Improvements to sanitation delayed exposure to the virus, so that children were not immune and thus more susceptible to the disease’s worst effects.

In short, polio is a disease of development, not underdevelopment. The horrible racism of the pre-civil rights medical system can’t be denied, but the observed disparities in disease incidence might have not been imagined given the disparities in sanitation and access to clean water.

Presently, we are fighting a battle to insure that all kids in Sub-Saharan Africa are vaccinated. However, there still exist pockets where the medical system so dysfunctional and the politics so chaotic, that vaccination rates are low and disease continues to flourish. In places like Afghanistan and Northern Nigeria, the hope of polio elimination is almost non-existent


1.    Rogers N: Race and the Politics of Polio: Warm Springs, Tuskegee, and the March of Dimes. American Journal of Public Health 2007, 97(5):784.


The need to look for more than just malaria

I was just reading a comment in the new Journal of the American Society of Tropical Medicine and Hygiene “After Malaria is controlled, what next?”

Fortunately for all of our jobs, there is little to worry about. Malaria, as a complex environmental/political/economic public health problem, won’t be controlled anytime soon. As there’s no indication that many sub-Saharan countries will effectively ameliorate their political problems and also no sign that, despite the “Rising Africa” narrative, African countries will develop in such a way that economic rewards will trickle down to the poorest of the poor, malaria transmission will continue unabated. This is a horribly unfortunate outcome for the people, particularly small children, who have to live with malaria in their daily lives.

In all of the places it occurs, malaria is merely a symptom of a greater political and economic failure.

Indeed, we really know less about the causes of suffering and death in the tropics than many believe. Even vital statistics of birth and death are unrecorded in many areas of the world, much less the accurate causes of disease and death. Some diagnoses, such as malaria, dengue fever, and typhoid fever, are often ascribed to patients’ illnesses without laboratory confirmation. Under the shadow of the umbrella of these diagnoses, other diseases are lurking. I have found significant incidences of spotted fever and typhus group rickettsioses and ehrlichiosis among series of diagnostic samples of patients suspected to have malaria, typhoid, and dengue in tropical geographic locations, where these rickettsial and ehrlichial diseases were previously not even considered by physicians to exist.4–8 Control of malaria or dengue would reveal the presence and magnitude of other currently hidden diseases and stimulate studies to identify the etiologic agents.

This is the problem with our public health fascination with malaria. We are missing all of the other pathogens and conditions which case untold suffering in the poorest and most isolated communities. It can’t be the case that malaria acts in a box. In fact, it could be the case, that multiple pathogens coordinate their efforts to extract as many human biological and behavioral resources as possible to obtain maximum opportunities for reproduction and sustenance. A public health system only designed to look for and treat a limited window of diseases misses the opportunity to disrupt what is probably a vast ecological complex.

First, we have a problem of poor diagnostics. Facilities traditionally treat most fevers presumptively as malaria, dispensing drugs appropriate to that condition. However, conditions like dengue fever exhibit similar symptoms. While is it extremely likely that dengue is all over the African continent, particularly in urban areas, there is little ability to identify true dengue cases in the public health sector, and thus, in addition to mistreating patients, the extent of the disease burden is unknown. We cannot tackle large public health issues without proper data.

Second, we have the problem of all of the “known unknowns,” that is, we know for a fact that there’s more out there than we have data for but we also know (or at least I do) that there is a greater disease ecology out there. We know that many pathogens interact with one another for their mutual advantage or to haplessly effect significantly worse outcomes. The awful synergy of HIV and TB is just one example.

OK, I’m going to go and deal with my own pathogenic tenant which I think I’ve identified as an enteric pathogen of the genus Pseudomonas, which might have taken hold opportunistically through an influenza infection. This is complete speculation, however. Data quality issues prevent a reliable diagnosis!

A day to celebrate JICA toilets in Nyanza, Kenya

DSC_2057Today I went along with some of my colleagues to not one, but four, dedication ceremonies for a JICA sponsored clean water project.

It’s been an extremely long day.

Nearly 80% of people in this area of Kenya practice open defecation. They don’t use toilets. Of course, fecal matter washes into the lake, which happens to be where they all get their drinking water from. Diarrheal disease is, of course, out of control.

As a public health professional, I’m justifiably annoyed that there are people out there who can’t handle even the simplest sanitation solution: shitting in a single hole. However, it is what it is.

JICA has sponsored the construction of put latrines and the installation of water tanks at several schools in the area. These interventions are dirt cheap, but are way beyond the financial reach of impoverished communities along Lake Victoria. While we would assume that the Kenyan government would be expected to contribute money to help protect their children, the reality is that this area has been politically marginalized since independence. Schools can’t depend on the government to provide even sufficient wages for teachers, let alone sanitation infrastructure. Given the political problems between the current Kikuyu government and the Luo, it’s unlikely that the funds would be provided, even if they were available.

One of the schools we visited is 100% community funded. While it was a rudimentary facility, the locals have to be commended for taking matters into their own hands. I just wish they’d take sanitation more seriously.

Talked to a great bunch of people, listened to some great stories and drank 7 bottles of Coca-Cola. Off to bed.

Did pathogens influence the course of human development?

Roman toilets

Roman toilets

I would say “it depends.” I was just reading an interesting article on the “pathogen stress theory” of the development of human societies, most often attributed to Randy Thornhill, an evolutionary biologist at the University of New Mexico.

According to the “pathogen stress theory of values,” the evolutionary case that Thornhill and his colleagues have put forward, our behavioral immune systems—our group responses to local disease threats—play a decisive role in shaping our various political systems, religions, and shared moral views.

If they are right, Thornhill and his colleagues may be on their way to unlocking some of the most stubborn mysteries of human behavior. Their theory may help explain why authoritarian governments tend to persist in certain latitudes while democracies rise in others; why some cultures are xenophobic and others are relatively open to strangers; why certain peoples value equality and individuality while others prize hierarchical structures and strict adherence to tradition. What’s more, their work may offer a clear insight into how societies change.

This is a reasonable view, and something I’ve long observed from working on infectious diseases in developing countries. The developmental trajectory of a country is influenced by the deliberate avoidance of illness. An example can be seen in the locations of African cities. Many African administrative capitals are located on isolated, cool hilltops, far away from rivers and lakes. Colonialists would intentionally set up shop in areas where they were unlikely to encounter malaria.

Developmentally, this has had major implications for trade within Africa. European cities are often placed along water ways amenable to domestic European trade. The lack of trade between African countries is one of the reasons the continent has developed so poorly. This is the direct result of not only colonial priorities of resource extraction to Europe, but also the unfortunate placement of economic centers in response to malaria.

Certainly, the nature of cities themselves have much to do with the control of infectious diseases. Public works often involve the management of sewage waste and the delivery of clean water. Thornhill might suggest that the development of democracy, citizen involvement and taxation to pay for urban improvements are in direct response to enteric diseases.

However, while it is interesting to try to apply this view, it can be taken to the extreme:

Fincher (a graduate student of Thornhill) suspected that many behaviors in collectivist cultures might be masks for behavioral immune responses. To take one key example, collectivist cultures tend to be both more xenophobic and more ethnocentric than individualist cultures. Keeping strangers away might be a valuable defense against foreign pathogens, Fincher thought. And a strong preference for in-group mating might help maintain a community’s hereditary immunities to local disease strains. To test his hypothesis, Fincher set out to see whether places with heavier disease loads also tended toward these sorts of collectivist values.

I’m not sure it’s that easy to boil down political differences between Asia and Europe to a need to manage infectious disease. Certainly, Sweden is more collectivist than England, but I wouldn’t say that their infectious disease profiles are all that different.

Worse yet, if taken to the extreme, this “hunt for significance” will provide one with evidence to support any crazy theory at all. Pathogens exist wherever humans do. Moreover, we risk attributing the contribution of pathogens to human development based on current conditions, assuming that the present is deterministically preordained centuries ago. Until very recently, nearly the entire world was at risk for malaria, but despite this, various societies have embarked on different social and political trajectories.

The biggest problem I have with the theory is in its basic in rational theory. It assumes that humans are making rational choices based on pathogen threats, when we know, and particularly those of us who work in the tropics, that humans often have poor conceptions of disease transmission and causes of illness. At times, despite very obvious threate, humans will act in manners which exacerbate that threat. The history of enteric disease is filled with tales of ignorance and folly.

If we are going to subscribe to a rational model of political and social development which includes pathogens, then we have to also address first, the ability of pathogens to hijack human behavior to create new opportunities for replication and survival and second, that social changes can exacerbate the worst effects of infection. For the first point, I would look to the development of international trade systems which allow pathogens such as influenza to move around the world quickly, increasing opportunities for mutation to avoid immune responses. For the second I would point to polio, a disease which becomes a problem on after the introduction of water sanitation practices.

Thornhill’s ideas are interesting, and certainly provide good material for the popular press and BBQ conversation, but they require that the reader suspend too much consideration of the details of the complex history of human social and political development. Taken with restraint, as in the example of the locations of African cities, they can provide interesting insights into how current conditions are impacted by past pathogenic threats.

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