Millennium Global Challenges No. 8. How can the threat of new and reemerging diseases and immune microorganisms be reduced?

Reference: The Millennium Project

World health is improving, the incidence of diseases is falling, and people are living longer, yet many old challenges remain and future threats are serious. Over 30% fewer children under five died in 2010 than in 1990, and total mortality from infectious disease fell from 25% in 1998 to less than 16% in 2010. Funding for global health continues to increase to an estimated $26.8 billion in 2010, which has also increased the need for better coherence among the many new actors in world health.

Non-communicable diseases and emerging and drug-resistant infectious diseases are increasing. Because the world is aging and increasingly sedentary, cardiovascular disease is now the leading cause of death in the developing as well as the industrial world. However, infectious diseases are the second largest killer and cause about 67% of all preventable deaths of children under five (pneumonia, diarrhea, malaria, and measles). Poverty, urbanization, travel, immigration, trade, increased encroachment on animal territories, and concentrated livestock production move infectious organisms to more people in less time than ever before and could trigger new pandemics. Over the past 40 years, 39 new infectious diseases have been discovered, 20 diseases are now drug-resistant, and old diseases have reappeared, such as cholera, yellow fever, plague, dengue fever, meningitis, hemorrhagic fever, and diphtheria. In the last five years, more than 1,100 epidemics have been verified. About 75% of emerging pathogens are zoonotic (they jump species).

During 2011 there were six potential epidemics. The most dangerous may be the NDM-1 enzyme that can make a variety of bacteria resistant to most drugs. Previously only found in hospitals, it was found this year in New Delhi’s drinking water and sewers, making it easier to spread. Other notable developments this year include the European E. coli/ Hemolytic Uremic Syndrome food-borne outbreak; the progression of arteminisin-resistent malaria near the Cambodian border; the cholera epidemic in Haiti; the continued global threat from MDR and XDR tuberculosis in the AIDS population; and the potential for epidemics and nuclear contamination in post-earthquake, post-nuclear-meltdown Japan.

The H1N1 (swine flu) that infected millions around the world ended in August 2010 due to the ability of the World Health Organization (WHO) and the global network to detect, isolate, genetically evaluate, vaccinate, and persuade the public to act. Mexico (where the virus was first identified) responded with praiseworthy professionalism in handling the A/H1N1 flu outbreak. The H5N1 (avian flu) of 2007–08 killed half of the people infected. Spreading slowly, it has mutated three times in 15 years, and could mutate again. The best ways to address epidemic disease remain early detection, accurate reporting, prompt isolation, and transparent information and communications infrastructure, with increased investment in clean drinking water, sanitation, and hand-washing. WHO’s eHealth systems, international health regulations, immunization programs, and the Global Outbreak Alert and Response Network are other essentials of the needed infrastructure.

New HIV infections declined 19% over the past decade; AIDS-related deaths dropped by 19% between 2004 and 2009; the median cost of antiretroviral medicine per person in low-income countries has dropped to $137 per year; and 45% of the estimated 9.7 million people in need of antiretroviral therapy received it by the end of 2010. Yet two new HIV infections occur for every person starting treatment; 2.6 million were newly infected and 2 million died during 2009; and 33 million people are living with HIV/AIDS today. Some experts recommend a combination of annual voluntary universal testing in high-prevalence populations coupled with the immediate initiation of antiretroviral therapy (ART) for those who test positive. Because ART reduces the viral load to the point where it cannot be detected, it also prevents transmission. Others say this “test and treat” approach is too expensive and a human rights violation. WHO has adopted a new 2011–15 strategy instead that seeks to optimize HIV prevention, diagnosis, treatment, and care outcomes; to leverage broader health outcomes through HIV responses; to build strong and sustainable health systems; and to address inequalities and advance human rights.

Neglected tropical diseases are a group of parasitic and bacterial infections that are the most common afflictions of the world’s poorest people. They blind, disable, disfigure, and stigmatize their victims, trapping them in a cycle of poverty and disease. Many low-cost interventions are available, yet the majority of affected people do not have access to them. Some of the largest health impacts remain: schistosomiasis (200 million cases), dengue fever (50 million new cases a year), measles (30 million cases a year), onchocerciasis (18 million cases in Africa), typhoid and leishmaniasis (approximately 12 million each globally), rotavirus (600,000 child deaths per year), and shigella childhood diarrhea (600,000 deaths per year). About half of the world’s population is at risk of several endemic diseases. Hepatitis B infects up to 2 billion people. There is more TB in the world now than ever before, even though TB treatment success with DOTS exceeded 85%. Between 1995 and 2008, over 43 million people have been treated and 36 million people cured. There is progress with malaria: 38 countries (9 in Africa) documented reductions of more than 50% in the number of malaria cases between 2000 and 2008, and more than 100 million long-lasting insecticide-treated bed nets have been distributed in the fight against malaria.

To counter bioterrorism, R&D has increased for improved bio-sensors and general vaccines able to boost the immune system to contain any deadly infection. Such vaccines could be placed around the world like fire extinguishers. Some small viruses have been found to attack large viruses, offering the possibility of a new route to disease cures. New problems may come from unregulated synthetic biology laboratories of the future. People are living longer, health care costs are increasing, and the shortage of health workers is growing, making telemedicine and self-diagnosis via biochip sensors and online expert systems increasingly necessary. Better trade security will be necessary to prevent increased food- or animal-borne disease. Viral incidence in animals is being mapped in Africa, China, and South Asia to divert epidemics before they reach humans. Future uses of genetic data, software, and nanotechnology will help detect and treat disease at the genetic or molecular level.

Regional Considerations

Africa: With 11% of the world’s population, Africa has 25% of the world’s disease burden, 3% of its health workers, and 1% of its health expenditures. Sub-Saharan Africa accounted for 68% of all people living with HIV in 2010; it has one of the world’s worst tuberculosis epidemics, compounded by rising drug resistance and HIV co-infection. Patients on ART increased from 1–2% in 2003 to 48% by the end of 2009. PEPFAR (a U.S. program) is funding 105 medical schools in the sub-Saharan region to encourage graduates to stay in Africa and is funding laboratories across the continent. Some 16% of children in Zimbabwe and 12% in Botswana are AIDS orphans; 34 sub-Saharan African countries stabilized or decreased HIV infections by more than 25% between 2001 and 2009.

Asia and Oceania: The emergent research on NDM-1 gene and drug resistance found in the New Delhi water system has alerted WHO investigators to a “potential nightmare” situation. Asia is an epicenter of emerging epidemics. If Asian poultry farmers received incentives to replace their live-market businesses—the source of many viruses—with frozen-products markets, the annual loss of life and economic impacts could be reduced. HIV continues to increase in central Asia. At least 5 million people have HIV/AIDS in India and China. Japan’s life expectancy at birth in 2010 was 83 years; in China it was 74.

Europe: The Ukraine has the highest prevalence of HIV in Europe, focused on sex workers and drug users, with 161,119 cases (31,241 AIDS and 17,791 deaths), but it has decreased the incidence from 18% to 6% from 2006 to 2009 due to extensive HIV programs. The aging population of Europe continues to pressure government medical services, while infant mortality under five has been cut in half since 1990 and maternal mortality has dropped by one-fourth. TB deaths continue to increase in Europe after a 40-year decline. President Dmitri Medvedev initiated obligatory drug tests in Russian schools and universities.

Latin America: The region has the highest life expectancy among developing regions. While Haiti’s HIV rate has fallen from 6% to 2.2% over the last 10 years, the earthquake killed 300,000 people and has devastated medical systems and brought on a cholera outbreak, with more than 1,200 deaths and the possibility of spread to the Americas. The HIV/ AIDS epidemic remains stable, with 2 million people and 0.6% prevalence, and antiretroviral therapy is at almost 60%. Brazil has shown that free antiretroviral therapy since 1996 dramatically cut AIDS mortality, extended survival time, saved $2 billion in hospital costs, and keep prevalence to 0.6%. Neglected tropical diseases affect 200 million people in Latin America (intestinal worms, Chagas, schistosomiasis, trachoma, dengue fever, leishmaniasis, lymphatic filariasis, and onchocerciasis).

North America: A California Biobank 20-year study will evaluate genetic markers for risk of disease in 250,000 patients by linking DNA samples to electronic medical records. The U.S. has 1.2 million people with HIV; Canada has 73,000. About 33% of children in the U.S. are overweight or obese, and one survey found that children aged 8–18 spent on average 7.5 hours a day with entertainment media.

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