Global Challenge 8. How can the threat of new and reemerging diseases and immune microorganisms be reduced?
The health of humanity continues to improve; life expectancy at birth increased globally from 46 years in 1950 to 67 years in 2010 and 71.5 years in 2015. Total mortality from infectious disease fell from 25% in 1998 to 15.9% in 2015. Children are receiving the highest level of routine immunization coverage in history. Indigenous measles and rubella have been eliminated from the Americas, and maternal and neonatal tetanus have been eliminated in Southeast Asia. Malaria cases decreased by 41% from 2000 to 2015. As the world ages, chronic diseases are increasing (i.e., deaths due to stroke, heart disease, and cancers). However, WHO verified more than 1,100 epidemic events over the past five years, and antimicrobial resistance, malnutrition, and obesity are increasing. TB is the leading infection cause of death globally, with increasing drug resistance. Zika in the Americas and cholera in Yemen (half a million) and Haiti (1 million) continue to spread, while urban yellow fever in Angola and the Democratic Republic of Congo prompted the largest emergency vaccination campaign ever undertaken in Africa—30 million people were successfully vaccinated. WHO is monitoring avian influenza in nearly 50 countries and continues to warn that the world is not prepared for a major epidemic.
The most advanced vaccine for malaria will be tested in 2018 in Ghana, Kenya, and Malawi, while human trials for an HIV vaccine are in progress. HIV/AIDS continues to decrease: about 1.8 million people were infected with HIV in 2016, down from 5.4 million in 1999; 1 million died of HIV‑related illness in 2016, down from 2 million in 2010; and 19.5 million people with HIV (53%) were on treatment, up from 17.1 million in 2015.
Embryo gene editing has begun and could eventually eliminate inherited disease tendencies, including infectious diseases; however, such editing for human enhancement is quite controversial, and a U.S. National Academy of Sciences panel has recommended against such research at this time. Regenerative medicine holds the potential to create living, functional cells and tissues extending life, and DNA repair and other longevity research continue.
But investment and development of new antibiotics have not kept pace with current and potential antibiotic resistance around the world. No new classes of antibiotics have come on the market for more than 25 years. A superbug (with mcr-1 gene) resistant to antibiotics now exists on several continents. Making antibiotics much stronger is being explored to prevent drug residence by reducing the time needed to be cured. A universal vaccine to bring up the immune system could become an alternative to slow the process of making new vaccines for new versions of diseases. Genomic vaccines are being tested to inject DNA or RNA into cells to produce a desired protein to help train the immune system to eliminate a selected pathogen. But how should we prioritize funds for infectious diseases? Should it be number of currently infected people or economic impact vs. potential for spread of infection vs. mortality rates? As the aging populations of richer countries are expected to exhaust medical budgets, will China, India, and other growing economies pick up to burden?
Meanwhile, global health research investment has been stagnant or falling since 2009, excluding the billions in emergency funding set aside during the Ebola outbreak. The new U.S. administration proposes to cut funding for global heath by 24% along with local cuts in both NIH and CDC. From 2000 to 2009, global health spending grew an average of 11.4% annually, but it fell to 1.8% annually from 2010 to 2016.
Actions to Address Global Challenge 8:
- Implement WHO Global Vaccine Action Plan.
- Increase support to anticipate and counter drug resistance.
- Improve global plans and resiliency training to address future major epidemics.
- Create and implement strategies to counter the barriers to developing new classes of antibiotics and bringing them to market.
- Complete mortality records worldwide to improve data base for research; only half of all deaths have recorded causes.
- Increase global health funding to its previous annual increase of about 10%.
- Focus on early detection, accurate reporting, prompt isolation, and transparent information and communications infrastructure.
- Increase tele-medicine and AI diagnostics as the shortage of health workers continues to worsen in poorer regions of the world.
- Increase investment in clean drinking water, sanitation, and hand washing.
- Optimize the use of current health technologies (drugs, devices, biological products, medical and surgical procedures, support systems, and organizational systems) with corporate/NGO partnering for holistic approaches to health care.
- Encourage telemedicine, including online self-diagnosis and AI, expert software.
- Climate change and other global environmental changes are resulting in changes in the magnitude and pattern of risks, underlining the need for increased investment in monitoring and surveillance
Figure 1.8 Health expenditure per capita (current $)
Source: World Bank indicators, with Millennium Project compilation and forecast
Short Overview and Regional Considerations
According to UN data, the number of deaths in children under five declined from 12.7 million in 1990 to 6.3 million in 2013. This is a reduction from an estimated 90 deaths to 46 deaths per 1000 live births. Nevertheless, less than one third of all countries have achieved or are on track to meet the MDG of reducing child mortality by two-thirds from 1990 levels by 2015. At the current rate, this goal is not expected to be achieved until 2028. About 80% of child mortality occurs in sub-Saharan Africa and Southern Asia. Rates have worsened in Syria, Iraq, some sub-Saharan African countries, and some members of the former Soviet Union since 1990. Maternal mortality fell 43% between 1990 and 2015. But this is still far short of the MDG of a 75% reduction. Maternal mortality shows very little decrease in the regions with the highest rates.
More than half the developing world at any given time is suffering from diseases associated with unsafe water and poor sanitation. Although an additional 2.5 billion people have gained access to improved drinking water since 1990, there are still over 700 million people without such safe access today. Diarrhea causes over 1.8 million deaths per year (68% of these are children under the age of five). About 25% of the world gained access to improved sanitation between 1990 and 2012, but many—possibly over 40%—do not use the available facilities, and WHO estimates that 2.5 billion people did not have access to basic sanitation in 2014 and 1.1 billion people practice open defecation, linked to 280,000 diarrheal deaths annually. It is estimated that a third of these deaths could be prevented by simple hand-washing.
The health of humanity continues to improve; people are living longer—life expectancy at birth increased globally from 67 years in 2010 to 71.4 years in 2015. Although WHO has verified more than 1,100 epidemic events worldwide over the past five years, the incidence and mortality rates of infectious diseases are actually falling due to medical advances and accessibility to medical care. WHO reports that if current trends continue, the world will have met global targets for turning around the epidemics of HIV, malaria, and tuberculosis. However, the mortality rates from noncommunicable diseases continue to rise—from 60% in 2000 to 68% in 2012. Other health problems like antimicrobial resistance, malnutrition, and obesity continue to rise. Political instability is a major health concern in many countries such as South Sudan, Syria, Mali, and the Central African Republic, where rebuilding infrastructure and establishing health care will take many years. There are over 42 million refugees or displaced persons in the world (down from 50 million in 2013), who have little access to health care. The prevalence of undernourished children in fragile states is 39%, compared with 15% in the rest of the world. The spread of disease in such areas, compounded by having fewer health workers, represents a dangerous trend witnessed during the Ebola epidemic.
With longer life expectancies, rising health care costs, and a shrinking health workforce, telemedicine and self-diagnosis via biochip sensors and online expert systems will be increasingly necessary. Better trade security is also needed to prevent food- or animal-borne diseases. Falling costs of gene sequencing and improved genomic understandings will make personalized medicine possible for the public, at least in high- and middle-income families. According to PricewaterhouseCoopers, U.S. personalized medicine is a $286 billion per year industry and growing 11% annually. IBM’s Watson is improving diagnostics; nano-medicine could one day detect and treat disease at the genetic and molecular levels, making treatments more precise; 3D bio-printing is opening a new field of tissue and organ replacements from one’s own genetic material; and longevity research has significantly extended the lives of lab animals.
Current high risks of epidemics that are predictable or a continuation of ongoing trends include the following:
- Zika continues to spread in the Americas
- Ebola does not have any FDA-approved vaccine or treatment. Without supportive care and a healthy immune system, it is essentially fatal. The lack of knowledge about the reservoir and the mode of entry of this virus put people without access to healthcare at high risk. The UN is planning to continue Ebola response activities into 2016 in light of the efforts needed to stop transmission.
- Several cases of highly pathogenic avian influenza have been reported, including strains H5N2, and H5N8. The global movement of avian flu, H5N2 mutant, has been seen for the first time in the central flyway of the U.S., with millions of birds killed in Iowa and Minnesota.
- Antimicrobial-resistant “superbugs” resistant against antibiotic classes fluoroquinolones and carbapenems and third-generation cephalosporins
- Hospital-borne MRSA (Methicillin-resistant Staphylococcus aureus)
- Influenza in its many forms, especially persisting and highly deadly avian flu (H5N1) in Egypt (115 cases, 36 deaths reported from January to March 2015)
- Drug-resistant TB in Eastern Europe and the Middle East in HIV-positive patients
- Artemisinin-resistant malaria in Cambodia, Lao PDR, Myanmar, Thailand, and Vietnam
- Dengue, with a 30-fold increase in incidence over the past 50 years, is estimated to be the cause of 390 million infections per year, particularly in the Asia-Pacific countries, where 1,800 million people are at risk of infection. The actual numbers of dengue cases are underreported, and many cases are misclassified
Current high risks of epidemics that are emerging or re-emerging infectious diseases and other health threats include the following:
- Measles and tuberculosis are increasing in low-risk areas like the U.S. and the UK due to migration and the anti-vaccination attitudes.
- Polio-like enterovirus D68 was associated with rampant, severe respiratory illness in children, muscle weakness, and paralysis, particularly in those with asthma. In the U.S., 1,153 cases were identified with infection of the virus that has no vaccine or treatment.
- More than 800,000 cases of chikungunya have occurred in the Caribbean (6,600 in U.S. travelers), and it continues to spread to 44 countries or territories with more than a million cases. A spike in reported chikungunya cases pushed the outbreak total in the Americas past the 1.5-million-cases mark as of June 5, 2015.
- As of February 2015, a total of 971 laboratory-confirmed cases of human infection with coronoavirus (MERS-CoV) have been reported to WHO, with at least 356 deaths. The MERS, first appearing in Saudi Arabia in 2012, has continued to spread globally. The sudden outbreak in South Korea, currently with 87 cases, emphasizes the need for resilient infectious control mechanisms.
- Cholera continues to be an issue in Haiti and a concern in Nepal. Haiti has shifted from 1,000 new cases per month to almost 1,000 per week. Following the 2010 earthquake, 736,000 Haitians were infected and 8,800 deaths occurred.
- Fast-progressing HIV in Cuba that is a combination of three subtypes of the virus
- Food-borne epidemics, most notably in China
- Lack of international controls for bio-research facilities that could contribute to accidental or terrorist-induced epidemics
Current high risks of epidemics that were surprises include:
- Insecticide-resistant fleas that transmit plague from rats to humans led to 40 deaths and 119 cases of the age-old plague in Madagascar.
- A “super-bug” strain of typhoid bacterium is driving a hidden epidemic in Africa, affecting 22 million people globally.
Prior to the Ebola disaster, WHO announced in 2013 that the International Health Regulations— an international detection, warning, and rapid treatment system for global epidemics—was not sufficiently in place to manage a major (H7N9) global epidemic. Because pandemics represent national security risks, much of the best epidemic surveillance is carried out by military and intelligence agencies, especially in poorer countries with insufficient health infrastructure. Basic public health systems, which include treatment facilities, laboratories, and surveillance systems, are fundamental to controlling outbreaks of infectious disease. The lack of adequate health care systems allowed Ebola to spread faster and farther that it would have had such systems been in place in countries such as Liberia. New sequencing technology will provide the opportunity to create a global system of linked databases for identification and detailed genetic characterization of all microorganisms. This would result in a reduction in characterization time and hence strengthened surveillance of infectious diseases.
Antimicrobial resistance: Antibiotic resistance “is the single greatest challenge in infectious diseases today,” says Dr. Keiji Fukuda, WHO’s Assistant Director-General for Health Security. WHO published its first report on antimicrobial resistance in 2014, recognizing this as both a long-range problem and one that needs immediate attention. Investment and development of new antibiotics have not kept pace with current and potential antibiotic resistance around the world. This could make major antibiotic classes (such as beta-lactams, carbapenems, fluoroquinolones, and aminoglycosides) useless and lead to the reemergence of TB, malaria, and HIV. It could also increase the likelihood of new “superbug” pandemics. The emergent research on New Delhi metallo-beta-lactamase-1 (NDM-1) gene and drug resistance found in the New Delhi water system has alerted WHO investigators to a “potential nightmare” situation. NDM-1 is a gene carried by some bacteria. If a bacterial strain carries the NDM-1 gene, it is resistant to nearly all antibiotics, including carbapenem antibiotics—known as the antibiotics of last resort. WHO calls on more countries to “step up” and develop national plans for antibiotic resistance, identifying only 34 of 133 countries with basic national guidelines. While monitoring is key for controlling antibiotic resistance, WHO reports that in many countries poor laboratory capacity, infrastructure, and data management prevent effective surveillance.
Although antibiotic-resistant microbes and new “superbugs” are increasing, only four new antibiotics have been approved by the FDA since 1998. Despite the launch of the 10 x 20 initiative by the Infectious Diseases Society of America, pushing for 10 new systemic antibiotics by 2020, only 2 new systemic antibiotic drugs have been developed since the 2010 launch. The highest-ranking pathogens (considered “urgent”) are carbapenem-resistant Enterobacteriaceae, Neisseria gonorrhoeae, and Clostridium difficile. This antibiotic crisis reflects the combined impact of overuse of antibiotics (“use it and lose it”) and the failed market response. Major pharmaceutical suppliers have largely abandoned the antibiotic development field owing to very poor economic returns. However, the pipeline for new antibiotics is slow but not dry. Three new anti-MRSA drugs were recently FDA approved. In an effort to stem antibiotic-resistant diseases, the FDA is moving to collect more information on antibiotics used in animals that are intended for human consumption.
Health funding: Global health funding hit an all-time high of $31.3 billion in 2013, five times greater than in 1990. Yet with 3.9% growth from 2012 to 2013, the year-over-year increase falls short of the rapid rates seen over the previous decade. New pledges for development, including health, would add $80 billion annually from 2015 onward. However, the dramatic improvements in health and medical services over the past 20 years could be dangerously reduced by continued slow economic growth, tight government budgets, and political changes. As funding from many bilateral donors and development banks has declined, growth in funding from private philanthropists and tailored funding institutions aim to counteract these cuts (e.g., the Bill and Melinda Gates Foundation, the Global Fund, and the Global Alliance for Vaccines and Immunization). The Bill and Melinda Gates Foundation is a notable player, having donated around $45 billion from its commencement. By embarking on various initiatives like vaccination campaigns, rich-poor gap reduction strategies, and agricultural investments, they support high-impact, multilevel organizations such as the Global Alliance for Vaccines and Immunization, WHO, and the World Food Programme. As one of the largest private donors to WHO, the BMGF wields significant power on the global health landscape. Private donors are distorting health care in low-resource settings as they set the agenda, often not in consultation with local stakeholders. Their contributions often deprive other health issues of crucial resources, such as local health care workers. In addition, the European Union’s Horizon 2020 program will manage a proposed €8 billion budget for biomedical research in the EU. The single most important variable today to address the gap between the current and desired global health status is continued and directed global health funding.
In March 2015, the Lancet Commission on Global Surgery estimated that about 33 million individuals face catastrophic expenditure from accessing surgical and anesthesia care each year on the basis of out-of-pocket costs of surgery alone. Universal public financing of surgical care and use of non-specialist surgical care providers offer some hope for the poor, until highly skilled providers become available outside urban and peri-urban areas. This strengthens the case and highlights the need for universal health care coverage, especially in the Developing World.
The Institute for Health Metrics and Evaluation compared development assistance funding for different health issues to disease burden. For example, sub-Saharan African countries received less than $60 of malaria funding for every year of healthy life lost to malaria between 2006 and 2010. In comparison, Latin America and the Caribbean received nearly $2,000 of malaria funding per year of healthy life lost during this same period. For NCDs, the funding per year of healthy life lost was much smaller, less than 50¢ in South Asia from 2006 to 2010 and just over $2 in Latin America and the Caribbean. In contrast, high-income countries display excess demand and overuse of medical facilities as medical technology advances and expands.
There is also a call for a Global Fund Mechanism focused on the “broken” research and development sector to study diseases and antimicrobial resistance, following the Ebola epidemic. This aims to prevent such outbreaks that are controlled primarily by monitoring and to revive areas that suffer from chronic underinvestment from the pharmaceutical market. This trend could also lead to a brighter focus on developing drugs for superbugs. The Global Alliance for Vaccines Initiative initiated by the Gates Foundation, WHO, UNICEF, and the World Bank has made significant funding progress with clear goals and new funding initiatives.
Infectious Diseases: Total mortality from infectious disease fell from 25% in 1998 to less than 16% in 2010, even though much antibiotic resistance emerged during this period. Approximately half of all deaths caused by infectious diseases each year can be attributed to just three diseases: tuberculosis, malaria, and HIV/AIDS. Together, these diseases cause over 300 million illnesses and more than 5 million deaths each year. 40 million people are living with AIDS. Infectious diseases (pneumonia, diarrhea, malaria, and measles) cause 67% of all preventable deaths among children under 5 years old. This is linked with undernutrition, which contributes to 50% of childhood mortality. Undernutrition results in higher susceptibility to these diseases, and children with infectious diseases are at higher risk of becoming undernourished. Poverty, political unrest, urbanization, travel, immigration, trade, increased encroachment on animal territories, and concentrated livestock production facilitate the animal-to-human transmission of infectious organisms in less time than ever before and could trigger new pandemics. About half of the world’s population is at direct contact risk of several endemic diseases. On average, a significant new infectious disease has been discovered each year over the past 40 years. 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 can be transmitted to humans from other species through a variety of infection routes), which could increase as more humans convert nature to human habitat. According to a new estimate, there are at least 320,000 viruses in mammals alone, the vast majority of them awaiting discovery. Scientists state that collecting data on pathogens that may lurk in wildlife before they are passed on to humans could help officials detect and stem future outbreaks. Early studies of viral incidence in animals are being tracked in Africa, China, and South Asia to anticipate epidemics before they reach humans.
Tuberculosis: More people have TB today than ever before, even though its incidence rate and death rate among HIV-negative cases has been falling since 2006 and although DOTS treatment is 85% successful. An estimated 13.7 million people are infected with active, infectious TB worldwide, while almost 2 billion (nearly one-third of the world’s population) are infected with the TB bacillus (includes latent infection). In addition, new drug-resistant strains of TB have emerged that are difficult to treat successfully. The extremely resistant drug strain (XDR-TB) is fatal in a large proportion of cases. Current rapid TB tests and a potential susceptibility test could make a significant difference. The TB vaccination BCG is not recommended in all situations; 11 new vaccines to prevent TB are moving through development stages.
The Millennium Development Goal to halt and reverse the TB epidemic by 2015 has already been achieved. However, drug-resistant strains are increasingly prevalent, and drugs that are used to treat this variant are not very effective. Some 5% of TB cases were estimated to have had MDR-TB in 2013 (3.5% of new and 20.5% of previously treated TB cases). Drug resistance surveillance data show that an estimated 480,000 people developed MDR-TB in 2013 and that 210,000 people died. Extensively drug-resistant TB has been reported in over 100 countries. On average, an estimated 9% of people with MDR-TB have XDR-TB.
Neglected tropical diseases are chronic diseases that collectively affect 10 times as many people as HIV/AIDS does. The 17 NTDs that are parasitic and bacterial infections are the most common afflictions of the world’s poorest billion; examples are schistosomiasis, dengue fever, and onchocerciasis. They blind, disable, disfigure, and stigmatize their victims, trapping them in a cycle of poverty and disease. Many of these are waterborne diseases and highly preventable. High-density population growth and slow progress in sanitation in poorer areas keep these diseases active. There are seven NTDs with mass-drug administration potential.
WHO reports that 711 million people were treated in 2010 for at least one of the four neglected tropical diseases (lymphatic filariasis, onchocerciasis, schistosomiasis, and soil-transmitted helminthiasis). WHO projects that treatment for schistosomiasis (bilharzia) will reach 235 million people over the next four years, and some observers are talking about eradication. In 2013, only 6,314 cases of human African trypanosomiasis were reported, representing the lowest levels of recorded cases in 50 years. Dracunculiasis reached historically low levels, with 126 cases by 2014. Eradication and elimination of these diseases are targeted for 2020. WHO anticipates global elimination of this preventable disease by 2020. It also plans to eradicate yaws by 2020. Neglected tropical disease have received more funding than ever in the past decade, with 700 million people treated with one or more drugs for these diseases in 2014.
HIV/AIDS: The world has begun to reverse the spread of HIV: there were 2.1 new cases reported in 2015 down from 3.4 million in 2001; and AIDS-related deaths have fallen by 45% since the peak in 2005 (In 2015, 1.1 million people died from AIDS-related causes, compared to 2 million [1.7 million–2.3 million] in 2005). The majority of new HIV infections among young people are girls. The revised target of achieving universal access to treatment for HIV will be more challenging as WHO’s recommendations have resulted in much higher numbers of people needing treatment. As of June 2016 according to UNAIDS18.2 million [16.1 million–19.0 million] people were accessing antiretroviral therapy.
WHO has a new set of goals for 2020: 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained ART; and 90% of all people receiving ART will have viral suppression. Treatment and diagnosis for HIV/AIDS are becoming increasingly affordable with the introduction of generic medicines and improved technology. The cost of first-line regimen antiretroviral medicine per person in low-income countries has dropped to $115 per year and is free in some areas. However, UNAIDS reports that 19 million of the 40 million people living with HIV are not aware that they have the virus.
UNAIDS estimated that nearly 14 million people worldwide were receiving ART by the end of 2014. HIV incidence has fallen by more than 50% in 26 countries, but infection rates are still increasing in Eastern Europe, the Middle East, and North Africa. AIDS-related deaths dropped from 2.3 million in 2005 to 1.6 million in 2012. A recent UNAIDS report reveals that 15 countries accounted for more than 75% of the 2.1 million new HIV infections in 2013. In sub-Saharan Africa, just three countries—Nigeria, South Africa, and Uganda—accounted for 48% of all new HIV infections. However, it appears that entire countries are being left behind from interventions and will be forced to face the triple threat of high HIV burden, low treatment coverage, and no or little decline in new HIV infections. Examples of these include the Central African Republic, Indonesia, and South Sudan.
Truvada (antiretroviral daily pill) was the first drug approved in the U.S. to reduce the risk of HIV infection in uninfected individuals. The FDA approved it for prophylactic use on July 16, 2012. Truvada is still new; hence it has little impact so far compared with ART. Other medical advanced research has shown that some small viruses attack large viruses, offering the possibility of a new route to disease cures. Another advance involves gene therapy that causes a mutation in the CCR5 receptor, which prevents binding of the virus to host immune cells and the APOBCE3 gene family, which produces antiretroviral enzymes. Researchers are also studying several different injectable drugs that can suppress the HIV virus for months at a time, or a monthly injectable as opposed to a daily pill. Vaginal rings are also being tested that release antiretroviral drugs slowly, over time, to protect women from contracting HIV. Broadly neutralizing antibodies are another new technique of treatment in which proteins that have been shown to neutralize multiple strains of HIV.
Malaria: The first vaccine for malaria will be tested in 2018 in Ghan, Kenya, and Malawi.Despite the recent alarming finding of artemisinin-resistant malaria in Southeast Asia, malaria mortality rates have fallen by more than 25% since 2000 and by 33% in the WHO African Region. Furthermore, malaria deaths among children have fallen 51% since 2000, according to WHO. Between 2000 and 2013, an expansion of malaria interventions helped to reduce malaria incidence by 30% globally and by 34% in Africa. However, the statistics still look grim. There were an estimated 198 million cases of malaria worldwide (range 124–283 million) in 2013 and an estimated 584,000 deaths (range 367,000–755,000). About 90% of all malaria deaths occur in Africa. In 2014, an estimated 214 million long-lasting insecticidal nets were delivered to malaria-endemic countries in Africa, bringing the total number of LLINs delivered to that region since 2012 to 427 million. International and domestic funding for malaria control and elimination totaled $2.7 billion in 2013. The Bill and Melinda Gates Foundation has been a major contributor toward the efforts against malaria by investing and supporting strategic interventions. Although funding for malaria represents a threefold increase since 2005, it is still significantly below the $5.1 billion that is required to achieve global targets for malaria control and elimination. The MDG goal of halting and reversing malaria incidence has been met, and Malaria Vaccine Initiative’s malaria vaccine candidate (RTS,S) has completed phase III clinical trials. Results demonstrated a 36% reduction in children cases of clinical malaria despite a low perceived impact; it has the potential to protect children in malaria-endemic areas.
In recent years, parasite resistance to artemisinin has been detected in five countries. In areas along the Cambodia–Thailand border, P. falciparum has become resistant to most available antimalarial medicines, and multidrug resistance is a major concern. Between 2010 and 2013, some 53 countries globally have reported mosquito resistance to at least one insecticide. Of these, 41 have reported resistance to two or more insecticide classes.
Polio: As a global effort, we are running the final mile to eliminating this disease. However, polio vaccination will need to continue after eradication. Viral shed post-vaccination has the potential to revert back to wild type in the environment, threatening new outbreaks in several countries. However, only three countries (Afghanistan, Nigeria, and Pakistan) remained polio-endemic in 2013. The Eradication of Polio by 2018 campaign has financial commitments of $5.5 billion (an additional $1.5 billion will be needed) to vaccinate 1 billion children. The urgency is linked to the tremendous advances made in 2012 and the narrow window of opportunity to seize on that progress and stop all poliovirus transmission before polio-free countries become re-infected. There have been multiple reports of attacks on polio workers from abroad in the three countries that polio is still considered endemic. Hence, effectively delivering vaccines requires addressing the political situation in these countries.
Hepatitis: Viral hepatitis (hepatitis A, B, C, and E) is a leading cause of disease burden in terms of DALYs, being attributed to acute infection, cirrhosis, and hepatocellular carcinoma. With approximately 170 million infected by HCV alone, the increased focus has resulted in conversations of coordinating a global response. A significant number of those who are chronically infected will develop liver cirrhosis or liver cancer. Some 350,000–500,000 people die each year from hepatitis C-related liver diseases. Awareness of this disease, however, is very low. Up to 75% of those infected are unaware they have this disease. The global mortality largely rests in Southeast Asia, with the possibility of considering it a disease of emerging markets. The delay to obtain treatment, not the lack of treatment, causes high mortality. WHO’s resolution calls for better testing and global campaign for safe injections. There is sufficient disease for pharmaceutical innovation and provision. However, despite a HCV vaccine in development, there has been limited surveillance data available for HCV. HCV treatment, although curative, has the potential to be very expensive. With the pricing determined by free-market demand, sofosbuvir treatment has the potential to be inaccessible to high-income countries until generics reach the market. In contrast, HBV is preventable but once infected requires lifelong treatment.
Noncommunicable diseases/chronic diseases: Noncommunicable diseases are increasingly threatening population health and pressuring health systems worldwide. As NCDs claim 38 million people annually, almost three-quarters of the deaths occur in low- and middle-income countries. Considered an emerging global crisis arising from the epidemiological and nutritional transitions, a range of these diseases have become easier to control and manage because of healthy public policies and medical advances. Chronic diseases, led by heart conditions and stroke, have significantly overtaken infections as the leading causes of death and disability except in sub-Saharan Africa. Cardiovascular diseases account for most deaths from noncommunicable diseases, with 17.5 million people annually, followed by cancers (8.2 million), respiratory diseases (4 million), and diabetes (1.5 million). The recent WHO strategy, 25×25, aims for 25% reduction in preventable mortality from significant NCDs (cardiovascular disease, diabetes, cancer and chronic respiratory disease) that account for 54% of NCD DALYs. However, a global response against NCDs narrowly constructed around traditional preventable risk factors (e.g., smoking, cholesterol, high blood pressure, alcohol abuse) is insufficient. With over 6 million annual deaths attributed to air pollution, nontraditional risk factors (e.g., climate change, infections etc.) need to be included in a broader preventive and mitigation strategy. Chronic risk factors and noninfectious diseases have the potential to perpetuate infectious diseases. For example, diabetes affects around one-third of the world’s total population. Diabetes mellitus is a fast-emerging, still-little-known risk factor for TB—and the burden of diabetes is moving from industrial to developing countries.
The global economic burden of NCDs, estimated to be $6.3 trillion in 2010, is projected to reach $13 trillion by 2030. Few low- and middle-income countries have the financial and structural capacity to respond to these burdens. Their health systems need to support NCDs and multi-morbidities and recognize the potential for new co-morbidity patterns with infectious diseases. Studies have shown that primary-level health services are more cost-effective and efficient, resulting in better health outcomes than complex and specialized health systems. Following the MDGs, many health systems are currently invested in vertical structures targeting individual conditions. Weak and fragmented organization will be hindered if the NCD agenda proceeds without acknowledging a need for stronger health systems, further compounding the burden of NCDs.
Immunization: The 68th World Health Assembly has called for a Global Vaccine Action Plan to “unleash vaccines’ vast future potential—because their impressive history is nothing in comparison to what they could yet achieve.” The framework is to prevent millions of deaths by 2020 by ensuring equitable access to vaccinations for people of all communities. The overall goal is to eradicate polio globally, eliminate maternal and neonatal tetanus globally, and eliminate (guided by regional targets) measles and rubella. The most promising licensure is for the dengue virus vaccine. Considering its heavy global burden, its 50% efficacy has potential in denting its consequences.
Although an estimated 83% of all infants in 2011 have adequate DPT vaccinations (diphtheria, tetanus, and pertussis) at 20¢ per dose in developing countries, over 22 million infants remain unimmunized in the world each year. The number of measles deaths fell by 71% between 2000 and 2011. Increased routine vaccination for measles, bacterial meningitis, tetanus, diphtheria, polio, pertussis, yellow fever, and rotavirus greatly improved with better coordination, discrete budget sources, and additional outside funding from groups like the Global Alliance for Vaccines and Immunization.
Despite these successes, improving access to current and long-standing vaccines remains crucial in preventing mortality. Around 20% of children in developing countries do not receive the complete immunizations scheduled for the first year of their life. If all countries immunize 90% of children under five years of age with 14 vaccines recommended by the Global Immunization Vision and Strategy, immunization could prevent an additional 2 million deaths a year in this age group, WHO estimates.
Bioterrorism: 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 potentially be placed around the world like fire extinguishers. New problems may also come from unregulated synthetic biology laboratories of the future. See Global Challenge 10 for more on biology-related security issues.
Strategy: The best ways to address epidemic diseases remain early detection, accurate reporting, prompt isolation, and transparent information and communications infrastructure, with increased investment in clean drinking water, sanitation, and hand-washing, along with optimizing the use of current health technologies (drugs, devices, biological products, medical and surgical procedures, support systems, and organizational systems). Climate change and other global environmental changes are resulting in changes in the magnitude and pattern of risks, underlining the need for increased investment in monitoring and surveillance.
WHO’s eHealth systems, smart phone technology, international health regulations, immunization programs, and the Global Outbreak Alert and Response Network are other elements addressing this Global Challenge. WHO’s Global Health Observatory and Global Burden of Disease project are increasingly making information clearer for setting policy and priorities.
Alongside the other BRICs, China has pushed to redefine mechanisms imported on the global health landscape and significantly contributing to achieving several health-related MDGs. UN Secretary General Ban Ki-moon stated: “The countries of the South are building new models of development cooperation that emphasize mutual benefit and solidarity as well as cost-effectiveness. This is helping to provide people with improved access to affordable medicines, technology and credit.”
With the conclusion of the MDGs this year, the focus has shifted to the 17 new Sustainable Development Goals within a post-2015 agenda. Although all goals address the social and structural determinants of health, Goal 3 stands as the only explicit health-related goal, with a view to ensuring healthy lives and promoting well-being for all at all ages. This relates to the passage of a UN General Assembly resolution on universal health coverage in December 2012. Universal health coverage is still out of reach for many countries. Highly fragmented health systems have the potential to undermine previous development efforts and leave people’s health vulnerable to external shocks (e.g. conflict, natural disaster etc.). The resolution urged member states to develop health systems that avoid substantial direct payments at the point of delivery and to implement mechanisms for pooling risks to avoid catastrophic health care spending and impoverishment. Furthermore, WHO’s World Health Report 2013 states that universal health coverage cannot be achieved without the evidence provided by scientific research.
The WHO Regional Office for Europe has published Health 2020 (its new health policy strategy) and an accompanying European Action Plan. Both documents have been endorsed by the 53 member states, giving WHO a mandate to ensure progress and hold member states accountable. Through an extensive process of consultation among the countries, overarching targets have been established in the three foci of Health 2020: reducing the burden of disease and risk factors, improving health and well-being, and improving governance and systems for health.
Challenge 8 will be seriously addressed when life expectancy grows to 75 years of healthy life, with little disparity among and within nations; when resilient global health funding is assured; when effective global disease detection, surveillance, and therapy systems are in place; and when vaccines and medicines for new diseases are developed in a timely fashion.
Africa: The first vaccine for malaria will be tested in 2018 in Ghan, Kenya, and Malawi.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. Africa is short 1.5 million health workers, and more nurses leave South Africa than are trained there annually.
The Ebola pandemic (2014–15) highlighted weaknesses in African and global health systems, regulations, and surveillance and monitoring. The Ebola epidemic overshadowed other persistent health issues in this region because of its extremely infectious nature and the high mortality rate. This deadly disease claimed 11,095 lives out of 26,858 cases across the world (May 2015). HIV incidence has fallen by 26% overall in 22 countries in sub-Saharan Africa due to ART, although the region still accounted for the majority of all people living with HIV in 2012. Nearly one in every 20 African adults (4.9%) is living with HIV. Patients on ART increased to 64% by the end of 2012, with an additional 1.3 million people added in the last year and with “universal access” (greater than 80%) in Botswana, Namibia, and Rwanda. UNICEF estimates there are about 1.6 million AIDS orphans in South Africa and that 16% of children in Zimbabwe and 12% in Botswana are AIDS orphans. Clinics in northern Malawi provided free antiretroviral drugs, which reduced 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. 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. Progress in reducing TB incidence and prevalence rates has been slow due to high HIV/AIDS prevalence rates. Nevertheless TB-related deaths are on the decline, falling by 23% between 1990 and 2011.
The incidence of and death rates from malaria fell by an average of 31% and 49%, respectively, in Southern, East, and Central and West Africa as a group. Nevertheless, 90% of the estimated 627,000 malaria deaths worldwide in 2012 occurred in sub-Saharan Africa, and 77% were among children below the age of five. The number of polio cases fell 15% from 2013 to 2014. WHO received reports of 125 cases from 54 villages in 2014: South Sudan (70), Mali (40), Chad (13), and Ethiopia (2).
In terms of NTDs, mapping of schistosomiasis has improved: 25 countries were entirely mapped (61%) in 2014 and 15 countries partially mapped (37%). The reported number of people receiving preventive chemotherapy for schistosomiasis increased by nearly 25% from 2011 to 27.5 million in 2013, but the coverage is far lower than WHO’s target of 75% of school-age children. Elimination projects have been started in three countries (Burundi, Rwanda, and United Republic of Tanzania (Zanzibar)), with integrated approaches combining all the necessary strategies, including health education, improved sanitation, water supply, and snail control. In 2012, some 45% of the population in Southern, East, Central, and West Africa used either shared or unimproved sanitation facilities, and 25% practice open defecation.
While average life expectancy for both sexes remains less than 55 years in nine sub-Saharan Africa, low- income countries have made substantial advances (an increase of 9 years of average life expectancy between 1990 and 2012 —from 51.2 to 60.2 years for men and 54.0 to 63.1 years for women). However, progress in halving the proportion of undernourished people has been slow in all developing regions, with an average reduction of 22.3% for Africa between 1990 and 2013. Africa has reduced its maternal mortality ratio by 47% between 1990 and 2013. Despite these achievements, meeting MDG 5 remains unlikely. Limited access to contraceptives, skilled birth attendants, and antenatal care as well as high adolescent birth rates has contributed to the high maternal mortality ratio in Africa.
Asia and Oceania: Asia and the Pacific regions have made the most progress in health in the last two decades. Nevertheless, they remain an epicenter of emerging epidemics and there are concerns about data collection and assessment in many countries. Most statistics are based on only 30 countries in region. Infant mortality rates in Asia and the Pacific fell by 52% during the period 1990–2012, from 6.4% to 3.1%. However, this is not close to the MDG goals for child health, although dramatic reductions have taken place in the incidence of postpartum maternal death. The maternal mortality rate (the number of women who die during pregnancy and childbirth per 100,000 live births) fell in the region by 61%, a rate of reduction faster than the global average of 46%. The number of people living with AIDS has gradually increased, with the highest prevalence in Thailand, Cambodia, and Myanmar. The reported number of people in China with HIV/AIDS fell from 780,000 at the beginning of 2012 to 437,000 at the beginning of 2014. In some countries, the incidence rate of AIDS has reduced by more than half since 2001, including India (a 57% reduction) and Papua New Guinea (a 79% reduction). Treatment coverage varies substantially across the region. The percentage of adults and children living with HIV and receiving ART ranges from 5% in Afghanistan to 67% in Cambodia.
Despite impressive reductions, the prevalence and incidence of tuberculosis in the Asia-Pacific region in 2012 remained higher than in all other regions except Africa. The rate of TB prevalence in low-income countries exceeded five times the rate in high-income countries, while the rate of TB incidence remained more than four times higher in low-income countries than in high-income ones. Region-wide, the incidence of malaria increased from 1990, peaking in 2002 and declining since, although the rate in 2012 remained 9% higher than in 1990. Pacific island developing countries had by far the highest malaria rates among subregions in Asia and the Pacific, with rates more than 40 times higher than the regional average. India, Indonesia, Myanmar, Pakistan, and Papua New Guinea account for 89% of all malaria cases in the region. Nevertheless, only 2% of deaths from malaria globally occurred inside the Asia-Pacific region.
Japan and Singapore have the longest life expectancies in Asia: in Japan the figure is 84.7 years (2015 estimate) with 87 years for women and 80 years for men; in Singapore, it is 84.68 (2015 estimate). A number of other Asian countries are among the most improved for healthy life expectancy since 1990, including Singapore, South Korea, and Taiwan. China is investing $127 billion in new health infrastructure over the next two years. 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. Environmental health will get greater attention due to the alarming air and water quality in China (Beijing has had air quality recordings three times higher than hazardous levels; Ludhiana in India is even worse.) Pakistan spends only 2% of its GDP on health care.
In terms of NTDs, unprecedented progress has been made in the elimination of visceral leishmaniasis in the Indian subcontinent. In Bangladesh, technical expertise, political commitment, and community mobilization have contributed to the more than 70% reduction achieved in the number of new reported cases between 2009 and 2013. In 2014 a Memorandum of Understanding was signed by Bangladesh, Bhutan, India, Nepal, and Thailand for the elimination of visceral leishmaniasis, with all five countries adopting the use of single-dose liposomal amphotericin B. Only Indonesia has populations that require preventive chemotherapy for schistosomiasis, and 10,392 people were treated for this in 2013, compared with 14,102 people in 2011. Four countries (Egypt, Somalia, Sudan. and Yemen) have populations requiring chemotherapy. The number of people reported to have received preventive chemotherapy there was 2.7 million in 2012. In 2013, Egypt, Sudan, and Yemen reported treating nearly 12 million people (45.1% being school-age children), representing a considerable increase against 2012. Yemen accounted for 80.1% of those reported treated in 2013.
Europe: Although the aging population of Europe and increasing migration are stressing government medical services, under-five mortality has fallen 50% since 1990 and maternal mortality has dropped 25%.The European Health Report 2012: Charting the Way to Well-being, by WHO, gives country statistics for mortality, causes of death, risk factors and risky behaviors, and six goals for Europe by 2020 in premature mortality, life expectancy, inequities in health, well-being, universal health coverage, and national targets set by member states. WHO Europe (Health 2020) is changing its focus toward prevention amid a funding crisis due to the global recession. Hospital-borne infections affect 3 million Europeans per year. TB deaths continue to increase in Europe after a 40-year decline. Ukraine has the highest prevalence of HIV in Europe, but this has been decreasing since 2006. In Russia, drug tests are obligatory in schools and universities. In order to maintain and optimize its free health care system, Russia reduced the number of health facilities in rural areas from 8,249 in 2005 to 2,085 in 2013, including a drop in hospital numbers from 2,631 to only 124.
Latin America: The OAS and PAHO are integrating the region’s eHealth and eGovernment systems. The LAC region has the highest life expectancy among developing regions and the highest rates of antiretroviral treatment for HIV/AIDS of any WHO region. Vaccination coverage is also among the highest in the developing world. 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, spreading to Cuba and the Dominican Republic, and may become endemic. Some 100,000 Haitians are expected to be vaccinated against cholera this year. The HIV/ AIDS epidemic remains stable throughout Latin America. Brazil has shown that free ART has since 1996 dramatically cut AIDS mortality, extended survival time, saved $2 billion in hospital costs, and keeps 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) mostly in Brazil. Canine rabies and human rabies transmitted by dogs have been eliminated in many countries in Latin America. Between 2010 and 2014, human rabies transmitted by dogs was restricted to the Plurinational State of Bolivia, the Dominican Republic, Guatemala, Haiti, Honduras, and some limited areas within Brazil and Peru; elimination of dog-transmitted human rabies is expected in Latin America (by end-2015).Traffic accidents are the second leading cause of death in Mexico for children and young people from 5 to 29 years of age.
North America: Future health threats from climate change such as extreme weather conditions and changing diseases carriers are expected to worsen for the foreseeable future. The current urgent threats in the U.S., according to CDC, are carbapenem-resistant enterobacteriaceae, drug-resistant gonorrhea, and clostridium difficile (a serious diarrheal infection causing 250,000 hospitalizations and 14,000 deaths annually that is usually associated with antibiotic use). Although the U.S. spends almost 20% of its GDP on it health care, results have not been satisfactory and there are too many uninsured, resulting in the new U.S. health care legislation. Some 21 states have chosen not to take advantage of the expanded Medicaid part of the law, leaving many of the poorest without maximum benefit. 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. The FDA approved Truvada, the first drug approved to reduce the risk of HIV infection in uninfected individuals. The U.S. has 1.1 million people with HIV (50,000 new HIV infections acquired in 2012); 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. CDC reports that roughly half of new HIV infections in the U.S. originate from the 20% of people living with the virus who are unaware of their infection. The Americas has been declared the first region to eliminate rubella, following 15 years of vaccination campaigns. The Bill and Melinda Gates Foundation has committed nearly $2 billion in malaria grants and more than $1.4 billion to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. According to a Gallop Poll over half of Americans what a single payer federal healthcare program.