Category Archives: Migration

Health worker migration – push or pull?

The New Vision of Uganda reports that according to the 2009 Human Development Report, “THE majority of Ugandans who migrate to other countries are among the higher educated group. And those who migrate, whether within their own country or abroad, are doing better in terms of income, education and health than those who stayed where they were born.”

dscn3845a.JPGHealth workers are among those educated emigrants, but the factors behind their movement are complex.

Citing the case of health workers deserting Africa, (the World Development Report) explains that this is being caused by poor staffing levels and poor public health conditions. “Migration is more accurately portrayed as a symptom, not a cause, of failing health systems.”  It notes that improving working conditions at home might be a better strategy to stop the brain-drain than restricting emigration.

The Canadian Medical Association Journal explains the problem thus:

You can’t force someone to stay and attempt to work in a place that  is lacking even minimum provisions for them to do their job. “If you tell them they can only hand out band-aids and aspirin, no  one will stay,” says Dr. Otmar Kloiber, secretary general of the  World Medical Association. “People should have the privilege to  migrate. For medical workers it’s important to have exchanges in  order to learn and to work. You can’t put someone on a dead end road and ask them to build a health care system.”

WHO also reminds us that health workforce maldistribution and migration occurs within countries, too. “Approximately one half of the global population lives in rural areas, but these  people are served by only 38% of the total nursing workforce and by less than a  quarter of the total physicians’ workforce.” Health workers locate in urban centers to gain greater economic, educational and social opportunities for themselves and their families.”

The loss of health workers is a major impediment in implementing malaria coverage targets and making progress toward disease elimination even when malaria commodities are provided in adequate amounts. More generally, WHO notes that, “Without available, competent, and motivated health workers, the potential for  achieving the Millennium Development Goals, and for effective, efficient use of  the financial and other resources committed to achieving the Goals, remains  extremely limited.”

The solution, according to the comments above is not simply finding more people to deliver malaria services in isolation, but ensuring that malaria control services are integrated into a well functioning health system. Donors who provide malaria and other health and development support are also cautioned to become aware of how their own programs, policies and activities can disrupt the health workforce in the countries receiving aid.

Getting tough on monotherapy artemisinin drugs

In Guyana Stabroek News reports that, “Minister of Health Dr Leslie Ramsammy has thrown down the gauntlet to pharmacies to desist from selling the single dose artemisinin malaria drug by the end of this year or he would instruct officers from the Food & Drugs Department to size the drug from their shelves.” Guyana has been promoting ACTs since 2004.

In Guyana, the coastal areas are considered to be malaria free while the interior areas are considered to be high-risk malaria areas. Guyana therefore, may not me among the most endemic countries for malaria, but all endemic countries need to take the disease seriously, like Guyana’s Minister of Health, in order for global elimination to succeed.

Guyana has seen success in promoting malaria control. In endemic areas bednet use by children under 5 years of age increased from 7% to 70% between 2000 and 2006, according to the Multiple Indicator Cluster Survey.

Guyana’s Round 7 Global Fund proposal also aims to decrease malaria incidence by 70%. Included in the strategies are diagnosis and treatment with the intention that all health facilities (including the private sector) would be appropriately trained and equipped with microscopes and have adequate amounts of drugs and rapid tests. This is why the need for appropriate treatment with ACTs, not monotherapy drugs is being stressed.

As we have mentioned before, Guyana’s malaria control efforts are complicated by migrant miner populations in the endemic areas. It is such populations that may help drive the demand for cheaper, though inappropriate malaria medicines like artemisinin monotherapies.

An interesting irony is that WHO lists Guyana among the 16 countries that have never registered artemisinin monotherapy drugs. This implies that the availability of such medicines in Guyana is truly against the law and also shows how slippery the pharmaceutical import business can be.

WHO as of 16 November 2009, lists 33 endemic countries as not taking adequate steps to stop the sales of monotherapy artemisinin drugs.  Another 29 have “taken regulatory measures to withdraw the marketing authorization of oral artemisinin-based monotherapies after implementing ACT policy.” The approach of these 29 does not mean the immediate withdrawal of monotherapies, as some like Nigeria are simply letting the current registration of these drugs run out – meaning they may be on the market for another 2-3 years.

Unless all endemic countries take action like that proposed in Guyana, we may not be proceeding along the pathway to elimination, but down the road to drug resistance.

Malaria in Guyana – Community Dynamics

The Americas have the lowest rates of malaria among the major endemic areas of the world. So when concerns are raised that Guyana may not be able to keep its total cases in 2009 below 10,000, countries like Nigeria, Tanzania and DRC may wonder what the fuss is all about. We must remember therefore, that for malaria eradication to succeed, the disease must be eliminated in EACH endmic country, no matter how few the number of current cases appears to be.

Success in Guyana has been mixed, with great reduction in some target communities, but now “There are areas in the country which did not have a problem now, but are not recording measurable and or moderate levels of malaria.” In the Omai area, “hundreds of small miners have appeared on the scene.” They are not paying attention to environmental control, but instead are responding to the increasing price of gold on the world market.

guyana-regions-and.jpgGuyana has received Global Fund grants from Round 3 and 7 for malaria control. Though the country has around three-quarters of a million people, the proposals focused on the more endemic regions. For example, Regions 7 and 8 are populated mostly by a little over 20,000 Native American peoples. These regions have also been inundated by another 20,000 informal miners and loggers.

The GFATM performance report on case management in the Round 3 grant shows that while appropriate malaria drugs are available in all target communities, actual appropriate treatment of vivax and falciparum malaria hovers around only 60% of cases. (Round 7 was signed only in May 2009 so a detailed progress report is not yet available.)

Community participation indicators also show high marks, but then one needs to consider that the non-indigenous miners and loggers may not really be part of a community.

The 2006 Multiple Indicator Cluster Survey found that sleeping under bednets by children under five years of age increased from 6.5% to 70% between 2000 and 2006. Of course this leaves open the question of whether adult migrant miners are using nets and are harboring the disease. Palmer and colleagues describe one typical mining camp in this region –

The mining camp … was approximately 400 km inland from Georgetown, the capital of Guyana, in the heart of the Amazon region of the country. It was typical of many of the mining camps in the jungle. Men sleep in rows of 20 to 40 hammocks strung underneath a large tarp-like covering. The tarp coverings are not enclosed, but the men usually sleep under mosquito netting, as malaria infection is a constant problem.

If Guyana is to meet its 2012 target of only 8,000 annual cases of malaria some serious thinking is needed about strategies to reach the diverse populations in the endemic regions.  The indigenous peoples have their community structures, and it appears that these have been reached.

The challenge then is to distinguish the other residents of these endemic regions and organize malaria control activities that will be appropriate to their social context, recognizing at the same time that their mining practices may be detrimental to the environment and the elimination of malaria.

When Parasites Travel

Mobile population importation of drug-resistant infections and diseases is a focus of the November 2009 issue of Emerging Infectious Diseases. In that issue, MacPherson and colleagues cite, “Many examples of imported multidrug-resistant (MDR) infectious diseases are associated with migrant populations, e.g., MDR Plasmodium falciparum malaria in immigrants, tourists, and returned foreign-born travelers.”

Parasites travel –

  • According to Monge-Maillo, malaria accounted for nearly 10% “of 2,198 immigrants referred to the Tropical Medicine Unit of Ramón y Cajal Hospital over a 20-year period” in Spain.
  • CDC received reports of 1,324 cases of malaria, including four fatal cases, with an onset of symptoms in 2004 among persons in the United States or one of its territories. This number represents an increase of 3.6% from the 1,278 cases reported for 2003,” as reported in MMWR by Skarbinski and colleagues.
  • In the Netherlands 5043 laboratory cases of imported malaria were confirmed between 2000 and 2003 according to Klein and Bosman.

fly_dscn0185.JPGThe problem is worse when drug-resistant parasites travel. Chan and co-researchers have been examining archival human sera “to explore the origin and evolution of Plasmodium falciparum chloroquine resistance in the Pacific.”

In 2002 Afghan refugees brought malaria into northwestern Pakistan. They experienced a 28% treatment failure rate when chemically substandard locally manufactured sulfadoxine-pyrimethamine was used for routine treatment. This is a potential way of producing drug resistance that could be carried back home by returning refugees

MacPherson and colleagues demand what they call, “Pharmaceutical security systems for standard and quality medicines,” in an effort to combat “commonly substandard or counterfeit” drugs in endemic countries.  Progress in eliminating malaria in Zanzibar, Rwanda and Zambia can easily be threatened if resistant parasites cross their borders. These parasites don’t need passports and visas.