A New Year's resolution after a lost decade

All in all, 2003 has not been the best of years. The war in Iraq has been followed by the further destabilisation of the Middle East; the spin doctoring activities of government on both sides of the Atlantic have left their populations increasingly distrustful of politicians; and, closer to home, we have been regaled almost daily by stories of a dysfunctional healthcare system and the incompetence of doctors. Yet buried beneath all this gloom, and only rarely mentioned by the media, is the disturbing fact that over the past 10 years the already huge gap in the economic standing and state of health between the poor and rich countries of the world has widened even further. For many in the developing world it has been a decade of lost opportunity.

Although during the 1990s gross domestic product per head in the developing countries grew by 1.6% a year, and the proportion of people living on less than $1 a day fell from 29% to 23%, most of this progress was made in Asia.¹ In other regions the number of poor people increased, even though the overall proportion in extreme poverty has fallen.¹ Furthermore, 150 million children in low and middle income economies are still suffering from malnourishment, and, unless the situation improves, a similar number will be underweight in 2020.

As if poverty were not enough, the plight of developing countries has become even more acute because of our inability to control their major killers.² In many countries the problem posed by HIV and AIDS infection has worsened; about 70% of the 40 million affected people are concentrated in countries with dysfunctional healthcare systems. Tuberculosis has re-emerged, with nine million new cases and two million deaths each year. Similar death rates are occurring from malaria, and in all these diseases the emergence of drug resistant organisms is increasing.

And the problems do not end there. As they pass through the epidemiological transition from infectious to non-infectious disease many developing countries are already encountering major epidemics of the diseases of westernisation. Already about 150 million people worldwide have type 2 diabetes, and that number is expected to double by 2025.³ In some of these populations the rate of stroke and cardiovascular disease is already greater than that in richer countries.

It is easy to cite reasons why the gulf in health between developing and developed nations has widened during the past 10 years. Although ineffective or dishonest administrations, war, and natural disasters have undoubtedly played a part, the depressing truth is that the major reason is lack of awareness and support from developed countries. The evidence for this is overwhelming: less than 10% of global spending on medical research has been devoted to diseases that account for 90% of the global disease burden⁴; of the 1233 new drugs marketed in 1975-99 only 13 were approved for tropical diseases⁵; and because of commercial pressure from richer countries the World Trade Organisation has still not provided adequate access to medicines for poorer countries.⁵

Figure 1.

Poverty and ill health still go together

Credit: RBM/WHO/INT

Paradoxically, this period of deterioration in the health of the developing world has occurred at a time of major advances in medical research and development in richer countries, particularly in epidemiology and basic biomedical sciences. As we move into the new millennium it is clear that many of the diseases of the developing countries are preventable or amenable to treatment, and those that are not (the chronic killers of the richer countries) may well become so in the future, given the combination of epidemiologically based public health and the possibilities of genomic medicine.⁵

Sensibly, the World Health Organization has approached these problems by recommending the widespread application of better public health measures combined with a major attack on known risk factors for common diseases.² And a recent WHO report has emphasised the importance of losing no time in applying the tools of genomic medicine (which are already relevant to diseases of the developing world) as they emerge.⁵ The central questions that remain, however, are: how will these developments be funded; and, equally important, what kind of organisations need to be established so as not to repeat the past 10 years of neglect?

Much current thinking about how to direct the skills and resources of richer countries for the benefit of the health of the developing world revolves round government aid, tax incentives to encourage the pharmaceutical industry to tackle some of its problems, the mobilisation of earmarked funds by non-government organisations, and hopes for further large donations from philanthropic bodies. However, concerns exist about the efficiency, bureaucracy, and, above all, sustainability of many of these international sources of funding.

Among several models that have been suggested one of the most attractive is the establishment of virtual global networks for health research in the developing countries, involving both governmental and charitable funding.⁶ With this kind of organisation the agencies would retain their autonomy and mechanisms of funding, while, at the same time, their individual programmes would be better integrated towards the problems of global health. The great advantage of this approach is that these funding bodies can evolve the kind of long term research initiatives that are required to solve many of the problems of the developing countries. In the UK both the Medical Research Council and the Wellcome Trust already have a few commitments of this kind. Their successes should provide enough evidence to persuade the British government that at least some of its overseas aid might be used in a more cost effective way to help to underpin an expansion of these programmes.

However they are funded, the main aim of these developments must be the establishment of sustainable research and development partnerships between developing and developed world. This in turn will require a complete change of attitude among universities in the richer countries. To persuade young people towards careers in science and medicine they will have to broaden the scope of both teaching and research to take on a much more global view of disease.⁷ The great value in developing academic partnerships between developed and developing countries is that they function on a personal basis to the mutual advantage of both parties—and, above all, are sustainable.

The encouragement of a much more global view of teaching and research in the universities of the richer countries would be an excellent New Year's resolution for those who run them. Academia in the developed world must evolve lasting ties with its partners in the developing countries, which cannot survive another 10 years of neglect. This is not simply a humanitarian view: the horrendous rise in terrorism over the last few years, although often cloaked in the guise of religion, is surely a desperate cry for help from the poor of the world. We continue to ignore it at our peril.