For some of you, 1977 is synonymous with disco and Jimmy Carter. Maybe for my fellow Philadelphians, 1977 brings to mind the opening of the movie Rocky. And I’d guess that for many of you, 1977 is ancient history, and somewhere in the era of things called “records” that your parents talk about. But for a nerdy public health scientist like me, 1977 is the year of a unique accomplishment in human history, one that demonstrates our ability to work together to achieve a universal goal—the eradication of smallpox.
For centuries, smallpox killed people by the hundreds of millions. Despite the fact that the smallpox vaccine had been in existence since 1796, in the middle of the 20th century 50 million people still died of smallpox every year. Overwhelmingly these people lived in poor countries in Africa, South America, India, and Southeast Asia, where there were no vaccination programs, and limited access to medical care. In other words, the people who died from smallpox in the mid-20th century are from the same places where today people die from malaria and HIV/AIDS; preventable or treatable conditions that we have the ability to curb.
So what happened? How did we pull off eradication of a deadly virus that struck the most vulnerable and poverty-stricken areas of the world? Well, it’s true that there are some things about smallpox itself that helped us, like that facts that we have an effective vaccine for smallpox and that it only lives in humans. But those things had been true for decades, and then something happened starting in the 1950s that lead from 50 million deaths to zero deaths in fewer than 30 years. There was an international call for resources; across the globe countries prioritized smallpox eradication, and dedicated money, time, and personnel to do so. And it worked.
Millennium Development Goal 6 (MDG 6), to combat HIV/AIDS, malaria, and other diseases, recognizes that the world’s poor continue to suffer and die from health conditions that can be prevented and treated in rich countries. Essentially, it calls all people to work to repeat our smallpox success. HIV/AIDS and malaria may be more complicated diseases than smallpox, but medical knowledge has advanced significantly. We can prevent both diseases, cure malaria, and provide treatment so that people with HIV/AIDS live long, healthy lives. So how have we done in the last ten years?
Some specific targets of MDG 6 related to HIV/AIDS are to halt the spread of HIV and begin to reverse the epidemic by 2015. The World Health Organization estimates that in 2010 approximately 2.7 million people became newly infected with HIV globally. At the peak of the epidemic in the late 1990s, approximately 3.5 million people became infected each year, so overall we have seen decreases in the pace of the spread of HIV. However, the decline has been geographically uneven. Between 2001 and 2009, countries in sub-Saharan Africa, India and Southeast Asia saw declines of more than 25% in the numbers of new HIV infections. These are areas of the world where considerable amounts of aid were channeled through international organizations like UNAIDS, and where local leaders recognized the urgency of the epidemic. During the same time period, numbers of new HIV infections increased in Central Asia and Eastern Europe, where international aid was less.
In addition to curbing the number of new infections, a target of the original MDG 6 was to achieve, by 2010, universal access to treatment for HIV/AIDS to all of those who need it. Although access to life-saving medications has been expanded in all regions of the world in the last decade, universal access to treatment has not been achieved. This is partly due to the number of new infections; for every two people who start on treatment each year, five become infected. In 2008, about 40% of people in the developing world who needed HIV medication were receiving it. The 60% who were not able to receive medication correspond to 5.5 million people, many of whom have died or will die from their disease. Although this specific goal of MDG 6 was not realized by 2010, there are continued efforts to achieve it by 2015, and it seems a particularly urgent target. Denying some people life-saving treatment because they live in an area that lacks the infrastructure to distribute and monitor it is structural violence and injustice of the clearest kind. As demonstrated by our smallpox success, there is no reason creativity and determination cannot overcome obstacles to providing basic health care.
MDG 6 also includes the target “to have halted by 2015 and begun to reverse the spread of malaria and other diseases.” Insecticide-treated bed nets can be used to prevent the mosquito bites that cause malaria, and according to the UN and others there are more people sleeping under the bed nets today than there were in 2000. Since 2000, some countries have reported decreases in their malaria prevalence, while others, including Democratic Republic of Congo, Nigeria, Mali, and Mozambique continue to have large numbers of malaria infections and deaths. In 2010, an estimated 216 million malaria infections occurred, causing 655,000 deaths, 86% of which were in children under 5 years old. Despite those high numbers, since 2000 deaths due to malaria have decreased by about 25% due to improvements in diagnosis, treatment and access to care.
So what do those numbers tell us? Well, we can look back over the last decade and be confident that we can make a difference; that with global resolve to put prevention campaigns, health workers and inexpensive medications in the parts of the world that need them, change can happen. But we still have a long way to go to achieve MDG 6. How can we continue and improve this work, particularly in the middle of a global financial crisis that has decreased international aid?
We can refuse to accept gross inequalities in health as a fact of life, and continue to insist, with our donations, our votes, our voices, that resources get to those who need them. We can choose to educate ourselves further about these issues, reading work by Paul Farmer, and we can ask our government to continue funding The United States President’s Emergency Plan For AIDS Relief and the Global Fund for AIDS, Tuberculosis, and Malaria despite our budget constraints. Achieving MDG 6 is possible, but requires continued international aid from resource-rich countries to impoverished one, and recognition that we are responsible for one another. With sustained focus on health care as a human right, perhaps one day in the future someone will be writing about the year that universal treatment for HIV/AIDS was achieved or malaria was eradicated.
Camille Introcaso, M.D., is a dermatologist with a focus on global health, and she has worked as a clinician in Africa and North and South America. She completed the Global Health Equities Residency Program at the Hospital of the University of Pennsylvania in 2010 and earned a Diploma in Tropical Medicine and Hygiene in Peru in 2011. She is currently working as a public health practitioner in Atlanta, Georgia.