Weighing Our Woes

Weighing Our Woes

The horror of September 11 is difficult to absorb. We all looked in disbelief as the tape of the buildings collapsing was played over and over and over again. We watched thinking that if we saw it often enough perhaps we could feel the magnitude of the loss. For more than three months the New York Times ran biographical sketches of the people who were killed that day in an effort to help us slowly come to understand the magnitude of this mind-numbing tragedy.

On November 2, the Department of State in cooperation with the National Academies sponsored an all-day meeting on a human disaster of even greater magnitude–the spread of infectious disease in the developing world. The day that 3,000 people died at the Trade Towers and the Pentagon, more than 8,000 people died of AIDS, 5,000 people died of tuberculosis, and several thousand more died of malaria. Of course, these deaths are different, because disease is not murder. Nobody wanted these deaths to occur, no one made them happen.

Yet these deaths are not exactly the same as deaths from disease in the developed world. With the exception of AIDS, infectious diseases are not taking the lives of young people in the rich countries, because most diseases can be prevented or treated relatively inexpensively, and even AIDS is being contained by prevention efforts. In Africa infectious diseases are the cause of almost 70 percent of all deaths. What makes the enormous toll of death in the developing world not just the way of all flesh is that we know very well what has to be done to prevent most of these deaths. But we don’t act. And by not acting, we know that we are signing an early death warrant for tens of millions of people.

The nation’s leaders are not insensitive to the seriousness of this neglect. Even as the nation reeled in shock from the events of September 11, Sen. Bill Frist (R-Tenn.) and State Department science advisor Norman Neureiter told participants at the meeting how important it is to address global health problems. Secretary of State Colin Powell was scheduled to speak but was called away to meet with congressional leaders. His prepared remarks, which were read at the meeting, indicate that he understands the severity of the problem and is looking for ways to take effective action.

The most comprehensive description of the problem and what will be needed to fix it came from Barry Bloom, dean of Harvard University’s School of Public Health. Using data from the World Health Organization, he painted a devastating picture of human suffering and economic disaster.

Tuberculosis infects 8.4 million people per year and results in 2 million deaths, virtually all in the developing world. About one-third of deaths of AIDS patients in Africa are attributed to tuberculosis. It results in $1 billion in lost income from people too sick to work, $11 billion in future lost income from those who die, and $4 billion in diagnosis and treatment costs. Malaria infects 400 million-900 million people a year and results in 0.7-2.7 million deaths. More than 36 million people are living with AIDS, and 25 million of them are in sub-Saharan Africa. Of the roughly 3 million AIDS-related deaths that occurred last year, about 2.4 million were in sub-Saharan Africa. Of the 5.3 million new infections in 2000, about 3.8 million were in sub-Saharan Africa.

The pain and suffering caused by infectious disease do not end with the infected individuals and their families. Bloom explained that the economic repercussions touch everyone in the developing countries and deepen the cycle of poverty that is the breeding ground of disease. Too many people are dying before they can use their education to contribute to the society through work. WHO estimates that the short life expectancy in the least developed countries (49 years) compared to the 77 years of people in the industrialized world results in an annual economic growth deficit of 1.6 percent, which becomes an enormous difference over time.

Opportunities for action

Although these numbers are daunting enough to lead to despair, Bloom sees plenty of opportunity for effective action, even with AIDS. He cites a vivid example of how effective prevention efforts can be. In 1990, AIDS infection rates were about 1 percent in South Africa and slightly lower in Thailand. Thai officials recognized how devastating an AIDS epidemic could be and instituted an ambitious AIDS education and prevention program. In 2000, HIV prevalence in Thailand had increased, but it was still below 3 percent. By contrast, South Africa did little to control the spread of the disease, and the infection rate is now close to 25 percent.

The prospects for improvement are much better with malaria and tuberculosis, because we have effective vaccines and treatments. The solution is simple–money. Bloom explains that a billion people live on less than $1 a day. In the 44 countries with average per capita income of less than $500 per year, the average health expenditure is $12 per person per year. Bloom has worked with other public health experts to help WHO develop a plan that would dramatically decrease the incidence of deadly infectious diseases at a cost that the developed countries could easily afford.

The experience of countries that have implemented programs for the early detection and treatment of tuberculosis indicates that extending this effort worldwide would cost about $900 million per year and result in an estimated economic return of $6 billion per year through increased worker production. With malaria the key is more aggressive prevention efforts to stop mosquitoes from stinging people. Actions would include increased insecticide treatment of existing mosquito netting, the purchase of additional nets and insecticide, increased spraying of breeding areas, and chemoprophylaxis for children. Economic analysis indicates that a 10 percent reduction in the incidence of malaria could lead to a 0.3 percent increase in annual economic growth. Bloom estimates that implementing an AIDS prevention program such as the one used in Thailand would yield an economic return of 37-55 percent through averted income losses and medical expenditures.

A comprehensive program for addressing the related economic and health problems of developing countries was released by the WHO-appointed Commission on Macroeconomics and Health in December 2001. The report (available online at www.who.int) contains a detailed analysis of how annual expenditures of about $34 per capita aimed at reducing the harm caused by HIV/AIDS, malaria, tuberculosis, childhood infectious diseases, maternal and perinatal conditions, micronutrient deficiencies, and tobacco-related illnesses could prevent 8 million premature deaths per year. Money for the program would come from increased spending by the developing countries themselves and a significant increase in support from the wealthy countries. Donor spending would reach $27 billion during 2007 and $38 billion in 2015. About a third of the donor funding would go to the Global Fund to Fight AIDS, tuberculosis, and malaria. Estimated economic benefits would be in the hundreds of billions and would be reflected not only in better health but also in more robust economic growth that would eventually make it possible to reduce the need for assistance from the wealthy nations.

With the war on terrorism absorbing increased government spending and the economy in recession, it might seem an inopportune time to talk about additional government expenditures. But this is a time when people are willing to think outside their individual needs and concerns and when they are painfully aware that the well-being of all the world’s people is of direct importance to the United States. The humanitarian and economic reasons to take action against global infectious disease have never been more compelling.