IN 1900, average life expectancy in America was barely 40 years, and in Japan it was even shorter. Today it is 77 and 81, respectively, in the two countries, largely because infants and young children are much more likely to survive.
This dramatic improvement was largely unrelated to direct investments in health or the discovery of high-tech magic bullets. Measles, typhoid and tuberculosis deaths in America declined before there was a vaccine to prevent measles or effective anti-microbial therapy for typhoid or tuberculosis.
Everyone benefited from improvements in public health - better nutrition, which drastically increases resistance to serious infections; better living and safer working conditions, with improved ventilation; clean water and effective sanitation, which virtually eliminate the risk of waterborne diseases such as typhoid; and isolation and quarantine of infected patients and their contacts..
Immunization has provided additional protection from measles, tetanus, diphtheria, pertussis (whooping cough), polio and other infections. But vaccines require a stable, functioning health delivery system. For maximum benefit, immunization needs to be added on top of basic societal standards of adequate nutrition, housing, hygiene and sanitation.
Security and political will are essential to health. A concerted global effort eradicated smallpox, once a dreaded, naturally occurring infection with high mortality and, to this day, no effective treatment. Polio, on the other hand, for all the wrong reasons is still with us. Eradicated from the Americas 10 years ago, the number of cases worldwide had declined from 350,000 in 1988 to fewer than 2,000 in 2002 - by an astounding 99 percent.
But last year the fundamentalist Muslim governor of Nigeria's Kano state halted all polio immunization efforts because of alleged (and unsubstantiated) claims that it was part of a plot to sterilize Muslim girls. By the time he relented, polio had spread to 12 African countries that had been freed of the disease, dramatically setting back global eradication efforts and forcing the rest of the world to continue vaccination programs.
In general, health and longevity were improving nearly everywhere by the mid-1980s. Some 80 percent of African children were receiving routine childhood immunizations, and both child and maternal health were benefiting from birth spacing, fewer unintended pregnancies (therefore, fewer maternal deaths), more widespread breast-feeding and better maternal nutrition and education.
In contrast, the past decade has been a global health disaster. While the health indices of high-income countries continue to improve, these have dramatically worsened in much of the rest of the world. Fewer than half of Africa's children presently receive basic childhood immunizations. Russian men lost five years of life expectancy following the break-up of the Soviet Union, partly from a collapse of basic health services, and partly from deteriorating living conditions and a growing use of tobacco and alcohol, much of it the result of insecurity and uncertainty.
HIV/AIDS has already had a disastrous impact on many populations, particularly in sub-Saharan Africa, where it has disproportionately affected the already scarce educated and professional classes. This has fed political instability, curtailment of human rights and a further breakdown in societal security.
Women (and secondarily their children) have suffered from rape, trafficking and the loss of educational opportunities, family planning services, prenatal care and trained midwives. Maternal deaths in industrialized countries are 13 per 100,000 live births. Rates in sub-Saharan Africa and some south Asian populations are 50- to 100-fold higher.
Loss of women's rights is particularly egregious. In Africa, young girls are frequently coerced into sex with HIV-infected men. In southeast Asia, where HIV is increasingly spread by intravenous drug use, trafficking of young girls has become an economic mainstay. As forced sex workers become infected, they in turn spread the virus to their clients and relations.
Strong political leadership and investment in HIV prevention can be effective. Thailand and Uganda have reduced the rate of new infections by openly educating the public and making barrier protection, particularly condoms, widely known, acceptable and available. The potential benefits of some outside investments, like the United States' President's Emergency Plan for AIDS Relief, however well intended, are undermined by the conditions attached to them.