NEWSBYISAAC HOLEMAN

Recently, Victor argued here that talk of social justice should be more prominent in global health debates. I agree -- though I don't think a rhetoric of social justice is a universal panacea. Using social justice as a frame, though, does help enrich my personal relationships and get me through the hardships associated with my work building information technology (IT) systems for Malawi's health systems. And here are some of the ways:

1). It helps identify the difference between harm and suffering
Like millions of people the world over, I followed the recent winter Olympics filled with awe. Growing up as a competitive athlete, I experienced just a small measure of the burden Olympians bear in preparing for the games. I've broken bones, watched fellow athletes hospitalized and endured various dietary restrictions. Seriously training to compete is far from the healthiest lifestyle. As a public health professional, why doesn't it bother me that would-be Olympians cause themselves enormous pain (let's call their condition Olympyosis)? Perhaps for the same reason that I care little when a sick 90-year-old signs a do-not-resuscitate order, or when well-informed adults smoke cigarettes. Not all factors that influence wellness and long life are matters of inequity, and it's only when poor health is structured by unjust circumstances that my conscience flares. I do care when smokers force their fumes upon passersby, for example. So I only work where my conscience sings, and somehow that clarity lends me great energy. Is this narrow-minded? Does anyone work in global health with motivation other than of serving the cause of justice?

2). It helps find common cause
One of the ironies of development is that international workers often think we're more motivated than our clients. It is so disheartening when an HIV+ mother gets her baby tested, but doesn't return to the hospital to see the result, or when a client uses their free HIV medications to add kick to the local moonshine. This occasional soul-sucking sense of distrust, baffled incomprehension and lack of common cause is not unlike the view many recipients of aid have of westerners. How can we find common cause?

(photo credit: ms. Tea)

This post is part of the ongoing Tournament of Pandemics.

How Chikungunia could be the next pandemic:

The bottom line is that this disease is not usually fatal. Even if global warming and spreading to other species enabled the disease to affect many more people than it currently does, it is extremely unlikely that Chikungunia would become a devastating global pandemic.

How Tuberculosis could be the next pandemic.

TB wins this match, and I think XDR-TB is going to win the tournament of pandemics. TB has a killer social strategy: continue to plague the world's poor and let those with the resources to stop TB think they are safe, meanwhile taking advantage of ineffective treatment to build up resistance to all of our antibiotics. The drugs that treat XDR-TB are very expensive and we do not currently have infrastructure in place to produce them at a scale that would be necessary to treat a pandemic or even a significant epidemic. In the next 2-10 years XDR-TB could easily break out in a region with sluggish health infrastructure and high co-infection with HIV.  If it does, there are not very many reasons to believe that we could stop it before it became a pandemic more devastating than HIV. We need to continue to scale up vaccination (sadly only effective for children right now) and treatment, and slow the development of drug resistance very aggressively if we are to prevent XDR-TB from getting loose and spiraling out of our control.

Perhaps the strongest argument for TB winning the tournament is the observation that tomorrow is already today: How many of the world's poor does this disease need to infect before we call it the next pandemic?

A note about personification: The purpose of describing a disease's "social strategy" is to highlight the fact that diseases adapt to the collective behavior of groups as well as they adapt to the biological defenses of individuals. I am personifying these bugs because I have found that it can help our social brains move past biomedical individualism; when we understand that diseases can target group behavior, then we can critique and change social conditions rather than implicitly blaming individuals by focusing on their risk factors. If the notion of "pathogenic social strategy" helps you understand how social systems pattern the distribution of disease, I hope you will empower others by introducing them to this idea.

Tuberculosis has plagued humans for millennia, evidenced by tubercular decay in the spines of Egyptian mummies like this one from the British Museum. (photo credit: Wikipedia)

This is part of the ongoing Tournament of Pandemics.

Chikungunya owes its interesting name to the Makonde word meaning "that which bends up," thought to be a reference to the disease's arthritic symptom's, which often cause the afflicted to develope a stooped posture. The Chikungunya virus is transmitted to people by mosquitos, including the same Aedes aegypti mosquitoes species that can transmit malaria, dengue, or yellow fever. Chikungunya's symptoms resemble dengue, however, it is significantly less prevalent than either dengue, malaria, or yellow fever.

Three components of Chikungunia's strategy that we should look out for:

1. A few days ago Lisa Walker noted on this blog that global warming could affect the domain of many species of mosquitoes, potentially exposing large, new populations of people to yellow fever. The same concern applies to Chikungunia.

2. Chikungunya is thought to spread primarily through bites from Aedes aegypti mosquitoes; some strains appear to be mutating so that they can be transmitted by other types of mosquitoes.^[1]

Tuberculosis (TB) is caused by mycobacteria that usually attack the lungs.  The classic symptoms of tuberculosis include coughing with bloody sputum, fever, and weight loss. Treating TB is difficult; it requires long courses of multiple antibiotics.  Tuberculosis is spread through the air by coughing, sneezing, or spitting. One third of the world's current population is said to have been infected with M. tuberculosis, and new infections occur at a rate of one per second.^[2] In 2004, there were 14.6 million chronic active cases of TB, 8.9 million new cases, and 1.6 million deaths, mostly in the global south.^[2]

We should look out for TB's Social Strategy.

TB has been treatable for a long time, and today it primarily affects the poor. Fatalities are concentrated in the global south, and infections within countries like the U.S. are concentrated among poor and marginalized populations such as the homeless. TB's social strategy is to target the poor because they do not have the resources to fight back. TB has been largely eradicated from wealthy populations, producing a false sense of security while TB affects the voiceless majority of the world's communities.

The poor often receive partial or ineffective treatment, which helps TB develop resistance to antibiotics. The World Health Organization reports that approximately 50 million people worldwide are infected with multiple-drug resistant TB (MDR TB), with 79 percent of those cases resistant to three or more antibiotics. Extensively drug-resistant TB (XDR-TB) was identified in Africa in 2006. In the first widely publicized outbreak of extensively drug-resistant TB (XDR-TB), 53 South African patients were diagnosed and 52 of them died within days or weeks.^[3] We don't know exactly how prevalent XDR-TB is, but 49 countries have confirmed cases of XDR-TB, totaling about 40,000 cases per year.^[4] There are even more reasons that TB is scary, but I'll leave those to later rounds of the tournament.