Christopher Exeter on the Global Burden of Disease study

c_exeterMid December saw the launch of the decennial Global Burden of Disease (GBD) study at the Royal Society in London.  The study is the global rating of mortality, morbidity, and disability.

The data tells a familiar story.

Where infection and malnutrition related illnesses were once the primary causes of death, these have now been replaced by death from heart disease, cancer and other chronic disorders. The disease burden is now increasingly defined by disability rather than premature death—with much of this now caused by musculoskeletal disorders, back and neck pain, injuries, and mental health conditions.  

Ensuring data quality, the need for greater comparability, improved systems for more accurate collection, and analysis, were considered particularly important in understanding the links between communicable and non communicable disease (NCDs).

There was a lengthy discussion on the risks to humans and these as expected centered on hypertension and tobacco. The full list of risks were presented and there was disagreement over whether the sheer number may be a distraction and there should be greater focus on the principal causes. On balance it was felt that for completeness the full risks needed to be known—and one of the major benefits of the GBD was that it offered the ability for evidence-based prioritisation. This was underlined by one speaker who referred to the islands of despair in the seas of joy; meaning whilst money going into specific diseases was important—others miss out. There is also not enough learning from the success of one therapy or intervention to another.

There was a feeling more needed to be done to deal with premature death in the under 5s.

The Institute of Health Metrics and Evaluation, based in Seattle, USA, will be providing country level data in 2013, which alongside health expenditure, will provide greater transparency and accountability for the public to challenge health services and politicians; understand the costs and where their money is going; and question why some systems are more successful than others.

The medical knowledge is clear, but what does the GBD data tell us in terms of the economic and policy response: the levers that will make the changes required to respond?

Firstly, as the data makes plain the world is indeed getting older. Between 1970-2010 life expectancy at birth has increased by 10.7 years for males and 12.6 years for females, explained due to decreasing mortality across every age group, although this is slower in young adults. One of medicine’s great successes of the twentieth century was to reduce the risk of premature death from infection. But conversely the “ageing population” is frequently blamed for increases in NCD. Fortunately, the GBD data puts the record straight: whilst NCDs are on the rise, it is chronic disease and disability in the 15-59 age group that are responsible for the biggest rise. The ageing population “problem” is nothing more than a failure of bureaucracies to respond to known facts by not putting in place adequate social care provision.

Secondly, NCDs are as much an economic problem as they are medical. The impact that NCDs have on established health systems and the threat they pose to establishing universal care in LMICs are well rehearsed. Economics and healthcare are strange bedfellows, frequently eyeing each other with suspicion, usually about costs.  There is a cost containment issue, but this doesn’t have to mean negative historic cutting (aka efficiency) instead properly organised economists, clinicians, and health leaders could do much more with the resources they have in the future (aka productivity) by examining the best ways of delivering healthcare.

Thirdly—and the overriding message of the day—was the need for greater prevention.  In many respects this is quite hackneyed, we all know it and, albeit with some limited successes, existing institutions have been pretty weak at making this a reality. Western systems for example are still geared towards the treatment of mass infection, not the prevention of chronic diseases. Indeed, as one speaker at the conference put it, despite knowing simple screening is effective, it is scandalous that hypertension is such a problem. Yet there is light on the horizon:  simple and widely available technologies, such as smartphone apps, can provide a potential solution to mass screening, which will help with prevention. However, how that data is managed, owned, and used to help populations by managing resources has yet to be successfully explored. A much more mature approach is required to promote prevention, and certainly not one that penalises people.

Finally, there is an important lesson in how the GBD was developed.  Much was made during the day of the international effort that took place to create the GBD. This is undoubtedly true, and all those involved should be congratulated. However, especial congratulations must go to the Institute of Health Metrics and Evaluation, for coordinating the GBD.  The leadership provided by the University of Washington is an example, like so many others, of the risk and investment US organisations are prepared to take. Sitting in London at the launch conference, one could not fail to reflect on how this contrasted sharply with the timidity and short-termism of the UK.

I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

Christopher Exeter is a senior fellow in the Division of Surgery at Imperial College London.  By background he is an economist and specializes in technology to prevent NCD.  He was previously a civil servant in the UK Government and prior to that worked in corporate finance for a city firm.