A viral illness in Cambodia that killed scores of children this summer is a potent reminder that improving global health is not only a matter of measuring success against known diseases but also a constant battle to contain new ones and ensure that medications are safe.
As cheaper generic drugs or reduced prices on rich-world pharmaceuticals become more widely available, fighting diseases grows easier and more affordable. Yet at the same time, unregulated medications flooding international markets may be risky and more likely to be sold by unscrupulous producers and traffickers of fake or substandard drugs, risking the health of people in both well-off and poor countries.
Still another challenge in dealing with fast-spreading diseases is now evident in Cambodia. Where medications or doctors lay out of reach and health education is scant, especially in developing countries, families often turn to homegrown potions or local practitioners whose “prescriptions” can worsen an illness or delay people from seeking more professional help. Doctors in the steamy Cambodian capital, Phnom Penh, are telling reporters that parents from the countryside are often waiting too long to bring sick children to a city hospital and many are dying soon after being admitted.
On the positive side of the global health picture, there are signs of some success in progress toward reaching Millennium Development Goal 6: combating HIV/AIDS, malaria and other diseases. The latest data on the eight Millennium Goals from the 2012 report show for Goal 6, fewer people are being infected with the virus that causes AIDS. New infections in sub-Saharan Africa, the region most severely affected by the epidemic, were falling in 22 countries.
But — there is always a “but” when measuring the Millennium Goals — the number of infections is growing in Central Asia and the Caucasus region. Worldwide, 34 million people were estimated to be living with HIV in 2010, up 17 percent from 2001, even as new cases in many places have been dropping. On the positive side, the higher number of people living with HIV reflects those who are surviving longer because of antiretroviral drugs.
Beyond medicine, politics and prejudice can spoil the fight against HIV/AIDS, an independent commission reported to the United Nations on July 9, echoing American efforts in the UN to end discrimination and persecution of homosexual and other gender-vulnerable people in numerous countries as well as HIV-positive men and women in heterosexual relationships.
The report, “HIV and the Law: Risks, Rights and Health,” by the Global Commission on HIV and the Law, said that “punitive laws and human rights abuses are costing lives, wasting money and stifling the global AIDS responses.” The commission, supported by the UN Development Program as part of the Joint United Nations Program on HIV/AIDS, consists of former heads of state and leading legal, human rights and HIV experts.
The 2012 report on the Millennium Goals shows progress is being made against malaria in its various forms. “The estimated incidence of malaria globally has decreased by 17 percent since 2000, and malaria-specific mortality rates by 25 percent,” it said. The report added, however, that based on 2010 figures, this progress is still short of the level needed to be on track to meet the goal in full by the 2015 deadline.
The prevalence of tuberculosis and deaths from the disease are also decreasing, albeit slowly, the UN said. But the 2012 report noted: “Although increasing numbers of tuberculosis patients have access to high-quality treatment, more than one-third of new cases still go unreported and are not treated in DOTS [Directly Observed Treatment Short Course] programs.”
More than 84 percent of nearly 300,000 known cases of multidrug-resistant tuberculosis were not being treated according to international guidelines, the report also noted.
International guidelines and standards figure in the growing concern about health hazards in the global pharmaceutical business. Laurie Garrett, a senior fellow for global health at the Council on Foreign Relations in New York, recently compiled a statistics-packed report on what health experts view as a rapidly accelerating problem. The report, a policy memorandum for world leaders, titled “Ensuring the Safety and Integrity of the World’s Drug, Vaccine, and Medicines Supply,” used information accumulating in the World Health Organization and other relevant bodies. 
“Regulation and distribution systems to ensure access and protect public safety, where they exist, are outdated,” Garrett wrote. “And over the past decade all aspects of raw materials extraction, ingredients synthesis, formulation, packaging, and distribution have globalized to such an extent that nearly every pill, injection, and salve contains elements derived from multiple countries. The supply chain of production is compromised: hundreds of thousands of people are dying annually from false, poisonous, or substandard medicines.”
American drug producers now import 80 percent of their active pharmaceutical ingredients from foreign manufacturers, compared with nearly 100 percent domestic production 15 years ago, Garrett wrote. “Those ingredients are primarily made or processed by some ten thousand companies located in India and China, where regulatory lapses have often proven serious, even fatal.” Inert ingredients used in medications may also be harmful, she added.
Garrett’s research found that around the world, pharmacies and hospitals are discovering that more of their products each year contain no active ingredients or substandard concoctions. Drugs may be contaminated or deliberately faked by criminals to imitate legitimate medicines. “This is a crisis for the rich, emerging, and poor worlds alike,” she wrote.
“The World Health Organization estimates that counterfeiting, substandard formulation, contamination, fakery, and active ingredient substitution constitute a $431 billion market; 83.4 percent of that, or $359 billion, had direct public health impact,” Garrett said, adding that this is a 300 percent increase over such clinically dangerous sales in 2000.
She found that a 2009 study by the International Policy Network, a nonprofit group sharing information and educating policy makers on global issues, estimated that 700,000 people die annually from substandard treatments for tuberculosis and malaria alone.
Experience with malaria and other diseases shows that medical research can never stand still. In the outbreak of the virus that killed Cambodian children, doctors were hampered by the knowledge that there is no vaccine or treatment for the infection, which has been tentatively diagnosed as hand foot and mouth disease, common in infants and young children, the World Health Organization said.
The symptoms include fever, mouth sores and a rash with blisters on hands, feet and also buttocks. Two viruses can cause the disease, and the strain in Cambodia has been identified as enterovirus 71.  It is highly contagious and spreads from person to person “by direct contact with nose or throat discharges, saliva, fluid from blisters, or the stool of infected persons,” WHO said in reports on its Web site.
This article is the seventh in a series assessing the status of the Millennium Development Goals.
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Barbara Crossette is the senior consulting editor and writer for PassBlue and the United Nations correspondent for The Nation. She is also a member of the Council on Foreign Relations. She has also contributed to the Oxford Handbook on the United Nations.
Previously, Crossette was the UN bureau chief for The New York Times from 1994 to 2001 and previously its chief correspondent in Southeast Asia and South Asia. She is the author of “So Close to Heaven: The Vanishing Buddhist Kingdoms of the Himalayas,” “The Great Hill Stations of Asia” and a Foreign Policy Association study, “India Changes Course,” in the Foreign Policy Association’s “Great Decisions 2015.”
Crossette won the George Polk award for her coverage in India of the assassination of Rajiv Gandhi in 1991 and the 2010 Shorenstein Prize for her writing on Asia.
