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6 1 A Changing Landscape in Global Health Encountering poor people and diseases of the poor in proximity to wealth is not new, but it is remarkable that these populations account for so much of today’s global burden of neglected diseases. A key force driving blue marble health and the finding that most of the world’s neglected diseases now occur in wealthy nations may be related to substantial success over the past 15 years in reducing those diseases in the world’s most devastated low-­income countries, especially in Africa. As the incidence and prevalence of these neglected diseases began to diminish, a new health landscape was revealed. Has peeling the onion exposed a new paradigm? In 2000, the attention of the then Group of 8 (G8) countries (now G7 with the departure of the Russian Federation) turned to Africa and other profoundly impoverished regions. This notice was manifested under the auspices of a set of United Nations Millennium Development Goals (MDGs) that were developed to address global poverty. Described here are some amazing gains that were achieved in Africa and elsewhere by means of these goals. Before describing blue marble health in any further detail, let’s first look at what happened between the years 2000 and 2015 in the world’s poorest countries, notably in Africa. Launched in 2000, the MDGs represent an ambitious set of eight goals (together with specific targets for each of the goals) that were established to sustain poverty reduction, particularly among the group sometimes known as the “bottom billion”—the more than one billion people who live below the World Bank poverty figure, then set at $1.25 per day, but recently increased to $1.90 per day (fig. 1.1). What impresses me most about the MDGs is how they Hotez.indb 6 6/22/16 11:02 AM A Changing Landscape in Global Health 7 effectively provided a key policy framework for channeling overseas development assistance, especially for many of the infectious diseases found among the poor. A rationale for linking infectious diseases to poverty arose in part from landmark reports from the World Bank, including a 1993 World Development Report titled “Investing in Health,” led by Dr. Dean Jamison and others ; an international Commission on Macroeconomics and Health, led by the development economist Dr. Jeffrey Sachs; and the Commission for Africa, under the leadership of then British Prime Minister Tony Blair [1]. Ultimately, two of the MDGs that heavily emphasized infectious diseases of the poor—MDG 4 “to reduce child mortality” and MDG 6 “to combat AIDS, malaria, and other diseases”—stand out for how elected leaders and heads of state came together in order to respond to a global health crisis , especially in sub-­ Saharan Africa [2]. In my opinion, the international response to these two goals and its convergence on Africa represent the first of the truly great humanitarian achievements of this new century. One reason I am confident about the successes of MDGs 4 and 6 is because of an initiative by the Bill & Melinda Gates Foundation to specifically measure the morbidity and mortality toll from each of the major human diseases and to examine how that burden of disease has changed over the past two decades. The Global Burden of Disease Study (GBD) actually began in 1990, but it was relaunched in order to assess individual disease burdens for the year 2010 (GBD 2010) and then again for 2013 (GBD 2013). Figure 1.1. The United Nations’Millennium Development Goals (MDGs), 2000–2015. Courtesy of UNDP Brazil. Hotez.indb 7 6/22/16 11:02 AM 8 Blue Marble Health Led by Dr. Christopher J. L. Murray, who heads the Seattle-­ based Institute for Health Metrics at the University of Washington, the GBD 2010 and GBD 2013 brought together hundreds of investigators worldwide (including this author) to determine the impact of up to 300 different disease conditions (ranging from infectious diseases to noncommunicable ailments such as cancer, diabetes, and heart disease to injuries) [3]. The health impact of each condition is measured both in terms of annual deaths and disability. The disability component is especially important because many of the most common NTDs, such as hookworm infection and schistosomiasis, are major disablers, although they are not necessarily leading killers. Together, years of life lost (YLLs) and years lived with disability (YLDs) are combined to produce a metric known as the disability-­ adjusted life year (DALY). The GAVI Alliance and MDG 4 An important action...


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