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. 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.

Malaria57.9% Childhood Diseases55.0% Diarrheal Diseases53.2% Perinatal Conditions45.0% Tuberculosis44.4% Maternal Conditions43.2% Respiratory Infections42.6% HIV/AIDS41.8% Source: Davidson R. Gwatkin, May 1999 The Poor Bear the Burden of Infectious Disease: Percentage of Deaths from Infectious Disease that Occur in the Poorest 20% of the Global Population

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

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

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

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

Number of People per Physician Source: PAHO 2000

Number of surgeons per 100,000 population Cuba56 United States51 Japan31 Sweden29 Germany13 China10 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

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

Highest Maternal Mortality per Live Births Source: PAHO 2000

Malaria: The Costs of Inequality 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 Sources: WHO 2001; WHO Press Release 2000

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

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

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.Prevention programs ignore the 30 million people who are already infected.

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

Projected changes in life expectancy in selected African countries with high HIV prevalence, 1995–2000 Source: United Nations Population Division, Average life expectancy at birth, in years Zimbabwe Zambia Uganda Botswana Malawi

Fortune 500 Drug Industry Ranks #1 in All Measures of Profitability, 1999 Source: Public Citizen’s Congress Watch ( from Fortune Magazine, April 2000, Fortune 500 (

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