Case 1: To Medicate or Not to Medicate

Terry Kelly received a National Institute of Mental Health grant for research in the Western Tropics. As part of her personal gear, she took along a considerable amount of medication, which her physician had prescribed for use, should Kelly find herself in an active malaria region. Later, after settling into a village, Kelly became aware that many of the local people were quite ill with malaria.

Kelly's Dilemma: Since she had such a large supply of medication, much more than she needed for her personal use, should she distribute the surplus to her hosts?

Kelly's Decision

Kelly decided not to give any medication to the villagers who were exhibiting symptoms of malaria, even though she had a considerable surplus in her personal supply. She reasoned that since the medication did not confer permanent immunity to the disease and because she would not be present to provide medication during future outbreaks of the disease, it was more important to allow affected villagers to develop their own resistance to malaria "naturally.

Readers' Response

Dennis Tully at the University of Washington wrote:

"I am astonished at the solution that you printed to Case 1 in your newsletter column. While that may be what Kelly did, I would not propose it as a model for others.

"Malaria is an extremely unpleasant illness. It is often fatal for the very young, and considerably less so for adults. While infant mortality may remove those who are most susceptible, adults do not develop immunity to malaria; it often continues to afflict an individual throughout his life, in episodes. These episodes can usually be relieved with drugs. When I have had episodes of malaria, I have always chosen to terminate it with drugs rather than suffering through in the hope that I would develop some resistance for the next time, in spite of my expectation of spending substantial time in malarial zones. While engaged in fieldwork in Sudan, I have made the same option available to all takers, through medication made available to me by the local health officials. To do otherwise, to allow affected villagers to develop their own resistance naturally seems to me callous.

"There are more complex issues here. One might have a valid concern for ecological and demographic consequences, the effects of creating a demand for 'urban' medicine, or for the competence of the fieldworker to diagnose malaria and deal with side effects of the drugs. Cutting even closer is the problem of the medical anthropologist or demographer who would directly affect his data by providing medicine. . . ."

Judith T. Irvine of Brandeis University wrote:

"I disagree with the decision made by the anthropologist in Case 1, not to administer any treatment [for malaria] on the grounds that it would interfere with the 'natural' acquisition of immunity. As I see it, there are two main issues here: (1) the scientific basis of Kelly's argument about natural immunity to malaria, and (2) how the anthropologist lacking medical training should make a decision about providing treatment other than simple first aid.

"Concerning (1): Although I am not as well versed in the facts as I would like to be before making a pronouncement, I do not believe one can acquire immunity to malaria the way one can acquire it to measles. It is true that where malaria is endemic, malarial attacks seem to be less frequent and less severe for the local population than for European or American visitors, but this difference is partly due to genetic rather than acquired resistance. In any case it does not alter the fact that serious attacks can still occur. They can pose a real danger, I believe, especially to an individual who is weakened by age or malnutrition, or who suffers from some other condition at the same time. Treating these attacks is a different matter from the preventive treatment administered to foreigners, although the drug is usually the same. I do agree that the preventive measures should probably not be undertaken by visiting anthropologists. But few anthropologists would have the enormous supply of drugs (let alone a reliable way to distribute and administer them) that would be needed for prevention anyway.

"Still, the real point here is that neither Kelly nor I can make an ethical decision without informing ourselves of the medical facts. It may be, for instance, that the different strains of malaria present quite different possibilities for the acquisition of immunity. I would welcome the comments of a physical or medical anthropologist on this problem.

"Concerning (2): As the case is summarized, Kelly apparently thinks that the decision whether or not to treat the local population for malaria is the anthropologist's alone. I think, however, that two other groups must be party to it: the prospective patients, and the health authorities responsible for the region. These are the people at risk and the people who have a long-term acquaintance with (and responsibility for) the area; the health authorities will usually include people with more medical training than the anthropologist has. Of course, particular circumstances will differ. But to refuse aid if both these parties request it, and if it is feasible for the anthropologist to provide it, presents an ethical problem in itself.

"Like Kelly, I have worked in a country where malaria is a serious health problem, but my decision about treating malarial attacks was the opposite of hers. The basis for my action was largely issue (2) above; but actually, this incorporates issue (1). The local health authorities who advised me (and supplied me with instructions about recognizing and treating malaria and some other conditions) included physicians, both Americans and nationals of that country, whose understanding of the medical facts about those diseases in the local environment was clearly superior to my own. It would have been foolish of me to suppose that I knew anything about 'natural immunity' that they did not."