Though the title of my May 28 post refers to a much less serious misdiagnosis than the kind brought to my attention by Dr. Desiree LaBeaud of Children’s Hospital Oakland, a common source connects these misdiagnoses. When I complained about “The unbearable agony of the three-minute download” of the Bacho Community Survey linked to my earlier, May 18 post, I suspected my blog’s WordPress.com platform as the culprit. Yet having recently replaced—or, to give due credit, having had a friend of my son replace—my laptop’s Windows operating system with Ubuntu, for which nobody bothers to write viruses, I can now download the survey in a few seconds.
My misdirected frustration with WordPress implies that I understand computer viruses almost as badly as I understand the sorts of viruses which can debilitate our bodies or kill us, especially in poor countries. When I met Dr. LaBeaud for lunch last Tuesday at Children’s Hospital, she highlighted my misunderstanding of the latter kind of virus. I don’t mean that she condescended to me in any way, or to the other non-physicians at our table, Jeff Chow of Collaborate for Africa and Barbara Beery, Children’s Hospital’s Director of Planned Giving, the two people who had arranged the lunch and generously included me. Based on the two hours we all spent together, I don’t see a capacity for arrogance or condescension in Dr. LaBeaud’s nature. But she brought her hard copy of the Bacho Community Survey to lunch and had already scanned it with the trained eye of an expert in neglected tropical diseases. So just about the first thing she said after introductions, as she flipped to page seventeen of the survey with one hand while trying to secure a forkful of lasagna with her other hand, was that our survey’s over-representation of the prevalence of malaria typifies such surveys.
“A lot of these cases aren’t really malaria,” she told me, pointing to the line indicating that forty-three percent of Bacho’s children under five years old had suffered from malaria. “But the international aid community pours all its money into fighting three diseases: HIV, malaria, and tuberculosis.”
Dr. LaBeaud suggested that this community’s approach affects how sick people in poor countries and the people treating—or burying—them think about disease.
“Everybody knows about malaria, so if there are malarial symptoms, of course that’s what gets diagnosed. But usually there’s no test to confirm this.”
I described my visit with Marianne last year to the public clinic closest to Bacho, a brisk half-hour walk away—for a strong, healthy adult—in Dareda. One lone, exhausted community health worker, with neither a doctor’s nor a nurse’s training, staffs this clinic intended to serve more than thirty thousand residents of several villages. Nobody in Bacho owns a car or truck and not many people own bicycles, which the rough footpath from Bacho to Dareda would flog, anyway. How long would it take to carry a sick child over that path to the clinic? And how would that forlorn health worker administer a reliable test to confirm a diagnosis of malaria? His clinic had no running water and had access to a toilet only fifty yards away at the public outhouse, with its squat-hole and parallel lack of any sink or running water. I felt some guilt for our VIP visit which interrupted this man’s attempt to care for his patients, about eight or ten mothers sitting outside with their children. Then again, he looked like he needed a break from patient-care, anyway—perhaps a couple of weeks on the beach in Hawaii, which he will never see. I can’t remember his name, but I recall thinking he may have been around thirty although the dark circles under his eyes made him seem older. And I also remember thinking, maybe a little eccentrically, that it must take a profound level of exhaustion to produce visible dark circles on the skin of a black African. That’s probably silly; I’ve seen plenty of hard-working people in Tanzania, however, yet never anybody else who appeared as tired as this health worker did. He told us not to worry too much about making his patients wait, since some of the mothers had brought their children for checkups rather than treatment. He gestured toward the tree outside that shaded his window and mumbled something, in Swahili as always. Karimu’s Tanzanian Board Member, Joas Kahembe, had driven fifteen miles from his home in Babati and then driven Marianne and me on an indirect route from Bacho to the clinic, sparing us the long walk. Joas was translating for us, so we asked him what the health worker had said about the tree. “He says that’s the only place he can hang his scale to check the babies’ weights.” Marianne asked how he checks their weights during the rainy season and Joas translated. The man shrugged, then stared at his shoes.
Dr. LaBeaud would have experienced even worse conditions. A couple of times a year she leaves her husband—a neurosurgeon, I think at Stanford—and two small children behind to do field studies in Kenya, sometimes among seminomadic pastoral peoples like the Masai, who might live hours away from any clinic. She concerns herself particularly, out of all the neglected tropical diseases, with nonmalarial arboviruses, or diseases borne by arthropods. This takes in arachnids, crustaceans, and insects, mainly mosquitoes. She has studied Rift Valley fever virus, which I suppose one could mistake for malaria because of the fever it produces. Health officials know that in 2007 an outbreak of this virus killed people in Kenya and in two areas of northern Tanzania to which Karimu’s volunteers go: the Manyara Region, where Bacho and Dareda lie, and the Arusha Region. In an article from 2008, “Why Arboviruses Can Be Neglected Tropical Diseases” (http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0000247), Dr. LaBeaud writes that Rift Valley fever virus “can lead to permanent visual loss or impairment, which can have a great impact on long-term productivity and quality of life.” One should put her claim that full or partial blindness can damage productivity and quality of life in the context of existence in poor countries like Kenya and Tanzania, which lack the means we have in the rich world to address the severe disadvantages historically associated with blindness. The Masai people of Kenya and Tanzania certainly fall among the seminomadic pastoralists whom, as Dr. LaBeaud notes, Rift Valley fever virus “disproportionately attacks. . . because resource-limited conditions lead to high-risk animal husbandry practices and lifestyle.” On the other hand, nearly all the people of Bacho and Dareda, while they keep livestock, possess nothing like the numbers of animals that the Masai own. The villagers that Karimu’s volunteers work with lead a settled agricultural lifestyle rather than a seminomadic pastoral one. But the Barabaig people whom we visit for one day, and about whom I wrote in my May 30 post, live a lot like the Masai do, passing their days with large herds of cattle. I estimate the Barabaig we know would have to walk for at least two hours to reach a clinic. Although that feature of their lives had always upset me, it didn’t help me understand what Dr. LaBeaud meant by “high-risk animal husbandry practices and lifestyle.” Therefore I asked her about this by e-mail and she sent the following reply:
“The high risk activities are slaughtering, birthing, and assisting with animal abortions, in particular. The more animals you have, the more risky. But just being around animals can also confer risk since the mosquitoes get infected after biting on the highly infectious animals and then infect us by biting on us.”
Karimu will supply everybody in Bacho who wants one with a mosquito net when we start our visit in just over a week from today. Our nets can’t keep away all the mosquito-borne diseases, however, no matter how faithfully the villagers cover themselves at night. Dr. LaBeaud also writes as follows:
“[T]reated bednets, which have proven most effective against malaria transmission, are most active against biting Anopheles spp. mosquitoes, which live peridomestically and feed at night. Most mosquitoes carrying arboviruses are not anopheline species. These types of mosquito can feed during the day or at dusk, both outdoors and indoors, meaning that bednets will not be a panacea for all mosquito-borne diseases.”
If mosquitoes which live around households and feed at night do not exhaust the mosquito species carrying serious diseases, I wondered about the Barabaig and the Masai, who walk many miles away from their households during the day in order to graze their livestock. (In recent years these distances have often increased for both peoples, as well as for pastoralists elsewhere in Africa, after forced relocation has taken them farther from the best pasture land. Consider, for instance, the relocation of the Barabaig to make room for the mammoth and unsuccessful Tanzania Canada Wheat Programme, discussed in my May 30 post.) So I wanted to know not only what high-risk animal husbandry practices and lifestyle meant, but if Rift Valley fever virus would afflict pastoralists like the Barabaig and Masai far more than it would the settled residents of Bacho and Dareda. Dr. LaBeaud answered with that mix of caution and passion–embodied in her exclamation mark–crucial always and everywhere to good science: “We should do the studies and find out!”
Yes. Of course, that won’t happen anytime soon. Dr. LaBeaud has studies already scheduled, including another one in Kenya this September and October. And so far I have no idea what kind of effort it would require to set up visits to Bacho and Dareda–and to the area around Mt. Hanang where the Barabaig live, an hour’s drive away–that entailed permission from the Tanzanian government to conduct such studies. Nevertheless, besides my own increased concern about mosquitoes, the other thing to come out of talking to Dr. LaBeaud is precisely what Jeff Chow and Barbara Beery had hoped for when they organized our lunch: the chance that the little nonprofits in Jeff’s Collaborate for Africa network, like Karimu, could work with Dr. LaBeaud and some of the other doctors involved in a new Children’s Hospital Oakland program. This is the Children’s Global Health Initiative which aims to “relieve suffering and meet the needs of children worldwide in an environment of trust, compassion and care.” It remains much too early to know whether the trust that little outfits such as Karimu build in poor communities can pave the way for more studies and additional works of compassion and care by Dr. LaBeaud and her colleagues. I have to emphasize that all of this is preliminary in the extreme. But, since it’s what I’m here for, I’ll keep you posted.–Don Stoll