Tricky Parasites

This is almost too crazy to be true so I’m going to explain it as if it is a hypothetical situation. That way its just part of my imagination rather than reality pissing me off.

Imagine it is the height of malaria season in one of the poorest countries in the world. Most adults who have lived in the area get over this illness without much difficulty because they have built up good immunity after dealing with multiple infections throughout their lives. However, young children and pregnant women regularly die from this disease. These days there are a limited variety of available drugs to treat malaria. Because the country is so poor, with the average person completely unable to pay the market price for these medicines and with the government not even close to being able to generate enough revenue to supply the country’s health centers with an adequate supply of these medicines, it relies upon places like the United States to supply the malaria medications.

Over the past year and beyond, there have been more and more reports about healthcare workers in the country stealing these donated drugs from the hospitals they work at so that they can sell them on the black market for 100% profit. Albeit slowly, the United States has caught on to this nefarious behavior and has decided to crack down hard. All health centers must now record the basic information of each and every individual receiving these medications. This new record keeping is in addition to the typical records for individual patients and pharmacy inventory—both of which are notoriously inaccurate. A new list of those receiving the medicine and where each of them lives must be available so that the cranky Americans can come at anytime and crosscheck this list by going into the community and making sure those who reportedly received the drugs indeed received the drugs. If there are any discrepancies, the supply of these lifesaving medications will be cut off. It turns out that many health centers aren’t organized (or motivated or aware or whatever) enough to even do this new record keeping. There is an entire district that can’t produce these records, and they just lost their entire donated supply of malaria medications.

Adjacent to this district, there is a large mission hospital that has been able to relieve some of this devastation because it is relatively well organized. Although their staff is completely overwhelmed this time of year with spikes in admissions due to severe malaria, they have been keeping good enough records that the Americans haven’t cut off their supply of malaria medications (yet). The people in the district nearby without any medications flock to the mission hospital in search of care. This hospital was already overwhelmed to begin with, and this further influx of patients further stresses its capacity. Furthermore, the patients coming from the district without any medicine are traveling long distances to get there and often arrive after much delay so that their illness is very severe by the time they get to the hospital.

To add to this, there is a parallel story that demonstrates the mission hospital’s difficult predicament: for many years, they have had a service level agreement (SLA) with country’s government. With the SLA in place, they received enough funding to subsidize basically all patient costs at the hospital. The SLA also allowed them to spray insecticides in houses throughout their catchment area of 80,000 people on a yearly basis before each rainy (ie malaria) season. This insecticide spraying is a powerful public health intervention for preventing malaria in endemic areas. While the hospital was doing this spraying over the past few years, they have seen a large decrease in the number of admissions and deaths during the rainy season. (There is an interesting story of natural selection and how the mosquitoes have rapidly gaining resistance to these insecticide sprays, but we'll have to save that for another day.) Unfortunately, due to a variety of reasons (including government officials stealing almost all the money from the treasury while the former president was visiting the USA a few years back) leading to depletion of funding for the program, the country’s government had to break the SLA a few months ago. As a result, the impoverished patients now encounter a fee for service billing structure. Word spread quickly that everyone now has to pay when going to the hospital, and many (not just those traveling from form the neighboring district) are now delaying to go to the hospital until they become very sick. Hospital staff also think that more people are seeking help from traditional healers rather than going to the hospital. Not only do these traditional healers swindle the poor with hoax therapies, but many of these therapies are dangerous. Only a small fraction of the hospital’s catchment area was sprayed prior to the current rainy season, and this is thought to be another big factor in the recent increase in overall malaria cases, death rate, and total death count.

Last week, the medical director of the hospital went to the Ministry of Health to discuss the possibility of reimplementing the SLA. He was armed with lots of facts about how detrimental the dismantling of the SLA has been over the previous months. The meeting never took place because there was no one there to talk to. Just before this meeting was planned, over 60 officials in the Ministry were fired because they mishandled funds from the CDC.

At this point, healthcare in the country is in complete disarray. But it has more or less always been this way so there’s not really any general sense of urgency to improve things in a meaningful way.