WoodsHole

ECONOMIC AND POLITICAL IMPLICATIONS OF INFECTIOUS DISEASES: 

ECONOMIC AND POLITICAL IMPLICATIONS OF INFECTIOUS DISEASES Barry R. Bloom Harvard School of Public Health Ellison Foundation Global Infectious Diseases Marine Biological Laboratory Friday Evening Lecture June 21, 2002 Woods Hole

DYNAMICS OF A HYPOTHETICAL BIOLOGICAL ATTACK: 

DYNAMICS OF A HYPOTHETICAL BIOLOGICAL ATTACK DATE CASES 9/12 1 9/18 6,674 9/23 12,604 (727 deaths) In 6 mos, 25% of Civilian Population Infected 4% of the Population will die

INFLUENZA, 1918: 

INFLUENZA, 1918 Camp Devens, MA , 1918 Cases 9/12 1 9/18 6,674 9/23 12,604 (727 deaths) US. 25% of Civilian Population Infected 4/100 Died Global: In 6 months 20 – 40 million deaths (In 4 years of WWI, 15m deaths)

INFECTIOUS DISEASE RISKS --- US 2001: 

INFECTIOUS DISEASE RISKS --- US 2001 Anthrax: 18 cases, 7 deaths Influenza: 20,000 influenza deaths in US 100,000 hospitalizations Pneumonia: 40,000 deaths

US - PUBLIC HEALTH PREPAREDNESS: 

US - PUBLIC HEALTH PREPAREDNESS < 50% half of public health workers in US have any formal training in public health. <50% of local public health agencies have access to the internet, or ability fax multiple recipients Lack of Surge Capacity Dustin Hoffman received more money from Outbreak, than the CDC special pathogens lab. Lack systems architecture to respond to terrorism E.g. quarantine, mandatory vaccination Or to immunize against flu or pneumo

PUBLIC HEALTH EXPENDITURES --- US: 

PUBLIC HEALTH EXPENDITURES --- US <5%

CONTEXT: 

CONTEXT Poverty: 1.2 billion people live on less than US$1 per day; 2.8b live on less than US$2 per day; 1 in 6 chronically hungry. Global Population: 6.2 Billion, 200,000 people added each day; In 68 countries >40% of population is under age 15; Environment: Temperature will rise 1-4.5oF this century Health: 94% of premature death and disability occurs in developing countries, Life expectancy has dropped below 40y in 5 African countries. Civil Society: 31 Civil and Foreign War, 35m Displaced Persons and Refugees, 127 Failed States (1955-1998)

IMPACT OF DISEASE ON ECONOMIC GROWTH: 

IMPACT OF DISEASE ON ECONOMIC GROWTH Reduced years of healthy life expectancy and productivity due to early death or chronic illness Direct Costs of Medical Care Reduction in returns to business and infrastructure investment, social cooperation, political stability Parental investments in children – the ‘quantity-quality tradeoff’

INFANT MORTALITY RATE vs FERTILITY RATE: 

INFANT MORTALITY RATE vs FERTILITY RATE

ESTIMATING THE BURDEN OF DISEASE: 

ESTIMATING THE BURDEN OF DISEASE Metrics: Mortality DALYS – Disability Adjusted Life Years [The annual number of lost life years due to each disease] X [a multiple of per capita income] = a rough estimate of the aggregate economic loss

GLOBAL BURDEN OF DISEASE (DALYS): 

GLOBAL BURDEN OF DISEASE (DALYS) Communicable 42.8% HIV 6.2% Diarrhoea 5.0% Respiratory 7.0% Non-Communicable 43.2% CVD 10.9% Cancer 5.9% Respiratory 4.7% Injuries 13.9%

GLOBAL BURDEN OF INFECTIOUS DISEASES: 

GLOBAL BURDEN OF INFECTIOUS DISEASES Infectious Diseases = 32% of Total Global Deaths Infectious Diseases = 41% Global DALYS Infectious Diseases = 68% of deaths in Africa = 37% in SE Asia WHO,WHR, 2001

LEADING INFECTIOUS KILLERS 1998: 

LEADING INFECTIOUS KILLERS 1998 WHO

GLOBAL BURDEN OF TB, 2000: 

GLOBAL BURDEN OF TB, 2000 8.4 million new cases each year, 80% in 23 high- burden countries 2 million deaths each year 98% in developing countries TB is attributable cause of death in 32% of AIDS patients in Africa, 40-70% of TB patients HIV + Multi-drug resistant TB is present in 72 countries WHO

ECONOMICS OF TB: 

ECONOMICS OF TB Global Economic Burden 8.7m sick = loss of 30% income = $ 1 b 2m deaths x 15y income = $11 b Diagnosis and Treatment = $ 4 b Total $16 b A 50% Reduction in Deaths would cost $900m/y. The Return on Investment by 2010 would be: 22 million cures, 16m deaths averted $6 billion in Economic Return. Data from WHO

HEALTH BURDEN OF MALARIA: 

HEALTH BURDEN OF MALARIA 400-900 million febrile infections/year 0.7-2.7 million deaths/year, >75% African children <20% come to attention of the health system Pregnant women at high risk of dying, low birth weight kids Children suffer cognitive damage and anemia Families spend up to 25% of income on treatment WHO

MALARIA MORTALITY ANNUAL RATES: 

MALARIA MORTALITY ANNUAL RATES

ECONOMIC BURDEN OF MALARIA: 

ECONOMIC BURDEN OF MALARIA 31 Countries with intensive malaria grew 1.3% less per year than those without. Aggregate Loss = $73 billion (in 1987$) > 15% of GDP over 15y (25 countries) A 10% reduction in malaria  0.3% higher growth Gallup and Sachs,Am. J. Trop. Med.Hyg. 2000.

RESISTANCE TO ANTIMALARIAL DRUGS: 

RESISTANCE TO ANTIMALARIAL DRUGS 1940 1950 1960 1970 1980 1990

TB: EMERGING DRUG RESISTANCE: 

TB: EMERGING DRUG RESISTANCE Country US UK Argentina Dominican Republic Republic of Korea Latvia Cuba Russia (Ivanovo Oblast) 1 Drug Resistant 23% 35% 42% 50% 50% 76% 93% 100% MDR 9% 19% 22% 22% 28% 58% 12% 24% WHO

EMERGENT DRUG RESISTANT PATHOGENS: 

EMERGENT DRUG RESISTANT PATHOGENS

GLOBAL AIDS BURDEN: 

GLOBAL AIDS BURDEN 36.1 million people living with AIDS (25m in SSA) 5.3 million new infections (3.8m in SSA) 3 million deaths in 2000 (2.4m in SSA) 21.8 million cumulative deaths UNAIDS, Dec. 2000

Adults and children estimated to be living with HIV/AIDS as of end 2000: 

Adults and children estimated to be living with HIV/AIDS as of end 2000 Western Europe 540 000 North Africa & Middle East 400 000 sub-Saharan Africa 25.3 million Eastern Europe & Central Asia 700 000 South & South-East Asia 5.8 million Australia & New Zealand 15 000 North America 920 000 Caribbean 390 000 Latin America 1.4 million Total: 36.1 million (UNAIDS) East Asia & Pacific 640 000

HIV PREVALENCE: THAILAND AND S.AFRICA : 

HIV PREVALENCE: THAILAND AND S.AFRICA Source: UNAIDS

HIV PREVALENCE: THAILAND AND S.AFRICA: 

HIV PREVALENCE: THAILAND AND S.AFRICA Source: UNAIDS

RISING CONDOM USE & DECLINING STDS: 

RISING CONDOM USE & DECLINING STDS

Slide27: 

EFFECTS OF FAILURE TO SUSTAIN HIGH LEVELS OF CONDOM USE IN SEX WORK (Figure Assumes Condom Use Falls to 60% from 85% Starting in 1998) Thai Working Group on AIDS Projections, 2001

Slide28: 

Injecting drug users in Thailand (Kitayaporn et al, 1994, AIDS 8:1443) Source: UNAIDS. 1999. Trends in HIV incidence and prevalence: natural course of the epidemic or results of behavioural change? INCIDENCE vs PREVALENCE

Slide29: 

Source UNAIDS June 2000 Adult (15-49) Population and % Prevalence, by Country, Africa

ECONOMIC BURDEN OF AIDS SUB-SAHARAN AFRICA: 

ECONOMIC BURDEN OF AIDS SUB-SAHARAN AFRICA Estimate 72 million DALYs lost due to AIDs. Each AIDS death is estimated to have resulted in 34.6 DALYs lost on average in 1999. Assuming each DALY is valued at the per capita income, the economic value of lost life years in 1999 due to AIDS would be 11.7 percent (= 72 / 616) of the GNP. If each DALY is valued at 3X the per capita income, the losses represent 35.1 percent of GNP. WHO Macroeconomics Report, 2001

THE POWER OF PREVENTION: IMPACT OF VACCINES IN THE U.S.: 

THE POWER OF PREVENTION: IMPACT OF VACCINES IN THE U.S. 000322-1 Poliomyelitis Diphtheria Measles Pertussis (Whooping Cough) Mumps Rubella (German Measles) 2.0 1.5 1.0 0.5 0 0.6 0.4 0.2 0 25 20 15 10 5 0 1960 1970 1980 1990 30 25 20 15 10 5 0 1960 1970 1980 1990 1960 1970 1980 1990 1960 1970 1980 1990 1960 1970 1980 1990 1960 1970 1980 1990 10 8 6 4 2 0 60 50 40 30 20 10 0 Cases per 100,000 Cases per 100,000 (Adapted from data presented by the Boston Consulting Group)

COST-BENEFIT OF VACCINES IN US: 

COST-BENEFIT OF VACCINES IN US SMALLPOX MMR (Measles, Mumps & Rubella) DPT (Diphtheria, Pertussis, Tetanus) POLIO ERADICATION $32 million every 20 days $21 for every dollar spent on vaccine $29 for every dollar spent on vaccine $3 billion annually by 2015

PROJECTIONS OF AIDS VACCINE IMPACT IN HIGH-PREVALENCE COUNTRY: 

PROJECTIONS OF AIDS VACCINE IMPACT IN HIGH-PREVALENCE COUNTRY 50% efficacy, 90% coverage could reduce prevalence from ~20% to ~5% Grey et al. Global AIDS Vaccines 2001, abst. For R0<1 (epidemic would eventually die out) Need a 75% effective vaccine with 50% coverage Or a 50% effective vaccine with higher coverage, Or a 25% effective vaccine with 75% coverage Anderson et al., Pr. Roy Soc, Lond. 261, 147-51, 1995

Thailand/Uganda/Senegal – Keys to Success: 

Thailand/Uganda/Senegal – Keys to Success Good Governance - Involvement of President Research and Evidence-based Decisions Educated and Informed Public Target Interventions to High Risk Group Recognition of the Role of Women in Health Engagement of Communities, esp. the Poor Engagement of Business Broad Partnerships of Government, NGO’s, ODA’s Adequate Resources

STANDARD ECONOMIC MODEL: 

STANDARD ECONOMIC MODEL ECONOMIC GROWTH HEALTH

NEW ECONOMIC MODEL: 

NEW ECONOMIC MODEL ECONOMIC GROWTH HEALTH

RELATION BETWEEN LIFE EXPECTANCY AND ECONOMIC GROWTH: 

RELATION BETWEEN LIFE EXPECTANCY AND ECONOMIC GROWTH Each 10 percent increase in life expectancy at birth (LEB), is associated with a rise in economic growth of around 0.3 – 0.4% per year, holding other growth factors constant. The difference in annual growth accounted for by LEB between a typical high-income country (LEB = 77 years) and a typical least developed country (LEB = 49 years) is about 1.6 % per year, which cumulates over time. WHO Macroeconomics Report 2001

SOME BASIC INDICATORS : 

SOME BASIC INDICATORS WHO Macroeconomics Report, 2001

LINKING TREATMENT TO PREVENTION: 

LINKING TREATMENT TO PREVENTION Effective anti-TB treatment both cures TB and blocks transmission STD treatments reduce HIV as well as STD transmission. Access to ARVs increase voluntary counseling and testing. ARVs diminish maternal-child transmission and improve survival of mothers. ARVs reduce viral loads and reduce transmission. From a Meeting at the Harvard School of Public Health, September, 2001

THE WHO MINIMAL HEALTH PACKAGE: 

THE WHO MINIMAL HEALTH PACKAGE Childhood Immunization TB Treatment Malaria Prevention and Treatment HIV Prevention and Treatment, including OI’s and ARVs Integrated Management of Child Illness – ARI, Fever Maternal Mortality, ANC, vitamin A and micronutrients Smoking Prevention WHO Macroeconomics Report, 2001

PER CAPITA COST OF WHO PACKAGE BY 2007: 

PER CAPITA COST OF WHO PACKAGE BY 2007 WHO Macroeconomics Report, 2001

HEALTH RESOURCES REQUIRED ($ BILLION) : 

HEALTH RESOURCES REQUIRED ($ BILLION)

ECONOMIC BENEFITS OF ESSENTIAL HEALTH PROGRAM: 

ECONOMIC BENEFITS OF ESSENTIAL HEALTH PROGRAM HEALTH BENEFITS (Total ODA 2001 = $53b (0.2% GDP); Life Years Saved: 330 million Deaths Averted: 8 million ECONOMIC BENEFITS: Conservative Valuation: Each life year valued at 1x GNP 330 million x $550 = $182 billion Standard Valuation: 330 million x 3 x $550 = $545 billion WHO Macroeconomics Report, 2001

OVERSEAS DEVELOPMENT ASSISTANCE: 

OVERSEAS DEVELOPMENT ASSISTANCE

Slide47: 

Proposal for a POWELL PLAN

THE POWELL PLAN: 

THE POWELL PLAN Declaring a War on Disease and Hunger in Poor Countries Committing US to Major US Investments in Health, Nutrition, and Education in Poor Countries, would: Save Millions of Lives Improve Economic Development in the Poorest Countries Protect America’s Health from Emerging Threats Inoculate US Foreign Policy against Anti-American Attack Change the US Image from Self-Interest to Human Interest

(International dollars are derived from national currencies by assessment of purchasing power parity, not by exchange rates.  Source: World Development Report 1993 p. 34.: 

(International dollars are derived from national currencies by assessment of purchasing power parity, not by exchange rates. Source: World Development Report 1993 p. 34.

THE 90:10 DILEMMA: 

THE 90:10 DILEMMA Burden of DALYS % Research Dollars

TWO VIEWS OF HEALTH IN DEVELOPMENT: 

TWO VIEWS OF HEALTH IN DEVELOPMENT Health as an Instrumentality to Economic Development vs Health as a FundamentalValue, Human Right or Capability

THE BLACK DEATH, 1348: 

THE BLACK DEATH, 1348 Killed 50-70% of Europe’s Urban Population Reduced Marginal Labor Increased and Stabilized Wages Forced Increased Productivity Stimulated new technology Led to the Founding of the Great Universities Killed 50-75% of Europe’s Urban Population Herlihy: The Black Death an the Transformation of Europe

Slide53: 

“The GNP tells you everything about a country that is not important. It does not inform about the beauty of the countryside, the joy and value of its music and art --- or the health of its children…” Margaret Catley-Carlson, 1990

Acknowledgements: 

Acknowledgements David Bloom, Marc Lipsitch, Michael Reich, Jeffrey Sachs, Joshua Salomon and Dyann Wirth at Harvard University Jon Simon, Boston University And colleagues at WHO in the Stop TB, Tropical Diseases Research and Training (TDR), and UNAIDS Programmes, and Jeff Sachs, Chair of the WHO Macroeconomics Commission Report for access to the report prior to publication.