POLICY BRIEF. Small bugs, big issues: vector-borne disease in the age of mobility and climate change INTRODUCTION 1

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1 Small bugs, big issues: vector-borne disease in the age of mobility and climate change Policy implications of findings on malaria and its sociopolitical drivers in Greece February 2016 INTRODUCTION 1 Vector-borne disease: a reemerging threat in Europe 1 Controlling disease is a social challenge Disease also creates social vulnerability The risk of vector-borne epidemics has increased in Europe, as invasive mosquito species (of the Aedes genus) are establishing in areas that previously have been unsuitable or unreached by them, and as local mosquitoes (of the Culex or Anopheles genus) spread faster and in times of the year when they are not expected. The intensified movement of materials, animals and people across the globe, has contributed to changes in the geographical presence of both insects and pathogens. Climate change impacts have also played a significant role in creating conditions favorable to the spread of such diseases, in areas before considered risk-free (i.e. increased average temperatures, disrupted seasons, weather extremes). The vector-borne diseases in the focus of attention during the last 10 years in Europe include: West Nile fever, malaria, Dengue fever, and Chikungunya. The successful prevention of infectious diseases remains a core challenge worldwide, despite biomedical advancements of treatment and control. The absence of coordinated institutions to monitor, document and control epidemics in a timely way are major factors in this challenge. Apart from the complex physiologies of insects and pathogens, however, attention also needs to be paid to the socio-economic factors that define the spread of disease, such as income inequality, social exclusion, inaccessible healthcare services, and the barriers people face in reaching relevant information around prevention strategies. Vulnerability to disease is subject to social inequality, making the latter an urgent target in the design of prevention policies. Epidemics can spark or worsen social marginalization of minority groups, when the latter are stigmatized as associated to disease and its spread. Vicious circles of health vulnerability and social exclusion not only cause tears in the social fabric, they also disallows disease control. Institutional and ecological factors exacerbating epidemics are thus not independent from, but contingent to the socio-political context within which such vicious circles operate. These connections are here explored, in order to better understand and prevent circumstances under which disease threatens public health, social cohesion, 1 A (re-) emerging infectious disease is one already known but spreading to new geographic areas, new populations, or reappearing after having been eradicated. Mosquitoes are popular carriers (vectors) of such diseases passing it from person to person and from place to place.

2 2 equality and justice. Policy recommendations include flexible and inclusive measures that will avoid marginalising vulnerable populations (including migrants) in ways that are likely to leave them untreated and invisible in the health system. KEY OBSERVATIONS Malaria & migration in Greece: a false link Greece was declared malaria-free in 1974, only sporadically reporting locally acquired (domestic) cases but, notably, maintaining a number of around imported cases annually since. In recent years, the domestic cases have increased significantly, peaking in 2011 and gradually falling in subsequent years. Table: number of malaria cases reported in Greece (data from the Hellenic Centre for Disease Control and Prevention - HDCD) Year Reported as imported cases Reported as domestic cases Total of cases The main malaria hotspot identified in the country, the case study of this research, is an agricultural area at the Evrotas River Delta, in Southern Peloponnese. A coastal wetland, with 105km of irrigation canals for the cultivation of oranges, the area is extremely favourable to mosquitos. However, a number of other areas in the country are malaria-prone (Marathonas, Euvoia, Trikala, Larisa, Evros), most of which are highly agricultural. A common denominator of these areas is the presence of land workers from malaria endemic countries. This fact, however, has been misrepresented as a cause of disease. Although 78% of the cases during in Greece have been migrant patients, there is no conclusive evidence of whether the disease was contracted before or after leaving their country of origin. Considering the circumstances migrants encounter during border crossing, and while living and working in Greece, both assumptions could be true. Greek state authorities and large part of the media, have presented epidemiological information disaggregating statistics on the basis of nationality and emphasizing migration as the cause of disease, thus stigmatizing an already vulnerable social group. Health and ethical sacrifices for saving the economy The background of the outbreak has been one of climaxing economic crisis. Austerity measures impinged on the quality of public health services and social welfare was overall crippled during the years malaria was on the rise. Medical supplies for its diagnosis and treatment were not available in local hospitals when needed, many public doctors across the country failed to report incidences to HCDC due to work overload, while also the funds available for preventive

3 3 mosquito control were shrinking. All this has contributed to late institutional reactions, allowing disease to get out of control within 3 years. In 2011, certain areas of Greece were on the verge of being listed malaria endemic. The consequences of such red-flagging were feared to be grave for the economy, mostly affecting the tourist sector. With the lack of a proper action plan in place, the state was on reactive alert, mobilizing resources and taking ad-hoc measures, including the preventive mass treatment of all immigrants in the region of Evrotas. The desired results were obtained, but ethical questions concerning the selective treatment on basis of nationality, as well as seeking-consent procedures before providing treatment - particularly in a context of fear of detention or deportationwere never questioned in public. People as factors : feeding exclusionary and xenophobic reactions The invisibility of migrants: a double-edged sword The on-going period of crisis in Greece has seen the rise of extreme-right ideology and increase of racist commentary in the country. In this context, the portrayal of social groups as factors of an epidemic, instead of parts of a population, is exclusionary and can cause social conflict. Right-wing politicians, government members and local authorities repeatedly used such portrayals for their own political interests. Namely, between 2012 and 2013 migrants were openly declared a public health bomb, while legal regulations were established allowing the detention or deportation of vulnerable individuals on the basis of their health status (Law ΓΥ/39Α of 2012, and articles 58 & 59 of Law 4075/2012). In Evrotas, police violence against migrant workers escalated during the same years, sowing fear and ending up in a number of detentions - including of asylum seekers - without legal reasoning apart from them lacking residence permits. One of the main challenges faced by public health professionals working in the region was the timely tracing of malaria incidences, in order to treat patients and test people close to them as quickly as possible. Migrant workers, the most vulnerable group due to their living circumstances, were extremely cautious of revealing their identity and living locations to state authorities, in fear of a crackdown, police violence and/or deportation. Many would further avoid interaction with the healthcare system, either because they were not aware of their right to free treatment, 2 or due to language restrictions, or also due to previous experiences of discrimination practices against them. The role of local translators was instrumental in building trust between public health workers and the community of land workers, leading to the mapping, treatment and monitoring of malaria. In face of state violence, staying invisible unfortunately becomes a strategy of survival, at the same time increasing their vulnerability to disease. 2 Treatment is free for migrants without legal documents, only if they suffer from infectious diseases and thus pose a public health threat. Law 84 article 1 (3386/2005), however, forbids and penalizes the offer of healthcare to migrants without legal documents in any other case, pushing doctors into violating their oath to serve any person in need. As a consequence, patients that just have symptoms of fever (a first indication for malaria), in places where there is no malaria alert, would be denied healthcare services, or will most likely not even try to seek them.

4 4 Disease in context: local realities of exploitation At this point, it is important to emphasize that disease is allowed to spread given the right circumstances. As clearly observed in the case study region, land workers were living in huts or warehouses without windows, in the fields, next to irrigation canals and rich vegetation. Anopheles mosquitoes (vectors of malaria) thrive in such rural environments. Provision of bed nets and residual indoor spraying was not enough, thus people lacked any efficient way to avoid being bitten. Living in the fields was a way of maintaining invisibility but also unavoidable, as decent housing in the village of Skala (more urbanized, thus not as welcoming for the vector) was either denied to them or overcharged. Certainly, disease moves across urban/rural borders, and labor brings people to the fields for most hours of the day anyway. But the activity of the Anopheles is known to increase at nighttime, thus an important factor of exposure that should be targeted is where and under which conditions a person sleeps. Beyond migrant culpability : the case of West Nile fever Notably, the rise of malaria in Greece was concurrent with the rise of another vector-borne disease, West Nile fever, which is also transmitted via mosquitoes, but of the Culex genus. In 2010 the number of incidences peaked to 262, falling since to 86 in 2013, and 14 in Similarly to malaria, the acceleration of procedures and mobilization of national and European funding in response to the high number of incidences effectively helped its control. However, West Nile Virus is a completely different type of pathogen, for which humans are dead-end hosts. In other words, the disease cannot be blamed on migrant human populations inserting it into the country. The conjunction of both diseases being on the rise during the same years, points thus to real factors which consolidated, creating the ideal circumstances for their spread, and particularly to the absence or insufficiency of a vector control mechanism, on the one hand, and the unpreparedness and unfitness of the healthcare sector on the other. Research indicates that the system of public institutions, responsible for managing the control of mosquito populations, has been laden with opportunities for corruption and bureaucratic delay. Namely, the same entity (either Prefecture or Municipality) which assigns mosquito-control projects to a private company was also the one monitoring the execution and assessing the results of the project, often being also involved in that company s administration (though the so-called local development companies ). Mosquito control projects thus become profit opportunities, creating antagonism between companies, at the same time giving significant power to local government administrations. As one result, non-selected companies would file complaints, object and appeal to higher courts for unfair decisions; delaying the assignment and start date of the project every year. Delayed spraying thus often ended up to missing the larvae stage of mosquitoes (March/April), which bio-pesticides (a type of bacillus) are supposed to target. The newly established action plan for malaria ( Meropi, 2015) addresses some of these organizational and institutional complications, however continues to portray migrants from endemic countries as disease factors, without contextualizing the issue with the marginal living conditions, health vulnerability and forced invisibility of land workers in malaria-prone regions.

5 5 RECOMMENDATIONS FOR POLICY-MAKERS Integrate, include and protect the population as a whole, including migrants Make public health attentive to vulnerable populations Raise awareness of vector-borne disease and its socio-political determinants Strengthen the system s capacity and integrity: health as a priority sector Research shows that a large number of migrants are invisible for the public health mechanism, also being excluded from health services. Alleviating these obstacles would help in assessing and monitoring the epidemiological profile of the country, and in controlling any kind of epidemic more effectively. Any such systematic effort of surveying and documenting people without legal documents needs to be disassociated from disciplinary measures and thus should not involve the police. Access to basic health services should be free for everyone living in the country, as the Constitution demands (art.5). Speeding up the process of acquiring citizenship would also be crucial in alleviating health risks as it would facilitate integration in local societies and descent housing. Furthermore, regulation around the living conditions and the criteria for placing people in detention centers needs urgent change, not least because they constitute loci of infectious disease. Last but not least, an effort of controlling incoming populations for disease at the point of entrance would help early detection and treatment, also avoiding misunderstandings on whether and how many of incidences are imported or locally acquired. The context-specific conditions of malaria-prone areas need to be taken into account when programs of prevention are designed and implemented. This includes considering the realities and needs of minorities, such as in the case of malaria in Evrotas. Handing out bed nets, fans, and other mosquito control appliances, as well as intensifying spraying in the proximity of risk-prone houses or living establishments are measures that, while not targeting the core of the problem, can prove helpful in protecting from disease. Moreover, research pointed to an increasing need for facilitating communication between patients and medical stuff, overcoming language issues. This can be addressed both by offering Greek lessons to foreign speakers and by establishing a network of translators who can be reached in times of need. Research has also highlighted the need for raising awareness on the risk of vector-borne disease, countrywide. In fear of bad international reputation and the public s indignation towards state authorities, efforts to inform the public on the issue of malaria and WNV (re-)emergence were inadequate. Targeted information and communication activities in disease-prone areas were limited and reactionary. Health education needs instead to be pragmatic, developed in collaboration with the public, involving all social groups and aiming at participation and social empowerment. In this regard, the actual factors that led to the spread of the disease should be explained in public information campaigns, including the social and political action that could reduce those factors. First and foremost, health prevention and healthcare services should be given priority in the national allocation of funds, if diseases such as malaria are to be successfully controlled now and in the future. Furthermore, local healthcare establishments need to be strengthened and equipped to deal with emerging health risks, including the presence of staff for the continuous surveillance and

6 6 control of infectious disease, especially in areas of high risk. Research moreover indicates the need for health professionals to be trained, assisted and monitored on how they treat patients from vulnerable social groups, considering the respect of medical ethics and international human rights, as well as with regards to cultural sensitivity. RESEARCH PARAMETERS Objectives of research Scientific approach/ methodology The concrete objectives of this ongoing research project consist in understanding: (i) How did the changes in governance and policy that came along with the socioeconomic crisis in Greece contribute to the rise of vector-borne diseases in the country? (ii) How have environmental changes, in global and local levels, shaped the conditions for mosquito vector populations to increase in the disease-affected regions? (iii) How are discourses around disease reflecting and shaping the values, beliefs and power dynamics in local societies? The scientific approach of this project was structured around the wider theoretical framework of political ecology, and employing a mixed-methods research strategy, juxtaposing social science evidence (generated through in-depth and semistructured interviews and group discussions) with secondary information on hydroclimatic change, epidemiological data and health statistics, as well as an analysis of official legal documents, published press articles and international regulation and reports around the issue. The explored case study is the Evrotas Delta in Lakonia (for malaria) but also the region of Marathonas in East Attica (for West Nile fever). Map: case study site in Evrotas, Lakonia, with a cluster of malaria domestic cases in 2009

7 7 Further reading Kousoulis, A.A., Chatzigeorgiou, K.-S., Danis, K., Tsoucalas, G., Vakalis, N., Bonovas, S., Tsiodras, S., Malaria in Laconia, Greece, then and now: a 2500-year-old pattern. Int. J. Infect. Dis. 17, e8 e11. Marka, A., Diamantidis, A., Papa, A., Valiakos, G., Chaintoutis, S.C., Doukas, D., Tserkezou, P., Giannakopoulos, A., Papaspyropoulos, K., Patsoula, E., West Nile virus state of the art report of MALWEST Project. Int. J. Environ. Res. Public Health 10, Bonovas, S., Nikolopoulos, G., High-burden epidemics in Greece in the era of economic crisis. Early signs of a public health tragedy. J. Prev. Med. Hyg. 53. Keil, R., Ali, H., Multiculturalism, racism and infectious disease in the global city: the experience of the 2003 SARS outbreak in Toronto. Topia Can. J. Cult. Stud. 23. PROJECT IDENTITY Coordinators Prof. Dr. Giorgos Kallis (project coordinator), giorgoskallis@gmail.com Dr. Christos Zografos (project manager), christos.zografos@uab.cat Institute for Environmental Science and Technology (ICTA), Universitat Autònoma de Barcelona, Spain ( Consortium Institute for Environmental Science and Technology (ICTA), Universitat Autònoma de Barcelona, Spain ( Centre for Social Studies of the University of Coimbra, Portugal ( The University of Manchester, UK ( Lund University, Sweden ( Humboldt University of Berlin, Germany ( Harokopion University of Athens, Greece ( Bogazici University, Turkey ( University of Chile, Chile ( Environment and Management, Spain ( Centro di Documentazione sui Conflitti Ambientali, Italy ( Friends of the Earth Middle East, Israel Jordan Palestinian Territory, Occupied (foeme.org) Duration May 2012 April 2016 Website Author(s) of this brief Panagiota Kotsila (postdoctoral fellow), panagiota.kotsila@gmail.com Institute for Environmental Science and Technology (ICTA), Universitat Autònoma de Barcelona, Spain (