Global health, personal action.

Received 15 December 2003; accepted 15 December 2003; electronically published 26 February 2004. Reprints or correspondence: Dr. Gerald T. Keusch, Boston University Medical Campus, 715 Albany St., T443W, Boston, MA 02118 (keuschg@nih.gov) Clinical Infectious Diseases 2004; 38:879–80 This article is in the public domain, and no copyright is claimed. 1058-4838/2004/3806-0017 For those concerned about disparities in health between rich and poor nations, 1993 was a momentous year. First, the World Bank’s World Development Report for 1993, subtitled “Investing in Health” [1], forcefully put forward the thesis that improving the health of the poor is an engine for economic development. This is the case because healthier workers are better able to cope with both the intellectual and the physical demands of work and, therefore, are not only healthier but also more economically productive. Second, the World Bank published a book entitled Disease Control Priorities in Developing Countries [2] that, for the first time, assessed the cost-effectiveness of a set of tools designed to address the major health problems of the poor in developing countries and provided a means for developing nations to prioritize interventions on the basis of disease burden, available resources, and maximum impact per dollar invested. To be sure, it would be preferable if these nations had the resources necessary to provide for the basic health needs of their populations; however, as that is not the case, there is utility in using analysis of cost-effectiveness to guide decision making. In the past decade, considerable work has been done to measure the burden of disease due to specific conditions and to predict the distribution of these diseasespecific burdens over the next several decades [3]. These studies have largely made use of the newly created metric of disability-adjusted life years (DALYs). This metric is designed to weigh and cumulate the burden imposed by premature death plus years lived with disabilities due to the diseases and conditions considered. In 1990, the burden due to infectious diseases (which accounted for the majority of DALYs at the time) was predicted to diminish and the burden due to noncommunicable illnesses was predicted to rise considerably, under the assumption that control of infectious diseases was both feasible and achievable. This scenario now seems overly optimistic. Although great advances have been made, these have not resulted in the control of infectious diseases. Rather, the spread of HIV infection (and, with it, tuberculosis) has continued, and, in developing countries, there has been growing resistance among tuberculosis, malaria, and common bacterial enteric and respiratory illnesses to commonly used drugs—a problem magnified by the failure to eliminate vaccine-preventable diseases by comprehensive and sustainable immunization programs in these settings [4]. In the current issue of Clinical Infectious Diseases, Hotez et al. [5] report on the results of a meeting, organized by the Disease Control Priorities Project (DCPP) team, that focused on tropical infectious diseases as part of a process of revising the original 1993 publication [2] in the light of new knowledge. Their report [5] highlights several key issues and indicates several points of departure from the earlier publication [2]. First, priorities for research and program implementation do not mirror disease burden (as measured in DALYs). Second, several new features are prominent on the world stage. These include the growing database provided by longitudinal demographic surveillance surveys conducted in different parts of the world (providing more accurate information on disease trends than has ever been available), the greater attention being paid to health by the world’s development banks, and the greater investment in research on tropical infectious diseases by both developed and developing countries. Third, the DCPP will consider the potential impact new knowledge can have and will also prioritize those research areas with the highest potential payoff. The report [5] classifies 13 diseases and conditions into 3 categories, as follows: diseases with effective control measures (Chagas disease, onchocerciasis, lymphatic filariasis, leprosy, and infectious causes of vision and hearing loss), diseases lacking effective control measures (dengue, leishmaniasis, and African trypanosomiasis), and widespread major infectious diseases for which