Newsday - June 5, 1992
Laurie Garrett

MANY INFECTIOUS diseases are making a dangerous comeback and few countries are shifting resources to cope with the rising need for all kinds of health care, according to the World Health Organization.

In 1977, the United Nations set the year 2000 as its target to eradicate the world's leading infectious diseases, control others and, in general, to upgrade the global standard of health. Dubbed Health for All by the Year 2000, the goal seemed attainable.

But last month, WHO told the world's leaders that, "the expectations for Health for All by Year 2000 will not be realized," adding that global economic stagnation and the rising toll of infectious and chronic diseases threaten to push the world backwards, in terms of health.

"I think that assessment is correct," Dr. Ade Lucas said in a recent interview. Nigerian-born Lucas once headed malaria control efforts at WHO in Geneva, and now leads the Department of Population and International Health at Harvard University.

"Where countries have put in a little effort," he said, "there have been huge benefits in infant and child mortality rates. But many people are still dying of preventable conditions. And while we are busy solving the old problems, new problems are developing."

For example, chronic diseases such as diabetes, cancer and heart disease are increasing problems in developing countries in Asia, Africa and Latin America as people live longer. But these same people now face epidemics of cholera, yellow fever, dengue fever and tuberculosis.

"Tropical diseases seem to have gone on a rampage, with cholera spreading to the Americas for the first time this century," a recent WHO report to the United Nations stated. "Yellow fever and dengue epidemics affecting ever greater numbers, the malaria situation deteriorating, schistosomiasis establishing itself in new areas, and leishmaniasis and nonvenereal endemic syphilis increasing. The AIDS pandemic is spreading globally, as also are genital herpes and sexually transmitted chlamydial disease."

Chronic diseases associated with tobacco - particularly lung cancer and heart disease - are on the increase and account for nearly 70 percent of all cancer in the United States and Europe.

But cancer is also on the rise in the poorest nations of the world, reflecting both cigarette smoking and the fact that more people are surviving diseases such as measles, polio and pertussis - all reasonably successful targets of international vaccine campaigns.

"The standard view [of experts] is that there will be this attenuation of infectious diseases all over the world, people will live longer, then there will be this acute switch to chronic diseases," Dr. Barry Bloom of the Albert Einstein School of Medicine in the Bronx said. As a top disease researcher and leading adviser to WHO, Bloom has viewed health care firsthand all over the world. He thinks the standard view of global health is flat out wrong.

"My view is there will be this very long period of simultaneous high death rates from infectious diseases in these [poorer] countries and, at the same time, chronic diseases like cancer," Bloom said. "Nobody has the slightest idea how the system will cope."

Chronic diseases are extremely expensive to treat, while infectious diseases are lethal in children and debilitating for adult members of the work force. The result of having both health problems in a country at the same time is devastation of health care resources, and the loss of a sizeable portion of the work force.

Such is the case, for example, in Brazil, where cancer and heart disease rates are soaring at the same time as the country faces out-of-control epidemics of dengue fever, cholera and AIDS.

The crisis is further exacerbated in Brazil by the development of the so-called megacities of Sao Paulo and Rio de Janeiro, which last year were inhabited by 23 million and 11 million people, respectively. Such a megacity, one with more than 10 million inhabitants, is a place where most people have poor drinking water, sewage, housing and are plagued by acute pollution hazards, Lucas said. Furthermore, megacities survive by shifting social services from rural areas, forcing farmers and peasants to come to the cities for education and health care, he said.

By the year 2000 nearly 4 billion people - more than half the world's population - will live in one of 25 megacities. The top 10 include Mexico City, Sao Paulo, Tokyo, New York City, Calcutta, Bombay, Shanghai, Tehran, Jakarta and Buenos Aires. By far the majority of the world's urban dwellers will be poor, according to the UN agency.

Faced with such grim prospects, international health experts such as Lucas say all countries - regardless of their national poverty - must develop health research and treatment infrastructures that match those in Europe and the United States.

But that costs money. According to WHO, all but the poorest nations have decreased the percentage of their national budgets that are spent on health care in the past six years. In the richest nations, typical spending for health has dropped from nearly 4 percent of GNPs to 3.1 percent since 1985. In Eastern Europe the decline has been from 2 to 1 percent of GNP. But the least developed nations on the planet have increased health care spending from 1 to 1.5 percent. Despite these increases, extremely poor nations, such as Tanzania and Mozambique, are only able to spend an average of less than two dollars per person each year on medical care.

Lucas believes world health can only be realized if the world's richest nations underwrite the cost for the poorest.

"The threat to the world security as a whole should be best tackled by having appropriate inputs into population and development everywhere in the world," Lucas said.

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