“[Brown’s] ability to make a complicated subject accessible to the general reader is remarkable...” –Katherine Salant, Washington Post
Chapter 7. Eradicating Poverty, Stabilizing Population: Better 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. Besides AIDS, the principal diseases of concern are diarrhea, respiratory illnesses, tuberculosis, malaria, and measles.
Many countries can no longer afford the vaccines for childhood diseases, such as measles, and are falling 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, ensuring access to a safe and reliable supply of water for the estimated 1 billion people who lack it is essential to better health for all. The realistic option in many cities now may be to bypass efforts to build costly water-based sewage removal and treatment systems and to opt instead for water-free waste disposal systems that do not disperse disease pathogens. (See the description of dry compost toilets in Chapter 11.) This switch would simultaneously help alleviate water scarcity, reduce the dissemination of disease agents in water systems, and help close the nutrient cycle—another win-win-win opportunity.
One of the most impressive health gains has come from a campaign led by UNICEF to treat the symptoms of diarrheal disease with oral rehydration therapy. This remarkably simple technique, which involves drinking 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. In Millions Saved, Ruth Levine describes how Egypt used oral rehydration therapy to cut infant deaths from diarrhea by 82 percent from 1982 to 1989. 32
Some leading sources of premature death are lifestyle-related. Cigarettes take a particularly heavy toll. The World Health Organization (WHO) estimates that 4.9 million people died in 2000 of tobacco-related illnesses, more than from any infectious disease. Today there are some 25 known diseases that are linked to tobacco use, 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. 33
Impressive progress is being made in reducing cigarette smoking. After a century-long buildup of the tobacco habit, the world is turning away from cigarettes, led by WHO’s Tobacco Free Initiative. This gained further momentum from 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. 34
Ironically, the country where tobacco originated is now leading the world away from it. In the United States, the number of cigarettes smoked per person has dropped from its peak of 2,872 in 1976 to 1,374 in 2003—a decline of 52 percent. Worldwide, where the downturn lags that of the United States by roughly a decade, usage has dropped from the historical high of 1,035 cigarettes smoked per person in 1986 to 856 in 2003, a fall of 17 percent. Media coverage of the health effects of smoking, mandatory health warnings on cigarette packs, and sharp increases in cigarette sales taxes have all contributed to the steady decline. 35
Indeed, smoking is on the decline in nearly all the major cigarette-smoking countries, including such strongholds as France, China, and Japan. The number of cigarettes smoked per person has dropped 22 percent in France since peaking in 1984, 5 percent in China since 1989, and 20 percent in Japan since 1991. 36
Following approval of the Framework Convention on Tobacco Control, a number of countries took strong steps in 2004 to reduce smoking. Ireland imposed a nationwide ban on smoking in workplaces, bars, and restaurants; India banned smoking in public places; Norway banned smoking in bars and restaurants; and Scotland banned smoking in public buildings. Bhutan, a Himalayan country of 1 million sandwiched between India and China, has prohibited tobacco sales entirely. 37
In 2005, smoking was banned in public places in Bangladesh, in bars and restaurants in New Zealand, and in public places in Italy. In the United States, which already has stiff restrictions on smoking, the Union Pacific Corporation stopped hiring smokers in seven states as an economy measure to cut health care costs. General Mills imposes a $20-a-month surcharge on health insurance premiums for employees who smoke. Each of these measures helps the market to more accurately reflect the cost of smoking. 38
The war against infectious diseases is being waged on a broad front. Perhaps the leading privately funded life-saving activity in the world today is the childhood immunization program. In an effort to fill the gap in this global program, the Bill and Melinda Gates Foundation has invested $1.5 billion through 2005 to protect children from infectious diseases. 39
One of the international community’s finest moments came with the eradication of smallpox, an effort led by WHO. This successful elimination of a feared disease, which required a worldwide immunization program, saves not only millions of lives but also hundreds of millions of dollars each year in smallpox vaccination programs and billions of dollars in health care expenditures. This achievement alone may justify the existence of the United Nations. 40
Similarly, a WHO-led international coalition, including Rotary International, UNICEF, the U.S. Centers for Disease Control and Prevention, and Ted Turner’s UN Foundation, has led a worldwide campaign to wipe out polio. Since 1988, Rotary International has contributed an extraordinary $500 million to this effort. Under this coalition-sponsored Global Polio Eradication Initiative, the number of polio cases worldwide dropped from some 350,000 per year in 1988 to just 800 in 2003. 41
By mid-2003, pockets of polio remained only in Nigeria, Niger, Egypt, India, Pakistan, and Afghanistan, but then some of the Muslim-dominated states of northern Nigeria stopped vaccination because of a rumor that the vaccine would render people sterile or cause AIDS. By the end of 2004, when the misinformation was corrected, polio vaccinations were resumed in northern Nigeria. But during the interim, polio had become reestablished in several countries, apparently aided by the annual pilgrimage of Nigerian Muslims to Mecca. New infections appeared in Saudi Arabia, Yemen, Côte d’Ivoire, Burkina Faso, the Central African Republic, Chad, Mali, Sudan, Indonesia, and Somalia. 42
These countries, once free of the disease, are scrambling now to contain and eradicate the new outbreak that as of September 2005 had grown to 1,260 cases. With two recently confirmed cases in Somalia, a failed state, the fear is that the virus may spread further not only in this country where there is no government to work with, but to other countries as well, making it extraordinarily difficult to eradicate. 43
A 2001 WHO study analyzing the economics of health care in developing countries 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 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, or an average of $33 billion per year. In addition to basic services, this $33 billion includes funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria and for universal childhood vaccinations. 44
31. John Donnelly, “U.S. Seeks Cuts in Health Programs Abroad,” Boston Globe, 5 February 2003.
32. Jeffrey D. Sachs and the Commission on Macroeconomics and Health, Macroeconomics and Health: Investing in Health for Economic Development (Geneva: World Health Organization (WHO), 2001); Ruth Levine and the What Works Working Group, Millions Saved: Proven Successes in Global Health (Washington, DC: Center for Global Development, 2004).
33. WHO, World Health Report 2002 (Geneva: 2002), 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, “Air Pollution,” fact sheet 187 (Geneva: revised September 2000).
34. 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.
35. Cigarette consumption from U.S. Department of Agriculture (USDA), Production, Supply, & Distribution, electronic database, Washington, DC, updated 31 May 2005; per capita estimates made using
population from United Nations, op. cit. note 4; Daniel Yee, “Smoking Declines in U.S.—Barely,” CBS News, 10 November 2004.
36. USDA, op. cit. note 35; per capita estimates made using population from United Nations, op. cit. note 4.
37. Smoking Bans Around the World,” Reuters, 10 January 2005.
38. “Bangladesh Bans Smoking in Many Public Places,” Reuters, 15 March 2005; “New Zealand Stubs Out Smoking in Bars, Restaurants,” Reuters, 13 December 2004; Bernard Wysocki, Jr., “Companies Get Tough With Smokers, Obese to Trim Costs,” Wall Street Journal, 12 October 2004.
39. Bill and Melinda Gates Foundation, “Vaccine-Preventable Diseases,” at www.gatesfoundation.org/GlobalHealth/Pri_Diseases/Vaccines/ default, viewed 9 September 2005.
40. Sachs and Commission on Macroeconomics and Health, op. cit. note 32; WHO, “Smallpox,” fact sheet at www.who.int, viewed 10 October 2005.
41. United Nations Foundation, “The United Nations Foundation Honors Canadian Government for Contributions in Fight Against Polio,” press release, 27 January 2005; United Nations Foundation, “Donate: Polio,” at www.unfoundation.org/donate/polio.asp, viewed 9 September 2005.
42. David Brown, “A Blow to Anti-Polio Campaign,” Washington Post, 10 May 2005; Global Polio Eradication Initiative, “Polio Eradication Situation Report—September 2005,” press release (Geneva: September 2005).
43. Global Polio Eradication Initiative, op. cit. note 42; Global Polio Eradication Initiative, “Global Case Count,” at www.polioeradication.org/casecount.asp, 20 September 2005.
44. Sachs and Commission on Macroeconomics and Health, op. cit. note 32.
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