Infectious diseases, together with poor governance, corruption and poverty, are conspiring to make life miserable for millions of people in sub-Saharan Africa and other regions in the developing world. Three diseases in particular — AIDS, malaria and tuberculosis (TB) — are posing a formidable threat to fragile public-health systems.

Credit: LARRY TOWELL/MAGNUM/CONTRASTO

In the face of this dire situation, the global community has led a concerted effort to tackle these diseases, in particular by increasing access to existing drugs and boosting financial support for research into new drugs and vaccines.

The results have been encouraging. The number of people with HIV in developing countries receiving highly active antiretroviral therapy (HAART) increased almost threefold between 2003 and 2005 from 450,000 to 1,300,000. In Uganda, there has been a vast increase in access to HAART from 3,000 in 2001 to a projected 131,000 during the first quarter of 2008. That includes a significant number receiving treatment for the prevention of mother-to-child transmissions. In addition, all registered patients living with HIV in developing countries now take daily cotrimoxazole (CTX) prophylaxis. CTX is an inexpensive 'combination' antibiotic that thwarts such opportunistic infections as bacterial and Pneumocystis pneumonia, some forms of diarrhoea and even malaria.

There has been progress too with malaria prevention and treatment. More than 30 countries in sub-Saharan Africa have adopted artemisinin-based combination therapies (ACTs), a product of traditional Chinese medicine, for the treatment of malaria. Furthermore, an estimated 42% of Ugandan children under the age of 5 years now sleep under protective bed nets to prevent malaria. That represents more than a 40-fold increase since 2000.

We cannot deny that these are significant achievements. Nevertheless, there is still much to do. Despite the commitment by many governments to provide combination therapies to tackle malaria, logistical problems and government ineptitude stand in the way of getting the treatment to everyone who needs it. Likewise, the number of children sleeping under bed nets is far short of the number needed. Just as seriously, the lack of laboratory capacity for the monitoring of treatment programmes remains a vexing problem. Malaria is commonly misdiagnosed, and millions of dollars are wasted on expensive combination therapies for patients who are malaria-free.

The campaign against HIV/AIDS is also fraught with difficulties. The widespread availability of antiretroviral drugs and CTX has led to the emergence of forms of HIV that are resistant to HAART, and to several common bacteria that are resistant to CTX. This threatens to undermine the progress achieved thus far against the disease. Furthermore, despite efforts by the World Health Organization (WHO), the United Nations Joint Programme on HIV/AIDS (UNAIDS), the Global Fund to Fight against AIDS, Tuberculosis and Malaria, the William J. Clinton Foundation, the Bill & Melinda Gates Foundation, the US President's Emergency Plan for AIDS Relief and others, 70% of those living with HIV/AIDS in developing countries had yet to receive HAART in 2007.

WHERE TO

So, where do we go from here? What is crucial is that the scientific and medical communities in developing countries demonstrate assertive leadership to spur governments to confront the challenges of infectious diseases.

The key tasks are as follows: to maintain and expand the benefits that have been achieved in the treatment and prevention of malaria and AIDS; to draw attention to diseases that do not share the same spotlight, such as leprosy, sleeping sickness, filariasis, bubonic plague, cholera, meningitis and Ebola; and to champion the rights of all people in the developing world to receive adequate health-care. It is important to caution both donors and government agencies that the increased attention being paid to malaria, HIV and TB must not be allowed to overshadow neglected diseases or other initiatives vital to preparing for epidemic diseases.

One priority should be to make HAART and ACTs available to patients in all regions, which would include adequate provision for children. This would require strengthening the laboratory capacity of rural clinics to enable them to provide the treatments and establishing regional laboratories to monitor drug resistance. We must work with HIV and malaria control programmes to identify alternative drugs to replace CTX in the light of antibiotic resistance, and we must collaborate with national governments to delay the emergence of ACT resistance. At the same time, we must stockpile alternative anti-malarial drugs for use in the event of escalating ACT resistance. Moreover, to control water-borne diseases, we must rebuild dilapidated sanitation and wastewater systems with the help of municipal and district health-care authorities and develop new technologies for water purification in areas where fresh water is scarce.

As scientists, we must take advantage of the improved political climate for direct foreign investment by entering into joint ventures, technology-licensing agreements and investment opportunities for the local manufacture of HAART, ACTs, vaccines, diagnostics and water-purification systems. Instead of serving as junior partners in research initiatives and clinical trials created by our colleagues in the developed world, we must take the lead in developing new interventions for the control of infectious diseases. Public-health officials too can provide more effective leadership in disease control by acquiring new skills that draw on goal-orientated strategies common in the business world.

ON OUR OWN?

The scientific and medical communities in the developing world will stand trial in the court of public opinion as culpable accomplices if the voiceless and powerless continue to die of preventable diseases. We have a moral obligation to condemn stridently the inertia and lethargy of national governments in providing health-care to the needy. We must never be silenced by the constant refrain, “There are no funds”. Governments in the developing world have money. Yet public health too often takes a back seat to other 'concerns', including perks and privileges for political leaders, and military ventures that divert funds from critical social and economic needs.

Combating infectious diseases in the era of globalization requires new skills and proactive leadership by health-care professionals in developing countries — abilities and qualities that we, in the developing world, must develop and apply on our own.