SWBP: Solutions for the World's Biggest Problems
Chapter 17, Disease Control, by Dean T. Jamison,
of Harvard and UCSF.
Summary and Commentary
Future D.C. policy from D.C.?
The chapter emphasizes opportunities in S. Asia and sub-Saharan Africa, and builds on results of a project (the DCCP) that engaged over 350 authors and estimated the cost-effectiveness of 315 interventions, some of which are more attractive, others which are clearly lower priority. Addressing multiple problems with constrained budgets will require hard choices, he says.
He summarizes with 7 interventions that range from 30:1 to 10:1 in their cost-benefit ratios.
There has been great progress in recent history, but challenges remain. Progress has been uneven. Microbial threats evolve; and HIV is still a big deal.
Specifically, life-expectancy for low and middle-income countries averaged 44 years in 1960, whereas in 2002 it was 65. Not too shabby (progress). Mortality is a key emphasis in this chapter. And keeping people alive should be the highest policy priority. Some countries have lagged on this score. "There are continued high levels of inequality in health conditions within and between countries." But I would also add that quality of life, and what has been called gross national happiness, are the vital component. If people are happy, they'll be more motivated to keep others alive. More hopeful about the human condition, if we feel good about ourselves. I would surmise that every country has room for improvement, and there is a role for all of us in making an alive, healthy, happy world. Good nutrition and fitness and a positive attitude, with healthy relationships, including maybe pets, seems to be the basic prescription. Maybe every individual has their own recipe.
Challenges
1.Uneven progress
by place: in Africa, China, and with indigenous communities:
by age: under 5, adult
by disease: some problems are cheaper to solve than others
AIDS in Africa
But because of AIDS in sub-Saharan Africa, life-expectancies there, which were 40 in 1960, and 60 in 1990, went back down to 46 in 2002 (There's either a typo or a misunderstanding on pg. 297 (sub-Saharan Africa either lost 4 years or 14)).
Other regions, like Sierra Leone remain far behind, and the interior provinces of China lag behind the more advantaged coastal regions.
Indigenous populations, generally speaking, everywhere, have not joined the party, as well, so to speak. Technology diffusion, and education levels of the population are important factors in improved health, while income growth much less so.
Good News
Policies, he says, make a huge difference, and "today's tools for improving health are so powerful and inexpensive that health conditions can be reasonably good even in countries with low incomes." Cool.
Although health conditions in many countries remain unacceptably -and unnecessarily- poor, the outlook is good. Grief and misery could be said to be on the decline. Global inequality in health is declining faster than income inequality. That is to say, the world is becoming more equal, as regards health, toward the upper-end of life-expectancy. Highly effective and low-cost interventions financed by the public sector can improve welfare health and population health where the needs are greatest. (FYI: The average income is 7,880 dollars (2002) and the average human life expectancy at birth is 66.12 (2008 est.)).
I want to say, The graph of income distribution for humanity is here, and the graph of life expectancy for humanity is here. Health influences income, and income influences health; it's a virtuous spiral, and It can also be a vicious downward one, and the relationships can be mathematically defined, or maybe painted in broad strokes...But basically, the chapter just says Income growth is neither necessary nor sufficient for sustained improvements in health. Which is good, and a lot simpler for me :-)
To meet the MDG-4 (reducing under-5 mortality by 2015), treatments for diarrhea, pneumonia, TB, and malaria, in addition to immunizations, to reduce stillbirths and neonatal deaths, are all highly cost-effective. TB treatment stands out as the most cost-effective investments, for all ages, because of it's C:B (cost-benefit ratio) of 30:1. It is also has a "high level of financial risk protection," moderate systemic requirements, and a large size disease burden potentially averted. For an annual cost of 1B$, 1M adult deaths would be averted per year. Many countries need to get their butts in gear on the millenium development goals. Besides official national policy, I think every doctor should be a member of MSF (Doctors without borders), too. Any doctor that doesn't have his hands full already, I mean, which I imagine is probably a rarity. What is the global demand for doctors? Anyway, if the people lead, the leaders will follow. We should lead by example. But we should also lobby for effective policy. 23 countries had their under-5 mortality rates remain stagnant or increase between 1990-2001, while another 53 countries were less than half-speed to be on track to meet the goal (including China).
Some categories of progress:
Causes of childhood mortality
There's a table of 11 causes of under-5 mortality, with the numbers of neonatal (0-27 days) and 0-4 deaths. The causes are HIV/AIDS, diarrheal disease, measles, tetanus, malaria, respiratory infection and sepsis, low birth weight, birth asphyxia and trauma, congenital anomalies, injuries, and other. The total, worldwide, for 2001, was 13,874,000 (est., by the GBD [initialism for?]). Only 0.9% occurred in high-income countries. Half of under-5 deaths occur within the first 28 days of life, adding stillbirths to neonatal deaths. Email me if you want the specifics from the book (or on anything I write, anywhere, if you like).
So various categories are used to parse medical problems into: a) for each country, b) by age, c) by each disease/cause of death. I think the stats should be all online in a really accessible format. I bet they are.
Anyway,
There's a table in the book that lists the causes of death (age 5 and older, in low and middle-income countries), giving deaths in millions, and percentage of total, broken into 3 categories: injuries, noncommunicable diseases, and (communicable, maternal, perinatal, and nutritional conditions).
Injuries are 4.4M (11.6%), ncd's are 25.2M (66.7%), and the last one is 8.2M (21.7%). There were 37.8M deaths in 2001. Injuries are broken into road traffic accidents, suicides, and other (1.0, 0.7, and 2.7M, respectively). NCD's are cancers (4.9M/13%), diabetes (0.7M/1.9%), Ischaemic and hypertensive heart disease (6.5M/17.2%), Stroke (4.6, 12.2), COPD (2.4, 6.3), Other (6.1, 16.1). And then Communicables, etc. are broken into TB (1.5, 4.0), AIDS (2.2, 5.8), Respiratory Infections (1.5, 4.0), Maternal conditions (0.5, 1.3), and Other (2.5, 6.6).
This is really about reducing grief and misery while creating the conditions for happiness (survival and health). Unhealth and SID vicious (Sickness, Illness, Disease) also sustain poverty, and brake economic growth, to use more dour terminology. Like Kaiser says, Thrive! Like your car says, do Preventive Maintenance. Like my old high school said, Be a man for others. Like Spiderman says, Action is his reward. Anyway..
The chloroquine and sulfadoxine-pyramethamine (SP)-resistant malaria parasite is rapidly spreading, and the loss of these inexpensive, highly-effective, widely available drugs is leading to a rise of malaria mortality and morbidity in Africa. A high priority, the book says, is creating the rapid transition to effective new treatments like ACTs (artemisinin combination therapies). Also, insecticide treated bed nets, expanded use of intermittent preventive treatment for pregnant women, and indoor residual DDT sprayings are called for.
Also, for kids,
-immunizations need to be expanded,
-diarrhea and pneumonia treatments (simple, low-cost, highly-effective) need to be expanded, along with treatment for all childhood illness,
-ensured distribution of key micronutrients,
-and expansion of the use of packages of measures to prevent mother-to-child transmission of HIV.
2. Epidemiological transition
Dr. Jamison relates that the trend, the transition, is from the traditional scourges of infectious diseases and undernutrition to the major noncommunicable diseases (ncd's) and injury, as a consequence of fertility decline and population aging (I'm not sure I see the relation, exactly). The major ncd's are circulatory system diseases/cvd, cancers, and major psychiatric disorders. Road-traffic injuries are increasing, and replacing "traditional forms of injury" (like a fiddler falling off a roof?). Noncommunicable diseases account for 2/3 of all deaths in low and middle income countries. 22% of deaths, though, are still from infection, undernutrition, and maternal conditions. This is called a "dual burden." The challenge is to respond to them with constrained resources (has the overall health burden become more expensive?).
A good chart with the numbers for all causes of disease, by country income, is in the chapter.
Here's a salient fact:
The public health research and policy community has been surprisingly silent about the epidemics of CVD (cardiovascular disease), cancers, psychiatric disorders, and automobile-related injuries, despite their killing over twice as many people in 2001 as AIDS, malaria, and TB combined (in low and middle-income countries).
Smoking is a risk factor for multiple NCDs. See my article on smoking.
-CVD results in over a quarter of low/middle-income country deaths (about 13M deaths/yr).
The risk factors for CVD collectively account for 78% of these countries' deaths. These risk factors are high blood pressure, high cholesterol, smoking, obesity, excessive alcohol use, physical inactivity, and low fruit and vegetable intake. Efforts to change most of these, at the population level, have had little success. (What works, though? Let's do that
).
But the tobacco front has seen favorable development. Many promising approaches remain to be tried, the author says, which will require systematic efforts to evaluate. Developing other ones might be important, too. All the risk factors need aggressive experimentation, and dynamic policy measures/effort. Systematic efforts are required to acquire hard knowledge about which approaches work and which do not, so that unsuccessful efforts will be discontinued, and successful ones expanded.
The world spends x dollars/year on tobacco products. Think what that could do if spent on health, like food or cookbooks or cleats or jumpropes or dumbells or gym memberships or even bicycles.
Individuals at high risk of a heart attack or stroke, such as those who have already experienced a cardiovascular event, have the option of taking cost-effective pharmaceutical interventions for hypertension and high cholesterol which can reduce CVD risks by 50% or more (even in the absence of behavior changes).
Aside:
Healthcare personnel and systems, in addition, can use improvement, in low/middle-income countries. Well, in high-income countries, too, but the author adopts the approach for developing countries, the focus of the chapter, of the model of strengthening systems by creating specific capacity to deliver priority services in volume and with high quality, in which capacity strength spreads to other areas from high-performing initial nodes. Love of life, respect for life, the desire to be healthy, a culture that encourages healthy living, is the prerequisite. Then, good hospitals for when the preventive maintenance, etc. isn't enough.
3. HIV
Successes and control efforts have been real, but with few exceptions limited to upper middle-income and high-income countries. Poorer countries have been mostly screwed, and remain in dire straits (The sultan of swing wants his mtv). AIDS deaths are often associated with excruciating pain. And by the numbers, with the possible exceptions of the use of nuclear weapons in densely populated areas or a devastating global episode like the 1917-18 influenza pandemic, HIV-AIDS devastation is the greatest threat to development for dozens of countries around the world, including several of the most populous. Thailand and Uganda are examples of success in countries with fewer financial resources, against more established epidemics. Of upper middle-income countries, Brazil and Mexico successfully forestalled potentially serious epidemics. Mexico, in particular, is singled out for responding early and forcefully. Although unfortunately development assistance was slow in coming, the Global Fund (to fight AIDS, TB, and Malaria) had initial years of substantial success. R&D, both public and private, made rapid progress, however, although a vaccine or cure has not been found (this 2007 book says. Is there one yet? I guess I would know, probably).
-The prevention record has been dismal. Little has been spent, and little achieved. Fewer than 1 in 5 high-risk people by even 2003 had access to even the most basic preventive services. There is plenty of blame, including for the US administration that discouraged condom use and stigmatized and alienated commercial sex workers.
-As the absence of STI's (sexually transmitted infections) greatly reduces transmission of HIV, treatment of them is a high priority, in addition to deserving treatment in their own right.
-Medically inappropriate restrictions on the use of inexpensive but powerful opiates for pain control continue to deny dignity and comfort to millions of patients with AIDS and cancer in their final months.
-Antiretroviral treatments, over a dozen of them, though originally costly, are feasible, at least in principle, for effective use in low-income settings now, due to scientific advances. Challenges to this are formidable, however. Substantial resources could be diverted from prevention or other healthcare high-payoff activities, and a false sense of complacency has led to increased risky behavior and increased HIV transmission. Interruption of drug supplies and low adherence are also problems. Systematic effort to study which approaches work or do not requires variation in approach and careful evaluation, to prevent needless deaths from not halting ineffective programs or giving resources to effective ones. Evaluate. Also, the cheapest possible drugs are often used, risking problems with toxicity and resistance. In Jamison's view, widespread adoption needs to be carefully sequenced, and only with a benefit-cost ratio greater than 1, because other highly attractive health investments exist.
So, for HIV/AIDS, the answers are a)condoms/needle exchange/other preventive services, b)std treatment, c)opiates, and d)ART (anti retroviral treatments), in ways that work, and with profitable b:c ratios, properly sequenced.
In Conclusion
The 7 big investments he recommends are
1.TB, appropriate case-finding and treatment..............B:C is 30:1
2.Heart attacks, acute mgmt. with low cost drugs........B:C is 25:1
3.Malaria, prevention and treatment............................20:1
4.Childhood diseases, expanded immunization coverage.......20:1
5.Cancer, heart disease, tobacco taxation......................20:1
6.HIV, prevention..............................................12:1
7.surgical capacity at district hospital (injury, difficult childbirth, other)...10:1
