This is a joint post with Rachel Silverman, consultant and candidate for MPhil in Public Health at the University of Cambridge.

On Halloween, children and adults alike pay tribute to history’s most frightening fictional characters – monsters, witches, super-villains, and the list goes on. But one need not search under beds or deep in closets for spooks and scares. Many of the most terrifying Halloween archetypes have very real counterparts, with very real health consequences:

1.      Vampires: Dracula may have been from dark and dreary Transylvania, but the most perilous blood-suckers don’t shy away from sunnier climes. Malaria-carrying Anopheles mosquitos are primarily found in Sub-Saharan Africa and other equatorial regions, where they are responsible for between 655,000 and 1.2 million global malaria deaths each year (depending on who you ask). These vampire-esque buggers are also responsible for the continued spread of Dengue fever, west Nile virus, leishmaniasis, and yellow fever.

2.      Ghosts: In global health, everything old is new again – including, unfortunately, the ghosts of diseases from years past. Unfounded anti-vaccination panic has led to lagging vaccination rates in industrialized countries to below the levels required for herd immunity, enabling resurgent epidemics of entirely preventable childhood diseases. For example, MMR coverage in many United Kingdom regions plunged below 60% at the height of the autism-vaccination panic. Though vaccination rates have partially rebounded in the interim, most areas still remain below 95% coverage – the rough threshold necessary for a community to acquire measles herd immunity. Unsurprisingly, measles outbreaks are back in a big way, with over 2,000 cases recorded there in 2012 (see below). The UK is not alone (see CFR’s nifty interactive map) – large pertussis outbreaks have also been recorded across the US; mumps along the north-east corridor; and measles clusters throughout Western Europe and North America.


3.      Mutants: No, not the X-men or ninja turtles – think much, much smaller. Tiny mutant microbes may be small in stature, but acquired antibiotic resistance looms large as a global health threat. Years of misuse and poor adherence for previously effective tuberculosis drugs have caused a multi-drug resistant (MDR) and extensively-drug resistant (XDR) TB pandemic, complicating efforts to control and treat a common scourge. Similarly, the CDC recently classified “super gonorrhoea” as an “urgent” domestic threat, with a whopping 246,000 cases estimated for 2012. And if mutants aren’t scary enough on their own, perhaps a mutant-vampire cross-breed will inspire some fear – after years of aggressive vector control efforts, mosquitos are growing increasingly resistant to the most commonly used insecticides. Gulp.

4.      Zombies: While robust debate continues on the biological and epidemiological plausibility of a zombie apocalypse, the CDC’s Office of Zombie Preparedness knows that the threat of emerging infectious diseases is deadly serious (see below). Over the last decade, several virulent and deadly new pathogens have seen a rapid global spread, enabled in large part by global transport links and increasingly mobile populations. In early 2003, Severe Acute Respiratory Syndrome (SARS) spread from an isolated outbreak in China, eventually infecting almost 10,000 individuals in an estimated 37 countries. Although an aggressive containment and control effort eventually stemmed SARS’ dispersion, it came at great economic and human cost, estimated at 1,000 lives and $30-$100 billion in worldwide losses. More recently, the 2009 H1N1 ‘swine flu’ virus went global following an outbreak in Mexico, killing between 151,700 and 575,400 before eventually receding – despite a distinctly lackluster inter-governmental and health sector response. The apparently quick and effective response to this year’s new and highly lethal coronavirus (MERS-CoV) is encouraging, but far more robust funding is needed for continuing disease surveillance and outbreak management.

5.      Mummies: Beware casts and bandages: injuries now account for 11.2% of global DALYs. For some perspective, that’s more than malaria, HIV, and tuberculosis combined – a truly frightening statistic. Of particular concern are road injuries, which make up 27% of all injury-related DALYs and are the ninth leading cause of global death. The good news is that many injuries are preventable; helmets, seatbelts, airbags, traffic enforcement, speed limits, and many other interventions have been shown to successfully lower accidental injury rates. The bad news is that the preventable injury rate remains unacceptably high; for example, the WHO estimates that “every day, 1000 child deaths could be prevented by proven injury prevention measures.” Worse, injuries disproportionately affect children and young adults – all too often leading to premature death or lifelong disability.

6.      Fear itself: If FDR was indeed correct, we should be terrified: the global burden of anxiety disorders and other mental illnesses such as major depression and bipolar disorder is on the rise, cumulatively accounting for 7.4% of global DALYs in 2010. Since one generally cannot die from a mental illness (and the Global Burden of Disease considers self-harm as a distinct category), this figure suggests that widespread mental health morbidity is wreaking havoc on people’s quality of life worldwide. And despite effective treatments for many psychiatric disorders, mental illness frequently goes undiagnosed and unaddressed – among people suffering from severe mental illness, the WHO estimates that only about 20% in low- and middle-income countries and about 60% in high-income countries receive any treatment for their conditions.

Despite all these real-world scares, there’s no need to panic; while no rigorous evidence suggests that stakes or garlic are particularly efficacious, most global health monsters can be stopped with cheap and effective vaccines, prophylaxis, or remedies. Yet funding remains scarce for some of the most essential global health interventions, particularly as government and donor budgets face an increasingly austere budget environment. We hope this gentle “threat-down” serves as a gentle reminder that real people, including those of us in high-income countries, are unnecessarily facing real but preventable and treatable health scares. This Halloween, lets recommit to the fight against global health’s greatest demons – starting, of course, with a generous contribution to your friendly neighbourhood UNICEF ambassador.