Sunday, March 23, 2008

Relating to malaria

The following is more or less an excerpt from my book One for the Road. It's a travel book intended to be read as a novel, although there's lots of useful information for travellers in it.

This is my take on how to relate to malaria as a traveller. I am no doctor, and you should not seek out medical information on the Internet without discussing it with your physician. There's a lot of flawed information out there, even though it's usually posted in good faith. However, I live by these guidelines myself, and I do believe you should read and consider the following before you decide how you will avoid becoming a malaria victim.

Both malaria and malaria medication are at the same time scary and fascinating stuff. Malaria is an illness that affects half a billion people every year. It kills one, two or three million of them, depending on which source you believe. No other disease spreads more efficiently. We have tried many ways to stop it, but we just can't do it.

Exactly how and why malaria medicine works is still a mystery to science. Using it can to some people lead to psychedelic experiences recognizable only to the most eager flower children of 1968. Other users have been driven by the medicine to murder the person next to them on the bus, themselves or their families back home several years later. At least that's the claim of the rumours you constantly hear when you travel in tropical regions.

From Medieval Italian, "Mala aria" translates to "bad air". European explorers realized early on that there was a connection between the outbreak of the illness and staying in places with unmoving water and damp, moist air. These are of course places where mosquitos prosper. Still, as we all know, mosquitos don't limit themselves to pestering people near swamps and bogs. No, mosquitos are almost everywhere, and they're happy to attack not just humans. Apes, frogs, birds and large deer are some other favourite targets. If there's blood in a body they will go for it, whether they'll have to penetrate skin, feathers, fur or scales first.

The keenness of hunting mosquitos is possibly only eclipsed by the willingness of biologists to map the diversity of species on our planet. Somehow they have managed to identify more than three thousand different species of mosquitos! Some four hundred of the them belong to the anopheles branch of the mosquito family tree. These are the mosquitos who can carry the malaria parasites that make people sick. In some cases so sick that we die, other times only so sick that we wish we were dead. The risk of actually dying of malaria depends on which malaria parasite you are exposed to. There are four different kinds; vivax, malariae, ovale and falciparum. The last one is the one you really should worry about. It kills.

You may take slight comfort in the fact that to the mosquito, you are the carrier of the infection. In many ways it is just as correct to say that we infect the mosquitos with malaria as the other way around. Both human beings and mosquitos are slaves of the malaria parasite.

To outwit us in our attempts to eliminate them through the use of medicaments, the parasites use a complicated life cycle which begins and ends neither here nor there. To understand how it works, let's begin with a healthy, young and pregnant mosquito of the anopheles family. She, the poor thing, buzzes around in the air, desperately seeking just the tiniest amount of blood to ripen her eggs with. Sooner or later she finds what she seeks: A human. The person is probably sleeping, or maybe not. It doesn't matter. He won't see the mosquito anyway, as she sensibly hunts only in the dark.

The mosquito prepares its proboscis and plugs it into the human source of life-giving, thick, red liquid. Most often this is good for her. Other times, when the mosquito has picked a human that carries malaria, Miss Mosquito will leave its prey as an infected and soon to be sick insect.

Have you ever felt sorry for yourself after waking up in the morning with a pounding head and a dysfunctional stomach? Well, imagine how it would be to feel like that when your expected lifetime is about two weeks, and you know that you have to go to work today, no matter what. That's what it's like to be a mosquito with malaria.

The parasites acquired from the human blood stream find their way to the mosquito's stomach. If the temperature is at least 16 degrees Celsius both inside and outside the mosquito's body, the malaria parasites will start having massive orgies in there. As a result of all the passion, the rascals will melt together and fasten themselves as cysts to the walls of the stomach. We know precious little about what this feels like to the mosquito, but I wouldn't be surprised if it was a triggering factor behind the suicidal behaviour often observed in mosquitos.

Sooner or later the cyst breaks, and the parasites again move through the fragile body of the mosquito. They meet up again near their host's salivary glands. The next time the mosquito strikes a human blood vessel, the parasites will accompany the chemicals that are injected into the human by the mosquito to keep the blood flowing. In a few seconds or minutes, the parasites will have reached the human liver.

There they calm down for at least eleven or twelve days. Some of them will remain dormant for a long time. Months and years can go by before they develop any further. Others will almost immediately start invading and destroying red blood cells as they spread through the human body and excrete poisons. The new carrier of the disease gets sick from the poisoning and must lie down, unable to defend him- or herself against the next bloodthirsty mosquito to come around. And there you are, the cycle is kept going, apparently forever and ever.

For obvious reasons, our battle against malaria has focused on eliminating only one of the two involved carriers of the parasite, namely the mosquito. Many methods are in use, everything from the universal, forceful pat on the mosquito's back, to mosquito nets, repellents, burning spirals and even extensive use of DDT in areas where they can't afford to stop using it. All these actions limit the spreading of malaria, but it's not at all enough to make neither mosquitos nor malaria parasites disappear from the planet. Unless we get rid of the mosquitos, we will not get rid of malaria. Therefore antimalarial drugs is something tropical travellers must relate to, whether they like it or not.

Fortunately there are many ways to avoid being infected by malaria. Sadly, the safest method is to stay in polar regions, preferably far away from any international airport. If you insist on going to the tropics, you will have to stay inside air-conditioned rooms and make sure that you keep your skin covered in a highly toxic liquid. This is hardly compatible with having memorable travel experiences.

If you want to go places where there's a real risk of meeting up with infected mosquitos, you can choose from a wide range of antimalarial drugs. This kind of medication will not stop malaria from entering your body. Instead it aims to prevent the parasites from developing the disease in your body. Sounds good? The problem is just that, well, actually there are several complicating factors.

The problem that should be of most interest to you, is that the medicine may not work at all. Every time we come up with a drug that kills malaria parasites, the parasites will sooner or later develop a strain that is resistant to our chemicals. If you read the small print that came with your medicine, you typically find that medicine X gives you seventy percent protection when travelling in area Y. Hmm. We're talking about life and death here. Your life. How many condoms would be sold if they were marketed like this: “With this thing on, only three out of ten women will become pregnant”? How popular would bungee-jumping be if the brochures on it said “Jump off this ridiculously tall bridge! (The bungee cord occasionally snaps)”? Not much, is my guess. But okay, if you know exactly where you're going and you have updated information on what strains of malaria parasites are at large there right now, you can find a drug that will give you decent protection.

Then comes the second problem, which is also the reason why we will never get rid of malaria completely. Medicine that actually works is expensive. To poor people they are prohibitively expensive, and even to a tourist on a long-lasting trip the cost can be harder to swallow than the pills themselves, as the medicine must be taken both before, during and after the duration of the trip. Two weeks of travelling may mean seven weeks on drugs. If you travel on a limited budget, you may end up spending more money on protecting yourself against malaria than on food or accommodation.

Some of the drugs, typically those that actually work, can only be used for a limited amount of time before to continue taking them becomes seriously harmful to your body. These medicines will of course never be an option for those who live permanently in malaria areas. And there are plenty who do, so the parasites will for a long time to come have lots of victims to attack.

The high price of the medicine may be related to the third problem, namely the many potential side effects. The pharmaceutical giants must pay good money to print the pamphlets that accompany the pill bottles, where all known side effects of the medicines are listed. In addition I guess the companies have to pay an army of lawyers for their assistance as new side effects present themselves.

The number of identified side effects from taking normal antimalarial drugs is vast. Your skin may become more sensitive to sun, which isn't really that dangerous, but neither is it desirable when the reason you take the pills is because you're going to the tropics. You may experience nausea and vomiting, cramps, rashes, loss of hair, an irregular heartbeat and dizziness. You lose your balance, and in return you just get paranoia and problems with sleeping, often due to frantic nightmares. If you're really unlucky, the medicine can give you anxiety attacks and psychotic reactions. That another side effect is depression can hardly come as a surprise. Tragically, it has also been documented that individuals have been driven to clinical madness and suicide after taking some of these drugs. Because the chemicals are active and stay in the blood for a long time, the side effects can be experienced for several months after you stop taking the pills.

Fortunately only a few people experience the most severe side effects. It's still easy to be scared off by the long list of worst case possibilities. Especially when at the same time you know that no one really understands why or how the medicine works. The chemicals used to make the drugs have been extracted from various rainforest plants. I can imagine how a witch doctor with a feather hat and an eerie wooden mask took a bearded white scientist into the jungle and pointed out the plants that his tribe had always used to cure malaria. The white man brought the plants back home, analysed them, scratched his head and did some testing on rats. Sure enough, they seemed to work. Granted, they had some side effects, but who cares about that? He certainly didn't. Now he's sitting somewhere by a swimming pool with lots of servants running around, hoping for the best while his bank account keeps filling up.

Before you choose to take the drugs, you must give them a test run at home. Maybe you'll discover that your trip probably will be better without the medicine after all. If you find the right medicine for your destination, at a price you're fine with and without you starting to see pink elephants the second you swallow the pills, there's still at least one key point to consider: Should you do what's best for you or what's best for the greater good, here represented by the lives of people living in the areas you visit?

Despite what you may think, malaria can in many cases easily be cured. If you get sick, one treatment consists of taking a large dose of the same drugs that are usually taken to prevent you from being infected with malaria in the first place. (Note that this cure is only an option if you have not already taken the medicine as a prophylatic, meaning to prevent you from getting malaria. If you take the medicine and still get infected, you have to go through a treatment that is much tougher on your body.) This is the cheapest cure, hence it is also the one that is usually offered to financially challenged locals in malaria areas. The only problem is that when people use medicine to prevent them from being infected, malaria strains will develop immunity to exactly that medicine. This will in turn lead to the medicine becoming useless as a cure for people living in malaria-prone areas. Tough luck for them, huh?

If you value other people's lives anywhere near as highly as your own, you should probably do what they do. Only use the drugs in the fairly unlikely case that you're actually infected with malaria. If you ask doctors back home what to do, they will probably tell you that for the sake of your own health you should take the pills. It's their job to say that, and you are free to listen to them. But you should at least investigate what strains of malaria actually exist where you're going. If the lethal one, falciparum, is among them, there's more sense to taking malaria pills than if it isn't.

All things considered, the most important thing is to take all necessary precautions to avoid being bitten by mosquitos at all. You know, put on mosquito repellent, wear long sleeves, don't fall asleep drunk in the jungle and just try to stay away from mosquitos, especially when it's dark. If you still get bitten, don't panic. Most likely there are no malaria parasites in the mosquitos that bite you. Just be aware of any symptoms of illness. Remember that it'll take almost two weeks before the malaria can be felt. If you know you've been to a region where malaria exists and you start feeling feverish and shivering cold in turns, immediately seek out a doctor. In places where malaria is common, medical personnel will quickly find out whether you're infected or not, and if necessary they will treat you in the best possible manner. Soon you'll be fine again and can move on.

It's not often you can make a choice that saves both other people's lives and your own money, plus you can avoid some nasty side effects! This is one such opportunity!

Please see the following links for more relevant information:

- Map and detailed information from the World Health Organization, including a list of health issues to consider for travellers. Here you can see that contrary to common belief, you probably don't need to take any antimalarial drugs when going to:

* The Caribbean, except for Haiti and Dominocan Republic
* Egypt
* India, as long as you stay in Goa or further south
* Mexico, as they don't have the strain that can kill you
* Morocco
* South Africa
* Thailand, except on the borders to neighbouring countries

- http://en.wikipedia.org/wiki/Antimalarial_drug
Extensive information from Wikipedia regarding various medicines you may be recommended to take by your physician.

- http://www.map.ox.ac.uk/data/
Up-to-date maps (country/continent) showing fairly recently observed spread of malaria. More information about the map data can be found at the Malaria Atlas Project, http://www.map.ox.ac.uk/.
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