Many high-income countries' healthcare systems, like those of the U.S., had previously begun to place a higher priority on non-communicable and chronic illnesses than they did on infectious diseases. Conditions like cancer and cardiovascular disease took precedence, overtaking infections like tuberculosis among the list of the greatest contributors to American morbidity and mortality. To be sure, issues like antibiotic resistance and vaccine hesitancy have undermined first-world efforts against infectious diseases for many years now. Yet, only recently did they return to the forefront of our minds.
The theory of the “Epidemiologic Transition,” first put forward by author Abdel Omran in 1971,
represents the foundational idea in public health that a gradual, global shift has occurred away from infectious disease burden and toward non-communicable illnesses. However, modern professionals have noted that while such a change has indeed taken place in high-income nations like the U.S., propelled by sanitation, antibiotics, vaccines, health infrastructure, and other measures, low-and-middle-income countries (LMICs) continue to suffer from both rampant infectious diseases and chronic illnesses - a “double burden of disease.”
In this way, the “Epidemiologic Transition” has become a pervasive misconception. Today, per the WHO, communicable diseases account for 5 of the top 10 leading causes of death in low-income countries. Furthermore, the aforementioned 21st century factors like antibiotic resistance and rapid, globalized air travel call into question the notion that even developed countries can protect themselves from infectious threats abroad, as witnessed during the pandemic.
The emergence of the COVID-19 pandemic dispelled any remaining notions of having fully conquered infectious pathogens. A globalized economy, in combination with overreliance on seemingly quick fixes like broad-spectrum antibiotics, has rather generated newer microscopic foes that evade our medical advancements. Wealthier nations’ clinical hygiene practices and unfettered deployment of therapeutics counterproductively select for the strongest forms of disease, like multidrug resistant tuberculosis and C. difficile. Such superbugs, often nosocomial, make even the hospital one of the most dangerous places for our ever-aging populations, where the very medical vanguards we admire give rise to their own, ill-intentioned rivals.
On the other hand, few low-and-middle-income countries ever fell under the illusion of escaping infectious diseases or undergoing an “epidemiologic transition.” Instead, they face the "double burden" of timeless deadly microbes like malaria as well as the rise of lifestyle-related threats such as cardiovascular disease. And even when the globe’s privileged states find ways to mitigate both pathogens old and new, from polio to HIV, they too often turn a blind eye to the needs of nations that can’t pay out. People just like you and me suffer and die unnecessarily, born to socioeconomic circumstances in which an easily curable infection elsewhere becomes a death sentence. They aren’t unlucky, but ignored.
Fortunately, the last several decades have seen humanity edge toward triumph over inequities in global health that have become much too difficult to witness idly. President Bush and Dr. Fauci’s PEPFAR initiative successfully furnished lifesaving antiretroviral treatments to Africans with AIDS, and in India more children have benefited from international efforts to distribute polio vaccines. The Global Fund for HIV, TB and Malaria has made strides in the past 20 years that exceed all expectations.
However - therein lies the next big problem. Several other communicable illnesses, including respiratory infections and diarrheal diseases, actually constitute a higher proportion of disease burden in low-income countries. For although well-off nations have finally begun to share their cures for headline diseases with the less fortunate, innumerable neglected diseases (which primarily impact the developing world) receive few resources and little attention. Why does Ebola continue to have a 50% mortality rate where it's endemic, but those who seek treatment in Europe or North America rarely pass away? Why do treatable, preventable diarrheal diseases still kill millions of infants and young children each year?
Diving deeper on this question - globally, diarrheal diseases remain a leading cause of morbidity and mortality in children under five years old. Among infants and young children, they result in millions of deaths each year and long-term health effects such as malnutrition and developmental delays. The main risk factors include poverty, overcrowding and contaminated food and water sources. Socioeconomic and environmental factors like health infrastructure aren't the only cause of disparity - there are plenty of biomedical ones. Rarely do vaccines or effective therapeutics exist to treat or prevent the symptoms of these diarrheal pathogens, because there is little profit incentive to invest R & D into an illness that largely afflicts the poorest of us. The WHO maintains a long list of neglected tropical diseases, which include parasites like river blindness and schistosomiasis.
So too often, diseases impacting vulnerable populations fail to rise to notoriety, remaining more or less unknown in the arena of public attention, and struggling to receive adequate research funding or dedicated personnel. This trend is especially pronounced for communicable illnesses, with resource-rich nations turning their focus toward high-impact ones that also concern their population. HIV is a prime example of this, as only long after drug development was undertaken to rescue first-world populations was a helping hand finally extended to the Global South.
Although the U.S. continues to invest heavily in global efforts against infections like HIV, many pathogens, like parasites and diarrheal diseases, receive only a fraction of the funding. Per the U.S. Office of Management and Budget, the U.S. still directs almost 70% of its Global Health Funding, over $8.5 billion, towards HIV, tuberculosis, and malaria, leaving initiatives on hundreds of other contagions to battle for the rest of the resources.
Moreover, factors like redundancy in vertical approaches toward "big name" illnesses, with many unorganized government and non-profit bodies replicating each other's work, lead to unnecessary spending. And whereas millions of dollars do drive research into some pharmaceutical candidates for treating neglected infectious diseases, augmenting investment in underlying elements of infrastructure, like water treatment systems, might alleviate their spread more quickly and directly.
It's truly tragic that funding availability from governments and NGOs, especially the U.S. government and the Gates Foundation, incentivizes work on a small group of diseases,
disproportional to their impact. Such financial control over global health priorities leaves
many developing nations without the capability to address neglected infectious diseases. In all regions, it hinders research on other illnesses and the development of novel treatments.
On balance, diverting the lion’s share of global health resources to a few threats poses a challenge to global health security, including in high-income countries. In the case of emerging infections like COVID, whose threats often originate in low-resource regions, the present configuration of global health governance and its main priorities fall short. Despite their inexcusable persistence in LMICs, those exact circumstances render neglected infectious diseases an afterthought.
Small children and other vulnerable groups bear the brunt of these terrible diseases, either succumbing to it or facing severe and lifelong consequences. The fact that few safe and effective treatment options exist for them, nor a substantial effort to improve their social conditions,
remains emblematic of the illnesses’ poor standing in the arenas of public health finances, other
resources, and attention. Beyond our responsibility to demonstrate good-faith leadership and altruism on the global stage, we may at least find ourselves selfishly worried that the next pandemic might start somewhere we weren't looking. If we continue to fail to take decisive action on the issue of neglected diseases, our own nation's biodefenses will be caught with their guard down - again.
In the meantime, and quite luckily for us, the dedicated consortium of scientists, physicians, and public health professionals who do find themselves working on neglected infectious diseases progress further each day. Hopefully, such advances will accelerate as more professionals begin to advocate for neglected illnesses.
Grant J. GianGrasso is an MPH candidate at the University of Virginia, and the Editor-in-Chief of the Virginia Medical Review.
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