We stayed at a hotel in Florida a little while ago. It was next to a forested lot with a canal surrounded by a high chain link fence. One day as we left the hotel, my boys asked if there were alligators in the forest next door. We responded that we hadn’t seen any, but it was possible. My husband (who is a wonderful father and very protective) said that because of the potential threat of alligators, he didn’t want our two year old daughter running around unattended. I reminded him that before she could get over to the fenced in, forested lot with a canal and possible alligators, she would have to get through the parking lot, where she was far more likely to be hit by a car. So yes, we needed to watch her, but cars were a more pressing danger than alligators.
This isn’t to say that I’m not concerned about alligators or don’t think we need to take precautions against them, it’s just that I’m concerned about cars in this scenario. Are there other situations where I would be more concerned about alligators than cars? Yes. If we were camping in a place where alligators live and there was a pond nearby and especially if it were alligator mating season, you bet I would be concerned about alligators, probably even more so than parking lots.
A Hierarchy of Causes of Death
I would like to propose that causes of death in developing nations are the same way. There is a hierarchy of causes of death. (Granted, this is an oversimplified hierarchy, but there's a framework here.) At the bottom, you have death from widespread, ongoing conflict in a region or nation. This is when you have atrocities going on, lack of rule of law in a nation, warfare, starvation used as a weapon by dictators, etc. People are basically wondering if they are going to live through another day. That's Level 1.
In this state of mind, you think only about what is going to get you through another day. Disease, infant and maternal mortality and malnutrition are not going to be as high of priorities because the most immediate cause of death is someone trying to kill you as part of a genocide or political purge. Whether your child has enough calcium in his diet, who will deliver your baby and even HIV and polio aren’t going to matter if you can’t escape a genocide or purge.
Once the problem of conflict is solved and you’re not worrying about your village being brutally razed to the ground, you start worry about whether you will have enough food, water, and shelter. In this state of mind, you are starting to think in terms of living years rather than days. Things like malnutrition become a concern and having a permanent dwelling. That's Level 2.
But you’re still not going to be as concerned about things like infectious diseases because if you can’t get enough to eat or a house that shelters you from the elements, it won’t matter if you’ve been immunized for a disease or can get an emergency c-section. If you can’t get enough to eat or enough nutrients these things will be non-issues because rickets, pellagra, encephalopathy or severe dehydration will kill or injure you anyway. If you’re pregnant, you may die from pregnancy complications before you can even reach delivery.
Now let’s say that a majority (>75%) of your country can solve this problem. At this point you’re ready to start worrying about things like infectious diseases. Now we’re thinking in terms of living decades instead of years. This is where we might start adding in some programs to expand education. We’re no longer worried about our village getting brutally destroyed and we have enough to eat and have shelter. When those things are taken care of, diseases are what will most likely kill us. That's Level 3.
Now, let’s say that we’ve got most infectious diseases under control. Now we’re going to worry about chronic diseases like cancer, heart disease and diabetes. That's Level 4 at the top of the pyramid.
Side note: At this point in our narrative, disease control is going to take on a new level complication though with antibiotic resistance, newly emerging diseases and newly emerging strains will start to hit the scene. Then vaccine escape mechanisms, waning immunity and gaps in coverage. This can loop us back around because HIV and antibiotic resistance are big problems in developing nations as well. So this is kind of an issue that feeds back into level three with developing nations (as I said, oversimplified, but a framework nonetheless). But putting that aside for a minute, when you have good healthcare facilities and low morbidity and mortality from diseases, then you see people starting die to from chronic diseases. Suicide may also come up as a big problem here too.
People are dying. What does a hierarchy of causes of death do? Shouldn't we just help in any way?
Well, in an increasingly connected world, we have started setting worldwide goals for health. But not everybody in the world is at the same stage. Take Sudan for example. Sudan met the criteria for polio elimination in 2004…until wild poliovirus was found circulating through certain regions. Genetic sequencing of the virus revealed that it had been circulating for three years, even while Sudan was declared to have an adequate disease surveillance system. What’s wrong with this picture?
Sudan was in the middle of one of the most brutal conflicts in the world at this time (and continues). People feared for their lives on a daily basis and many fled to refugee camps. When this level of violence is present on a widespread basis, people don’t stop to think about whether their child’s summer cold might be polio and any doctors who are left in the area are dealing with massive casualties and unlikely to think about reporting polio. In my opinion, it’s naive to think that you’re going to get accurate reports about highly contagious infectious diseases when this level violence exists in a country on a daily basis.
Believe it or not, the risks of polio are actually less than the risks associated with the war in Sudan and its aftermath. According to the World Health Organization, polio leads to paralysis in 1 in 200 cases. (.5%). Of those paralytic cases, 5 to 10%. Sudan has been declared polio free since 2009 with the last cases being detected in 2008 (40) and 2009 (24). But the war in Sudan left 50,000 to 383,000 dead and 2.5 million children live with malnourishment, 700,000 in its most severe form. If we were to compare landmines and polio in their destructive capacity (not prevalence), some studies have found that landmines kill 31% of their victims and maim virtually any survivors. On a global scale, landmines exact a smaller death toll, but they are hundreds of times more deadly and more prone to maiming people than polio or a non-polio enterovirus.
So we come to a really hard issue: If we eradicate polio in a very conflict ridden place with persistent malnutrition/starvation or a high rate of waterborne illnesses have we really got something to celebrate? Because if war, starvation and waterborne illnesses persist in these areas, the death toll remains very high, even if we eliminate a single virus. I’m not offering any solutions or course of action here, because we need to eliminate diseases as well. (Remember, I want to keep my children safe from both cars and alligators.) But in our efforts to create global goals, do we sometimes address alligators when there is a parking lot that is closer?