Malaria Medicine Advice

A friend sent me this question:

Speaking of healthy, when you’re in Africa, do you take malaria medication the whole time you’re there? Is 45 days too long to take it?

First, taking it 45 days is no big deal. It’s taking it for months on end (9, 18, 60) that is not recommended — not because of actual risks, but because of not enough study.

Second, here’s Jeff’s “cut-through-the-crap” guide to malaria meds:

  • Doxycycline: It’s an antibiotic which means you can get the side effects of long-term antibiotic exposure — development of resistance in the bugs, GI problems, and for women, yeast infections. On the other hand, those aren’t common, are easy to recognize, and switching off the doxy is easy. And the side-effects of low-level exposure to anti-biotics are also useful: you don’t have to worry so much about eating street food! For fair-skinned people, the most dangerous side effect is light sensitivity, but it’s not a common problem.
  • Lariam: This has a bad reputation because of side effects. 9 in 10 have no side effects. Of the 1 in 10 who have side effects, 9 in 10 overcome them in a couple weeks. The reason it has a bad reputation is that the side effects are psychological, not physical. So people get wigged out about it a lot more. If it works for you, it really works, and it’s better than the others. If it doesn’t work, it really doesn’t work, and the process of finding that out is a little bit scary (sleep problems, depression, even risk of suicidal thoughts). But when you do the math, you see it’s 99% likely you’ll be in the first group. Taking it only once a week is a little hard to remember, but it less hassle than every day.
  • Malarone: It is expensive. It has less drawbacks than the others. Consider it the last choice — because it is guaranteed to work out nicely, but the others have useful features you should consider  before giving up and accepting the drawbacks of malarone.

I’ve taken all three. Right now, I use Lariam.

Third, no matter which you decide: TAKE IT. Malaria in white people ranges from a small case, which makes you completely useless for 1 to 2 weeks, to a major case which makes you completely dead for the rest of your life. It is easy to get confused, because malaria often presents itself in native Africans like the flu — a little under the weather, but they can still go to work. So you get confused and can’t remember why you are supposed to be taking your medicine for this thing that is only a minor inconvenience for your colleagues.

And to drive home point #3, two anecdotes:

  • A USAID official who worked in Ghana told me that every year in West Africa, Peace Corps has two or three volunteers die from malaria. Why? Because the kind of people attracted to Peace Corps are young, invincible hippies who are too cool to take their medication (and don’t believe in it anyway), and too cool to ask for help when they feel sick. So they get malaria, get complications, are too far from medical help, and die.
  • I once met an MSFer who told me he told his coworkers he was feeling a bit bad and left the dinner table early to get to bed. He woke up, 3 weeks later, in Paris, recovering from cerebral malaria. His colleagues found him comatose in the morning and arranged for his evacuation.

But to calm you back down now that I scared you, let me make this final point… when treated, malaria is not deadly to healthy people (neither to Africans, nor to whites). The complications from malaria (anemia, cerebral swelling, liver failure) are deadly, but they are not guaranteed, nor do they set in immediately. If you are pregnant or living with HIV/AIDS, then complications can rise much quicker. If you have a fever in malaria endemic areas, you must start Artemisinin-based combination therapy (ACT) as soon as possible. Don’t wait for a test, and do not wait to get to high class medical treatment. Find anyplace that has ACT and start yourself, even if they disagree and won’t start you. If you don’t respond in 24 hours, start the trip to find the best treatment you can (and keep taking the ACT during the trip).

PS: Best quote ever from a guy who did deadpan humor well: “Wow, I’m really having trouble sleeping… I don’t know why… I’ve been taking my Lariam every night before bed, and for some reason the side effects just aren’t going away!”

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