Sunday, December 11, 2011

Neglected Tropical Diseases: Neglected for a Reason

It's good to hear calls for 'neglected tropical diseases' to be addressed, rather than taking the sort of vertical (single disease at a time) approach that is favored by big institutions and by countries who allocate large amounts of money to health related development. But even some of those calling for this move are still pegging vital broader health issues to the extremely narrow HIV agenda.

People living in areas with a high disease burden, poor nutrition, poor living conditions and the like, are going to be infected with many diseases during their life, HIV being just one. This is not a recent discovery, nor is it very surprising. It is also not a surprising discovery that HIV positive people are more likely to transmit HIV if they are also suffering from other, easily treatable and preventable diseases.

So, the big missed opportunity is not one for HIV prevention and treatment alone, it is for health and development in general. Picking off a few headline diseases is little better than concentrating almost all attention on HIV. But making lasting improvements to living conditions, nutrition, water and sanitation, infrastructure, health systems and education are the real missed opportunities, without which HIV prevalence will remain high for a long time to come.

I hope the American Society of Tropical Medicine and Hygiene succeed in getting more general, non-HIV related health issues some attention and funding. But addressing health more generally, avoiding the 'silo' or 'vertical' approach, is probably the best way to treat and prevent HIV, also. Doing things the other way around has not worked and never will. If you see HIV as the problem and set up a parallel health infrastructure you will fail with most or all of the other health issues and this is unlikely to have much impact on HIV either.

But Walson and others put their finger on the very difference between HIV and other diseases they now hope to deal with, ones they refer to as 'diseases of poverty'; HIV is not a disease of poverty, at least, not to the extent that intestinal and other parasites, malnutrition related conditions, waterborne diseases and acute respiratory diseases are. HIV in African countries tends to concentrate to a disproportionate extent in urban dwelling, wealthier, better educated, more mobile populations.

From a commercial point of view, there just isn't much money in 'diseases of poverty', whereas there is a huge amount of money available for HIV; that's what makes HIV an entire industry, and diseases of poverty a mere development issue. In wealthy countries enough people can afford HIV drugs, despite the fact that they are grossly overpriced.

But even in developing countries, donors, up to now anyhow, have been interested in funding HIV. They're mostly interested in funding treatment because that's a lot more lucrative than prevention. But the word on the street now is that 'treatment is prevention', so even more money may end up being spent on this single disease. Though HIV treatment is not, in any useful sense, prevention, this is unlikely to worry those whose income comes from treatment.

Waterborne diseases, respiratory diseases and the like, those that kill more people than all the headline diseases put together, do not involve lifelong treatment with expensive drugs, which need to be replaced, eventually, with even more expensive drugs as resistance builds up. Some of the most ignored drugs are ones for which the treatment is a once or twice off occurrence and the treatment is dirt cheap. What self-respecting pharmaceutical multinational corporation wants to bother producing such drugs?

There is mention of the Gates Foundation but this institution has only shown token interest in anything but wealthy institutions and industries, with pharmaceuticals and genetically modified organisms receiving massive amounts of funding. Gates himself is not shy about promoting vaccines, preferably one for each disease, but he's a lot less interested in, for example, water and sanitation, provision of which could take care of a whole spectrum of diseases. Which is not to say he spends nothing on water and sanitation, just comparatively little.

People and institutions who wish to address various health issues because they reduce the quality of life and the life expectancy of hundreds of millions of people are to be encouraged, particularly if their 'success' is not going to be judged entirely by HIV related indicators. But HIV is not just highly funded because it threatens the livelihood, health and lives of so many people; just about all diseases fit into that  category. There's long been an obsession with HIV that may not be so easy to dislodge by a few public calls for change.


No comments: