Approaches to endemic and infectious disease

As cities in the developing world grow, slums become more densely packed, exposing residents to unsanitary conditions and increasing the risk of contracting infectious disease. Endemic diseases such as dengue fever, swine flu, malaria, and tuberculosis spread quickly, overwhelming limited health services and infrastructure. With health care facilities remote or non-existent, medication unavailable or unaffordable, health knowledge shaky, and caregivers in short supply, how can informal communities keep contagion in check? Read on for solutions from Mumbai, Nairobi, Jakarta, São Paulo, and Mexico City.



Carlin Carr, Mumbai Community ManagerRainy season brings public health risks to Mumbai

Carlin Carr, Mumbai Community Manager

Monsoon clouds moved over Mumbai last week, opening up into a deluge. It's the start of the rainy season in India — a welcome relief from the summer heat and a time to recharge water levels that had dropped to drought levels. While most people celebrate the wet months ahead, the season also brings with it a number of public health and safety hazards. Malaria is among the deadly diseases that raise alarms for public health officials, and it is slum dwellers who are most widely affected.

Malaria is spread through the bite of the ubiquitous female Anopheles mosquito. These mosquitoes breed in stagnant water where drainage is often clogged. The slums areas of Mumbai are always hardest hit. While some precautions include taking anti-malarial drugs, spraying with repellent or using mosquito nets, these are rarely options for the poor. A study on malaria interventions in Mumbai slums found that in the Parel slum, a central part of the city, 90 percent of slum dwellers live below the poverty line and cannot afford preventive measures against malaria.

While malaria remains a perennial issue, city officials launched a targeted intervention in 2009 that has become a model for other Indian cities. Numbers prove its success: there were 198 deaths due to malaria in 2009; dropping to 145 in 2010; 69 in 2011; and 45 in 2012. According to a Times of India article, the city has created a booklet documenting the approach and an awareness-raising film. "The BMC [Mumbai's city government] adopted a multi-pronged approach to deal with malaria, with focus on slums and construction sites, door-to-door screening, regular fogging and keeping tabs on malaria patients to ensure they underwent the entire treatment so that there was no relapse," says the article from earlier this year.

Malaria is not the only concern; officials have seen a rise in dengue during the rainy season as well. Municipal commissioner Sitaram Kunte said that their focus will now turn to combating this other mosquito-borne illness using the malaria model: "We carried out extensive house-to-house screening programs to keep a check on malaria; similar steps will be taken for dengue. Societies who don't follow the BMC guidelines will be penalized."

In addition, the city needs to ensure that storm drains are cleaned to avoid water logging. While officials has ensured civic organizations that it has taken the necessary measures to prepare the city, experience has proven otherwise. In just the first few days of the monsoon, flooding was rampant.

Monsoon-related illnesses know no boundaries. And while slum areas are most adversely affected, the entire city is on watch. Mumbai's anti-malaria program shows that proactive interventions can not only prevent infections but can also quickly deal with cases that come in. Most importantly, the city has seen how one program can be adapted to lessen the impact of other diseases, with life-saving results.

Photo credit: Dinesh Bareja



I found it discussion about endemic and infectious disease is very interesting in term of collaboration between government and community to overcome the problem. Any national movement or campaign when it combined with community work most of the time will work very well as happened in Indonesia, India and Mexico, or as in Nairobi even though first initiative came from private Clinic.

However, looking at how fast urbanization in cities like Indonesia or else where, it needs to find new formula to cope with endemic or infectious disease because there might be infrastructure of resources gap. For example, Indonesia at the moment experience fast urbanization at the sub-district level with inadequate city infrastructure support. The consequence is that many of these people are lack of access to basic health or housing and many lives in informal settlement and disease spread easily in those areas. This is going to be challenge for district government especially after decentralization took place few years back.

In addition, I really interested in Catalina stories, as we have similar issue this time. I would like to know more about the fact that the city trained 6000 community health agents. Can you explore more about this, are they volunteer? And how they recruited? Is it sustainable? Do they receive incentives? If so, who pays? I am asking because in decentralized system like Indonesia have, any expenses would be on local government, and national government will only support some part of the program.

widya anggraini

Hi Widya, there are in fact various similarities in terms of responses against dengue fever in both Jakarta and São Paulo, especially regarding joint efforts by the local government and communities.

Regarding your questions on community health agents in São Paulo, I must start by saying they aren’t volunteers, but workers from the municipal health network. They perform a key role in providing information to low income communities about various health issues, from infectious diseases to family planning. These agents are usually original from the same communities they work for in order to ensure they know well their neighborhoods and their people. These workers are paid by the local government, more specifically from the Municipal Health Secretariat’s budget. Unfortunately their income isn’t very high and providing a better salary is actually a key challenge, especially if the intention is to ensure quality and timely provision of health information and support to the city’s poorer communities.

As basic service provision of most urban and social services (including health) is a municipal/city responsibility in Brazil, I must clarify that this decentralized scheme isn’t particular to São Paulo, but it is common to most municipalities in Brazil.

Las enfermedades contagiosas son un reto para los sistemas de salud por le riesgo de convertirse en pandemias; lo cual pone aprueba la capacidad para responder a las necesidades de la población. En el caso del Distrito Federal la capacidad de las clínicas públicas se vio rebasada para atender y brindar tratamiento a las personas con la enfermedad de la influenza AH1N1, así como desarrollar en el momento la vacuna contra el surgimiento de un nuevo virus. La población en el Distrito Federal respondió de manera reactiva ante la amenaza por medio del abastecimiento en el sector privado; los geles antibacteriales, cubre bocas y el medicamento para el tratamiento de la influenza se agotaron en las farmacias y supermercados. Ante el caos de una enfermedad contagiosa es mucho más complejo operativamente y más costoso desarrollar estrategias de atención de emergencia que invertir en sistemas de prevención que eviten llegar a estados de emergencia con sistemas de salud rebasados. En este sentido, las campañas de vacunación e informativas son un aliado para que la población esté alerta y prevenga el contagio masivo de enfermedades. Por lo anterior el involucramiento de la sociedad civil es una herramienta para consolidar y fortalecer dicho plan.

Katy, it's really tragic to see that people around the world continue to die of TB when it is such a curable (and even preventable) disease. In Mumbai, the rickshaws often have stickers on the back that admonish spitting because it spreads TB. Many, many people chew tobacco and spitting is prevalent. These types of simple awareness-raising campaigns have become a big part of the government's approach to prevention. On the early detection side, one of the issues is that many people go to the local pharmacist with what they think is a common cold cough when, in fact, it is more serious. The pharmacists are not trained to detect TB, so they misprescribe. One initiative that they've started here is to train pharmacists to be aware of the signs of TB and refer patients to doctors and clinics. These seem like promising approaches that would have great appeal in other cities. Have you seen any innovative awareness-raising programs in Nairobi?

Hi Carlin, every year on World TB day (in March, not quite sure of the date), there are TB related campaigns in Nairobi. A few years ago I believe a march was organised through Kibera in order to raise awareness amongst residents of the gravity of the disease. The "Stop TB in my lifetime" campaign, in line with a push to eliminate TB globally by 2050, is also in its second year here. However unlike in India, apparently there is no large-scale campaign underway which uses billboards and or stickers to get the message out to everyone.
Also in many communities there is actually stigma attached to contracting TB and people often prefer not to share the information with their close ones potentially putting them at risk. This problem is especially prevalent amongst the Somali community in Nairobi and Dr Kerrow explained that women often wait until its very late before coming in to get tested.

Katy Fentress
URB.IM - Nairobi Community Manager

Katy, thanks for sharing some of the challenges faced by communities throughout Nairobi in the fight against TB. You mentioned the treatment lasts a minimum of 8 months, and I was wondering about the treatment cycle itself; is it just medicine that is provided to the patient or does it require any additional intervention or follow up? Are medicines easily accessible?

I also wonder how patients are encouraged to come back for check-ups. Maybe the main challenge here, as with many other diseases, is about finding adequate and direct ways of communicating the risks of the disease to vulnerable populations and providing incentives for periodic checkups and early detection. Any thoughts regarding these issues?

Hi Catalina, I have passed on your question to MSF staff themselves because I felt they could give you a more thorough answer than me.
To the best of my knowledge most of the TB medecine at the Blue House is in fact provided free of charge by the Kenyan government. I believe it is mainly a question of taking the right course of antibiotics for the right period of time (I am not familiar with the specifics of how it is different to treat a TB patient that also has HIV).

With regards to checkups I know that staff at the Blue House encourage people to come back and as I mentioned in the article they do treat any cough as suspicious. However, due to the stigma that I previously mentioned to Carlyn, I don't know how much people actually encourage each other to go and treat coughs as potentially dangerous. While prevention is of course better than cure, it is very hard to envisage how exactly a prevention campaign could be put into action when one of the main reasons for contagion or the very issues that characterises the existence of many people in a place like Mathare: lack of sanitation and cramped, airless sleeping quarters.

Katy Fentress
URB.IM - Nairobi Community Manager

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