“[Brown’s] ability to make a complicated subject accessible to the general reader is remarkable...” –Katherine Salant, Washington Post
Chapter 10. Responding to the Social Challenge: Health for All
While heart disease and cancer (largely the diseases of aging), obesity, and smoking dominate health concerns in industrial countries, in developing countries infectious diseases are the overriding health concern. Beyond AIDS, the principal infectious diseases are diarrhea, respiratory illnesses, tuberculosis, malaria, and childhood diseases such as measles.
Hunger amplifies the effects of infectious diseases. Diarrheal disease, which is seldom fatal in industrial countries, claims some 1.5 million lives each year, mostly of children in the developing world. Among well-nourished children, measles are rarely fatal, yet this disease kills some 800,000 children annually, nearly all of them weakened by hunger and easily overwhelmed. Respiratory illnesses, a minor problem in a healthy population, also take a heavy toll among children with weakened immune systems.28
Traditional infectious diseases, such as tuberculosis and malaria, annually claim 1.6 million and 1.1 million lives, respectively. Tuberculosis is particularly challenging for doctors because some strains are resistant to antibiotics. It is a leading health issue in Russia and neighboring countries as well as in developing ones.29
Malaria has a sharp geographic focus, with 90 percent of the 1 million deaths last year occurring in Africa. A Roll Back Malaria initiative from the World Heath Organization (WHO) is designed to reduce the malaria threat. Among other things, it involves providing low-cost insecticide-treated bednets. New initiatives within Africa in malaria research and drug and vaccine development could also help curb the disease.30
Many countries that are no longer able to afford the vaccines for childhood diseases, such as measles, have fallen behind in their vaccination programs. Lacking the funds to invest today, they pay a far higher price tomorrow. There are not many situations where just a few pennies spent per youngster can make as much difference as vaccination programs can.31
Along with the eradication of hunger, the provision of safe water is one of the keys to better health for children. The realistic option now may be to bypass efforts to build costly water-based sewage removal and sewage treatment systems and to opt instead for water-free waste disposal systems that do not disperse disease pathogens, like the dry toilets described in Chapter 7. This switch would simultaneously help alleviate water scarcity, reduce the dissemination of disease agents in water systems, and close the nutrient cycle.
Beyond infectious diseases, air pollution, automobiles, and cigarettes claim millions of lives each year. WHO estimates that air pollution, largely from power plants and automobiles, claims 3 million lives a year. While most industrial countries have made progress in reducing urban air pollution, in developing countries this problem is worsening.32
Worldwide, automobile accidents kill 1.2 million people a year, making car ownership almost as dangerous as cigarette smoking. And cars are also a major source of the air pollution that kills drivers and nondrivers alike. If we allocate a third of air pollution deaths to pollutants from automobile exhaust, auto fatalities would exceed 2 million.33
Some leading sources of premature death are lifestyle-related. Cigarettes take a particularly heavy toll. WHO estimates that 4.9 million people died in 2000 of tobacco-related illnesses. Today there are some 25 known tobacco-related diseases, including heart disease, stroke, respiratory illness, several forms of cancer, and male impotence. Cigarette smoke kills more people each year than all other air pollutants combined—nearly 5 million versus 3 million.34
Impressive progress is being made in reducing cigarette smoking. After a century-long buildup of a tobacco habit, the world is turning away from cigarettes, following the U.S. lead and with a strong boost from WHO leadership in its "tobacco free" initiative. This will no doubt be helped by the Framework Convention on Tobacco Control, the first international accord to deal entirely with a health issue, which was adopted unanimously in Geneva in May 2003.35
Ironically, the country that gave the world tobacco is now leading us away from it. In the United States, the number of cigarettes smoked per person has dropped from 2,844 in 1976 to 1,593 in 2002—a decline of 44 percent. Worldwide, where the downturn lags that of the United States by roughly a decade, usage has dropped from the historical high of 1,020 cigarettes smoked per person in 1986 to 878 in 2002, a fall of 14 percent.36
Indeed, smoking is on the decline in nearly all the major cigarette-consuming countries, including such strongholds as France, China, and Japan. The number of cigarettes smoked per person has dropped 20 percent in France since peaking in 1985, 8 percent in China since 1990, and 14 percent in Japan since 1992.37
One of the principal achievements of the international community in recent decades has been the eradication of smallpox, an effort led by WHO. This successful elimination of a feared disease, which required the worldwide immunization of the poorest of the world's poor, not only now saves hundreds of millions of dollars each year in smallpox vaccination programs but also billions of dollars in health care, and has lightened the burden of disease worldwide. Similarly, the WHO-led international campaign to eradicate polio is on the verge of eliminating another of the world's great scourges, one that did not distinguish between the rich and the poor.38
Another impressive gain on the health front has come from a campaign led by UNICEF to treat the symptoms of diarrheal disease with oral rehydration therapy. This remarkably simple technique, the oral administration of a mild saline solution, has been extremely effective—reducing deaths from diarrhea among children from 4.6 million in 1980 to 1.5 million in 1999. Few investments have saved so many lives at such a low cost.39
A recent study commissioned by WHO Director-General Gro Harlem Brundtland looked at the economics of health care in developing countries and concluded that providing the most basic health care services—the sort that could be supplied by a village-level clinic—would yield enormous economic benefits for the developing countries and for the world as a whole. The authors estimated that providing basic universal health care in developing countries will require donor grants totaling $27 billion in 2007, scaled up to $38 billion in 2015. Of the first commitment, for 2007, $6 billion is already being provided by donors. In addition to basic services, this figure includes funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria and for universal childhood vaccinations. The report estimated that the total program would cost one tenth of 1 percent of the gross national product of industrial countries. Thus health care is a prime example of an ounce of investment being worth a pound of cure.40
28. Hunger as a risk factor for disease in World Health Organization (WHO), World Health Report 2002 (Geneva: 2002), and in Majid Ezzati et al., "Selected Major Risk Factors and Global and Regional Burden of Disease," The Lancet, 30 October 2002, pp. 1-14; information on the toll of measles and diarrhea in Jeffrey D. Sachs and the Commission on Macroeconomics and Health, Macroeconomics and Health: Investing in Health for Economic Development (Geneva: WHO, 2001), pp. 43-44.
29. Tuberculosis from WHO, op. cit. note 28, p. 157; malaria from WHO/UNICEF, The Africa Malaria Report 2003 (New York: 2003), p. 17; "Agency Puts Hunger No. 1 on List of World's Top Health Risks," Agence France-Presse, 31 October 2002.
30. WHO/UNICEF, op. cit. note 29; Declan Butler, "Malaria Initiative Cries Out for Action in Africa," Nature, 20 November 2002, p. 351.
31. John Donnelly, "U.S. Seeks Cuts in Health Programs Abroad," Boston Globe, 5 February 2003.
32. WHO, "Air Pollution," fact sheet 187, revised September 2000, at www.who.int/inf-fs/en/fact187.html.
33. Automobile fatalities from World Bank, "Road Safety," at www.worldbank.org/html/fpd/transport/roads/safety.htm, viewed 5 May 2003.
34. WHO, op. cit. note 28, p. 10; "The Tobacco Epidemic: A Crisis of Startling Dimensions," in Message From the Director-General of the World Health Organization for World No-Tobacco Day 1998, at www.who.int/archives/ntday/ntday98/ad98e_1.htm; air pollution from WHO, op. cit. note 32.
35. Alison Langley, "Anti-Smoking Treaty Is Adopted by 192 Nations," New York Times, 22 May 2003; information on WHO's Tobacco Free Initiative is at www5.who.int/tobacco/index.cfm.
36. Cigarette consumption from U.S. Department of Agriculture (USDA), Production, Supply, and Distribution, electronic database, Washington, DC, updated 13 May 2003; per capita estimates made using population from United Nations, op. cit. note 1.
37. USDA, op. cit. note 36.
38. Sachs and the Commission on Macroeconomics and Health, op. cit. note 28; WHO, "Fact Sheet on Smallpox," at www.who.int/emc/diseases/smallpox/factsheet.html, October 2001.
39. Sachs and the Commission on Macroeconomics and Health, op. cit. note 28.
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