Diseases of Poverty and the 10/90 Gap Diseases of Poverty and the 10/90 Gap Diseases of Poverty and the 10/90 Gap

Diseases of poverty and the 10/90 gap Diseases of poverty and the 10/90 Gap Diseases of poverty and the 10/90 Gap Written by Philip Stevens, Director of Health Projects, International Policy Network November 2004 International Policy Network Third Floor, Bedford Chambers The Piazza London WC2E 8HA UK t : +4420 7836 0750 f: +4420 7836 0756 e: [email protected] w : www.policynetwork.net © International Policy Network 2004 Designed and typeset in Latin 725 by MacGuru Ltd [email protected] Cover design by Sarah Hyndman Printed in Great Britain by Hanway Print Centre 102–106 Essex Road Islington N1 8LU All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of both the copyright owner and the publisher of this book. Diseases of poverty and the 10/90 Gap Introduction: What is the 10/90 Gap? Figure 1 Number of daily deaths from diseases7 Activists claim that only 10 per cent of global health research is devoted to conditions that account for 90 Respiratory 10,814 per cent of the global disease burden – the so-called infections 1 ‘10/90 Gap’. They argue that virtually all diseases HIV/ 7,852 AIDS prevalent in low income countries are ‘neglected’ Diarrhoeal 5,482 and that the pharmaceutical industry has invested diseases almost nothing in research and development (R&D) Tuberculosis 4,504 for these diseases. Childhood 3,611 diseases Citing this alleged imbalance as justification, Malaria 3,079 activists have been calling for a complete redesign of Neglected 378 the current R&D paradigm in order to ensure that diseases* more attention is paid to these ‘neglected diseases’.2 0 2,000 4,000 6,000 8,000 10,000 12,000 This could include measures such as an ‘essential *Neglected diseases are defined as African trypanosomiasis, Chagas disease research obligation’ that would require companies to and leishmaniasis reinvest a percentage of pharmaceutical sales into R&D for neglected diseases, either directly or revealed that of the 20 global pharmaceutical through public R&D programs.3 companies surveyed, only two had research projects But does such an imbalance really exist and what underway for the ‘neglected’ diseases of Chagas and would be the effect of redesigning the R&D system? leishmaniasis.6 This paper investigates the realities of the 10/90 gap and its relation to the diseases of poverty. Neglected diseases are a tiny fraction of total mortality Neglected diseases However, these bare statistics serve to mislead Many scholars and activists have suggested that the people into thinking that the poor are suffering at pharmaceutical industry is failing to devote the expense of the rich. The reality is that sufficient R&D effort towards finding effective cures ‘neglected’ diseases often do not represent the most and treatments for tropical infectious diseases such pressing public health priorities in low income as leishmaniasis, lymphatic filariasis, Chagas’ countries. They constitute a small fraction of their disease, leprosy, Guinea worm, onchocerciasis and total disease burden (Figure 1). According to the schistosomiasis. These so-called ‘neglected’ diseases 2002 World Health Organisation’s (WHO) World predominantly effect poor populations in low Health Report, tropical diseases accounted for only income countries,4 and pose particular social and 0.5 per cent of deaths in high-mortality poor economic problems for those affected. countries, and only 0.3 per cent of deaths in low- mortality poor countries. Patrick Trouiller, for example, has pointed out that of the 1,393 total new drugs approved between 1975 Moreover, treatments already exist for many of these and 1999, only 1 per cent (13 drugs) were diseases. Schistostomiasis (bilharzia), which specifically indicated for a tropical disease.5 predominantly affects children in Africa, can be Research conducted by the DND Working Group and treated with praziquantel at a cost of 30 cents per the Harvard School of Public Health in 2001 child per year. Onchocerciasis (river blindness) is 3 Diseases of poverty and the 10/90 Gap controllable with ivermectin. A range of treatments nutrition, and can be treated with DOTS therapy. exist for lymphatic filariasis (elephantiasis). The This can detect and cure disease in up to 95 per only significant tropical disease for which there is no cent of infectious patients, even in the poorest existing medicine is dengue fever, but even for this countries.12 disease there are five compounds currently at the ■ Education is vital for the prevention of state of discovery and preclinical development, a HIV/AIDS – and this entails the full engagement further two in Phase 1 trials and one more in Phase of civil society. A combination of anti-retrovirals 2 trials.8 In fact, the WHO acknowledges that there (ARVs) and good nutrition can help to control are only three diseases that are genuinely the viral load and suppress the symptoms of ‘neglected’: African trypanosomiasis, leishmaniasis HIV/AIDS. and Chagas disease.9 ■ Treatable childhood diseases such as polio, Most disease in lower-income measles and pertussis, account for only 0.2 per countries is caused by poverty cent of Disability Adjusted Life Years (DALYs) in high-income countries, while they account for A large proportion of illnesses in low-income 5.2 per cent of DALYs in high mortality low- countries are entirely avoidable or treatable with income countries.13 Vaccines for these diseases existing medicines or interventions. Most of the have existed for at least 50 years, yet only 53 per disease burden in low-income countries finds its cent of children in sub-Saharan Africa were roots in the consequences of poverty, such as poor immunised with the diphtheria-tetanus- nutrition, indoor air pollution and lack of access to pertussis (DTP) jab in 2000.14 proper sanitation and health education. The WHO ■ Diarrhoeal diseases are caused by the poor estimates that diseases associated with poverty sanitation inherent to the condition of poverty, account for 45 per cent of the disease burden in the yet are easily and cheaply treatable through oral poorest countries.10 However, nearly all of these rehydration therapy. However, diarrhoeal deaths are either treatable with existing medicines diseases still claim 1.8 million lives each year. 15 or preventable in the first place. ■ Respiratory infections caused by burning ■ Tuberculosis, malaria and HIV/AIDS, for biomass fuels in poorly ventilated areas also example, together account for nearly 18 per cent place a considerable health burden on poor of the disease burden in the poorest countries.11 people. According to the WHO, exposure to ■ Malaria can be prevented through a combination biomass smoke increases the risk of acute lower of spraying dwellings with DDT, using respiratory infections (ALRI) in childhood, insecticide treated mosquito nets and taking particularly pneumonia. Globally, ALRI represent prophylactic medicines such as mefloquine, the single most important cause of death in doxyclycline and malorone. Malaria can also be children under 5 years and account for at least treated with artemisinin combination therapy. two million deaths annually in this age group.16 Education can also play an important role in ■ Malnutrition particularly affects people in poor reducing the incidence of insect-borne diseases, countries. As a result of vitamin A deficiency, for for example by encouraging people to remove example, 500,000 children become blind each sources of stagnant water (insect breeding sites) year,17 despite the fact that such outcomes can from near their dwellings. be avoided by cheap, easy-to-administer food ■ Tuberculosis can be prevented by improving supplements.18 4 Diseases of poverty and the 10/90 Gap Table 1 Deaths caused by poverty-related diseases20 % of deaths caused by/in High mortality Low mortality High-income low-income countries low-income countries countries Infectious and parasitic diseases 34.1 24.8 2.1 Respiratory infections 9.9 8.0 3.7 Perinatal and maternal conditions 8.4 6.8 0.4 Nutritional deficiencies 1.3 1.1 0.0 Tropical diseases 0.5 0.3 0.0 Total ‘poverty-related’ diseases 54.1 40.7 6.2 Poverty-related diseases cause far higher levels of rich and poor countries is converging rapidly, with mortality in low-income than high-income countries both spheres suffering from an increasingly similar (Table 1). Most of these diseases and deaths can be spread of diseases. For example, non-communicable prevented with pre-existing treatments and diseases such as cancers, neuropyschiatric and prevention programmes. Diseases for which there is cardiovascular diseases – traditionally associated no treatment currently available, such as dengue with high-income countries – now represent over 60 fever, contribute towards a far smaller proportion of per cent of the total global disease burden, and low-income country mortality rates than diseases impact both rich and poor countries. Cardiovascular which are easily preventable or treatable. It is diseases alone account for one-quarter of all deaths estimated that 88 per cent of child diarrhoeas, 91 in low mortality low-income countries, with this per cent of malaria and up to 100 per cent of proportion set to rise as these countries gain access childhood illness, such as measles and tetanus, can to diets richer in fats and calories. In absolute terms, be prevented among children using existing non-communicable diseases now kill greater treatments.19 This means that up to 3 million child numbers of people in the lower-income countries lives could be saved each year if these medicines than they do in high-income countries. could be distributed effectively to all areas of need.

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