Treating symptoms versus fighting causes - improving health in the developing world

Naïve faith in scientific progress to solve health issues in developing countries distracts from solutions that are presently available and that could be promptly implemented

15 April 2011

It is a common perception that a lack of novel drugs and vaccines is the primary impediment to the improvement of health conditions in developing countries. Consequently, trying to satisfy this "unmet medical need" by increasing financial support for research and development of novel drugs is widely regarded as the best strategy to support poor countries.

Yet, does it make sense to rely on the hope that novel drugs and vaccines at some point in the future will enable us to solve the health problems of poor countries?

While novel drugs and vaccines may contribute to the solution of global health problems to some extent, research cannot add anything to improve the situation faced at present. Naïve faith in scientific progress rather distracts attention from solutions that are presently available and that could be promptly implemented.

The most pressing health problem in poor countries is the spread of infectious diseases. These are fostered by key factors such as poverty, malnutrition, contaminated water, lack of sanitation, the destruction of livelihoods and poor hygienic conditions in general. In contrast, health conditions in wealthier nations show that infectious diseases can be kept at bay in the presence of an adequate public health care and social welfare system. While even in rich countries it is not always possible to heal, powerful means exist to prevent and to combat infectious diseases. In fact, the failure to achieve significant progress in developing countries is mainly due to the fact that those means and measures that are successfully used to prevent and combat infectious diseases in developed countries are either entirely unavailable or only sporadically applied in developing countries.

Thus, key to improving the situation is not necessarily an introduction of novel drugs or vaccines, but rather making available the very basic resources that have accounted for the progress in health care in the developed world. In many poor areas, merely reproducing the accomplishments of the 19th century would represent great progress – most developing countries fail to provide even the lowest hygiene standards. Addressing these deficits is more effective than treating the ensuing symptomatic consequences with drugs. Ideally, drug should be used alongside efforts to eliminate fundamental causes of endemic diseases. Strategically, however, it is absolutely vital that primarily those measures are implemented that can be sustained as much as possible by the affected communities themselves. The transfer of existing knowledge and established means needs to precede calls for novel drugs and more research.

The success of the Carter Center is an excellent example of how infectious diseases can successfully be controlled by simple means and with limited resources. Founded by former US President Jimmy Carter and his wife, the Carter Center aims to eradicate so called “neglected diseases” in Africa and Latin America. Some of these diseases i.e. malaria used to be endemic in developed countries as well but have fallen into oblivion during the last century – and this in spite of the fact that sometimes no drugs to fight them were available. Their eradication in developed countries has mainly been achieved due to improved sanitation, hygiene, nutrition, education and the introduction of basic health care. An example for such a “neglected tropical disease” is the infection with the Guinea-worm. This parasite is transmitted through consumption of water contaminated with larvae and causes painful infections. Currently no drug treatment or vaccine against the disease is available. However, suspending the reproduction cycle of the worm by supplying the affected communities with clean water is able to stop the transmission of the disease. With the support of the Carter Center and other NGOs Guinea-worm infections have almost entirely been eradicated. This was achieved exclusively by the introduction of filters to prepare clean drinking water, the use of a mild pesticide to eliminate the larvae from water supplies, as well as fostering behavioral change in affected communities to discourage reintroduction of larvae into water supplies. This encouraging example demonstrates that the use of rather simple, readily available means and prompt action can have a great impact on health outcomes. This is a viable and more sustainable option than waiting for pharmaceutical improvements that may or may not .

Another example of strategic misalignment in improving global health becomes evident if we consider the problem of diarrheal diseases, which contribute considerably to childhood mortality in developing countries. It is sometimes argued that the problem could be solved by the development of novel vaccines. But even if one assumes that vaccines against the multitude of pathogens that can cause diarrhea could be developed it does not change the fact that the problem is primarily caused by the consumption of contaminated drinking water. It is an absurd strategy to attempt to vaccinate against all pathogens that can be found in contaminated drinking water. Instead of struggling to treat the ensuing health problems, we need to tackle the underlying causes. Of course this is not to deny the usefulness of vaccines against diarrheal diseases in individual cases. Nevertheless, aiming to deliver clean drinking water supplies is the most efficient strategy to combat diarrheal diseases.

Hence, the prevailing calls for more money for drug and vaccine research need to be preceded by a process of deliberation on the purpose and goals of these projects. This reflection is rarely spoken of in the current debate about development priorities, and unfortunately productive initiatives are regularly distorted by particular interests of powerful lobby groups.

The development of novel and more effective drugs and vaccines should of course not be neglected and we ought to try to improve and extend our armory. It should, however, be kept in mind that if currently available drugs are not affordable for developing countries, this is unlikely to improve for novel drugs.

We should not overcharge developing countries by solutions that are too often a reflection of our own business interests. Instead, we need to focus on a small number of effective strategies. First and foremost we should seek to transfer and implement well-established measures, preferably those that were responsible for the initial success of our own health care and social welfare systems. These may not suffice to solve all problems, but would have the added benefit of generating autonomous development in target countries. An excellent package of simple measures specific for each setting is required to sustainably solve problems.

Industrialized countries could profit from their support as well: It could help our societies regain a sense of what is essential for a reform of our own health care and social welfare systems, showing us where we have perhaps ourselves begun to treat symptoms instead of aiming at causes. We are lulling ourselves with a false sense of security and are therefore running the risk of putting our accomplishments at stake. Lax handling of hygienic provisions and the overuse of antibiotics are examples. The consequences are not only unnecessary treatments and increasing costs, but also the outgrowth of resistant bacterial strains against which we have no defense.

In order to sustainably improve health in poor countries we need to travel old trails anew. The goal must be to transfer accomplishments of medical progress to developing countries – by avoiding the unnecessary and by improving on some of our own wrong turns.

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