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Human Population Movement and Malaria Transmission Perspectives Malaria on the Move: Human Population Movement and Malaria Transmission Pim Martens and Lisbeth Hall Maastricht University, Maastricht, the Netherlands Reports of malaria are increasing in many countries and in areas thought free of the disease. One of the factors contributing to the reemergence of malaria is human migration. People move for a number of reasons, including environmental deterioration, economic necessity, conflicts, and natural disasters. These factors are most likely to affect the poor, many of whom live in or near malarious areas. Identifying and understanding the influence of these population movements can improve prevention measures and malaria control programs. Malaria, the world’s most prevalent vector- reintroducing disease. Population movement is borne disease, is endemic in 92 countries, with also increasingly implicated in the spread of drug pockets of transmission in an additional eight resistance in malaria (5). countries (1). Approximately 41% of the world’s The unprecedented increase in mobility in population is at risk, and each year 300 million to the last few decades has led to greater concern 500 million clinical cases of malaria, >90% of about the relationship between mobility and them in Africa, are reported. Worldwide, malaria. There are a number of reasons for approximately 2 million deaths per year can be increased mobility. First, sophisticated forms of attributed to malaria, half of these in children transport now permit the swift movement of under 5 years of age. people over huge distances. Air travel has Historically, population movement has con- increased by almost 7% a year in the last 20 years tributed to the spread of disease (2). Failure to and is predicted to increase by >5% a year during consider this factor contributed to failure of the next 20 years (6). Second, in the developing malaria eradication campaigns in the 1950s and world a rapidly increasing population is putting 1960s (3). The movement of infected people from pressure on scarce resources, leading to major areas where malaria was still endemic to areas population redistribution. This particularly where the disease had been eradicated led to involves the movement from rural to urban areas. resurgence of the disease. However, population Third, natural disasters such as droughts and movement can precipitate or increase malaria floods have created approximately 25 million transmission in other ways as well. As people environmental refugees (7). Finally, conflict, move, they can increase their risk for acquiring often a result of population pressures and the disease through the ways in which they environmental degradation, displaces vast num- change the environment and through the bers of people. We examine the impact of technology they introduce, for example, through population movement on malaria transmission. deforestation and irrigation systems (4). Such activities can create more favorable habitats for A Typology of Population Movement Anopheles mosquitoes; at the same time, workers The decision-making process leading to may have increased exposure to the vector. population movement can best be understood in Furthermore, people can inadvertently transport the light of “push and pull” forces (8). When their infectious mosquitoes to malaria-free areas, needs can no longer be met in a particular environment, people move elsewhere. The “push factor” could be environmental degradation, Address for correspondence: Pim Martens, International population pressure on land, droughts, famines, Centre for Integrative Studies, Maastricht University, P.O. Box 616, 6200 MD Maastricht, the Netherlands; fax: 31-43- conflict, or loss or lack of employment. When 388-4916; e-mail: [email protected]. people are satisfied with their situation but Vol. 6, No. 2, March–April 2000 103 Emerging Infectious Diseases Perspectives believe that a move elsewhere will provide new Based on the above definitions, a typology can and attractive opportunities, a “pull factor” is be devised that identifies categories of population involved. This pull factor could be better political, movement. Different activities can be associated economic, or social opportunities or improved with these categories, and these activities, in living conditions. Push and pull factors can turn, can be associated with differing risks for operate simultaneously; for example, people can malaria transmission. All types of population be pushed by environmental deterioration and movement can be accommodated in this typology, scarce resources and pulled by the economic and people may exhibit more than one type of opportunities offered by development projects. mobility. Population movements can be differentiated by their temporal and spatial dimensions. Population Movement and Malaria Temporal dimensions include circulation and In developing countries, activities involving migration. Circulation encompasses a variety of population movement include urbanization, movements, usually short-term and cyclical and colonization, labor related to agriculture and involving no longstanding change of residence. mining, and conflict. In industrialized countries, Migration involves a permanent change of the impact of population movements on malaria residence (9). Circulation can be subdivided into risk is mainly related to intercontinental travel. daily, periodic, seasonal, and long term (Table) (9). In some regions, malaria risk may increase as Daily circulation involves leaving a place of a result of a combination of different forms of residence for up to 24 hours. Periodic circulation mobility, as well as other factors unrelated to may vary from 1 night to 1 year, although it is population movements. For example, in the usually shorter than seasonal circulation. African highlands, many of the issues described Seasonal circulation is a type of periodic below act concurrently (10). The categorization of circulation in which the period is defined by the various examples below simplifies a complex marked seasonality in the physical or economic issue but is useful for indicating major processes environment. This type of circulation involves related to mobility and malaria risk. persons or groups who are absent from their permanent homes during a season or seasons of Urbanization the year. Long-term circulation, defined as The world’s urban population is growing at absence from home for longer than a year, affects four times the rate of the rural population (11). groups such as wage laborers and traders, who Urban pull is prevalent throughout the developing maintain close social and economic ties with their world, with rural-to-urban migration taking place home area and intend to return. faster than ever before (12). Sub-Saharan Africa is In terms of spatial dimensions, the movements the most rapidly urbanizing region in the to and from malarious areas are of epidemiologic world (13), and the urban population in India has importance. People who move can be categorized as doubled in the last 2 decades (14). When either active transmitters or passive acquirers (2). accompanied by adequate housing and sanita- Active transmitters harbor the parasite and tion, urbanization can lead to a decrease in transmit the disease when they move to areas of malaria through reductions in human-vector low or sporadic transmission. Passive acquirers contact and vector breeding sites. However, in are exposed to the disease through movement developing countries, rapid, unregulated urban- from one environment to another; they may have ization often leads to an increase in or resumption low-level immunity or may be nonimmune, which of malaria transmission because of poor housing increases their risk for disease. and sanitation, lack of proper drainage of surface Table. A typology of population movement (adapted from [2]) Circulation Daily Periodic Seasonal Long-term Migration Commuting Trading Fishing Laboring Urbanization Trading Pilgrimage Pastoralism Colonization Refugees Cultivation Mining Laboring Colonization Wood-cutting Tourism Emerging Infectious Diseases 104 Vol. 6, No. 2, March–April 2000 Perspectives water, and use of unprotected water reservoirs that humans to mosquitoes. Activities to develop an increase human-vector contact and vector breeding. area, such as deforestation and irrigation, can Although water pollution in urban areas increase the number of vector breeding sites, usually leads to decreases in vector populations, contributing to an increase in malaria. Coloniza- some vectors, such as An. arabiensis in the forest tion may be accompanied by major building belt of West Africa, may adapt to breeding in projects, such as dams, canals, highways, or polluted waters (15). In Asia, An. stephensi is mining activities—referred to as the tropical proving adaptable to urban conditions, and in aggregation of labor—which can further enhance India it is a well-established vector of urban malaria transmission. malaria. In urban areas of India, water is not Reemergence of malaria through mobility supplied regularly and is stored in houses, related to colonization occurred in Brazil. Malaria providing extensive breeding places for had been practically eradicated from most areas An. stephensi in overhead tanks and cisterns. In of the Amazon region by the national malaria periurban areas, where 25% to 40% of the urban campaign in the 1950s and 1960s (16). Since the population live in poor housing without proper 1960s, however, the incidence of malaria has water supply and drainage, another
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