Diseases of Poverty - who.int

1 Diseases of povertyand the 10/90gapDiseases ofpoverty and the10/90 GapDiseases of Poverty and the 10/90 GapWritten by Philip Stevens, Director of Health Projects,International Policy Network November 2004 International Policy NetworkThird Floor, Bedford ChambersThe Piazza London WC2E 8HA UKt : +4420 7836 0750f: +4420 7836 0756e: w : International Policy Network 2004 Designed and typeset in Latin 725 by MacGuru design by Sarah Hyndman Printed in Great Britain by Hanway Print Centre102 106 Essex RoadIslington N1 8LU All rights reserved. Without limiting the rights undercopyright reserved above, no part of this publicationmay be reproduced, stored or introduced into aretrieval system, or transmitted, in any form or byany means (electronic, mechanical, photocopying,recording or otherwise) without the prior writtenpermission of both the copyright owner and thepublisher of this book. Diseases of Poverty and the 10/90 Gap3 Introduction: What is the 10/90 Gap?Activists claim that only 10 per cent of global healthresearch is devoted to conditions that account for 90per cent of the global disease burden the so-called 10/90 Gap.

2 1 They argue that virtually all diseasesprevalent in low income countries are neglected and that the pharmaceutical industry has investedalmost nothing in research and development (R&D)for these this alleged imbalance as justification,activists have been calling for a complete redesign ofthe current R&D paradigm in order to ensure thatmore attention is paid to these neglected Diseases .2 This could include measures such as an essentialresearch obligation that would require companies toreinvest a percentage of pharmaceutical sales intoR&D for neglected Diseases , either directly orthrough public R&D does such an imbalance really exist and whatwould be the effect of redesigning the R&D system?This paper investigates the realities of the 10/90 gapand its relation to the Diseases of diseasesMany scholars and activists have suggested that thepharmaceutical industry is failing to devotesufficient R&D effort towards finding effective curesand treatments for tropical infectious Diseases suchas leishmaniasis, lymphatic filariasis, Chagas disease, leprosy, Guinea worm, onchocerciasis andschistosomiasis.

3 These so-called neglected diseasespredominantly effect poor populations in lowincome countries,4and pose particular social andeconomic problems for those affected. Patrick Trouiller, for example, has pointed out thatof the 1,393 total new drugs approved between 1975and 1999, only 1 per cent (13 drugs) werespecifically indicated for a tropical conducted by the DND Working Group andthe Harvard School of Public Health in 2001revealed that of the 20 global pharmaceuticalcompanies surveyed, only two had research projectsunderway for the neglected Diseases of Chagas Diseases are a tiny fractionof total mortalityHowever, these bare statistics serve to misleadpeople into thinking that the poor are suffering atthe expense of the rich. The reality is that neglected Diseases often do not represent the mostpressing public health priorities in low incomecountries. They constitute a small fraction of theirtotal disease burden (Figure 1). According to the2002 World Health Organisation s (WHO) WorldHealth Report, tropical Diseases accounted for per cent of deaths in high-mortality poorcountries, and only per cent of deaths in low-mortality poor , treatments already exist for many of thesediseases.

4 Schistostomiasis (bilharzia), whichpredominantly affects children in Africa, can betreated with praziquantel at a cost of 30 cents perchild per year. Onchocerciasis (river blindness) isFigure 1 Number of daily deaths from diseases710,8147,8525,4824,5043,6113,079 378*Neglected Diseases are defined as African trypanosomiasis, Chagas diseaseand leishmaniasisNeglecteddiseases*MalariaCh ildhooddiseasesTuberculosisDiarrhoealdis easesHIV/AIDSR espiratoryinfections02,0004,0006,0008,00 010,00012,000 Diseases of Poverty and the 10/90 Gap4controllable with ivermectin. A range of treatmentsexist for lymphatic filariasis (elephantiasis). Theonly significant tropical disease for which there is noexisting medicine is dengue fever, but even for thisdisease there are five compounds currently at thestate of discovery and preclinical development, afurther two in Phase 1 trials and one more in Phase2 fact, the WHO acknowledges that thereare only three Diseases that are genuinely neglected : African trypanosomiasis, leishmaniasisand Chagas disease in lower-incomecountries is caused by Poverty A large proportion of illnesses in low-incomecountries are entirely avoidable or treatable withexisting medicines or interventions.

5 Most of thedisease burden in low-income countries finds itsroots in the consequences of Poverty , such as poornutrition, indoor air pollution and lack of access toproper sanitation and health education. The WHOestimates that Diseases associated with povertyaccount for 45 per cent of the disease burden in thepoorest , nearly all of thesedeaths are either treatable with existing medicinesor preventable in the first place. Tuberculosis, malaria and HIV/AIDS, forexample, together account for nearly 18 per centof the disease burden in the poorest Malaria can be prevented through a combinationof spraying dwellings with DDT, usinginsecticide treated mosquito nets and takingprophylactic medicines such as mefloquine,doxyclycline and malorone. Malaria can also betreated with artemisinin combination can also play an important role inreducing the incidence of insect-borne Diseases ,for example by encouraging people to removesources of stagnant water (insect breeding sites)from near their dwellings.

6 Tuberculosis can be prevented by improvingnutrition, and can be treated with DOTS can detect and cure disease in up to 95 percent of infectious patients, even in the Education is vital for the prevention ofHIV/AIDS and this entails the full engagementof civil society. A combination of anti-retrovirals(ARVs) and good nutrition can help to controlthe viral load and suppress the symptoms ofHIV/AIDS. Treatable childhood Diseases such as polio,measles and pertussis, account for only percent of Disability Adjusted Life Years (DALYs) inhigh-income countries, while they account per cent of DALYs in high mortality low-income for these diseaseshave existed for at least 50 years, yet only 53 percent of children in sub-Saharan Africa wereimmunised with the diphtheria-tetanus-pertussis (DTP) jab in Diarrhoeal Diseases are caused by the poorsanitation inherent to the condition of Poverty ,yet are easily and cheaply treatable through oralrehydration therapy. However, diarrhoealdiseases still claim million lives each year.

7 15 Respiratory infections caused by burningbiomass fuels in poorly ventilated areas alsoplace a considerable health burden on poorpeople. According to the WHO, exposure tobiomass smoke increases the risk of acute lowerrespiratory infections (ALRI) in childhood,particularly pneumonia. Globally, ALRI representthe single most important cause of death inchildren under 5 years and account for at leasttwo million deaths annually in this age Malnutrition particularly affects people in poorcountries. As a result of vitamin A deficiency, forexample, 500,000 children become blind eachyear,17despite the fact that such outcomes canbe avoided by cheap, easy-to-administer of Poverty and the 10/90 Gap5 Poverty -related Diseases cause far higher levels ofmortality in low-income than high-income countries(Table 1). Most of these Diseases and deaths can beprevented with pre-existing treatments andprevention programmes. Diseases for which there isno treatment currently available, such as denguefever, contribute towards a far smaller proportion oflow-income country mortality rates than diseaseswhich are easily preventable or treatable.

8 It isestimated that 88 per cent of child diarrhoeas, 91per cent of malaria and up to 100 per cent ofchildhood illness, such as measles and tetanus, canbe prevented among children using means that up to 3 million childlives could be saved each year if these medicinescould be distributed effectively to all areas of of low and high-incomecountries are convergingExponents of the 10/90 Gap are also inaccuratewhen they claim that low-income countries, whichconstitute the majority of the world s populationand disease burden, suffer from completely differentdiseases than high-income countries. The premisethat only 10 per cent of the global health researchbudget, both private and public, is used for researchinto 90 per cent of the world s health problems isfactually incorrect. In reality, the nature of Diseases suffered by bothrich and poor countries is converging rapidly, withboth spheres suffering from an increasingly similarspread of Diseases . For example, non-communicablediseases such as cancers, neuropyschiatric andcardiovascular Diseases traditionally associatedwith high-income countries now represent over 60per cent of the total global disease burden, andimpact both rich and poor countries.

9 Cardiovasculardiseases alone account for one-quarter of all deathsin low mortality low-income countries, with thisproportion set to rise as these countries gain accessto diets richer in fats and calories. In absolute terms,non-communicable Diseases now kill greaternumbers of people in the lower-income countriesthan they do in high-income countries. It is hardly surprising that a significant amount ofresources are being devoted by the current globalR&D effort towards developing treatments forcancers, cardiovascular Diseases , neuropyschiatricdiseases and diabetes. Although such Diseases havebeen traditionally associated with richer countries,they are now also significant and growing problemsin poorer parts of the world. This convergence of patterns of mortality suggeststhat, in the future, low-income countries will derivesignificant benefit from drugs currently beingresearched with high-income country markets inmind. This is particularly the case for those drugs inwhich most R&D effort is currently being focused,Table 1 Deaths caused by Poverty -related diseases20% of deaths caused by/in High mortality Low mortality High-income low-income countrieslow-income countriescountriesInfectious and parasitic Diseases Respiratory infections Perinatal and maternal conditions Nutritional deficiencies Tropical Total Poverty -related of Poverty and the 10/90 Gap6namely treatments for cancers, cardiovascular andneuropyschiatric Diseases .

10 The fact that low-income countries are rapidlycatching up with high-income countries in theirlevels of obesity only serves to reinforce the pointthat the two spheres will increasingly suffer fromsimilar Diseases in the future. According to theInternational Association for the Study of Obesity(IASO), 50 per cent of South African women arenow overweight, whilst in Morocco 40 per cent ofthe population are overweight. In Kenya, the figure stands at a startling 12 per cent,and in Nigeria it is estimated that between 6 percent and 8 per cent of people are obese. As ProfessorArne Astrup of the IASO puts it, on an African levelwe see now that obesity is a really major disease, inline with HIV and malnutrition. 23 With growinglevels of obesity, it is safe to predict that low-incomecountry populations stand to suffer more in thefuture from obesity-related Diseases such as strokesand would seem rather unjust, then, to vilify thepharmaceutical industry for spending researchmoney on finding treatments for these areas; it is asimple case of the supply of research following thedemand of mortality patterns (Figure 3).