Richard Smith: Rethinking priorities in global health

Richard SmithLast week’s conference to launch Edinburgh University’s Global Health Academy left me thinking that priorities in global health may be very wrong.

David Molyneaux from Liverpool said that an alien observing earth for the first time would think that it had only three diseases: AIDS, TB, and malaria. He is one of the “three dinosaurs of neglected tropical diseases (NTDs)” who spoke at the meeting, pointing out that sums that are very small by the standards of AIDS could make a huge difference in alleviating the suffering of the world’s poorest people from schistosomiasis, onchocerciasis, sleeping sickness, elephantiasis, and the other neglected tropical diseases. Some of these diseases can be treated very effectively and cheaply. Deworming people—as animals have long been dewormed—for 60 cents a year could make huge differences to child growth and development and levels of disability.

Neglected tropical diseases have received some funds and had successes with treatment and eradication, but why have they not received the attention and funding of AIDS when much more could be achieved with much less money?

Molyneaux thought that one problem was that most people in rich countries had never heard of these diseases and had no idea of the extent of harm they can cause. Broadcast media are reluctant to make programmes on the diseases because people don’t know what they are—and the pictures of people severely affected by the diseases they judge to be just too horrible. Then health ministers in the affected countries—mostly in SubSaharan Africa—are highly unlikely to get the diseases themselves because they are the diseases of the poorest people living away from the capitals and often away from any health services at all.

The preoccupation with AIDS, TB, and malaria may well be creating harm, argued the Lancet’s Rhona McDonald, a passionate advocate for global health and social justice. She described first hand experience of intense political battles over whether the “vertical programmes” for treating AIDS, TB, and malaria—the “global health initiatives”—had done harm by diverting attention and resources from basic health systems.

Then she emphasised the importance of clean water, sanitation, food security, and human rights. Health is impossible without these basics, and preoccupation with the medical model can be a distraction.

Allyson Pollock from Edinburgh built on this theme, reminding the audience that the huge advances in life expectancy and quality in the developed world in the past 150 years came mainly from public health not from drugs and vaccines. She also emphasized the importance of the collection of routine data on births, deaths, and the like and feared that data on the global burden of disease may be misleading because so many countries do not collect routine data.

If the alien that observed that the earth had only the three diseases of AIDS, TB, and malaria had found its way into the meeting it would have emerged thinking that the earth needed to rebalance its priorities.