Writing the Self: Creating Health (TEDx)

In December I had the opportunity to join the line-up for TEDxUCL in which I shared my personal experience of writing through and out my health, and how this informed the ‘Writing Health‘ section of this website.

You can watch the talk here, and find the transcript following.

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Dear Ana,

You are twenty-five years old, standing in front of some 1000 people in the Logan Hall in London’s Bloomsbury. You are a stone’s throw away from the Institute of Child Health where you are studying for a Masters in global development. You are a five-minute cycle away from the Cruciform building where you began your medical degree in 2010.

You are about to tell them what got you here. Of how an eating disorder saw you hospitalized after A-levels, and about the unwanted deferral of your much coveted entry to medical school, and the subsequent curtailment of it eighteen months later following a relapse.

You are anxious. Anxious that the audience will wonder what merit there is in your talk, whether it’s worth the ticket price, whether you are worth being heard, how it will feel to tell this many people a verbal and very personal narrative of mental disorders only your nearest know about.

You are talking to them. You are highlighting that because we cannot see mental illness, it is hard to understand, but that this talk is still relevant, because all of us in this room seek meaning through connection. This is what you call a sense of being ‘grounded’, and that every listener here will know someone with, or personally experience, mental health disorders at some point in their life.

 Yours, Ana

 

It is true that, of the audience today, approximately 250 of you will experience some form of psychological disorder at some point in your adult lives. That’s one in four of you: one member of a nuclear family, at least one of the people sitting immediately next to you, one of a virtuouso string quartet. But I don’t want to talk about diagnoses or labels, but rather start from an awareness that every one of us has a psychological self, of which we are variously aware.

What is also true is that you all have the capacity to feel, to think, to write. And I want to share how writing is a greatly undervalued tool in appreciating our personal composition and to try and understand how that can become disordered.

It won’t come as a surprise to you that reading can be a form of escapism and writing can be therapeutic. We could look at lots of studies about how the medical humanities (i.e. the cross over between disciplines including social science and literature) are beneficial to our wellbeing, as shown here. And I want to show you tools that might help you at some stage in the way they came to help me. But more importantly, I want to consider why this might have helped.

Mental health is still commonly underrepresented and discussed at both personal and policy levels. But things are slowly changing. As humans we are programmed to try and keep ourselves well and others well. But this begs the question: what does it mean to be ‘well’ or ‘ill’, how can you tell where you sit between those and what happens if you’re not sure?

For those of you hoping for a magic bullet I’m afraid I can’t offer a simple answer, because I don’t think there is one. Instead, I want to offer up Chapter VI of Lionel Trilling’s ‘Sincerity and Authenticity’ in which he adopts Freud’s assertion that “we are all ill – neurosis is of the very nature of the mind. Its intensity varies from individual to individual”.

But one way that we can address the answers to these questions is by entering into a written dialogue with ourselves through language. Through my own process of writing out my health, I came to realize that for me, mental disorder and external modes of control are symptomatic of a version of myself that is adrift from any solid sense of history.

When I was first hospitalized I struggled through the treatment plan and managed to follow the medication and instruction regime until I had convinced myself – and everyone around me – that I was ‘well’ enough to get on with my life and start my medical degree. It was only when I found myself back in treatment again a year later that I realized I couldn’t just do what I was told which was a pretty big deal for someone who enjoyed being liked and accommodating.

When I relapsed I felt broken. I knew that following the rules had only given me an alternative system of false reality which was untenable in the realities of my actual life. More so than ever before I felt completely adrift – completely groundless – unsure how to find a state of physical and mental wellness that was sustainable and thorough. But, what was different this time around was that there were therapy classes of which one was creative writing. Now I’d always adored reading, and writing poetry (very badly I should add) but during those months and ever since words became my grounding: both those I wrote for myself, and to myself, and those of others along the way.

Writing and revising my own narrative strengthened a previously fragile self awareness, and over time I started to initiate and reinforce positive behaviour change by acting as the written me felt able to. As I entered into an understanding of the strengths and limitations of my body and mind so too my collection of journals and notebooks grew. Although they’re now stored away in my Mum’s loft, they became a tangible construct of who I was at that time, in which I expressed myself freely so discovering things I never realized I doubted or feared or hoped for.

That was perhaps the greatest thing: discovering I did actually have and wanted to hope and own a purpose. Someone once told me that the most optimistic people suffer the worst. Perhaps this is true, but just as we all sit on a spectrum of self awareness, so too do we vary in our willingness to have hope for ourselves.

So, writing to and of the self is a wonderful method for creating personal growth and mental wellbeing. Of course, this idea isn’t new. Just as I opened with a letter I’d written to my future self, many of you will have encountered Leslie Pole Hartley’s ‘The Go-Between’ (1953) in which letters become the substance of an alternative reality for two forbidden lovers. So too, John Clare’s letters from the asylum recount his episode spent in an institution for the mentally unstable. His letters written during this time are frequently associated with an othering Clare wrought on himself through the adoption of new personae and life narratives.

Eric Robinson, a prolific editor of John Clare, has suggested that in these letters ‘it seems as if Clare is struggling to retain his sanity by writing down each image as it floats into his mind’[1] which echoes true in his poem ‘Shadow of Taste’: ‘in living character and breathing word / Becomes a landscape heard and felt and seen’ (ll. 72-3).[2] This psychological mapping of moments and territories became crucial to constituting and re-constituting the land and self for Clare.

‘Writing health’ is a process of self-development and prompted me to create a blog platform which invites multimedia contributions from all people on mental health and has produced some deeply moving and reflective pieces. Take David, a medical researcher who contributed a piece called ‘Autumn’ in which he tried to make sense of his role as clinical practitioner and facilitator on a placement in a psychiatric tertiary care unit.

This model of writing for health offers a construct through words that can either be used to create a fuller or more representative evaluation of who you are at any given moment or as labels to distance oneself from. For instance, during my treatment for disordered eating I was encouraged to write a letter to the ill me which challenged what it means to be ‘ill’ and ‘well’ forcing a degree of disassociation. This became one of the most formative steps in my recovery progress enabling me to detach myself and my physical health from mental imposters. This was followed up with a letter to my future self allowing me to engage with the parts of me that were healthy, sustainable and carried personal integrity.

There is purpose in writing a letter; there is a need to actually create something rather than just a process of expunging. I want to encourage you to create a self-portrait in letters channeling a modernist focus on the interiority of the self. Modernist writers, including Freud, James Joyce and Virginia Woolf were among the first to prioritise the entangled nature of the self and a ‘turn inward’ that is increasingly relevant today.

You will see that you all have a postcard on your seat. I would like to invite you to pick it up and keep hold of it until I finish. Who has heard of Andy Warhol? Good. In 1949, the managing director of Harper’s Magazine Russell Lyne wrote to a then unknown Warhol requesting biographical information. To which the 21-year old artist replied: Hello mr lynes / thank you very much / my life couldn’t fill a penny postcard.

What you are holding now is the same size as one of those early 20th century penny postcards. I’m pretty certain we all agree that Warhol could have more than a postcard written about him these days. But it isn’t about the quality or quantity of what you write either to yourself or to others. It is about using words with integrity – by that I mean penning thoughts instinctively and without restraint – to create a verbal self that can help to reflect on, and reflect who you are, at any given point. So there’s only one thing left for me to do.

 

Dear audience,

I have shared with you a biographical history, but more importantly this talk has helped write out why and how composing letters got me from feeling completely detached to being able to feel grounded. Keep hold of that postcard, and when you can, write something. Perhaps to a past you, a future self, or how you are right now, whatever feels right. Just write with abandon and you never know what you might learn or the self care you might establish.

 And I want to leave you with another example from the fantastic ‘Letters of Note’ collection that is about as far away from Warhol as you could possibly get. On May 4th, 1941, the renowned American sociologist Jessie Bernard wrote a letter to her first child, a then unborn daughter. It opens: ‘my dearest, / Eleven weeks from today you will be ready for this outside world’.  

You, listeners, readers, writers are already living in and through this outside world. But whether you are ready or not, writing out our experiences in it can help make a lot more sense of it as we grow-up in it right to the very end. 

Yours,  Ana.

 

 

References:

[1] Clare, The Oxford Authors, p. xxiv.

[2] Clare, The Oxford Authors, ‘Shadows of Taste’, p. 171.

Image Credit: Lulu Fernandez

MdM Talks: Life after Ebola

I was introduced to Dennis Akagha by a friend on my Masters in Global Health & Development programme, and over the course of the winter break I was moved and touched by the experiences related in Dennis’ correspondence. He has agreed for his story to be shared below.

Image courtesy of D. Akagha

Image courtesy of D. Akagha

Dennis comes from a  family of four living in Nigeria and his desire to work in banking motivated his studies in Business Management then Banking and Finance at university. Post-graduation, rather than working in this sector, he started his own business while also collaborating with an independent organisation to gain a better insight into its operational management.

He highlights that he also had a lot of marketing experience and briefly employed these skills with an oil and gas firm which was the last position he held before the Ebola crisis. Following his diagnosis with, and treatment for, Ebola, he decided to volunteer with the World Health Organization as a community mobiliser aiming to sensitise communities about the virus. As his passion for social work developed, he travelled to India for an 8-month training scheme from which he has recently returned, to become a social change-maker alongside running his own health promotion project.

In his own words, Dennis shares his experience of Ebola: I became infected with Ebola through my late fiancée who was one of the nurses caring for Patrick-Sawyer, a Liberian-American lawyer who entered Nigeria carrying the virus. Tragically she, and her two-month old foetus, died two weeks following this exposure. I was the one who cared for her during her miscarriage caused by the viral load making the foetus non-viable and that was how I became exposed and infected. A couple of days after her death , I started experiencing the tell-tale Ebola symptoms (high fever, body and joint pains). I alerted the Lagos State Ministry of Health who immediately transferred me to a unit for testing which confirmed my fears. I was then placed in the isolation ward for care and treatment alongside other infected persons, under the management of Médecins Sans Frontières.

I coped with being infected through retaining my characteristic positivity and relying on my Christian belief. In spite of my diagnosis and the limitations of the isolation ward, I continued with my normal habits such as morning push-ups, praying and reading. Ebola causes severe dehydration so I was given oral rehydration therapy and some therapeutic foodstuffs because we were told that these measures boosted the immune system and help fight the virus. As there was no cure available at this time, all treatment was maintenance based.

Dennis recalls that he had very little trouble in both accessing and receiving treatment, instead citing psychological setbacks and stigma pre- and post-discharge from the isolation ward as his greatest challenges. He recalls how, in spite of his awful experience, he suffered rejection from friends, neighbours and people I relied on to lead a happy life. He continues: I was nearly evicted from my house, I lost my job during the process, and I couldn’t make purchases locally but instead had to travel further afield where I was effectively incognito.

I always tell people that, in most cases, people don’t know their purpose in life until they undergo a tragic event such as the one I experienced. As an Ebola survivor, I have been given an opportunity to better understand what people facing similar stigmatising and life-threatening health traumas such as  HIV/AIDS or cancer go through. I experienced what it means to be an outcast through discrimination. This was what prompted me to come up with a project that campaigns against stigma and discrimination of people living with HIV/AIDS and other infectious diseases that could cause them to be socially marginalised. Ebola has impacted my life to such an extent that I now see my purpose completely differently and I am able to use my story to bring healing to others – often those who have lost hope .

At first, there was inadequate information and a lot of false communications surrounding the Ebola crisis in Nigeria, exacerbated by social media. For instance, one morning, a group who knew what had happened to my fiancée called me telling me that I should bathe in hot water mixed with salt. It was only after some days of delay that the local media started working effectively to educate the general public on how Ebola is spread and promote preventative measures. There was also a great deal of international coverage and Nigeria became a spotlight for many international media organisations. I remember giving interviews to news agencies including Aljazeera, the BBC, and more who came to my apartment to get first-hand information.

Prior to my infection with Ebola I didn’t know much about the virus and had not heard of any intervention programmes. Moreover, while in the isolation ward, I only went online to check the survival count of people who had been infected. I needed to draw strength from their stories. Therefore, the singular most important intervention I was aware of was when Ebola spread to Nigeria because prior to this  benchmark there was a dearth of information. I commend Nigeria for working alongside international organisations and NGOs and for being very proactive in their approach that was both supportive and sought to prevent further viral spread.

From my own perspective, one lesson that should be learnt from the Ebola crisis is that governments and international organisations must ensure everyone is working together which was largely the case in Nigeria and so contributed to the rapid curtailment of the disease spread. No country should be left alone to handle their health challenges regardless of the disease and its characteristics. So too, people should always report themselves as quickly as possible if they have been exposed to Ebola – such timely personal and government intervention helped get the virus under control in my country.

My initiative ‘JustCare’ organises projects such as workshops, campaigns, life-skills sessions and entrepreneurship training for people living with HIV/AIDS and other infectious diseases that could result in the infected person(s) experiencing stigma. We act as a united voice for people living with these diseases, and with the help of our partners, are slowly changing the way people think about HIV/AIDS by bridging the knowledge gap between how the virus spreads and its implications that exists among the general population of Nigeria.

Image courtesy of D. Akagha

Image courtesy of D. Akagha

Currently our project is self-funded, and our immediate focus is to improve our social media presence and credibility. We believe that the more people see the little changes we are making, the more likely we are to gain their trust and support for future projects we already have in the pipeline. Our goal is to impact lives and employ the expertise of  related organisations to create the change we want to see in Nigeria regarding HIV/AIDS. Presently, there has been a set-back from international donors for antiretroviral therapy (ART) funding and this is affecting those least able to access treatment. We believe there is still more to be done in this area and we want to give this initiative our best shot to save lives, reduce stigma and lower the infection rate in Nigeria.

 

Image Credit: trust.org,  Flickr

MdM Talks: Daniel Flecknoe on Darfur

Daniel Flecknoe is a Specialty Registrar in Public Health and a senior tutor at Leicester Medical School with over a decade of emergency nursing experience across the South of England and overseas. He worked with a mission team for Médecins Sans Frontières (MSF) in Northern Darfur between 2008-2009 at a critical time prior to the retrospective identification of this zone by the International Criminal Court as a genocide situation.

While there he was also involved in health education, teaching and training for the local nursing team which demanded making information context appropriate. For instance, one of his most memorable teaching sessions discussed the differences between sympathy and empathy and he relates the satisfaction of finding a common inter-cultural understanding of these concepts with the local staff via an Arabic interpreter.

Image courtesy of D. Flecknoe

Image courtesy of D. Flecknoe (Dan second from right, front row)

How can MSF communicate and deliver aid with integrity in hostile and complex humanitarian situations? By extension, when does one identify that a field mission and its aims have become untenable?

Fundamentally MSF is a non-partisan organization which operates for the benefit of all those affected by conflict and emergency situations. But not taking sides can cause it’s own problems in maintaining safe access to those who need medical care. For example, the MSF Kunduz hospital, which was recently bombed by coalition forces treated wounded Afghan Government fighters, wounded Taliban fighters as well as sick and wounded civilians, Treating enemies can be a very tricky affair, and working on a shifting frontline makes it hard to keep the service running, let alone to stay in all sides’ good books. Unfortunately, the rules of war regarding the rights of injured combatants to treatment are not always respected, and humanitarian organisations can become a target. It is getting harder and harder for humanitarian groups to operate in places like Syria, Afghanistan, Iraq, because the warring parties do not abide by their obligations under international law to let them do so safely. This is a matter of very serious concern.

My current interest is in the primary prevention of armed conflict, and how healthcare professionals can get involved in this effort, but it is very clear to me that MSF and similar NGOs will always be required. Somewhat like A&E departments, however much we all agree the demands upon them need to be reduced by prioritising preventative health measures. Even if we get much much better at the primary prevention of armed conflict, there will still be a global need for humanitarian work.

When to withdraw from a situation is always going to be a bit of a judgement call, and often a very traumatic one for people who have put their heart and soul into a project. You have to consider the way things are trending, so a one-off event such as an armed robbery may not be enough in isolation, but cumulatively, as part of a general escalation in violence, it may warrant the withdrawal of an NGO from the area.  Of course gradual change can be difficult to detect, so it is sometimes easier to assess the situation with external or fresh eyes. MSF capital teams take on the role of wider security and contextual surveillance while the project teams on the ground focus more on the situation in front of them.

Some people think of humanitarian aid work as a wholly positive endeavour, but there are situations where it is possible to unnecessarily endanger yourself, or to do more harm than good. Prospective aid workers should be aware of the necessary compromises and contradictions, issues of wrongly imposing our own values, culturally-relative medical definitions, advancing the interests of Big Pharma, and confronting White or Western privilege, which may be brought up by the experience of working overseas with an NGO. 

Image courtesy of D. Flecknoe

Image courtesy of D. Flecknoe

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Image courtesy of D. Flecknoe

In terms of being heard, how can indigenous care providers best receive coverage and credit for their work?

Their stories definitely deserve to be told, and their hard work recognized. Unfortunately I don’t think that such stories would sell very well in the Western media, because we (as a media-consuming population) are generally more interested in stories about people like us doing things that we would not normally do. […] Unfortunately this means the amount of column inches that someone will get does not correlate to the amount of good work that they have actually done because they don’t fit the right demographic to generate media interest. I don’t think this is really a racism issue; it’s like the prioritization of stories that you see in local news […] we are all drawn to narratives that pertain to us in some way. Nevertheless it remains an injustice, in terms of media coverage, done to a lot of indigenous aid workers who do a lot of difficult and dangerous work.

NGOs don’t always do enough to promote the stories of their indigenous staff because their priorities include, of course, fundraising. Personally I consider myself as an international volunteer for MSF to be much more useful on my return from missions in terms of spreading the word and raising awareness, and for me that definitely includes representing my brave Darfurian colleagues.

Image courtesy of D. Flecknoe

Image courtesy of D. Flecknoe

One of the supposed changes between the Millennium Development Goals and the Sustainable Development Goals is the role of UN member state or country level actioning of goals. But what about those goals that require cross-country efforts? How should these be coordinated?

The public health experience on behaviour change at both the individual and the population level seems to show that giving people information, especially when it is unpleasant information often doesn’t work. People tend to block it out […] and not identify with it. We are pre-disposed to accept pleasant information, which is congruent with what we already believe or how we already behave, and reject the unpleasant information. The “Nudge” concept in public health takes a different approach, byincentivising positive health behaviours and de-incentivising negative behaviours without banning or limiting or criminalising anything. This makes it easier, cheaper and more appealing to make healthy choices, and the technique may also have some wider democratic applications. For example, as citizens it is possible to make global health and human rights into political priorities through our votes and democratic engagement. We all have the power to incentivize political change in our countries towards peace, equity and positive health care policies through democratic action, and I would encourage everyone to consider how they can contribute to the goal of making their country not only a better place to live, but also a more ethical actor on the world stage.

Image courtesy of D. Flecknoe

Image courtesy of D. Flecknoe

What do you think is the priority of the sustainable development agenda?

The most pressing imperative for me right now is promoting and also reinforcing the responsibility of warring parties to prioritise the health needs of the civilian population […] Whenever that doesn’t happen I think it is deplorable, because while it is easy for political actors to get bogged down by their own priorities, the health and safety of the civilian population should always be paramount [… They] have a right not to have their health impacted because of political goals being pursued by violent means, however pressing those goals may be.

I don’t mean that humanitarianism is automatically a pacifist philosophy. Prioritising humanity does not necessarily exclude supporting military interventions sometimes. There are circumstances where you could advocate a military invasion on humanitarian grounds. It’s not unthinkable.

Image courtesy of D. Flecknoe

Image courtesy of D. Flecknoe

You said preventative medicine should be the focus of future MSF work. What does this mean in practice?

I’m not sure that this is a job for MSF. MSF has its own sphere of competence and expertise, and as Jose Bastos recently said, humanitarian action is a visceral impulse, motivated by outrage and empathy. That is not at all the same as primary prevention.

I could use the analogy of parenting (and bear with me here, because I am not a parent). Obviously as a parent you would be motivated to reduce the risks to your children, to forbid that dangerous playground or this unsafe skate park. That’s primary prevention, and it’s incredibly important work. But you would also be driven to hold them on your lap and give them caring first aid for the wounds they have already received, which you cannot prevent because they have already happened. That’s humanitarianism, and they are two separate fields, which I happen to have a dual interest in.

Primary prevention in this case requires tackling the root causes of armed conflict – stopping them before they get started, in other words. MSF is focused upon the tertiary prevention of armed conflict – minimizing the collateral damage.  But either way, it’s important for healthcare professionals to have a voice at a political level, and to advocate for the universal right to health and security.

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Image courtesy of D. Flecknoe

So why public health rather than global health?

I don’t think that there necessarily needs to be a distinction. Public health in the UK already has to cross inter-professional boundaries, and we have to engage with people across the spectrum of disciplines if we are to tackle the root causes of health problems. For instance, in the case of TB coming back into high prevalence in some parts of this country [UK], it isn’t just about screening immigrants, it is about housing, deprivation, overcrowding and other social and political issues not traditionally within the domain of health […] As public health professionals we have to get involved across the spectrum in order to address the problem.

Just raising our focus from the local, we can see the same interconnectedness requiring a broader view and engagement at the global health level. Climate change, armed conflicts, political instability, infrastructure breakdown – all of these things, which predominantly directly impact on other parts of the world, will also have an effect on the health of the UK population if they are not addressed. Whether through mass population movements, interruption of food supplies, exported diseases, we will feel the effects here. There were incredibly pressing humanitarian reasons to fight the Ebola outbreak in West Africa, for example, but there were also selfish reasons, because we live in a globalized and interconnected world where you can’t just close the doors to your own country and expect to stay safe. Western countries had to get involved with tackling Ebola at the source, because they couldn’t afford to let it spread further.  I would prefer that the humanitarian motives were more dominant, but if self-interest ultimately motivates the right course of action then,… well, I’ll take what I can get!

It’s commonly and rightly said in my profession that “there is no health without mental health”.  It’s very true, but I would also say that in the longer term there is no local health without global health either.

Image courtesy of D. Flecknoe

Image courtesy of D. Flecknoe

What key learning from operational work with MSF could you pass on?

It’ll probably be different than you expect. It’s not a rescue mission. The main goal of Western aid workers, as I see it, should be to learn as much as possible from their local colleagues who have far more experience and who know the culture and context better than we ever will. Our job is to support them as best we can, and to come to terms with the fact that we may be of more assistance to them and their struggle once we return from the field. While you’re out there, you can definitely be useful, applying and sharing the medical skills and knowledge that you’ve been lucky enough to gain through your education. You also demonstrate solidarity with them and their cause, which is a valuable and important thing. However, once back home you can bear witness to what you have seen, and be involved in raising awareness and money for their ongoing efforts, and in some ways that is the best thing that you can do for them.

Image courtesy of D. Flecknoe

Image courtesy of D. Flecknoe

Where next? 

At the moment I am professionally focused on my public health training, although in my own time I can also pursue projects which have an international and conflict-prevent slant. I would also like to work with MSF again in the future because it is an organization that I really love and respect. I get very uncomfortable with simplistic portrayals of aid workers as saintly and selfless altruists, because that’s not really me, and I’m sure many of my colleagues in the field would also dismiss such one-dimensional stereotyping. People are complicated, and we do this work for a variety of reasons […] There are certainly many reasons why I want to do it again, some of them selfish and some of them less so.  But working with MSF was one of the most satisfying things that I have ever done, I benefitted from it enormously in terms of my personal resilience and capabilities, and I think with the benefit of my public health experience I’d probably be better at it now too.  Maybe I also want to have some good stories to tell my grandchildren!’.

Going back to MSF may also help me to clarify my ideas about a possible synthesis of humanitarianism and primary prevention, which at the moment seems to me to be an interesting and important area of work to get involved with.

Fundamentally, aid work is about coming to terms with what you can do and what you can’t and what you might have to sacrifice along the way […] It is like fighting massive forest fires with buckets of water. It absolutely has to be done if you’re going to save even a few houses from the flames, and it can look sort of heroic while at the same time being massively inadequate to the scope of the problem. As a species, it is incredibly important that we devote more energy to preventing these fires from burning out of control in the first place. 

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.