MdM Talks: Richard Howe on malaria

As with all MdM talks, content should be recognised as the thoughts and opinions of the person with whom I am holding a conversation. Richard Howe first approached me while I was interning at the then World Health Organization (WHO) funded Roll Back Malaria Partnership Secretariat, based in Geneva. MattersduMonde plays host to our interview, and addresses Howe’s view that action to fight malaria has represented ‘a failure of the imagination’.

Richard is the Managing Director of Application Dynamics which he founded some five decades ago. Starting out as an apprentice agricultural pilot (‘crop duster’), Richard moved up through the ranks and aircraft, finally converting nine craft into adult mosquito control spray planes. His company’s control programmes are primarily centred in Florida with existent contracts with Palm Beach County. Having already treated over 42 million hectares, Richard plans to pass on his experience, aerial application methodology and approach to a new generation of pilots who, he hopes, will explore the limits of this technology in conjunction with the application of natural insecticide compounds.

 

Richard, based on your 60 years experience working in this sector, what are the determinants or contributing factors that have most impacted global activity to combat mosquito-borne diseases?

An attempt to eliminate malaria, dengue and lymphatic filariasis, all mosquito vector borne diseases over the past 60 years in developing countries has, by all accounts, been a dismal failure. The reason is, in my opinion, due to a lack of leadership in the Non Governmental Organisation (NGO) community and from WHO.

 

How do you view the latest publication from the Roll Back Malaria Partnership – Action and Investment to Defeat Malaria, 2016-2030 with its adoption of a multi-sectoral approach?

To eliminate these diseases, the WHO recommends a defensive, not an offensive strategy. A study promoted by the WHO at the inception of the Roll Back Malaria campaign on the effectiveness of mosquito nets produced a 25% reduction in infections. Indoor residual spraying was not tested to my knowledge, however, 50% of the biting occurs outdoors, so this method is only 50% effective overall, provided indoor residual spraying is 100% effective, which I seriously doubt.

 

How would you propose amplifying these tools, or what would an offensive strategy comprise?

At this time I would like to propose a new concept: large area aerial application of mosquito control insecticide. Why not go on the offensive and eliminate the cause of these diseases; mosquitoes. The technology to accomplish this [exists], and is used in Florida, USA. It is called a High Pressure Aerosol Generator that operates at 3000 psi (pounds/square inch) and produces an eight micron droplet. This is the ideal droplet size for control of mosquitoes based on operational and laboratory research that goes back to 1944. This technology does not require the use of a large aircraft due to the efficiency of this method. For example, a US $50,000 Cessna aircraft with a 500 pound payload can treat up to one million acres or [approximately] 1500 square miles in one night.

Reproduced with permission from Richard Howe.

Reproduced with permission from Richard Howe.

What about the development of vector resistance, that has been a well-documented [click here for Hemingway, Kelly-Hope & Ranson 2008 study] threat to such strategies?

Another concept available to offset the growing resistance to existing chemical concoctions currently used would be plant based insecticides. There are about 2000 plant species with insecticidal properties. Extracting the active ingredient of the more promising ones could be an answer to the problem of resistance. Some of the compounds have a molecular structure so complex the mosquito will never develop resistance.

 

Why do you think that wide area aerial application technology in conjunction with alternative natural insecticides has only been employed to a limited extent in mosquito vector control programmes?

It has to do with institutional inertia. As a rule, the larger an organisation the more resistant it is to change. These institutions are so lethargic, they eventually become irrelevant. The problem: the nature of WHO leadership. Bureaucrats, medical doctors and academics take the lead in an operational matter. The NGO community is treating the symptoms while ignoring the problem, the mosquito. It is going to take leadership that lives where the rubber meets the road to solve this problem.

 

To make such change at the policy level, there needs to be benefit estimations that will contribute to a decrease in the global burden of disease. Will figures be enough?

I would like to discuss body counts and how accurate they are. The WHO takes great pride in announcing [that] the number of deaths from malaria have been cut in half. I take issue with this statement. It is pretty well established there is no accurate accounting of deaths from malaria in Africa, so how can this estimate be verified. It can’t!

Reproduced with permission from Richard Howe.

Reproduced with permission from Richard Howe.

Any final comments?

In conclusion, [malaria] should have been eliminated years ago for a fraction of the billions of dollars wasted on this effort to date. However, from my perspective, it looks like amateur hour all over again after doing the same thing for 60 years with no success. [So] perhaps it is time to reassess, strategise and start thinking outside the organisational box, to eliminate the problem once and for all time.

Thank you to Richard for his time and contribution. Interview dated October 2015.

 

Image Credit: Chuck Simmins, Flickr.

Am I hearing right?

Global Health communication is something to invest in. At a local level I have been involved with a leading leprosy awareness charity in the UK – Lepra – commissioning the Polygeia thinktank to devise a communications marketing strategy appropriate to engage, convey information and increase awareness of the charity’s central aims to a university demographic. More widely, while working with the Roll Back Malaria Partnership (RBM) in Geneva this summer, my team was tasked with producing advocacy messaging packs for simultaneous publication with the Sustainable Development Goals, 2016-2030 (SDGS), highlighting their relevance to malaria (these can be accessed here). Our target audience canvassed both the Secretariat’s partners and colleagues in the field.

Reproduced with permission of RBM.

Reproduced with permission of RBM.

The collective aim of global health communications is, as the FHI Center for Global Health Communication and Marketing (CGHCM) articulates, to bring ‘about positive changes in the actions of individuals, communities, and institutions that will improve the health and well-being of vulnerable populations around the world’. To communicate is the practice of sharing, as well as encouraging the feedback loop of hearing from the initial audience. The Lepra-Polygeia commission employs this methodology. Our team initially analysed (through social media analytics) the digital and physical communications channels employed by Lepra, namely Facebook, Twitter, Instagram, YouTube and in-person workshops in junior level schools and related outreach events.

Across the board, there was little evidence of targeted communication or messaging to those pursuing higher education, and no physical outreach. Over the space of six months, until World Leprosy Day 2016, Polygeia are implementing a communications strategy designed to capture this as yet untapped field of potential ambassadors, supporters and motivators across tertiary education institutions. At a most baseline level, this means identifying how these individuals hear and process information both digitally and verbally, and ensuring that we are meeting these criteria. Even before that, it is a case of ensuring that these individuals are being reached by appropriate delivery (from including appropriate handles on Twitter messaging to initiating a series of rotating Lepra-Polygeia appearances at student led careers and high-profile events). In the ‘internet age’, global health leaders are becoming increasingly aware of changing worldwide connectivity, and are driving online live-updating tools to share information risks across social media and interactive maps, as well as to disseminate educational care packs.

Front pages of Lepra-Polygeia strategy commission. Reproduced with permission of A Bow-Bertrand.

Front pages of Lepra-Polygeia strategy commission. Reproduced with permission of A Bow-Bertrand.

By comparison, the international, much more disparate targets of RBM’s SDG communications strategy similarly had to address studies of behaviour change (a theory which attempts to find a framework to structure how we experience health) and how users consume messaging. Across the board we prioritised authentic, persuasive messaging, but it became apparent that many of our target audience (withstanding those individuals in developed, ‘highly connected’ regions) could not be reached with the typical digital communications arsenal. Instead, we were required to return to the roots of communication. Stories and narration derive from an oral tradition in which information is relayed from one party to the next via voice and recollection. Radio functions along similar patterns, albeit with a more comprehensive and reliable sourcing and constructing of information and narrative pre-delivery.

Radio is a key example of community-led communication strategies, and is cited as a frontline channel in the World Health Organization’s Communication for Behavioural Impact (COMBI) toolkit which advises on communication strategies (both preventive and control-centred) in an outbreak situation. COMBI also reinforces the need for trust in the source (be that the original deliverer of the message, its handler or transmitter). While multi-level methods are recommended for communications in both acute and chronic, local and global health circumstances as adopted by the Sustainable Development Goals, the crossover between reliable and panicked, rapid and rushed, valuable and scare-mongering is becoming all too present a problem in crisis situations when social media can often lead to the counter-productive spread of potentially damaging messages.

Taken from COMBI. Reproduced with permission of WHO.

Taken from COMBI. Reproduced with permission of WHO.

Notwithstanding the added complexities of communicating for reduced mortality in disasters, cross-sectional strategies are key to improving healthcare in a consistent and intuitive manner. In areas of low connectivity, radio remains a pivotal tool, and in almost every country in the world, mobile health (that is to say, access to physical, mental and psychological support, information and training through a handheld device connected to a mobile provider and/or wireless internet) continues to be the focus of much marketing research. Indeed, the Roll Back Malaria advocacy messaging produced was designed to be recycled from paper pamphlets to digital tweets to a series of rollover text messages, targeting those individuals and healthcare workers that were not accessible by any other mean.

Reproduced with permission of RBM.

Reproduced with permission of RBM.

And it is not just healthcare workers that must be reached. Lepra has sister branches in both Bangladesh and India, and the latter’s increased public access to the Internet will be pivotal in our drive to recruiting policy makers and communicators at a higher education level. Trends in digital growth in this country show an exponential rise in online users. Of those active, the Indian Express recently reported that the 350 million this year will be expected to reach 500 million by 2017. Of these, 314 million will be mobile internet users.

Global improvements in digital literacy and effective infrastructures must collectively employ e-communications that are heard by the least accessible – both geographically (such as in developing nations and particularly rural communication ‘holes’) and individually (to the so-called complacent recipient and user of social media who requires innovative and compelling digital discoveries to respond amidst an overwhelming flood of material of all genres).

Striking a balance between telling a story in a way that moves peoples and causes ripples of reflection, implementation, retelling and building comprehensive communication packages for uses globally both at peace and during conflict is a near impossible task. But in hearing the need to feature effective communications high on priorities in global health, the future world will be better placed to answer the question: ‘am I hearing right?’.

 

Image Credit: Tomas Belardi, Flickr

Photojournalist of the month: Paolo Pellegrin

“I’m more interested in a photography that is unfinished – a photography that is suggestive and can trigger a conversation or dialogue. There are pictures that are closed, finished, to which there is no way in.”

Paolo Pellegrin’s visual work is shaped by his initial studies in architecture at Sapienza Università, Rome,  a city where he was to continue with photography courses. Since those early explorative years in Italy, Pellegrin’s drive took him to Paris and via a membership of Magnum Photos he became contracted as freelance photographer to Newsweek for a decade from the start of the millennium.

His work prioritises capturing subjects and scenes of global disasters and exposing temporal and political fallacies. Most remarkable is his globally recognisable coverage of the recent Médecins Sans Frontières sea mission on the Bourbon Argos aiming to intercept vessels packed with migrants travelling from Libya to Europe. His journey through the lens relates how they rescued many of these migrants at sea (estimated at near 700), safely transporting them to Reggio Calabria, Italy. Entitled ‘Desperate Crossings’ this series is characterised by a visual rhetoric of monochrome stills amalgamated into meta-visual frames within frames

Reproduced with permission from Magnum Photos.

Reproduced with permission from Magnum Photos.

The merit of his portfolio is heavily weighted towards his most recent commissions, with shots of refugees in Lesbos, Greece powerful not only in the confused, emotive subject matter, but in his skilful capturing of desperation, multi-layering of peoples, strengths, movements in an unsettlingly nostalgic monochrome filter.

Reproduced with permission from Magnum Photos.

Reproduced with permission from Magnum Photos.

Reproduced with permission from Magnum Photos.

Reproduced with permission from Magnum Photos.

Reproduced with permission from Magnum Photos.

Reproduced with permission from Magnum Photos.

Among the many authored  books and awards that no doubt populate Pellegrin’s shelves, Double Blind (Trolley, 2007) is MdM’s choice for those new to the  photojournals of this man, in this instance covering the 2006 War in Lebanon. To get a taster of the images you’ll encounter, have a watch of this.  Featuring his earliest successes finding angles of stillness and chaos within the same real-time situation, Double Blind suggests the inability of the photographer to fully apprehend his creative experience and its products. It is, perhaps, the best instance of the ‘unfinished’ work Pellegrin so beautifully articulates.

Reproduced with permission from Magnum Photos.

Reproduced with permission from Magnum Photos.

Image Credit: Paolo Pellegrin, reproduced with permission from Magnum Photos. Lebanon, Beirut. August 2006. Moments after an Israeli air strike destroyed several buildings in Dahia.

World Mental Health Awareness Day: double act

The ‘about me’ section of MattersduMonde identifies Bertrand Russell as a man and philosopher who has shaped the way I live my life, not least by the three mantras identified in his biography: ‘the longing for love, the search for knowledge and the unbearable pity for the suffering of mankind’. Such a motivation should come with a caveat on World Mental Health Awareness Day 2015 – few people that are societally or clinically identified as occupying any state of ‘other’, be that in terms of physical or psychological integrity, seek the downward-reaching reaction of pity.

Rather than objectifying a quality of being ‘other’ through pity, this state, for me, orientates towards the overwhelming, albeit lessening, national reluctance to address mental health as a composite of many of our citizens. No longer is this a country in which mental health is a possible addendum – it is part (a growing part) of the fabric of our society. One only needs to return to the well-documented statistics that one in four UK adults will experience a mental disorder at some point in their lives to ascertain that at any present point society is influenced by – not distinct from – psychological health conditions.

Reproduced with permission of mental health.org

Reproduced with permission of mentalhealth.org

But this piece won’t feature me writing out, through statistics and evidence, the ultimately human occurrence and experience of a spectrum of mental wellness. Instead, I will delineate a little of my own self (minus any identifier terms) in a way that I have never before done in writing, nor shared for public perusal. It isn’t that I don’t feel that one should be open about classifications or diagnoses of mental health – certainly, transparency and notably celebrity acknowledgements of supposed infirmity can help many people accept and seek help for deviances from their own normal wellbeing.

For me, however, I feel little desire to share so called labels, for even if they are integral to my being at any period, they are certainly not terms by which I wish to be defined. So too, mental turbulence for me is not equivalent, nor necessarily relatable, to others who experience such states, and the disclosure of labels is, to my reading, as productive as comparing a dog to a cat – of limited correlation or benefit.

This is why I am also sceptical of the trigger warnings (TW) that have been mass adopted by journalism of a so-called sensitive nature. Originally they were designed to alert readers to a potential experience of post-traumatic stress following exposure to material that related to rape or graphic assault, warning former victims in particular of exposure consequences that might be debilitating. Their use, however, has been exploited by an all too correct and self-consciously considerate online society that problematically seeks to acknowledge the fluid nature of ‘sensitive’ material. Potentially triggering content now covers anything from corpses, medical procedures to catcalling. Their original value is all but lost in cliché, crystallised by their catchy acronym.

That aside, my choice not to outline the precise characteristics of my mental state is not intended to be self-righteous nor exclusive, but I think is the most appropriate way to enable every person from every context to access what I hope to express through writing.

After all, mental health is something which every cognitive being – including non-human animals – is subject to. The spectrum of wellness is deeply personal, but equally exists as something universally experienced. To illustrate my thinking, it might be suggested that certain states of personal mental deviation arose at the precise times in my teenage years when I was clinically diagnosed with a condition. I really doubt that this is the case.

For me, mental health is about how grounded I feel at any point in time. As a young child, I would go through phases of feeling wholly disembodied from myself, and learned to return to a me I was comfortable with by finding a mirror and repeating out loud basic criteria of identity: my name, my age, where I lived, the fact that I have a twin brother. All things that, for me, make me feel ‘grounded’, in both mental and physical space.

The timeworn adage that you never know what goes on behind closed doors stands true. Many of my closest friends do not know that my medical records dictate anything other than ‘perfect’ health (withstanding my sectionable cackle). This is OK – I absolutely wouldn’t want it any other way. However, many of these same friends describe me as ‘put together’, ‘sorted’ and ‘an all-rounder’. Lots of days I am all of those things, and even on those days when I am not, I wouldn’t wish to alienate myself from these characteristics. Instead, by acknowledging that there are periods when I am not those things, I hope the societal blueprint of a perfectly functioning, emotionally stable non-being is dispelled for being just that – unrealistic and idealistic.

These ‘not’ days are not of lesser value (indeed, I challenge the appropriateness of comparative negative terms of mental ‘distress’ or ‘perturbation’) – they are just times which range from not feeling myself to being completely dissociated from the being I identify with when at my most grounded. That can be an absence – in my case an absence of familiarity or contentment in and with myself – but it is not something I consider to reduce my personal worth. Of course, historically those periods when my mental state has been changed in frightening and non-familiar ways, I wish away these experiences, but that carries little impact. A critical part of any self-stabilising care approach is the often very tortuous acceptance that the state and experience of feeling ‘other’ is inextricably part of our bodily and emotional make-up for that temporal space.

At 18 years old, my parents bought me a really very lovely watch. It is my most treasured accoutrement. The fact that I wear it continuously is often met with surprise at my inability to ‘switch-off’. In fact, I generally use my phone for time keeping; my watch is something that figuratively keeps me on point and grounded.

The wanderlust gene in me (sorry – anachronism at its worst) is sparked by what I consider to be a primal desire to experience myself in an alien environment, but in reality I am not always as comfortable with the self I discover, often with reckless activity and destablising consequences. My watch is a physical reminder; a mindful token, that my mind and body is situated in a time continuum that extrapolates into the future and looks back to memorialised experience.

It will take more than my 24 years to fully accept and realise that my security in who I am at any given time is liable to change through factors and states often beyond my control. The certainty that does remain is that regardless of how lost I may feel, stability is always to be found even if at an undefined, and seemingly intangible, point in the future. Experiencing mental integrity and shifts away from that is, to my mind, an all too natural reaction to the conditioned and reconditioned nation and age we live in. Being able to acknowledge that, even in light of practical or socioeconomic impacts, makes for some of the most intuitive and fascinating individuals precisely because they are in acute communication with their own mind.

Awareness of mental health is, first and foremost, an individual mindfulness of where we are, and how we are subject to the pressures, expectations and services of our society as shaped by the model of governance. Thereafter, awareness must lead to politically driven policy to prioritise services that support such mental shifts. That might take the form of readiness to fund research into virtual reality tools and computer-based therapy to substitute for face-to-face contact, or e-mental health programmes and streamlining referral pathways. Awareness (etymologically suggesting ‘caution’ or ‘wariness’) must shake off connotations of ‘beware’ and should always react to the human in flux as something to be embraced as a power for personal change and discovery.

 

To find out more about World Mental Health Awareness Day 2015, please head to: http://www.mentalhealth.org.uk/our-work/world-mental-health-day/world-mental-health-day-2015/.

Image Credit: Rocco Lucia, Flickr.

Book of the Month: The Spirit Level

Anthropologists, lawyers and medically-minded readers among you will have probably already encountered the life-changing read that is ‘The Spirit Level: Why Equality is Better for Everyone‘. However, this is an essential everyman’s read with something of a following, if the number of comments I received while reading it at the pub, mid-way through the disappointment of England’s weekend rugby performance, are anything to go by.

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Co-authored by Kate Pickett and Richard Wilkinson, this work poses societal questions that are as relevant to a new global health Masters student, as they are readers who want to explore questions such as ‘why do Americans have higher rates of teenage pregnancy than the French?’ or ‘why were the England team so much worse at scrummage than Australia last weekend?’ (not verbatim). The book points to an overarching answer: inequality.

Of course,  inequality is not a new consideration on the political and health-related agenda, but ‘The Spirit Level’ pushes it beyond concepts, supporting every statement with accessible statistics, compelling visualised data and associated commentary or caveats to this evidence. Context is, of course, important.

Published in 2009, the book’s relevance to a now Conservative government works differently, but to similarly pressing ends ,as it did in the Labour political arena into which it was launched. More so now, perhaps, as readers and government leaders manage an increasingly democratised society, aware that each policy formula equates to inequality, variance in public capability and party support.

‘The Spirit Level’ calls for a global attendance to the risk factors of inequality in a controversial move away from projects that prioritise acquisition of exponential national financial growth. Labelled a work that could challenge political thinking, surely it is deserving of its iconic status, and should continue to prompt and provoke an ever wider audience.