"Urban transport systems based on a combination of rail lines, bus lines, bicycle pathways, and pedestrian walkways offer the best of all possible worlds in providing mobility, low-cost transportation, and a healthy urban environment." –Lester R. Brown, Plan B 4.0: Mobilizing to Save Civilization.
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. Child mortality is high.
Progress in reaching the MDG of reducing child mortality two thirds by 2015 is lagging badly. As of 2005 only 32 of 147 developing countries are on track to reach this goal. In 23 countries child mortality has either remained unchanged or risen. And only 2 of the World Bank’s 35 fragile states are on track to meet this goal by 2015. 36
Along with the eradication of hunger, ensuring access to a safe and reliable supply of water for the estimated 1.1 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 10.) 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 situation. 37
One of the most impressive health gains has come from a campaign initiated by a little-heralded nongovernmental group in Bangladesh, BRAC, that taught every mother in the country how to prepare oral rehydration solution to treat diarrhea at home by simply adding salt and sugar to water. Founded by Fazle Hasan Abed, BRAC succeeded in dramatically reducing infant and child deaths from diarrhea in a country that was densely populated, poverty-stricken, and poorly educated. 38
Seeing this great success, UNICEF used BRAC’s model for its worldwide diarrheal disease treatment program. This global administration of a remarkably simple oral rehydration technique has been extremely effective—reducing deaths from diarrhea among children from 4.6 million in 1980 to 1.6 million in 2006. Egypt alone used oral rehydration therapy to cut infant deaths from diarrhea by 82 percent from 1982 to 1989. Few investments have saved so many lives at such a low cost. 39
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 invested more than $1.5 billion through 2006 to protect children from infectious diseases like measles. 40
Additional investment can help the many countries that cannot afford vaccines for childhood diseases and are falling behind in their vaccination programs. Lacking the funds to invest today, these countries 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. 41
One of the international community’s finest hours came with the eradication of smallpox, an effort led in the United Nations by the World Health Organization (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. 42
Similarly, a WHO-led international coalition, including Rotary International, UNICEF, the U.S. Centers for Disease Control and Prevention (CDC), and Ted Turner’s UN Foundation, has waged a worldwide campaign to wipe out polio, a disease that has crippled millions of children. Since 1988, Rotary International has contributed an extraordinary $600 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 fewer than 700 in 2003. 43
By late 2007, only 10 countries were still reporting polio cases, including Afghanistan, India, Myanmar, Pakistan, and several countries in central Africa and the Horn of Africa. The number of cases reported worldwide dropped from roughly 2,000 in 2006 to 545 during the first nine months of 2007. A reinvigorated program in Nigeria was on the verge of eradicating polio there. 44
For the coalition, the prospect of total eradication was within its grasp. But once again, hard-line clerics, this time in a remote region of Pakistan, began saying that the vaccination program was a U.S. conspiracy to render people infertile. Health workers have been attacked and driven from parts of Pakistan’s North West Frontier Province where the polio virus still exists. Two workers have been killed. A small group of people refusing to cooperate with the initiative could prevent the eradication of this dreaded disease for all time. 45
One of the more remarkable health success stories is the near eradication of guinea worm disease (dracunculiasis), a campaign led by former U.S. President Jimmy Carter and the Carter Center. These worms, whose larvae are ingested by drinking unfiltered water from lakes and rivers, mature in a person’s body, sometimes reaching more than two feet in length, and then exit slowly through the skin in a very painful and debilitating ordeal that can last several weeks. 46
With no vaccine to prevent infection or drug for treatment, eradication depends on filtering drinking water to prevent larvae ingestion, thus eradicating the worm, which can survive only in a human host. Six years after the CDC launched a global campaign in 1980, the Carter Center took the reins and has since led the effort with additional support from partners like WHO, UNICEF, and the Gates Foundation. The number of people infected by the worm has been reduced from 3.5 million in 1986 to 25,217 cases in 2006—an astounding drop of 99 percent. In the three countries where the worm existed outside Africa— India, Pakistan, and Yemen—eradication is complete. The remaining cases are found in a handful of countries in Africa, mainly in Sudan and Ghana. 47
Some leading sources of premature death are lifestyle-related, such as smoking. WHO estimates that 5.4 million people died in 2005 of tobacco-related illnesses, more than from any single infectious disease. Today there are some 25 known health threats that are linked to tobacco use, including heart disease, stroke, respiratory illness, many forms of cancer, and male impotence. Cigarette smoke kills more people each year than all other air pollutants combined—more than 5 million versus 3 million. 48
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 when the Framework Convention on Tobacco Control, the first international accord to deal entirely with a health issue, was adopted unanimously in Geneva in May 2003. Among other things, the treaty calls for raising taxes on cigarettes, limiting smoking in public places, and strong health warnings on cigarette packages. In addition to WHO’s initiative, the Bloomberg Global Initiative to Reduce Tobacco Use, funded by New York City Mayor Michael Bloomberg, is working to reduce smoking in lower- and middle-income countries, including China. 49
Ironically, the country where tobacco originated is now leading the world away from it. In the United States, the average number of cigarettes smoked per person has dropped from its peak of 2,814 in 1976 to 1,225 in 2006—a decline of 56 percent. Worldwide, where the downturn lags that of the United States by roughly a dozen years, usage has dropped from the historical high of 1,027 cigarettes smoked per person in 1988 to 859 in 2004, a fall of 16 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. 50
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 20 percent in France since peaking in 1991, 5 percent in China since its peak in 1990, and 20 percent in Japan since 1992. 51
Following approval of the Framework Convention, 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 and New Zealand banned smoking in bars and restaurants; and Scotland banned smoking in public buildings. Bhutan, a small Himalayan country sandwiched between India and China, has prohibited tobacco sales entirely. 52
A number of countries have since adopted a variety of measures designed to limit smoking and exposure to smoke for non-smokers. In 2005, smoking was banned in public places in Bangladesh, and Italy banned it in all enclosed public spaces, including bars and restaurants. More recently, England has forbidden it in workplaces and enclosed public spaces, and France is phasing in a similar ban by 2008. 53
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. 54
More broadly, 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 estimate 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. 55
36. World Bank, op. cit. note 1, p. 5.
37. Lack of access to safe water from ibid., p. 13.
38. Mustaque Chowdhury, Health Workforce for TB Control by DOTS: The BRAC Case, Joint Learning Initiative Working Paper 5-2 (Global Health Trust, 2004).
39. 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); “UNICEF Lists Top Causes of Child Deaths,” Reuters, 13 September 2007; Ruth Levine and the What Works Working Group, Millions Saved: Proven Successes in Global Health (Washington, DC: Center for Global Development, 2004).
40. Bill and Melinda Gates Foundation, “Vaccine-Preventable Diseases,” at www.gatesfoundation.org/GlobalHealth, viewed 13 September 2007.
41. John Donnelly, “ U.S. Seeks Cuts in Health Programs Abroad,” Boston Globe, 5 February 2003.
42. Sachs and Commission on Macroeconomics and Health, op. cit. note 39; WHO, “Smallpox,” fact sheet at www.who.int, viewed 10 October 2005.
43. WHO, “Polio Eradication: Now More Than Ever, Stop Polio Forever,” at www.who.int/features/2004/polio/en, viewed 17 September 2007; Rotary International, “About PolioPlus,” at www.rotary.org/foundation/polioplus/index.html, viewed 17 September 2007.
44. Polio cases from “Wild Poliovirus 2000–2007,” in WHO Global Polio Eradication Initiative, “Wild Poliovirus Weekly Update,” at www.polioeradication.org, updated 2 October 2007; Nigeria from WHO, Global Polio Eradication Initiative: Annual Report 2006 (Geneva: 2007), p. 6.
45 “ Pakistan Polio Drive is Suspended,” BBC News, 8 August 2007.
46. Michele Barry, M.D., “The Tail of Guinea Worm-Global Eradication Without a Drug or Vaccine,” New England Journal of Medicine, vol. 356, no. 25 (21 June 2007), pp. 2561–64.
47. Ibid.; country information from “Reported Cases of Dracunculiasis by Country, 1972–2005,” in Peter H. Gleick, The World’s Water 2006–2007 (Washington, DC: Pacific Institute, 2006), pp. 293–97.
48. Tobacco deaths from WHO, “Chronic Obstructive Pulmonary Disease (COPD),” fact sheet (Geneva: November 2006); “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; air pollution from WHO, “Air Pollution,” fact sheet 187 (Geneva: rev. September 2000).
49. Alison Langley, “Anti-Smoking Treaty Is Adopted by 192 Nations,” New York Times, 22 May 2003; information on WHO Tobacco Free Initiative at www.who.int/tobacco/index.cfm; treaty goals and Bloomberg from Alexi A. Wright and Ingrid T. Katz, “Tobacco Tightrope—Balancing Disease Prevention and Economic Development in China,” New England Journal of Medicine, vol. 356, no. 15 (12 April 2007), pp. 1493–96.
50. Cigarette consumption from U.S. Department of Agriculture (USDA), Production, Supply and Distribution, electronic database, at www.fas.usda.gov/psdonline, updated 31 August 2006, and from Tom Capehart, Tobacco Outlook (Washington, DC: USDA Economic Research Service, 24 April 2007); per capita estimates made with population from U.N. Population Division, op. cit. note 4; Daniel Yee, “Smoking Declines in U.S.—Barely,” CBS News, 10 November 2004.
51. USDA, op. cit. note 50; per capita estimates made using population from U.N. Population Division, op. cit. note 4.
52. Smoking Bans Around the World,” Reuters, 10 January 2005; “ New Zealand Stubs Out Smoking in Bars, Restaurants,” Reuters, 13 December 2004.
53. “Bangladesh Bans Smoking in Many Public Places,” Reuters, 15 March 2005; Italy from “Europeans Back Public Smoking Ban,” BBC News, 31 May 2006; “England Smoking Ban Takes Effect,” BBC News, 1 July 2007; France from Howard K. Koh et al., “Making Smoking History Worldwide,” New England Journal of Medicine, vol. 356, no. 15 (12 April 2007), pp. 1496–1498.
54. Bernard Wysocki, Jr., “Companies Get Tough With Smokers, Obese to Trim Costs,” Wall Street Journal, 12 October 2004.
55. Sachs and Commission on Macroeconomics and Health, op. cit. note 39.
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