The ethics of neglect: Why malaria remains a global catastrophe

“ Malaria is one of the world's most deadly diseases. Even though it is highly preventable and treatable, it causes approximately 881,000 deaths every year [1] , with nine out of ten deaths occurring in sub-Saharan Africa, and 85% of malaria-related deaths in children under five years of age. This is the equivalent of a child dying of malaria in Africa every 30 seconds [ [2] . The most serious forms of the disease are caused by the parasite Plasmodium falciparum ”

“ Opportunities for further reducing uncertainty in clinical burden estimates by hybridizing alternative burden estimation procedures are also evaluated.
Please see later in the article for the Editors' Summary==Abstract== Editors' Summary
Background
Malaria is a major global public-health problem. Nearly half the world's population is at risk of malaria, and Plasmodium falciparum malaria—the deadliest form of the disease—causes about one million deaths each year. Malaria is a parasitic disease that is transmitted to people through the bite of an infected mosquito. ”

“ It is a controllable disease, so soon as physicians, public health authorities and the patients themselves will combine on an adequate scale to adopt measures already within reach. These measures will be less [Pg 77] costly than the present position of partial inertia; health is always less costly than disease, and, as Dr. Herman Biggs has often reminded us, can be purchased within natural limits, to the extent which we really desire. This is preëminently true for tuberculosis.
Medical triumphs have not been restricted to preventive medicine. ”

“ Every unpleasant social fact, every outrage to our best instincts, every exhibition of incapacity, incompetency, inefficiency, indifference, every example of super-criminal negligence is pardoned as an effect of that universal sin, human nature. Take the case of the statesman and the diplomats who failed to prevent the Great War, though they saw it coming for years, and who should therefore all, Entente as well as German, American as well as Japanese, be indicted for their criminal negligence, precisely as a physician would be for failure to report and stop the spread of an epidemic disease. ”

“ Malaria causes an average loss of 1.3% of economic growth per year in Africa [ [3] .
The growing prominence of vector control
The success of malaria control measures in some highly-endemic countries, such as Rwanda, Zambia, Zanzibar, Sao Tome & Principe, The Gambia and Kenya has led to reductions in deaths from malaria of 50% or more [1] . In these countries, the widespread use of LLINs and IRS, together with treatment of uncomplicated Plasmodium falciparum malaria with artemisinin-based combination therapy (ACT) , have all contributed to the reported reductions in malaria. ”

“ Although malaria remains a major health burden in tropical and subtropical countries; with the majority of cases in sub-Saharan Africa, several regions show an impressive decline of malaria cases and a lower number of malaria-associated deaths. A renewed global interest in malaria eradication and increased international funding has boosted malaria control efforts all over the world. The elimination of malaria from low-transmission areas seems feasible. Throughout history, Suriname is one of the countries that have effectively decreased the incidence of malaria cases within its borders. ”

“ And this is the country from which yellow fever has been banished for more than six years; where the mortality from typhoid fever and dysentery has been reduced to the minimum; where malaria has become mild and controllable; the country where the deaths per thousand among canal employees, instead of De Lesseps's 240, is only seven and one half. It is almost unbelievable, but it is true. Among white American employees the death rate is less than three per thousand. The lowest death rate of any considerable number of people in the world is now found in the Canal Zone. ”

“ All delay is dangerous, and not only so, it is criminal. The evils of which we complain have been allowed to remain from a general ignorance of the laws of health. Up to a recent period, there was a want of knowledge amongst even the educated classes on these vital subjects. We cannot offer that plea now, to excuse our indifference or neglect. The evils have been fully explored, and most clearly exposed. The connexion between filth and disease—the suffering and vice flowing from them, have been exhibited in so striking a manner as to leave no room for mistake or misapprehension. ”

“ The neglect to conform, in the treatment of the epidemic cholera, to this acknowledged and universal law, has, no doubt, been the prolific cause of the sacrifice of thousands of valuable lives. For this principle is the key to unlock the mystery of disease, unfold the process of diseased action, and, as an unfailing and definite rule, must govern all correct theories as well as all rational practice of medicine, under whatever name it may be conducted. ”

“ So important, too, has the control of all kinds of disease become, now that people, animals, insects, plants, and goods move so freely along the great trade routes of the world, that nations everywhere feel the necessity, now that scientific research has revealed to questioning man the methods of transmission of the diseases which once decimated armies and cities, destroyed stocks, and ruined harvests, of developing ample quarantine service and medical staffs to cope with diseases—human, animal, and plant—from without, and to control those which arise within. ”

“ Even that most intractable of enemies, disease, may be indefinitely reduced in dimensions by good physical and moral education, and proper control of noxious influences; while the progress of science holds out a promise for the future of still more direct conquests over this detestable foe. ”

“ Less than half (22/49) of the malaria endemic countries (MECs) in Africa provided information for the most recent reporting year, 2003; the rest were older. These data are neither reconciled at sub-national scales, nor against populations at risk of any standard definition of the intensity of malaria transmission.
Recent work has also involved the assemblage of historical and contemporary evidence on the distributions of malaria risk and Anopheles vector species into a compendium of maps and geographic descriptions of various malaria indicators by region and country [19] . ”

“ Malaria remains a public health problem in the countries affected by fake artesunate—with estimates of over 2 million cases/year and over 10,000 deaths/year in the Western Pacific Region of the World Health Organization (2001 data [13] ) . With an estimated prevalence of counterfeit artesunate of 33%–53% in mainland SE Asia and a high proportion of patients obtaining antimalarials outside the public health provision of ACTs, the health impact on malaria morbidity and mortality must be considerable—but extremely difficult to quantify. ”

“ If a man knew that he was using medicines beyond his knowledge and was meddling with things above his reach, that was culpable rashness. Negligence might consist in using medicines in the use of which care was required, and of the properties of which the person using them was ignorant. A person who so took a leap in the dark in the administration of medicines, was guilty of gross negligence. ”

“ For it is one of the peculiar intellectual accompaniments of democracy that the concept of the insoluble becomes unfashionable—nay, almost infamous. To lack a remedy is to lack the very license to196 discuss disease. The causes of this are to be sought, without question, in the nature of democracy itself. It came into the world as a cure-all, and it remains primarily a cure-all to this day. Any boil upon the body politic, however vast and raging, may be relieved by taking a vote; any flux of blood may be stopped by passing a law. ”

“ America is leading the fight against disease. With your help, we're working to cut by half the number of malaria-related deaths in 15 African nations. And our Emergency Plan for AIDS Relief is treating 1.4 million people. We can bring healing and hope to many more. So I ask you to maintain the principles that have changed behavior and made this program a success. And I call on you to double our initial commitment to fighting HIV/AIDS by approving an additional $30 billion over the next five years. ”

“ For the rich, the whole world is a safe asylum, but for us, indigent and wretched, what fate is reserved but to stay and perish? If the disease spare us, we must perish by neglect and famine. Alarm will be far and wide diffused. Fear will hinder those who supply the market from entering the city. The price of food will become exorbitant. Our present source of subsistence, ignominious and scanty as it is, will be cut off. Traffic and labour of every kind will be at an end. We shall die, but not until we have witnessed and endured horrors that surpass thy powers of conception. ”

“ They will ever remain the worst.
That ignorance plays its part, as well as poverty and bad hygienic surroundings, in the sacrifice of life is of course inevitable. They go usually hand in hand. A message came one day last spring summoning me to a Mott Street tenement in which lay a child dying from some unknown disease. With the “charity doctor” I found the patient on the top floor, stretched upon two chairs in a dreadfully stifling room. She was gasping in the agony of peritonitis that had already written its death-sentence on her wan and pinched face. ”

“ Here is a case of heart disease consequent on a rheumatic fever that followed a reckless exposure. There is a case of eyes spoiled for life by overstudy.
“Not to dwell on the natural pain, the gloom, and the waste of time and money thus entailed, only consider how greatly ill health hinders the discharge of all duties,—makes business often impossible, and always more difficult; produces irritability fatal to the right management of children, puts the functions of citizenship out of the question, and makes amusement a bore. ”

“ SCARLET FEVER, MEASLES, AND WHOOPING-COUGH
Why is a disease a disease of childhood? First and fundamentally, because that is the earliest period at which a human being can have it. But the problem goes deeper than this. There is no more interesting and important group of diseases in the whole realm of pathology than those which we calmly dub "the diseases of childhood," and thereby dismiss to the limbo of unavoidable accidents and discomforts, like flies, mosquitoes, and stubbed toes, which are best treated with a shrug of the shoulders and such stoic philosophy as we can muster. ”

“ In medicine, as in war, the gravest and deadliest mistake that you can make is to despise your enemy. These trivial disorders, these trifling ailments, which every one takes as a matter of course, and expects to go through with, like teething, tight shoes, and learning to smoke, sweep away every year in these United States the lives of from forty to fifty thousand children, reaching the bad eminence of fifth upon our mortality lists, only consumption, pneumonia, heart disease, and diarrhœal diseases ranking above them. ”

“ I take it for granted, that if it can be shown that great numbers of lives have been and are sacrificed to ignorance or blindness on this point, no other error of which physicians or nurses may be occasionally suspected will be alleged in palliation of this; but that whenever and wherever they can be shown to carry disease and death instead of health and safety, the common instincts of humanity will silence every attempt to explain away their responsibility. ”

“ Here is one class of men, consisting of not more than one-fortieth part of the whole people, not more than one-thirtieth part of the free population, exclusively devoted to their personal interests identified with their own as slaveholders of the same associated wealth, and wielding by their votes, upon every question of government or of public policy, two-fifths of the whole power of the House. In the Senate of the Union, the proportion of the slaveholding power is yet greater. ”

“ The planters justify the practice, by saying it is absolutely necessary for their own safety; because runaway negroes, who collect in the woods and swamps, will soon begin to commit depredations on the neighboring estates. Thus the evils inevitably growing out of this bad system are made use of to justify its cruelties. Free laborers would have no inducement to run away and hide in swamps. It would obviously be for their own interest to keep at work. ”

“ Moreover, it was only in the last ten years, yes, within the last five years, that we fairly grasped the real method and nature of the spread of the disease, and recognized the means that must be adopted against it. And as all of these factors are matters which are not only absolutely within our own control, but are included in that programme of general betterment of human comfort and vigor to which the truest intelligence and philanthropy of the nation are now being directed, the outlook for the future, instead of being gloomy, is distinctly encouraging. ”

“ The regret is the more poignant, because, speaking from the vantage of seventy years, I believe that the highest realization of human hopes for the welfare of our race, must come through medical science. It is, however, to preventive medicine that the world must learn to look, not to the conquest of disease by new drugs or new serums. There are ailments, which every year in England and America are responsible for thousands of preventable deaths. ”