Neglected Tropical Diseases: Making Poverty Profitable?

I would like to make some clarifications to yesterday's blog after receiving comments on Twitter. I am not opposed to the use of vaccines, especially for diseases like polio. But there are too many diseases to line up vaccines, one by one, for each remaining disease. And all the time vaccine programs are going on, people are drinking contaminated water, sewage is being dumped in the water supply, nutrition levels are low, etc. Vertical health programs, tackling one disease at a time, is not the best way of approaching deadly diseases. And health is not just an array of diseases to be 'fought' with various different pharmaceutical products. Think of it this way; we don't have cures for many diseases but we do know that where living conditions are terrible, disease burden will be high.

Gates is in favor of vertical programs and is using the example of polio vaccination, which has been going on for decades, slowly eradicating the disease in one country after another, to push for the same approach to other diseases. Some of these other diseases might better be addressed by spending more on provision of clean water and sanitation or nutrition or a combination of measures. But his aim is to spread technology (drugs, GMOs, geoengineering, birth control, etc), not to ensure high levels of health. The amount of time, money and effort spent on polio eradication is worthwhile; but if the same amount of time, money and effort were spent on water and sanitation, the need to spend time on vaccinations for each serious water-borne disease would be reduced considerably.

Gates and his half baked ideas about development have become so ubiquitous that it is rare to hear people criticizing him. There's a kind of grotesque parallel to herd immunity, where even those who might otherwise question him are somehow inhibited from doing so by those around them. It's as if his cash injections into the programs he feels are worth promoting has silenced any potential objections even in those programs that haven't yet received anything, but hope to do so in the future. If the current polio eradication efforts succeed, that should be used as an argument to approach other diseases individually, but rather to address the primary determinants of health and aim to reduce incidence of multiple diseases.

The current approach to neglected tropical diseases, something Gates also claims to be interested in eradicating (one by one, presumably), is questioned in a recent article in The Lancet, by Tim Allen and Melissa Parker. The authors are not opposed to addressing these diseases but they do question the way in which control strategies are being implemented. Very large, well funded programs that tend to take a top-down approach can undermine existing health systems in various ways, including indiscriminate use of drugs and by creating a lot of misunderstanding, both among the putative beneficiaries of the programs and among those who monitor and fund them. Such misunderstanding can affect take-up of health programs among target populations (for example, polio eradication in parts of Nigeria?), but also, it can eventually reduce the potential benefits of such programs, perhaps even where conditions are closer to optimal.

The authors briefly raise the issue of intense competition being involved in such programs, which can strongly influence critical analysis; also the "conflation in medical journals of fine-grained and detailed scholarly research (undertaken mainly by parasitologists and epidemiologists) with broad assertions that are best understood as advocacy statements", an example of which may be found in a recent post on this blog (though much of the conflating was done by the lead author of the article); and the authors call for insights from social scientists not to be dismissed, as they so often are. They feel that current efforts will not be sustainable and will not 'make poverty history', as the popular slogan has it.

Gates and others seem to take a kind of scorched earth approach to health and development, as if money and technology are weapons. But what is worse, they seem to think of people suffering from diseases, or at risk of those diseases, as the enemy, to have various techniques and technologies shoved down their throat (or elsewhere), whether they like it or not. The latent contempt and violence behind mass male circumcision and the highly aggressive marketing of Depo Provera and various birth control methods are obvious enough to some, but other health (and development) programs also need to take into account the recipients, not just those who have decided who the recipients should be.

[For more about mass male circumcision and injectable Depo Provera, see the Don't Get Stuck With HIV site.]