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None of them had to die
Yesterday, 24,000 people worldwide could have been saved with basic care.
he same number could have been saved the day before, and the day before that. In all, over the last year, 8.8 million lives were lost needlessly to preventable diseases, infections, and childbirth complications.
The number of deaths is so vast, so unthinkable, that it seems to make sense only between the covers of a report by the World Health Organization, which issued the estimate. Perhaps it helps to note that the figure is roughly the population of New York City, or the population of Massachusetts, New Hampshire, and Maine combined.
But what makes the number real is to see someone die, and to know that this man, woman, or child would have survived in the United States or in much of the world.
The Globe undertook to become witness to some of these deaths. Only as a witness could we tell the stories of people who were dying by the thousands -- of how they died and why, and how they could have been saved if there had not been such maddening barriers to simple health care.
For several weeks last fall, eight reporters and photographers traveled around the world -- to Cambodia, Malawi, Russia, Guatemala, and Zambia. They found obstacles to health care that could be overcome. The people they met could have lived.
If only the 1-year-old boy in Guatemala hadn't missed two vaccinations that would have protected him against pneumonia.
If only a midwife had been available to stop the bleeding of a first-time expectant mother in Cambodia.
If only a father in Malawi had not gone days without being seen by a nurse, a fatal error committed by a depleted and demoralized hospital staff.
Each death a tragedy -- and an outrage.
"What we need to do is take this complex problem and simplify it into what are the basic barriers to improvement," said Bill Foege, a leading global health figure and adviser to Microsoft founder Bill Gates, a major health care philanthropist. "You bring it down to two things: No. 1, we don't apply what we know. You can take anybody on a global health team, set them any place in Africa, and they will do OK."
The second major barrier is poverty. "If you force me to live on a dollar a day in that African village, I couldn't afford the firewood to boil the water," he said. "I couldn't afford to put screens on the doors to keep out mosquitoes."
Foege and other specialists said those obstacles cannot be surmounted all at once, but rather a bit at a time -- like mountain climbers attacking a peak in stages, establishing base camps, and then moving on.
"It doesn't take that much to get immunizations to kids," Foege said. "It takes outside help. We still haven't figured out how to get enough condoms to Africa, and a world that can't get enough condoms to Africa, well, there is just something wrong with us."
If attempts at improving the health of the poor had always been dismal failures, then the situation today could be written off as hopeless. But public health efforts have had many moments of quiet glory, in the rich and poor nations. In the United States, malaria was widespread in the 1800s. By 1940, it was virtually eliminated. In the early part of the 20th century, smallpox had killed millions of people. But by the mid-1970s a determined band of experts, led by Foege and others, succeeded in systemically eradicating it -- a mobilization that stands today on par with putting a man on the moon, though the smallpox campaign had the additional benefit of saving millions of lives.
And on the heels of smallpox eradication, health workers decided to expand childhood vaccinations to the poorest parts of the world, with dramatic success. From 1977 to 1990, the number of children vaccinated increased from 5 percent to 75 percent, a difference calculated to have saved at least 3 million lives a year. And today, an effort to eradicate polio is nearing its final stage, down to what organizers hope are the last few thousand cases.
But in the last decade or more, a time period coinciding with the rise of the great pandemic of AIDS, the efforts to save lives in many poorer countries have begun to noticeably slip.
Some of that has to do with AIDS' destructive impact on entire health systems, specialists say. Some of it also is because organizations lost their enthusiasm for long-term, low-profile campaigns such as the vaccination push. Some groups, such as UNICEF, shifted their focus away from vaccinations, and donors cut funds. The result was that in the 1990s many poor countries have seen a major fall-off in coverage of children.
Today half the world receives good health care, while the other half doesn't.
Of the half-million women who die in pregnancy or while giving birth, 99 percent are from poor countries. Of the 5 million babies who die in the first month of their lives, 98 percent are from poor countries. In the developed world, a woman's risk of dying in pregnancy or during childbirth is 1 in 1,800; in some poor countries, the risk is 1 in 7.
There are no shortages of pronouncements from the United Nations on poverty and health for all. There seem to be more heads of state every week saying that the world needs to do more to stop the spread of AIDS.
But after the WHO Commission on Macroeconomics and Health issued its findings on the vast numbers of preventable deaths over a year ago, then gave detailed prescriptions on how to attack the issues, little outcry ensued. Perhaps, some panel members suggested, the problems seemed too great to solve.
Yet the WHO panel concluded that the way to save lives in the future is not dependent on discoveries today. It's more about getting tetanus shots for children; training more midwives; providing safe drinking water to more villages; and a few dozen other measures that most Americans take for granted. The report stated that the way to save lives is to implement good ideas and spend more money on health care in poor countries. The commission calculated that of the 17.7 million people who die every year from infectious diseases and maternal and perinatal conditions -- about 48,000 a day -- half could be saved.
"We can't have one part of the world dying at extraordinary rates while the rich countries are sailing off on their own," said Jeffrey D. Sachs, the chairman of the WHO commission. "Directly addressing the public health disasters in poor countries is a critical step in ending the spiral of decline, impoverishment, and instability in those countries."
But even in countries with political leadership committed to improving health systems, many officials acknowledge they cannot absorb major infusions of assistance immediately.
"I don't think we're prepared to get the money yet," Anne Conroy, an adviser to Vice President Justin Malewezi, said last year after Malawi's government was told it would not receive the first part of a $200 million grant until later this year. "Our capacity constraints are enormous. People are overwhelmed."
This special section launches an extended effort by the Globe on the humanitarian challenge of world health, the struggle of people to stay alive, and the solutions that are within reach.
Health experts say any solution will require Americans and others in the developed world to view health as a basic human right, not just a luxury for those who can afford it. Foege also worries that Americans "never really are making eye contact with people who are ill and suffering."
This section provides eye contact -- disturbing as it is -- with the dying: Rebecca Makwenda in Malawi; Franklin Veliz in Guatemala; Sath Yan in Cambodia; and Nikolai Bogdanov in Russia. Behind each of them are the stories of thousands more.
"You have to suddenly wonder," Foege said, " 'What if I were in that position? What if that were my child? What if that were my wife? What would I do?' "