Colombia, Addendum #3: The origins and causes of disease at a population level

If we know that mosquitoes spread disease, then what do we need to combat them and the diseases they spread? Do we need material resources to have environmental controls? Or do we need knowledge to know how to prevent them from establishing reservoirs? These are the questions in my head.

For the record, I’ve never claimed to be smart. Heck, I’m convinced that getting into the most prestigious public health school in the world is a fluke, more the result of inspiration and guidance from some very smart people than from my actual achievements. Some people tell me that I’m suffering from “impostor syndrome,” but I’m pretty sure I’m the dumbest person walking those halls… The dunce amongst the nerds.

Upon seeing a picture of the places where I went the other day, and reading the story of the mother with the special needs child, a brilliant friend of mine and fellow student at the school asked something that has had me thinking. He asked if the woman having mosquitoes in her house was a result of her ignorance or her poverty, or both. This made me think about it a lot because it speaks to the kind of interventions needed to keep Chikungunya at bay here and in other places in the world. (And not just Chikungunya. There are plenty of other vector-borne diseases.)

If it’s her poverty, then the solution would be to provide her with the resources needed to install screens on her windows and doors, air conditioning so they don’t have to open windows to cool the home, and running water in enough supply so she doesn’t have to keep it in open containers. How that assistance would be delivered is for a whole other blog post. But would that be enough?

If it’s her ignorance of the entomology of mosquitoes and the epidemiology of vector-borne diseases, then the solution would be to tell her to cover any water containers, add clorox to the water, and properly scrub containers when she cleans them out. She would also be given information on identifying mosquito larvae and the different species of mosquitoes and the diseases they carry. Of course, she would be educated on other health things that she could combat at home.

The third inevitable cause is that there is a combination of things contributing to the larvae in the household. But to know how each contributor does its thing would require some sort of a study. (Though I’m very sure that there is some knowledge out there on this… I just don’t have the internet bandwidth to go searching for it right now.)

More uncovered standing water containers

Are there larvae in here because of lack of resources or because of lack of knowledge?

This, ladies and gentlemen, is the everlasting tension in public health policy. On the one hand, you have people who say it’s the resources. On the other, you have those who say it’s the knowledge. You may also have some people who say that it’s the woman’s own fault for not seeking out the knowledge, or not having a good-paying job, or some such nonsense. And others, also on the extreme, will blame the whole of society for not stopping what they’re doing and coming to the woman’s aid.

But I like to stick with reality.

We are arriving at an age where information will travel from point A in the world to B in another part of the world in an instant. Cellular telephones, which are more computers and less telephones nowadays, will allow people of different social strata to all communicate and have access to information. It has to be the right information, though. The worst thing that could happen in the case of the woman in question would be for her to subscribe to the idea that Germ Theory is false.

Delivering that kind of information to the hands of every person in the world is a problem of both resources and knowledge. You have to have the resources to deliver the vehicle that will transfer the information, and then you have to deliver the right kind of information to confer the most knowledge. How to do it is, again, something for a later blog post.

Of course, there are likely consequences to all this. Mess with the balance of resources and information/knowledge, and you can have worse consequences than you started off with. Just look at all the people who do “their own research” online. Or deliver the right knowledge without resources and the intervention is useless. Then there are matters of lifestyle and social pressures.

These are the things that keep me up at 3am on a Thursday night in Barranquilla, Colombia.

  1. Your posts are reminding me why I am spending the summer refreshing my public health and data analysis skills. Looking forward to work that isn’t always in front of a computer screen..
    Resources and knowledge are key, but I think buy in and culture go a long way.
    All the Best,
    Mimi aka @yayayarndiva

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  2. There is an old saying, give a man a fish, he’ll eat a meal. Teach a man to fish, he’ll have a meal for a lifetime.
    I say this from one who has conducted train the trainer in multiple nations. Detailed explanations as to *why* something is being done in a certain way and answering the torrent of questions is also part of that.
    I’ve actually had to explain why the outhouse shouldn’t be three meters uphill from a well. Their reasoning was, it was farther from the home, hence healthier. The old miasma theory does tend to be instinctive. I had to explain a few things, one was germ theory, one was monsoon rains can create a horrific truism.
    Shit goes downhill, straight into the well.
    Water purification, via low technological means, improvised filtration units, Chlorox, where to draw the water, etc. It was more fun with English speakers, where I could use my ancient joke of water petrification. After all, the filter is part rock and Chlorox…
    Then, there was the training of disposing of human waste of those with GI bugs. Cholera *is* a messy disease in the extreme. Improper cleaning, improper disposal of waste all can spread the disease and burn pits aren’t effective on such a wet and messy illness. Deep pit with lime or chlorine products can lower the risk of spread, assuming a deep aquifer.

    A lot is simple ignorance of contagion, fomites, basic sanitation, a fair amount is poverty. But, covering water supplies is a thing that can be done with scrap rags. Boiling water is plentiful, even amongst the most poverty stricken. Processing foods for storage without refrigeration is something that humans have done for literally tens of thousands of years and salt, a key preservation chemical is plentiful.

    A case in point; While I was in the Persian Gulf region contracting after retirement from the military, my wife and I began to have some GI distress and after drinking a heavily colored drink (pomegranate concentrate colored), I noticed worms in my watery stool.
    I sought treatment for the unwanted internal guests and after, examined our water supply.
    The nation uses a low pressure water supply system, with storage tanks on the roofs of buildings. Our villa was no exception.
    As there were no reports of other water borne illnesses, I suspected it was local. To my horror, the water tank on the roof was not only uncovered, it had dead insects and a dead bird in it!
    I spoke with the villa maintenance workers, nice folks from Nepal, the Philippines, Egypt, etc. All rural folks, with limited education. The explained that they unscrewed the cover for maintenance work and didn’t bother covering it, as leaving it open was thought harmless.
    I explained that dead animals in water isn’t very healthy, indeed we became ill over it and a sandstorm would fill the tank with dust, which would harden and eventually clog the plumbing, creating a massive mess to repair.
    They kept the lids screwed on tight on the tanks from that time forward. I helped them sanitize my water tank and we moved on from there.
    Ignorance can be treated by education to great effect.

    Watching them work on plumbing, well that was like a slapstick comedy act. They’d routinely forget to turn off the pump and water valve. Often enough that I joked with their Moroccan supervisor that his entire crew were now Christian.
    He looked at me with a shocked expression and asked why I said such a thing?
    I explained, as the water sprayed from the partially disassembled faucet, “Because they keep baptizing themselves!”
    He nearly fell over laughing.
    Some day they’ll learn to turn the pump and valves off… 😉

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  3. In both Cuba and the isthmus of Panama William Gorgas enacted very military systems to control mosquitoes. Those methods would not be well accepted these days. I hope the genetically modified mosquitoes will soon help.

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    1. DDT did wonders, then the horrors of what else it did caused it to be rarely used.
      So, I hope those GM mosquitoes do the job well as well!

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      1. DDT was not commonly used during the first couple decades of the 20th century, actually according to its Wiki page it was not known to be an insecticide until the late 1930s. Gorgas was an Army doctor and he ordered swamps drained, putting oil on ponds, some kind of fumigate, mosquito netting, and had military personnel going around making sure there were no containers of water anywhere. The reason his methods would not work to well now is that it requires an almost military dictatorship with lots and lots of dedicated soldiers.

        From http://www.pbs.org/wgbh/americanexperience/features/general-article/panama-fever/ :

        President Roosevelt granted the funding, and Gorgas unleashed one of the most extensive sanitary campaigns in history. In the summer and fall of 1905, more than 4,000 people worked for Gorgas on his “mosquito brigades” in what would become a yearlong effort to prevent the insects from depositing their eggs. An army of fumigators visited every private home in Panama repeatedly, armed with cleaning agents, insecticide powder, and wire mesh for screen windows and doors. Teams sprayed drains and cesspools with oil and filled in pools of standing water. In all, Gorgas’ group used 120 tons of pyrethrum powder, 300 tons of sulfur, 600,000 gallons of oil, 3,000 garbage cans, 4,000 buckets, 1,000 brooms, and 1,200 fumigation pots.

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