1. Higher: Development and Health POOR HEALTH, POVERTY & MALARIA

2. Success Criteria By the end of this section you should be able to: n List the factors which affect levels of malnutrition leading to a downward spiral of poverty and poor health. Describe and explain differences in the provision of safe water and sanitation particularly between urban and rural areas. Case Study Disease: Malaria n Describe the human and physical factors which contribute to the spread of the disease. n Describe the methods used to control the disease and comment on their effectiveness. n Describe primary healthcare methods used to improve health standards and explain why they are appropriate. Explain how disease prevention can benefit developing world countries.

3. There are six main geographical factors that help to determine the state of health of an area or country. CLIMATE WATER SUPPLY WEALTH NUTRITION REMOTENESS Let us look at each factor in turn;- SANITATION

4. CLIMATE Areas that are hot and wet encourage the spread of infectious diseases. These conditions often provide the ideal breeding conditions for the VECTOR - the host of the disease. Areas that are dry cause water supplies to be restricted and for people to congregate around the few supplies that are available, increasing the risk of contamination.

5. REMOTENESS Areas that are difficult to get to due to being mountainous or hard to traverse ( eg. deserts) or those that are physically a long way from the rest of the country, like Siberia, will of course get a raw deal when it comes to getting help. Getting there will be costly and add to the price of the aid being delivered. Supplies may take too long to get there or may be intercepted on the route.

6. WEALTH Developed countries can afford the four basics of good health- A balanced diet Clean water supplies Good housing Effective health care services. Developing countries cannot afford mass immunisation programmes or to educate their people on how to prevent disease.

7. NUTRITION Nutritional problems come in two broad categories: ‘Under’ and ‘Mal’ nutrition. Under nutrition is not getting enough food of any kind. This retards physical growth and limits human potential. It is also called starvation! Malnutrition is not getting a balanced diet. The sufferer may not die of this, but has a limited amount of energy to work, and is more prone to other diseases.

8. One day’s food for this Ethiopian woman.

9. 9 Causes of death, 2004

11. WATER SUPPLY In Developing Countries, on average 50% of people who lack access to adequate clean water supplies. This figure increases dramatically in rural areas. Why? It is easier to pipe water in urban areas and it gets to more people per km of pipe.

12. WATER SUPPLY A foreign aid project to pipe water to a town.

13. WATER SUPPLY In rural areas wells provide the water, and they can run dry easily. It is often a long distance to walk to get to a well, and women and children spend much of their day fetching water. This can also impact on their health.

14. SANITATION Related to the issue of clean water supplies is the lack of basic sanitation. Few people, even in urban areas, have access to sewerage system. Diseases caused by contact with sewage are common in both rural and urban areas.

15. Public latrines in Accra are squat plates with a trench underneath, shared by hundreds of people. The latrines lack sinks, running water and soap. People who can’t make it to a latrine may resort to squatting over a plastic bag, then tying up the excreta and tossing it into the household trash, or simply flinging it out a window. This method is known as the “flying toilet.” Open drains line the unpaved streets where children play. “You’ll see children kicking a ball, and if the ball lands in the drain, one of the kids will climb in, get the ball out and they’ll just keep playing with it,” Moe says, pointing to a photo of a little boy rummaging amid raw sewage in a drain (see above). Urban agriculture pops up in the slums wherever people can find a spot to grow a few vegetables. For irrigation, they dip containers into the drains and pour the water over the plants. “There are so many ways that people can be exposed to faecal material, it’s hard to know how to prioritize an intervention,” Moe says. “In our study, we’re trying to get information that will help policy makers develop the most effective solutions.” http://esciencecommons.blogspot.co.uk/2011/11/world-toilet-day-aims-to-make-splash.html Reinvent the toilet video http://www.youtube.com/watch?feature=player_embedded&v=fdwvuTrycYU

16. These problems can lead to a range of different diseases: WATER-BASED DISEASES WATER-BORNE DISEASES WATER-RELATED DISEASES DIET-RELATED DISEASES BEHAVIOUR-RELATED PROBLEMS These are not the only types but they are the most common.

17. WATER-BASED DISEASES These are spread by parasites living in the water and infecting an intermediary host/vector that gives us a disease. They can include;- The freshwater snail infected by a parasite that infects people and carries SCHISTOSOMIASIS (Bilharzia).

18. WATER-BORNE DISEASES These are spread by people using contaminated water;- Contaminated water – often with raw sewage- that allows bacteria to infect people using it, like CHOLERA or TYPHOID.

19. WATER- RELATED DISEASES These are where the organism which causes the disease lives in water for at least part of its life-cycle. Including: The mosquito that breeds in water and causes MALARIA.

20. DIET-RELATED DISEASES MALNUTRITION- Kwashiorkor is a disease linked to protein deficiency. The result is that physical growth particularly in children is retarded, hair may fall out, skin loses its colour leading to social stigma, it may fall out completely, and the stomach is greatly distended. Another example is rickets where the legs bow outwards at the knees due to weak bones not taking the weight properly. This is due to lack of vitamins C and D.

22. BEHAVIOUR-RELATED PROBLEMS People in Developed Countries suffer more from degenerative diseases linked to lifestyle, environment and technology. Lack of exercise is an important cause of ill health in Developed Countries, not releasing the stored energy we eat. Too much of the wrong types of physical work can create problems with joints, bones and muscles. Drug abuse, including alcohol and tobacco, and certain sexual behaviours can cause health problems.

23. MALARIA - Cause & Effects - Costs - Distribution/Spread/Risk Factors - Control - Effectiveness of Controls

24. MALARIA TODAY… n Number infected - 200 - 500 million people n Has killed nearly 50 million people in the last 15 years. n In the time it takes to say the word malaria, ten people, seven of them children, will have caught it. n Every 20 seconds, a child dies of malaria. n Those who survive can be re-infected and tend to suffer frequent reoccurrences. n Leaves suffers with a weakened immunity so prone to other diseases.

25. After dropping steeply between 1930 and 1970, malaria is now making a real comeback, especially in Africa, south of the Sahara, where 90% of all deaths occur.

26. Background The name comes from the Italian mal (bad) and aria (air) – it was originally thought the disease was spread by the damp air from swamps. The link between the disease and the female Anopheles Mosquito was first made by Ronald Ross, a Scottish army doctor, working in India.

27. AREAS AT RISK… Malaria is mainly a disease of the tropics. In many countries Malaria is Endemic which means always present (opposite of epidemic)

28. …with global warming, malaria may be closer than you think…

29. The Cause: INFECTION n You can catch Malaria from blood transfusions, n …or infected needles, n …or intra placentally i.e from a mother to the baby in her womb. n But by far the most common way is by being bitten by the female Anopheles Mosquito.

30. When the Anopheles Mosquito “bites”, it actually sinks a long, thin mouth part, the proboscis, into the skin. The mosquito then pumps saliva under the skin, to stop the blood clotting – so that it can drink uninterrupted! In the saliva is the main culprit, the Plasmodium, a single-cell blood parasite.

31. If the person is infected, then they will transfer the Plasmodium into the mosquito, which can then fly off and infect someone else. If the mosquito is carrying the Plasmodium, then it will transfer it to the victim’s bloodstream in its saliva.

34. Mosquito larvae hang from the surface tension of the water, breathing through their siphon tube.

35. Pupae ready to hatch into adult mosquitoes

36. An adult emerges, the males to look for plant nectar, the females for blood.

37. EFFECTS

38. Sudden onset of cold stage – patient shivers violently and turns blue with cold, even though his actual temperature is rising. Lasts about one hour… Hot stage – high temperature, headache, sickness and dizziness. Lasts several hours… Sweating stage patient soaked in sweat, but begins to feel better after 2-3 hours… Several days of weakness and slow recovery INFECTIONSeveral days of headaches and vague, flu-like pains of the body…

39. A remarkable close-up of destroyed red blood cells.

40. Falciparum malaria - blood vessels to the brain are blocked with dead red blood cells, starving the brain of oxygen. Coma or death will follow rapidly.

41. Most at risk are the very young, who have not yet developed any degree of natural immunity… …along with pregnant women, whose immune system is weakened.

42. A young victim of Falciparum Malaria

43. …and another

44. Without rapid medical help, many of these children will die: currently one every 30 seconds or less.

45. Adult victims will have repeated attacks for many years, unless treated. When ill, they cannot work.

46. THE COSTS n The huge cost in terms of human suffering: 1 – 3 million deaths a year. Hundreds of millions ill. n Massive impact on attendance of children at school and as a result education suffers. n Large numbers unable to farm their land or collect in the harvest. The harvest coincides with the peak biting season for mosquitoes.

47. THE COSTS n Enormous financial cost to families to buy anti malarial medicines. In some cases 25% of their annual income - this is on top of paying preventative costs and lost income. n Over $2 billion dollars spent on fighting the disease in Africa alone, money which could be spent on development. n Africa’s GDP would be $100 billion greater if malaria had been wiped out thirty five years ago. n Tourists and foreign investors avoid malaria ridden areas.

48. MALARIA - Cause & Effects - Costs - Distribution/Spread/Risk Factors - Control - Effectiveness of Controls

49. Distribution/ Spread/ Risk Factors

50. ENVIRONMENTAL n The presence of Anopheles mosquitoes. n The presence of the plasmodium, in either the mosquitoes or human population. n A warm, humid climate - temperatures between 16°C and 40°C and abundant rainfall. n Areas of still/standing water. Only a tiny area of water is needed for mosquitoes to breed. n Vegetation nearby to provide shade for the mosquito during the day whilst it digests the blood meal from the night before.

51. HUMAN n Poor water supply and sanitation – meaning people have to collect water from ponds and lakes. n People working in the fields, in irrigation ditches, near or on lakes and at reservoirs. n Migrants moving into and out of malarial areas – clearing land, looking for work, refugees etc. n People (and mosquitoes!) travelling abroad, especially by air; airport malaria.

52. Ideal breeding grounds for mosquitoes – still, shallow water.

53. Mosquito larvae at the edge of a pool.

54. Mosquitoes will breed in small puddles, even in animal hoof prints, empty cans and bomb craters.

55. A high risk area – people, vegetation cover and standing water during the wet season.

56. Collecting water, an essential fact of life for millions of people, poses real risks of being bitten. However, you cannot catch the disease by drinking water containing larvae.

57. Poor housing, like this shanty, offers little protection.

58. CONTROLLING MALARIA

59. 3 Areas of Control 1. Against the adult mosquito; 2. Against the eggs and larvae; 3. Against the Plasmodium - treating victims

60. 1. AGAINST ADULT MOSQUITOES INSECTICIDE TREATED BED NETS (VERY SUCCESSFUL) INSECTICIDE TREATED BED NETS (VERY SUCCESSFUL) GENETIC ENGINEERING (VERY LIMITED SUCCESS) GENETIC ENGINEERING (VERY LIMITED SUCCESS) DDT MALATHION STERILE MALES INSECTICIDE SPRAYS (SUCCESSFUL…BUT) INSECTICIDE SPRAYS (SUCCESSFUL…BUT)

61. Insecticide sprays are very efficient, but there are several drawbacks: 1.They are relatively expensive, often beyond the means of poor villages; 2.Sprays must be applied repeatedly for long-term effectiveness.; 3.They may contaminate water and crops. Insecticide sprays are very efficient, but there are several drawbacks: 1.They are relatively expensive, often beyond the means of poor villages; 2.Sprays must be applied repeatedly for long-term effectiveness.; 3.They may contaminate water and crops. 4. Most importantly, mosquitoes can quickly develop immunity to the spray.

62. The effect of stopping the use of DDT in Sri Lanka (Ceylon). Was the banning of DDT one of the costliest mistakes of all time? One estimate suggests that 50 million children have died of malaria since the use of DDT was greatly reduced in the 1960s.

63. A simple mosquito net may mean the difference between life and death…

64. …even better if they are dipped in insecticide, as in this Kenyan village. The normal chemical used for ITNs (Insecticide Treated Nets) is Permethrin, which is harmless to humans, but deadly to mosquitoes. Several African countries are trying to get more people to use these nets, by removing tax on them, reducing their cost.

65. 2. AGAINST EGGS AND LARVAE PHYSICAL CHEMICAL BIOLOGICAL DRAINING BREEDING SITES FLUSHING BREEDING SITES PLANTING EUCALYPTUS TREES SPRAYING WITH LARVICIDES ADDING OIL, EGG WHITES OR MUSTARD SEEDS ADDING FISH TO PONDS AND PADI FIELDS ADDING Bti IN COCONUTS

66. PHYSICAL CONTROL Draining breeding places: because mosquitoes need so little water in which to lay their eggs, it can be virtually impossible to find and drain them all. Flushing out breeding sites by weekly release of water can drown the larvae, but can only be done in suitable areas and where there is surplus water. Planting Eucalyptus trees to absorb excess water from the soil helps drain breeding sites.

67. BIOLOGICAL CONTROL Adding larvae-eating fish, such as the Muddy Loach, to padi fields and pools, can clear them of larvae within a day.

68. BIOLOGICAL CONTROL - Bti The bacteria Bti (Bacillus Thuringiensis Israelensis !!!) can be incubated in coconuts, where it multiplies. The coconuts are then broken open and thrown into pools, where the bacteria are eaten by the mosquito larvae. They kill the larvae by destroying its gut. Spraying Bti from a boat The incubation stage Adding to pools

69. BIOLOGICAL CONTROL - Bti You can even buy Bti over the counter in the U.S.

70. BIOLOGICAL CONTROL – Oil, Egg Whites & Mustard Seeds Mustard Seeds – become wet and sticky and drag the mosquito larvae under the water, drowning them. Spraying egg white or oil on the surface of the water to clog the breathing tubes of the larvae.

71. 3. AGAINST THE PLASMODIUM… An ingredient of Tonic Water (check in the supermarket), Quinine was often taken with Gin to mask its bitter taste. However, you would need to drink about 25 Gin and Tonics a day to get the recommended dose. 1.Quinine: Originally extracted from the bark of the South American Cinchona (Fever Tree), it was for a long time the main anti malarial drug.

72. AGAINST THE PLASMODIUM… 2. Chloroquine: Now the most common anti malarial drug, but, like Quinine, becoming ineffective as the Plasmodium mutates and becomes immune to it.

74. ..AGAINST THE PLASMODIUM 3. Artemisia (Wormwood): Used as an anti malarial herbal remedy by the Chinese for hundreds of years (known there as Qinghaoshu), it was “rediscovered” during the Vietnam war and may prove to be a major weapon in the fight against malaria, as plasmodium do not seem to become immune to it.

75. VACCINATION At the moment, there is no effective vaccine against malaria, although scientists all over the world are trying to develop one.

76. The search goes on to try to find a vaccine: the Bill Gates Foundation recently donated more than $168 million towards malaria research, most of that to find an effective vaccine available to all.

77. ROLL BACK MALARIA Started in 1998, Roll Back Malaria is a global programme aimed at halving the world's malaria problem by 2010. It is a coordinated attempt involving the WHO, UNICEF, the World Bank and many governments and scientific and medical experts across the world. Started in 1998, Roll Back Malaria is a global programme aimed at halving the world's malaria problem by 2010. It is a coordinated attempt involving the WHO, UNICEF, the World Bank and many governments and scientific and medical experts across the world.

78. Who…? International Organisation WHO is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, health research, setting standards, providing support to countries and monitoring health trends. Launched a campaign to eradicate Malaria in 1950s and 1960s. Drugs Insecticides to kill the mosquito Success? Overall a Failure Expensive for poor countries to buy insecticides Mosquito became resistant to the chemicals and drugs used. India WHO reduced cases from 75 million in 1950 to 1 million in 1960 But… Now more than 2 million people have the disease and it is on the increase.

79. The WHO also employs scientists to find better ways of curing and preventing malaria. They developed DDT then Deildrin (when DDT became less effective and was banned in many places due to environmental damage) Genetic Engineering – like introducing sterile male mosquitoes to reduce breeding Developed fish that eat mosquito larvae But… only £40 million is spent per year on research into Malaria – compare this to £600 million spent on AIDs research.

80. “The Red Cross is uniquely placed to tackle some of the problems affecting poorer nations. Through our volunteers and staff in 186 countries, we address everyday health and social care needs in the communities we work in. Our aim is to give people the skills and knowledge to help them address their own problems. We teach people how to provide first aid to save an injured family member and give information on how to prevent HIV and other diseases.” The Red Cross (an Aid Agency) Provide emergency help (drugs, nurses…) when an epidemic of Malaria occurs. But also believe that prevention is better than cure so provide long term medical help. Primary Health Care (PHC) - take someone from each village and train them – the person then returns and educates everyone else in the village on health matters. That person becomes the Village Health Worker.

81. Healthcare at the most basic level of necessity. Local people are trained as part time medical auxiliaries – BAREFOOT DOCTORS. Advice on how diseases eg. Malaria are spread and low cost ways of reducing the diseases: 1.Persuading people to use mosquito bed-nets 2.Covering water containers 3.Filling in puddles and draining some breeding grounds 4.Reducing visits to the river at times when mosquitoes are more likely to be present. Healthcare at the most basic level of necessity. Local people are trained as part time medical auxiliaries – BAREFOOT DOCTORS. Advice on how diseases eg. Malaria are spread and low cost ways of reducing the diseases: 1.Persuading people to use mosquito bed-nets 2.Covering water containers 3.Filling in puddles and draining some breeding grounds 4.Reducing visits to the river at times when mosquitoes are more likely to be present. PRIMARY HEALTH CARE

82. Success or Failure? Primary Health care can be very effective because it: - involves the local people (locals are more likely to listen to, and trust, one of their own people instructing them, rather than an outsider). - cheap methods are used which are affordable by the villagers. Success or Failure? Primary Health care can be very effective because it: - involves the local people (locals are more likely to listen to, and trust, one of their own people instructing them, rather than an outsider). - cheap methods are used which are affordable by the villagers. PRIMARY HEALTH CARE

83. Success or Failure? However, many schemes have run in to financial difficulties burdened with debt repayments. In other areas schemes have been destroyed by Civil War or Natural Disasters. Many are now reliant on funding from charities. Success or Failure? However, many schemes have run in to financial difficulties burdened with debt repayments. In other areas schemes have been destroyed by Civil War or Natural Disasters. Many are now reliant on funding from charities. PRIMARY HEALTH CARE

84. OVERALL SUCCESS OR FAILURE? n At the moment there is no doubt that the battle against malaria is being lost. n This is mainly due to the ability of mosquitoes to develop immunity to insecticide sprays… n …and to the parasites ability to develop resistance to drugs n Ongoing issue of cost. n At the moment there is no doubt that the battle against malaria is being lost. n This is mainly due to the ability of mosquitoes to develop immunity to insecticide sprays… n …and to the parasites ability to develop resistance to drugs n Ongoing issue of cost.

85. Exam Advice n Practice this topic using past papers – the questions don’t vary that much from year to year. n Concentrate more on the Risk Factors, Costs and the Solutions, less on the cycle of infection and medical symptoms of the disease. n You must be able to comment on the effectiveness of your chosen solutions, but don’t just say “very effective” for them all and hope to get marks – the markers will be looking for detailed knowledge of the effectiveness of each solution you quote. n Try to learn a few (four or five) solutions in detail and be able to quote names of pesticides, drugs, etc. n Practice this topic using past papers – the questions don’t vary that much from year to year. n Concentrate more on the Risk Factors, Costs and the Solutions, less on the cycle of infection and medical symptoms of the disease. n You must be able to comment on the effectiveness of your chosen solutions, but don’t just say “very effective” for them all and hope to get marks – the markers will be looking for detailed knowledge of the effectiveness of each solution you quote. n Try to learn a few (four or five) solutions in detail and be able to quote names of pesticides, drugs, etc.

86. 5. KEY REVISION POINTS n Anopheles Mosquito; n Plasmodium (e.g. Plasmodium Falciparum); n Humid climate; 16-40ºC, abundant rainfall; n Vegetation for shade; n Areas of still or stagnant water; n Humans to act as blood reservoir. n Anopheles Mosquito; n Plasmodium (e.g. Plasmodium Falciparum); n Humid climate; 16-40ºC, abundant rainfall; n Vegetation for shade; n Areas of still or stagnant water; n Humans to act as blood reservoir. (i) – THE PROBLEM

87. 5. KEY REVISION POINTS n 1-3 million deaths each year, mostly children; n Lost education through bouts of illness; n Lost productivity by adults, especially at planting and harvest time – less food, lower income; n Huge amount spent on trying to prevent or control malaria - $2 Billion in Africa each year, maybe $100 Billion damage to Africa’s GDP; up to 25% of family income; huge burden on health services; n Negative impact on foreign investment and tourism. n 1-3 million deaths each year, mostly children; n Lost education through bouts of illness; n Lost productivity by adults, especially at planting and harvest time – less food, lower income; n Huge amount spent on trying to prevent or control malaria - $2 Billion in Africa each year, maybe $100 Billion damage to Africa’s GDP; up to 25% of family income; huge burden on health services; n Negative impact on foreign investment and tourism. (ii) THE EFFECTS

88. 5. KEY REVISION POINTS n DDT, Malathion; n Genetic engineering – sterile male mosquitoes; n ITNs – Insecticide Treated Bed nets; n Draining and flushing breeding sites; n Larvicide sprays to kill larvae; n Oil, egg whites and mustard seeds; n Bti, Fish (Muddy Loach), Eucalyptus trees; n Quinine, Chloroquine, Artemisia; n No effective vaccines yet - several on trial; n World Health Organisation campaign – Roll Back Malaria. n DDT, Malathion; n Genetic engineering – sterile male mosquitoes; n ITNs – Insecticide Treated Bed nets; n Draining and flushing breeding sites; n Larvicide sprays to kill larvae; n Oil, egg whites and mustard seeds; n Bti, Fish (Muddy Loach), Eucalyptus trees; n Quinine, Chloroquine, Artemisia; n No effective vaccines yet - several on trial; n World Health Organisation campaign – Roll Back Malaria. (iii) – THE SOLUTIONS

89. Referring to a disease that you have studied in the developing world, explain in detail the main causes of the disease(5 marks) Malaria is actually caused by a tiny parasite that enters a person’s bloodstream. The disease is spread by the female anopheles mosquito and so is found where this insect lives. The mosquito picks up the parasite from an infected person and then passes it on when it bites someone else. There are a number of physical conditions that the mosquito prefers such as warm, humid conditions and areas of still, standing water like lakes and puddles where it can breed. These conditions are mainly found in tropical areas and especially in large parts of Africa. Humans can also contribute to the spread of malaria. People have built dams (still water) to help with irrigation giving mosquitoes more places to breed. People also migrate much more now and even tourists can pick up and spread the disease by visiting infected areas. Note: this is an Int 2 Q & A

90. Explain the consequences of Malaria on the population in economically less developed countries.(5 marks) Malaria affects people of any age and can cause death or long periods of illness. If people are ill for long periods of time they can fall into the Vicious Cycle of Disease (see below). (quick sketch of diagram) If they are ill, they cannot work; if they cannot work they are more likely to be poor and unable to afford food and medicines. Without food and medicine they become weak and then are more likely to catch malaria or other diseases. Also, relatives may also be unable to work as they are looking after sick family members. Malaria is expensive to treat. If there was no malaria, the Government could spend the money on developing the country like building roads, schools and hospitals. Malaria can also have an impact on school attendance. If children catch the disease they will miss long periods of school and so miss out on their education. Note: this is an Int 2 Q & A

91. Describe the measures taken to control malaria and indicate how effective they have been. (5 marks) There are many ways that have been used to try and control malaria. One way is to use drugs to kill the parasite once people have become infected. This method was initially successful in reducing the disease but the parasite has become resistant to the drugs and the medicines are expensive. The mosquito that spreads the disease can also be controlled by spraying insecticides (like DDT) in peoples’ homes and over breeding grounds. This method was used by the WHO in the 1950s and 1960s. Again this was successful for a while but the mosquitoes have become resistant to the sprays, the insecticides are expensive and the environment can become polluted with the sprays. The best way to control malaria is by educating people. The Red Cross train people in PRIMARY HEALTH CARE. Local people then go back to their village and educate people about using mosquito nets and draining mosquito breeding grounds. This method is most effective because it is cheap and local people are more likely to trust someone from their village and not an outsider. However overall the battle against malaria is not being won as more than 400 million people still suffer from the disease. Note: this is an Int 2 Q & A