What is state failure? See my conceptualisation of state failure on the right flank below.

Tuesday, June 5, 2007

The bite of the sandfly II

MStFB Backgrounder Update The previous (news)bite of the sandfly
Last month I have written of how parasite-spreading sandflies thrive in the post-conflict environment in Afghanistan, with waste collection not functioning optimally in places like Kabul. Well, I did another round of surfing for information, and I came across remarkable facts I should probably note in order to best serve my readers. Among all that there was one thing that felt like a punch right in the nose. I'll leave it to the end of this post.
I have noted that about 350 million people live in areas worldwide where they are threatened by leishmaniasis, the disease caused by the parasites, that are spread by the sandflies, with the latter feeding on humans, rodents, dogs, and cattle, and basically anything that moves and is breathing. Well, despite that figure I wouldn't have thought that the actual number of people getting infected each year can be so high as it is estimated to be, at 2 million, e.g. here. And actually that is just an uncertain estimate, because many people who are affected either don't know that they have a problem requiring medical assistance, or don't realise that until it's too late.
I also noted that visceral leishmaniasis, a much more dangerous form of the disease, in the case of which parasites attack not directly under one's skin, but spread to inner organs as well, potentially causing organ failure and death at some later stage, represents a minority of cases. Well, even there the picture is a bit more complex. In areas where it occurs, visceral leishmaniasis (VL) can represent a significant portion of all cases - still only a minority of them, but more significant in number than I imagined. A case in point could be the 1991 Operation Desert Storm, during the time of which U.S. troops stationed in Saudi Arabia experienced 34 cases of leishmaniasis, about a third of which was of the visceral type, which is quite common in some areas in Saudi Arabia. In contrast, in Iraq, however, there is a huge difference, with VL being rather uncommon, even while actually a large number of infections are happening - such a large number that soldiers have long since started calling the disease there the 'Baghdad boil', and, as one U.S. soldier put it, skin lesions have become so common that 'You ain't cool unless you got it'. Some soldiers speak of getting bitten hundreds of times a night when they spend the night out in the open (for instance because of sleeping outdoors to take the heat), and so it's small wonder that many are infected.
Treatment for leishmaniasis is usually quite brutal. An often used therapy builds on the drug Pentosam, a main component of which is the heavy metal antimony. Arguably it is chemotherapy as such, actually, that patients have to go through, often with several quite serious side effects.
I mentioned the DNDi initiative, which fights neglected diseases like leishmaniasis. There are other programs as well, however, among them one run by the U.S.-based Institute for OneWorld Health. One World has recently come up with a new drug, an antibiotic, taking which I guess may be a less cruel form of treatment than the antimony diet, though I of course can't really judge this. The new drug is called Paromomycin IM, and it is an injection, or a series of injections rather, specifically developed to take on VL cases. BBC has recently aired a documentary about its introduction in Bihar, India. There VL cases are extremely common, in poor villages where people use cow dung in all sorts of ways, e.g. as fuel or the material they plaster their makeshift huts' walls with - one of the reasons why the disease, in many places where it occurs, is also regarded as the poor man's disease, an indicator of social status, which probably may make some governments reluctant to act, or uninterested in acting, against it. (Even while mere public education campaigns, telling people that sleeping two metres above ground where sandflies active in the night find it difficult to fly is much safer, could actually significantly reduce risks to them.)
But what about places that have seen an absence for a while of anybody interested in governance, in the public goods-producing sense of the word? What about Iraq, and the sanctions-hit 1990s there, as well as the aftermath of the 2003 U.S.-led invasion? Well, pointing back to key facts about the disease first of all, moving from one area to another may make a great difference. The proportion of sandflies carrying parasites is considered nearly irrelevant in the Baghdad area, whereas it is on average at 1.2 percent for all of Iraq, and whereas it can even be around 3 percent in Tikrit, or 2 percent in Nasiriyah, according to 2004 figures cited here. So what do those communities do that are affected by the disease there? In some places "local residents have come to accept the disease, he (Col. Douglas Hack, a doctor at the Walter Reed Army Medical Center - P.M.) said, exposing young children to sand flies in hopes of building immunity". That's what I felt really bad about, as I indicated at the beginning of this post. That people knowing about the disease can be in such a desperate situation that that's the best, actually rational, answer to it that they are left with.
The distribution of very finely meshed bednets (minimum 18-holes-per-inch), as well as the spraying of bednets, clothes and, in some places, fields with insecticide, can help. For that governance is needed, however, or at least a working economy allowing people to fend for themselves more effectively. And for those purposes a secure environment is also needed of course. The international forces in Iraq can manage the logistics for sure, but I doubt if the issue of sandflies is a priority for them currently, even after all these years of their presence in the country.

1 comment:

Marcie Hascall Clark said...

Very informative articles on leishmaniasis and much appreciated.
I am neither a scholar nor student but leish has become an important part of my life since my husband came home from Iraq with it in July 2003.
I would like to add that leish is a blood borne parasite even in it's cutaneous forms. No one knows why cutaneous only attacks the skin. The cutaneous species tropica and major are evolving, diffusing and visceralizing. There is no sterile cure and leish is growing resistant to the available drugs, Pentosam in particluar. Leish can live in stored blood for at least 30 days and is transmittable sexually, and congentially.
Global warming, travel, negligence on the part of our military are causing this disease to spread.
The lack of attention paid to this health threat has been appalling.
It is a shame that it will take more first world people dying from it to bring the plight of our third worlders to light.
Thank you again
Marcie Clark
www.leishmaniasis.us