Funding Health is Cheaper than Paying for Disease

To continue a theme I hit on in my last post, Reuters AlertNet lists lower respiratory infections as the top killer, accounting for more than 4 million deaths in developing countries. HIV/Aids is listed as number two, accounting for three million deaths, although serious under-reporting of HIV deaths must place a question mark over whether HIV/Aids is really number two or number one.

But the number three killer is interesting because malaria is said to be responsible for between one and five million deaths every year. Added to this, diarrhoea, at number four, kills an estimated 2.2 million people every year. So if deaths caused by poor water and sanitation were added up, they could easily be a contender for 'top killer'.

AllAfrica.com are excited at the possibility that diarrhoea may now get as much attention and funding as HIV/Aids. But funding and attention for a specific condition is missing the point. The number of people suffering and dying from diarrhoea is dwarfed by the number who suffer and die from water borne conditions and others that result from lack of decent standards of water and sanitation.

Health is not merely a matter of curing sickness; it is primarily a matter of ensuring that people live in circumstances that will maximise their health. In other words, they need a decent standard of living. Treatment and immunisation are great but they are no substitute for prevention. A lot of disease and death could be much more cheaply prevented by providing people with good water and sanitation.

Similarly, many of the lower respiratory infections that are said to comprise the top killer result from poor living and working conditions. Added together, water borne diseases and lower respiratory infections probably outnumber all other killer diseases in prevalence and mortality. So the effect of improving living and working conditions combined with improving water and sanitation would be profound.

But a health strategy that effectively consists of targeting diseases, or even risk factors, and starting with the biggest, seems to miss the reasons why so many people suffer and die unnecessarily. There isn't a need to target diarrhoea, for example, because it kills more children than HIV/Aids. There is a need to provide people with a standard of living that enables them to avoid all water borne diseases. Lower respiratory infections may be the top killer but simply vaccinating everyone and treating everyone infected will still leave people living in poor conditions.

To use a different example, malaria prevention is not just a matter of distributing bed nets. If you continue to ignore the festering pools of water that you find everywhere, your children will still go out and play in or near them when they wake up. Festering pools of water are not conducive to good overall health. The bed nets are vital in some areas but the risk of both malaria and other water borne diseases can be lowered by an improvement in sanitation and hygiene conditions.

Luckily, the WHO recommendations to which the AllAfrica article refers includes improvements in water and sanitation. But it remains to be seen if the World Bank and the International Monetary Fund (IMF) keep in step with the WHO. Since the early 1980s, these institutions have worked to reduce health, education and infrastructure in developing countries. They have concentrated on dismantling the structures which allow people to live healthy lives.

There's a sense in which health policy and funding seem to concentrate on downstream effects, particular diseases and health conditions, rather than on the upstream determinants of health.