Explain through a case study of Malaria the global aspects of disease.
The economic burden of Malaria.
Malaria is a life threatening disease caused by a parasite called Plasmodium which is transmitted through the bite of an infected mosquito. In the human body the parasites multiply in the liver and then infect red blood cells. Symptoms of malaria include fever, headache and vomiting, and if not treated quickly becomes life threatening by disrupting the blood supply to vital organs. Most cases and deaths are in sub-Saharan Africa, however, Asia, Latin America, the Middle East and parts of Europe are also affected. In 2006 malaria was present in 106 countries and territories, resulting in 247 million cases recorded in this year. This in turn caused nearly one million deaths which were mostly amongst African children where it is estimated that one child dies every 30 seconds from the disease. In 1958 Weller stated that 'It has long been recognized that a malarious community is an impoverished community'. My case study is going to examine this statement and the argument that Malaria is not just a disease commonly associated with poverty but one that causes poverty and a major hindrance to economic development. Tropical regions are most affected, however the furthest extent to which malaria has reached is into some temperate zones with extreme seasonal changes. The disease has been associated with major negative economic effects on regions where it is widespread. During the late 19th and early 20th centuries, it was a major factor in the slow economic development of the American southern states. In countries where malaria is common, the average per capita Gross Domestic Product (GDP) has risen only 0.4% per year, compared to 2.4% per year in other countries. Poverty is both a cause and effect, because the poor do not have the financial capacities to prevent or treat the disease. In its entirety, the economic impact of malaria has been estimated to cost Africa $12 billion USD every year. The economic impact includes costs of health care, working days lost due to sickness, days lost in education, decreased productivity due to brain damage from cerebral malaria, and loss of investment and tourism. In some countries with a heavy malaria burden, the disease may account for as much as 40% of public health expenditure, 30-50% of inpatient admissions, and up to 50% of outpatient visits.
The links between malaria and poverty are multiple and complex, it has long been recognised that there is a correlation between the two however what is more difficult to understand is the nature and magnitude of this relationship. This is supported by Packard who claims that the idea that malaria blocks development has been supported since the end of World War II., He suggests that few studies actually define the extent of the relationship between malaria and development. This was further supported by Gunnar Myrdal who pointed out in the early 1950s that economists had paid little attention to health as an economic variable.
In their studies Gallup and Sachs indicate that there are other correlations and implications on the severity and distribution of malaria. They claim that malaria has always been geographically specific and that intensive malaria is confined to the tropical and subtropical zone. However, poverty is also geographically specific and poorer countries are predominately found in the same regions as malaria. Similarly almost all of the richer countries are outside the regional bounds of intensive malaria. Gallup and Sachs go on to state that not only are malarial countries poorer but the economic growth in these countries is far more superficial than that of more developed countries. However, this does not completely answer the question of whether malaria causes poverty and low growth.
Poverty underpins the conditions where malaria thrives and malaria impedes economic growth and keeps communities in poverty. In their article Malaria and Poverty, Teklehainmanot and Mejia argue that malaria can be considered to be both a cause and effect of poverty. For those exposed to the infection, poverty can be seen as an effect as often the dwellings occupied by poorer people are prone to mosquito proliferation. Preventative measures such as insecticide, and treated bed-nets are often unaffordable especially when coupled with other expenditures which go with the treatment of malaria such as the cost of transport, consultation and drugs. These costs often mean that poor families will postpone seeking help in the hope that they will get better naturally which often leads to more extensive health problems. Moreover, the implementation of health care models by governments hoping to cut their own expenditure and which require patients to pay for care is another factor that can lead to poverty. In particular he poorest people are most effected not only because they have limited access to health services, particularly in rural settings where there are not only financial but also geographical barriers due to remote areas with scant roads.
Poverty is also considered to be a cause of poverty by, Teklehainmanot and Mejia because they suggest that 'in many areas of rural Africa, where people are engaged in subsistence agriculture, time lost to work because of malaria can mean less food for consumption.' Malaria's effect on households has usually been measured on a short-term basis, but it is likely to affect poverty and vulnerability at the household level over time. Many studies fail to take into account the ways in which households and businesses adapt their productive activities or cope in response to the malaria diseaseburden. In a study in rural Kenya, the most commonly used strategy was intra-household labour substitution in response to lost employment time of household members.
Households most often coped with direct costs by mobilizing cash reserves and savings, selling livestock, or receiving gifts from other households. These strategies can have negative implications, influencing household ability to withstand other contingencies in the future. The risk of malaria may have a pervasive effect on economic incentives, behaviour, and strategies. Housing conditions that expose more than protect, warfare that displace millions and destroy scant infrastructure, unhealthy working conditions and poverty that makes prevention measures and appropriate health care unaffordable for people and nations. In such a situation, the very existence of malaria in a community imposes a cost on the entire community by modifying social and economic decisions taken in response to the perceived risk of infection. It has been widely observed in the descriptive literature that decision making in such diverse areas as crop choice, trade, investment, and fertility is affected by the risk of acquiring malaria, with a potentially sizeable negative effect on economic productivity and growth. Standard household-based studies naturally fail to capture these effects. One example of such a cost is the effect of the fear of malaria may have on discouraging foreign trade and investment. In a rapidly globalizing economy, malaria's burden can turn heavier than ever, leaving Africa yet more isolated and impoverished.
A further argument supporting the idea that malaria is caused by poverty can be seen in evolution. In areas with the most severe cases of malaria such as sub-Saharan Africa and parts of the Middle East and Africa many ethnic groups have developed a partial genetic defence against sickle-cell anaemia. In parts of Africa this genetic mutation is carried by up to 30% of the population, however those who inherit the trait also inherit a substantial protection against malaria. Gallup and Sachs argue that the value of this 'protection against malaria must be great as it comes at a high cost: all children in developing countries who inherit the trait from both mother and father die before they reach child bearing age'
However, Gallup and Sachs acknowledge that although Malaria is prevalent in the poorest countries, so are many other serious diseases which are a 'direct consequence of poverty, caused by inadequate sewage treatment, unsafe drinking water, poor hygiene or substandard housing.' Malaria does not follow these patterns and they believe that its severity can also be determined by climate and ecology. Although preventative measures such as screens and bed nets and the general level of development of a country also effect the prevalence they are not the major determinants. Furthermore, Gallup and Sachs point to the fact that there are countries with high incomes that still face serious problems with regard to malaria. For example 'Oman, with an income per capita of almost $10,000, has severe malaria throughout the country except in remote areas of high altitude and desert.' Similarly the United Arab Emirates which geographically is situated next to Oman and has one of the highest income levels in the world has also been unable to eliminate malaria.
Furthermore, some of the most effective efforts at control have used few material resources other than labour and thus do not fit to the constraints of poverty. The elimination of breeding sites of mosquitoes in parts of Panama at the time the canal was built, control of the Anopheles mosquito in north-eastern Brazil in the 1930s and the malaria free enclaves around some African mines provide examples of this. Unfortunately, Gallup and Sachs also acknowledge that these control efforts have never been sustained in more than small areas or for more than a short period of time. In addition malaria control in sub-Saharan has never proved to be effective with many failed attempts at malaria control outside of the temperate southern tip. In the 1960s the WHO sponsored various intensive malaria control and research projects, over the course of 7 years, WHO and the Nigerian government spent more than $6 million to try to eliminate malaria in 164 villages. As a result, the evidence suggests that there are no proven ways of controlling malaria in these areas of intense transmission thus it is difficult to argue that poverty is a cause of malaria.
Conversely, Packard illustrates the problems with the claim that malaria blocks development. He argues that development often refers, in these areas, to economic growth linked to increases in agricultural production. However, this link is limited in that it leaves many questions unanswered such as 'what kinds of agricultural development were hampered by malaria? Did malaria affect all forms of production equally? Conversely, was malaria control a benefit to all forms of production? Who benefited from the development generated by malaria control?' Packard uses a case study of the Lowyeld region of the eastern Transvaal to examine the complex relationship between malaria and development. He points out that despite the fact that agricultural production increased after the introduction of vector control in the 1950s, commercial agriculture had already flourished in the region from the end of the nineteenth century. Furthermore during the 1920s and following the Depression in the 1930s large white capitalised farms experienced a boom agriculture production. Therefore it is possible to suggest that if malaria does play a role in restricting economic growth it effects different social groups in different ways. Whilst the large scale capitalist farmers and large-scale projects appear to have been the least effected, smaller under-capitalised white farmers were less successful. It is important to note here that these studies show the economy in the post war period and thus the economic expansion occurring in South Africa at the time could be part of a larger post-war economic boom. Nonetheless malaria control provided new opportunities new for both richer and poorer whites in the area despite the fact that poorer whites were only partially benefited. However, malaria control significantly limited the agriculture opportunities for African farmers. While they were never as successful or as economically prosperous as white farmers they may have in fact benefited from the presence of malaria as the presence of the disease discouraged white farmers from settling in the area providing more opportunities for Africans to gain land. It is clear from this case study that the relationship between development, agriculture growth and malaria is complex however, what can be asserted is that 'the impact of disease on South African society has seldom been uniform. Rather, it has always been mediated by race and class, producing a wide range of diverse experiences', one could also argue that this is also an analogy for the general global relationship between development, poverty and malaria.
Gallup, J., & Sachs, J., The Economic Burden of Malaria, Centre for International Development, Harvard University, Cambridge, Massachusetts, (The American Society of Tropical Medicine and Hygiene, 2001).
Packard, R., Malaria Blocks Development' Revisited: the Role of Disease in the History of Agricultural Development in the Eastern and Northern Transvaal Lowveld, 1890-196, (Journal of Southern African Studies, Volume 27, Number 3, September 2001).
Weller TH, 1958. Tropical medicine. Encyclopedia Britannica. Chicago: William Bennet, 495-497.
WHO - Malaria (Accessed 31/03/10) 〈http://www.who.int/topics/malaria/en/〉
Teklehainmanot, A., & Mejia, P., Malaria and Poverty (Malaria Program, The Earth Institute at Columbia University, New York, New York, USA) (Accessed 31/03/10)〈http://cnhde.ei.columbia.edu/files/1/6/Malaria%20and%20Poverty.pdf〉
 Weller 1958
 Teklehainmanot, A., & Mejia, P
 Packard 2001 p593
 Gallup, J., & Sachs 2001
 Teklehainmanot, A., & Mejia, P
 Gallup, J., & Sachs 2001.
 Ibid p4
 Packard 2001 p593