"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 and Stabilizing Population: Toward a Healthy Future
While heart disease, cancer, obesity, and smoking dominate health concerns in industrial countries, in developing countries infectious diseases are the overriding health threat. The principal diseases of concern are diarrhea, respiratory illnesses, tuberculosis, malaria, measles, and AIDS. Child mortality is high because childhood diseases such as measles, easily prevented by vaccination, take such a heavy toll.
Progress in reaching the MDG of reducing child mortality by two thirds between 1990 and 2015 is lagging badly. As of 2007 only 33 of 142 developing countries were on track to reach this goal. No country in sub-Saharan Africa was on that list; in fact, child mortality rates in seven sub-Saharan African countries have actually increased since 1990. And only 1 of the World Bank’s 34 fragile states is likely to meet this goal by 2015. 24
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 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 6.) 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. 25
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 a measured amount of 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. 26
Seeing this great success, UNICEF used BRAC’s model for its worldwide diarrheal disease treatment program. This global use 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 between 1982 and 1989. Few investments have saved so many lives at such a low cost. 27
Perhaps the leading privately funded life-saving activity in the world today is the childhood immunization program. In an effort to fill a gap in this global program, the Bill and Melinda Gates Foundation has invested more than $1.5 billion to protect children from infectious diseases like measles. 28
Additional investments 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. 29
Similarly with AIDS, an ounce of prevention is worth a pound of cure. More than 25 million people have died from HIV-related causes thus far. Although progress is being made in curbing the spread of HIV, 2.7 million people were newly infected in 2007 and 2 million died of AIDS during that year. Two thirds of those living with HIV are in sub-Saharan Africa. 30
The key to curbing the AIDS epidemic, which has so disrupted economic and social progress in Africa, is education about prevention. We know how the disease is transmitted; it is not a medical mystery. Where once there was a stigma associated with even mentioning the disease, governments are beginning to design effective prevention education programs. The first goal is to reduce quickly the number of new infections, dropping it below the number of deaths from the disease and thereby shrinking the number of those who are capable of infecting others.
Concentrating on the groups that are most likely to spread the disease is particularly effective. In Africa, infected truck drivers who travel far from home for extended periods often engage in commercial sex, spreading HIV from one country to another. Sex workers are also centrally involved in spreading the disease. In India, for example, educating the country’s 2 million female sex workers, who have an average of two encounters per day, about HIV risks and the life-saving value of using a condom pays huge dividends. 31
Another target group is the military. After soldiers become infected, usually from engaging in commercial sex, they return to their home communities and spread the virus further. In Nigeria, where the adult HIV infection rate is 3 percent, President Olusegun Obasanjo introduced free distribution of condoms to all military personnel. A fourth target group, intravenous drug users who share needles, figures prominently in the spread of the virus in the former Soviet republics. 32
At the most fundamental level, dealing with the HIV threat requires roughly 13.5 billion condoms a year in the developing world and Eastern Europe. Including those needed for contraception adds another 4.4 billion. But of the 17.9 billion condoms needed, only 3.2 billion are being distributed, leaving a shortfall of 14.7 billion. At only 3¢ each, or $441 million, the cost of saved lives by supplying condoms is minuscule. 33
In the excellent study Condoms Count: Meeting the Need in the Era of HIV/AIDS, Population Action International notes that “the costs of getting condoms into the hands of users—which involves improving access, logistics and distribution capacity, raising awareness, and promoting use—is many times that of the supplies themselves.” If we assume that these costs are six times the price of the condoms, filling this gap would still cost less than $3 billion. 34
The financial resources and medical personnel currently available to treat people who are already HIV-positive are severely limited compared with the need. For example, of the 7 million people who needed anti-retroviral therapy in sub-Saharan Africa at the end of 2007, just over 2 million were receiving the treatment that is widely available in industrial countries. Although the number getting treatment was only one third of those who need it, it was still nearly double the number treated during the preceding year. 35
Treating HIV-infected individuals is costly, but ignoring the need for treatment is a strategic mistake simply because treatment strengthens prevention efforts by giving people a reason to be tested. Africa is paying a heavy cost for its delayed response to the epidemic. It is a window on the future of other countries, such as India and China, if they do not move quickly to contain the virus, already well established within their borders. 36
One of the United Nations’ finest hours came with the eradication of smallpox, an effort led 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 each year but also hundreds of millions of dollars in smallpox vaccination programs and billions of dollars in health care expenditures. 37
In an initiative patterned after the smallpox eradication, a WHO-led international coalition—including Rotary International, UNICEF, the U.S. Centers for Disease Control and Prevention (CDC), Ted Turner’s U.N. Foundation, and, more recently, the Bill and Melinda Gates 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 $800 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. 38
By 2003, pockets of polio remained largely in Nigeria, India, Pakistan, Niger, Chad, and Burkina Faso, but then some of the predominantly Muslim 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, after 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 the Central African Republic, Côte d’Ivoire, Indonesia, Mali, Saudi Arabia, Somalia, Sudan, and Yemen, which by 2006 allowed the global total of infections to rebound to nearly 2,000. 39
By 2007, the number of reported new cases of polio was again shrinking when another roadblock emerged. In early 2007 violent opposition to vaccinations arose in Pakistan’s North West Frontier Province, where a doctor and a health worker in the polio eradication program were killed. More recently, the Taliban have refused to let health officials administer polio vaccinations in the province’s Swat Valley, further delaying the campaign. 40
Despite these setbacks, in early 2009 the international community launched another major push to eradicate polio. This $630-million effort is being underwritten by the Gates Foundation, Rotary International, and the U.K. and German governments. But this was not all. In June 2009, President Obama announced in Cairo a new global effort working with the Organisation of the Islamic Conference to eradicate polio. Since so many of the remaining pockets of polio are in Muslim countries, this enhances the prospect of finally eradicating this disease. 41
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. They then exit slowly through the skin in a very painful and debilitating ordeal that can last several weeks. 42
With no vaccine to prevent infection and no 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 under 5,000 cases in 2008—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 mainly in Sudan, Ghana, and Mali. 43
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 infectious disease including AIDS. 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. 44
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. 45
Ironically, the country where tobacco originated is now the leader in moving away from cigarettes. 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 this encouraging development. 46
The prospect of further reducing smoking in the United States got a major boost in April 2009 when the federal tax per pack of cigarettes was increased from 39¢ to $1.01 to reduce the fiscal deficit. Many states were contemplating a raise in state cigarette taxes for the same reason. 47
Indeed, smoking is on the decline in nearly all the major countries where it is found, including such strongholds as France, China, and Japan. By 2007, the number of cigarettes smoked per person had dropped 20 percent in France after peaking in 1991, 5 percent in China since its peak in 1990, and 20 percent in Japan since 1992. 48
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, has prohibited tobacco sales entirely. 49
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 imposed a similar ban in 2008. Both Bulgaria and Croatia have since followed. 50
Another disease that is often lifestyle-related, diabetes, is on the rise, reaching near epidemic levels in, for example, the United States and cities in India. Reversing the rising incidence of diabetes, an illness that appears to enhance the likelihood of Alzheimer’s disease, depends heavily on lifestyle adjustments—fewer calories and more exercise. 51
Effective responses to many emerging health problems often lie outside the purview of the Ministry of Health. For example, in China deaths from cancer have reached epidemic levels. Birth defects jumped by 40 percent between 2001 and 2006, with the biggest jumps coming in coal-producing provinces such as Shanxi and Inner Mongolia. The ability to reverse these trends lies not in the Ministry of Health but in altering the country’s energy and environmental policies. On their own, doctors cannot halt the fast-rising number of deaths from cancer, now the leading cause of death in China. 52
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 on average $33 billion a year through 2015. In addition to basic services, this figure includes funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria and for universal childhood vaccinations. 53
24. World Bank, Global Monitoring Report 2009, op. cit. note 1, Annex; UNICEF, “Under-five Mortality Rate,” at www.childinfo.org/mortalityunderfive.php, updated January 2009.
25. World Bank, Global Monitoring Report 2009, op. cit. note 1, p. 72.
26. Mustaque Chowdhury, Health Workforce for TB Control by DOTS: The BRAC Case, Joint Learning Initiative Working Paper 5-2 (Global Health Trust, 2004).
27. 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).
28. Bill and Melinda Gates Foundation, “Global Health Program Fact Sheet” (Seattle, WA: 2009).
29. John Donnelly, “U.S. Seeks Cuts in Health Programs Abroad,” Boston Globe, 5 February 2003.
30. Joint United Nations Programme on HIV/AIDS (UNAIDS), Report on the Global AIDS Epidemic 2008 (Geneva: August 2008), pp. 15–16, 30.
31. Nita Bhalla, “Teaching Truck Drivers About AIDS,” BBC, 25 June 2001; C. B. S. Venkataramana and P. V. Sarada, “Extent and Speed of Spread of HIV Infection in India Through the Commercial Sex Networks: A Perspective,” Tropical Medicine and International Health, vol. 6, no. 12 (December 2001), pp. 1,040–61, cited in “HIV Spread Via Female Sex Workers in India Set to Increase Significantly by 2005,” Reuters Health, 26 December 2001.
32. Mark Covey, “Target Soldiers in Fight Against AIDS Says New Report,” press release (London: Panos Institute, 8 July 2002); “Free Condoms for Soldiers,” South Africa Press Association, 5 August 2001; HIV prevalence rate from UNAIDS, op. cit. note 30, p. 215.
33. Condoms needed from Population Action International, “Why Condoms Count in the Era of HIV/AIDS,” fact sheet (Washington, DC: 2008); cost per condom and condom distribution from United Nations Population Fund (UNFPA), Donor Support for Contraceptives and Condoms for STI/HIV Prevention 2007 (New York: 2008).
34. Nada Chaya and Kai-Ahset Amen, with Michael Fox, Condoms Count: Meeting the Need in the Era of HIV/AIDS (Washington, DC: Population Action International, 2002); cost per condom from UNFPA, op. cit. note 33.
35. UNAIDS, “Global Facts and Figures,” fact sheet (Geneva: August 2008); UNAIDS, op. cit. note 30, p. 135.
36. “AIDS Summit: The Economics of Letting People Die,” Star Tribune, 16 July 2003.
37. Sachs and Commission on Macroeconomics and Health, op. cit. note 27; WHO, “Smallpox,” fact sheet at www.who.int, viewed 10 October 2005.
38. WHO, “Polio Eradication: Now More Than Ever, Stop Polio Forever,” at www.who.int/features/2004/polio/en, viewed 11 June 2009; Petina Dixon, Rotary International, discussion with Jignasha Rana, Earth Policy Institute, 6 July 2009; Bill and Melinda Gates Foundation, “Financial Innovation Will Buy Vaccine to Help Eradicate Polio Worldwide,” press release (Seattle, WA: 29 April 2003).
39. “Wild Poliovirus 2000–2009,” in WHO Global Polio Eradication Initiative, “Wild Poliovirus Weekly Update,” at www.polioeradication.org, updated 3 June 2009; Donald G. McNeil, Jr., “Mecca Pilgrims May Be Spreading Polio, Experts Say,” New York Times, 11 February 2005; Nigeria from WHO, Global Polio Eradication Initiative: Annual Report 2006 (Geneva: 2007), p. 6.
40. “Wild Poliovirus 2000–2009,” op. cit. note 39; “Pakistan Polio Drive is Suspended,” BBC News, 8 August 2007; Isambard Wilkinson, “Taliban Blocks UN Polio Treatment in Pakistan,” Telegraph (London), 27 March 2009.
41. Declan Butler, “$630-Million for Push to Eradicate Polio,” Nature News, 21 January 2009; Barack H. Obama, “Remarks by the President on a New Beginning,” speech at Cairo University, Cairo, Egypt, 4 June 2009.
42. Michele Barry, “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. 2,561–64.
43. “Grants Push Guinea Worm to All-Time Low,” news release (Atlanta, GA: The Carter Center, 20 January 2009); The Carter Center, “Distribution by Country of 4,647 Cases of Indigenous Cases of Dracunculiasis Reported During 2008,” at www.cartercenter.org/health/guinea_worm/index.html, viewed 13 May 2009.
44. 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).
45. 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. 1,493–96.
46. Cigarette consumption from USDA, Production, Supply and Distribution, op. cit. note 9, and from Tom Capehart, Tobacco Outlook (Washington, DC: USDA, Economic Research Service (ERS), 24 April 2007); per capita estimates made with population from U.N. Population Division, op. cit. note 2; Daniel Yee, “Smoking Declines in U.S.—Barely,” CBS News, 10 November 2004.
47. Betsy McKay, “Cigarette Tax Clouds Boosts Among States,” Wall Street Journal, 8 February 2009.
48. Cigarette consumption from USDA, Production, Supply and Distribution, op. cit. note 9, and from Capehart, op. cit. note 46; per capita estimates made using population from U.N. Population Division, op. cit. note 2.
49. “Smoking Bans Around the World,” Reuters, 10 January 2005; “New Zealand Stubs Out Smoking in Bars, Restaurants,” Reuters, 13 December 2004.
50. “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. 1,496–98; “French Cafes Set to Ban Smoking,” BBC News, 28 December 2007; “Bulgaria Votes for Smoking Ban in Public Places,” Reuters, 15 May 2009; Ivana Sekularac, “Smoking Ban Angers Cafes, Smokers in Croatia,” Reuters, 6 May 2009.
51. “Connections between Diabetes and Alzheimer’s Disease Explored,” Science Daily, 11 May 2009.
52. “Cancer Most Lethal Illness in China Last Year,” China Daily, 8 May 2007; Barbara Demick, “China Blames Pollution for Surge in Birth Defects,” Los Angeles Times, 2 February 2009.
53. Sachs and Commission on Macroeconomics and Health, op. cit. note 27.
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