Global Health

Richard G. A. Feachem, CBE, PhD, DSc(Med)

Dean-Emeritus, London School of Hygiene and Tropical Medicine, and Senior Advisor, Human Development Department, The World Bank

I would like to pick up the story of global health and global population change, begun by Lincoln Chen. As he stated, the life expectancy picture that we have seen in recent decades has been quite remarkable. One way to think about where we are in human history is that in the beginning, there was high mortality and high fertility; and in the end, there will be low mortality and low fertility.

The interesting thing is that the beginning was quite recent, probably about 1800, and the end may be about 2050. The transition through which humankind is passing, from high mortality and fertility to low mortality and fertility, is occurring in this brief time span, and it is occurring more rapidly in the decade in which we are living and working than at any other time.

The changes in life expectancy in the world have been rapid in recent decades, and they have affected not only the more prosperous regions in the world—for example, the established market economies—but also the poorest regions of the world, where life expectancy has also increased greatly.

The region of the world with the poorest economic performance in recent decades, sub-Saharan Africa, has nonetheless gained greatly in life expectancy over the last four decades. Another way of putting this is that the life expectancy of humankind overall has increased more in the last 40 years than in the previous 4,000 years.

This rapid change in life expectancy and mortality is going on at the same time as a rapid change in fertility. Again, we are privileged and challenged to live in a period of human history when the rates are exceptional.

As recently as 1955, there were two worlds. There was a high-fertility world and a low-fertility world. Today, we no longer have two worlds. We have the gradation that Dr. Chen referred to. The low-fertility world has stayed low fertility, but the high-fertility world has broken up, with some



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2020 Vision: Health in the 21st Century Global Health Richard G. A. Feachem, CBE, PhD, DSc(Med) Dean-Emeritus, London School of Hygiene and Tropical Medicine, and Senior Advisor, Human Development Department, The World Bank I would like to pick up the story of global health and global population change, begun by Lincoln Chen. As he stated, the life expectancy picture that we have seen in recent decades has been quite remarkable. One way to think about where we are in human history is that in the beginning, there was high mortality and high fertility; and in the end, there will be low mortality and low fertility. The interesting thing is that the beginning was quite recent, probably about 1800, and the end may be about 2050. The transition through which humankind is passing, from high mortality and fertility to low mortality and fertility, is occurring in this brief time span, and it is occurring more rapidly in the decade in which we are living and working than at any other time. The changes in life expectancy in the world have been rapid in recent decades, and they have affected not only the more prosperous regions in the world—for example, the established market economies—but also the poorest regions of the world, where life expectancy has also increased greatly. The region of the world with the poorest economic performance in recent decades, sub-Saharan Africa, has nonetheless gained greatly in life expectancy over the last four decades. Another way of putting this is that the life expectancy of humankind overall has increased more in the last 40 years than in the previous 4,000 years. This rapid change in life expectancy and mortality is going on at the same time as a rapid change in fertility. Again, we are privileged and challenged to live in a period of human history when the rates are exceptional. As recently as 1955, there were two worlds. There was a high-fertility world and a low-fertility world. Today, we no longer have two worlds. We have the gradation that Dr. Chen referred to. The low-fertility world has stayed low fertility, but the high-fertility world has broken up, with some

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2020 Vision: Health in the 21st Century regions, such as China, coming very close to the low-fertility world of the more wealthy countries and all regions except one showing remarkable declines in fertility. The one exception is sub-Saharan Africa, but fertility rates in Africa have now begun to decline. Changes in life expectancy are obviously brought about by changes in particular age-specific, cause-specific mortality rates. As you are aware, the greatest engine of life expectancy increase is infant and child mortality decrease. In 1960 there were many countries in which more than 17.5 percent of the children born alive never reached the age of five. Today there are fewer and the very highest infant and child mortality patterns have become primarily an African phenomenon. Clearly, the challenges remain great, the inequities remain very large, and there is absolutely no room for complacency. As we think of those challenges, of the dramatic progress made in the last four decades, and of the progress that still needs to be made in the decades leading up to 2020, we first have to remind ourselves that the major influences on population health are not health professionals and do not lie within the mandate of the health sector. This is a sobering thought. Those of us who work in health and the health sector need to bear in mind that the levers in our hands are not the most powerful ones. The most powerful levers are four. First, reduction of poverty at the national level, the community level, the family level, and the individual level has been and will continue to be the greatest engine for health improvement and for fertility reduction. Second, improvements in education will go hand-in-hand with that, particularly for girls' education. Despite a decade of giving lip service to the education of women, disparities around the world between the education of boys and girls remain wide. Third, fertility decline will make an important contribution to the improvement of health, and the improvement of health will make an important contribution to fertility decline. Last, there is the environment—not those aspects of the environment that the green movements in this country and elsewhere like to emphasize. Not air pollution, global warming, the ozone layer, or biodiversity. In health terms, these are trivial. I refer here to the domestic environment—the water supply, sanitation, indoor air pollution, and drainage in and around homes—because these things have a large influence on the health of the majority of the world's population. As they improve, so will health improve. Now, curiously enough, when a team of people gathered in 1991 and 1992 at the World Bank to write what became the 1993 World Development Report entitled Investment in Health, they discovered to their amazement that there was no map of mortality for the world. When I talk about a map of mortality for the world, I mean a disciplined statement of cause of death by region, by gender, and by age. If you surveyed experts in various parts of the World Health Organization about particular causes of death, and you asked

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2020 Vision: Health in the 21st Century people dealing with diarrhea how many diarrhea deaths there were; people concerned with pneumonia how many pneumonia deaths there were; and people working on malaria how many malaria deaths there were, and so on, the figures would add up to about two times the total number of deaths in the world. For this reason, we set about to create a disciplined map of mortality in the world, which allowed only the true number of total deaths. The outcome for the developing countries in 1990—that is, all countries minus the OECD, was 39 million deaths. The unfinished agenda of childhood infections is represented by the second most common cause (pneumonia) and the fifth most common cause (diarrhea). However, the new agenda of noncommunicable diseases and injury is not something to worry about in a few years' time. It was with us in 1990, with cardiovascular disease in first place, cancers in third place, and injuries in fourth place. As many of you are aware, the use of mortality as a way to measure the health status of the population is unsatisfactory because it downplays causes of ill health that may be very important but that lead to low mortality. One of the most common causes of morbidity in the developing world—skin infections, which cause almost no mortality—does not show up on mortality statistics but nonetheless is important. Another example is mental illness. Therefore, a new measure was constructed—the DALY, the disability-adjusted life year, which combines morbidity with mortality and enables a burden of disease to be defined that can be used across age groups, across genders, and across causes. All causes of illness have been divided into three groups: Group 1 represents communicable and reproductive causes; Group 2 represents noncommunicable diseases; and Group 3 is injuries. In the younger age groups in which the burden of disease is high, the unfinished agenda—Group 1 causes—dominate the picture. In middle age, the Group 2 causes of morbidity and mortality become relatively more important. The exception is sub-Saharan Africa, where Group 1 remains the dominant cause of disease burden. In the older age group, not surprisingly, noncommunicable diseases constitute the major cause of disease burden. Injuries make an important contribution throughout, but with no very obvious linkage to overall burden or socioeconomic status. We can use the DALY as an outcome measure for cost-effectiveness analysis. We can be particularly excited about any intervention that will save a DALY, buy a DALY, or win a DALY for less than $100 expended. That has got to be a very attractive purchase. Fortunately, we have cost-effective interventions suitable for application even in low-income countries for the top causes of burden of disease for children. For adults, the situation is not so good. Yet—and this is key—having a highly cost-effective intervention and actually purchasing that intervention are two very different matters. For example, although cost-effective interventions are available for the top four contributors to burden among women aged 15–44 years, there is no country in which we are purchasing these interventions to the level indicated by the prevalence of the problems.

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2020 Vision: Health in the 21st Century We have the interventions, they are highly cost-effective, but we do not buy them. You can visit many low-income countries and find that while STDs are not being diagnosed and not being treated, despite the highly cost-effective nature of such interventions, at the same time, public moneys are being used in the capital cities, especially in teaching hospitals, to do, for example, open-heart surgery. We are spending public money on highly inefficient investments at the same time we are failing to purchase highly efficient investments. This is not only true of Ghana; it is also true of the United Kingdom, the United States, and all other countries. It represents a major challenge in the allocation of health resources, particularly public resources. This type of analysis will tend to set the agenda for the future. Relative burden will change through time: HIV/AIDS will rise in women, for example, and tuberculosis will increase in both sexes. The challenge is to keep a careful eye on the numbers and to develop better—more effective and more cost-effective—weapons against these particular causes of disease burden. Having gotten them, we must then actually purchase them. What are the challenges over the next three decades? Although we might have different lists, they will probably overlap. My list follows: First is closing the gap—the concept of equity between countries and equity within countries. In every low-income country today, there are subpopulations who enjoy a health status roughly similar to that in OECD countries. Yet other subpopulations have a health status that is orders of magnitude worse. Thus, closing gaps within countries can be a powerful motivator for politicians and communities and could also be a powerful approach for analysis. In my own country, the United Kingdom, the large gaps in health status between the folks who are disadvantaged and those who are not have at last become a matter of public debate. Second is resisting emerging infections. HIV/AIDS is the most important and widespread, but there are others, as we are well aware. These challenges are not going to go away; HIV/AIDS remains a rampant pandemic and is now spreading rapidly through Asia with no evidence that it is going to be attenuated by weapons currently in our possession. Third are the resurgent plagues, of which tuberculosis and malaria are the most salient. Fourth, we must confront the tobacco-related epidemic. A country such as the United States, where so much work has been done on tobacco-related ill health and so many public and private measures have been taken to attenuate this epidemic, must bear in mind that in most of the world, tobacco abuse rates in men are rising and tobacco abuse rates in women are increasing rapidly. Most low-income countries in the world have no discernible policy toward tobacco. You can visit country after country and find no government position on tobacco, no legislation, no use of price control, no use of effective public education campaigns. In most of the world, the epidemic of tobacco use has not peaked, and the epidemic of tobacco-related ill health will extend well into the next century.

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2020 Vision: Health in the 21st Century Fifth is preparing for the new agenda in the low-income countries of the world. Cardiovascular disease, diabetes, cancer, and injuries are already major problems and are becoming increasingly prominent, primarily because of the aging of the population. Now, let me make one or two comments about regional differences as we look toward 2020. In subdividing the world, we realize that we are not all on the same trajectory as far as health trends are concerned. it is interesting to look at countries that do much better or much worse than predicted by their income level. A striking outlier is China, which—as we well know—is an overachiever in health in relationship to its wealth. It is worth debating whether those achievements are robust and secure. In the United States, we worry about having 30 million uninsured people. The Chinese have over 700 million uninsured people whose medical expenses are out-of-pocket. There are doubts about maintenance of the essential public health and preventive services that put China in its strong position. Unless the right action is taken now, the special position that China occupies may not be sustained. Another outlier is the northern part of Central and Eastern Europe. Central and Eastern Europe in this definition includes all of the former Soviet Union and its satellites. Imagine a group of countries of which the most southerly is Hungary, the most easterly is Russia, and the most northerly are the Baltics. These countries are poor health performers in relation to their wealth. The story there is dramatic. In the late 1950s, Czechs and Slovaks were more healthy than Austrians in terms of life expectancy. By 1990, they had become much less healthy. There, male life expectancy had declined, whereas in Austria, male life expectancy had, as with the rest of the OECD countries, improved steadily, leaving a major life expectancy gap. That life expectancy gap did not occur because of the revolution of 1989–1990; it occurred during the last four decades of the Communist regime. This pattern is repeated throughout the subregion. Since the revolutions that occurred in the late 1980s and early 1990s, we have seen two distinct patterns. One pattern is that the gap between Eastern and Western Europe continues to grow wider because health conditions in the former Communist countries continue to decline and, in some cases, decline at an even greater rate. Contrasting patterns are found in the more successful reforming countries of the region; here, decline or stagnation has come to an end, and life expectancy has begun to increase, although the gap has not necessarily begun to close. What of the work of the World Bank in this changing scene? For all regions of the world, the Bank currently has a portfolio worth $8 billion, which is invested in 153 projects in 78 countries. Those 78 countries are spread across all regions of the world.

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2020 Vision: Health in the 21st Century In terms of the numbers of projects, they are highest in Africa, while the largest proportion of the $8 billion is invested in Latin America and the Caribbean. That commitment by the World Bank has grown very rapidly. Prior to about 1980, the Bank had very little activity in the health sector. The World Bank has become a major source of external finance for the health sector of low- and middle-income countries. Investing that money wisely, getting those investments right, and designing projects in the most appropriate way are incredibly important. The Bank will have to call increasingly on the international health community and the community of experts worldwide, including the United States, for guidance on how to target those large investments so that they have the most positive effects both on health and on the efficiency and equity of health services in borrowing countries. A dimension of this that cannot be avoided if one is speaking in this particular capital city is the IDA, the International Development Association. As some of you are aware, the loan and credit money provided by the World Bank is provided partly by IBRD, the International Bank for Reconstruction and Development, at near commercial interest rates, and partially by IDA, at zero percent interest with a 50-year repayment period—highly concessionary lending. The IDA window of the World Bank is accessible to any country that has a per capita GNP of less than about $865 per year. Sixty percent of the $8 billion in the Bank's current health portfolio comes from IDA. IDA, as you are aware, is threatened by current debates taking place in this city. The results of these debates will affect the pattern of World Bank support to health sectors around the world. The survival of IDA is essential for the Bank's ability to maintain a high level of assistance to the poorest countries, where of course the needs are undeniably the greatest. In conclusion, what of science? For a given level of national wealth—$5,000, or any other example—the amount of national health associated with it is far greater today than 100 years ago. It is far greater today even than 30 years ago and will be far greater in 2020 than it is today. It would be interesting to have a 3-day meeting of the IOM devoted entirely to debating the reasons for this pattern. The main reason, I suggest, is that, whereas 100 years ago we knew almost nothing about the etiology, prevention, treatment, and rehabilitation of disease, today we know an enormous amount. By 2020, we will know much more. In this environment of expanding knowledge, the behavior of individuals is affected. For example, people will wash their hands in ways they would not have thought of in 1870. This knowledge also affects the behavior of households and the behavior of communities. It affects the behavior of corporate entities, and it greatly affects the behavior of states and national governments and how they choose to spend the public dollars entrusted to them.

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2020 Vision: Health in the 21st Century It is this power—the knowledge environment generated by health science and by biomedical science—that has, in my view, been the main engine of health improvement in the 20th century. My conclusions are, in light of this and of the challenges ahead, medical science matters; public health science matters; you, the teachers and researchers in the biomedical area, matter; and the Institute of Medicine matters. Long may it prosper. DISCUSSION* PARTICIPANT: Could you expand on your comments on environmental risks? DR. FEACHEM: Are you referring to the Central and Eastern Europe story or speaking more broadly? PARTICIPANT: Both. DR. FEACHEM: Clearly, this is an ever-moving area of scientific knowledge. I think our impressions at the moment are that if we look globally, there is one subset of the environment that matters hugely and all other factors matter relatively little. The factors that are globally important are the domestic environment, water that is clean and plentiful near the home, removal of human waste from the home, indoor air pollution, and drainage. These things have a huge effect on global human health. Environmentalists who comment on Central and Eastern Europe like to believe that the environment, particularly air pollution, is a major cause of some of the negative health trends that I discussed, but the evidence is to the contrary. The evidence is that environmental factors are a minor cause of those health trends. That is an unpopular view in Central and Eastern Europe, because it is much more comfortable to believe that somebody else's problem, which causes the smoky chimneys that pollute the air I am forced to breathe, is responsible, rather than my body mass index of 35, my cigarette smoking, and my poor driving. PARTICIPANT: Can the World Bank do more to raise the profile of diseases such as diabetes in developing countries? DR. FEACHEM: Indeed, there is a debate going on at the World Bank, and between the Bank and its clients, about the health agenda over the next decade. With countries such as India the topic of noncommunicable diseases is clearly on the table. Among other client governments there is a variable degree of awareness of—and interest in—the noncommunicable diseases at this time. One of the roles the Bank can play, aided and abetted by expert *   Because of technical difficulties, the participants' questions had to be reconstructed; therefore, they are not verbatim.

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2020 Vision: Health in the 21st Century opinion such as that from the IOM, is to put these topics firmly on the table and include them in the debate so that some actions may follow. PARTICIPANT: Does the World Bank listen to the opinions of professionals and people at large, or only to the voice of governments? DR. FEACHEM: As you are aware, the Bank has a new, dynamic, and outward-looking president in James D. Wolfensohn. This is high on his agenda—to improve both the actuality and the perception of the Bank's interaction with all stakeholders in the health sector and other sectors in countries in which we are lenders. We have to deal formally with governments, but we are aware of and interested in broadening the debate to include all those able to contribute to our common goal of improved health and more equitable and efficient health services.