From triple helix - summer 2009 - MDG 6 - HIV, TB and malaria [p14-15]
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The Millennium Development Goals are eight key commitments made by 192 member countries of the United Nations to address global poverty, with targets to be achieved by 2015. Three have an explicit health focus.
Current achievements against specific targets are reviewed for HIV and AIDS, malaria, and TB and at present they are going to be met at best only partially.
The author compares the extra billions needed to achieve these targets with the trillions in economic stimulus packages and bailouts recently committed by developed world governments, and asks whether the real issue is the commitment our governments, and we to whom they are accountable, have towards tackling the global health crisis?
Triple Helix has previously highlighted the Millennium Development Goals (MDGs) (1), eight key commitments made by 192 member countries of the United Nations to address global poverty, with explicit targets to be achieved by 2015 (2). With six years left to that deadline, the next three editions of Triple Helix will review the three MDGs which have an explicit health focus.
Progress towards these targets is regularly reviewed by the UN and other international bodies. It now seems few if any will be reached by 2015, but some progress has been achieved. The news is not as good as it should be, but is also not as bad as it might be.
A big concern raised time and again is that the global credit crunch and recession will have a downward pressure on spending to meet these targets (3). The 2009 Data Report (4) shows that the G8 countries have given to date only $7 billion of the $21.5 billion in aid they had promised in 2005 to deliver by 2010. While a global debate rages over whether aid actually achieves anything in terms of development and poverty reduction, (5) (6) there is evidence it can have an impact in healthcare. This is especially true in the delivery of affordable and effective treatments and prevention for malaria, TB and HIV/AIDS (7) (8) (9).
Access to antiretroviral therapy (ART) for HIV/AIDS rose by 42% in 2007 (10). This represents an unprecedented scaling up of treatment for any major infectious disease in the developing world, largely financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria (11). By the end of 2007, the number receiving ART in developing countries reached 3 million, and deaths from AIDS-related illnesses had declined from 2.2 to 2 million a year. (12)
However, significant as that progress may be, the reality is somewhat grimmer. An estimated 9.7 million people need ART, and while 950,000 were put on ART in 2007, there were 2.7 million new HIV infections that year. So ART is getting to less than a third of those who need it, and new infections outstrip threefold the increase in treatment access. The scale up has been massive, but is still way behind what is needed. Universal access to ART is unachievable by 2010 and very unlikely by 2015 (13).
If treatment is falling behind need, what about preventing new infections? 75-85% of HIV-positive adults have been infected through unprotected intercourse, mostly heterosexual. Recent evidence shows that sustained, intensive behaviour change programmes promoting increased use of condoms, delayed sexual initiation, and fewer sexual partners are reducing HIV incidence. (14)
In 2007 international funding for such programmes in low and middle-income countries reached $10 billion - a tenfold increase in less than a decade; again, an impressive achievement. Yet this sum still falls short of the $18 billion in aid that UNAIDS estimates is required annually for AIDS prevention. Overall, the rate of new infections is declining only slowly, and shows no sign of going into reverse by 2015 (15).
The picture is not really any better when it comes to malaria, which causes 250 million cases of fever a year, and claims the lives of about a million people. In sub-Saharan Africa it is the largest infectious cause of death for children (16). One of the most effective ways to prevent infection is to sleep under an insecticide-treated bed net, and a major prevention initiative has been distributing these nets (which cost ~£5 each) to all those in at-risk areas (17).
A huge amount has been achieved in this one simple initiative. By 2007, 95 million nets had been distributed - 65 million in three years. All sub-Saharan African countries with endemic malaria have seen bed net distribution increase. However this is still below target, and while the UN Secretary General has urged this initiative to continue so that universal coverage is reached by 2010, it looks questionable whether this is still achievable. Nevertheless, universal bed net coverage may be achieved by 2015.
Treatment has seen less progress, however. Although treatment among febrile children is moderately high across sub-Saharan Africa, few countries have expanded coverage since 2000, and most patients often receive less effective medicines. In 22 sub-Saharan African countries (accounting for nearly half the region's population) the proportion of children with a fever who received anti-malarial medicines dropped from 41% in 2000 to 34% in 2005.
Furthermore, artemisinin-based combination therapies, regarded as the most effective, are not only not being used as widely as they should, but recent evidence from Cambodia suggests that the malaria parasite is developing resistance to the drug. There is a very real risk that effective treatment options for malaria will decrease over the next few years (18).
While HIV and malaria targets look at best likely to be met only partially, the picture for TB is possibly even worse. Figures from 2008 show that worldwide two billion people are infected with TB! 14.4 million have active TB infections; there are 9.2 million new cases each year, and two million deaths. Around one million new cases each year are due to HIV co-infection, and 300,000 people each year are infected with multi-drug resistant strains (19).
The target of reducing TB prevalence and mortality by 2015 is not going to be met, especially in Africa and the former Soviet Union, where TB is a growing public health problem (20). There is some good news, however. Where they are in place, Directly Observed Treatment Short-course (DOTS) programmes are achieving an 85% success rate in cure and prevention of transmission. There are 4.6 million people on DOTS worldwide, but this is still only a fraction of the 14.4 million in need of treatment (21).
MDG 6 is off target in every area. The scale of health problems in the developing world is outweighing the considerable efforts and funding that have been put in so far, and in the current climate these will be hard to sustain both politically and economically.
The irony is that the extra billions in funding needed to achieve these targets are but a drop in the ocean compared to the trillions in economic stimulus packages and bailouts recently committed by developed world governments. Perhaps the real issue is not the scale of the problem, but the commitment our governments, and we to whom they are accountable, have towards tackling the global health crisis?
Yet at the local level and on smaller scales, some amazing work is being done, much of it by Christians. As much as 60% of the healthcare in many parts of sub-Saharan Africa is coming from churches and Christian hospitals, especially in response to HIV and AIDS (22), and in other parts of the developing world Christian health initiatives are a smaller but still significant response (23).
While swine flu and the credit crunch make the headlines (24), we should not be forgetting these major public health challenges that affect the lives of tens of millions - health challenges with effective solutions. We should be holding our governments accountable for the aid they give, while supporting those working on the front line (25).
Steve Fouch is CMF Head of Allied Professions Ministries and works with the International Department.
1. Barratt H. Act justly. Triple Helix 2008; Easter: 6-7
2. Millennium Development Goals: An Overview. Micah Challenge International
3. Hopkins K. Don't use the recession as reason to cut aid, say MPs
The Guardian, 2 June 2009
5. Moyo D. Why Foreign Aid is Hurting Africa
Wall Street Journal, 21 March 2009
6. Gershon M. 'Dead Aid', Dead Wrong
Washington Post, 3 April 2009
10. UN MDG Report Ibib
12. Global Fund Diseases Report. Ibid
13. UN MDG Report. Ibid
14. Green £. Rethinking AIDS Prevention Praeger, 2003
15. UN MDG Report. Ibid
16. Malaria is alive and well and killing more than 3,000 African children every day.
WHO Press Release, 25 April 2003
17. UN MDG Report. Ibid
18. Noedl et al Evidence of Artemisinin-Resistant Malaria in Western Cambodia
NEJM 2008; 359:24
20. UN MDG Report. Ibid
21. Global Fund Diseases Report. Ibid
23. Philip V. A Distant Thunder and a Different Drum Beat: The Challenge of Medical Mission in India.
Evangelical Medical Fellowship of India, 2002
25. Isaiah 1:17; Isaiah 58; Luke 10:25-37; James 4:17