The Face of Malaria Movie Link http://siteresources.worldbank.org/INTMALARIA/Images/feature-img-malaria Towards a Christian Response to Malaria Jeffrey Larson November 17, 2005 http://www.planet.nl/upload_mm/2/e/5/1986205283_1999996984_malaria.jpg www.bprc.nl/BPRCE/ L4/ResearchPar.html Surgeon-Major Ronald Ross August 16, 1897. This day relenting God Hath placed within my hand A wondrous thing, and God Be praised. At this command, Seeking His secret deeds With tears and toiling breath, I find thy cunning seeds, www.cdc.gov/.../history/ ross_laboratory.jpg Oh million-murdering Death. History of the Disease Egypt Connection with Swamp Mal aria or ―bad air‖ Meckel and Afanasiev http://www.defence.gov.au/dpe/dhs/jhsa/ami/Image23.jpg Charles Louis Alphonse Laveran Ronald Ross http://www.canalmuseum.com/photos/1905_fumigation_car.jpg Life Cycle malaria_lifecy cle.exe www.cdc.gov Life Cycle Continued www.brown.edu/.../maleandfemalegametocytes.jpg Classification of Plasmodium P. vivax P. ovale P. malaria P. falciparum http://bepast.org/docs/photos/malaria/Malaria.jpg Plasmodium vivax Benign tertian malaria Fevers every 48 hours Relapse Plasmodium ovale Mild tertian malaria Quite rare Hard to Diagnose Plasmodium malaria Quartan malaria, Paroxysms every 72 hours Large distribution Recrudescenses for up to 53 years Plasmodium falciparum Malignant tertian malaria 50% of all malaria cases Large distribution Recrudescenses for up to 3 years Merozoites can invade erythrocytes at any age Diagnosis Clinical manifestations Smears of peripheral blood Fluorescent dyes, DNA probes, PCR and reverse transcriptase PCR, and antigen dipstick Too expensive http://www.ibms.org/images/images_science/malaria_rapid_test.jpg Pathogenesis Inflammatory response Too much tumor necrosis factor (TNF) Fever and chills Anemia Destruction of parasitized erythrocytes Complement mediated autoimmune hemolysis www.impact-malaria.com/.../ images/paroxysm.jpg Pathogenesis Continued Prior to the first paroxysm… Malaise Muscle pain Headache Loss of appetite Slight fever www.developments.org.uk/ data/11/wv_killers.htm Pathogenesis Continued Paroxysm begins Cold Stage Rapid increase of fever to 104˚F to 106˚F. Teeth chatter Nausea Vomiting Hot stage 30 minutes to an hour later Intense headache Copious perspiration Mild delirium www.impact-malaria.com/.../ images/paroxysm.jpg Pathogenesis Continued Cerebral malaria (Falciparum) Accounts for 80% of malaria related deaths. Peak incidence in 3 to 4 year old children in areas of low endemicity (Miller et al, 1880). Progressive headache followed by coma, uncontrollable fever (above 108˚F), psychotic symptoms or convulsions and death within hours. ―Plugging‖ of capillaries leading to blood clots and cerebral anoxia Pathogenesis Continued Pulmonary edema Algid malaria (rapid development of shock) due to septicemia Blackwater fever Systemic lysis of erythrocytes Fever Jaundice Persistent vomiting www.impact-malaria.com/.../ malaria-paroxysm.jpg Renal failure Immunity and Resistance High endemicity Maintain high levels of parasitemia Few symptoms of disease Premunition ―resistance to reinfection of superinfection, conferred by a still-existing infection. The parasite remains alive, but its reproduction and other activities are restrained by the host response‖ (Roberts and www.who.int/ features/2003/04b/en/ Janvoy, 674). Resevoir Immunity and Resistance Low endemicity Acute deadly disease Duffy blood groups - P. vivax. Sickle-cell anemia http://www.wfu.edu/~shapiro/research/sick1.gif Epidemiology - Control and Treatment A comprehensive multifarious approach must be employed. Roberts and Janvoy suggest that 5 main factors contribute to control: 1) Reservoir 2) Vector 3) New Hosts 4) Local climate 5) Habitat http://history.amedd.army.mil/booksdocs/wwii/Malaria/figures/figure17.jpg Reservoir Asymptomatic parasitemia Permanent reservoir http://www.calvarychapel.com/savinggrace/uganda/200305mayjune/child2.jpg Vector Anopheles mosquito Abundance Blood-feeding behavior Survival Ability to support malaria parasite WHO/TDR/Stammers development New Hosts Increase in mobility (Martens and Hall, 103). Increased air travel Population redistribution from rural to urban areas Civil conflict Environmental http://www-nlpir.nist.gov/projects/tv2003/active/topics/example.images/Airplane%20Taking%20off%20Small.gif degradation High birth rates Climate Changes in rainfall patterns El Niño and global warming http://www.osdpd.noaa.gov/PSB/EPS/SST/data/anomnight.current.gif Habitat Increase in habitat Deforestation Irrigation systems. Increased building projects Dams Canals http://medent.usyd.edu.au/fact/fwslide3.jpg Highways Mining activities (Martens and Hall, 106). Control Strategy Problems vary enormously therefore control activities must be adapted accordingly if they are to succeed‖ (Kondrachine and Trigg, 26). http://stat.qwest.net/imgs/globe.gif Strong research base, strong international collaboration, and sustained government support (Nchinda, 402). http://www.dhss.mo.gov/Images/handshake.jpg Control Strategy Several fronts Drug development Vaccine development Vector control. Integrated approaches must be pursued for effective and sustainable control (Beier, 520). http://www.malariasite.com/Mal7.jpg Drug Development Quinine - used for more than three centuries. Until 1930’s only effective treatment. Cinchona tree. Intravenous quinine for severe malaria Atebrin- No longer used due to complications with undesirable side effects. Chloroquine - Between 20% and 30% of strains are highly resistant (Nchinda, 400). Proguanil - Proguanil is still used as a prophylactic in some countries. Malarone - Effect in malaria treatment. The drug is 95% effective in cases of otherwise drug resistant falciparum malaria. There are few side effects; yet, the drug is prohibitively expensive to be used on a wide scale. Maloprim, Fansidar, and Mefloquine - Widespread resistance. Halofantrin - Side effects Artemisinins - Currently prohibitively expensive http://home.att.net/~steinert/_borders/Copy_of_atabrine.jpg for widespread use. Bill and Melinda Gates Distribution system Foundation Compliance is essential because sub-therapeutic dosages facilitate drug resistance (Salako, 25). Vaccine development ―Currently prevention of the disease is dependent on avoiding contact with mosquitoes or on chemoprophylaxis‖ (Miller et al, 1878). However, the emergence of drug- resistant parasites have rendered chemoprophylaxis less effective (Mehra et al, 955). Drug resistance has caused a dramatic rise in the cost for treating an uncomplicated case ($0.15-2.00). This increase necessitates the www.uni-giessen.de development of malaria vaccines. Vaccine Development Four basic types 1) Pre-erythrocytic vaccines which prevent the sporozoites stage form entering or developing within liver cells. 2) Asexual blood-stage vaccines which prevent the merozoite from entering or developing within red blood cells. 3) Transmission-blocking vaccines which inhibit development of sexual stages within the mosquito. 4) Vaccines based on cocktails of the previous three. Yet, development of http://www.nature.com/news/2004/041011/images/inject.jpg a vaccine is complicated due a number of factors. Vaccine Development Complications No relevant animal model for studying P. falciparum No potential to grow malaria parasites in a sufficient quantity (traditional) Live but weakened organisms Crude antigen preparations The parasite undergoes rapid antigenic variation (Miller et al, 1878-1879) 95% of those affected by malaria could only afford cheap vaccines (The Heavy, 24) Pharmaceutical companies will not invest in a vaccine Intellectual property rights stifle the possibility of a generic vaccine Prospects Governments and foundations (Bill and Melinda Gates Foundation) More than a dozen potential vaccines that are in progress Novel adjuvants developed which enhance immune response to antigens Additional delivery systems such as salmonella (Engers and Mattock, 12) Vector control “There are numerous examples of how vector control measures like indoor spraying of insecticides, larval control, and environmental management have helped control or eradicate malaria” (520). http://www.psi.org/malaria/malaria/net_retreatment.jpg Genetic engineering (Nchinda, 402). DDT Synthetic pyethroid bed nets (Matteson, 310). Cost Risk trade-off Challenges of Control Western approach, cultural modalities, and treatment-seeking behavior Nchinda writes, ―African populations have traditional perceptions about disease causation and management. Some diseases are considered suitable for management by western medicine, while others are considered the exclusive domain of local traditional health practitioners‖ (400-401). Western medicine is often seen only a last resort. The formal system must become more accessible, acceptable and affordable to ordinary people. (Salako, 24). http://www.itg.be/itg/Departments/Parasitology/Images/Malarb.jpg Education and Empowerment Burden of the Disease ―Despite 50 years of world experience in malaria control, more people are dying of malaria now than when such campaigns began‖ (Nabarro and Tayler, 2067). Approximately 41% of the world’s population is at risk 300 and 500 million clinical cases annually. Two million deaths each year are attributable to malaria (Martens and Hall, 103). Ninety percent of these deaths are in children less than 5 years of age (Nchinda, 398). ―Of the children who die before their fifth birthday, http://www.ghs.org/images/Haiti_Mission_Trip_Teruel_with_Young_Girl.jpg 98 percent are in the developing world‖ (152). 2% of global disease and 9% of the disease burden in Africa (Salako, 24). Sub-Saharan risk to fatal malaria is 160 times greater then the rest of the world (Morrison, 105). One African child dies every 30 seconds (Fedunkiw, 1046). Burden of Disease Malaria kills just slightly less than AIDS. ―What makes the malaria deaths particularly tragic is that malaria, unlike AIDS, can be cured‖ (Robinson, 50). ―The death rates from malaria are as high as those from HIV…In many ways, it’s a kind of silent Holocaust‖ (Robinson, 50). ―There is hope for the future but any impact the strategy will have on malaria illness and death will depend http://www.unicef.org/media/images/971148E.jpg first and foremost on maintaining the political will to combat the disease‖ (Kondrachine and Trigg, 27). The Problem of Healthcare Distributive Injustice: Nations have not beaten their swords into plowshares (Isaiah 2.4). Industrialized nations spend 5.3% of GNP on the military and only .3% GNP on overseas development assistance (Tan et. al., 8). $1.3 billion dollars each year is required for prevention and treatment Less than $23 million  has been awarded by the Fund for Malaria (Tan et. al., 8). Global military spending totaled $1 trillion in 1990 alone (Tan et. al., 8). Ten-percent of all health research funding is used to address ninety-percent of the world’s burden of disease (Delisle et. al, 2). ―Pneumonia, diarrheal diseases, tuberculosis and malaria, when combined, have been estimated to account for more than 20% of the disease burden in the world (mostly in developing countries), yet they receive less than 1% of the total public and private funds which are devoted to health research‖ (Delisle et. al, 3). http://www.cog21.org/site/cog_archives/ac_bcc/AC%20Bible%20Correspondence%20Course/Pictures/Sword%20into%20plowshare.jpg Malaria research receives approximately $42 per fatal case, while HIV/AIDS receives $3,270 and asthma $789 (Nchinda, 401). Healthcare Distributive Injustice http://www.syrrx.com/images/H_mainimg_static.jpg Of 1393 new chemical entities marketed over this time period [25 years] only 16 were for tropical diseases and tuberculosis‖ (Tan et al, 7). ―World’s pharmaceutical companies would rather develop a drug against baldness than invest in a drug against the scourge of sleeping sickness‖ (Vesely, 39). Sub-Saharan Africa accounts for only 1% of the world’s drug sales, while North America, Japan and Western Europe account for over 80%. Francois Grois, a spokesman for the Franco-German Aventis pharmaceutical company laments, ―Unfortunately we have a financial commitment to our shareholders‖ (Vesely, 39). Dr. James Orbinski, president of Doctors Without Borders, finds this attitude unacceptable. ―The poor countries have no consumer power, so the market has failed them.‖ Furthermore states that he is tired of the logic that says, ―He who can’t pay, dies‖ (Vesely, 39). The Need for a Distributive Ethic Tan et al write that healthcare distribution ―must ultimately include the ethical responsibility to redress gross inequalities. Adequate attention to the systemic forces underlying these infections thus necessitates correspondingly systemic solutions‖ (Tan et al, 9). http://photos1.blogger.com/blogger/4332/1214/1600/malaria%20patient%20recovering.jpg Conceptions of Distributive Justice To each according to his merit or desert. To each according to his societal contribution. To each according to the open market. To each according to his basic needs. Similar treatment for similar cases. http://www.who.int/multimedia/ethiopiaweb/MALARIA/WHO-208696.jpg To each according to his merit or desert Advantages are allocated in accordance with the energy expended and results achieved. ―Commitment to desert is revealed as the retrospective aspect of our commitment to free choice‖ (Sher, 10). To each according to his societal contribution Moral primacy is given to: public interest, the common good, the welfare of the community, or the greatest good for the greatest number Distributive questions are determined democratically by utilitarian standards. To each according to the open market Consumer free-choice is tantamount. An individual has the right to select personal values, determine how they are realized, and dispose of them how one chooses (Outka, 20). To each according to his basic needs Basic needs are assumed to be given rather than acquired Inequalities in need reflect human finitude and not merit or desert. The ethic is concerned with ―those generic endowments which people share; the characteristics of a person qua human existent‖ (Outka, 22). Similar treatment for similar cases The accepted treatment standards are applied impartially and universally. Treatment standards are determined democratically. ―There should be no obstacles: financial, racial, sexual, or geographical to initial access to the system as a whole‖ (Daniels, 175). Healthcare Distributive Ethics, Public or Private? Postmodernity Ethical medicine is understood as nothing more than furthering the ends of life as defined by the individual. Individuals are free to make any medical decision because it is a private decision. Autonomy Informed consent Privacy http://photos1.blogger.com/img/125/922/640/Postmodern%20Lyotard%20Condition.jpg Confidentiality Shortcomings of private ethics ―The goal of keeping quality of life, resource allocation, and other relevant value choices completely at the private level is ill-suited to the contemporary health care environment‖ (Dresser, 21). ―The sum total of much of our ethical thinking about individuals has given us an unethical health system. Alas, no modern nation can build a health care system one individual at a time‖ (Lamm, 14). The sum total of private ethical decisions creates a public ethic. ―Individual decisions, in short, sooner or later create a culture. We must decide in what kind of culture we want to live‖ (Callahan, 28). There is no such thing as a private moral decision. ―My private moral life and the kind of person I have chosen to be makes a great difference to my neighbor’s life no less than my own‖ (Callahan, 31). Shortcomings of private ethics ―When autonomy is the answer, the question is largely limited to asking whether the person decided freely. Autonomy counsels us not to ask if the decision was wise, or even good in the short run for the person making it. For many decisions, that is sound counsel. But not for all decisions, and certainly not for the sum of all decisions‖ (Murray, 32). Need common vision of what distributive ethic should be employed. ―If there is no common picture of what biomedicine can do to foster a good life- if the very question of what constitutes such a life has been banished in the name of pluralism- then that life will be pushed about in ways it is helpless to control, a frail ship that has lost its direction on a stormy confused sea‖ (Callahan, 31). Gilbert Meilaender, 14 Insofar as the search for consensus and the related fear of language that includes substantive moral claims about who we are or how we ought to live has driven bioethics to the purportedly neutral public language of rights, it is well on its way to losing its critical edge and even becoming boring. Endless affirmations of our autonomous right to die with dignity, but no help in understanding what that might mean of the significance of a human being’s death. Continued affirmation of the necessity of beneficence, but little help in discerning the best interests of a living human being. Rigorous commitment to justice, but relatively little help in understanding how human beings are harmed or wronged. We can say little about ourselves except that we have the right freely to determine the meaning of our living and dying. What threatens to come upon us without our choice-illness, suffering, infertility, a child, death- can have no human meaning or significance. This may seem to enlarge our freedom, but it diminishes the being who bears that freedom How do we get out of this mess? What is the task that we are avoiding? Religion. Religion is the source of meaning for human lives. Each form of religion is not commensurate in the society it will produce. Relativistic pluralistic religion is no more constructive as http://admission.owu.edu/images/religion.jpg relativistic pluralistic ethics. What religion is then needed? The Need for Christianity The particularity of the gospel of Jesus Christ is fundamental to comprehensive systemic change. Jesus Christ is the norma normans for humanity. He defines what it is to be human. He is God made man. His resurrection is paradigmatic of restoring health and wholeness. Healthcare merely images his ministry of healing body, soul and mind. Jesus has given us the example of self-sacrifice needed to establish healthcare distributive justice. The Holy Spirit empowers ideology to become praxis. The Holy Spirit’s activity is cardinal to systemic distributive justice. Actions flow from character, and character from the heart, mind and soul. The Holy Spirit must change the heart, mind and soul in order for the actions of healthcare http://people.lulu.com/storage/users/296/42296/images/23756/cross%20light.jpg distributive justice to be fully manifest. Political Theology of the Church Christians are held in dialectical tension between the ―already‖ and the ―not yet‖. Analogously, there is a similar dialectical tension between ―proclaiming the ideal and working in a setting that falls short of that ideal‖ (Cook, 60). ―not yet‖ Transformative integration Common Grace Realist expectation ―already‖ Transformative antithesis Redemption Idealist expectation http://www.townofhobgood.com/Country%20Church%20before%20moving.jpg While they are dialectically opposed, they are not mutually exclusive. The Church must witness to the Kingdom of God though creating an alternative community that embodies and proclaims Jesus’ ideal while concurrently seeking to transform this world into Kingdom likeness through political advocacy and cultural engagement. Church Response to Healthcare Distributive Injustice What does this political theology of engagement compel the Church to be in response to healthcare distributive injustice? What does it entail in a Christian response to malaria? ―There must be two elements in any move towards shalom. There must be the proclamation and description of the ideal of shalom and just health. But that ideal must be matched by a realistic strategy for dealing with the issues of justice and health as they actually face our world and us in the twenty first century‖ (Cook, 60). The Church must then articulate and embody a theological description of the ideal of shalom and just health. http://www.dltk-kids.com/world/images/munity2.gif The Church must wrestle with realistic strategies for dealing with issues of justice and health as they face our world. The Church will not be faithful to its calling of cultural engagement if either component is neglected. Critique of Conceptions of Distributive Justice To each according to his merit or desert. To each according to his societal contribution. To each according to the open market. To each according to his basic needs. Similar treatment for similar cases. http://www.who.int/multimedia/ethiopiaweb/MALARIA/WHO-208696.jpg Individual Christian Response Conscientisation. The Holy Spirit will work in us to feel the desires of His heart through every medium which a human can epistemologically experience. The Spirit works through cultivation of the heart, mind, soul and strength. With respect to malaria this cultivation may include increased: Solidarity Education Purpose Deed http://playback.trufun.com/images/oralleebrown03small.jpg Theological Qualification and Foundation We do not serve others simply as humanitarian philanthropists. We serve because in so doing we serve Christ, his body, and those he loves. Matthew 25.37-40 the righteous ask, ―Lord, when did we see you hungry and feed you, or thirsty and give you drink? And when did we see you a stranger and welcome you, or naked and clothe you? And when did we see you sick or in prison and visit you?' And the King will answer them, 'Truly, I say to you, as you did it to one of the least of these my brothers, you did it to me.‖ www.impact-malaria.com/.../ images/paroxysm2.jpg Jesus explains in Matthew 25.35-36, 'For I was hungry and you gave me food, I was thirsty and you gave me drink, I was a stranger and you welcomed me, I was naked and you clothed me, I was sick and you visited me, I was in prison and you came to me.'‖ Theological Qualification and Foundation We are not only called to love others as we love ourselves, but we are called to love others as Christ loved us. How did Christ love us? He died. We are called to die to ourselves so that we and others might live. We do not affect salvation, but Christ graciously chooses to use us and our will as his instrument. http://uashome.alaska.edu/~jndfg20/website/cross.jpg Local Church Response The following list is not exhaustive, and it is an invitation for more creative thinking to follow these suggestions: 1) Set up child sponsorships from regions endemic with malaria. 2) Form sister church’s in endemic regions and set up pen pal relationships. 3) Sacrificially give to a number of Christian organizations that are already helping with the disease. 4) Send out missionaries to malarial regions. 5) Encourage medicine as a good opportunity for Christian service and vocation. www.ssndmankato.org/ open%20hands.JPG Local Church Response 6) Establish clinics through organizations such as the Jericho Road Foundation (Kilner et al 233). 7) Lobby government to make policy that is guided by the principles of the Kingdom of God. For example, there should be licensure controls to avoid comparatively excessive concentrations of physicians in regions of affluence, and a period of time in an underserved area as a requirement for licensing (Outka, 26). Furthermore, churches could lobby for debt relief, and reformed trade policy etc. 8) Facilitate incentive subsidies to physicians, hospitals, and medical centers to provide services in regions of poverty. 9) Develop Christian insurance agencies such as http://www.afghan-web.com/gallery/hug.jpg the Christian Brotherhood that would provide for Christians who are infected with malaria (Kilner et. al. 240-244). Global Church Response We are unaware of our own body. When we neglect the body we neglect ourselves and we stultify Christ’s witness. (1 Cor. 12) The body is a unit, though it is made up of many parts; and though all its parts are many, they form one body. So it is with Christ. For we were all baptized by one Spirit into one body—whether Jews or Greeks, slave or free— and we were all given the one Spirit to drink We are all baptized into one Spirit. Revelation 7.9 says, ―After this I looked and there before me was a great multitude that no one could count, from every nation, tribe, people and language, standing before the throne and in front of the Lamb.‖ The kingdom of heaven will be a vibrant kaleidoscope of nations that God has created diverse yet unified in Christ. Our individuality is consummated in diversity. The beauty of God’s creating each person unique is fulfilled when it is juxtaposed to the unique nature of God creating a diverse panoply of community, color, and culture. The kingdom of heaven will be diverse and unified; we should seek to transform society into the image of, and witness to the Kingdom of God. Global Church Response Now the body is not made up of one part but of many. If the foot should say, "Because I am not a hand, I do not belong to the body," it would not for that reason cease to be part of the body. And if the ear should say, "Because I am not an eye, I do not belong to the body," it would not for that reason cease to be part of the body. If the whole body were an eye, where would the sense of hearing be? If the whole body were an ear, where http://126.96.36.199/Images/blogger/eye-big.jpg would the sense of smell be? But in http://upload.wikimedia.org/wikipedia/commons/thumb/b/b8/Ear.jpg/180px-Ear.jpg fact God has arranged the parts in the body, every one of them, just as he wanted them to be. If they were all one part, where would the body be? As it is, there are many parts, but one body. Global Church Response It is good that we are not all created alike. As God is infinite, finite persons can not fully image His character. We see more of God through the full spectrum of peoples who were created in his image, and are indwelt by the Holy Spirit. We compartmentalize God when we only allow ourselves to see Him through the lens of our particular culture, gender, and socioeconomic class. Furthermore, Christ ministry is handed over to the Church, not individual Christians. All of the gifts are not manifest in any one Christian or any one parish church. All of the gifts are manifest in the global Church. Consequently, parish churches should become more unified in order to have the full complement of spiritual http://www.williamstownbaptist.com/img/diversity.jpg gifts available for the service of the Kingdom. Global Church Response The eye cannot say to the hand, "I don't need you!" And the head cannot say to the feet, "I don't need you!" On the contrary, those parts of the body that seem to be weaker are indispensable, and the parts that we think are less honorable we treat with special honor. And the parts that are unpresentable are treated with special modesty, while our presentable parts need no special treatment. But God has combined the members of the body and has given greater honor to the parts that lacked it, so that there should be no division in the body, but that its parts should have equal concern for each other. If one part suffers, every part suffers with it; if one part is honored, every part rejoices with it. http://copies.anglicansonline.org/churchtimes/000303/pics/girl.jpg Global Church Response http://www.econ.ucdavis.edu/faculty/fzfeens/photo_6/10_Girls%20at%20the%20well.JPG When one part of the body suffers, the entire body suffers. Division in the body causes disease, and disease in the body causes division. physical disease is not disconnected from spiritual disease. Therefore, neglecting the physical disease of the Third world will result in spiritual disease for the Global Church. 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