In Lwala malaria is graded on a curve. A mild case is “a touch of malaria.” It goes up from there; “a dash,” “a bit,” “a case,” “a serious case,” “dead.” People in Lwala are accustomed to getting malaria several times a year, even if they sleep under a bed net, which many don’t. My friend Omondi, director of the hospital in Lwala, came down with malaria and came to me for treatment (this was before the clinic was running). I asked him how long it had been since he last had malaria. “Oh, a long time,” he said. “Nine months.” He’s the only person in the village who take prophylaxis against malaria, doxycycline. He also sleeps under a bed net. “You got malaria in nine months even taking doxycyline?” I asked. “Yeah, it really works,” he replied.
Malaria is so common in Lwala that any headache is assumed to be malaria. The correlation is so strong that the two maladies share a single word. Malaria is a fatal disease, untreated, and it is a given fact of life for people in Lwala, as in much of sub-Saharan Africa and Latin America.
Lots of people came to my hut in Lwala sick with malaria. I got really sharp at diagnosis. A typical history: “I have malaria.” “Oh, I’m sorry. Do you have malaria the disease, or does your head just hurt?” “It’s malaria the disease.” Diagnosis: malaria. Malaria has a pretty wide variety of symptoms, and each person tends to experience it a bit differently. The good news it, if a person has had malaria several times a year for her whole life, she’s usually got a pretty good sense of when she has it. (Disclosure: Don’t try this at home. Good malaria diagnosis, particularly if you’re trying to run a cost-effective health system, is more complicated than this). After exercising my diagnostic muscles, I would give her a few Tylenol to knock down the fever and headache a bit and thirty Kenyan Shillings, roughly forty-five cents, to go pick up the malaria medicine from a local “pharmacist,” an untrained guy with a mud kiosk who sells drugs out the shutter. A malaria cure costs forty-five cents on the open market in Lwala, and people still die from it left and right. Often it’s not worth such big money until they’re really quite sick, and by then they need more than forty-five cents worth of medicine.
One day I treated a woman with a very straightforward case of malaria, with the help of my friend Yuca as interpreter. After I sent the person away, she said “Tylenol? That’s a bad medicine. It doesn’t work.” I was perplexed. “Tylenol never cures malaria.” she told me. “It just makes you feel better for a little while, and then the malaria comes back stronger than ever.” It turns out the local manufacturers of Tylenol are wise to the common naming of headache and malaria, and they advertise their drug as the strongest cure for headache. This is technically true, but it confuses a whole raft of people who just have one word for these two maladies. Tylenol costs less than what the real malaria medicine costs, so people who aren’t in on the joke buy it to cure their malaria. It’s cheap, but surprise – it doesn’t work. So someone for whom it’s a major sacrifice just spent her money on a pain killer when she could have spent it on a drug to cure the malaria. And the malaria may kill her.
The lost productivity from malaria is staggeringly high (as much as 1.3% decrease in GDP in African countries), and the cost of a single cure is staggeringly low. But prevention is much cheaper than treatment – if everyone uses bed nets and they do a little insecticide spraying it’s possible to eradicate malaria in an area surprisingly quickly. We use to have malaria in the southern United States. Certain mining companies in Africa, the kind that employ thousands, have found it cheaper to eradicate malaria in their entire region than to deal with the lost productivity from employees sick with malaria. And they only pay these guys pennies! In places without such campaigns, malaria treatment accounts for up to 40% of public health expenditures. Treating malaria is cheap on an individual basis, and it’s easy, but it adds up fast when there are over 250 million cases a year worldwide. Eradicating malaria is a relative bargain, if you can see a few years out. But in the absence of either a moral vision to provide a cheap cure to everyone, or a pragmatic vision to eradicate the disease, over a million people die of malaria worldwide every year, most of them African children.
One fall after coming back from Lwala I started to get relapsing fevers. One day I’d get a terrible headache and fever and crawl into bed. The next day I’d wake up feeling fine, which would last a day or two before the headache and fever came on again. Figuring I had some kind of flu, I took each brief interlude as a cure. One night, just as one of the fevers was starting to come on, in vigorous denial, I went to a dance performance. One of these was a performance of one of the first modern dance numbers, a very spare piece performed to a poem about the tyranny of the clock in the life of the factory worker. A tall woman was reciting a poem in a sharp ringing voice, very slow and measured: “TICK… TOCK… TIME.” Next to her a guy was dancing out the slow tick of a giant clock, very mechanical, mostly slow with occasional paroxysms of speed. I was afraid I was going to die. Apparently part of the point of the piece was to make the audience feel the slow drag of time for the factory worker. It was very effective. By the end I was afraid that maybe I wasn’t going to die after all. I ducked out of the performance and crashed into bed with a temperature of 104. By the next afternoon I felt fine again, and stupidly assumed I was better.
I landed in a hospital in New Hampshire a couple of days later, with hallucinations and a fever that no amount of Tylenol or IV fluids would bring down. My malaria was the toast of the medical school community, and every student in the place came to talk to me. Apparently they don’t treat a lot of malaria in New Hampshire. They gave me doxycycline and quinine, and kept me overnight for observation, which I figured was mostly for educational purposes.
The total bill for my cure: $7,364.15. That same money could have cured 16,365 cases of malaria in Lwala, which is easily two or three years worth of cures for the entire village. Or better yet it could have gone a long ways toward eradicating malaria in the whole area.
Before the trip to Lwala when I got that $7,364.15 mosquito bite, I met a young doctor from Romania. I’d just come back from a different trip that took me across much of east Africa, and shared some of my experiences over a couple of beers. “Your life is schizogenically dichotomous,” he suggested.
He was right, but not just about my life. Our whole human society is schizogenically dichotomous. The gap between the way the rich minority live and the way the poor majority live is utterly shocking. For most of the world’s people, the other extreme is the farthest thing from their mind most of the time, certainly for those of us who are rich. (If you’re reading this blog, this almost certainly includes you). I’ve had the privilege of experiencing both of these realities, of living the connection between these poles. I’m at no risk of dying from malaria, but a lot my friends in Lwala live with that constant possibility, along with the likelihood of losing their children to malaria. The coffee I’m drinking as I write this cost four malaria cures in Lwala, and I spend thousands of malaria cures every year for health insurance so I can get a $7,000 cure in case I get another unlucky mosquito bite.
Living the extremes of this global dichotomy is implicating in a very uncomfortable way. Suddenly the tiniest details of my social, economic and political life seem like moral decisions. Even things I think of as systemic, beyond my control, start to feel like moral issues. It’s all rather complicated, isn’t it? Maybe I should be buying my coffee from a mining company. Maybe you should too.
