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New Publication: ITNs on Vanuatu

Today, in Malaria Journal, a new publication appeared with my name on it (though I am not the main author). This will be a record of one of the most challenging experiences of my life.

In 2012, my friend Akira and I went hiking in the mountains outside Osaka. It was a pretty easy hike, but on the way down Akira twisted his ankle and sort of lumbered down the rest of the trail. After a few days, the pain got worse and he had to cancel an upcoming research trip to Vanuatu. He asked me to go in his place and offered to pay my expenses. I was due to go on a couple of other research trips that summer so I couldn’t commit, but the only other gringo on the trip begged me and at the last minute I decided to go.

Long story short, it was a crazy set of interpersonal dynamics, we suffered bacterial infections, got stuck on an island for ten days because a plane needed to be repaired, one of us didn’t eat or drink water for ten days, much fish was eaten (but the people who ate), much kava was drank and stories were told. Our diet alternated between delicious seafood and fresh fruits to ramen noodles over rice.

It was a surreal experience. I lost ~16 pounds, down from 175 to 159, came back with numerous skin infections and was a general physical wreck for months, more so than usual. It was challenging, but an experience I am unlikely to forget. I hope to go back one day.

The paper can be found here.

Pictures from Vanuatu (back when I took pictures) are here.

“Background
Insecticide-treated nets (ITNs) are an integral piece of any malaria elimination strategy, but compliance remains a challenge and determinants of use vary by location and context. The Health Belief Model (HBM) is a tool to explore perceptions and beliefs about malaria and ITN use. Insights from the model can be used to increase coverage to control malaria transmission in island contexts.

Methods
A mixed methods study consisting of a questionnaire and interviews was carried out in July 2012 on two islands of Vanuatu: Ambae Island where malaria transmission continues to occur at low levels, and Aneityum Island, where an elimination programme initiated in 1991 has halted transmission for several years.

Results
For most HBM constructs, no significant difference was found in the findings between the two islands: the fear of malaria (99%), severity of malaria (55%), malaria-prevention benefits of ITN use (79%) and willingness to use ITNs (93%). ITN use the previous night on Aneityum (73%) was higher than that on Ambae (68%) though not statistically significant. Results from interviews and group discussions showed that participants on Ambae tended to believe that risk was low due to the perceived absence of malaria, while participants on Aneityum believed that they were still at risk despite the long absence of malaria. On both islands, seasonal variation in perceived risk, thermal discomfort, costs of replacing nets, a lack of money, a lack of nets, nets in poor condition and the inconvenience of hanging had negative influences, while free mass distribution with awareness campaigns and the malaria-prevention benefits had positive influences on ITN use.

Conclusions
The results on Ambae highlight the challenges of motivating communities to engage in elimination efforts when transmission continues to occur, while the results from Aneityum suggest the possibility of continued compliance to malaria elimination efforts given the threat of resurgence. Where a high degree of community engagement is possible, malaria elimination programmes may prove successful.”

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Pictures from Vanuatu

Been busy recently and just haven’t had the time to write.

In the meantime, here are some pictures from my recent trip to Vanuatu. I should be writing about Vanuatu, but the pictures will just have to speak for themselves.

For those unfamiliar, Vanuatu is a small set of islands in the South Pacific. It’s a poor struggling country that has just about anything a person could ask for: great people, great beaches, great weather and access to just about anything you could ever want to eat. Couldn’t ask for a better place to do research. Now that I’ve fallen back into a repetitive life of writing and work, I’ve forgotten when a great trip this was.

The Price of Sex in Developing Countries

During my recent trip to Vanuatu, I had an interesting conversation with the single worker at the local health clinic on Aneityum, a small island of approximately 700 people. He noted a recent and disturbing rise in sexually transmitted infections (STIs) among the islanders.

The small village of Anelcauhat has a population of approximately 400 people. Out of those 400, approximately 200 (or more) are thought to be sexually active. He reported that he has seen more than 50 symptomatic STI cases in the past 6 months, a shocking number, particularly when one considers that an estimated 70% of all bacterial STI infections are asymptomatic.

The reasons for this are unclear though Aneityum has a long relationship with STIs. In the early 19th century, the population of Aneityum was more than 12,000 (depending on who you ask or believe). By the early 20th century the population had been reduced to a mere 200 people, in part because of a sudden drop in fertility. Gonorrhea and syphilis had rendered the entire female population infertile.

In Vanuatu, like many developing countries, more than 50% of the population is under 24. Youth is a major determinant of risky sex everywhere. A lack of educational resources for youth and low knowledge of STI prevention practices exacerbate the problem and increase risk for everyone. Worse yet, traditional structures make discussion of sexual issues taboo, and male community leaders have been known to discourage condom promotion, thinking that it promotes sex (sound familiar?).

Culture enables increased STI risk. Partnerships in developing countries are often difficult to assess. In some areas of Sub-Saharan Africa, despite the presence of strong religious groups, multiple concurrent relationships are the norm. Concurrent partnerships have long been shown to be a major driver in the HIV epidemic. In Aneityum, formal polygamy does not exist, but any man may have many “Custom Wives” in the community, a connection that must certainly come with extracurricular benefits though people are incredibly vague on the subject.

The shift to cash based economies is fueling STI transmission. Vanuatu, like all developing countries is experiencing not only a population boom, but also an urbanization boom as young people increasingly move to urban areas for jobs, social and economic opportunities. This crates disconnected populations, who often negotiate social connections through romantic partnerships, free of their local watchdogs.

Gender inequality places everyone at risk. Cash wielding older men readily take younger women under their wing, exposing young women to STIs of an older generation. Formal prostitution flourishes where men increasingly have ready cash, and a supply of disconnected, unemployed women rises. No 16 year old girl wants to be a village prostitute where everyone knows her family.

Truthfully, noone knows what the future holds. The fact is, though, that around the world, STIs are diseases of the poor and particularly do well in areas where access to health care is scant. I worry for an area like Aneityum. Clearly, all of the mechanisms to transmit STIs are there. If HIV hits their shores, the entire community would be ripped apart.

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