Since the turn of the century, Lao PDR has been on a bullet train to graduate from its “Least Developed Country Status” by 2020. According to a recent UNDP report, the country was “on track” to achieve this goal. Since 2000, its GDP has increased about 7% annually, mostly due to its enormous developments in the agricultural, hydropower, and mining industries. The 8.1% growth in 2013 prompted the World Bank to designate the Laotian economy as “fast-growing.”
In conjunction with economic growth came a steady decrease in malaria incidence. However, this trend was broken in 2011, when an outbreak hit the southern provinces, where most of the development had taken place, strengthened by the increased prevalence of drug-resistant parasites. This epidemic has since gone unchecked, with a 26% increase in malarial deaths just between 2014 and 2015, despite the nation’s goal to eliminate it and reduce multidrug resistance by 2020. Elimination is best sought through effective implementation of “elimination accelerators”. Given its enormous economic and infrastructural improvements over the past two decades, and the fact that the nation had seemed en route to total elimination of the disease but seven years ago, this failure is striking. In fact, it exposes the enormous gaps in the supposed economic improvements that have occurred in the government’s haste to promote as efficient growth as possible. Indeed, Lao PDR’s difficulty in coping with malaria is a direct result of the failure to increase living standards of rural inhabitants, improve their opportunities for socioeconomic mobility, and to implement adequate immigration regulation.
The low standard of living of people in the rural south is reflected in the outbreak and continued eminence of malaria in the region, despite enormous infrastructural and economic expansion. The heavily-forested region is the source of most of Laotian economic growth; agriculture and mining have both boomed, and the region houses 30 of the 53 hydropower dams built since 2000. However, those living in the area have not reaped the benefits of growth. The Laotian labor supply is large and growing. Indeed, 70% of Laotian workers are agricultural, and with an enormous young population, 96,000 more workers are expected to enter the workforce in the next ten years. However, demand is only marginally increasing as the industry becomes larger and more efficient and the government neglects to put in place other avenues for employment. Therefore, the workers themselves are still exploited and impoverished; the villages in which they live remain overwhelmingly remote and underdeveloped in healthcare, education, and other basic public amenities. Hardly coincidental, this demographic group also counts for 95% of the nationally reported malaria cases.
The isolation of each village, not just from urban areas but from each other, makes both tracking and effective treatment of the disease very difficult, both of which are essential to eliminating it. While the government implemented a project to “group” villages in order to remedy this issue, the UNDP reports that the effort has not been very successful due to a lack of “urgency” and attention to “local sensibilities.” Furthermore, many workers are illiterate, reducing their ability to seek assistance and advocate for themselves, and impeding them from receiving information to prevent infection in the first place. This deficiency in education is a result of government negligence despite economic growth: a 2014 World Bank report strongly recommended that public education be improved, after a survey found that 57% of 2nd graders lacked basic reading comprehension, and 32% were illiterate. This deficiency is even more alarming when considering that the average Laotian only receives about 4-5 years of schooling, typically at the primary level.
In addition, further problems have been caused by poor sanitation. Contamination and pooling of water create ideal environments for infectious mosquitoes to breed. The meteoric increase in agricultural activity, paired without insufficient investment in infrastructure to compensate for resulting environmental implications, has led to increased contamination of water by runoff from farms. Moreover, as both access to education and adequate plumbing systems have remained low, only 19%of children’s feces are disposed of safely (since parents lacking both the resources and knowledge to do so). Furthermore, only 48.2%of rural households and less than 50% of public schools have access to sanitation facilities. This issue is clearly not one of government resources, but of oversight: sanitation in urban areas has increased dramatically over the past 20 years, 91.3%of households now with adequate water supply and toilet facilities.
The malaria outbreak has also illuminated another important weakness in Lao PDR’s economic development: a failure to create jobs as a vector for socioeconomic improvement, an imperative trait of any healthy economy. This gap has proven a hindrance to the malaria elimination as it becomes clear that there is a dearth of human resources in healthcare necessary to carry out the effort. A 2017 study sponsored by Lao PDR’s National Institute of Public Health and the World Health Organization, among others, found that lack of training and knowledge of opportunities, both tied to the poor education systems, as a well as a lack of government incentives are at fault for this deficiency. Furthermore, the World Bank stated that the “wage premium,” or the expected increase in salary accrued by changing jobs, has become too low to motivate entrance into the healthcare workforce. This lowering in perceived value has occurred as government investment has become focused increasingly on the mining, agricultural, and hydropower industries, which have fueled its GDP increases. What is more, in 2012, the Ministry of Home Affairs issued Ministerial Decree 633, which inhibited families from moving, thereby robbing them of their ability to move to urban centers, where the vast majority of jobs in healthcare are available.
Lastly, the malaria epidemic points to deficient immigration policy. Increased immigration ought to be expected and addressed by any nation that undergoes significant economic advances. However, Laos PDR’s borders have remained very porous, allowing for an influx of immigrants looking for work, especially in agriculture. The immigrant population, lacking previous exposure to the disease, is particularly at risk from malaria. A Health Poverty Action survey found that 70%of reported malaria cases are migrant workers, although only 34%of the entire workforce is made of immigrants. The vast majority of these people are employed by private enterprises for their cheap labor and are either unregistered or illegal, living in unauthorized housing developments. The government has been happy to turn a blind eye to this phenomenon, as it allows domestic companies to flourish. However, it is now nearly impossible to accurately track the incidence of malaria cases: with an estimated 54,135 to 200,000 workers (in a population of only about 7 million) unaccounted for, the government is lacking an enormous chunk of data that is needed to combat the disease.
Moreover, the resources are not in place to treat these immigrants. While both the Laotian government and international community have committed extensive funds to combat malaria, the majority of it has gone into the public sector. 97.8% of public health facilities are equipped with proper treatments, compared to a staggeringly low 6.5% of private outlets. However, the private sector is responsible for the majority of anti-malarial dissemination. This over-dependence is due largely to immigrants, who are loath to seek out healthcare, especially from public sources, fearing deportation.
There is a vast consensus that malaria in Lao PDR must be combatted with elimination being the ultimate goal. However, the mode of economic growth has created circumstances that make achieving this goal extremely difficult. The government has prioritized expedient growth above all else, and has inevitably failed to create many of the widely beneficial advances that more natural, gradual advancement typically sees. Sanitation, education, immigration policy, and social mobility have all failed to improve. It would be wise for the government to take a step back and pose itself the following question: what is the value of economic growth if not to improve the lives of the Laotian people as a whole? It would certainly be worth sacrificing some growth to ensure that living standards improve and thus hindrances to development, such as malaria, can be eliminated. As the malaria epidemic continues to spread, the consequences of such shortcomings will only become more apparent.