1. GLOBAL IMPACT OF INFECTIOUS DISEASES Teresa Smith de Cherif, MD, MIA Fellow, Division of Infectious Diseases

2. People in the developed world consume most of the world’s resources. 25% of global deaths are from infectious diseases, but the burden of disease is carried largely in the developing world.

3. Infectious Diseases Mortality There are marked differences between developed & developing nations with regard to mortality from infectious diseases. There are marked differences between developed & developing nations with regard to mortality from infectious diseases.

4. SCENARIOS Rather than using statistics alone to provide brief snapshots of infectious diseases, I hope to aim broader: to use the African tradition of story telling, to think outside the box, to explore how seemingly unconnected events & trends can work together to expand or limit an epidemic. “The decisions we make about the future are guided by our view of how the world works and what we think is possible. Scenarios are stories about the future, but their purpose is to help make better decisions about the present.” --AIDS in Africa: Three Scenarios to 2025

5. Diving hippo illustrates that the patterns of behavior lie below the surface, and the structure of the system lies deeper still.

6. Overview Explore and expand understanding of the AIDS epidemic, particularly in Africa. Explore and expand understanding of the AIDS epidemic, particularly in Africa. Understand that the AIDS epidemic is a small part of a wider international peace and development crisis, requiring an exceptional response within its wider social and economic contexts. Understand that the AIDS epidemic is a small part of a wider international peace and development crisis, requiring an exceptional response within its wider social and economic contexts. Understand that infectious diseases affect not just individuals, but collectives—families, communities, nations, the world. Understand that infectious diseases affect not just individuals, but collectives—families, communities, nations, the world.

7. Front page, New York Times Book Review, 11 December 2005. Perceptions: Is AIDS a health problem or is it a symptom of underdevelopment and poverty? Will there be incentive and capacity to deal with AIDS?

10. 2/3 of all people living with HIV are Africans. Nations most affected: South Africa, India, Nigeria.

13. From Algiers to Cape Town, Dakar to Dar es- Salaam, the red earth of Africa is dotted with 15 million white tombstones, because that is how many people have died from AIDS. The primary social events in South Africa at present are funerals.

15. Prevalence of HIV in Africa The number of all new and old cases of HIV in Africa during a particular period. The number of all new and old cases of HIV in Africa during a particular period. The prevalence of HIV infection has stabilized in Africa, but let’s not be misled. The prevalence of HIV infection has stabilized in Africa, but let’s not be misled. Stabilization does not necessarily mean that the epidemic is slowing. Stabilization does not necessarily mean that the epidemic is slowing. “Stabilization” can mask the reality that equally large numbers of people are being newly infected with HIV and are dying of AIDS. “Stabilization” can mask the reality that equally large numbers of people are being newly infected with HIV and are dying of AIDS. Prevalence is also affected by data capture. In rural South Africa, where voluntary test and counseling is in place, prevalence is at 30-40%. Prevalence is also affected by data capture. In rural South Africa, where voluntary test and counseling is in place, prevalence is at 30-40%.

16. Africa is three times the size of the United States.

17. Presently, Africa has inadequate resources to face the burdens of AIDS, TB, malaria, and other infectious diseases. AIDS has led to a resurgence in the incidence of TB. 1/3 of Africans carry a latent TB infection. Each year, 5-10% of those co-infected with TB & HIV develop active TB; up to 50% will develop TB at some point. African governments actually are reducing health expenditures in order to repay external debt.

18. Africa is precariously dependent on the resources it supplies to the world.

19. AIDS deepens the traps of poverty, underdevelopment, and marginalization in a globalizing world. Poverty: Informal settlements surround the urban centers of Africa. More than 1 in 4 South Africans—12.5 million people—live in shantytowns. Within the last year, ~900 protests over squalid conditions erupted.

20. AIDS has spread by poverty and war.

21. Countries at war and bordering nations experience increased HIV transmission.

22. Impact of Conflict on Children Hotel Rwanda

23. African women & HIV 60% of HIV+ African adults are women. 60% of HIV+ African adults are women. 75% of all women with HIV, worldwide, are African. 75% of all women with HIV, worldwide, are African. Young African women of childbearing age have the highest incidence rates. Young African women of childbearing age have the highest incidence rates.

24. As the most productive members of society—teachers, agricultural workers, healthcare personnel, public service staff—are dying from AIDS, the continent is being robbed of its human capacity. Life expectancy has dropped to <40 years in 9 African countries, among them Zimbabwe. There, life expectancy was 52 years in 1990; in 2003, it fell to 34 years.

26. Economic Costs of Disease at the National Level

27. “Doctor, who is going to take care of my children?” AIDS stresses families, as grandparents take care of orphaned children. Parents die, there is loss of income to the family, debt is incurred.

28. Fikelala Children’s Centre in Khayelitsha (Cape Town), South Africa. Infants whose mothers had no access to antiretroviral therapy are being born with HIV and soon after are left as orphans.

29. If present trends continue, by 2025, there will be a missing generation of grandparents. Will there be a sense of family, community? The large number of children orphaned by AIDS will be less skilled, less nurtured, and less socially integrated than their parents were.

30. South Africa: Africa’s most developed country. RSA has the highest number of people living with HIV in the world, >5.3 million; ~3 million women. RSA has the highest number of people living with HIV in the world, >5.3 million; ~3 million women. One in 4 South Africans is HIV+. One in 4 South Africans is HIV+. AIDS is the leading cause of death. AIDS is the leading cause of death. More than 1/5 of the workforce is HIV+. More than 1/5 of the workforce is HIV+. Absenteeism from the workplace has risen with employee deaths from AIDS. Absenteeism from the workplace has risen with employee deaths from AIDS. The RSA Dept. of Health Study 2002 estimated that 250 babies per day were infected by mother to child transmission. The RSA Dept. of Health Study 2002 estimated that 250 babies per day were infected by mother to child transmission. AIDS-related illnesses are responsible for 40% of deaths in kids <5 years. AIDS-related illnesses are responsible for 40% of deaths in kids <5 years. Yesterday South Africa is being cast into deepening poverty. The post- apartheid political, social, and economic gains risk being reversed by the downward spiral in health. How can South Africa partner for prosperity with other African nations?

32. Scenarios: Which way forward?

34. 43 million new HIV infections could be prevented over the next 20 years if African governments implement comprehensive strategies and if global assistance is increased.

35. Presently, in most cases, palliation is all we have to offer to African individuals suffering from advanced AIDS. Confronting this devastation will require strengthening human & institutional capacities, including scaling up HIV prevention programs and implementing large-scale treatment programs.

36. PREVENTION New ABC (Acknowledgement of the realities of sexuality; Behavioral change  safer sex; Communicating). New ABC (Acknowledgement of the realities of sexuality; Behavioral change  safer sex; Communicating). Investment in health systems infrastructure Investment in health systems infrastructure Voluntary test and counseling Voluntary test and counseling Infection control Infection control Safe blood banks Safe blood banks Vaccine*development Vaccine*development EDUCATION EDUCATION Immunization can eradicate infectious diseases. Most famous example: small pox. Others: polio, measles, H. influenzae type B, Yellow Fever.

37. Treatment Less than 5% of Africans are on highly active antiretroviral therapy (HAART). Less than 5% of Africans are on highly active antiretroviral therapy (HAART). Roll out of HAART must progress. Roll out of HAART must progress. Reverse African brain drain. Reverse African brain drain. Invest in drug manufacturing capacity in Africa. Invest in drug manufacturing capacity in Africa.

38. Projected Costs of Tackling the AIDS Crisis Global spending on AIDS has increased 15-fold since 1996 to approximately 5 billion dollars annually. Global spending on AIDS has increased 15-fold since 1996 to approximately 5 billion dollars annually. But, even this amount falls short of UNAIDS estimates of $12 billion required annually. But, even this amount falls short of UNAIDS estimates of $12 billion required annually.

39. Everyone must participate… Leverage what is available to achieve more, especially given limited resources. Leverage what is available to achieve more, especially given limited resources. No AIDS funding without investment in social and economic development. It shouldn’t be easier to get HAART than adequate nutrition & H20. No AIDS funding without investment in social and economic development. It shouldn’t be easier to get HAART than adequate nutrition & H20. Fikelala. Xhosa, “reaching out.” Fikelala. Xhosa, “reaching out.”

41. Change South Africa’s first democratic election, 1994. It may seem futile to challenge the world’s “misery, injustice, and violence…But, it is through numberless acts of courage and belief that human history is shaped. Each time a person stands up for an ideal, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current which can sweep down the mightiest walls of oppression.” –Robert F. Kennedy at the University of Cape Town