A recent report from the World Bank, The Challenge of Non-Communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa, says that traffic accidents will be the leading killer of sub-Saharan African children aged 5-15 by 2015. The report points out that “for some [sub-Saharan African] countries, such as Mauritius and the Seychelles, and some populations, such as those over 45 years, NCDs [non-communicable diseases] are already the leading cause of death … NCDs are at least as common among the poor as they are among the more affluent.”
I am currently involved with a research project among African health policymakers (in all 47 sub-Saharan African countries) where many are saying that while, yes, HIV, malaria and TB are serious problems, diseases like heart disease and diabetes are becoming much more significant and could soon outstrip infectious disease. Yet, according to a report in The Guardian, programmes to combat NCDs comprise less than 3% of global development assistance.
The road deaths statistic will not be news to anyone who has travelled in a mutatu (the minibuses or pickup trucks who are the main form of transport in Africa). Ironically donor investment is infrastructure may well be partly to blame – many moons ago, when I did a lot of driving around East and Southern Africa, on most roads it was impossible to travel at more than 30mph, either because the road was dirt, or tarmac so covered with potholes you risked your suspension driving any faster. As speeds and traffic have increased, more are dying. Yet the report says interventions are often cheap and cost-effective – though some are likely to be contentious as (for example) well-maintained vehicles will cost more to run, and charges to passengers will be higher.
The real mystery to me is why there is the almost exclusive donor focus on infectious disease despite evidence that NCDs are becoming an ever larger part of the problem.
Perhaps we have to travel back to the pivotal point in the access to medicines debate – the collapse of the court case bought by big pharma against the South African government in 2001 on preserving patents on HIV antiretrovirals. As one former MSF activist said to me, “The days leading up to the decision were fantastic … I’ve never hunted, but you could smell the blood of our prey.” At that time big pharma was investing hugely in NCDs – seen as diseases of the rich world – but were doing almost nothing in infectious disease, and fielding phalanxes of lawyers in response to demands for medicines access. An easy target.
Those same activists also then made a huge contribution to setting the donor agenda in global health, with initially an almost exclusive focus on HIV, later widened to include malaria and TB – thus the familiar MDG targets.
The irony is that a dozen years on from the landmark SA court case, you would think that those same activists would be lining up to lobby national governments and donors to take action on traffic accidents and access to medicines to treat NCDs. However, now there is no big bad (Western) corporation to attack. All that big pharma investment in NCDs in the 1980s and 1990s – so criticised by activists at the time – paid off, leading to breakthroughs such as statins for heart disease. Such medicines are now long off patent and available for pennies from Indian generics manufacturers.
The next stage in sub-Saharan African health is for the hard graft of integrating the vertical programmes in HIV, TB and malaria in many countries into a horizontal system which has the capacity to provide basic treatment for the most common NCDs – or, indeed, victims of road traffic accidents. This may lead in time to some unexpected ideas – can you see a big Western development NGO, for example, supporting a request for funding from an African government to set up an anti-obesity programme for urban dwellers?
Unfortunately, however, the process of building such a health system is slow, grinding, and often thankless work which provides little opportunity for grandstanding, or attacking “heartless” multinationals. So I am not holding my breath to see that 3% figure increasing any time soon.