It is Possible to Control Infectious Diseases in Poor Countries
The evidence is clear. Infectious diseases can be controlled in the
world's poorest countries. Throughout the world, communities have mobilized
to use their knowledge, skills, and resources to reverse the devastating
impact of killer diseases such as AIDS, TB, malaria, and diseases that
kill children, infants, and mothers.
Uganda, Thailand, and Senegal are all national success stories in the
fight against HIV/AIDS. Over a million lives have been spared from TB
in the past decade due to the success of TB control efforts in countries
such as China, India, Nepal, and Peru. Malaria has been turned back
in Azerbaijan and Viet Nam and reduced in some parts of Kenya and Ethiopia.
Childhood deaths and disability have been reduced in Bangladesh, Benin,
Brazil, Malawi, Mexico, Pakistan, Tanzania, and Thailand. And maternal
deaths have been reduced in a number of countries, including Sri Lanka.
Yet many of these achievements remain invisible and unrecognized by
the world at large. As a result, many people remain sceptical about
the possibility of controlling disease in poor countries. As this report
shows, such fatalism is no longer scientifically defensible. Over the
coming decade, it is possible to make huge gains against the major infectious
diseases which have a disproportionate impact on the health and well-being
of the poor.
Effective Tools are Available
It is estimated that as many as one in two malaria deaths can be prevented
if people have ready access to rapid diagnosis and prompt treatment
with antimalarial drugs --often costing no more than US$ 0.12 for a course
of treatment. Meanwhile, 25% of child deaths can be prevented if children
sleep under insecticide-treated bednets at night to avoid mosquito bites.
Yet in Africa, where an insecticide-treated bednet could be provided
for as little as US$ 4, only an estimated 1% of children sleep under
Millions of lives can be saved, and the threat of antimicrobial resistance
reduced, if people with TB have access to DOTS, a 5-pronged strategy
for TB control. And millions of new cases of HIV can be prevented through
well-targeted, low-cost HIV prevention and care strategies. More widespread
use of low-cost vaccines, vitamin A supplements, oral rehydration salts,
and inexpensive antibiotics to treat pneumonia could prevent millions
of child deaths. And a package for the Integrated Management of Pregnancy
and Childbirth, ensuring good health care throughout pregnancy and childbirth,
together with family planning, could prevent maternal and perinatal
deaths as well as the lifelong disabilities due to complications of
pregnancy -- for as little as US$ 3 a year per capita.
Keys to Success
Many low-income countries have shown that by using the available tools
both widely and wisely the disease burden of infectious diseases can
be reduced dramatically. But it is not easy, as the success stories
that follow will show, especially in the over 20 countries worldwide
that have less than US$ 20 a year per capita to spend on health. Many
countries have succeeded in spite of poverty. Malawi is set to eliminate
measles in a country where only 3% of the population have access to
adequate sanitation and Bangladesh has reduced neonatal tetanus death
rates by over 90% at a time when most mothers in this country do not
have access to a clean delivery.
In many cases, efforts to reduce the burden of disease have been driven
by firm political commitment
at the highest level. Examples include Uganda and Thailand where political
leadership has been critical in the fight against HIV/AIDS and where
every government sector has been involved. Another example is Peru,
where the government has established TB control as a social, political,
and economic priority.
Success has often involved new ways of working : entering into partnerships
with the private sector, nongovernmental organizations (NGOs), and UN
agencies -- for the social marketing of condoms in Uganda and for malaria
control in Azerbaijan. In some countries, governments are providing
health services and commodities outside the formal health sector in
an effort to broaden access to health care. In Senegal, mosques throughout
the country are a focal point for HIV prevention efforts, counselling
and support. In the United Republic of Tanzania (Tanzania) a school-based
programme has improved the health of children infected with intestinal
worms, and in Kenya, employers are supplying bednets to their workforce
through payroll purchasing schemes.
born out of a pragmatic approach to achieving results, has made all
the difference in some countries. In Nepal, hostel accommodation is
provided for TB patients from remote mountain areas to encourage compliance
with treatment. In China, cash incentives are provided to local health
workers for every case of TB they detect and cure. And in Thailand,
the government worked with brothel owners to ensure 100% condom use --
despite the fact that prostitution remains illegal. Meanwhile, in
Senegal, religious leaders opposed to condom use have had the courage
to refer people to other service providers.
Elsewhere, efforts to promote the
home as the first hospital --in a bid to ensure rapid
diagnosis and prompt treatment for malaria and diarrhoeal diseases,
for example-- have helped reduce child deaths in Ethiopia and Mexico.
Training of health care workers and education of mothers have been key
elements for success, as witnessed in Sri Lanka where high female literacy
rates and midwifery training for health care workers have both been
instrumental in preventing maternal deaths. In India, a massive training
programme involving 100 000 health workers has helped ensure that treatment
of TB can be provided within the community. Meanwhile, sex education
for children and adolescents has been an integral part of successful
HIV prevention programmes in Thailand, Senegal, and Uganda.
Well-stocked supplies, medicines,
and other low-cost tools at the community level are essential. Without
the availability of these lifesaving commodities, health workers are
unable to do the job for which they are trained. In some cases, local
production of drugs, vaccines, and other commodities has helped keep
prices down. Examples include community production of bednets in Kenya,
manufacture of tetanus toxoid vaccine in Bangladesh, and local production
of antimalarial drugs in Viet Nam. In Mexico, supplies of oral rehydration
salts were increased almost tenfold in the fight against childhood diarrhoeal
deaths. Elsewhere, social marketing of condoms in Senegal and Uganda
has been a key factor in preventing HIV.
Finally, an approach focused on achieving measurable
results is central to most of the success stories that follow.
In Senegal, Thailand, and Uganda, disease surveillance and monitoring
systems have been essential in tracking the course of the HIV/AIDS epidemic
and monitoring the effectiveness of interventions. Meanwhile, Malawi's
success in controlling measles has involved efforts to improve surveillance
and monitoring systems. And Viet Nam's dramatic success in reducing
malaria deaths has been backed up by strengthened disease reporting
and epidemic forecasting systems.
The Challenge is in Scaling Up
Much is at stake. Almost half of all deaths in developing countries
are due to infectious diseases. And most of these deaths are among newborn
babies, children under five, and young adults -- among them parents and
Meanwhile, repeated bouts of illness and chronic disability keep children
away from school and prevent adults from working or caring for their
families -- trapping families in a downward spiral of poverty, lost opportunity,
and ill-health. While life expectancy edges ever higher in the industrialized
world, children in some developing countries are not expected to live
beyond 50. And for 3 million of the children born each year, life begins
and ends before they are even a week old.
But this vicious cycle of poverty and ill-health can be broken. The
success stories that follow are evidence that widespread and wise use
of low-cost tools, coupled with new flexible ways of working, often
through partnerships and across sectors other than health, can have
a major impact, even in the poorest countries. What is needed now is
a massive effort to replicate these successes on a global scale.
Many other countries could achieve similar results if they could afford
to massively increase their supplies of urgently needed medicines, vaccines,
and other lifesaving commodities. However, in countries where health
systems are both under-resourced and under-performing, critical efforts
will also be needed to strengthen the capacity of the health system
to identify and respond to the most urgent health needs, to ensure universal
access to health care, to work with operational partners, and to develop
effective systems for disease reporting and for the delivery of health
supplies and services.