Viral hepatitis is a major cause of global mortality, yet the MDGs don't mention it at all. Photograph: Graham Turner for the Guardian
With mortality rates comparable to HIV/Aids, TB and malaria, is it time the global health community addressed viral hepatitis with the urgency it needs?
Guardian Professional, Friday 9 August 2013 06.02 EDT
In December 2012 the global burden of disease project released its mortality data for 2010. It reported that viral hepatitis caused 1,445,000 deaths. This compares with 1,465,000 from HIV/Aids, 1,196,000 from TB and 1,169,000 from malaria. And this is not some new phenomenon suddenly emerging from nowhere.
Viral hepatitis mortality in 1990 was just under 1m. Given those figures and the relative profile and priority of the diseases, it is clear that a major cause of global mortality has been consistently overlooked and neglected. For example, hepatitis does not feature in the MDGs, despite its prevalence in many developing countries in Asia and Africa. Nor are treatment and prevention programmes financed though the global fund.
Before people living with hepatitis took action in 2008 there was not a single person in the WHO with 'hepatitis' in their job title. How was that possible in the face of such a global burden?
There has been some recent progress in persuading governments to develop national hepatitis strategies, andadopting the 2010 WHO resolution.
Prior to 2008 no-one had looked at viral hepatitis, not least because the viruses that cause it are different, making messaging complex, and because they cut across many parts of a health ministry; for example immunisation, HIV, food and water safety, blood safety, injection safety and cancer. Yet in a world increasingly sceptical of vertical programmes, this is an advantage because a comprehensive hepatitis policy looks much more like a programme to strengthen the whole health system. Equally, because most of these areas will have their own programmes, any hepatitis programme will need to be integrated, leveraging existing infrastructure.
A WHO global policy report on prevention and control of viral hepatitis in member states, published on 28 July, over half the countries that reported having a national hepatitis strategy said it was integrated into other areas.
This is particularly pertinent in the case of HIV where there are overlapping populations and risk factors. On top of that, about 10% of those with HIV also have chronic hepatitis B and 3 to 4m (10-15%) with hepatitis C. What is the point of investing billions of dollars to prevent people dying of HIV/Aids only to let them die of liver disease? Hepatitis co-infection is now part of Unitaid's 2013-16 strategic plan.
The historic neglect of viral hepatitis was also the key reason that the 2010 resolution was adopted. Although there were only six official WHO days at the time, there are so many semi-official ones like World Cancer Day that there was initial reluctance to adopt World Hepatitis Day. However, countries were persuaded that viral hepatitis was an exceptional case as in no other area was the difference between the size of the problem (enormous) and the level of awareness (negligible) so great.
However, since the adoption of the resolution in 2010 the global health landscape has shifted and this has required hepatitis advocacy to move too. Just as hepatitis was getting recognition as the fourth major communicable disease, attention started to focus on non-communicable diseases.
But this too is an opportunity: viral hepatitis is responsible for 78% of primary liver cancer and liver cancer is globally the fifth most important cause of cancer mortality in men (first in Africa) and sixth in women (third in Africa) so hepatitis prevention and control is also a significant contributor to cancer and hence non-communicable disease prevention and control.
Advocacy is working and viral hepatitis is on the agenda for the world health assembly in 2014. A new, far stronger resolution is likely. But one of the biggest challenges lies just ahead. The post-2015 sustainable development goals are under discussion. If HIV/Aids, TB and malaria are included, for example as indicators in the health goal, but viral hepatitis is not, it will be a huge setback.
The omission of viral hepatitis from all major global health initiatives to date has massively impeded the flow of resources. Getting hepatitis into the post-2015 goals should be easy if HIV/Aids is there – indeed advocating for hepatitis generally should be easy – because the new global burden of disease numbers speak for themselves. But it isn't. Too much of health prioritisation is decided by what one might call fashion and so often fashion is about timing. Hepatitis has never been in fashion. Maybe finally the time is right.