title: Febrile illness diagnostics and the malaria-industrial complex: a socio-environmental perspective.
abstract: Global prioritization of single-disease eradication programs over improvements to basic diagnostic capacity in the Global South have left the world unprepared for epidemics of chikungunya, Ebola, Zika, and whatever lies on the horizon. The medical establishment is slowly realizing that in many parts of sub-Saharan Africa (SSA), particularly urban areas, up to a third of patients suffering from acute fever do not receive a correct diagnosis of their infection.
  
  
  
  Malaria is the most common diagnosis for febrile patients in low-resource health care settings, and malaria misdiagnosis has soared due to the institutionalization of malaria as the primary febrile illness of SSA by international development organizations and national malaria control programs. This has inadvertently created a "malaria-industrial complex" and historically obstructed our complete understanding of the continent's complex communicable disease epidemiology, which is currently dominated by a mélange of undiagnosed febrile illnesses. We synthesize interdisciplinary literature from Ghana to highlight the complexity of communicable disease care in SSA from biomedical, social, and environmental perspectives, and suggest a way forward.
  
  
  
  A socio-environmental approach to acute febrile illness etiology, diagnostics, and management would lead to substantial health gains in Africa, including more efficient malaria control. Such an approach would also improve global preparedness for future epidemics of emerging pathogens such as chikungunya, Ebola, and Zika, all of which originated in SSA with limited baseline understanding of their epidemiology despite clinical recognition of these viruses for many decades. Impending ACT resistance, new vaccine delays, and climate change all beckon our attention to proper diagnosis of fevers in order to maximize limited health care resources.
authors.affiliation: Department of Geography and Regional Studies, University of Miami, Coral Gables, FL, USA. stoler@miami.edu.|Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA. stoler@miami.edu.|Abess Center for Ecosystem Science and Policy, University of Miami, Coral Gables, FL, USA. stoler@miami.edu.
authors.forename: Justin
authors.identifier: 0000-0001-8435-7012
authors.initials: J
authors.lastname: Stoler
authors.affiliation: West African Centre for Cell Biology of Infectious Pathogens, University of Ghana, Legon, Ghana.|Department of Biochemistry, Cell and Molecular Biology, University of Ghana, Legon, Ghana.
authors.forename: Gordon A
authors.initials: GA
authors.lastname: Awandare
mesh_terms: D017954:Africa South of the Sahara; D065632:Chikungunya Fever / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D003906:Developing Countries; D003937:Diagnosis, Differential; D003951:Diagnostic Errors; D004777:Environment; D005334:Fever / Q000209:etiology*; D005869:Ghana; D019142:Hemorrhagic Fever, Ebola / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D006801:Humans; D008288:Malaria / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D012959:Socioeconomic Factors; D000071243:Zika Virus Infection / Q000150:complications / Q000175:diagnosis* / Q000628:therapy
keywords: Africa; Communicable disease; Diagnostics; Fever; Malaria