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The Future of Primary Health Care: Ensuring Equity

The Future of Primary Health Care: Ensuring Equity. Paul Farmer, MD, PhD Harvard Medical School Partners In Health. Priority Setting. Cardiovascular disease and cancer are the first cause of mortality in Latin America.

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The Future of Primary Health Care: Ensuring Equity

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  1. The Future of Primary Health Care:Ensuring Equity Paul Farmer, MD, PhD Harvard Medical School Partners In Health

  2. Priority Setting • Cardiovascular disease and cancer are the first cause of mortality in Latin America. • But the notification of cases of tuberculosis, malaria, and HIV/AIDS keeps increasing [1]: Tuberculosis196,630 (1980)232,262 (1995) Malaria535,273 (1980)1,056,072 (1997) HIV/AIDS66,315 (until 1991)31,699 (in 1995) • Need to continue research and investment on poverty-related diseases. [1] OPS 2000.

  3. The Poor Bear the Burden of Infectious Disease: Percentage of Deaths from Infectious Disease that Occur in the Poorest 20% of the Global Population Malaria 57.9% Childhood Diseases 55.0% Diarrheal Diseases 53.2% Perinatal Conditions 45.0% Tuberculosis 44.4% Maternal Conditions 43.2% Respiratory Infections 42.6% HIV/AIDS 41.8% Source: Davidson R. Gwatkin, May 1999

  4. Leading infectious killersmillions of deaths, worldwide, 1999 4.0 million Deaths (in millions) 2.7 million 2.2 million 1.7 million 1.1 million Acute respiratory infections Diarrheal diseases AIDS TB Malaria Source: WHO, 2000

  5. Infectious diseases as a cause of mortality: Worldwide vs. low-income countries, 1998 Source: WHO, 1999

  6. Reported TB cases, U.S.-born and foreign-born persons United States, 1999 Foreign-born 43% U.S.-born 56% Unknown 1% Source: CDC, 1999

  7. The Outcome Gap Grows Improved Outcomes Non-Poor Poor Time Introduction of effective technology

  8. Number of People per PhysicianSource: PAHO 2000

  9. Number of surgeons per 100,000 population Cuba 56 United States 51 Japan 31 Sweden 29 Germany 13 China 10 Columbia 7 United Kingdom 6 South Africa 6 Philippines 1.5 Kenya 0.6 Tanzania 0.3 Bulletin of the American College of Surgeons, 1987 J. Perez, personal communication, 2000

  10. Leading causes of maternal mortality, developing countries Cause of death % of deaths Hemorrhage 25-33% PIH/eclampsia 7.4-30% Sepsis, infection 8.3-65% (including malaria, TB) Uterine rupture 27.6% Anemia 30-65% Abortion up to 50% Stokoe U. Determinants of maternal mortality in the developing world. Aust NZ J Obstet Gynaecol 1991; 31:8-16.

  11. Highest Maternal Mortality per 100.000 Live BirthsSource: PAHO 2000

  12. Malaria: The Costs of Inequality • 300-500 million people are infected with malaria each year. • Malaria causes more than 1 million deaths each year, 90% of which occur in Sub-Saharan Africa. • If malaria had been eliminated 30 years ago, Africa’s GDP would have been as much as $100 billion greater in 2000. Sources: WHO 2001; WHO Press Release 2000

  13. Tropical Disease Research Between 1975 and 1996, 1,233 new chemical entities were registered. Of that number, only 11 were for tropical diseases such as malaria. Source: Sylvia Pfeifer, “Public-Private Partnership Attacks Tuberculosis—Aim is to Spur Development of New Drugs,” Knight Ridder/ChicagoTribune, October 20, 2000.

  14. Current State of “AIDS Care” in Poor Countries • Palliative care • Programs in “community-based care” or “home care” are inadequate, even as hospice care • no real analgesia, no antifungals, too few antibacterials, no central or even peripheral lines for rehydration

  15. Why Prevention Alone Is Insufficient • Many of those at greatest risk of HIV infection already know that HIV is a sexually transmitted pathogen and that condoms could prevent transmission. • The risk of HIV in vulnerable populations stems less from ignorance than from the precarious situations in which millions live. • Gender inequality adds a special burden to women living in poverty. • Prevention programs ignore the 30 million people who are already infected.

  16. Meanwhile in the US: Trends in Age-Adjusted Death Rate due to HIV Infection,1982-1998 *Using the age distribution of the projected year 2000 US population as the standard. **Preliminary 1998 data

  17. Projected changes in life expectancy in selected African countries with high HIV prevalence, 1995–2000 65 60 55 50 45 40 35 Average life expectancy at birth, in years Botswana Zimbabwe Zambia Uganda Malawi 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 Source: United Nations Population Division, 1996

  18. Fortune 500 Drug Industry Ranks #1 in All Measures of Profitability, 1999 Source: Public Citizen’s Congress Watch (www.citizen.org), from Fortune Magazine, April 2000, Fortune 500 (www.fortune.com).

  19. The HIV Equity Initiative • To expand the treatment of HIV with HAART to those sick with AIDS in Haiti’s Central Plateau • Programmatic approach on successful DOTS-based tuberculosis-control efforts • The program gives medical and social support

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