Tessa Richards: Preventing disease with plastic water bottles and esprit de corps

Tessa RichardsA mosquito buzzed idly against the window inside the coach. Was it carrying the dengue virus we wondered? And if it was, what is the chance of dying from dengue haemorrhagic fever?

Such questions run through your mind when you are in a country where the disease is endemic, and as the WHO has recently flagged up, this now exceeds a hundred countries. As the incidence of disease has increased steadily so has concern about its toll on health and economies. Being reminded of this was a good reality check for conference participants as we bussed up to a small community in the Saraburi province, around 150km north of Bangkok to see “community self reliance” in action.

This visit, was one of several pre conference field trips organised by the Prince Mahidol Award Conference, convened to debate cross sector initiatives to tackle emerging and re-emerging infectious disease. Its purpose was to show delegates how a local community has mobilised a largely lay health work force to combat chronic and infectious disease; not least dengue.

As we were ushered into a spotless hall in Kaengkhoi Hospital for a formal presentation, I looked in vain for a sight of the patients among the exquisitely well mannered and welcoming staff. I spotted none, and settled down to learn about the local burden of disease (cancer and cardiovascular disease top the list) and how the community has organised infectious disease surveillance and rapid response teams. Most disease prevention and control for chronic as well as infectious disease is carried out by lay volunteers drawn from the local community, mostly middle aged women. They work in teams and go to patient’s homes to carry out their work which is done “from the heart,” and for which they get only a very small stipend.

As we left for a visit to the sub district Ban Pa Health Promoting Hospital, I caught a glimpse of some patients, waiting, as is the lot of patients, in a second hall. Most were older people, many in wheel chairs.

At Ban Pa we were shown old and new methods to reduce the population of the dengue vector, Aedes aegypti. Traditional mosquito deterrents include putting sachets of crushed seafood shells mixed with lime, various local plants, and guppy fish in domestic water supplies (mostly large water pots kept close to villagers houses). We looked down microscopes, and admired paper mache mosquito models and water tanks full of eggs and larvae, the latter being consumed with enthusiasm by legions of little guppy fish.

An innovative and cheap new method of vector control deploys small plastic water bottles. These are cut in half, the top inverted into the bottom and then plunged under water. The larvae migrate into them and when they hatch the mosquitoes are trapped in the bottle.

By a combination of approaches, including education about disease prevention in schools and pagodas the incidence of dengue in the district has been reduced to a target level of 50 per 100,000 of the population.

On our return journey our guide asked us to guess how many different countries we 30 participants came from. The answer was 20 and the number of disciplines represented, almost as large. The same was true of the meeting.

Listening to an interdisciplinary group debate “solutions” to emerging disease and other global health threats is illuminating. Experts in animal health and the environment, agriculture and nutrition, social scientists, and anthropologists see disease from different perspectives. It hammers home the obvious truth that so much of what is known about health and disease, and the factors which determine them, lies beyond the purview of most health professionals.

It can also provide broad lessons: the long tail health risks posed by dwindling vulture populations decimated through their consumption of chemicals and drugs in the environment, the extent to which antibiotic resistance is being fuelled by their ubiquitous use in commercial animal feeds, and the imbalance between the large sums spent on medical interventions and drugs compared with the amount invested in implementing disease prevention initiatives outside, as well as inside, the health sector.

A vet I talked to used rabies as an exemplar. Central hospitals in countries where rabies is common have invested in providing state of the art anti-rabies treatment. But scant attention has been paid to the logistics which prevent people getting to hospital—or even attempting to get to hospital in countries where the poor have no health insurance and can’t afford to pay for medical care. Vaccinating dogs he said, provided a much greater bang for the buck.

Unsurprisingly, the big take home message was for more dialogue and closer collaboration across the human, animal, and environment sectors at both national and international level. Vets had got this message, but doctors, it was suggested, had been slow to pick it up. That said many joint initiatives were described, including the UK’s Human and Animal Infections and Risk Surveillance group. One online initiative to further cross sector exchange is www.onehealthtalk.org, but there was agreement that  “one health” teaching needed to be embedded early on, ideally in undergraduate training programmes. A few joint modules where vet and medical students are taught together have already been set up and the benefits of mutual learning were extolled.

Much greater engagement with local communities and civil society groups, particularly in low income countries, was called for as well. The importance of understanding the factors which govern people’s life and work patterns was heavily underlined as was the potential of respecting and tapping into local “wisdom” and harnessing lay support to deliver evidence based interventions.

Tessa Richards is the analysis editor, BMJ.