I spent the morning, and early afternoon, in a meeting of local organizations, all of whom are engaged in cross-border malaria work. There were a variety of groups at the table, and each had a slightly different mission. One runs a series of clinics in the more stable parts of the conflict areas. One has mobile medics that range throughout the somewhat less stable areas, and another focuses on emergency relief immediately following an attack. My organization doesn't run any programs directly, and was there because we provide technical assistance to all of these programs.
Malaria is the number one cause of death in eastern Burma. This is particularly alarming as it is an entirely preventable, entirely treatable disease. The fact that it is so prevalent, and causes such harm, is evidence of the complete lack of health infrastructure in the conflict areas, and the difficulty in providing the necessary medical interventions. My organization has been providing technical assistance to malaria programs for six or seven years. Over that time, we have measured a drop in malaria prevalence from well over 10% to less than 1% in some areas. This is a huge accomplishment. But even though the malaria programs we assist cover a population of over 40,000, there are over 500,000 IDP (internally displaced persons) in Eastern Burma. Other programs reach some more people in other areas, but there are still many that it is difficult to get to at all.
We had this meeting because the group that provides emergency relief wants to strengthen its malaria treatment component. Typically, when they get word of an attack, they send a team to the area and provide emergency medical care and humanitarian assistance, but they can only stay in the area for a few days. This organization goes wherever there is immediate need, and as such they are often operating in the most unstable areas, where other programs are not able to function. These populations are often on the run, having fled or been forced out of their village, and it is extremely difficult to provide health services to a mobile population in hiding. Or even if they have stayed in their village, it is not possible to offer much more than emergency relief in areas of active conflict. There is a gap, therefore, between when the emergency relief team leaves, before other services can resume. In part, the meeting today was to figure out how to help the community deal with the burden of malaria during this gap.
The immediate idea is just to leave a stockpile of medication with the community. The problem is that malaria in this region is highly drug resistant. Over 40% of cases are resistant to the traditional quinine treatment. The gold standard treatment is Artesunate combination therapy. Artesunate is currently the best drug for fighting malaria - it is highly effective, and there is no resistance to it yet. In order to keep it that way, it is given in combination with another drug (several combinations exist), and health programs are very careful to ensure that patients finish each complete course of treatment, to avoid any chance of developing resistance.
The problem with leaving a stockpile of drugs, therefore, is that if you leave Artesunate, without someone there to ensure its proper usage, you are risking the development of resistance. If you leave another drug in place of Artesunate, a large percentage of cases won't be cured.
So the next step is to figure out how to ensure that someone in the community knows how to correctly use the drugs. Because the population is on the run, or in a highly unstable area (or generally, both) it isn't safe to leave someone from outside the community there. That person becomes a target, and also endangers the community. So the next option is to train someone in the community to oversee drug distribution. The emergency relief teams are only with the community for 2-3 days, so in that time, they need to be confident in the ability of the health volunteer that they train. So at the meeting we were considering how to draw from other village health volunteer training programs some core elements to form into an abbreviated training that could be conducted in this setting. A village member thus trained could then be left with a stockpile, and be trusted to dole out medicines appropriately, and ensure proper compliance.
The final question, then, is how can we make sure that, even after training a volunteer, the Artesunate is being used properly. In this unstable setting, is there any kind of monitoring or evaluation that is possible to ensure that we are not risking Artesunate resistance. This, is the most difficult question. It is extremely difficult to do so.
The dilemma then, is this: Effectively treating malaria in those highest conflict areas seems to require leaving a stockpile of drugs, which if used incorrectly risk developing resistance, rendering malaria untreatable in that area, with the possibility of global impact. Clinical medicine requires that the patient in front of you be given the benefit of all of the resources available to you, and the benefit of the best possible treatment. Public health seems to imply that the risk involved demands a more cautious approach. A very delicate balance indeed.
Long ago (a term used only relative to the course of my own lifetime) I switched my aspirations from clinical medicine to a public health approach, because of a dedication to social justice, the desire to impact many individuals and not just the one in front of me, and because of an interest in attempting to address distal, rather than proximal causes of ill health. In doing so, I have striven to never forget that a population is comprised of individuals, each equal in human dignity and worthy of individual consideration. This commitment has caused me to disagree with some aspects of national public health policy, and ultimately to end my service with the Virginia Department of Health. Still, public health requires all kinds of balancing acts. The individual v. the community, domestic priority v. international need, treating symptoms v. addressing root causes, focussing on treatment v. focussing on prevention. I have tried in my own small contribution to public health, to draw on the Quaker tradition, and seek the third way, that honors both needs in a common solution rather than seeing them as opposing forces that must be decided between.
I find myself now perched on a wall between two ends of the table. Between those who are unwilling to sacrifice even one life standing before them, and those who are concerned primarily with the continued ability to treat malaria effectively. I am determined to find a way to meet the interests of both parties, to honor the lives on either side of this wall, but at the moment, all I can feel is the very tenuous nature of my perch, on a wall that feel very narrow, swathed in barbed wire and studded with broken bottles, death, useless death from a preventable, treatable disease, waiting on either side. In all my studies of bioethics, of finding arguments to line up in defense on either side of an issue of life and death, I always felt a sense of remove. Sitting here now feels, perhaps, a little too real.
I know this isn't my decision, or my problem alone. But neither is it a dilemma I can ignore. I can't help feeling nearly crushed by the desperateness of a situation like this. And that, at this moment, its my obligation to see what I can do here, for these few lives, in this small portion of a small country in this small corner of the world.
Really, the solution is to end the conflict in Eastern Burma, and help establish a Burmese government that sees health care, even for its ethnic minorities, as a priority worth investing in. In the meantime, we need to find a way to honor both the person standing in front of us with malaria, and the one who will require treatment tomorrow.
Frankly, treating a person standing before you is immensely more gratifying than seeing the small ripple your immense energies in public health can create. It is tempting to abandon hopes of having a larger impact, and committ oneself to the only meaningful impact you can be sure to have: on one life at a time as they stand before you. Treating someone's illness, or even helping them die with dignity, witnessing to their life, and promising that they will not die forgotten, that is real, and meaningful.
I don't know what the answer is. But I will participate in trying to find an answer. To find some workable solution, thought it be a very delicate balance.
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