May 20

Kyle Poplin

Weekly Roundup: It’s a New World in Global Health … If You Act On the Old Study

Remember the Global Burden of Disease study? That 25-year, quarter-billion-dollar, 1,000-scientist effort to catalog death and disability in nearly 200 countries? Well, it’s still out there and relevant, even though not every country’s bought in.

The countries that are buying in, however, have reaped huge rewards.

That’s the message of Jeremy N. Smith, who’s studied the study and written a book about it, “Epic Measures: One Doctor. Seven Billion Patients.” He gave a presentation on Monday at the University of Michigan’s Institute for Healthcare Policy and Innovation, and made a compelling case that countries should use the study to set priorities.

“If you don’t know what people are dying from,” he asked, “how do you save lives?”

Accurate health care numbers have long been hard to come by. Smith talked about organizations that take singular aim at maladies like AIDS, malaria, lung disease, breast cancer – “hugely important groups doing wonderful, valuable, lifesaving work every day,” he said – and have historically had the dual functions of advocating and measuring. Their advocacy, Smith said, tends to skew their numbers. How badly?

In the 1980s the global health community was focused on childhood ailments, he said, and the World Health Organization (WHO) included separate groups – all in the same building but working independently – studying diarrhea, pneumonia, malaria and measles. One day a scientist took the time to add up the deaths reported by the four groups, and the total was 10 million more than the total number of childhood deaths around the world that year. In other words, Smith said, “The world’s leading authority on global health had invented 10 million extra dying children.”

Meanwhile, by 1990, he said, tuberculosis was killing about 2.5 million people a year, making it “the AIDS of its time.” But because TB primarily affected adults, and the global health community was still focused on children, only one person at WHO worked solely on TB. Around that time, the Institute of Medicine in Washington, D.C., surveyed its members, asking them to rank diseases in terms of priority: highest, medium and lowest. The members didn’t deem TB worthy of even the lowest priority, but listed leprosy in the highest category. In 1990, Smith said, “You could literally miss the leading infectious disease killer.”

The landscape eventually changed and TB became a global priority, but “the issue with that kind of response is you’re always going to be a generation or two behind the problem you’re trying to solve,” he said.

Prioritization issues are still prevalent. Two-thirds of today’s deaths in developing countries are from chronic and lifestyle ailments like heart disease, diabetes and obesity. But, according to Smith, only 1.2 percent of all medical aid money is targeted at those diseases.

What happens when health officials choose to use new evidence and measures? Smith cites Mexico, Australia and Rwanda as examples.

Mexico’s minister of health was so interested in the Global Burden of Disease study that he organized one specifically for his country in 2000. It showed that Mexico’s health system had been built for the 1950s, when children were dying mainly of infectious diseases and women were having lots of kids and often dying in childbirth. By 2000, those diseases had largely been tamed and women were having fewer children, with better outcomes. Instead, chronic diseases topped the death charts, and about 50 million Mexicans were excluded from health care because they weren’t insured. The minister of health had the data to make a compelling case to Mexico’s lawmakers, and within a few years the country implemented universal health care.

Then there’s Australia. Two generations ago, life expectancy there paralleled the U.S. – basically in the middle of the pack among the world’s approximately 40 “wealthy” nations. Then Australia commissioned a country-specific Global Burden of Disease study, took specific action targeted at the disease patterns discovered, and now Australia’s life expectancy is among the best in the world. The U.S., meanwhile, slipped to near last place.

And in Rwanda, Smith said, officials took a look at the original Global Burden of Disease study and were shocked to find that indoor air pollution was much more deadly than previously assumed; even more deadly than the lack of sanitation. The problem, Smith said, was widespread use of old-style cookstoves, which were basically equivalent to entire households smoking cigarettes all day, every day. The government took action, swapping out 1 million dirty cookstoves for cleaner-burning versions.

The Global Burden of Disease study is far from perfect. Besides the fact that it’s impossible to define and measure health – with factors like education, housing and employment to consider – the available data, no matter how comprehensive the effort, remains spotty. For instance, Smith said, 50 million people will die this year around the planet, but only one in three will have a death certificate.

Still, he’s excited about the huge leap the study represents. In 1990, he said, people viewed the global health landscape in much the same way as they viewed the map of the world in 1491, before Columbus’s journey: “You had people kind of out there in different places, sort of courtiers and spies, with whispers and rumors about what’s going on. And we’re going to a place where we actually have all the continents on one map (in global health), and they’re somewhat the right size and you can see what one country is relative to another, one place is relative to another.”

What’s more, he said, change can happen in a hurry, like it did in New York City. Life expectancy is 10 years longer in NYC today than it was a generation ago. In fact, if the rest of the U.S. had seen a similar uptick, it would be the planet’s runaway leader in life expectancy. Why the turnaround in the Big Apple? Smith said it was due to “nanny state” policies like limits on smoking, labeling calories, watching soda sizes and the effort to “zero out” traffic deaths. They were all seen as “ridiculous, silly, stupid policies that could never catch on” … yet they not only caught on in NYC, but around the country. Smith lives in Montana, where 10 years ago it was legal to drink and drive, and now it’s illegal to smoke inside public places. “Policies can become the status quo very quickly,” he said.

It’s long been assumed, Smith said, that “if you’re rich you live, if you’re poor you die.” And while wealth remains a big driver of disparity, it’s comforting to know that money alone doesn’t buy health. It can sometimes be as simple as paying attention to, and acting on, the information available only a few computer clicks away.

– Kyle Poplin

Photo courtesy of the Institute for Health Metrics and Evaluation


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