This column was contributed by Kate Dieringer
Is it fear or fatalism that clouds vector borne disease outbreaks?
Boom. Boom. A louder, more authoritative ‘Thwack’. Four men are pounding around the previously unscreened house, covering bits ripped by their efforts with smaller, make shift patches of screen. Inside, others are scrambling to hang previously disregarded bed nets. Patients are showing up to the hospital in droves, complaining of arthralgia, fever and malaise. Medical staff members are succumbing as well; affecting hospital and clinic based operations with increased patient volume and decreased clinical capacity. The offending illness is chikungunya fever (ChikV), not malaria or dengue, and it is gripping Haitian society in more ways than physiological. This Caribbean nation has been devastated by hurricanes, earthquakes and a too recent cholera epidemic. Adding to the burden of disease and bandwidth of citizens and public health officials, the current chikungunya outbreak is causing quite a disruption here in Haiti...
Mythology and fatalism
Arboviruses and parasitic diseases are daunting to scientists, economists and public health professionals alike. They have complex life cycles, acute and chronic manifestations. They are often dependent on prehistoric, hardy little creatures. Political unrest and will add to the fray to further complicate efforts to eliminate disease. The general public and professional community have both created varying brands of mythology regarding disease transmission, prevalence and severity of illness.
With malaria, we often hear the “it’s just like the flu” explanation, which disregards the severity of both diseases and the destruction they have caused throughout centuries. There is the popular “adaptation fatalism” rationale, that surmises that because you know you are living in the context of disease, you deem its burden part of life. Also prevalent is the analytic conjecture that “nonchalance is a coping mechanism”, assuming people simply deal with loss and illness by writing the lack of alarm off as psychological response. This could certainly be true in some circumstances. All of these theories downplay the anxiety and action that we see happening in the global effort to combat disease, but perhaps there is some facet of truth to this mythology. Is fatalism a coping mechanism? Do people become accustomed to persistent inequity and disease transmission? Are people socialized for scarcity? If so, how can we work to best address these paralytic adaptations?
I struggle with these questions and their effect on uptake of services, prevention and treatment. With all of this, an interesting phenomenon is happening in the Caribbean. Previously naïve island nations are experiencing an epidemic of an arbovirus prevalent on the African, Asian and the Indian subcontinent. Chikungunya is literally sweeping the region, and allegations of how and why are flying faster than my colleagues can screen in homes and clinics across the country.
There is of course, massive fear, concern and concurrent global and state organizing to eliminate malaria throughout the world. But there is also this sense of ‘fatalism’ or ‘nonchalance’ with which anyone who works in the field has come into contact. General lack of alarm for malaria, an endemic disease that is more likely to be fatal or disabling than chikungunya, is fascinating if not concerning. The public’s reaction could perhaps offer insight into the populations’ perception of risk and severity of malaria in endemic countries. A curious thing happens when a non-endemic virus is first detected in a place, especially when that place is an island that has a natural sea barrier until global trade, ships and then planes opened ports to unknown vectors and villains. People inevitably start to become disturbed and uneasy, and rightly so.
Upwards of 40,000-50,000 cases have been reported in the island nation of 10 million since the epidemic began in May . Malaria is endemic, with approximately 30,000 malaria infections confirmed annually, primarily due to P. falciparum . Both diseases are cause for concern and require similar preventative measures, but malaria is a far more fatal and potentially debilitating disease. Patients who previously did not seek medical attention for malaria are presenting with apprehension that they are infected with the new virus. The reaction to the threat is not illustrative of the virus’ severity, especially when compared to malaria. Persistent arthralgias are common in patients affected with ChikV, and this is certainly cause for alarm and an organized, strategic response. But public perception, (misperception?) certainly colors action taken by us individuals experiencing the onslaught of the epidemic. This is where sociology, fear and all of that mythology comes into play.
The current fever pitch that the outbreak has reached and the subsequent response is informative in gauging perception on severity of illness and risk related to other mosquito borne diseases. Previously, governments and organizations worked towards control and treatment, but the increased effort by the general public to combat chikungunya virus highlights the nexus between what some would call fear and some would call fatalism. Perhaps this response is an interesting study in how to leverage opportunities for public health education and mobilization initiatives, or perhaps it is simply a demonstration in how panic can go viral in the face of the unknown. Either way, behavioral science is an essential factor in disease control efforts and is the topic of discussions surrounding the impact of perception here in Haiti and globally, as the virus continues to travel from country to country between human and mosquito.
As I slather on my DEET more vigorously than before chikungunya came onto the scene, I question my own perception and human nature in the face of an epidemic vs my rational, logical mind on malaria, dengue and other vector borne diseases that could land me with a hospital admission or worse. How can this newly drummed up concern and perhaps even panic be transmuted into further energy and effort on the malaria elimination front? We can discuss from the newly screened in triage area, I’ll be the one in long pants in the middle of the blazing day. Inexplicably fearful and fatalistic, simultaneously.
The opinions expressed in this column are those solely of the author and do not reflect those of the author’s current or previous professional affiliations.
Kate Dieringer RN, BSN, MPH worked as a technical advisor for the Malaria Alert Center/Centers for Disease Control and Prevention (College of Medicine, Malawi) providing support for malaria programming and operational research initiatives in Malawi. Her background combines global health and emergency/trauma clinical services. She is invested in malaria prevention and control through community based partnerships, as well as health systems strengthening and investment in human capacity. Kate’s scope has focused on Latin America and the Caribbean and Africa regions involving HIV, malaria and maternal child health programming. Currently, she is working with Partners’ in Health Haiti on capacity building and clinical program implementation.