1 Why research infectious diseases of poverty? 11 in chapteR 1: • Poverty and infectious disease – a problematic relationship • infectious disease – the true burden on communities • the value of research: new ways to end old diseases • moving beyond the Millennium Development Goals • the cost of inaction – social and economic consequences • tackling disease – a need for investment • ten reasons to research infectious diseases of poverty AUTHORS Research is the key to making things Professor SiAn GRiffiths happen for poor populations. This Director, School of Public Health introductory chapter of the Global and Primary Care, The ChineSe Report examines the need for research univerSity of Hong Kong, Hong into the infectious diseases that Kong SPecial AdminiStrative region, China disproportionately affect poor and marginalized communities – the so- Professor Xiao-NonG Zhou Director, National InStitute called “infectious diseases of poverty”. of ParaSitic DiSeaSeS, ChineSe It examines the link between poverty center for DiSeaSe Control anD and disease and outlines ten reasons Prevention, Shanghai, China to support research for such diseases. Such research represents unfinished Report fellOw Allison Thorpe business of global relevance, work that the world can no longer afford to neglect. 11 According to the latest published data in 2012, infectious (including parasitic) diseases were together responsible for the death of more than 8.7 million people worldwide in 2008 (1). The majority of these deaths were of poor people living in low and middle- income countries, with many of the deaths Infectious diseases have occurring in children under five years of age. shaped societies, driven Given the sketchy data, misdiagnosis and conflict and spawned the under-detection that are typical of health marginalization of infected systems in impoverished areas, these num- individuals and communities bers are almost certainly underestimated. throughout history. Today they are significant agents in the Infectious diseases have shaped societies, appalling poverty afflicting so driven conflict and spawned the marginal- much of the world. ization of infected individuals and communi- ties throughout history. Today they are sig- nificant agents in the appalling poverty af- Chapter 1 Chapter flicting so much of the world. Their impact is felt not only in massive loss of life but also in high-levels of morbidity and the accompa- Poverty nying impact on families, communities and of weak and under-resourced health systems in low and middle-income countries. Stepping tions underpin poverty and can directly and Diseases up research into the causes of infectious dis- indirectly affect health status and health out- eases and how to treat them effectively and comes. Major epidemics emerge and chronic prevent them from spreading would, if acted conditions cluster and persist wherever nfectious i on, have an enormous impact on efforts to poverty is widespread. Lack of food, shelter, on lift people out of poverty and would help security and social protection make people build a better world for future generations. more vulnerable to infections, while affected esearch populations are often unable to obtain even r the most basic means of prevention and for Poverty and infectious care. Poverty creates conditions that favour eport the spread of infectious diseases and pre- r disease – a problematic vents affected populations from obtaining lobal relationship adequate access to prevention and care. Ul- g timately, these diseases – infectious diseases According to The World Bank, the global rate of poverty (see Box 1.1) – disproportionately of extreme poverty (less than US$ 1.25 a day) affect people living in poor or marginalized has been falling over the past two decades communities. Social, economic and biologi- and will likely meet the Millennium Develop- cal factors interact to drive a vicious cycle of ment Goal (MDG) for 2015 (2–5). Much of poverty and disease from which, for many this improvement reflects rapid economic people, there is “no escape”. As stated in the growth in China and India, yet many African report of the Commission on Social Deter- countries with a high burden of infectious minants of Health (6): “Poverty is not only diseases are lagging behind. For example, lack of income. The implication, both of the almost 50% of African countries are far from social gradient in health and the poor health halving extreme poverty. of the poorest of the poor, is that health in- equity is caused by the unequal distribution However, from a global health perspective, of income, goods, and services and of the often there are criteria broader than income consequent chance of leading a flourishing with which to determine who is actually “liv- life. This … is not in any sense a ‘natural’ phe- ing in poverty”. Social and economic condi- nomenon.” 1213 Why reSearch infectious diSeaSes of poverty? Why reSearch infectious diSeaSes of poverty? 13 Box 1.1. InfectiouS diseaSeS of poverty infectious diseases are caused by pathogenic microorganisms, such as bacteria, viruses, parasites or fungi. The diseases can be spread, directly or indirectly, from one person to another1. “infectious diseases of poverty” is an umbrella term used to describe a number of diseases which are known to be more prevalent among poorer populations, rather than a definitive group of diseases. It is an overarching concept, recognizing the need to focus on the poor and vulnerable, who have less power to intervene. Many such diseases are also considered “neglected tropical diseases”, as defined by WHO (see list below). Infectious diseases of poverty are not restricted to low and middle-income countries, but manifest in poor populations globally. Apart from TB, malaria and HIV/AIDS, many other infectious diseases have not been high on the global agenda. However, an increasing number of organizations and partnerships are now engaged in their control. main neglected tropical diseases (6) as identified by WHO are listed below: • dengue • cysticercosis rabies dracunculiasis (guinea-worm disease) • • 1 Chapter • trachoma • echinococcosis • buruli ulcer • foodborne trematode infections Poverty endemic treponematoses (including yaws) lymphatic filariasis (elephantiasis) of • • • leprosy • onchocerciasis (river blindness) Diseases • chagas disease (american trypanosomiasis) • schistosomiasis (bilharziasis) • human African trypanosomiasis • soil-transmitted helminthiases (intestinal (sleeping sickness) parasitic worms) nfectious i on • leishmaniasis esearch r for eport Infectious diseases do not respect socio- infectious disease – the true r economic status. Biologically, we are all at burden on communities lobal risk – but the risk is not evenly distributed. g People already living in social and economic For the working poor, the economic impact deprivation have a greater exposure to the of infectious diseases can be catastrophic. risk factors for disease, and the economic Not only are infectious diseases causally consequences of living with chronic infec- linked to conditions of poverty; they can tious conditions are often more serious. actually make people poor. For example, a Investment in controlling the spread of study in Orissa, India showed that people infectious and parasitic diseases will have with chronic lymphatic filariasis lost 68 a powerful impact on global human, social working days per year and that their families and economic development. spent more on treatment than the aver- age government per capita expenditure on health (21). Thus, families that experience such a disease not only have death to fear but also the cost of illness in terms of treat- ment and lost working days. This easily perpetuates the vicious cycle of poverty and 1 Infectious diseases. http://www.who.int/topics/ infectious_diseases/en/, accessed 13 February 2012. infection. 1213 Why reSearch infectious diSeaSes of poverty? Why reSearch infectious diSeaSes of poverty? 13 taBle 1.1. RelationShIp between InfectiouS diseaSeS and poverty infectious diseases Risks risk factors are shaped by the conditions in which people live and work, particularly poverty, conflict, gender and education levels (8, 9). …are a proxy for poverty and infectious diseases contribute to lifelong disadvantage in already disadvan- disadvantage (7) taged groups. For example, the often-devastating effects on learning ability of worm infections and schistosomiasis acquired at an early age have life- long detrimental consequences (10, 11). …affect popula- infectious diseases are prevalent among populations living in conflict tions with low and war zones, internally displaced populations, refugees and those visibility and little affected by the consequences of natural disasters. political voice (7) People suffering from infectious diseases (such as Buruli ulcer) often …cause stigma experience stigma and ostracization from society. Reasons for this Chapter 1 Chapter and discrimina- can include fear of the disease or the belief that it is self-inflicted. This tion (7) stigmatization can have broad economic consequences for an affected individual, particularly if that person is unable to get work as a result. Poverty infectious diseases place a substantial health and economic burden on of poor populations in Africa, Asia and Latin America (12, 13). For example, malaria is the leading cause of mortality in children under five years of Diseases age in Africa, constituting one tenth of the continent’s overall disease burden. In areas with high malaria transmission