Alan S Miller

The stark realities of poverty and population growth provide the underpinnings for the tragic state of health care for people in the poorer two-thirds of the countries of the world. With global population now at 5.7 billion people, it is almost certain that our numbers will double in the next 50 years. Eighty percent of that total will be in what we now call the developing world. Given our inability to even begin to deal with the prevention of infectious disease the scope of the problem as the 21st century unfolds will be of a dimension almost inconceivable today. The spectre of future Rwandas with mass starvation and raging epidemics (all occasioned more by poverty than global upheaval), is now almost an inevitable image for the global world of tomorrow. The first step for all of us in trying to think about partial solutions is to first become aware of the scope of the problem.

Although human health is conditioned by a number of factors (malnutrition, violence, environmental contamination, lack of healthcare services), the most important single factor causing poor health in the 1990s is poverty. When nations are poor they are unable to provide the conditions for public health and wellbeing - clean water, adequate food supplies, housing, education, and preventative health care services. The harsh statistics of poverty are apparent everywhere. The elite within even the poorest nations usually skim off most of even the limited income available - leaving almost nothing for the large majority of the population. The poor of the world are thus placed in double jeopardy: first by global distributive injustice and then by the rapaciousness of their own national oligarchies.

The consequences of this global poverty are most clearly seen in the rapid increase in recent decades of infectious diseases. Half of all deaths in the poor nations are today due to infectious and parasitic disease (diarrheal, respiratory and other viral and bacterially vectored diseases). Most of the infectious diseases which now kill more than 50 million people annually are well understood and easily prevented with low-cost remedies. They are not treated for two basic reasons: poverty in the affected regions and indifference in the wealthy nations. Some examples suggest the problem.

Diarrheal diseases (where transmission is always fecal/oral) are probably the largest single cause of mortality and illness in the world today. 12,600 children die each day due to diarrhoea - almost 70% of all childhood deaths in the poor world. Illnesses related to diarrhoea which carry unknown future price-tags include for children: malnutrition, growth and mental retardation, immunological inadequacy; for adults, inability to work and adequately care for children, and early death.

Tuberculosis (TB) continues to be the leading cause of death from a single infectious disease. World health agencies estimate that more than 25% of the global population may be infected at any given time with 50% always at risk. Three million people die of the disease each year. Ninety-five percent of all TB deaths occur in the developing world although it is again on the increase in the wealthy world as well (with 30,000 cases now monitored in the US in all 50 states). Once again, the single most important factor in the increase in TB is the poverty which leads to overcrowding, malnutrition, poor workplace standards and stress.

In Africa, 275 million people are infected with malaria in any given year. Two million children between the ages of 1-5 die each year from malaria. In the last two decades malaria has shown a massive increase in the tropical areas of the world. Much of the increase is due to increased resistance to pesticides by the anopheles mosquito (most strains are now resistant to pesticides due to overuse in earlier years) and by the increase in mosquito-breeding areas in open pools of water following new agricultural practices and deforestation. Once again, simple and inexpensive means of control are available - planting shade trees in stagnant areas, stocking larvae-eating fish in ponds, flushing ponds with moving water. Sadly, poor people do not have the means on their own to implement control mechanisms. Central governments often neither have the will to enable local people to attempt to find their own solutions to the problems nor the means for long-term, ecologically sound eradication programmes. Without healthcare infrastructures there is really no way of dealing with infectious disease.

From January 1994, the Global AIDS Policy Coalition reports a total global HIV infection caseload of more than 22 million cases. There are 7-12 million cases of AIDS throughout the world. About 70% infected with HIV and/or showing full-scale AIDS symptoms live in sub-Saharan Africa. Another 13% of cases are found in South and South-East Asia. Because of generally poor public health African death rates from AIDS are ten times higher than those in the developed world. It is expected that 3 million children in the next ten years will die of AIDS, with another 10 million orphaned. Estimates suggest that 80-90% of AIDS-related diseases go unreported in Africa. Again, a major reason for the spread of the disease in poor nations is poverty. Virtually all AIDS patients suffer from diarrhoea and malnutrition. Many have tuberculosis. And in almost no instance is there the kind of public health infrastructure that can even begin to cope with the disease. Many health experts now predict that in many areas of Africa, 25% of working-age people will be dead from AIDS in the next 20 years.

Other diseases often related to poverty - cholera, measles, yellow fever, hookworm, schistosomiasis - are all on the increase globally and in almost every case the increases are most dramatic in poverty stricken areas. Sadly, neither international health organisations nor the governments of the wealthy countries are currently expected to provide much help in solving the health problems related to global poverty. The health organisations have greatly reduced research and prevention programmes in the infectious disease areas since these diseases are not that much of a problem in rich nations which provide research funds.

They are more interested in expenditure for exotic biotechnological therapies for older, wealthier people than preventative care for poorer, younger people.

As we deal with the reality of global population growth we must understand that the problems seen today will be terribly and regularly escalated in coming years. The only answers to providing available low-cost remedies to control infectious diseases are the establishment of new priorities by health planners and health providers - from therapy to prevention, to concern for the many poor rather than for the few wealthy. Whether such renewal in health policy formation is in any way possible in coming decades will determine the quality of life and kind of death facing billions of people.

Note: the figures in this report are as of 1995.