Malaria, Policy and Immigration in Suriname and French Guiana:

A Review of the Relevant Literature

Public Health Analysis

Heather Jordan

Tulane University SPHTM

International Health and Development

April 20, 2010

Heather Jordan

Abstract

Malaria is a major public health issue around the world, including the Americas. Malaria is

such a major threat to global health, halting and reversing the spread of malaria is part of the

sixth UN Millennium Development Goal for 2015. While overall, malaria in the Americas has

been declining, every country has a unique context which can either alleviate or exacerbate the

local malaria rate. Two neighboring countries, Suriname and French Guiana, have similar

environmental conditions, ethnic groups and, until recently, shared high rates of malaria. For the

last five years however, Suriname has nearly reached the sixth MDG while French Guiana has

seen an increase in infections that gives the small territory one of the highest rates of malaria in

the Western Hemisphere (PAHO, 2006). Even though mortality from malaria is low is in this

region, morbidity negatively impacts social and economic activity and remains is serious health

threat (WHO, 2008).

Considering the similar environmental conditions of the two countries, differing local policies

play an important role in the disparate rates of infection. Suriname has been more successful in

its choice of anti-malaria tools including an expansive internal campaign for distributing

insecticide treated nets (ITNs) and the use of aggressive active case detection (AACD) .

Suriname’s malaria efforts also differ in the way it handles the presence of illegal Brazilian

immigrants. While Suriname actively seeks out Brazilian gold miners for malaria interventions

(Global Fund, 2007), French Guiana has no such programs and regularly deports illegal

immigrants back to Brazil (The Guardian, 2007). As malaria rates are related to population

mobility, immigration policies could affect anti-malaria efforts.

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Background and Significance

Suriname and French Guiana belong to a geographic region called the Guiana Shield, which

also includes British Guyana, part of Venezuela and Northern Brazil. Suriname was formerly

known as Dutch Guiana and remains a Dutch speaking country. French Guiana was a former

French colony that is now a French Department. Within the Guianas it is often referred to simply

as “France.” The Guiana Shield is the northern most reach of the Amazon, characterized by

dense tropical rain forest and rich alluvial deposits including bauxite and gold.

For most of the last few decades, the Guiana Shield has had among the highest malaria rates

in the Americas. P. falciparum and p. vivax are the principal parasites. P. malarie infection is

rare, but does occur. The female anopheles darlingi is the primary mosquito vector (WHO,

2008). P. falciparum in the Guianas region is now chloroquine-resistant (CDC, 2010).

A majority of the population of each country is concentrated along the coast and in the capital

cities of Paramaribo and Cayenne. Malaria has been essentially eradicated from the capital cities

and most of the coastal areas (CDC, 2010) . In Suriname, malaria is concentrated around the

large man-made reservoir in the Brokopondo area and along the Marowijne River, the natural

border with French Guiana (Figure A). P. falciparum is most common along the Marowijne

(called the Maroni in French). P. vivax is more frequent along the Oyapock River, the natural

border between French Guiana and Brazil (Figure B) (Hustache et al, 2007).

Both countries have small populations of under one million; Suriname having roughly

500,000 people and French Guiana having around 200,000 (WHO, 2008). In 2006, the WHO

reported 3,631 outpatient malaria cases in Suriname and 4,074 in French Guiana. Considering

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the population of each country that year, the case rate for Suriname was 8 infections per 1,000.

For French Guiana it was 21 per 1,000. French Guiana had a population less than half that of

Suriname and a case rate that was more than twice as high (Figures C&D).

It should be noted that the population numbers do not include illegal immigrants and the

outpatient case numbers are only those reported to the surveillance system. In the interior forests,

many cases go unreported among people who are themselves uncounted (Theije et al, 2009).

In the 1950s, many countries in the Americas, including Suriname and French Guiana, saw

great successes in the reduction of malaria through the use of indoor residual spraying (IRS) of

DDT. IRS is a useful tool for malaria eradication in stable populations. However, in many areas

where there is social, demographic and political instability, IRS is not an effective anti-malaria

tool (PAHO, 2001). Suriname and French Guiana are both experiencing major demographic

shifts that are currently affecting malaria transmission.

Suriname has no malaria in its coastal provinces. During the 1980s, Suriname saw an increase

in malaria rates in the interior due to a disruptive civil war. In the 1990s, the war ended and the

country became open to gold mining, logging and rain forest destruction. According to

Suriname’s Medische Zending (MZ), the organization responsible for health in the interior, these

factors helped maintain a high malaria rate until 2004 when an intensive Global Fund anti-

malaria campaign began.

The coastal region of French Guiana is also considered malaria-free after the widespread use

of IRS in the 1950’s and mass use of prophylaxis in the 1960’s and 70’s. Malaria has

consistently been a problem in the interior, but has been exacerbated by immigration. In the

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1980s, an estimated ten thousand Maroons crossed into Western French Guiana fleeing

Suriname’s civil war (Hoogbergen et al, 2004). This, along with immigration from Haiti is

thought to be a cause of rising malaria rates in French Guiana at this time (Raccurt, 1997).

Another more recent factor in the increase is the movement of malaria-infected peoples across

the border from Brazil (Carme, 2005).

The interiors of both Suriname and French Guiana are home to communities of indigenous

Amerindians as well as Maroons. Maroons are the descendants of African slaves who escaped

into the forests and formed autonomous societies. They are culturally distinct from the coastal

Creoles who are also of African descent. Brazilian gold miners or garimpeiros are increasingly

becoming a major presence in the interior of the Guianas region. Though the number of

garimpeiros working in Suriname and French Guiana is uncertain, the estimates run into the tens

of thousands (Theije et al, 2009). In countries with such small populations, this is a significant

number of people.

There are several social and economic factors that lead to the increase in Brazilian

immigration to the Guianas. In the latter decades of the last century, the Brazilian government

made a push for development of the Amazon region. Highways were built to facilitate internal

migration and promises were made about infrastructure, land, employment and opportunities to

come. Such promises failed to materialize, leaving many Brazilians isolated and impoverished in

an area with no government services (Theije et al, 2009). The mass migration of Brazilians from

the northeast, where malaria was endemic but mild, to the Amazon was catastrophic for

Amerindians communities that had no prior exposure to the parasite (Macauley, 2004). Small-

scale gold mining provided employment for many Brazilians who were living in or had resettled

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to the Amazon region. In the 1990s, changes to Brazil’s gold policies made it difficult for small-

scale miners to continue work in their own country. Many tracts of land and gold concessions

were sold to larger corporations, displacing small-scale miners. In 1992, Suriname’s civil war

ended and it became a safe destination for garimpeiros looking to continue mining (Hoogbergen

et al, 2004). French Guiana has also become a destination for garimpeiros in the last few decades

both because of its gold deposits and its high standard of living. French Guiana is technically a

French Department and is therefore part of the European Union. All its citizens are considered

French and receive all the social benefits of the welfare state. It has the highest per capita income

in the entire region (Carne, 2005).

Amerindians do not tend to work in the gold mining industry, but Maroons often work

alongside Brazilian gold miners in the garimpos. They share in the economic benefits and in the

health risks associated with small-scale gold mining in the Guiana Shield. It should also be noted

that men involved in gold mining are not the only residents of the garimpos. Many men and

women also work in a supportive capacity as merchants, cooks or commercial sex workers

(Heemskerk, 2004).

Goals and Objectives

The goal of this paper is to present available and relevant data on malaria in Suriname and

French Guiana in an attempt to understand why the two countries have such disparate malaria

rates, despite similar environmental and social conditions. Why are the indicators in Suriname

improving, while remaining high or even getting worse in French Guiana? One objective is to

examine the different anti-malaria tools employed by each country. The other objective is to

investigate the extent to which immigration contributes to the malaria problem in the Guianas

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and how each country’s unique approach to immigration has a bearing on the overall malaria

outcome.

Materials and Methods

The research for this paper was conducted through searches on PubMed and Google Scholar

using key words such as malaria, Suriname, French Guiana, Brazil, active case detection,

immigration, gold miners and garimpeiros. Well known organizations such as the WHO, CDC

and Global Fund were used for reliable statistics on malaria rates in the Guianas Region. Sources

dating from the mid-1990s to as recent as 2010 were used. Sources from 2005 and later were

prioritized, however, information on Suriname and French Guiana was difficult to locate and

access. Any articles pertaining to malaria in the Guianas region were read. Some sources needed

to be translated from Dutch or French into English. Sources from the 1990s were useful for back

ground and historical perspective because they were written at a time when the malaria situation

of the Guianas was worse than it is today. Some articles concerning malaria in Brazil were

found to be quite relevant to this paper. As part of the Guiana Shield, the Northern Brazilian

Amazon has similar population concerns and environmental conditions.

As this paper is a comparison between two countries, I attempted to present the information in

a symmetrical structure. This was difficult as I found no parallel studies, no comparative articles

addressing malaria in both countries. Instead, studies has to be pieced together to form as

complete a picture as possible of malaria control and immigration policies in the Guianas.

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Results and Discussion

Frontier Malaria

Malaria in the Amazon is often called “frontier malaria” because the nature of human

settlement in the region has proven to increase transmission. Several studies were found that

addressed frontier malaria in the Northern Brazilian Amazon. The historic and massive internal

migration to the Amazon brought both malaria-infected as well as malaria-naïve Brazilians to the

undeveloped forest. The 1970s and 80s saw a reversal in the improvements Brazilian anti-

malaria campaigns had made in the 1950s. The environmental changes that accompanied new

settlements in the Amazon were favorable to malaria transmission (Castro et al, 2006).

While the studies that defined frontier malaria all concerned Brazil, the Amazon rain forest

stretches far into Suriname and French Guiana, covering more than 80% of those countries’

territories. The environment is the same, the mosquito vector, a. darlingi, is the same and with an

increase in Brazilian immigration to the Guianas, the human vector is also the same. For this

reason, studies on frontier malaria are very relevant to understanding the malaria situation of the

Guianas.

Settlement factors that contribute to transmission include: coming from a malaria-free zone

and having no immunity or coming from another malarious zone and being an asymptomatic

carrier, living in temporary housing such as a tent or shack, the degradation of small creeks and

deforestation which create desirable breeding and biting habitats for the a. darlingi (Katsuragawa

et al 2010).

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Frontier malaria affects Amazon settlers involved in many industries including agriculture,

rubber tapping and logging. But small-scale gold mining or garimpagem is particularly

conducive to malaria transmission (Silbergeld et al, 2002). The lifestyle of Brazilian and Maroon

gold miners contributes to transmission through all the factors addressed above. They often live

in open air camps without using mosquito nets (Figure E). Part of the practice of small scale gold

mining is to dam small creeks and tributaries to create pools of water from which the gold is

extracted. The disturbance of these streams creates water habitats that are optimal for a. darlingi

breeding sites (Figure F). The shady fringe of newly cleared forest – not the cleared space or the

forest itself - is the preferred habitat of a. darlingi (Castro et al, 2006).

As Amazonian settlements become more established, malaria can be controlled through

urbanization, which is hostile to the conditions preferred by a. darlingi. The human population

can even become somewhat immune, reaching asymptomatic status (Castro et al, 2006). Gold

mining, however, does not allow a settlement enough time to achieve this. Once the gold in a

certain creek bed has been completely exploited, the garimpo is abandoned and a new settlement

is constructed at another location (Katsuragawa et al 2010). Creek degradation and deforestation

and the continuous movement of humans in and out of malarious zones perpetuate the cycle of

frontier malaria (Silva et al, 2009).

Garimpeiros and Maroon miners are a highly mobile population. Not only do they constantly

create new garimpos, they travel back to large cities for supplies and they frequently move

between French Guiana and Suriname (Heemskerk, 2004). In the case of French Guiana,

garimpeiros sometimes abandon a site after being raided by the French immigration control.

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They are sometimes deported back to Brazil, where they might again illegally cross the border,

bringing their malaria infections with them (The Guardian, 2007).

Anti-malaria Efforts in Suriname

In a 2007 article on Scidev.net, Global Fund consultant Leopoldo Villegas reported that

Suriname had already reached its 2015 malaria Millennium Development Goals. He cited that

malaria cases has fallen 70% between 2001 and 2006. The mass distribution of insecticide

treated nets (ITNs) and aggressive active case detection (AACD) of malaria infections were the

principle causes of this success. Other anti-malaria activities included subsidized anti-malaria

treatment, insecticide sprays, educational campaigns and improved surveillance. Suriname is

currently on the path to malaria elimination. In the first decade of this century, malaria’s expanse

has been narrowed significantly from all inhabitants of the interior to only the most vulnerable

population in the country: the garimpeiros and Maroon miners.

In a comparison of Global Fund proposals from 2004 and 2007, the shift in focus can be

noted in anti-malaria efforts. The 2004 proposal claims Suriname had the highest p. falciparum

rate in the Americas at that time. The target populations for malaria interventions included

Amerindians, Maroons, garimpeiros and even Chinese merchants. This indicates that in 2004,

the disease was generalized to all people living in the interior. By 2007, the proposal is so

specific in its target that the malaria program is now titled “Looking for gold, finding malaria.”

Within the document there is recognition that to protect the gains made among the stable, native

populations of the interior, Amerindian and Maroon villages, malaria has to be controlled in the

more vulnerable gold miners.

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At the time of the Global Fund campaign, bed nets were already widely used in the interior of

Suriname. But there were several cultural barriers that had to be overcome before nets could

actually reduce malaria transmission. Most nets being used had not been treated with insecticide,

so they were not as effective as true ITNs. In addition, the Surinamese wash their nets often,

reducing the lifespan of the net. The 2004 proposal calls for the distribution of long lasting nets

treated with insecticide to combat this problem. In personal conversation with Dr. Villegas I

learned of another cultural barrier to consider. The Amerindian population uses bed nets for

privacy in their often crowed habitations. The first round of free ITNs were unpopular because

they were white and did not offer enough of a visual barrier. This problem was solved by

distributing colored nets which obstructed the view.

In addition to ITN distribution, Dr. Villegas cites aggressive active case detection (AACD) as

a cause of the reduction in malaria transmission. Most malaria programs use passive case

detection (PCD) in which only patients presenting symptoms are treated for malaria. AACD is

the practice of testing an entire community for malaria and treating all positive cases – regardless

of the absence of symptoms. AACD recognizes there may be asymptomatic carriers contributing

to malaria transmission within a geographic area and aims to reduce the parasite present in the

human reservoir (Macauley, 2005).

It is possible that immigration from Brazil has contributed to the chloroquine-resistant

mutations of p. falciparum. Brazilians have introduced new genetic variations into Suriname

(Peek et al, 2005). Gold miners also tend to self-medicate when they feel feverish (Heemskerk,

2004). Self-administering medication could lead to resistance as well, as often people only treat

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themselves until their symptoms go away. No studies was found on resistance in French Guiana,

though the CDC reports that there is chloroquine resistance there as well.

While most Brazilians are in Suriname illegally, due to the limited government presence in the

interior, there is a low risk of deportation. Two incidents in 1999 and 2000 demonstrate that the

Surinamese appear to hold the need for order above an interest in deporting illegal immigrants.

While Maroons and Brazilians typically work together peacefully, they do occasionally clash

such as in Sellakreek in 1999 and Benzdorp in 2000 when the Maroon miners expelled the

Brazilians. In both cases the Surinamese military and police helped re-establish stability and in

some instances helped Brazilians return to their homes and work (Theije et al, 2009).

This was also the case in the most recent violence in December 2009. In Albina, a border

town on the Marowijne, seven Brazilians were killed in violence between Brazilians and

Maroons. The Surinamese military was deployed to keep the peace and specifically to protect

foreign nationals – legal or not (Al Jazeera, 2009).

It is unclear as to why the Surinamese government is not interested in deporting illegal

Brazilians. There are certainly downsides to their work. The garimpos are sites of extreme

environmental degradation and mercury pollution (Silbergeld et al, 2002). It is possible the

government has accepted that the interior is too vast and isolated a place to police. Another

possibility is that gold makes too much of a contribution to Suriname’s economy to interfere

with the extraction process. Brazilians often bring superior technology and knowledge of mining

techniques and have contributed greatly to the production capacity of the region (Hoogbergen et

al, 2004).

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Anti-malaria Efforts in French Guiana

A 1997 article published in Médecine Tropicale describes French Guiana’s anti-malaria

control efforts as a “failure.” The French public health system is portrayed as resistant to

changing its anti-malaria policies, which rely heavily on IRS. French Guiana successfully used

IRS along with mass prophylaxis to eradicate malaria in the populated coast. But IRS as an anti-

malaria tool loses its efficacy in the interior where Amerindian and Maroon housing is often

open, without walls onto which DDT could be sprayed. Distribution of bed nets was described as

limited and no other anti-malaria activities were cited (Raccurt, 1997).

Current anti-malaria activities in French Guiana include free anti-malaria treatment, passive

case detection and IRS (Fouque et al, 2010). As a French Department, French Guiana is

considered part of a high-income country and is not eligible for Global Fund aid.

In a search of studies addressing malaria in French Guiana, most concentrated on malaria risk

within the Amerindian population. Studies as late as 2005 and 2007 were still researching the

risks associated with living in a traditional village. This is in great contrast with the literature on

Suriname, none of which cite the Amerindian population as still being at risk for malaria. As

malaria is concentrated in the gold mines and few Amerindians are involved in gold mining

(Heemskerk, 2004), they are generally no longer at risk. Malaria is still a generalized risk for all

populations living in the interior of French Guiana.

Several aspects of Amerindian villages were described as malaria risks. These included

living in a house with only one wall or less, living in crowded conditions, living close to a river,

and living in an area uncleared of vegetation (Hustache, 2007). Several of these risks apply to the

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living situation of gold miners as well. A major difference would be that Amerindian villages are

generally stable, permanent entities while garimpos are very temporary and gold miners are a

highly unstable and mobile population.

Another study addressed the kalimbe, the traditional loin cloth worn Amerindians. The

kalimbe itself could be considered a risk when compared to Western clothing because it covers

less surface area of the skin, leaving it exposed for insect bites. The research question was

whether the kalimbe should be discouraged to prevent malaria (Carme, 2009). While the need for

cultural sensitivity was noted, the question itself shows a certain amount of insensitivity.

Furthermore, wearing long sleeves and pants in an hot and humid climate can cause

dermatological problems in indigenous peoples (Plotkin, 1993).

No evidence was found to suggest French Guiana is addressing malaria in the gold mining

population, specifically the illegal Brazilian gold miners. The French government actively

pursues disrupting the activities of illegal immigrants. In 2003 the French Gendarme began

“Operation Anaconda,” a series of around 100 raids per year on illegal garimpos. Mining

equipment is often destroyed and Brazilian nationals are either told to return or physically

deported to Brazil. Many garimpeiros return to French Guiana even after being deported (The

Guardian, 2007). This further increases the amount of human and parasite traffic across the

border.

In 2004, there was an outbreak of malaria among French policemen after participating in an

Operation Anaconda raid. During their 108 day deployment near the Oyapock River, close to the

Brazilian border, the policemen stayed in a Brazilian mining camp living in similar conditions to

most garimpeiros. A retrospective study determined that most did not take their prophylaxis as

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instructed. 18 out of 40 men returned to France with malaria (Verret, 2006). Even as the French

government seeks to disrupt illegal immigration and mining, the malaria problem in the

garimpos makes itself known. Ignoring malaria in the gold mines may only worsen the situation

in the general population of the interior.

In a retrospective study of malaria cases in the previously malaria-free inland areas of Cacao

and Régina, it was noted that 61% of all cases between 1996 and 2003 affected a patient with a

“Brazilian sounding name”(Carme, 2005). What is interesting about this study is that the

nationality of the patients could not be confirmed and had to be assumed based on the surname.

This is not a reliable way to collect data on ethnicity. Brazil, like many countries, has a

population of mixed ancestry. It is possible that clinics in French Guiana do not collect data on

the ethnicity of patients because it is illegal to do so in France (The Guardian, 2009). This,

however, makes it difficult to see which populations are most affected by malaria.

French Guiana has failed to recognize in both policy and publications that illegal Brazilian

immigration plays a large role in its malaria problem.

Conclusions and Recommendations

From the literature, it seems Suriname’s success in malaria control stems from its choice in

appropriate anti-malaria tools, cultural sensitivity to its diverse population and a relaxed

immigration policy that allows the public health system to address malaria in the undocumented

population that is most vulnerable to the disease. Conversely, French Guiana seems unable to

move beyond past successes with IRS on the coast to find interventions that will work in the

interior. Suriname’s success in eradicating malaria in the Amerindian population highlights the

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failure of the French to make similar gains in their own interior. French Guiana’s strict anti-

immigration policies get in the way of recognizing that malaria is an issue that affects everyone

in the interior, legal or not.

While mortality from malaria is very low in both countries, there are strong reasons for

making elimination a goal. As long as malaria persists in the population, a great deal of money

and energy must be invested in treating the infected and in keeping the levels manageable. The

threat of drug resistance is a real concern. Malaria may negatively impact economic activity by

preventing people from going to work and even by deterring tourists from visiting these tropical

countries.

It seems Suriname and French Guiana should work together to combat malaria in the Guianas.

The porous borders mean that the malaria in one country can easily ride the wave of immigration

across the Marowijne and Oyapock borders, in either direction. A consistently high rate of

malaria in French Guiana could threaten all the gains made in Suriname as garimpeiros and

Maroons move from one garimpo to the next, looking for gold and ignoring international

borders.

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Figure A: Map of Suriname and Areas of Malaria Prevalence (Medische Zending, 2009)

Note: Areas in red indicate malaria prevalence.

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Brokopondo

Marowijne River

Paramaribo

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Figure B: Map of French Guiana and Areas of Malaria Prevalence (Raccurt, 1997)

1. Coastal zone with imported cases and possible micro-epidemics. 2. Area of endemic active transmission where p. falciparum and p. vivax coexist. 3. Area of endemic active transmission and predominate p. falciparum. 4. Area of seasonal epidemics and episodic transmission.

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1.

2.

3.

4.

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Figure C: Malaria Trends in Suriname (WHO, 2008)

Figure D: Malaria Trends in French Guiana (WHO, 2008)

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Figure E: Sleeping accomodations for garimpeiros in a mining camp in Benzdorp, Suriname. (Photograph taken by author)

Figure F: A garimpeiro pumps water from a dammed creek in Benzdorp, Suriname. (Photograph taken by author, 2009)

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