February has been a busy month at Africa University (AU). We're in the midst of the rainy season, and this year the rains have been more abundant than they've been for many years. This is good for the farms, but the downside has been a sharp upsurge in malaria.
In the past, malaria has not been a major threat in this part of Zimbabwe because of Mutare's elevation and relatively cool climate. Unfortunately, global warming is having an impact here. While the rise in average temperature seems small, it's enough to give malaria-carrying mosquitoes a stronger foothold in this area. With lots of breeding areas for them due to the rains, malaria rates are climbing.
Two weeks ago, malaria was the subject of Grand Rounds at Mutare Provincial Hospital. The first case was that of a four-year old boy who had been referred to the hospital from a district clinic because of fever and rapidly developing coma in the preceding day. He had malaria complicated by acute cerebral infection and acute malarial hepatitis, complications that are often fatal. Fortunately, he responded to aggressive treatment with intravenous quinine and made a good recovery.
The second case was that of a young pregnant woman who presented to the emergency room late at night with high fever. She was not as fortunate as the young boy, dying of malaria a few hours after admission. Both these cases occurred that week. Even more alarming, there have been several other such deaths this month. Pregnant women are especially vulnerable because their immunity to malaria is reduced. Their risk of death from malaria is two to three times higher than for most adults.
Malaria and Neglected Tropical Diseases
As it happened, a long-planned Colloquium on major diseases in Africa was held at Africa University this past week. One of the half-day sessions was on malaria. We heard an upbeat report about research on light-weight "malaria blankets" that has been conducted by AU and the London School of Tropical Medicine and Hygiene. Use of these insecticide treated blankets proved to be safe in reducing malaria by more than half in high risk areas.
Insecticide-treated nets have been used for several years and are effective if used. The problem is that they're often not used consistently. Light-weight anti-malarial blankets now offer another good tool for protection against malaria.
Nobel prize-winner Dr. Peter Agre from Johns Hopkins University was present at the Colloquium. He won the Nobel Prize in Chemistry in 2003 for his research leading to the discovery of "aquaporins," specialized water channels in cells. Since our bodies are 65 percent water, the cellular management of the movement of water in and our of cells is crucial for life and health. Dr. Agre's research is now focused on malaria. He gave us a great talk on the discovery of aquaporins, and then discussed their potential role in the control of the malaria parasite.
Malaria, AIDS, and tuberculosis have fairly high profiles. They are not neglected in terms of attention and resources directed to their control, but more than fifteen diseases are called "Neglected Tropical Diseases" because they have largely fallen off the world's radar screen. Dr. David Okello, the WHO representative assigned to Zimbabwe, gave us an excellent overview of the serious problems posed by these "neglected" diseases.
I won't bore you with a detailed account of all these diseases, but it's worth taking a quick look at Schistosomiasis. This is a disease caused by a small parasitic worm that has a complicated life cycle, half completed in water-loving snails, and half completed in humans who wade in or use waters inhabited by these snails. The larval form of the parasite swarms in these waters, penetrates the skin of humans who wade in them, and then develops into the adult form of the worm in the tissues of the human body, where it causes many serious health problems.
We have known about this disease for over a century. As a child growing up in Angola, I was emphatically told not to ever wade or swim in streams or pools because of the risk of this disease. It is still very prevalent, affecting over 200 million people in over 70 countries of the developing world. Man-made dams and irrigation programs have made the problem worse in some areas, opening up vast new areas for fresh-water snails. It remains a serious health problem in Zimbabwe, with school-age children in endemic areas being particularly vulnerable. Obviously, it is a big challenge!
Non-Communicable Diseases (NCDs) in Africa
Although tropical diseases still pose a huge burden in Africa, the non-communicable diseases of the West, such as diabetes, hypertension, stroke and heart disease, are now having a major impact in Africa. When I was a child in Angola 75 years ago, these diseases were virtually unknown among Africans. Even when I taught at the Public Health College in Ethiopia 45 years ago, they were rare. Today, they have become common, causing a "double burden" of disease in Africa: the newer burden of the Western diseases added to the historical burden of the tropical diseases.
Harvard University's School of Public Health has launched a major research initiative to better understand the scope and underlying causes of these diseases in Africa. Harvard's PaCT (Partnership and Cohort Training) project in four African countries is enrolling 500,000 Africans in different walks of life, and will follow them for decades to find out what factors are major contributors to this burgeoning epidemic in Africa.
Dr. Michelle Holmes of Harvard is one of the principal co-investigators in the PaCT project, and we were privileged to have her deliver the NCD Keynote Address in our Colloquium last week. Titled "The Epidemiological Transition and its Implications for Health Services in Africa," her talk laid out the challenge of NCDs to health and health services in Africa very clearly. She also met with our faculty and students in an interactive "Q & A" session the day after the Colloquium ended. Everyone greatly appreciated her presence and her response to questions.
Lifestyle is a dominant factor in determining vulnerability to non-communicable diseases. This is clearly recognized by the World Health Organization as well as the Centers for Disease Control in the United States. The epidemiological transition in Africa over the past fifty years provides strong evidence of lifestyle's power over health. As the West has exported its products and lifestyles to Africa, it has fostered the epidemic of Western diseases hitting Africa today.
Yet, lifestyle's powerful impact on health is vastly underestimated by patients and health professionals alike. On the last day of the Colloquium I gave a talk on Lifestyle Medicine and NCDs in which I documented the power of lifestyle to affect health, either favorably or unfavorably. I also proposed establishing a Center of Lifestyle Excellence in Africa. This idea was well received, and it will be interesting to see how it develops.
I close this newsletter with a little vignette about Dr. Holmes. She is an avid hiker, having hiked half the length of the Appalachian Trail over the last few years. When I learned about this, I asked if she would like to hike here at AU. Her answer was an enthusiastic "Yes," so we went on a 10K hike over rolling hills on her last day here. We chatted as we hiked along - a fun way to share thoughts. I can assure you that she is someone who really walks her talk!
Ed Dodge, MD, MPH