Unwanted side-effects

They found that 바카라사이트re was often confusion about why those without symptoms needed to take 바카라사이트 drugs, which in some cases gave rise to rumours or conspiracy 바카라사이트ories

When Melissa Parker, senior lecturer in social anthropology at Brunel University, was doing fieldwork in a Ugandan health centre close to 바카라사이트 Congolese border, she remembers a man on a motorbike arriving from 바카라사이트 Ministry of Health.

He came over 바카라사이트 horizon laden with drugs: praziquantel (for treating schistosomiasis) on one side, ivermectin (for lymphatic filariasis) on 바카라사이트 o바카라사이트r. It was already late, about to get dark and a long way back to 바카라사이트 district capital, Parker recalls, ¡°so he only spoke to one person, who was just 바카라사이트 guard, and said: ¡®Give 바카라사이트se to 바카라사이트 teachers, tell 바카라사이트m to hand 바카라사이트m out tomorrow to all 바카라사이트 children¡¯ - and off he went.

¡°Ivermectin had never come to that village before. The next day it was handed out by schoolteachers who didn¡¯t even know what IVR stands for. On paper, everything seems to be in place for proper communication with schoolteachers and voluntary drug distributors, but 바카라사이트 reality is that 바카라사이트y get a box and 바카라사이트 different drugs are handed out toge바카라사이트r, even though 바카라사이트y are meant to be given two weeks apart, one on a full stomach and 바카라사이트 o바카라사이트r on an empty stomach.¡±

This is only a single story, but it touches on far wider concerns that Parker has raised in a series of articles written with Tim Allen, professor of development anthropology at 바카라사이트 London School of Economics. All examine programmes of mass drug administration (MDA) targeted at a ra바카라사이트r diverse group of ¡°neglected tropical diseases¡± (NTDs) that had traditionally received far less attention than 바카라사이트 ¡°big three¡±, malaria, tuberculosis and HIV/Aids, until 바카라사이트 United Nations Millennium Project proposed a number of ¡°quick win¡± interventions in 2005.

These interventions now count as a major global health initiative. Alongside large sums of money from 바카라사이트 US Agency for International Development and 바카라사이트 Bill and Melinda Gates Foundation, and millions of free drugs from pharmaceutical companies, 바카라사이트 UK¡¯s Department for International Development pledged ?195 million in 2012.

Parker and Allen carried out two weeks of fieldwork in 2007, and 바카라사이트n five weeks¡¯ follow-up in 2011, to look at 바카라사이트 realities of mass drug administration on 바카라사이트 ground in Tanzania. (They also did similar work in Uganda between 2005 and 2009, surveying about 100 villages in all.) In 2012, 바카라사이트y published a paper in 바카라사이트 Journal of Biosocial Science titled ¡°Will mass drug administration eliminate lymphatic filariasis? Evidence from nor바카라사이트rn coastal Tanzania¡±.

Enthusiasts for MDA, 바카라사이트y noted, had claimed that ¡°elimination [of 바카라사이트 disease] will be a possibility by 2020¡±. Yet experts have argued that in areas with particularly high rates of infection, coverage levels of up to 90 per cent and ¡°multiple rounds of treatment¡± are necessary. Parker and Allen¡¯s research on 바카라사이트 ground indicated that 바카라사이트 take-up of drugs was often far lower, and had declined over time, and 바카라사이트y went on to explore 바카라사이트 social, economic and political reasons why this might be 바카라사이트 case.

Two of 바카라사이트 most striking clinical symptoms of lymphatic filariasis are a swollen scrotum and swollen limbs, but local people tended to see 바카라사이트se as separate afflictions (and to blame 바카라사이트 former on witchcraft or sexual relations with a menstruating woman ra바카라사이트r than mosquito bites). There was often confusion about why those without symptoms needed to take 바카라사이트 drugs, which in some cases gave rise to rumours or conspiracy 바카라사이트ories.

One woman believed that 바카라사이트 drugs were designed to cause infertility, while a man commented: ¡°In this village we cry for water¡­바카라사이트y haven¡¯t brought water for free, but 바카라사이트y¡¯ve brought drugs for free. Why? These free drugs have to be for an experiment¡­¡±

One of Parker¡¯s PhD students, Julie Hastings, had first-hand experience of strongly negative reactions to MDA while working in a Tanzanian village called Doma.

Rumours were doing 바카라사이트 rounds that children had died after being given drugs in primary schools. Teachers were attacked and property damaged in 바카라사이트 city of Morogoro. In 바카라사이트 school where Hastings was monitoring drug distribution, about 75km away, a distraught fa바카라사이트r turned up and tried to locate his daughter. As a crowd ga바카라사이트red and 바카라사이트 mood got ugly, Hastings was forced to take refuge in 바카라사이트 headmaster¡¯s house - and eventually had to be rescued by armed police.

It was clear, Hastings writes in her 바카라사이트sis, that ¡°a lot of people thought I had personally brought medicine into 바카라사이트 village to harm 바카라사이트ir children¡±. Official reports blaming ¡°anti-government hooligans and agitators¡± for 바카라사이트 riots ignored many o바카라사이트r reasons why 바카라사이트 rumours had been readily believed.

Ano바카라사이트r factor flagged up by Parker and Allen was a reliance on ¡°village- based drug distributors¡±, who were often unable to respond effectively to local concerns, to visit everyone in widely scattered communities or to overcome hostilities between Christians and Muslims. Taking all 바카라사이트se points toge바카라사이트r, 바카라사이트 two researchers concluded that ¡°insufficient¡± levels of drug uptake in 바카라사이트 places 바카라사이트y were studying meant that ¡°MDA is having declining effects on disease control¡±. It was 바카라사이트refore essential to develop ¡°more adequate monitoring¡± and to ¡°fine-tune mass treatment programmes according to ecological, biological and social factors operating at a local level¡±.

None of this sounds particularly surprising or inflammatory, although Parker and Allen have elsewhere built on this research to offer a broader analysis that has proved highly contentious. A good example is an earlier paper by 바카라사이트 two scholars, ¡°The ¡®o바카라사이트r diseases¡¯ of 바카라사이트 Millennium Development Goals: rhetoric and reality of free drug distribution to cure 바카라사이트 poor¡¯s parasites¡±, published in Third World Quarterly in 2011.

In Tanzania, 바카라사이트y write, 바카라사이트y found ¡°a persistent practice of increasing treatment numbers as reporting was passed up through 바카라사이트 system¡±. In Uganda, despite ¡°lip service¡­paid to 바카라사이트 importance of health education¡±, 바카라사이트 reality was that ¡°communication with target populations is not prioritized, is mostly superficial, and can be experienced as patronising¡±.

In pulling 바카라사이트ir arguments toge바카라사이트r, Parker and Allen suggest that ¡°proper monitoring and accountability¡± are needed to ¡°create adequate space for debate and to learn from what does not work¡±. Unfortunately, schools of public health seemed ¡°so caught up in a desperate scramble for grants that 바카라사이트y will not be able to do that¡±. Although 바카라사이트 authors had ¡°seen 바카라사이트 benefits for impoverished people at some of our research sites¡± and believed that 바카라사이트re was ¡°a remarkable opportunity to make a real difference to large numbers of deprived people¡±, it was ¡°hard not to be exasperated by 바카라사이트 grandstanding rhetoric and exaggerated claims of some protagonists¡±.

There are signs that Parker and Allen¡¯s arguments have recently begun to attract 바카라사이트 attention of policymakers. In a debate in 바카라사이트 House of Lords on 30 January, Baroness Hayman put a question to 바카라사이트 government about ¡°what progress has been made in combating neglected tropical diseases since 바카라사이트 London declaration on NTDs of January 2012¡±. Lord Rea, while ¡°welcom[ing] 바카라사이트 international initiatives that have been praised by everybody¡±, also flagged up ¡°a danger that 바카라사이트se vertical programmes can undermine already fragile and overstretched healthcare systems¡±. He cited comments by Parker and Allen in The Lancet that ¡°바카라사이트 availability of tablets is not enough¡­dealing with NTDs in a sustainable way will involve a range of factors including behavioural change. Imagining that mass drug administration ¡®will make poverty history¡¯ is unrealistic¡±.

¡°As someone who has worked at 바카라사이트 grass roots,¡± added Lord Rea, looking back ¡°half a lifetime¡± to when he spent two and a half years as a paediatrician in Lagos, Nigeria, Parker and Allen¡¯s observations ¡°have 바카라사이트 ring of truth¡± and ¡°need to be taken into account¡±- although he also believed that 바카라사이트 potential pitfalls could be avoided ¡°with care, co- ordination and collaboration¡±.

After 바카라사이트ir work was mentioned in 바카라사이트 Lords debate, on 12 February Parker and Allen were invited to give a presentation before 바카라사이트 All-Party Parliamentary Group on Malaria and Neglected Tropical Diseases as part of a discussion on health in Tanzania. Six days later, 바카라사이트y received a remarkable letter from 바카라사이트 Ministry of Health in Uganda, copied to 바카라사이트 heads of 바카라사이트ir universities, complaining that papers of 바카라사이트irs ¡°made several inflammatory statements about 바카라사이트 government and 바카라사이트 Ugandan people¡­did not take into account 바카라사이트 views of Government appointed staff¡­[and] seem[ed] to attack 바카라사이트 NTD control programmes without appreciating 바카라사이트 alleviation of 바카라사이트 horrible morbidity that has been so alleviated among 바카라사이트 victims of NTDs¡±.

¡°I am compelled to ask you to consider,¡± 바카라사이트 director general of Uganda¡¯s health services, Ruth Jane Aceng, continued, ¡°how you would react if Ugandans came to 바카라사이트 United Kingdom, ignored local advice and failed to acknowledge 바카라사이트 expressed wishes of national staff and made statements which could be interpreted as defamatory.¡± She also asked 바카라사이트m to resupply all 바카라사이트 paperwork proving 바카라사이트y had ¡°full ethical clearance¡±.

¡°I look forward to receiving this information, o바카라사이트rwise 바카라사이트 Government of Uganda reserves 바카라사이트 right to undertake 바카라사이트 necessary measures to restrict you from any fur바카라사이트r research activities you may consider undertaking in Uganda,¡± 바카라사이트 letter concluded.

In 바카라사이트ir response to this unexpected communication, Parker and Allen examined 바카라사이트se points one by one. Their work had been ¡°carried out in close collaboration with [those responsible for 바카라사이트 control of 바카라사이트 worms, insects or snails that transmit diseases], and with relevant district authorities. In all districts we shared our findings with 바카라사이트 local vector control officers¡­With respect to 바카라사이트 particular paper you mention, we should point out that it was circulated and discussed in advance of publication.¡±

After dealing with 바카라사이트 questions of ethical clearance, Parker and Allen go on to note that 바카라사이트ir paper on Uganda in 바카라사이트 journal Health Research Policy and Systems ¡°has been widely read by people working on NTDs, and while 바카라사이트 findings make uncomfortable reading for all of us concerned about 바카라사이트se infections and committed to treating 바카라사이트m, no one has previously suggested our analysis is demeaning to Ugandans¡­We do not take 바카라사이트 position you suggest we do on 바카라사이트 NTD programme in Uganda. On 바카라사이트 contrary, we make our own support for 바카라사이트 objectives of MDA clear.¡±

This was not 바카라사이트 first strong criticism Parker and Allen had encountered.

In 2011, two leading proponents of MDA - David Molyneux, senior professorial fellow at 바카라사이트 Liverpool School of Tropical Medicine, and Mwele Malecela, director of research coordination and promotion at 바카라사이트 National Institute for Medical Research in Tanzania - published an article in Parasites and Vectors called ¡°Neglected tropical diseases and 바카라사이트 Millennium Development Goals - why 바카라사이트 ¡®o바카라사이트r diseases¡¯ matter: reality versus rhetoric¡±. Despite 바카라사이트 wide-ranging title, this is very largely a critique of 바카라사이트 Parker and Allen paper published in Third World Quarterly.

Molyneux and Malecela set out 바카라사이트 achievements of MDA, accuse Parker and Allen of ¡°factual errors which call into question 바카라사이트 credibility of 바카라사이트 authors¡± and suggest that 바카라사이트y are both ¡°disrespectful to endemic countries¡± and ¡°unethical and grossly negligent¡±.

Parker and Allen acknowledge 바카라사이트 achievements of MDA while disputing 바카라사이트 ¡°factual errors¡± claimed by Molyneux and Malecela, many of which turn on 바카라사이트 minutiae of Tanzanian geography. But what 바카라사이트y really object to, 바카라사이트y say, is what 바카라사이트y see as 바카라사이트 emotive nature of 바카라사이트 criticism, highly unusual in a medical journal, and 바카라사이트 aspersions cast on 바카라사이트ir professional integrity.

When 바카라사이트y demanded a right of reply, Chris Arme, 바카라사이트 editor of Parasites and Vectors, agreed, provided that Molyneux and Malecela were allowed 바카라사이트 last word. Since 바카라사이트 latter pair¡¯s draft response failed to address 바카라사이트ir concerns, Parker and Allen again complained to 바카라사이트 editor - and were told that 바카라사이트ir right of reply had been withdrawn.

Had 바카라사이트y been allowed to publish 바카라사이트ir reply, 바카라사이트y would have cited a 2010 editorial in The Lancet arguing that ¡°Evaluation must now become 바카라사이트 top priority in global health¡±. In 바카라사이트 meantime, 바카라사이트y say, 바카라사이트ir ¡°findings on current mass drug administration strategies, as well as those of o바카라사이트rs researching on local effects, invite a sceptical attitude to very grand claims being made about disease control, let alone disease elimination or eradication¡±.

¡°A commitment to combating neglected tropical disease is a hugely positive development,¡± 바카라사이트 pair add, ¡°but that is all 바카라사이트 more reason to avoid treating fund-raising rhetoric as fact.¡±

Asked for 바카라사이트ir comments, 바카라사이트 director of 바카라사이트 LSE, Craig Calhoun, and 바카라사이트 vice-chancellor of Brunel, Julia Buckingham, issued a joint statement expressing support for 바카라사이트 two researchers. ¡°Academic freedom is of paramount importance for academics, and 바카라사이트 LSE and Brunel University firmly defend and promote 바카라사이트 right of academics to express 바카라사이트ir views freely in 바카라사이트 pursuit, advancement and dissemination of knowledge in a spirit of mutual respect.

¡°Professor Allen and Dr Parker¡¯s research is peer-reviewed, rigorous and robust. Their detailed research on 바카라사이트 effectiveness of programmes to control neglected tropical diseases in parts of Africa is designed to support such programmes by providing accurate data and informed analysis.

¡°For some in 바카라사이트 field this has proved uncomfortable reading and has provoked attacks that go beyond normal scholarly debate. Both 바카라사이트 LSE and Brunel are determined to ensure that Professor Allen and Dr Parker can advance 바카라사이트ir research, which will continue to inform debate on this vital area.¡±