Global Challenges Facing Humanity

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8. How can the threat of new and reemerging diseases and immune microorganisms be reduced?

The health of humanity continues to improve; the incidence of infectious diseases is falling, as is mortality from such diseases. And people are living longer, yet many old challenges remain and future threats are serious. The dramatic improvements in health and medical services over the past 20 years could be reduced by the ongoing economic problems cutting health budgets around the world. Bill Gates asked the G20 to keep their health commitments even though many face financial difficulties; if country health pledges are kept, they would add $80 billion annually from 2015 onward to create a healthier world.

Foreign aid for health increased 202% from 2000 to 2009. Previous health strategies, sustained growth in health budgets, and improving living standards over the last 20 years has resulted in at least 30% fewer children under five dying in 2010 than in 1990, total mortality from infectious disease fell from 25% in 1998 to less than 16% in 2010, and world maternal mortality fell from 4% in 1990 to 2% today. The number of malaria cases fell 23% in 105 countries between 2000 and 2009 and the number of deaths by 38%, even though antibiotic resistance emerged during this period. The number of measles deaths fell by 78% between 2000 and 2008. International collaboration to reduce HIV, SARS, and H1N1 (swine flu) had built better global health systems.

Non-communicable diseases and emerging and drug-resistant infectious diseases are also 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. On average, a new infectious disease has been discovered each year over the past 40 years, 20 diseases are now drug-resistant, and old diseases have reappeared, such as cholera, chikungunya, yellow fever, plague, dengue fever, meningitis, hemorrhagic fever, and diphtheria. In the last six years, more than 1,100 epidemics have been verified. About 75% of emerging pathogens are zoonotic (they jump species), which could increase as more humans convert nature to human habitat.

Although two new HIV infections occur for every one person starting treatment, the emergence and distribution of effective “test and treat” antiretroviral therapy (ART) has markedly changed the trajectory of the AIDS epidemic. According to the 2011 UNAIDS report, new HIV infections declined 21% over the past 12 years. HIV incidence has fallen in 33 countries, 22 of them in sub-Saharan Africa. AIDS-related deaths dropped by 19% between 2004 and 2010. Most of the success came in the last two years with rapidly increased antiretroviral medicine to treat and prevent HIV infection, fewer sexual partners per person, male circumcision, and increased condom use among African youth.

The median cost of antiretroviral medicine per person in low-income countries has dropped to $137 per year, although it is free in some areas; 47% of the estimated 9.7 million people in need of ART received it by the end of 2010. About 700,000 AIDS-related deaths were prevented by combination antiretroviral therapy. The new rapid “test and treat” strategy uses a variety of inexpensive tests (costing a few cents), from finger pricks to mouth swabs, and can now produce results in 1–20 minutes. Because ART reduces the viral load to the point where it cannot be detected, it also prevents transmission. Although there has been great progress in the last few years, during 2010 there were 2.7 million people newly infected with HIV and 1.8 million AIDS-related deaths. Today, 34 million people are living with HIV/AIDS, and an estimated 60% of people living with HIV are unaware of their HIV status. In Eastern Europe and Central Asia, the number of people living with HIV rose 250% from 2001 to 2010.

Highly visible epidemics were down in 2011–12 but current risks include NDM-1, an enzyme that can make a variety of bacteria resistant to most drugs (once found only in India and Pakistan, it has been detected in the United States, Canada, the Netherlands, the United Kingdom, and Australia); influenza in its many forms, especially avian flu (H5N1); food-borne epidemics, notably in China; cholera in Haiti, which due to the slow response could move to the Dominican Republic and Mexico; and the controversial laboratory-produced mutant avian flu as a potential intentional (terrorist) epidemic.

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.

The 17 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 of these are waterborne diseases. High-density population growth and slow progress in sanitation in poorer areas keep these diseases active. 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 a 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 also 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.
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 handwashing. WHO’s eHealth systems, smartphone technology, international health regulations, immunization programs, and the Global Outbreak Alert and Response Network are other essentials of the needed infrastructure.

Regional Considerations

Africa: With 12 % 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. HIV incidence has fallen by 26% overall in 22 countries in sub-Saharan Africa due to ART, although the area still accounted for the majority of all people living with HIV in 2012. It has one of the world’s worst tuberculosis epidemics, compounded by rising drug resistance and HIV co-infection. Patients on ART increased to 48% by the end of 2010 with an additional 1.3 million people added in the last year and “universal access” (greater than 80%) in Botswana, Namibia, and Rwanda. PEPFAR (a U.S. government 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. Clinics in northern Malawi provided free antiretroviral drugs, which reduces adult AIDS deaths by 57% in three years. AIDS deaths fell 40% in urban Addis Ababa in a similar two-year program of free antiretroviral drugs.

Asia and Oceania: A new strain of whooping cough in Australia has the potential to become a global epidemic. 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. While China is investing $127 billion in new health infrastructure, Asia remains 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. China had 780,000 people with HIV/AIDS at beginning of 2012, which is expected to increase to 1.2 million by 2015, causing a discussion about co-payment options for drugs offered at no cost since 2003.

Europe: In Eastern Europe and Central Asia, there was a 250% increase in the number of people living with HIV from 2001 to 2010. The Russian Federation and Ukraine account for almost 90%.  WHO Europe (Health 2020) is changing its focus toward prevention amid a funding crisis due to the global recession. 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.

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 in 2010 devastated medical systems and brought on a cholera outbreak of a half-million cases and perhaps 250,000 more as the cholera strain  is evolving and may become endemic. Some 100,000 Haitians are expected to be vaccinated this year. The HIV/ AIDS epidemic remains stable throughout Latin America. Brazil has shown that free ART 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: The U.S. Food and Drug Administration approved Truvada, the first drug approved to reduce the risk of HIV infection in uninfected individuals. New U.S. health care legislation comes into full effect in 2014. In the meantime, with a slowed economy, hospitals are increasingly merging to form insurance-like systems; insurance companies are buying and/or making deals with health care providers. The U.S. is upgrading its electronic health records and other forms of health information technology with $29 billion from the HITECH Act. 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.



Graph using Trend Impact Analysis; it is part of the 2012 State of the Future Index computation (See Chapter 2, SOFI 2012)

 

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