Malaria and TB remain the biggest killers in a militarised region that gives scant priority to health care.
There are some legacies of the past that refuse to be showpieced on a museum shelf. In the South Asian Subcontinent, even at the beginning of a century as medically advanced as this one, it is ‘ancient’ diseases like tuberculosis (TB), malaria, acute respiratory infections (ARI), including pneumonia and influenza, and diarrhoeal diseases, that remain the leading killers. Unlike smallpox that has been consigned to medical history books, these diseases continue to stalk the region wreaking havoc on the population. And given the political economy of the region, it is unlikely that they will bid farewell anytime soon.
Despite gigantic strides in modern medicine and the discovery of powerful anti-TB and -malarial drugs, it is significant that more people are dying today of the two diseases than in any other period in history, especially in the developing world. About 98 percent of the two mil-lion TB deaths every year and 95 percent of the eight million new cases are in the developing world. In South East Asia, TB kills 2000 people every day. In Bangladesh, it afflicts more than 60 percent of the adult population and in India every year, 500000 people die of the disease.
The world’s most important tropical disease even now—malaria—kills more people than any other communicable disease except TB. It is the major public health problem in 90 countries and is endemic in eight South East Asian countries. According to a UNICEF report, it kills 3000 children every day, and is one of the major causes of under-five deaths. According to a 1998 WHO report on infectious diseases that affect under-five children, 3.5 million died of ARI, 2.2 million of diarrhoeal diseases, 1.5 million of TB, and 0.9 million of measles.
There is no doubt that these deaths and ill-nesses are inextricably linked in developing countries to poverty. Living in impoverished dwellings, with immune systems weakened by malnourishment, the Subcontinent’s poorest men, women and children are more prone to deadly diseases. Malaria and TB are diseases that impact at least three times more greatly on the poor than any other disease. Studies reveal how in North Bangladesh, TB patients spend USD 130 on private doctors, while also losing 14 months of work time thereby pauperising an already impoverished population. Another study in Bangladesh shows that 40 percent of the households smitten by TB, sold assets and livestock to pay for the treatment, and also ac-cumulated debts. In India, a survey in Tamil Nadu and Maharashtra revealed similar findings as families had to borrow money and sell land, pushing them further into the poverty trap. It is poverty that breeds these diseases and coexists with them in a vicious circle, each reinforcing the other.
South Asia has remained one of the most deprived regions in the world, despite its rich resources, both natural and human. According to the Human Development Report (1997), the region has remained the poorest, most illiterate and the most malnourished. With 600 million people living below the poverty line and in conditions that match Sub Saharan Africa, it has 395 million illiterate adults, and 50 million children without access to schools. Its illiteracy levels exceed those of Sub Sahara–51 percent as against 43 percent in Sub Saharan Africa.
As global poverty increases, three billion people in developing countries live on as less as USD 2 a day, one billion do not have ad-equate housing, while 840 million suffer from malnourishment. At the other end of the spectrum, however, the assets of the three richest people in the world are more than the combined gross national product (GNP) of the 48 least developed countries. In fact, the three richest officers of Microsoft have more assets (USD 140 billion) than the combined GNP of the 43 least developed countries.
Consequently, indiscriminate borrowings by governments of South Asia to face the domestic crisis has led to a debilitating debt burden, disproportionately large compared to the GNP. This burden saps their economic vitality and drains scarce resources from social sectors, to service and repay high levels of debt. Too often a country has to divert resources, with the result that it has to deprive its people of health care, nutrition and education. In fact, each baby in South Asia on an average begins life encumbered with a debt of USD 417.
Today, the total external debt as a percentage of the GNP of some countries in the Subcontinent like Sri Lanka is as high as 51 percent, Nepal 49 percent and Pakistan 47. According to an IMF study, all of South Asia spends more on debt servicing than on basic social sectors like primary health care, nutrition, safe drinking water, sanitation and education.
Poor man’s diseases
Prioritising resources is a controversial issue; the persistence of the major diseases in South Asia is a commentary on the state of the public health policies and systems, and the allocation of funds. During the 1990s, the IMF induced Structural Adjustment Programme (SAP) was launched in the region, and privatisation of public services became the key. In 1997, India’s public expenditure on health was only 0.7 percent of its GDP, while it was 0.8 percent for Pakistan. With an over-emphasis on controlling population growth and achieving ‘targets’, resources for critical public health programmes to prevent contagious diseases, have been further curtailed leading to the virtual breakdown of primary health systems.
The outlay on control of communicable diseases in India declined from about 30 percent of the total health budget to a mere 8 percent by the early 1990s. On the other hand, population control programmes began to absorb 25 percent of the health budget, compared to 6-8 percent in the Second and Third Five Year Plans. The financial cutbacks on malaria control programmes in the early 1990s due to SAP has had a disastrous effect in the region, admits Gautam Basu, joint secretary, Health, Government of India. “In the mid-1940s, with the introduction of insecticides into a well developed health infrastructure and control system, death rates were practically halved, creating demo-graphic history,” says Dr Hiranthi Wijemanne of Sri Lanka. “A major reason for the resurgence of malaria today is because the malarial parasite has become resistant to insecticides. Malathion has proved to be ineffective during the epidemic. Resistance to insecticides like Malathion is also because of faulty and inadequate spraying. Moreover, the degradation of the environment such as piling garbage, stagnant choked rivers and water bodies have become lethal breeding grounds for mosquito larvae.”
Immunisation and infection containment strategies can only work if the public health services are enhanced, and the capacity and the quality of the health sector improved in general. The synergy between immunisation and the health system is critically essential. This is amply reflected in the relative success of the southern states of India, where, for example, the incidence of polio has fallen sharply. “This is because the health infrastructure there is much better organised and managed than the northern states. Even routine immunisation for diphtheria, BCG, tetanus of children has done well,” says Dr Robert Kim-Farley, WHO representative. On multi-drug resistant TB patients, Farley says, “More and more patients are be-coming resistant to TB drugs precisely because they are unable to take full course of the treatment. There are bottlenecks in the continuous supply of drugs.” When a patient discontinues treatment due to non-availability of drugs in the market or because he cannot afford it, he becomes resistant to the medicines. This has fatal consequences. The situation is aggravated in the Subcontinent because the health system is inadequate and non-existent in many parts.
“What is required is a basic health system which should be accessible, acceptable and ac-countable to the people,” says Imrana Qadeer of Social Medicine and Community Health, Jawaharlal Nehru University, Delhi. A survey of 170 rural women living 25 kilometres from the industrial town of Bokaro, India, showed that none of them were even aware of the existence of a primary health centre (PHC). One had visited the centre once in her life and had found it closed. A random survey in the Subcontinent shows the dismal state of PHCs where there is no doctor or medicine, and most structures have been converted into cattle sheds. Patients complain that in the name of ‘free’ treatment, doctors charge them not only for the medicine but also for consultation.
With the impending introduction of the new Patents Law in India and Bangladesh due to pressure from the World Trade Organisation, drug prices have already shot up substantially (by some estimates by as much as 200 to 800 percent). For example, in India, the cost to the patient for diagnosis and successful treatment for TB is an average USD 150, more than half the annual income of a daily wage labourer. In Bangladesh, TB is known as the “king’s disease” because only the rich can afford treatment. The poor are increasingly at the mercy of the emerging nexus of multinational drug companies, private doctors and their nursing homes, and expensive diagnostic laboratories.
It is in this context, that the resurgence of deaths due to malaria or TB, despite the avail-ability of powerful drugs, can be best under-stood. The poor have no access to health care or life-saving drugs. “TB and other diseases being a poor man’s disease have been neglected for several decades,” says Qadeer. Despite government rhetoric on its commitment to eradicate killer diseases from their respective countries, a cursory survey of programmes tell a different story. Recent reports on TB programmes in India show among the reasons for poor performance are dismal organisational set-up, in-adequate funds and shortage of drugs.
Today, in 80 countries across the world less than 50 percent of the population have access to health care. Of the USD 60 billion spent worldwide annually on health research (public and private), only about 10 percent is spent on 90 percent of the world’s health problems—those that affect the poorest people. “Never have so many had such broad and advanced access to health care. But never have so many been denied access to health,” says a WHO report. It is also significant that the WHO woke up to the TB menace and declared it a global emergency only when the illness was ‘discovered’ in a patient in New York.
Though debt imperils the progress of nations, waiving debt will not induce national governments not to indulge in social trade-offs. The vested interest of domestic ruling elites and their links with international powers is well established, says Qadeer. “It is important to understand the absorption of the ruling elite in the transglobal community of consumerists. They force structural adjustments within national economies on the people in the name of efficiency and progress.”
Governments of developing countries have a notorious reputation for favouring their elites over their poor, and are responsible for the deteriorating health conditions in their countries. Much of the borrowed money whether in Pakistan, Burma or India, goes into callous expenditure in buying arms, investment in inappropriate projects, and personal overseas bank accounts. “Peace in the Subcontinent will result in a large ‘peace dividend’ and release large resources which can be re-deployed for strategies of direct attack on poverty and illiteracy,” says economist Sushil Khanna.
It is not only the level of military expenditure that is an issue. Also important is the fact that a disproportionate amount of this is on ‘foreign’ arms. In other words, says Khanna, the proportion of expenditure on foreign goods (import intensity) is far higher in military spending than social sector expenditure. South Asia is largely a ‘closed economy’ and the economic development in the region has been con-strained by availability of foreign exchange. “A cutback in military expenditure will be ad-equate to reduce the pressure on balance of payments by diverting demand away from the global ‘merchants of death,” says Khanna.
In a recent report by the International Institute of Strategic Studies, India’s defence budget for a 1.2 million-strong military has gone up by 21 percent compared to the previous year’s budget. Thirty percent of this budget will be spent for procuring weapons and on military research and development even as India embarks on large-scale development and deployment of missile systems. It is telling that the outlay for military hardware procurement has increased by 30 percent over last year’s 16 per-cent increase.
What is obvious is that there are funds available—but not for development. The Human Development Report for South Asia estimates that merely an outlay of one percent of the GNP on education would be adequate to send all the children to school in South. This is meagre if we take into account that it is less than what is spent on cosmetics in the US or on ice cream in Europe annually. Says Khanna, “The abominable social conditions persist not because of lack of resources but political will.”
The tragedy of the Subcontinent is that the overwhelming amount of death and illness along with the debilitating socio-economic con-sequences, are immensely preventable. Diseases like malaria and TB do not have to be the death noose they once were. But that will only happen once the social and economic issues are addressed. But where’s the political will to achieve such an end?