This essay, on how social inequalities shapes the fight against disease, was my Observer column this week. It was published on 22 November 2020, under the headline “There’s a social pathogen stalking the world that’s as deadly as Covid-19”.
“What if tropical diseases had as much attention as Covid?”, asked Francine Ntoumi, director of the Congolese Foundation for Medical Research, recently. Ntoumi was really asking two questions. What is happening to all the other diseases that ravage the global south as the world’s attention has focused on Covid-19? And why can’t we put as much energy and resources into tackling diseases such as malaria and TB as we have into stopping the coronavirus?
Some developing nations, notably India and Brazil, have been particularly badly hit by the coronavirus, through a combination of gross inequalities and the sheer incompetence and negligence of the authorities. African nations, though, seem to have been surprisingly successful. Official estimates suggest around 50,000 deaths from Covid-19 across the continent, almost half of which have been in South Africa. These numbers need to be read with a large dose of scepticism, given the paucity of testing and healthcare facilities in Africa. The true figures are undoubtedly much higher. Nevertheless, fears of an explosion in Covid-19 case numbers in Africa have, so far, thankfully not been borne out.
One reason is that many African nations already have protocols in place for dealing with pandemics. Ntoumi’s Congolese health foundation was set up to monitor and combat gastrointestinal diseases, malaria, HIV, TB and chikungunya (a viral disease transmitted by mosquitos). However, it was able to “quickly pivot to diagnostic testing and blood-based epidemiological studies” for the coronavirus. Since March, she writes, “Three-quarters of our time has been spent on Covid-19”.
Success in the battle against Covid-19 has, however, come at a great cost. For attention has been taken away from other diseases, with devastating consequences.
So far, around 1.5 million people have died from Covid-19 worldwide. That’s the same number that tuberculosis kills every year, year after year. Some studies predict that between now and 2025, up to 1.4 million more people will die from TB than normal as cases go undiagnosed and untreated because of Covid lockdowns. Other studies suggest that deaths from malaria could increase by more than a third over the next five years. In India, registration of new TB cases between January and June this year dropped by more than 25% compared with the same period last year, while more than a third of people with TB found health facilities closed because of Covid-19 restrictions. In Uganda, the number of maternal deaths almost doubled in the first three months of this year, largely because there were far fewer births in hospitals and clinics.
Covid-19 highlights not just the lack of attention currently given to other diseases but also the lack of attention they received even before the coronavirus. A year ago, we did not know that Covid-19 existed. Three new vaccines have already been developed (two others have been approved in Russia, though details are scarce) while more than 200 are in various stages of development. TB has afflicted humanity since antiquity. Yet there is just one TB vaccine and it does not work well in adults, while a handful of possibilities are in the pipeline. There is currently no established vaccine to protect against either HIV or malaria.
The reason? A social condition that everyone acknowledges, many condemn, but few are willing to tackle head-on – health investments are based not on need but on wealth and power. In 2010, just 1% of global health research and development investments were allocated to so-called neglected diseases, mainly diseases endemic to the southern hemisphere. There were at least seven times as many clinical trials targeting diseases of relevance to high-income countries than diseases whose burden lies mainly in low- and middle-income countries. TB, malaria, diarrhoeal disease – the fact that they still haunt the world is as much the result of a social as a natural pathogen.
In 1793, the Marquis de Condorcet, a great Enlightenment radical, wrote, under the shadow of the guillotine, his final work, Outlines of an Historical View of the Progress of the Human Mind. “Our hopes for the future state of mankind”, he observed, “come down to three points: the destruction of the inequality among nations, advances in equality within individual nations and the real improvement of mankind.”
Two centuries on, Condorcet would probably be astonished by humanity’s technological and medical advances. When he died, Edward Jenner had yet to develop his cowpox vaccine. However, he would probably be equally astonished that the inequality among nations and within nations remains so stark, that we continue to tolerate a world ransacked by diseases that could be eliminated. Or, as Lucica Ditiu, executive director of Stop TB Partnership, has put it, “I think this world, sorry for my French, is really fucked up.”