An Ounce of Prevention

Lessons from a year working on Africa.

In the United States, we pride ourselves on having access to the highest–quality, most advanced healthcare tools available anywhere in the world, but this comes at a cost. Total spending per capita for healthcare in the United States is by far the highest in the world: around $5,000 each year. Even with these expenditures, recent reports suggest that our life expectancy (among other measures of healthcare success) falls well short of the best in the world.

We can find examples of this inverse relationship between expenditures and public-health outcomes in parts of Africa, where life expectancy has actually declined over the last decade. Take oil–rich Nigeria, the second–largest economy in Africa and neighbor to Niger, one of the poorest countries in the world, ranking dead last on the United Nations Development Fund index of human development. Total annual healthcare expenditures in both countries are around $50 per capita, but Nigeria has three times Niger’s rate of HIV infection and is one of the last places in the world where wild poliovirus continues to circulate.

When the H5N1 strain of highly pathogenic avian influenza first appeared in Africa, it was in northern Nigeria, which continues to see new outbreaks and the ongoing geographic spread of the disease among poultry. On three occasions it has spread across the border into Niger, where each outbreak has been fully contained and eradicated despite the higher density of poultry production on Niger’s side of the border.

What is Niger’s secret to controlling the threat of this dangerous zoonotic disease? Nothing particularly fancy or expensive. The government has a strong public awareness program that ensures poultry farmers report outbreaks by providing compensation for their losses. The program is also transparent and informative about outbreaks, using all available channels to inform its public and the international community. It quickly quarantines outbreak areas, and it culls affected livestock as recommended by the United Nations. These are all matters of leadership and organization, with only the most limited use of technology. Although Nigeria has somewhat better access to technology, its response in the same matters addressed by Niger has been noticeably weaker, and the result is that the disease is spreading continuously and has reached almost every part of the country.

An older–established health threat in Africa is malaria. An estimated 300 million to 500 million worldwide cases each year cause 1.5 million to 2.7 million deaths. More than 90 percent of the deaths are in children under 5 years of age, the bulk of them in Africa.

Treatment of the disease has grown more expensive as drug–resistant forms of the parasitic protozoa that cause it have emerged, prompting more and more exotic drug combination therapies which are now mostly based on costly artemisinin—a drug used to treat resistant strains of malaria. Each new drug that goes into the field eventually gives rise to a resistant strain of the disease.

Simple preventive measures such as using pesticide–impregnated mosquito nets have proven to be very effective in reducing the mortality from this disease. Each net costs about 35 cents. The present artemisinin combination therapy costs about $15 per six–dose course. However, the courses are often not completed because of this cost, rendering the patient a crucible for the development of resistant variants of the protozoa—some of which might even get to the United States.

The message is clear: High–tech, high–cost biomedical devices and medicines are wonderful things for those who can afford them and very profitable for those who develop them. We all look forward to the implantable artificial retina, a cure for cancer, or a cure for Alzheimer’s disease. But the real payoff is in engineering healthcare and disease management systems that are low cost and highly effective in the prevention of diseases like malaria and pandemic influenza that ultimately threaten the entire world.