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Forgotten Plagues: Development and the Neglected Tropical Diseases

jolt-small.thumbnail.jpgAccording to WHO, over 1 billion people suffer from the effects of a "Neglected Tropical Disease." If you read Dr. Margaret Chan’s speech on the progress on combating these diseases, it is filled with names which are strange to the eye. I doubt many Americans could list any of the four "highest burden" NTDs: lymphatic filariasis or Elphantiasis, onchocerciasis or river blindness, schistosomiasis or snail fever, and soil-transmitted helminthiasis – a disease so untroubling to the American mind that even it’s wikipedia article is a stub, and does not connect it to a name we would know: hookworm. Hookworm, affecting some 575 million people, and severely affecting 80 million, has largely been eradicated from temperate areas. The 13 highest burden diseases not only infect but compound. A billion people burdened, many several times over.

Most NTD’s share a common trait, they are based on parasitic, rather than bacterial or viral infection. To some extent this is the nature of beast: viral and bacteria infections can spread well beyond the tropics. For example, take a look at the list on this page. Most of the bacterial and viral names are familiar, only a few parasites are, and two of those such as Malaria, involve a vector that can carry the disease.

To put it bluntly: rich countries worry about problems that can strike them. The ultimate solution to many of these diseases is a simple technology: the toilet. Sewage systems are not sexy, but they are among the most effective technologies for relieving human misery known. At present, providing safe storage, point of use disinfection, and improved hygiene, would save what health officials call a "Disease Adjusted Life Year" at about the cost of 1,000 U.S. dollars per year. Is it worth it? Would you pay a thousand dollars for a year of healthy life? What about those people whose total economic output is less than a thousand dollars. The square of starvation rears its head again. There are people who are not worth keeping alive, from the point of view of the global economy. Piped water does not improve outcomes as much, but it does save time. Piped water pays for itself with the proceeds of about 4 weeks of paid labor. (Figures from WHO World Health Reports 2002, 2003, 2004, 2006, 2008) Or to be blunt again, these are people who are dying of poverty. It is not hyperbole to say that 50 cents can save a life.

The costs of parasitic infections is enormous, but the profits are also enormous. The misery falls on one group of people, the benefits on others. Consider, that according to the WHO 2008 World Health Report, getting to an equitably distributed per capita GDP of 5000 USD means that life expectancy will be 67. At 4000, it is 63. At 3000, it is 55. at 2000 it is 45. A difference of 3000 real dollars means 22 years of life. For comparison, an additional 3000 USD of GDP in a wealthy country adds less than 2 years of life expectancy. For the cost of 3 years of US life expectancy, we could add 20 to all of sub-saharan Africa. However, the catch is that it is a great deal easier to add 5000 GDP per capita to the US, than to sub-Saharan Africa. Of the gain in life for poor countries, much of that increase comes from controlling parasitic infections. It is a vicious circle: parasites don’t just kill, they maim the body and the mind. They slow children’s growth and ability to learn, they kill mothers in child birth or just after from anemia. They make people more susceptible to other diseases, which finally cause death.

What is particularly pernicious about parasites then, is that they degrade the ability of countries to develop at all. The converse is one reason why once development finally does take hold it goes more quickly: a population unburdened by parasites is more active, more intelligent, and brighter about the future in almost every way.

In 2007, the World Health Organization began to organize around a new strategy, on the assumption that heavily infected areas should be treated with a mass approach. Essentially, treat everyone with relatively safe mass chemical therapy. Kill the parasites, then purge. In some areas, it is basically true.hookworm.thumbnail.gif

This was a tactic that was used at the turn of the century when hookworm was a problem over large parts of the US – JD Rockefeller gave 1 million, equivalent to 50 million in modern dollars, for hookworm extermination.

However, the problems of the developed world in general apply to this in specific case. Namely, the problem of distribution. Development and health go hand in hand. That is one reason that Darcy Burner and Steve Clemons are going to be keynotes at Harvard’s 2009 JOLT Symposium on delivering medicines to the developing world. Many of the diseases of the developing world are neglected precisely because developed nations fought these battles long ago.

In April, the WHO’s, Strategic and Technical Advisory Group (STAG) on Neglected Tropical Diseases will take place in Switzerland, and they face a mounting problems. On one hand an unspoken reason for the deaths and impairment of over 1 billion people is that their labor literally is not worth the tiny cost it would take to procure.

On the other hand, the hidden costs are enormous, running the numbers in reverse, a work force that is bogged down by parasitic infection is worth about half of one that is not, even with similar levels of technological endowment. Or to put it another way, each sick person costs 3000 USD of GDP. Or 3 trillion dollars of output globally per year. And then there are collateral effects: one study has shown that mothers of sick children trade sex for money more often, and engage in much higher risk behaviors.

In the Bush administration, the focus on solving distribution was to give money to religions organizations, and to fund "abstinence only" health education. This was more than misguided, it was evil. First, because in many cases the religious organizations did not have a presence to begin with: their first goal was to build churches. Second, because the education provided did not follow through to other forms of development. In many cases these organizations have agitated against homosexuals, and even condoms and birth control in general. Obviously Africa doesn’t have enough hate already. Third, because the methods pursued did not create general improvement in hygiene.

Instead of purely government action, and most particularly instead of proselytizers, an avenue that needs to be opened is through growing world of micro-capitalism. Micro-lending gives access to credit. However, once credit is being extended, it becomes an incentive. Since women are the major users of micro-credit, having infant care and getting them to spend some of their increased wages on improved water and sanitation can be encouraged by lowering their interest rate. The same cooperative/competitive dynamics among the micro-lending pool will keep the participants both honest, and spur them forward. On top of this the presence of a technological line in allows for much higher targeting of resources. For example, soil is a major way that tropical parasites spread. Soil eradication is effective where it is applied to concentrated areas of parasites. Cellphones with GPS, if there are enough towers, can have numbers that the user dials, and reports the position of a concentration of infection. If it proves out, and the locus of the infection is eradicated, a reward can be paid. It is the equivalent of removing the pump handle.

So why worry about this now? Because one of the larger issues of our time is a thoroughgoing restructuring of global financial institutions. Bailed out bankers have had more money in bonuses than the non-military, non-security parts of the US foreign aid budget. The need for a permanent micro-finance component of the new institutions as part of IMF/WorldBank, becomes clear as soon as one looks at the enormous costs of doing nothing. Cutting the parasite burden in half would produce 1.5 trillion USD of GDP a year. It would probably cost under 100 billion for water, treatment and hygeine programs. There are very few places that one can produce wins of 15:1 in any government investment. And much of this would be pay as you go, because the people borrowing the micro-finance would paying back as they received the benefits.

So, that’s what I will be talking about on March 17th at Pound Hall at Harvard Law: how a reform of financial institutions must include a component that will create a new delivery channel to fight the vampire plague of parasitic infection as one of the most cost-effective single steps that we can take. It might seem that a global economic downturn is the worst time to do this, but, in fact, a global economic downturn is the best time to do this, because people can look at the long term, and not chase tomorrow’s dollar.

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