March 3, 2014—It is a commonplace that wealthy, industrialized countries have seen dramatic gains in health and longevity over the last 200 or 300 years. More recently, a group of middle-income nations known as “the four Cs”—Chile, China, Costa Rica and Cuba—have also enjoyed considerable increases. Yet with Millennium Development Goals’ deadline swiftly approaching, our less affluent neighbors have been left behind. How can we help the rest of the world catch up?
Dean Linda P. Fried addresses the audience at Columbia's Low Library
This question was the focus of a February 19 event hosted by the Mailman School and Columbia University that brought together economists and global health experts to discuss the Lancet Commission Report, Global Health 2035, a bold strategy to close the health gap between rich and poor countries within a generation.
Speaking before a packed house at Columbia’s Low Library, Linda P. Fried, MD, MPH, Dean of the Mailman School, praised the report, observing that its emphasis on health equity and support for universal health coverage mesh with the track record and aspirations of the Mailman School. To realize these shared goals, “academia needs to assume a more central role in the global health architecture.” This could be realized in part through the School’s new Better Health Systems Initiative, which will develop scholarship and offer training for global policymakers around the Global 2035 objectives, particularly strengthening health systems and implementing universal health coverage. (Read more about the Mailman School initiative here.)
Several Lancet Commission authors addressed other aspects of the report.
Margaret Kruk, MD, MPH, who will direct the new Mailman School program, spoke to the importance of a “pro-poor” approach. Universal health coverage doesn’t guarantee that the most vulnerable will benefit, said Dr. Kruk, assistant professor of Health Policy and Management at the Mailman School. Instead, as countries get richer, improvements in services and insurance “tend to flow to the wealthy.” For this reason, it is important to invest in high-quality clinics accessible to the poor and make essential services available at no cost.
Global Health 2035 authors, left to right: Dean Jamison, Margaret Kruk, and Gavin Yamey
Funding to boost global health equity—what the report terms the “grand convergence”—would largely be generated through in-country taxes, including on tobacco, alcohol, and sugar-sweetened beverages, and by removing fossil fuel subsidies. Supplementing this is outside investment of approximately $70 billion per year. According to Gavin Yamey, MD, associate professor of Epidemiology and Biostatistics at UCSF School of Medicine, these investments are safe. “This isn’t some kind of risky venture capitalism.” By investing in health, countries like Rwanda and Ecuador saw their child mortality rates drop by 40% or more in just a decade. If successful, the 2035 plan would avert 10 million deaths annually by its target year.
Using an accounting method that combines growth in GDP with the intrinsic value of living longer, the Lancet Commission calculated that every dollar spent to raise the status of low- and middle-income countries would return between $9 and $20. “I can’t think of anything vaguely similar that has such an amazing return when it comes to human development,” Yamey observed.
Intellectual Roots of Global 2035
The origins of the Global Health 2035 report go back to 1993 when the World Bank first looked at global health issues through the lens of economic policy. Prior to their 1993 report, health was seen as a consumer good rather than a factor in economic growth, reflected Tim Evans, DPhil, director of Health, Nutrition, and Population at the World Bank. The report shifted the paradigm, creating a “fundamental important and incredibly landmark opportunity not only for the world but also within the World Bank.”
Dean Jamison, PhD, emeritus professor of the University of Washington, who authored both reports with the well-known Harvard economist Laurence Summers, PhD, said much has changed in the 20 intervening years. Economic progress has transformed a mostly low-income world population into a middle-income population. As a result countries are now “increasingly able to finance the health systems needed to serve the purposes of ‘grand convergence.’”
Perspectives on Policy and Research
Two panel discussions moderated by Richard Besser, chief health and medical editor for ABC News, brought new voices to the conversation.
In a dialog on global health policy, Nils Daulaire, MD, MPH, assistant secretary for global affairs at the U.S. Department of Health and Human Services, called Global Health 2035 a kind of grand unified theory. “It brings together issues that I have not seen well articulated into a single framework covering the [reproductive, maternal, newborn and child health] arena, non-communicable diseases, healthcare financing, systems, and governance. And in that context it does an enormous service in helping us to see through a set of changes.”
Moderator Richard E. Besser, ABC News
Mona Kaidbey, deputy director at the United Nations Population Fund, asserted that the vulnerable populations like adolescent girls must be central to thinking about Global Health 2035. “The face of universal health coverage goals should be the face of young people, particularly young adolescent girls.” Unintended adolescent pregnancies are a major challenge for human and economic development, Kaidbey added.
One hurdle could be repressive governments and social unrest. Simon Bland, director of UNAIDS New York Office, said to make changes in these companies we should look to how the HIV/AIDS group ACT UP mobilized in the 1980s and 1990s.
Wafaa El-Sadr, MD, MPH, director of ICAP and the Global Health Initiative at the Mailman School, agreed, saying it is critical that global policymakers and researchers are responsive to local conditions and partner with community advocates who can push for change. “They are the people that are going to drive the locomotive; they are the people that are going to drive the agenda; they are going to push for quality; they are going to push for coverage; they’re going to push for funding.”
Money isn’t the only barrier to health, Thomas O’Connell, MBA, MsC, senior health specialist at UNICEF, added. Cultural mores also matter. In Vietnam, boys are much more likely to be vaccinated than girls. In Nigeria, giving birth at a clinic can go against tradition. What is needed, he said, is research to seize on the success stories and translate them into plans that other countries can emulate.
For Besser, a commensurate effort must also be applied to improving communications. The moderator suggested that the term “grand convergence” brought to mind traffic merging into the Lincoln Tunnel, not the reduction of health disparities. “If you want to talk to the general public and capture people’s hearts around these really important issues,” he said, “I would make sure that some of the research is around communications. You need the public behind this if you want to get the resources accomplish this.”
At the end of the day there was broad consensus that the Lancet Commission report makes a convincing case that global health equity is within reach and provides a way to get there. When the Mailman School’s new Better Health Systems program formally begins to scrutinize the way forward for developing nations, additional attention will be brought to bear on the health equity issues. Importantly, noted Dean Fried, the report is helping reframe health as a public good that we need to invest in. “That investment will have a huge return for the wellbeing of individuals and communities and their families.”
Watch video of the February 19 event: