GLOBAL IMPACT OF GLOBAL IMPACT OF INFECTIOUS INFECTIOUS DISEASESDISEASES

Teresa Smith de Cherif, MD, Teresa Smith de Cherif, MD, MIAMIA

Fellow, Division of Infectious Fellow, Division of Infectious DiseasesDiseases

People in the developed world consume most of the world’s resources. 25% of global deaths are from infectious diseases, but the burden of disease is carried largely in the developing world.

Infectious Diseases MortalityInfectious Diseases Mortality

There are marked There are marked differences differences between developed between developed & developing & developing nations with regard nations with regard to mortality from to mortality from infectious diseases.infectious diseases.

SCENARIOSSCENARIOS

Rather than using Rather than using statistics alone to statistics alone to provide brief snapshots provide brief snapshots of infectious diseases, I of infectious diseases, I hope to aim broader:hope to aim broader:

to use the African to use the African tradition of story telling,tradition of story telling,

to think outside the box,to think outside the box,to explore how seemingly to explore how seemingly

unconnected events & unconnected events & trends can work trends can work together to expand or together to expand or limit an epidemic.limit an epidemic.

““The decisions we make The decisions we make about the future are about the future are guided by our view of guided by our view of how the world works how the world works and what we think is and what we think is possible. Scenarios possible. Scenarios are stories about the are stories about the future, but their future, but their purpose is to help purpose is to help make better decisions make better decisions about the present.”about the present.”

----AIDS in Africa: Three AIDS in Africa: Three Scenarios to 2025Scenarios to 2025

Diving hippo illustrates that the patterns of behavior lie below the surface, and the structure of the system lies deeper still.

OverviewOverview

Explore and expand understanding of the Explore and expand understanding of the AIDS epidemic, particularly in Africa.AIDS epidemic, particularly in Africa.

Understand that the AIDS epidemic is a Understand that the AIDS epidemic is a small part of a wider international peace small part of a wider international peace and development crisis, requiring an and development crisis, requiring an exceptional response within its wider exceptional response within its wider social and economic contexts.social and economic contexts.

Understand that infectious diseases affect Understand that infectious diseases affect not just individuals, but collectives—not just individuals, but collectives—families, communities, nations, the world.families, communities, nations, the world.

Front page, New York Times Book Review, 11 December 2005.

Perceptions: Is AIDS a health problem or is it a symptom of underdevelopment and poverty?

Will there be incentive and capacity to deal with AIDS?

2/3 of all people living with HIV are Africans. Nations most affected: South Africa, India, Nigeria.

From Algiers to Cape Town, Dakar to Dar es-From Algiers to Cape Town, Dakar to Dar es-Salaam, the red earth of Africa is dotted with Salaam, the red earth of Africa is dotted with 15 million white tombstones, because that is 15 million white tombstones, because that is

how many people have died from AIDS.how many people have died from AIDS.

The primary social events in South Africa at present are funerals.

Prevalence of HIV in AfricaPrevalence of HIV in Africa The number of all new and old cases of HIV in The number of all new and old cases of HIV in

Africa during a particular period.Africa during a particular period. The prevalence of HIV infection has stabilized in The prevalence of HIV infection has stabilized in

Africa, but let’s not be misled.Africa, but let’s not be misled. Stabilization does not necessarily mean that the Stabilization does not necessarily mean that the

epidemic is slowing.epidemic is slowing. ““Stabilization” can mask the reality that equally Stabilization” can mask the reality that equally

large numbers of people are being newly infected large numbers of people are being newly infected with HIV and are dying of AIDS.with HIV and are dying of AIDS.

Prevalence is also affected by data capture. In Prevalence is also affected by data capture. In rural South Africa, where voluntary test and rural South Africa, where voluntary test and counseling is in place, prevalence is at 30-40%.counseling is in place, prevalence is at 30-40%.

Africa is three times the size of the United States.

Presently, Africa has inadequate resources to face the burdens of AIDS, TB, malaria, and other infectious diseases.AIDS has led to a resurgence in the incidence of TB. 1/3 of Africans carry a latent TB infection. Each year, 5-10% of those co-infected with TB & HIV develop active TB; up to 50% will develop TB at some point.

African governments actually are reducing health expenditures in order to repay external debt.

Africa is precariously dependent on the resources it supplies to the world.

AIDS deepens the traps of poverty, underdevelopment, and marginalization in a globalizing world.

Poverty: Informal settlements surround the urban centers of Africa.

More than 1 in 4 South Africans—12.5 million people—live in shantytowns. Within the last year, ~900 protests over squalid conditions erupted.

AIDS has spread by poverty and war.

Countries at war and bordering nations experience increased HIV transmission.

Impact of Conflict on Impact of Conflict on ChildrenChildren

Hotel Rwanda

African women & HIVAfrican women & HIV

60% of HIV+ African 60% of HIV+ African adults are women.adults are women.

75% of all women 75% of all women with HIV, worldwide, with HIV, worldwide, are African.are African.

Young African Young African women of women of childbearing age childbearing age have the highest have the highest incidence rates.incidence rates.

As the most productive members of society—teachers, agricultural workers, healthcare personnel, public service staff—are dying from AIDS, the continent is being robbed of its human capacity.

Life expectancy has dropped to <40 years in 9 African countries, among them Zimbabwe. There, life expectancy was 52 years in 1990; in 2003, it fell to 34 years.

Economic Costs of Disease at the National Level

“Doctor, who is going to take care of my children?”

AIDS stresses families, as grandparents take care of orphaned children.Parents die, there is loss of income to the family, debt is incurred.

Fikelala Children’s Centre in Khayelitsha (Cape Town), South Africa.

Infants whose mothers had no access to antiretroviral therapy are being born with HIV and soon after are left as orphans.

If present trends continue, by 2025, there will be a missing generation of grandparents. Will there be a sense of family, community? The large number of children orphaned by AIDS will be less skilled, less nurtured, and less socially integrated than their parents were.

South Africa: Africa’s most South Africa: Africa’s most developed country.developed country.

RSA has the highest number RSA has the highest number of people living with HIV in of people living with HIV in the world, >5.3 million; ~3 the world, >5.3 million; ~3 million women.million women.

One in 4 South Africans is One in 4 South Africans is HIV+.HIV+.

AIDS is the leading cause of AIDS is the leading cause of death.death.

More than 1/5 of the More than 1/5 of the workforce is HIV+. workforce is HIV+.

Absenteeism from the Absenteeism from the workplace has risen with workplace has risen with employee deaths from AIDS.employee deaths from AIDS.

The RSA Dept. of Health The RSA Dept. of Health Study 2002 estimated that Study 2002 estimated that 250 babies per day were 250 babies per day were infected by mother to child infected by mother to child transmission.transmission.

AIDS-related illnesses are AIDS-related illnesses are responsible for 40% of responsible for 40% of deaths in kids <5 years.deaths in kids <5 years.

Yesterday

South Africa is being cast into deepening poverty. The post-apartheid political, social, and economic gains risk being reversed by the downward spiral in health. How can South Africa partner for prosperity with other African nations?

Scenarios: Which way forward?

43 million new HIV infections could be prevented over the next 20 years if African governments implement comprehensive strategies and if global assistance is increased.

Presently, in most cases, palliation is all we have to offer to African individuals suffering from advanced AIDS.

Confronting this devastation will require strengthening human & institutional capacities, including scaling up HIV prevention programs and implementing large-scale treatment programs.

PREVENTIONPREVENTION

New ABC New ABC (Acknowledgement (Acknowledgement of the realities of sexuality; of the realities of sexuality; Behavioral changeBehavioral changesafer sex; safer sex; Communicating).Communicating).

Investment in health Investment in health systems infrastructuresystems infrastructure

Voluntary test and Voluntary test and counselingcounseling

Infection controlInfection control Safe blood banksSafe blood banks Vaccine*developmentVaccine*development EDUCATIONEDUCATION

Immunization can eradicate infectious diseases. Most famous example: small pox. Others: polio, measles, H. influenzae type B, Yellow Fever.

TreatmentTreatment

Less than 5% of Less than 5% of Africans are on highly Africans are on highly active antiretroviral active antiretroviral therapy (HAART).therapy (HAART).

Roll out of HAART Roll out of HAART must progress.must progress.

Reverse African brain Reverse African brain drain.drain.

Invest in drug Invest in drug manufacturing manufacturing capacity in Africa.capacity in Africa.

Projected Costs of Tackling the Projected Costs of Tackling the AIDS CrisisAIDS Crisis

Global spending on Global spending on AIDS has increased AIDS has increased 15-fold since 1996 15-fold since 1996 to approximately 5 to approximately 5 billion dollars billion dollars annually.annually.

But, even this But, even this amount falls short amount falls short of UNAIDS of UNAIDS estimates of $12 estimates of $12 billion required billion required annually.annually.

Everyone must participate…Everyone must participate… Leverage what is Leverage what is

available to achieve available to achieve more, especially given more, especially given limited resources.limited resources.

No AIDS funding No AIDS funding without investment in without investment in social and economic social and economic development. It development. It shouldn’t be easier to shouldn’t be easier to get HAART than get HAART than adequate nutrition & adequate nutrition & H20.H20.

Fikelala.Fikelala. Xhosa, Xhosa, “reaching out.”“reaching out.”

ChangeChange

South Africa’s first democratic election, 1994. It may seem futile to challenge the

world’s “misery, injustice, and violence…But, it is through numberless acts of courage and belief that human history is shaped. Each time a person stands up for an ideal, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current which can sweep down the mightiest walls of oppression.” –Robert F. Kennedy at the University of Cape Town