Trauma construction and traumatic events
In the first part of their essay series on cultural psychology, Kate and Mohammad draw attention to Dr Derek Summerfield’s critique of Western trauma narratives and reveal the limitations in our approaches to global mental health.
The era of white saviourism
Content warning: This article contains mentions of mental illness and racism.
In his groundbreaking work on decolonising trauma and post-traumatic stress disorder in Palestinian territories, Dr Derek Summerfield calls for the reform of the treatment and overmedicalisation of mental health, particularly in humanitarian circumstances. The following two-part essay series understands trauma, in line with Summerfield's arguments, to be a condition manufactured by Western psychiatry, whereby the complex, unique, and often collective suffering of individuals is reframed as a technical problem to which short-term, individually-delivered solutions are applicable. In the second essay, the implications of Western framings of post-traumatic stress disorder will be explored further through the actions of non-governmental organisations such as Médecins Sans Frontières. The series concludes by suggesting ways in which decolonising psychological care can improve inequalities in access to and treatment of mental health globally, as well as raise awareness surrounding the complexity of human nature and psyche.
Image credit: Unsplash
Western social constructions of trauma and traumatic events
“despite the fact that the diagnosis of PTSD was built from the specific experiences of male American veterans, its entry into the DSM-III meant that it became the definition applied to all, irrespective of culture, experience, background, ethnicity, or gender.”
Definitions of post-traumatic stress disorder (PTSD) first appeared in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). PTSD is described as “a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event” and is diagnosed through a series of DSM criteria, including “intrusion symptoms” like nightmares or flashbacks, and “negative alterations” in mood or reactivity like feelings of isolation and anger. The DSM-III and its subsequent versions (the DSM-5 being the most recent edition) are American-made manuals that have become used globally, supposedly offering a guide to psychiatry written in a “universal language for clinicians”. However, understandings of trauma were first premised on the early experiences of American soldiers returning from the Vietnam war in 1975. In part, the trauma experienced by these soldiers was given the label PTSD as a means to depict these soldiers as solely victims of the United States’ military establishment as opposed to individuals who had also perpetrated atrocities. In this case, the PTSD diagnosis legitimised the suffering of Vietnam veterans, and offered short-term relief to their distressing symptoms. Yet, despite the fact that the diagnosis of PTSD was built from the specific experiences of male American veterans, its entry into the DSM-III meant that it became the definition applied to all, irrespective of culture, experience, background, ethnicity, or gender.
The diagnosis of PTSD has spread to all countries subject to Western imperialism. The transition of PTSD from its localised socio-political origins into ‘objective biomedicine’ demonstrates the power of colonial channels and Western ideologies. Temporally specific diagnoses of trauma that emerged during America’s war on Vietnam have been erroneously regarded as universal and context independent, and thus applied worldwide. Suman Fernando—a lead scholar in the correlation between mental health treatment and racism—describes this as an imperialistic process: Western powers “marginalise other ways of knowing, destroy diversity, make alternatives to psychiatry vanish and create monocultures of the mind”.
“Temporally specific diagnoses of trauma that emerged during America’s war on Vietnam have been erroneously regarded as universal and context independent, and thus applied worldwide.”
How do Western conceptions of trauma engender inequality in mental health treatment?
In areas of conflict, Western non-governmental organisations distribute and deploy trained medical staff to deal with the fallout of violence and to treat early trauma signs. However, the deployment of medical staff trained in Western-centred psychiatric medicine in non-Western contexts is self-defeating. The challenge for Western medical staff is attempting to apply a ‘one-size-fits-all’ approach to mental healthcare in individuals with symptoms unexplained or not understood by Western training. In taking such an approach, ownership of what is deemed important in traumatic events is transferred from those experiencing it to Western bodies deemed to know better, those “whose knowledge carries a stamp of authority”. The understanding of Western psychiatry as a globally-applicable science implies that the vast experiences of trauma survivors can be easily reduced into a single mental illness classification of “PTSD”. Thinking of trauma in this regard is simplistic, and invalidates the experiences of trauma survivors.
“ownership of what is deemed important in traumatic events is transferred from those experiencing it to Western bodies deemed to know better”
For example, on the premise of a PTSD diagnosis, many patients receive Western treatments such as counselling or medication, which “offer little in the way of alleviating the underlying causes of collective trauma”. Collective trauma refers to the “psychological reactions to a traumatic event that affects an entire society”. Acknowledgement of collective trauma is vital to validating the stories and emotions of survivors both before and during the traumatic events. By accounting for broader frameworks of “social justice, quality of life, human rights and human security”, a more nuanced understanding of the survivors' responses within the collective memory and experiences of their society can be gained, and adequate treatment provided.
“Western narratives arguably regard sufferers of collective trauma and psychological ill-health as passive bodies in need of treatment, as opposed to survivors with valid experiences.”
Furthermore, emotional distress experienced by survivors is generally hard to empirically measure in the categoric style of Western psychiatry—a limitation further exacerbated by a lack of cultural understanding. Deployed medics’ lack of knowledge or willingness to understand local idioms of distress leads to misdiagnosis and misinterpretation, pathologising of symptoms, and prescribing medication that is in some cases unnecessary and of little effect. Western narratives arguably regard sufferers of collective trauma and psychological ill-health as passive bodies in need of treatment, as opposed to survivors with valid experiences. This narrow understanding shapes and often rewrites the ways in which people view themselves as victims, which can worsen or complicate existing experiences of psychological ill health.
The dominance of Westernised trauma narratives is contingent upon the funding of Western psychiatric research and the value attributed to the Westernised methods, with very little insight into varied cultural understandings of trauma and the local idioms in which they arise. Studies that are academically and financially valued are those which underpin Western institutions’ own understanding of trauma narratives, thereby deepening Western-centric knowledge systems, while simultaneously excluding the experiences, symptoms, and accounts of trauma globally—a symptom of the colonial legacy in scientific research. With many international organisations prioritising Western-centric understandings of psychology, along with research funding being allocated to institutes mainly in the West, culturally sensitive research is excluded from international policies.
“Studies that are academically and financially valued are those which underpin Western institutions’ own understanding of trauma narratives, thereby deepening Western-centric knowledge systems, while simultaneously excluding the experiences, symptoms, and accounts of trauma globally”
For example, in tracing the history of Palestinian mental health diagnosis and treatment, Giacaman et al. emphasise the importance of “separating clinical responses to mental illness from the public health response to mass political violation”. It must be recognised that war and violence is a collective experience. Summerfield states that when witnessing the destruction of their social world, survivors lose embodiments “of their history, identity and living values and roles”. Therefore, to exclude such experiences, and to exclude context-specific socio-political understandings of trauma, can only cause further harm to survivors. The authors emphasise the need for a shift from the individual focus of Western medical indicators to broader global factors in trauma, such as a lack of human security and human rights violations.
In sum, the trend of excluding cultural contexts of trauma sustains global hierarchies. The West and “the rest” mentality reinforces centuries-old colonial structures and channels of power that depend upon stereotypes and generalisations. Such power imbalances result in an inability to reconcile different cultures, widens racial inequalities, and limits access to proper mental healthcare in resource-poor settings.
Western conceptions of trauma
In the second part of their essay series on cultural psychology, Kate and Mohammad take a closer look at the origins of international aid group Médecins Sans Frontières and discuss future directions for the continuing decolonisation of global mental health.
The case of Médecins Sans Frontières
Content warning: This article contains mentions of mental illness, racism, and discriminatory language.
Trauma projects and expeditions to ‘aid’ victims in resource-poor settings have become increasingly attractive and are fashionable for Western donors and non-governmental organisations (NGOs). However, the permeation of Western schools of thought surrounding trauma limits the degree to which the actions of these non-governmental organisations are effective or helpful. For example, Médecins Sans Frontières (MSF) deploys hundreds of their staff to conflict situations or areas affected by natural disasters. They have saved the lives of people worldwide, providing medical aid to all regardless of differences in their race, religion, creed, or political affiliation. Whilst MSF and their staff (from Western and non-Western countries) have shown courage and selflessness in their attempts to care for those most vulnerable around the world, their acts of goodwill do not come without criticism. This second part of this essay series will explore the extent to which NGOs are manipulating situations in areas of conflict and natural disaster by constructing trauma narratives as ‘epidemics’ in urgent need of attention to gain further donations, publicity, and resources. Lastly, we will explore the damaging consequences of being depicted as receptive patients or helpless victims by aid missions.
Image credit: Unsplash
Founded in France in the second half of the twentieth century, MSF is a private international association of doctors and healthcare professionals working to “provide assistance to populations in distress”. Despite their pledge to observe “neutrality and impartiality”, their humanitarian aim is deeply rooted in Western ideals of human rights. The rigidity of these ideals mean issues are framed and solutions are generated through the lens of colonial thinking. In the simplest sense: a humanitarian mission originating from a European country to help people deemed to be in need in Africa or Asia resembles colonial civilising missions. More specifically, in the case of post-traumatic stress disorder (PTSD), repetitive quotes in the media referring to trauma as the “hidden epidemic” likens the psychological condition to concrete communicable diseases capable of causing mass pathology. Framing localised trauma as Westernised conceptions of PTSD provides an incentive and authority for companies such as MSF to “resolve the issue”.
For example, the MSF handbook on refugee health makes claims that “20% of survivors of traumatic experiences will not recover without professional help.” Such language works to posit MSF as saviours and superior bearers of knowledge and healing, linguistically reflecting a “modern echo of the age of Empire when Christian missionaries set sail to cool the savagery of primitive peoples and gather their souls, which would otherwise be lost”. The colonial use of language was exemplified in the wake of the Rwandan genocide, when European NGOs sought out to make an early psychological intervention for the Tutsi refugees as a “preventative measure to thwart the later development of more serious mental problems,” inciting a sense of fear towards trauma and a need to “control the mentally ill of the global south”. However, the NGOs failed to provide adequate treatments, as concepts integral to the English understanding of trauma such as ‘stress’ and ‘family member’ were not translatable in Kinyarwanda and didn’t apply to Rwandan social contexts. As such, Western knowledge and its tools are incapable of identifying the expressions of trauma and the appropriate treatments cross-culturally. Further, such absolute depictions of trauma not only simplify it as a biological entity to be ‘fixed’, but pathologise human emotions and victims of traumatic events.
“Members and employees past and present of MSF made attempts to challenge their work environment through publishing of an independent report exposing the racism, discrimination, and abhorrent behaviours observed within the organisation.”
The white saviour complex at the centre of MSF's ideology is a symptom of a historical mindset that is accepting of discriminatory language and generalisations. Members and employees past and present of MSF made attempts to challenge their work environment through publishing an independent report exposing the racism, discrimination, and abhorrent behaviours observed within the organisation. As an employee of MSF relays, “I hear harmful generalisations and racist comments all the time when working internationally for MSF, from fellow international colleagues.” Employees went on to take note of their experiences in varied settings, stating they have overheard senior colleagues using hateful and ignorant language such as “These people aren't careful”, “They smell bad”, “People here can't figure it out”, “People here don't know how to do s***.” Yet the organisation's work sustains its faultless appearance, continuing to appeal to the Western eye and be championed for its exemplary humanitarian action.
“MSF joins many other Western non-government organisations in an inability to concede and amend their colonial history, address their white saviorism discourse, and dismantle their archaic protocols and procedures.”
MSF's exacerbation of white supremacy and neo-colonialism—the use of power by developed countries “to produce a colonial-like exploitation” and maintain control—are further evidenced within its division of labour: workers are split into both ‘international’ and ‘national’ categories, providing individuals in the same role with varied rates of pay and privileges dependent on their nationality and passport. Such divisions were described by MSF staff as "coded racialised language", with over 50% of its workers reporting experiences of racism. Since many ‘international’ workers depend on MSF for employment, it is hard for them to confront the administration and demand tough reforms for fear of losing their jobs.
Members of the organisation have made considerable attempts to stand against their work’s ethos, calling for MSF to look deeper into its history and what it represents, and demanding accountability for their harmful actions. Their stance is summarised by present MSF staff in the MSF dignity report published in 2021: it is impossible to view current activities and policies in MSF “outside the legacies of colonialism itself, from which MSF and the wider humanitarian sector grew, or contemporary power dynamics that maintain oppressions”. However, the impact of the report has done little to tarnish the reputation of MSF, or to change the lived experiences of both its staff and those on the receiving end of its ‘aid’. MSF joins many other Western non-government organisations in an inability to concede and amend their colonial history, address their white saviorism discourse, and dismantle their archaic protocols and procedures.
“the West medicalises and objectifies despair—responses to mass social upheaval, poor human rights, and diminishing social security—by categorising them into identifiable somatic symptoms”
The future of trauma narratives
“non-Western expressions of trauma are either falsely medicalised, untreated, misdiagnosed, or underrepresented, leading to inequalities in access to treatment for poor mental health globally”
To conclude, modern Western psychiatry and the clinical protocols and manuals that form it are based on biased Western research and experiences that are not inclusive of other cultural understandings nor the contexts in which mental ill-health arises. It is argued that the West medicalises and objectifies despair—responses to mass social upheaval, poor human rights, and diminishing social security—by categorising them into identifiable somatic symptoms. The 5th and most recent edition of the DSM has been criticised for its cultural bias and tendency to categorise all mental illnesses that do not align with Western understandings of psychology as “culture-bound syndromes”—that is, diseases or illnesses that are deemed to be specific to a particular culture or society. Subsequently, non-Western expressions of trauma are either falsely medicalised, untreated, misdiagnosed, or underrepresented, leading to inequalities in access to treatment for poor mental health globally. Implications of these discriminations bleed into the social lives of those afflicted and can have adverse effects on survivors. As Western diagnoses and understandings are prioritised, traditional coping strategies and idioms of distress are no longer meaningful to discuss patients' suffering, nor utilised as a common language for survivors, therefore exacerbating mental illness itself.
“The decolonisation movement emphasises the diversity of human experience, arguing that no single lens or methodology can encapsulate various understandings, ways of life, or experiences without falling into generalisations and omitting elements of people’s existences.”
To address colonial cycles in healthcare, critics are calling for a decolonised approach to psychology. A decolonised approach places human diversity as a priority in its thinking through actions like rewriting the curriculum used in medical schools to expand upon the limited Western frameworks currently used. The decolonisation movement emphasises the diversity of human experience, arguing that no single lens or methodology can encapsulate various understandings, ways of life, or experiences without falling into generalisations and omitting elements of people’s existences. In the case of NGOs such as MSF, training should be provided to inform their staff of the cultures that they work in. Learning about the ideas and practices intrinsic to other cultures would be a step towards acknowledging the gap between their expertise and those of local healthcare workers, community leaders, and healers. Culturally-cognisant work empowers locals to lead humanitarian agencies towards the concerns of their survivor groups, and guide them in understanding their way of life through respecting their rights, integrity, and traditional ways of coping.
The cost of cobalt
In advance of its screening at the Global Health Film Festival (25 Nov–5 Dec), Megan Greenhalgh reviews The Cost of Cobalt—an exposé of how the world’s “insatiable appetite for cobalt” is causing untold damage in mining communities in the DRC.
Film review
Image credit: The Cost of Cobalt
Year: 2021
Director: Fiona Lloyd-Davies and Robert Flummerfelt
Language: English
Rating: Entertaining 3/5 | Informative 5/5 | Inspiring 3/5
With the recent events of COP26 and the Earthshot prize, the buzzword on everyone’s lips—finally— is climate solutions: strategies to protect our planet and future generations.
As climate-consciousness is growing, so is the world’s “insatiable appetite for cobalt”—a core raw material needed for electric car batteries. The Cost of Cobalt spotlights the mining communities in the Democratic Republic of Congo (DRC) that are supporting the world’s transition away from fossil-fuel vehicles.
Fiona Lloyd-Davies and Robert Flummerfelt’s short (but by no means sweet) exposé introduces us to the families in Katanga, DRC, for whom cobalt is a poisoned chalice. In high quantities, cobalt is toxic to the human body, and in Katanga it is seeping into waterways and being consumed in drinking water. Lloyd-Davies and Flummerfelt highlight the growing body of evidence that cobalt mining may be responsible for a range of malformations in the babies born in these mining communities, from cleft palates to stillborns.
Over the course of the documentary, we meet the doctors treating babies affected, families of cobalt miners, and scientists studying this issue. Whilst moving, the film’s intimate focus on these lives is arguably frustrating since it fails to sufficiently engage with the broader issues of climate inequity and injustice that its subject matter throws up.
However, in laying its findings bare the film allows us to come to our own conclusions, perhaps resulting in a more powerful evocation. It is uncomfortable to realise that this celebrated climate solution is damaging the health of the next generation in the DRC, and the film serves as a striking illustration that inequities exist not only in the climate problem, but also in its solutions. What use is there in trying to protect our future generations, whilst hurting them in another corner of the world? The Cost of Cobalt is a painstaking reminder that climate solutions must be equitable to not create further harm.
“The film serves as a striking illustration that inequities exist not only in the climate problem, but also in its solutions.”
The Cost of Cobalt is being screened live alongside Green Warriors: Coal in the Lungs at the Global Health Film Festival on Saturday 4 December, followed by a panel discussion including co-director Fiona Lloyd-Davies. Global Health Film Festival is the annual flagship event of Global Health Film, a UK charity promoting the power of storytelling in global health. More information and tickets can be found on their website.
Dear future children
In advance of its screening at the Global Health Film Festival (25 Nov–5 Dec), Frieda Lurken reviews Hot Docs winner Dear Future Children—an intimate portrait of three young activists and the struggles they go through to fight for what is important to them.
Film review
Image credit: Dear Future Children
Year: 2021
Director: Franz Böhm
Language: English
Rating: Entertaining 4/5 | Informative 3/5 | Inspiring 5/5
Social movements are booming. The last few years have seen protests spring up around the world and leave their mark on the public consciousness—you know activism has become mainstream when Pepsi produces an advert featuring Kendall Jenner handing a can of its namesake beverage to a police officer amidst cheers of a crowd of fashionable, young protesters. Clearly activism “hits the spot”.
Given all this, a documentary like Dear Future Children feels long overdue. It tells the stories of three young women: Pepper campaigns for democracy with the Anti-Extradition Law Movement in Hong Kong; Hilda tackles the devastating impact of climate catastrophe with Fridays for Future in Uganda; and Rayen fights against inequality with Estallido Social in Chile. It goes without saying that each of these issues has dramatic implications for public health. Social movements that promote them don’t only deserve the attention of public health professionals; they should be seen as crucial parts of a country’s public health landscape.
A team of young Europeans followed the three protagonists around with the explicit intention of looking at social movements from a youth perspective. By getting to know the activists and becoming their “friends” and “comrades”, the filmmakers aimed to draw intimate portraits of the three protagonists, their motivations, thoughts, and feelings. The result has already been awarded the Audience Award of the Hot Docs Documentary Festival which automatically qualifies it for the 2022 Academy Awards.
Dear Future Children is at its best when it does what it set out to do—highlighting the struggles that young activists go through to fight for what is important to them. Turns out activism has very little to do with the Pepsi-swigging Kendall Jenners of this world. Instead, Pepper, Hilda, and Rayen—like so many activists—work extremely hard, sacrificing their education and careers, their liberty and safety. Victory often appears unattainable. Stories of imprisonment, injuries, and death combined with lengthy and gruesome scenes of police violence make for difficult viewing.
While we get to know the documentary’s protagonists over the course of the documentary, it remains hard to situate them within their movements. At times, the film risks losing sight of the broader picture because of its strong focus on the clashes between police and activists. As a campaigner, I would have loved to see the film crew use their access to core activists to illuminate some of their movements’ strategies, tactics, and methods, which are so rarely captured by the media. Recent films such as 120 BPM and Knock Down The House demonstrate that it is possible to skilfully balance the portrayal of protagonists’ personal stories with fascinating insights into their political campaigns and movements. Admittedly, both films worked with budgets that Dear Future Children, a production that was mostly crowdfunded, could only dream of. However, had their film crew embedded the three heroes more deeply within their social movements, it may also have become clearer what their unique contributions as young people were.
Nonetheless, Dear Future Children is refreshingly sober in its depiction of the stark realities facing young activists. Although it celebrates its protagonists, it doesn’t glorify or stylise them but presents them as the brave and vulnerable humans they are. If watching these three women giving everything makes even a handful of audience members ask themselves how they could give more, then the Dear Future Children team deserves plenty of credit for that.
Dear Future Children is being screened live at the Global Health Film Festival on Saturday 4 December, followed by a panel discussion including the director, Franz Böhm. Global Health Film Festival is the annual flagship event of Global Health Film, a UK charity promoting the power of storytelling in global health. More information and tickets can be found on their website.
Revisionist History (‘The Dog Will See You Now’)
A dog-nostic dilemma? Micah Fineberg reviews a recent episode of the Revisionist History podcast.
Podcast review
Release Date: August 26, 2021
Rating: Entertaining 4/5 | Informative 4/5 | Inspiring 3/5
Can dogs be the answer to medical diagnostic challenges? Are they the missing link to early detection and preventing the spread of disease? Could they have been instrumental in controlling COVID-19?
We may be familiar with the concept of dogs being used to detect explosives, weapons, and narcotics, but the use of dogs to detect disease is perhaps less well known. In this episode of Revisionist History, the soothing, familiar voice of Malcolm Gladwell explores how dogs are being trained to sniff-out diseases.
The podcast presents compelling evidence that dogs may be the very solution we’ve been waiting for. Many of the currently available diagnostic tests have dangerously high error rates that can result in invasive and unnecessary treatment. Testing for prostate cancer, for example, has a 15% false positive rate. Conversely, according to the podcast interviewees, “dogs are better than any test” and experiments show that COVID-19 can be detected by dogs with “99% accuracy”. These findings are even backed by peer-reviewed studies.
“Dogs may be the very solution we’ve been waiting for.”
Gladwell proposes that dogs are a quick, cost-effective, non-invasive, and seemingly fool-proof solution to detecting many diseases. But, as I sat on the bus listening to this podcast, I started to consider the broader implications that dog-diagnostics may have on healthcare.
Introducing a new diagnostic method would require a massive overhaul of the healthcare system. Gladwell touches on the feasibility of training and placing thousands of dogs in schools, workplaces, transport hubs or public gathers.
Yet as I sat listening, I also wondered whether patients and healthcare practitioners alike would be accepting of the results. How would perceptions and norms need to change? What are the ethical considerations for training and taking care of these animals? These are just some of the questions I had considered in the 36 minutes of listening time and there are likely to be countless more questions that other listeners asked themselves. The evidence may be compelling, but I, for one, don’t see dog-diagnostics taking off just yet.
A step closer to malaria elimination? The RTS,S/AS01 vaccine recommendation
Public health gains a new tool in the fight against malaria. Charles explores the opportunities afforded by expanded production and mobilisation of the RTS,S/AS01 vaccine, as well as the inequities threatening to impede eradication efforts.
Image credit: Wikimedia Commons
In an extraordinary development in vaccine research and implementation, the World Health Organisation (WHO) announced on Wednesday 6 October 2021 that it is now recommending the rollout of the first and highly-anticipated malaria vaccine to children throughout sub-Saharan Africa and regions of moderate malaria transmission beyond the continent.
The vaccine in question, RTS,S/AS01 (brand name Mosquirix), was first developed in the 1980s by biotechnology firm GlaxoSmithKline and is classed as a pre-erythrocytic vaccine. This means that it is aimed at preventing the onset and development of clinical malaria through inhibiting transmitted malaria parasites invading liver cells (hepatocytes) where they begin to replicate, which in turn halts the parasites maturing into the well-known and lethal blood-stages.
Following a large-scale pilot vaccination programme quantifying safety thresholds, feasibility, and cost-effectiveness amongst children under five in Ghana, Kenya, and Malawi, 2 million doses have been delivered to more than 800,000 children since 2019. The results from this trial demonstrated that RTS,S/AS01 rollout is feasible when delivered alongside routine childhood vaccination programmes, and showed limited interference with existing malaria control interventions, including indoor residual spraying and sleeping under insecticide treated bed nets. Most importantly, the experiment proved that delivery is cost-effective in regions of regular (holoendemic) malaria transmission.
Malaria—which killed 409,000 people in 2019 and is transmitted via the infected bite of female Anopheles (genus) mosquito vectors—has continually blighted the world’s most marginalised populations. The approval and subsequent recommendation of RTS,S/AS01 vaccination by WHO Director-General Dr Tedros Adhanom Ghebreyesus was highly welcomed and comes just five months after committee members convening at the 74th World Health Assembly requested immediate technical support should an innovative tool against malaria become available.
“Malaria has continually blighted the world’s most marginalised populations.”
At the 68th World Health Assembly in May 2015, ambitious targets were set to reduce malaria incidence (new cases) and mortality rates globally by up to 90% by 2030. Various factors have hindered the progress attained in malaria control and elimination since the year 2000, including the complex parasite life cycle and reliance of insect vector species for transmission, meaning that disease eradication is sadly not yet attainable. However, since the 2015 declaration there have been numerous cries to diversify the treatment options to those suffering from malaria, since anti-malarial drug resistances, insecticide resistant mosquito vectors, and lack of adherence to vector control interventions continue to threaten the successes achieved by malaria elimination campaigns to date—hence the excitement when RTS,S/AS01 was approved for use.
The results from the phase III clinical trials indicate that among children aged 5–17 months who completed the 4-dose RTS,S/AS01 schedule, 39% of malaria cases were averted and a further 31.5% of severe malaria, malaria hospitalisation, and all-cause hospitalisations were reduced. Not only do these efficacy values fall significantly short of the WHO’s requested 75% malaria vaccine efficacy by 2030, but they also appear particularly inadequate when compared to routine vaccinations like diphtheria vaccines which has an effectiveness of 97% against infection. Worse still, we are increasingly accustomed to high vaccine effectiveness reporting—such as COVID-19 vaccine effectiveness against hospitalisation ranging between 75–95%—which distracts from the clinical and social importance of the RTS,S/AS01 malaria vaccine. Despite apparent ineffectiveness based on effectiveness values alone, estimates indicate that 4.3 million malaria cases could be averted annually if RTS,S/AS01 vaccinations were prioritised through sub-national administrative units and to children in countries with high malaria parasite prevalence.
“4.3 million malaria cases could be averted annually if RTS,S/AS01 vaccinations were prioritised through sub-national administrative units and to children in countries with high malaria parasite prevalence.”
With 141 malaria vaccine candidates, but presently only two viable vaccine options (RTS,S/AS01 and the unlicenced, experimental R21-Matrix M boasting 77% efficacy in clinical trials), the immediate requirement for novel therapies is obvious. On Tuesday 19 October 2021 Dr Tedros shared a damning reminder of the barriers that may hinder the delivery of RTS,S/AS01 in countries with low and middle incomes, as they have for the COVID-19 vaccine: “The harsh reality of vaccine inequity: the rate of booster doses in high-income countries is approaching the low-income countries primary dose rate. This injustice costs lives and livelihoods and only prolongs the pandemic.” It is therefore imperative that when delivery of RTS,S/AS01 across malaria endemic regions is initiated, delivery be equitable with surveillance networks established to monitor the progression of vaccination campaigns.
It is important to recognise that, despite the perceptions that RTS,S vaccinations will drive us towards malaria elimination, the WHO are recommending using RTS,S as an additional tool in the fight against malaria. Unlike the positive externalities that indoor residual spraying (IRS) or insecticide treated bed nets (ITNs) exert on limiting community-wide malaria transmission by reducing the density of malaria carrying mosquitos, RTS,S/AS01 can only provide protection against disease in those who are vaccinated. It is therefore key to reinforce that ITNs, IRS, and other preventative measures must also be upheld in malaria endemic regions, alongside RTS,S/AS01 vaccine campaigns.
The most effective delivery platform incorporating RTS,S/AS01 has yet to be evaluated. That said, a recent study following 6000 children aged 5–17 months in Burkina Faso and Mali reported reductions in malaria hospitalisation and deaths by as high as 70% in children which received RTS,S/AS01 with conventional seasonal malaria chemoprophylaxis (SMC, Antimalarial Drug Administration). Moreover, a single RTS,S/AS01 vaccination dose delivered prior to the rainy season (when mosquito vectors are most actively breeding, egg laying, and infectious biting) was found to be as effective at reducing clinical malaria in children under five as four annual SMC regimens.
It is hoped that soon, malaria would be controlled effectively by a single-dose multistage vaccine, effective antimalarial drugs, or innovative technologies such as gene drive or self-limiting mosquito populations. In the meantime, treatment options against malaria remain suboptimal. This being said, the introduction of RTS,S/AS01—used in combination with antimalarial chemoprevention in high transmission regions—is an exciting glimpse into the future elimination possibilities of this long standing disease.
Considering the WHO Global Tuberculosis Report 2021 in light of COVID-19
The new pandemic sheds light on an old foe. Page summarises the World Health Organisation's 2021 Global Tuberculosis Report and discusses disparities in vaccine advancement and equity.
In October of this year, the World Health Organisation (WHO) reported that deaths from tuberculosis (TB) have risen for the first time in a decade, a major blow to their End TB Strategy. Simultaneously, global spending on TB declined by 8.7%, falling far below targets. The report attributed the rise in deaths to the impact of COVID-19 on global healthcare capacity and access. This comes as no surprise—you would be hard-pressed to find a single area of healthcare that has not been negatively affected by the pandemic. However, I find that there is something particularly hard to swallow about the increase in TB deaths attributable to COVID-19.
In comparing the response to these two diseases, I do not intend to downplay the devastation that COVID-19 has wreaked upon our world. As of 1 November 2021, the WHO reports that approximately 5 million people have died of the virus since the start of the pandemic, and the effects of COVID-19 go far beyond the death toll, from economic devastation, to mass burnout of healthcare workers, to major disruption to education. The constant headlines, though tiresome, are certainly well-deserved. My question concerns why TB does not receive comparable media coverage—or more importantly, funding.
TB, one of the oldest infectious diseases to affect humanity, has been termed the “forgotten pandemic”. Prior to the COVID-19 pandemic, it was consistently the top single-agent cause of infectious disease death in the world, and it continues to kill approximately 1.5 million people per year. Along with this death toll come the other, less quantifiable effects many of us are much more familiar with now—missed school, financial ruin, and bereaved families. It is difficult to conceptualise the impact of this toll over the span of decades. And yet, because the brunt of the disease burden is borne by countries with lower incomes, TB rarely makes global headlines. TB is a disease of poverty, endemic in areas where many people do not have access to well-ventilated housing or where malnutrition is common. In endemic regions, TB perpetuates inequalities both within and between countries by acting as a constant financial drain on individuals and healthcare systems, stagnating economic development. Cases in most high-income countries are rare and tend to affect marginalised people such as those who are homeless. The dominant attitude towards TB is complacency. The world has decided that this death toll is not newsworthy.
Image credit: Unsplash
“In endemic regions, TB perpetuates inequalities both within and between countries by acting as a constant financial drain on individuals and healthcare systems, stagnating economic development.”
Consider the global vaccine response to COVID-19. Mobilisation to develop a vaccine for COVID-19 was swift, a remarkable and unprecedented success. Thanks to financial investment, researchers were able to develop multiple highly effective vaccines in mere months. The most recent data suggests that the Pfizer and Moderna vaccines are 88% and 93% effective at preventing hospitalisation respectively, both very impressive figures. For TB, by contrast, we have one vaccine, the 100-year-old Bacillus Calmette–Guérin (BCG) vaccine. This vaccine works well for preventing disseminated TB in children, but for pulmonary TB, the main contributor to TB deaths, it varies in efficacy from 0 to 80%. For unknown reasons, vaccine efficacy depends on latitude, decreasing closer to the equator—a cruel and peculiar parallel to the geographic gradient of global disease burden.
Image credit: Unsplash
We need a better vaccine for TB. In the long-term, this will save the most lives, and even moderate improvements in vaccine efficacy would be cost-effective. Through the hard work of those committed to the cause, there are currently 14 vaccine candidates in the pipeline. However, the funding needed to accelerate vaccine development and improve our understanding of TB is simply not there, despite the fact that investing in TB has high financial as well as population health returns. The unfortunate reality is that research for deadly diseases often does not receive sufficient support until those with the most financial and social capital are affected, as we have seen in the past with the HIV pandemic.
“The unfortunate reality is that research for deadly diseases often does not receive sufficient support until those with the most financial and social capital are affected.”
Most of us in non-endemic regions are lucky enough to not have to think about TB in our daily lives. However, COVID-19 has illustrated that in an increasingly globalised world, infectious disease is everyone’s problem. Although we are far from ending the COVID-19 pandemic, the rapid development of vaccines has shown us what we can accomplish when urgency demands investment. How much longer will the world wait for an effective TB vaccine? We are capable of better. Those affected by TB deserve better.
The WHO Global Tuberculosis Report 2021 can be found here: https://www.who.int/publications/i/item/9789240037021
Medicine man: the Stan Brock story
In advance of its international premiere at the Global Health Film Festival (25 Nov–5 Dec), Rosalie Hayes reviews Medicine Man: The Stan Brock Story which recounts the remarkable life of Stan Brock and his founding of the charity Remote Area Medical.
Film review
Image credit: Medicine Man: The Stan Brock Story
Year: 2020
Director: Paul Michael Angell
Language: English
Rating: Entertaining 4/5 | Informative 4/5 | Inspiring 5/5
“Part cowboy, part naturalist, part lots of other things—he is in many ways a baffling man.” So begins Medicine Man: The Stan Brock Story, a documentary focused on the remarkable life of Stan Brock and his founding of the charity Remote Area Medical (RAM).
The film charts Stan Brock’s life from humble beginnings in Preston, Lancashire to living as a vaquero, a barefoot cowboy, amongst the Wapishana people in what was then British Guiana. A chance meeting with a TV producer from Chicago eventually led to Brock presenting a hit wildlife TV show and starring in Hollywood films. But by 1985, he decided to take a different path, founding RAM with the intention of providing basic healthcare to people living in the most remote areas of the world.
Brock’s unusual early career may be what draws the viewer in, and understandably constitutes a significant chunk of the documentary, but he is the first to point out that it’s “not important really”. Indeed, any admiration one has for his resilience as a young man is tainted by his complicity in a colonial administration and his former disregard for the Wapishana people (which he later regrets). Instead, it is what he and the 135,000 volunteer clinicians have achieved through RAM that is truly extraordinary.
Despite its original intention to serve remote regions of the world, RAM soon turned its focus to the 50 million people without access to healthcare in the world’s richest country: the United States (US). Although RAM operates on a shoestring budget and Brock takes no salary, it has delivered free healthcare to nearly one million Americans since its inception. Scenes from RAM’s pop-up field hospitals in some of the most impoverished areas of the US, including the gratitude with which RAM patients receive their care, are moving to witness.
While the issues raised in Medicine Man: The Stan Brock Story won’t be news to anyone even vaguely familiar with the US healthcare crisis, it’s hard not to be shocked by the image of hundreds of people camping for days on the pavement so that they can receive basic medical care. The film powerfully showcases the human impact of the politicisation of healthcare and serves as an urgent reminder of the fragility and inadequacy of US healthcare reform. RAM patient Dee Bailey puts it best when she exclaims:
“In the land of the free and the home of the brave, it’s hard. In America it shouldn’t be this hard.”
Medicine Man: The Stan Brock Story is being screened live at the Global Health Film Festival on Wednesday 1 December, followed by a panel discussion including the director, Paul Michael Angell. Global Health Film Festival is the annual flagship event of Global Health Film, a UK charity promoting the power of storytelling in global health. More information and tickets can be found on their website.
Covid by numbers: making sense of the pandemic with data
Joanna Hindley reviews Covid by Numbers, in which statisticians David Spiegelhalter and Anthony Masters distill how we might “data” our way out of the pandemic.
Book review
Year: 2021
Authors: David Spiegelhalter and Anthony Masters
Rating: Entertaining 4/5 | Informative 5/5 | Inspiring 4/5
Image credit: Penguin Books
The COVID-19 pandemic saw conversations about data thrust into the mainstream as never before. Reproduction numbers (‘R’ numbers) and the relative efficacies of different brands of vaccine were not only discussed in academic journals and at conferences, but in newspaper headlines and ministers’ speeches. During this time, individuals such as Professor David Spiegelhalter and Anthony Masters became familiar voices to many, clearly communicating mathematical concepts and scrutinising the claims made by politicians and in the media. Following from their successful column in The Observer, Covid by Numbers aims to distill some of the key metrics that informed the debate, and the pitfalls that arose when they were misused and misunderstood.
Each short chapter explores a different question relating to the pandemic, mostly contextualised in the United Kingdom. These cover an impressive range—from the nature of the virus and the utility of epidemiologic modelling, to the wider consequences of successive lockdowns. Attention is given to debates that dominated the headlines, such as (incorrect) comparisons between COVID-19 and the flu, as well as issues less frequently discussed, such as the outcomes for patients being discharged after hospitalisation with the virus.
All of this is written in an uncomplicated style with clear and relevant figures. Excessive detail on statistical concepts is avoided, however there is much to be learned here for both the expert and general reader. Crucially, the authors emphasise the imperfect processes inherent in collecting and analysing data. They explain, for example, why it is challenging to measure levels of hospital-acquired coronavirus and how this led to wildly different estimates being quoted in the media. In doing so, they make clear that while statistical science is a powerful tool for understanding the world around us, it has limitations and claims of certainty should always be approached with a healthy degree of scepticism.
Masters and Spiegelhalter also carefully ensure that the data are never separated from the human suffering that each figure represents. “Counts and measurements are stories writ large” they say in their introduction, and this contextualisation is a continuing thread throughout each chapter. Such sensitivity is important: the reader is likely all too aware of the tragedy brought about by this virus. Furthermore, it strengthens their case for greater consideration of data in handling the present and future pandemics. It is easy to view statistics as a subject for dry academic debate. However, emphasising the human journeys that lie behind such numbers makes it hard to dispute their relevance in all our lives.