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Information provided by University of Wisconsin-Madison – Published: 2011-02-20

Asthma through the eyes of a medical anthropologist…

Asthma diagnosis and management vary dramatically around the world, said David Van Sickle, an honorary associate fellow at the University of Wisconsin School of Medicine and Public Health, during a presentation today at the annual meeting of the American Association for the Advancement of Science (AAAS).

Asthma affects an estimated 8 percent of Americans, and about 300 million people around the world, but varying practices in diagnosis and treatment have global implications in understanding a widespread, chronic condition, says Van Sickle, who applies an anthropological approach to medicine.

“Since the major way to learn how many people have asthma is to ask them, external factors that alter those estimates have a major impact on our understanding of how widespread asthma is,” he says. “Yet local culture and conditions make these estimates subject to a great deal of error.”

Van Sickle, who joined an AAAS panel discussing the role of anthropology in medicine, researched asthma diagnosis and treatment in India for several years. in one project, he had doctors watch videos showing classic asthma symptoms — wheezing, shortness of breath, waking up and coughing in the night.

“I asked, ‘If you saw this in the clinic, how would you describe it?’ and found very few of them used the term ‘asthma.’ Instead, many applied a label that was less stigmatized, more friendly, like ‘wheezy bronchitis.’”

When Van Sickle repeated the experiment in Wisconsin, “The physicians were much more likely to identify the signs and symptoms of asthma, and they applied a very different set of terms to describe the video scenes,” he says.

The difference in diagnostic practices may reflect different motivations. in India, Van Sickle says, “People resist being diagnosed with asthma for fear of being stigmatized. A diagnosis of chronic disease can impair a woman’s marital chances, and a physician is unlikely to make an unpopular diagnosis because one can always go down the street and get a different doctor. It’s a private medical marketplace, with many competing systems that include traditional medicine, which often market products for chronic diseases that western medicine cannot cure, but has little incentive for accuracy. The patient pays out-of-pocket, and there’s pressure on physicians to make the patient a satisfied customer.”

Physicians in high-income countries appear more likely to use the label of asthma for a variety of reasons, ranging from differences in the overall burden of respiratory disease to the structure of the health care system.

When Van Sickle looked at asthma management on Navajo reservations in Arizona and New Mexico, he found that extremely young children were expected to take preventive medications by themselves.

“In United States, the dominant approach to asthma is self-management,” he says. “People are expected to monitor and take care of asthma largely on their own. But in Navajo country, due to cultural ideas about individual autonomy, self-management means giving very young kids primary responsibility for managing the disease, and parents play a lesser role.”

Although that decision reflects Navajo traditions, Van Sickle says, “If kids are getting this responsibility, they need more training and education. But in the clinic, most doctors focus on the parent, not the child.”

Van Sickle says that rates of asthma reflect both the diagnostic habits of physicians and the differences in the actual frequency of disease. The origins of asthma have been tied to a host of risk factors, ranging from genes, allergy, viral infections and environmental conditions such as smoky fires. “It’s considered a ‘multifactorial’ disease, but I think that’s another way of saying we can’t fully explain the prevalence patterns or time trends,” he says.

A better understanding of the causes of the disease should emerge from better data about those with asthma and on under circumstances they develop asthma, Van Sickle says.

“Important differences in the incidence of asthma are built into different ways of life — such as diet, environmental exposures and clinical practices — and anthropology should be able to help us understand how to prevent and treat this disease,” he says. “I hope that my work can help make sense of the origins of asthma and the sizable differences in the rates of asthma across populations. Behavior and culture play major roles in the causation and treatment of many diseases, and anthropology is the study of culture and behavior.”

Link To “Medical Anthropologist looks at Asthma”

At seven government rural health clinics in Uganda from December 2006 to January 2007, it was estimated that between one and three percent of all adults who came to the clinics with suspected malaria were also diagnosed with acute or early HIV infection.

Recent evidence shows that testing for HIV in people who are suspected of having malaria could help discover people who recently got HIV in countries with a high HIV burden. This scientific claim allows for a new approach of testing both diseases; they can integrate HIV and malaria control activities at the primary care level, particularly if there are better developed and implemented care tests for diagnosing acute HIV infection. Providing regular primary care and a focus on the diagnosis and treatment of malaria in sub-Saharan Africa will be a unique prospect to discover a great number of people with acute HIV infection by offering point-of-care HIV testing and counseling.

Acute HIV has symptoms that mimic the ones of malaria.  In sub-Saharan Africa, where the burden of HIV is the greatest, more than 300 million people are diagnosed with malaria. Between 30 to 50 percent of the health clinic visits are due to flu-like symptoms for which patients are instantaneously diagnosed with malaria disregarding another cause for the flu-like symptoms (acute HIV aids). therefore, many people miss the opportunity to get treated and prevent the HIV transmission.

The author conducted a cross-sectional study to examine the percentage of people diagnosed with malaria who instead have acute HIV aids.  The study results   show that a great number of people with suspected malaria were actually suffering from acute HIV aids. The detailed statistics of this study can be viewed at the end of this summary.

People with flu-like symptoms in the sub-Saharan African region might have acute HIV aids. The authors believe that by examining patients who experience flu-like symptoms at general health clinics many people with acute or early infection can be classified. By adhering the test and acquiring a faster diagnosis of HIV aids when it is acute, the prevention of transmission can be successfully implemented.

Limitations of the study:

1. Cross-sectional analysis might have led to misclassification.
2. The method used for the study, which involved dried blood spots and pooling estimates,  could have miscalculated those with acute infection.
3. The resource-intensive nature of the testing used in this study is not sensible in most resource-poor settings.

The author’s findings create the potential for discovering a great number of Africans with acute or early HIV infection by synchronizing HIV and malaria control strategies. Being more careful with diagnosing malaria . Acute HIV aids in union with the appropriate counseling and continuum of treatment and care can be a significant step for global HIV prevention.

Results from the study:

1. 2893 (41%) who were included in the study had blood smears positive for malaria varying from 3.4%-30% by site.

2. 11.2%)  (324) were HIV-infected with site prevalence ranging from 1.4%-16.9%.

3. 26.5% of all HIV-positive adults were recognized as having acute (30 or 9.3%) or early (56 or 17.3%) HIV infection.

4. of the total population patients with acute, early and established infection represented 1.0%, 1.8% and 8% respectively.

5. Site prevalence for acute and early HIV infection varied ranging from 0.5% to 6% of all adult patients.

6. Site-level predictors for acute HIV infection, among all patients, included high HIV prevalence (greater than 10 percent) (OR 4.5, P=0.006) and low levels of endemic malaria (OR 2.8, P=0.015).

7. 4-6% of all adults suspected of having malaria and who met the criteria for acute HIV infection were from the three study sites with the highest HIV prevalence, ranging from 10.6% to 16.9%.

Tags: AIDS, diagnosis, HIV, Malaria, Sub-Saharan Africa, symptoms