The challenge of global elimination policies : a case study of malaria and other diseases of poverty

Malaria is a priority disease on the global public health agenda, with between 800 thousand and one million deaths reported annually. The endemic areas most affected by this parasitic disease have high poverty rates across broad population groups. Children and pregnant women suffer the biggest impacts from this disease, which is transmitted by Anopheles spp. mosquitoes. About 90 countries worldwide report indigenous cases with active transmission. Enormous efforts are ongoing to alleviate the disease burden and its devastating effect on health in vulnerable populations. This research presents a combination of methodological, ontological, and axiological approaches in order to further understand the intrinsic and extrinsic components of malaria which affect the dynamics of transmission and control measures. Limitations are inherent in the ability of the researcher, and this document is unlikely to fully present all factors and determinants which interact in the complex system of malaria. Nonetheless, it reflects a major effort to combine paradigms from positivism to historical constructivism. The purpose of this work is to contribute to the understanding of this phenomenon and compare qualitative and quantitative evidence in malaria-endemic areas of Colombia and the Americas. Additional effort is made to reconstruct the trajectories and experiences of control and prevention and recognize elements to improve models of control,
considering the specific contexts where malaria and other diseases of poverty persist. In Chapters I and II, the realities and nature of the problem are defined, specifically to establish paradigms as well as ontological, epistemological, axiological and methodological questions, while the objective of the research is defined in terms of variables such as time, people and places. The analysis process begins with a narrative review of gray literature and indexed texts covering the historical transformations of concepts of control, elimination and eradication of malaria. The compilation of sources interprets the effect of political, economic, social and cultural structures on trends of malaria and diseases of poverty. Additionally, the problem of elimination of infectious diseases is followed from a “biologist model” to a more inclusive and broad bio-socio-political context. Malaria is a complex phenomenon, and control/ elimination /eradication strategies should not underestimate the importance of partial achievements from interventions implemented over time. The search for "magic bullets" is a constant and continual process of recognition by all involved actors, including researchers, academic and public-private institutions, as well as sustained active participation by the affected communities. The detailed description of this process is presented in Chapter III, Concepts evolution of malaria control, elimination and eradication. Historical Review, as submitted to the Journal of Malaria. vii In order to correlate and triangulate the primary and secondary evidence, field work to identify epidemiological markers of advancement and a narrative review on the status of elimination of malaria in Colombia and Latin America are analyzed. These findings are reported in Chapter IV, Proportion of fever attributable to malaria in Colombia: Potential indicators for tracking progress towards malaria elimination. A cross-sectional survey descriptive study, conducted in two regions of Colombia, aimed to identify risk factors (epidemiological and socio-demographic) and baseline characteristics related to the dynamics of malaria transmission. These two regions shared similar structural problems with other malaria endemic regions of Latin America. The field results are strongly correlated with the narrative review. Part of the problem is explained through the primary productive sector, which consists of farmers, miners, fishermen, and migrants/displaced persons, reflecting social injustice and inequalities between regions under the same public policies. Poor governance and reduced infrastructure investment for the health and education sectors, combined with scarce development models for rural and peri-urban areas, produce inadequate living conditions which perpetuate diseases of poverty and high rates of maternal and infant mortality. Information systems for early prediction of outbreaks and epidemics are inadequate or non-existent. Recording of cases on a weekly basis and monitoring of therapeutic failures and insecticide resistance are poorly documented. The proportion of asymptomatic individuals, despite the low reported rates, remains a clinical and epidemiological problem. In the objectives of the Millennium Development Goals, the concepts of elimination particularly focused interest on public health programs. In the case of Colombia, other diseases of poverty can be used as epidemiological markers of the goals achieved. Using the example of endemic goiter, the policy of salt iodization has been adapted as the most cost effective strategy for elimination. By 1998, Colombia declared the country free of goiter. Unfortunately, the lack of monitoring and evaluation programs has hindered appropriate follow up to ensure continued iodization of salt. This study indicates that the disease is still prevalent in school children and pregnant women. In Chapter V, entitled Historical review of the current sanitary policy of goiter elimination in Colombia, 1990-2012, a review on the control policy addresses the decline from a constructivism paradigm. In Chapter VI, the impact of this research to improve the policy of elimination, considering local examples which are widely generalizable to other endemic areas in the same region of the Americas, is presented. New research questions for additional operational research and the development of novel interventions which impact on the incidence of disease are articulated. In conclusion, these results confirm the need to define mechanisms for monitoring and evaluation of programs for elimination. Given the complexity of the health problems, strategies of control must consider reducing inequities, social injustice, and, importantly, the gender component, which are consequences of violence in Colombia.