Tuesday, April 15, 2014

Week 5: Potential topics for the final assignment

As the due date for our final health and development assignment draws nearer, the task of choosing a topic grows more pressing.  The assignment requires the selection of 1) a country 2) a development issue and 3) a health issue.  The biggest challenge for me so far has been to narrow down a veritable world of possibilities to only a few workable options, but nevertheless here they are:

A.  The effects of migratory work patterns on the spread of malaria in Swaziland

I remember reading last semester about the efforts Swaziland has undertaken and considered implementing in order to minimize the prevalence of malaria.  Swaziland has reportedly succeeded in reducing its number of national cases from 3.8 to 0.2 per 1000 from 1999 to 2010 (WHO cited in Hsiang et al. 2012).  This has been accomplished through programs utilizing insecticide-treated nets, surveillance (reactive case detection in which people in the area surrounding a positively identified case of malaria are notified and screened), indoor residual spaying, rapid testing and treatment programs as well as education regarding issues such as avoiding stagnate water, etc (Kunene et al. 2011).  Despite the significant progress that has been made, Swaziland still faces challenges to eliminating malaria entirely, the largest of which is likely migration between countries (Koita et al. 2011).

Swaziland is a small landlocked country between South Africa and Mozambique.  There is a great deal of movement back and forth across the borders, particularly among workers in search of job opportunities, in Swaziland's farms and sugar cane fields for example (Hsiang et al. 2012; Koita et al. 2013).  This means that the success of Swaziland's elimination program not only has to account for what is going on within its borders, but also what is going on in the countries just next door.  If people come from or cross into South Africa or especially Mozambique (considering its particularly high rates of infection) and enter or re-enter Swaziland with malaria, they could act as the starting points, or sources for the resurgence of locally-based transmission (Koita et al. 2011). In fact, in 2012, 78% of malaria cases identified in Swaziland were reportedly imported (WHO 2012b) and a study by Koita et al. in 2011 found that 63% of the imported cases that they looked at to have originated in Mozambique. 

The Lubombo Spatial Development Initiative is a collaboration between Swaziland, Mozambique and South Africa that has been going on since 1999 (Sharp et al. 2007).  It involves cross border efforts to minimize malaria in the region through insecticide spraying, surveillance, etc (Kunene et al. 2011; Sharp et al. 2007).  In light of the number of imported cases in Swaziland, particularly from Mozambique, there is now interest in identifying and testing high risk groups at the border before they enter (Koita et al. 2011).  

In this case, the development issue would be migration, the health concern malaria and the country Swaziland.

Unfortunately, the spread of malaria via migrants is not only a problem in Swaziland.  According to the Thailand Migration Report in 2011, 2 million migrants were in the process of registering for eligibility to work in Thailand, while an additional 1 million migrant workers and their family members were undocumented (Huguet & Chamratrithirong 2011).  The truth is that Thailand's booming economy has become a very attractive prospect for people looking for work from nearby countries whose economies are struggling.  The economy in Thailand has significantly benefited from these imported workers, many of whom perform the dangerous, difficult and lower-paying jobs that locals are unwilling to do (Huguet & Chamratrithirong 2011).

Some of the countries from which these migrant workers originate, including Myanmar and Cambodia, have higher prevalence rates of malaria than Thailand, thereby increasing the likelihood of imported cases due to the considerable amount of cross-border traffic (Huguet & Chamratrithirong 2011; Kritsiriwuthinan & Ngrenngarmlert 2011).  Migrants also may not possess the immunity that locals do to the Thai strains of malaria, making them more susceptible to infection and illness (Huguet & Chamratrithirong 2011).  In fact, migrants accounted for 46% of all malaria cases in Thailand in 2003, a figure that rose to 55% in 2006 (Khamsiriwatchara et al. 2011).  A study performed by Kritsiriwuthinan and Ngrenngarmlert in 2011, found an infection rate of 1.5% among migrant workers from Myanmar, which was significantly higher than the overall prevalence rate of 0.041% reported in Thailand at the time.  

Migrants in Thailand, particularly those that are undocumented, reportedly experience considerable discrimination both in the workforce and in the healthcare system (Huguet & Chamratrithirong 2011).  Therefore, not only are they more likely to be carrying the disease from their countries of origin, but they are also less likely to seek and/or receive proper treatment when they are ill (Huguet & Chamratrithirong 2011).  As a result, they may end up carrying the infection for longer, acting as a reservoir from which local mosquitoes can transmit the disease and thereby impeding elimination efforts in Thailand.

B.  Urbanization and the Rise of Dengue Fever in Brazil

Brazil has seen massive amounts of fast and unregulated urbanization recently, resulting in densely populated urban areas.  In fact, approximately 85% of Brazil's population lives in urban centers.  With so many people coming to the city looking for work and not enough suitable housing built, many people have resorted to either living in overcrowded spaces or informal, poorly-constructed housing.  The sprawl of informal housing has resulted in the creation of numerous slums or "favelas" with very poor living conditions (lack of water drainage, no regular rubbish collection system, crime, etc).   It was estimated that in 2009, 26.9% of the urban population in Brazil or 44,947,237 people lived in slums (United Nations 2012). 

This rapid urbanization could account for the considerable rise in dengue fever Brazil over the past few years.  Urban environments, particularly slums, provide the perfect conditions for the spread of dengue because they are so densely populated and tend to provide ample breeding grounds for mosquitoes, which act as the disease vector (Alirol et al. 2011; WHO 2012a).  Water can pool in collections of trash and containers left outside, as well as in the streets and ditches of areas with poor drainage systems, where mosquitoes can lay eggs (Alirol et al. 2011; WHO 2012a)
.  Brazil was actually free of Aedes mosquitoes (the specific species that transmits dengue) until 1976 and of dengue until 1981, when it was reintroduced (da Silva-Nunes et al. 2008).  Since then, the occurrence of dengue in both Brazil and the world has greatly increased.  In 2007, Brazil reported 72, 000 cases, a figure that jumped to 1.2 million in 2010 (CONASS, cited in WHO 2012a).
Brazil has a very young population with a mean age of 30.7 years and 43.7% of the population between the ages of 25 and 54 (working age) (CIA 2014).  With a fertility rate that has decreased to 1.79/woman, a mortality rate of 6.54 deaths/1,000 and a large working age population, Brazil is in the stage of its demographic transition that has the potential to optimize economic growth (CIA 2014).  However, dengue could be impeding economic progress, with hemorrhagic fever having predominantly affected those aged 20 to 40 (within the working population) from 1998 to 2006 and those under the age of 15 (future working population) since 2007 (Teixeira et al. 2013).  
In 2010, dengue resulted in 26,492 DALYs and ended up costing a total of US$1,348.6 million in Brazil, or 7.12 per capita (Shepard et al. 2011).  In addition, a study from 2009 showed that the ambulatory and hospitalized patients in Brazil that were still studying at the time lost an average of 4.2 and 5.6 days of school, respectively, while those working lost an average of 6.6 and 9.9 days of work (Suaya et al.).  The lack of productivity, lost wages and missed learning experiences due to dengue could significantly affect Brazil’s economy (Bloom, Canning & Jamison 2004; Dornbusch et al. 2006; Gomes-Neto et al. 1997).  Perhaps this is why Brazil is considered to not be reaping the full benefits of its large working population (CIA 2014) Therefore, addressing the increase of dengue in Brazil is as much a health concern as it is an economic one.

In this case, dengue would be the health concern, Brazil the country and urbanization the development issue.

Ultimately, I find both options A and B to be very interesting, but B is looking like the better contender due to the overwhelming amount of resources that I have found.  Option B has also drawn my eye because of the severity of the issue of dengue in Brazil and its effect on the economy.  Hopefully I will choose the right topic for my final assignment, but at least I still have a few weeks to decide.  The trouble will be to refrain from coming up with other options as I do more research.



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