How effectively are communicable and non-communicable diseases dealt with

Malaria in Ethiopia introduction

• caused by a tiny plasmodium parasite which has two hosts, the Anopheles mosquitoes and humans

• mosquitoes act as vectors, transmitting the disease from person to person and the parasites enter people through the bite of an infected mosquito

• 2019 - malaria claimed 405,000 lives, ¾ of which were children under the age of 5 years

• Africa accounted for 94% of all malaria deaths in 2018

Ethiopia - incidence and patterns of malaria

• malaria is endemic in 75% of Ethiopia’s land area

• 2/3rd of the countries population live in areas at risk of the disease, which kills around 70,000 people a year, but it is not evenly distributed within the country

• areas with highest risk = western lowlands, in Tigray, Amhara and Gambella provinces

• Their transmission rates peak after the rainy season, between June and November

• In the midlands where altitude ranges from 1000m to 2200m, transmission is also seasonal, with occasional epidemics

• in Afar and Somali provinces in the Eastern Lowlands, the arid climate confines malaria to river valleys

• The central highlands, comprising around one-quarter of the country, are malaria-free

Ethiopia - Environmental and human causes of malaria

• most malarial mosquitoes thrive in warm, humid climates where stagnant surface water provides ideal breeding habitats for mosquitoes - these habitats are strongly influenced by altitude in Ethiopia

• the disease is endemic in the western lowlands where temps and humidity are high throughout the year

• absence of malaria in the highlands is explained by low average temperatures which slow down the development of mosquitoes and the plasmodium parasite

• Annually at harvest and planting time, large-scale, seasonal population movements take place between the malaria-free highlands and the agricultural lowlands

• The timing of this migration coincides with the rainy season and the peak malarial transmission period (June-September) in the lowlands

• Infection is also increased because harvesting often continues after sunset, and most migrant workers sleep in the fields overnight

• Irrigation projects in Awash Valley and Gambella province + cultivation of rice, have both expanded the breeding habitats for mosquitoes

• urbanisation - flooded excavations, garbage dumps, discarded containers provide breeding sites

• malarial parasites are becoming increasingly drug-resistant and some experts point out that the last sig. break throughs in anti-malarial drugs were made nearly 50 years ago

Socio-economic impacts of malaria

• significant social and economic impacts, the hardest hit are the poor who often live in poorly built dwellings that offer few barriers to mosquitoes

• Ethiopians suffer approx. 5 mill episodes of malaria/year, killing around 70,000 people

• Slow economic growth reinforcing the cycle of poverty because the disease has debilitating effects (economic losses estimated to cost $12 billion/year

• Malaria absorbs 40% of national health expenditure and accounts for 10% of hospital admissions and 12% of health clinic visits - overwhelming the health services and damages tourism + inward investment

• Implications for food security - western lowlands are resource-rich but malaria, which is endemic to the region, holds back development and this has a knock on effect in the highlands

• The malaria free highlands support unusually high population, its meager farming resources have been over exploited, resulting in widespread land degradation - contributing to the famines in 1980s

Strategies to control and treat malaria pt.1

• Chloroquine has been used to cause the pH of certain parts of the parasites cell to increase, preventing important biochemical reactions - but excessive use of this drug can be toxic to humans too

• growing resistance to chloroquine, first detected 70 years ago in Thailand, has led to development of alternatives such as mefloquine - but this has psychological impacts on a sig. % of those who take it

• The national malaria guidelines recommend Artemisinin-based combination therapies for the treatment of uncomplicated malaria caused by P. falciparum parasite (causing 60% of cases), whereas chloroquine still remains the most effective for P. vivax parasite (40% of cases)

• prevention and control programme is outlined in the National Malaria Strategic Plan in line with the WHO’s global campaign to Roll Back Malaria

Strategies to control and treat malaria pt. 2

• Current strategies - insecticide-treated mosquito nets, indoor residual spray and mosquito larvae source reduction

• 2015 - the malaria indicator survey showed that >70% of households in malaria-endemic areas were protected by ITN or IRS - however, the rate of improved household protection has slowed down in the past few years

• Ethiopia has recently targeted malaria elimination nationwide in 2030, aligned with the WHO’s global technical strategy through intensifying the existing malaria control activities

• 2019 - Ethiopia was on track to achieve the 2020 milestone by reducing the incidence of malaria by 40% - however, the emergence of insecticide resistant, migrant population, emerging chloroquine resistance for P. vivax, and the difficulty in both controlling and eliminating P. vivax are the challenging factors for malaria elimination in Ethiopia and worldwide

Cancer - social, economic and cultural causes

• cancer develops when mutations in a cells DNA cause the cell to grow out of control - some mutations are caused by chemicals or other toxic substances (carcinogens) and have the potential to cause cancer

• risk for developing cancer depends on many factors

• cancer frequency varies between socio-economic groups in most countries e.g. UK - consistent positive association has been found between increasing socio-economic status and the risk of cancers of the colon, prostate and breast, and skin melanoma, whereas inverse association has been found for lung, stomach, cervix cancer etc.(but correlation is not causation)

• environmental risk factors can explain at least 2/3rds of most AC’s cancer cases - but these lifestyle ‘choices’ are often constrained by poverty

• many cancers are preventable e.g. sunbathing/sunbeds indicate a cultural preference for tanning - opportunities for sunbathing has increased in the past 50 years due to growing wealth and affordable holidays to hot destinations

• along with wealth comes preference for meat/dairy, fast food and pre-packaged meals, correlated with a rise in incidence of bowel cancer + alcohol consumption rising, increasing risk of oral, oesophageal and liver cancer

• lack of exercise + changes in diet, have driven an epidemic of obesity in UK and increased the risk of cancer and CVD

• smoking remains the biggest single cause of cancer among both men and women - ~1/5th of cancer diagnosed each year in the UK are smoking related

Socio-economic impacts pt. 1 direct impacts

• more than 980 people are diagnosed with cancer daily in the UK, more than 440 people die from the disease daily

• incidence rates have increased by 12% since the early 1990s

• because the population is ageing, the number of cancer cases is projected to rise by more than 40% to around 514,000 new cases per year 2035, with greater increase in men than women

• direct impacts of cancer in the UK - ~35,000 people of working age die from cancer each year, removing productive workers from the labour force

• 120,000 people under 65 are diagnosed and are more likely to leave the labour force for treatment and recuperation - many cancer survivors do not return to work due to after-effects of the disease and treatment

Socio-economic impacts pt. 2 indirect impacts

• indirect impacts of cancer in the UK - there are over 1 million people in the UK caring for someone with cancer, so there is a reduction in economic productivity of friends and family members + the stress and well-being of those involved

• 2018 - 54,000 people under 70 lost their lives to cancer - this has amounted to a loss of £585 million in economic losses, across the rest of their working lives, £6.8 billion in real terms would have been contributed by these individuals to the UK economy in a single year

• at the current rate, the UK economy will lose over 200,000 potential workers over the next 5 years, and over 500,000 in the next decade

Socio-economic impacts pt.3 deprivation gap

• deprivation increases the likelihood of smoking, alcohol consumption and obesity - major causes of cancer

• UK cancer rates in some of the poorest areas are 3X greater than in the most affluent - these deprived areas are strongly entrenched in formal industrial areas in northern England, south Wales and London

• out of 50 most deprived - 34 in northwest region and 17 in Merseyside conurbation alone

• deprivation gap, with the more affluent having better survival chances than the most deprived e.g. 14.2% more women in the ‘most affluent group’ survive bladder cancer compared with their most deprived counterparts - the difference is largely explained by pre-existing health status and speed of diagnosis

• Northwest incidence of cancer compared to avg. = males +4.6, females +1.8

• East incidence of cancer compared to avg. = males -10.3, females -5.3

Government and international agency targets against cancer

• UK gov. targets - save 5000 lives a year, increase survival rates and reduce the gap in survival rates that currently exist between the UK and other EU countries, some of which have sig. lower GDP’s per capita than the UK

Direct strategies of gov. and international agencies to mitigate against cancer

• investment in advanced medical technology, e.g. more precise forms of radiotherapy, and diagnostic methods e.g. endoscopy for early diagnosis and intervention → diagnosing during stage 1 results in 91% survival rate

• mass screening for breast, cervical and bowel cancer is already well established and has proved highly effective - breast cancer screening detects around 19,000 cancers every year in the UK

• however, survival rates could be improved further by reducing waiting times between diagnosis and treatment and by giving more support to GPs in referrals to consultants - currently treatment begins within 62 days of a patients referral in the NHS

• cancer research focuses on improving understanding of the disease, developing new treatments, discovering new drugs and exploiting the potential of genetic engineering

Indirect strategies of gov. and international agencies to mitigate against cancer

• emphasises changes in lifestyle and cancer prevention

• education and health campaigns informing the public of the dangers of smoking, excessive drinking and sugary, unbalanced diets can reduce the incidence of preventable cancers

• The international Agency for Research on Cancer is part of WHO - conducts epidemiology and lab research into the causes of the disease

• Cancer UK is a charity that researches the prevention, diagnosis and treatment of cancer - funded by donations, legacies and charity events, it operates at hospitals and universities throughout the UK

• skin cancer has increased sig. in the past 3-4 decades and - rates of skin cancer so a rise of 3% each year

• the government has intervened by legislating to control the commercial use of sunbeds, with age limits for users, an standards of supervision and staff training - sunbeds est. to cause 440 malignant melanomas/year

• During the summer months, the Meteorological Office Advice regularly issues forecasts on UV intensities and safe limits of exposure - skin cancer is a preventable disease, which can be controlled by modifications of behaviour towards tanning