Infectious Diseases, Non-zero Sum Thinking and the Developing World
Erik Folch M.D., Isabel
Hernandez M.D., Carlos Franco-Paredes M.D.
AIDS International Training and Research Program
(AITRP)
Atlanta, GA
Correspondence to:
Carlos Franco-Paredes M.D.
Emory University School of Medicine
Division of Infectious Diseases
69 Butler Street
Atlanta, GA 30303
Phone: 404 616-3600
Fax: 404 880-9305
E-mail: cfranco@sph.emory.edu
Erik Folch M.D.
Born and Raised in Mexico City, Mexico.
Obtained his Medical Degree from the National Autonomous University of Mexico
Currently enrolled in the Masters of Science in Clinical Research Program at the Rollins School of Public Health, Emory University, Atlanta, GA
AIDS International Training and Research Program Fellow
Isabel Hernandez M.D.
Born and Raised in Guanajuato, Mexico
Obtained her Medical Degree from the Guanajuato University Medical School
Completed her Pediatrics Residency at the Children’s Hospital in Mexico City
Currently enrolled in the Masters in Public Health Program at the Rollins School of Public Health, Emory University, Atlanta, GA
AIDS International Training and Research Program Fellow
Carlos Franco-Paredes M.D.
Born and raised in Mexico City, Mexico
Obtained his Medical Degree from La Salle University, Mexico City
Completed his Internal Medicine training at Emory University
Currently enrolled in the Masters in Public Health Program at the Rollins School of Public Health, and second year fellow in Clinical Infectious Diseases, Emory University.
AIDS International Training and Research Program Fellow.
Despite some improvements in health status in the world during the past century, major gaps remain in these achievements. Health improvements have not been shared equally and health inequalities among and within countries remain deep-rooted, causing poverty to be the major reason for the persistently poor health outcomes.
Infectious diseases, which remain the major cause of death worldwide, are an incalculable source of human misery and economic loss. One quarter of all deaths and 30% of the global burden of disease are due to infectious diseases. More than 95% of these deaths, most of which are preventable, occur in the developing world. The three major infectious disease killers are HIV/AIDS, tuberculosis, and malaria. HIV/AIDS is responsible for 2.5 million deaths per year worldwide, with one new infection every 6 seconds. Two million people die from tuberculosis every year with one infection occurring every 11 seconds. Finally, malaria accounts for 1-2.5 million deaths per year worldwide, with at least one new infection occurring every 21 seconds.
The principles of Social Justice and Health as a Human Right in the developing world have been advocated as the main justification for health assistance from rich countries to poor countries. While we do not disagree with this, we argue that a strategy that emphasizes the shared benefit to rich and poor countries would facilitate this process. We propose that the accomplishment of these challenging tasks should be viewed from the perspective of game theory, where the interests of the parties (in this case rich and poor countries) overlap. As the world becomes increasingly integrated with globalization, economic development in resource-poor countries will increase the opportunities for richer countries to profit from investment in the developing world. In a true sense, we are not facing a game, but a matter of life and death.
Improving the health status in poor countries will surely impact the ability of these societies to develop. Development will lead to freedom. Freedom will allow wisdom to reveal itself.
art
cannot becomes manifest,
strength
cannot fight,
wealth
becomes useless,
and
intelligence cannot be applied”
Herophilus
325 B.C.
(Physician
to Alexander the Great)
The purpose of
this essay is to address the previously observed relationship among health,
poverty, and development in the context of game theory. In the first two sections, we will focus on
the link between economic inequalities and health outcomes, exclusively
concentrating our analysis on infectious diseases impact. Subsequently, we will outline the game, the
players and the potential win-win situation that could result. Finally, we will delineate what we consider
could be done with the commitment of the players in order to accomplish a shared
benefit.
Our world is marked by extremes of economic inequality, across and within countries, and poverty is widespread in today’s world. Approximately 1.2 billion people are living on less than $1.00 per day. National income and its growth matter for people’s health and lifetime expectancy. Wealthier countries tend to be healthier than poor countries, yet health outcomes vary also within countries. In many low-income countries, over half of the population may be living in poverty and those who are not will still be living in circumstances that contribute to the poor health of the country as a whole (1).
Throughout
history, socioeconomic status has been linked to health. Individuals higher in the social hierarchy
typically enjoy better health than those below. Nevertheless, socioeconomic status has been almost universally
relegated to the status of a control variable and has not been systematically
studied as a factor in its own right (2).
Human health is the foundation of economic growth. The health effects of inequalities impose a major economic burden, which reduces the competitiveness of societies (3). Moreover, the association of poverty and infectious diseases is entrenched by a never-ending cycle that starts with a lack of health that leads to poverty, underdevelopment, and macroeconomic growth retardation. This cycle ultimately predisposes these societies to the worsening of their overall health status. We know that healthier and better-nourished children are more educable, more skillful, and stronger as adults, thus better able to contribute to economic growth.
Resource misallocation has also contributed to the worsening of the problem in the developing world. As Howard Hiatt puts it, “We don’t have to be experts in foreign affairs to have an opinion as to how much security the industrialized nations of the world bought with the $300 million they spent over ten years to eradicate smallpox, as compared to what was achieved with the $28 billion spent in 1983 alone for arms exports to the third world countries. Perhaps a few million dollars given to improve the health of the children of central America would bring more security to the area than billions we have spent to arm their parents.” (4)
While the atom
bomb on Hiroshima killed 180,000 people, every few days a silent Hiroshima
occurs in the developing world.
Globally, children are dying at somewhere near the rate of 270,000 per
week, 14 million a year. One death in every three in the world today is the death
of a child. Most of these deaths are
due to infectious diseases (5).
Most developed
countries have undergone a prototypical epidemiologic and demographic
transition, characterized by decrease in overall mortality, primarily due to
decreased mortality from infectious diseases and increased rates of chronic
diseases. In contrast, many low-resource countries are not only struggling with
old and new infectious disease epidemics, but also are dealing with the emerging
epidemics of chronic non-communicable disease such as heart disease, stroke,
diabetes and cancer. This health status
picture is considered the “double burden of disease in the developing world” (6).
Diseases caused
by infectious agents have profoundly affected both human history and
biology. As agents of natural
selection, infectious diseases have played a major role in the evolution of the
human species, and probably have been one of the major agents of natural
selection. Infectious diseases have also
influenced cultural transformation in the world (7).
Indeed, infectious diseases remain the major cause of death worldwide. In 1999, the World Health Organization (WHO) reported that of 53.9 million deaths from all causes worldwide, 13.3 were due to infectious diseases. The human immunodeficiency virus infection / acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis (TB) and malaria contributed with 2.3, 1.5, and 1.1 million deaths, respectively. These epidemics are of special relevance to the poorest 20% of the world’s population living in sub-Saharan Africa and Asia (8).
Although poverty
is neither necessary nor sufficient for an individual to contract an infectious
agent, it may be a necessary element for an epidemic on the scale currently
witnessed in many parts of the world.
Similarly, poverty seems a necessary, though insufficient condition, for
large-scale transmission of tuberculosis, malaria and HIV infection. In this instance, causation is probably
bi-directional, where the economic consequences of epidemic infectious diseases
help to trap populations in further poverty and disease (9). In fact, many have suggested that these
conditions should be classified as socially determined conditions (10-11). Social relations that produce rural to urban
migration, unemployment, illiteracy, and malnutrition are the primary culprits
behind these epidemics (11-12).
Most infectious diseases tend to kill infants and groups in the most productive years. TB, AIDS and malaria, like war, kill those in the prime of life. Indeed, in one way it is worse than war. When armies fight, it is predominantly young men who are killed; TB, malaria and AIDS kill children and young women, as well (13).
Many of these concepts have been addressed by Turshen’s political ecology framework. She proposes that economic, social and political forces should be incorporated into the model of disease causality along with the interaction of host-pathogen and the environment (14).
Infectious diseases are responsible for almost half of mortality in developing countries. These deaths occur primarily among the poorest people in the world. Approximately half of infectious diseases mortality can be attributed to just three diseases: HIV, TB, and malaria. These three diseases altogether cause over 300 million illnesses and more than 5 million deaths each year (15).
The impact of
these conditions extends far beyond the suffering of those afflicted. Infectious diseases are not just a problem
of developing countries but also a threat to economic growth, globalization,
and international security. In addition to suffering and death, these diseases
penalize poor communities, perpetuating poverty through work loss, school
drop-out, decreased financial investment, and increasing social instability (11,
15).
There is strong evidence that the HIV/AIDS epidemic is both exacerbating poverty and creating new poor. The epidemic has impacted every segment of society. In the individual affected household, a 7% reduction in total income is suffered (16). The death of an adult to AIDS depresses per capita food consumption by 15% forcing families to reallocate their resources. Withdrawing children from school to help at home, work long hours, and adjust household membership and when available selling household assets are some of the consequences (17).
In the workplace, companies have recently faced the need to hire three people for each semiskilled job because people are expected to die just during training (18). The World Bank has even predicted a 0.3% decrease in GDP for the ten African countries mostly affected by AIDS. This might seem like a small figure, but is over one third of their annual growth rate, which is at best 1% per year (17).
Most of the
economic analyses regarding AIDS in Africa have not been able to demonstrate a
significant impact of AIDS on commonly used macroeconomic figures. Most of the economic impact of AIDS in
Africa is not a result of its incremental effect in reducing labor supply but
rather in the result phenomena of concentrated impact on vulnerable structures,
causing them to break down. The HIV
epidemic in Africa has also demonstrated the contribution of a disease to the
breakdown of a country, even threatening peace (19).
In a nutshell,
AIDS has already reversed 30 years of hard-won social progress in some
countries (20).
About one third of the world’s population is infected by Mycobacterium tuberculosis. Deaths from TB comprise 25% of all avoidable deaths in developing countries. These deaths affect mainly the economically productive age group (21).
Poverty and
widening of the gap between poor and rich are increasingly recognized in many
populations to be the culprit for the distribution and outcome of TB. Neglect,
rapid population growth, and the HIV epidemic are also considered significant
factors in the persistence of TB as a leading cause of death in the developing
world (22). In Dickens’s words,
tuberculosis is “a disease which medicine never cured, wealth warded off, or
poverty could boast exemption from, which sometimes moves in giant strides, and
sometimes at a tardy sluggish pace, but, slow or quick, is ever sure and
certain” (23).
The persistence of TB as the leading killer of young adults is associated to the advent of the HIV epidemic and the emergence of strains that are resistant to multiple drugs (MDRTB) (10, 24). Regretfully, the emergence of MDRTB represents a critical revelation of previous predictions earlier this century that a social disease could not be eradicated without social action (10).
In most settings where TB is prevalent, the relationship between individual agency and structural violence are significantly limited by large-scale forces that are beyond their control. In this instance, monotherapy and erratic drug ingestion, are directly involved in the development of multidrug resistant strains. In this manner, MDRTB represents a complex not only as a complex biological phenomenon but also socially determined (10, 25,26).
The death toll from malaria is currently estimated at one to 2.5 million deaths every year. According to WHO 300-500 million new cases of malaria occur every year (27). Eighty percent of these cases and 90% of malaria deaths occur in sub-Saharan Africa, and most occur in children under five years old. In fact, malaria accounts for one in five of all childhood deaths (28,29). Women are especially vulnerable during pregnancy.
Widespread illness and early deaths obviously hold back a nation’s economic performance by significantly reducing worker productivity. There are also long term effects that may be amplified over time through various social feedbacks (30). In addition to the cost of lost working days, the cost of treatment for repeated bouts of malaria might also represent a huge burden for the poorest families. In Nigeria, it has been estimated that subsistence farmers spend as much as 13% of total household expenditure on malaria treatment (15).
Poverty and
inadequate access to appropriate drug treatments is a critical force in the
development of resistance. Resistance
to chloroquine, the former treatment of choice, is now widespread in 80% of the
92 countries were a malaria is endemic, while resistance to newer second and
third line drugs continues to grow (31). Unfortunately, many of these new drugs are expensive and will
eventually become ineffective due to the malaria organism’s complex
epidemiology, and facility for rapid mutation, such as it has been suggested
with MDRTB. Preventive strategies such as impregnated bed nets can prevent 50%
of all malaria deaths. The cost of a
net and one year’s supply of insecticide is less than one hour’s parking in New
York, Paris or Tokyo (15).
In summary, there is an intimate connection between poor health outcomes from infectious diseases and poverty. Interventions against HIV/AIDS, TB, and malaria could help to alleviate poverty and could substantially boost economic growth in countries where their impact is most significant (32). These interventions could be addressed from the perspective of the game theory.
A) The
concept of game theory
Von Neumann and
Morgenstern developed the concept of game theory, distinguishing between
zero-sum and non-zero sum games. In
zero-sum games, the fortunes of the players are inversely related. In non-zero sum games, one player’s gain
not necessarily portrays a bad outcome for the others. Indeed, in non-zero sum games the “players”
interests overlap entirely. These interactions have shaped the history of the
human species from a social and a biological standpoint (33).
In addition, political scientists and economists have dissected human interactions into zero-sum and non-zero-sum elements. From an economical point of view, the game theory applies the concept of the “pareto optimum” as the threshold for non-zero sum interactions. In this analytical framework, the pareto optimum has been reached when it is no longer possible to make anyone in the society better off without making someone else worse off. In other words, this state is reached at the point at which all non-zero sum games have been realized. When two players have a mutually profitable transaction that could be possible, but not yet conducted, then the pareto optimum has not been attained (34).
The pareto optimum for resource-poor countries has not been reached. In many instances, it has not even been explored. In attempting to control infectious diseases in these settings, we argue that many profitable transactions can be performed with overlapping benefits for both rich and poor countries. In this instance, the setting of the game would be the global village. The developing countries, as one of the players, have been predisposed to lose. The other two involved players – rich countries and multinational corporations – have been attempting to support “the weakest link”. Unfortunately, such efforts have been only partially successful and therefore will require a new approach to solve old and new problems. We believe that perhaps the failure of these strategies could be explained because they were conceived from a zero-sum perspective.
Many arguments have been made regarding possible interventions to improve health in the resource-poor settings. While we do not disagree with the humanitarian approach, that includes the principles of Health as a Human Right and Social Justice, these strategies have been insufficient and largely inadequate. A win-win interaction among governments of poor and rich countries, and multinational corporations is what we argue could be a strategy that could benefit all parties.
The developing world is crying for money and development. Large amounts are needed and must come from rich countries, in the form of grants rather than loans, to support scientifically sound interventions (35). The priority of intervention should be determined by the extent to which the problem could be reduced for the available resources. Directing the resources to health conditions that have the greatest burden of diseases perhaps could be the most appropriate approach. This is why we believe that an attempt to control the epidemics of HIV/AIDS, TB, and malaria could have a significant impact.
To accomplish these difficult tasks, advocacy from the scientific community and commitment from governments of rich countries are required. Physicians and scientists in general share some of the responsibility for this. We have been unable to raise our voices loud enough to demand what really needs to be done to help the destitute sick in poor countries. We have forgotten our pledge to serve humankind and promote the betterment of society. Public health should take a higher place on political and budgetary agendas. Resource-rich countries of the world should target the world’s most vulnerable populations in order to successfully start to balance these inequalities (28). In summary, prevention and treatment of infectious diseases cannot be regarded as solely the province of wealthy countries.
As already been argued, the benefits of playing the game are directly involved in promoting health and development. Some of the benefits include:
On of the main
responsibilities of governments as a public entity, is to pay for the inherent
costs of society or public goods, because since no money will come out of them,
private firms will not produce them.
Macroeconomic stability is a public good and the government must
produces it so we can all benefit from it.
In the case of infectious diseases, the government has the fundamental
role of preventing the spread of infections while protecting them from
discrimination and stigmatization. This
is especially true in the case of developing countries where resources are
limited and only available through public and private institutions (21).
We think that the benefits obtained from the perspective of non-zero sum interventions (win-win situations) between rich countries include:
High-income countries with a relatively small epidemic, such as Japan, are likely to experience the greatest economic impact, not from infections in the Japanese work force but rather from a fall in trade because of infections in other countries. This suggest that it maybe in a country such as Japan’s economic self- interest to invest in HIV prevention in developing countries that are major trading partners (19).
We now live in a single epidemiological world system without defined boundaries. With mobilization of populations, travel and commerce among different regions in the world, diseases that exist in one region could easily spread to others. Without a wide and intelligent use of currently available antibiotics, antimicrobial resistance may threaten the national security of many countries (36).
The rewards of good citizenship, is not a mater of charity. Good international citizenship is a matter of national interest. A country’s interest in being seen as a good international citizen is as important a national interest as the two traditional national interest goals, security and economics. An example of this is the Nordics and the Scandinavians, which have derived an enormous reputational benefit over the years from being seen as the kind of countries that are willing to get out there and take the extra step (37).
Experience learned from societies substantially impacted by the HIV/AIDS epidemic, has shown the enormous weight imposed over already frail structures ultimately threatening peace. The correction of vulnerable structures and economic stability will be reflected in the reinforcement of young democracies and social peace (38).
If the required public health interventions are put in place, the promoting countries will establish a trust bond with the intended developing countries. Confidence will be built surrounding internal and external affairs and facilitating future political collaborations.
Previous international collaboration experiences and the current epizoonosis in Western Europe underline the importance of developing and strengthening present and future international networking.
E) PLAYER No. 3 – Benefits of non-zero sum thinking for multinational corporations
There is growing realization that investments in public health programs and infrastructure may ultimately prove to be extremely profitable in terms of economic growth, as well, as invaluable to those whose lives are affected. Poor health is a major limitation on economic productivity. An adequate public health system is a requirement for sustained economic development. The returns on investments to address these inequalities may be far greater than the returns on other economic investments (39,40).
The lack of commitment of the pharmaceutical companies to address the distribution of drugs in the developing world is associated to the concept of cost recovery. Bringing a new antimicrobials drug to the market costs about US$224 million (41). Therefore, a major obstacle to pharmaceutical companies is that they have no market incentive to address the health problems of the world’s poor. Private firms do not have sufficient incentives to develop the technology, both because is a public global good, and because beneficiaries are people with low ability to pay. The problem needs to be addressed in a different way.
Recently, pharmaceutical companies have acknowledged the importance of providing the necessary drugs to patients in developing countries. Nevertheless, the risk of lowering the cost of drugs is to set a precedent that could be followed by the current market in the developed world. This will likely bring research and development to an abrupt halt. Therefore, some alternatives to the involvement of pharmaceutical companies in providing assistance to resource-poor countries: 1) public-private partnerships where international grants are directed towards the purchase of large amounts of drugs at developing countries-intended prices, while maintaining current market prices and intellectual rights, and 2) a contingent loan or promissory note in which money will be kept until a manufacturer invents a vaccine or drug that would fulfill the specifications that the countries insisted upon (42).
By addressing
the need of antimicrobials to attack the epidemics, pharmaceutical companies
will obtain major benefits and switch from the position of villains to become
social heroes. A reputation for social
responsibility can improve the stock performance of a company. Although we do not have examples of the
impact on Wall Street of socially responsible behavior towards AIDS,
tuberculosis, or malaria, there is the example of pollution. When a newspaper in the Philippines
announced good environmental policies were being implemented by the national
corporation, their stock price went up (43).
Pharmaceutical
companies should take advantage of this link between reputation and stock
market performance. The public is now
reading about companies which are not responsible and making value judgments (43). If the unmet need for medications to
attack these infections continues in the developing world and pharmaceutical
companies fail to address these issues promptly, manufacturers from developing
countries alternatively will start compulsory licensing of antimicrobials
ignoring patent rights, as it has occurred already in India and Brazil (44,45).
The major infectious disease epidemics have affected the lives of many people worldwide. The stage was never set for these epidemics to be controlled due to a lack of scientific knowledge, international affairs, and mostly a lack socio-economic organization to attack these maladies. Considering the privileged historical moment in which we are currently living with its advances in scientific knowledge, globalization, and abundance of economic resources in the most developed countries, we ought to take advantage of this precious opportunity and intervene now. Many researchers suggest that disease-oriented intervention is impossible without the proper infrastructure, but this is more of an excuse than a legitimate analysis. Science should not be a prerogative of the rich. Science should be devoted to the betterment of humankind; poor and rich people alike should obtain the benefits of these advances. If scientific knowledge is not applied equally for development, science loses its purpose.
Resource rich
countries should take an active role, both by addressing health disparities
within their own countries and by committing resources to address health
problems in the developing world. A
serious effort at global development will require more financial support from
the rich countries to help overcome the burden of disease imposed by these
three major infectious killers. Improving the health of the poor is critical
from both an ethical, and a self-interested perspective. From an ethical perspective, the relief of
suffering due to illness is the moral basis for public health work. From a self-interested approach, the health
problems of the poor worldwide pose an increasingly intimate threat to all
populations (46).
Leaders from the most powerful countries agreed at the summit in Okinawa Japan last year to reduce the three disease of poverty, AIDS, Tuberculosis and malaria by devoting more funds into the developing world (47). Regretfully most of this help will be in the form of loans, which consequently will put these countries further into debt. An example of this was the proposal of the U.S. to lend $1 billion to sub-Saharan African countries to buy U.S. made antiretroviral drugs, when it would be cheaper for such countries to make their own. Furthermore, debt relief might not have the expected results since the net flow of resources to Africa is positive and some of the poorest countries are not paying any debt service from their own resources. These countries are “recirculating” new foreign assistance and concessional loans to avoid defaulting on the old (47).
In the case of AIDS, specific risk groups should be targeted first. Priorities in HIV/AIDS should start with the following steps:
These steps need not necessarily be taken simultaneously, but could be incorporated sequentially.
In the case of
TB, a broad biosocial view that brings into perspective the political,
cultural, and economic barriers to effective treatment of this condition should
be considered. The factors that govern
treatment failure or success are determined largely by economic variables (10). Directly observed therapy short course
(DOTS) has been central to the WHO-International Union against Tuberculosis and
Lung Disease strategy since 1991 (22).
This approach has been shown to be effective in controlling TB in many
low-resource settings. Nevertheless,
with the advent of the HIV/AIDS epidemic and the spread of MDRTB, the control
of TB worldwide urges for a more innovative, comprehensive, and dynamic
approach (25). Given the success
of DOTS in some setting in which resistance to first-line drugs is rare, the
concept of DOTS Plus has been advocated.
This approach involves individualizing treatment regimens according to
the susceptibility pattern of the TB isolates (10,24,26).
The challenge in controlling malaria is to use already existing drugs effectively. This means improving access to appropriate drugs and providing combinations of medications at a lower cost. Increasing surveillance to guide the proper use of drugs and more attention to alternative prevention strategies such as insecticide-treated bednets is also vital. Unfortunately, for these interventions to be successful, continuous financial support is needed. If present these interventions may have a significant impact in decreasing mortality due to malaria. Observed treatment –similar to the TB strategy- could be a key point to achieve success.
Interventions against HIV/AIDS, TB, and malaria can be made even more efficient if they are delivered as part of a package of essential public health interventions. This is, perhaps, the most powerful economic argument for reallocating funds to these infections. On the other hand, drug resistance is reducing the cost-effectiveness of some interventions, particularly of TB and malaria (48). The reward is clear: better health is key, not just to reducing peoples’ poverty and increasing national prosperity, but also to global stability and, for everyone, greater peace of mind.
Eloquently stated by Mary Fisher, the world’s response to major conflicts has been slow: “Silence is deadly, the developed world remained silent while the Germans killed 6 million people in their concentration camps.” How many deaths will it take before we intervene in the catastrophe of the developing world? (49)
The belief that each human life has absolute value entails an important duty to preserve it in all circumstances. In this regard, today, we possess the knowledge to prevent, cure, or halt the progression of tuberculosis, malaria, and HIV/AIDS anywhere on our planet. At the same time, in the last ten years, more money has been produced than at any time in history. These two factors in concert should prompt the resource rich countries to focus more attention into the human suffering imposed by these infectious diseases in the developing world. Moreover, we argue that the scientific knowledge attained at this time in history should not be viewed as a prerogative of the rich countries.
Providing health aid to the developing world is a duty of rich countries, understanding shared benefits to both parties in the perspective of the game theory. However, alleviating suffering in these societies is not really a game. It is a matter of life or death.
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