Anales de la RANM

14 A N A L E S R A N M R E V I S T A F U N D A D A E N 1 8 7 9 MIGRATION AND HEALTH INEQUITY Aagaard-Hansen J, et al. An RANM. 2025;142(01): 11 - 20 • Differential health care outcomes focus on the level of impact of the curative health care services. • Differential consequences pertain to the situation after concluded treatment, e.g., economically (3,17). The CSDH used the framework to differentiate between various levels such as individual, popula- tion group and society and to identify causal links between them. In the present article, this analyt- ical framework will be applied in a simplified form where the five levels individually allow to differentiate the ways in which the social determi- nants operate (3). The CSDH (2008) report was supplemented by a number of preparatory reports (16-17) and work focusing on specific public health programs (18). Graham (2004) pointed out that it is important to distinguish between determinants of health and determinants of health inequities, and the present article focuses on the former (19). Health care services have been identified as a social determinant of health in their own right (16) and deserves particular attention. The quality of the health care services is essential to differential outcomes. Based on the work of previous scholars, we will use the following elements of coverage: availability, accessibility, affordability, acceptability, and adherence (20-21). In short, there are several reasons why patients may not benefit from the required health care services and thereby achieve the desired ‘outcome’. 5. DISEASE CASES In this section we display three exemplary disease cases (visceral leishmaniasis, diabetes mellitus and tuberculosis) which in various ways illustrate the issues. These have been selected to cover non-communicable as well as (semi-acute and chronic) communicable diseases. 5.1. Visceral leishmaniasis Visceral leishmaniasis (VL) is a protozoan, vector-borne disease transmitted by sandflies and grouped among the neglected tropical diseases (NTDs). VL is present in 80 countries. If in 2006 67% of the cases were in South Asia and 17% in East Africa, today figures inverted to 12% and 60%, respectively, due to a successful elimination program in the former (22-23). Poor environmental sanitation increases sandfly density near infected reservoirs such as humans or dogs. Environmental variables such as temper- ature, soil type and vegetation coverage are the most important ecological determinants of the distribution of leishmaniasis vectors (24). Host susceptibility plays a major role in transmis- sion, being either herd or individual, acquired or natural, or based on immunosuppression or co-morbidity. VL is anthroponotic (i.e. transmitted from person to person) in the South Asia and East Africa regions, while it is zoonotic (transmitted via infected animal reservoirs) in Brazil, the Mediterranean basin, and Central Asia where dogs are the main reservoir. Anthroponotic VL may potentially be controlled and eliminated as a public health problem. Elimination of zoonotic VL is a more complex problem since canids and other mammals constitute reservoirs. Dogs are asymptomatic in more than 50% of the infected cases and highly infective to sandflies, and they can walk up to 40 km per day (25). Fatal if untreated, VL is closely linked to poverty and commonly transmitted in remote areas with fragmentary access to health care (26). The current anti-VL drug choices are still limited and have adverse effects, toxicity, high cost and poor efficacy. Furthermore, they need multiple injection and are prone to drug resistance. Several forms of population movement are respon- sible for the increase of VL incidence (27). In an analysis comprising the period 1995-2010, wars and political terror have been associated with a six folds increase of VL, directly related to health system disruption (28). In anthroponotic VL, civil unrest and wars impose major flows of naïve and probably malnourished population groups into endemic areas causing outbreaks and a disproportionally high mortality up to 30% (29). If returning to their place of origin the disease spreads to new areas, taking into account that the sandfly is globally present in various degrees (30). Labor migration is also well described as a reason for major outbreaks of VL. In Ethiopia, highlanders migrate to the more fertile lowlands in Tigray every year for harvesting sesame and sorghum, where they live in crowed shelters during several months being exposed to the bites of sandflies in a highly endemic area (31). It has been shown, that upon return the labor migrants have caused a major outbreak in the highlands, an area free from leishmaniasis previously (32). In South Sudan where the most important outbreaks happen regularly counting by thousands the patients in each epidemic, the establishment of sentinel sites, some in the expected corridors of migration, reduced the mortality from 30% to less than 4% among more than 20,000 patients (33). In Latin America, especially Brazil and northern Argentina, VL is undergoing a twofold urbani- zation process. Either the rural population migrates to the periphery of cities in contact with the forest where leishmaniasis is transmitted, or humans invade the forest provoking environ- mental degradation facilitating bringing humans closer to vector-breeding sites and facilitating vector adjustment to peri-domestic habitats (34).