Globally, urbanization is on the rise. In 2007, for the first time, the number of people living in urban areas exceeded the number of people living in rural areas. According to the CDC (Centers for Disease Control and Prevention), in 2014, “Continuing population growth and urbanization are projected to add 2.5 billion people to the world’s urban population by 2050, with nearly 90 per cent of the increase concentrated in Asia and Africa.” The increase in urban populations introduces a set of new challenges including the elimination of neglected tropical diseases in urban settings.
Neglected tropical diseases are a group of infectious diseases that often occur among those in poverty and shared geographic locations. NTDs are primarily concentrated in Asia, Africa and Latin America while also the places with heightened urbanization. One common way of addressing NTDs is through mass drug administration (MDA). However, most knowledge about the effectiveness of MDAs is regarding rural areas.
Some challenges of neglected tropical diseases in urban settings include complex governance, population heterogeneity and mobility. First, the government structure can influence the effectiveness of NTD programs significantly. Coordinating between different agencies, services and government positions can be confusing and hinder the NTD program. Different government alliances and rules of jurisdictions will change how the government will support NTD-specific MDAs. Furthermore, the lack of governance or rule and order will also hamper the delivery of MDA. Some slum settlements have high criminal activity, which poses a security threat for MDA workers and cultivates distrust of outsiders.
Urban areas tend to have high social and economic diversity leading to cultural divides. Those living in informal settlements, with poor access to clean water and other services are most at risk of NTD exposure. Conversely, high-income people are also hard to reach with MDA measures. In Ghana, many drug administrators did not feel comfortable working in high-income areas. Also, due to low perceived risk and higher perceived access to health care, high-income groups prove to be not compliant with NTD preventative measures.
Increased mobility among those who live in cities also poses a problem to MDA efforts. People in urban settings change addresses, address daily activities and leave town more often than those in rural settings. Drug administrators are less likely to find an individual at home during the day. Especially when the drug may require multiple rounds of administration, efforts to ensure coverage over those rounds becomes more difficult.
To address the challenges above, some strategies to battle neglected tropical diseases have proven helpful in urban settings. One strategy is to determine if an MDA campaign is necessary. Sometimes dividing the city into smaller areas and identifying groups of the city that do and do not need treatment can allow for more focused use of resources in a strategy called micro-targeting.
Other strategies are effective campaigning and identifying suitable distribution platforms. Depending on the population, the MDA campaign will have to look different. Identifying the different populations within the city is crucial to determining how each can be reached. MDAs are typically delivered through schools, door-to-door service or fixed posts. In urban settings, fixed posts tend to be the most appropriate. Flexible hours for these posts are also helpful to accommodate different schedules.
There are many other strategies including utilizing different communication channels, hiring of diverse backgrounds and addressing possible concerns effectively.
Urbanization is a growing reality for areas containing neglected tropical diseases. Adjusting the approaches to combat these diseases will determine the future of disease prevention. Current and future research into this issue will only deliver more insight and increase the effectiveness of MDAs in urban settings.
– Rachael So