Diarrhea is the second leading cause of death for children under five globally — with pneumonia being the first — and kills approximately 1.6 million children under five each year. Eighty percent of these entirely preventable deaths occur in the poorer regions of South Asia and Africa. Although major efforts in delivering treatments and effective prevention campaigns have reduced the global impact of infant diarrheal death, many low-resource communities still face barriers to accessing low-cost, life-saving remedies for their sick children. According to the World Health Organization (WHO), only 39% of children afflicted with diarrhea receive the recommended, inexpensive treatments of fluid replacement, zinc supplementation, and continued feeding.

The diarrhea treatment plan outlined by UNICEF and WHO proposes two main solutions — fluid replacement and zinc supplementation — in addition to continued breastfeeding. The proven, standard treatment for fluid replacement is known as oral rehydration therapy (ORT), a solution of salts and sugars. WHO/UNICEF advocates for a reformulated version of ORT known as ORS, or low-osmolarity oral rehydration salts, which may be more effective overall in reducing the severity of diarrheal disease. Zinc also plays a vital role in decreasing the severity and duration of diarrhea, but how it works is still unclear. TIME calls zinc “the miracle mineral” in a December 2009 article profiling the profound affect that zinc has had on changing health outcomes and community perceptions about managing infant diarrhea.

WHO/UNICEF’s prevention strategy makes up the five remaining points of the seven-point plan, including “[1] rotavirus and measles vaccinations, [2] promotion of early and exclusive breastfeeding and vitamin A supplementation, [3] promotion of hand-washing with soap, [4] improved water supply quantity and quality, including treatment and safe storage of household water, and [5] community-wide sanitation promotion.” Nearly 90% of all diarrheal cases worldwide are attributable to unsanitary water and poor hygiene. Diarrhea is caused by a “wide range of pathogens, including viruses, bacteria, and protozoa.” While infrastructural changes may take a long time — and are much more out of an individual’s control — changes in behaviors and perceptions can go a long way in reducing susceptibility to these pathogens.

The impact of diarrhea is far-reaching and not yet under control. Only with concerted efforts that target both technical and behavioral improvements — water sanitation methods and hand-washing, for example — will the disease burden on developing countries begin to lift. If these improvements are made, communities and parents in the developing world, who were once resigned to the life-threatening illness, may begin to see how diarrheal disease can be managed and easily overcome. Parents can then begin to take control of their children’s health with relatively little cost and little effort.

[Editor’s note: This is a guest post written by Danielle Brown.]

“There is more money put into baldness drugs than into malaria,” said Bill Gates at the annual Technology, Entertainment, Design conference. To underscore his point Gates released a jar full of mosquitoes into the crowd, stating, “there is no reason that only poor people should have this experience [malaria].” He quickly assured the audience that those particular mosquitoes were not carrying malaria.

For many, especially the poor, malaria is a reality and a daily threat to their lives. Gates’ presentation pointed to the fact that malaria has been eradicated in developed nations but remains a problem for many equatorial countries. Approximately half of the world’s population is at risk of malaria, and it remains the single greatest killer of children living in lower-income countries. In 2006 alone, there were 247 million cases of malaria and 880,000 deaths. For a disease that is preventable and curable, these numbers are far too high.

Gates also raised an important question: How do you stop a deadly disease that is spread by mosquitoes? His response for prevention includes insecticide-impregnated bed nets and indoor residual spraying using the insecticide dichloro-diphenyl-trichloroethane (DDT). The two, used in combination, can cut deaths from malaria by 50%.

Despite this potential, the global response to this question is defined in part by a debate over the safety of DDT, framed by the Stockholm Convention on Persistent Organic Compounds and by WHO guidelines regarding use of DDT. The Stockholm Convention outlines a plan for the long-term elimination of the production and use of DDT by 2020, while granting DDT an exemption for use in public health. This exemption is conditional on whether alternative insecticides that are as cheap and effective as DDT exist. However, such alternatives are not readily available.

WHO now faces the double challenge of combating malaria while also upholding a commitment to reducing reliance on DDT. WHO proposes an eventual phase-out of DDT but expects that it will play a continued role in malaria control until effective alternatives are developed.

The organization Africa Fighting Malaria states that the current lack of investment from public and private sources for new public health insecticides makes the future of malaria eradication initiatives highly DDT-dependent. Despite efforts to find a vaccine against malaria, it will be difficult to phase-out DDT without phasing out this vital prevention aspect for people in need.

The EU, a Stockholm Convention signatory, recently passed regulations to limit the use of insecticides for agricultural use in the EU. With DDT banned as an agricultural product, remaining production would be on a smaller scale and at a higher price. Affected countries and international aid groups should consider the consequences of legislation regarding DDT and the potential to make DDT inaccessible and unaffordable for countries affected by malaria.

Don Roberts, a professor of tropical public health at the Uniformed Services University of the Health Sciences, recognizes this potential and urges a commitment to using DDT. He explains: “For years, the rich, developed nations that no longer have malaria have pressured tropical countries, which do, into giving up DDT. When countries stop using DDT, malaria spirals out of control.”

Given this trend, DDT should not be automatically discounted from discussions on prevention and eradication of malaria, but used effectively and with adequate precautions as part of a comprehensive strategy for malaria control. This includes, but is not limited to, usage of insecticide-treated bed nets, antimalarial drugs, environmental changes to destroy breeding grounds for mosquitoes, and strengthening health systems for public health. Although WHO encourages elimination of DDT by 2020, WHO also states that reductions in the use of DDT should be gradual and ensure that the level of transmission interruption is maintained.

DDT is not the only solution to eradicate malaria, but it should be part of a comprehensive plan to eradicate malaria with the same vigor that it was used to fight the disease in America and Europe. WHO states that every country in the world is now party to at least one human rights treaty that addresses health-related rights, including the Universal Declaration of Human Rights. Restricting access to this life-saving tool is a lost opportunity to impact child survival rates in the world’s poorest nations and to advocate for health as a human right. Phasing out DDT requires focus on integration and eventual elimination of the pesticide — not an abrupt halt. With more than 1 million people dying from malaria each year and over 2 million affected, considering safe and appropriate use of DDT merits attention.

The WHO Synergies group, which includes several FXB Center affiliates, examined the interactions between country health systems and global health initiatives (GHIs), also known as global public-private partnerships or global health partnerships. GHIs have become increasingly prominent players in the field of global health, particularly with respect to disease-specific treatment and eradication projects. Although GHIs have provided billions of dollars of funding for health projects and have led the way in responding to infectious disease epidemics, particularly HIV/AIDS and malaria, these initiatives have also been criticized for placing additional burdens on already weak country health systems and for introducing inefficiencies by duplicating functions already (nominally) provided by country health systems.

To take an in-depth look into the interactions between GHIs and country health systems, the Synergies group examined the results of 99 peer-reviewed reports, 122 non-peer-reviewed reports, and 15 original studies completed specifically for this assessment. Because of their prominence, the Global Fund to Fight AIDS, Tuberculosis and Malaria; the Global Alliance for Vaccines and Immunizations (GAVI); the US President’s Emergency Plan for AIDS Relief (PEPFAR); and the World Bank Multi-Country AIDS Program (MAP) were the focus of this study. The lengthy article covers issues related to health service delivery, financing, governance, health workforce, health information systems, and supply management systems.

Based on their literature review, the WHO Maximizing Positive Synergies Collaborative Group makes five recommendations:

1. Infuse the health systems strengthening agenda with the sense of ambition and speed that has characterized the GHIs.
2. Extend the targets of GHIs and agree upon indicators for health systems strengthening.
3. Improve alignment of planning processes and resource allocations among GHIs and between GHIs and country health systems.
4. Generate more reliable data on the costs and benefits of strengthening health systems and gather evidence to inform additional and complimentary investments to those of GHIs.
5. Ensure a rise in national and global health financing and in more predictable financing to support the sustainable and equitable growth of health systems.

The Synergies group also provides a list of “action points” that, if adopted, have the potential to evaluate and improve the interactions between GHIs and country health systems.

One of the stated limitations of the article is that it focuses on the effects of GHI activities on country health systems and not vice versa. If global health practitioners are to make improvements in health by promoting favorable interactions between GHIs and country health systems, the negative effects of these interactions on GHIs must also be evaluated and addressed.

Once more data are available on the effects of GHIs on country health systems (and vice versa) and on the extent to which health is improved by interactions between GHIs and health systems, the global health community will have to revisit often-debated questions: What responsibilities do GHIs have concerning country health systems given that the mandates of many GHIs are focused on specific diseases? How big do improvements in health systems or general health indicators need to be for GHIs to divert resources from successful disease-specific programs? Or put another way, when are improvements in health systems or general health indicators small enough to justify decisions made by GHIs to NOT invest in strengthening health systems? What should be done when the priorities or policies of GHIs run counter to those of the countries in which they are working? Should the objectives of the GHIs – and indeed all vertical programs – be revised?

In addition to the 27-page report, Lancet devoted their June 20, 2009, podcast to a discussion of the WHO Maximizing Positive Synergies Collaborative Group. The podcast can be downloaded from the Lancet’s audio archive.