Richard Smith: Learning at a meeting on global health

Richard SmithEarlier this week I attended a meeting at the Royal College of Physicians of Edinburgh on global health to beat my drum on the importance of non-communicable disease (NCD). Others were there to beat other global health drums, and I tried to learn all that I could from them. My main learning was that there is lots of scope for us to learn from each other and that we need better ways of doing so.

I’d like to see more of the taxes I pay devoted to helping the poorest people in the world. I feel uncomfortable with the obscene global inequities. North America has 30% of the global health work force, but 2% of the global health burden, whereas Africa has 25% of the burden and 1% of the workforce. The UK spends $3609 per head on healthcare, while in Tanzania it’s $37. But not everybody frets about global inequity, and we have to keep up arguments for supporting global health.

Humanitarian and justice arguments are not enough, and David Heymann from Chatham House gave us other reasons, perhaps the most powerful being the need to protect ourselves from global pandemics of influenza, SARS, and whatever comes next. Investments in global health, like the money spent to eradicate smallpox, are cost effective for the world, including rich countries.

Another economic argument is that global health activities can minimise the negative impact of health problems on economies, reducing the need for rich countries to bail out poorer ones and preserving their customers. Finally, Heyman said that global health could provide solidarity in battles with global public health adversaries like the tobacco industry.

From Joy Lawn from the London School of Hygiene and Tropical Medicine I learnt that stillbirth is a much more neglected problem than NCD. I knew that the Lancet had a special issue on stillbirths, but I hadn’t got round to reading it. Lawn told us that there are 2.6m stillbirths a year, with 98% occurring in low and middle income countries and 55% in rural families. The figures, Lawn explained, are inexact because there different definitions of stillbirth and many countries don’t keep data. The problem has this been hidden and seems to remain hidden despite the Lancet issue and the massive media coverage it received.  Richard Horton, editor of the Lancet, received many letters from people around the world who had experienced a stillbirth in the family, and Lawn said how a stillbirth may mean “20 years of grief tinged with guilt.”

Half of babies stillborn are alive when labour begins, and labour complications are the biggest cause (although amazingly 200 000 stillbirths a year are caused by syphilis). Improving access to Caesarean section makes most difference in reducing stillbirths, and non-doctors can do them. Stillbirths are a problem in rich countries as well, and 30% of stillbirths in Britain are the result of suboptimal care; 50% are unexplained.

What I learnt for my work is that next time I’m asked about priorities in global health I’ll make sure that I mention stillbirths.

Trying to reduce deaths from malaria goes back to long before the term global health was coined, and Brian Greenwood from the London School of Hygiene and Tropical medicine asked “Malaria: are we winning?” His summary answer was yes but only just and that with any let up in trying to counter the disease it could bounce back with a vengeance. Greenwood’s biggest fear is that political and financial commitment many fade after the 2015 target date for the Millennium Development Goals.

Financial commitment to malaria programmes and research increased from low millions of dollars at the end of the 20th century to billions now. In 1997 Greenwood couldn’t find 50 African scientists working on malaria, but now there are hundreds.

Malaria activists worry that political and financial attention might shift to new agendas, including perhaps NCD. Those of us in the NCD ghetto have never expected the kind of dramatic increase in funding that AIDS, TB, and malaria experienced with the creation of the Global Fund. Luckily much can be done about NCD with minimal resources, through political and public health action, but funding will inevitably be needed for clinical programmes, the lifelong treatment that is needed in responding to NCD, and the research in low and middle income countries that is badly needed.

We don’t like to think that we are competing for political attention and finance, both of which are limited, but we are. We need perhaps to concentrate on developments—for example, in health systems—that can benefit all the global health communities. Shared learning will thus be essential.

Those who focus on reducing child deaths also have their own MDG (unlike us NCD folk), and, said, Mickey Chopra from UNICEF, we need to save another 3.5m child deaths in the next two years to achieve the target of halving child deaths.  Many countries have achieved the target, but, said Chopra, progress is too slow.

One important reason for the slow progress is inequity. What Chopra called “the tyranny of averages” can hide the fact that some groups are doing extremely badly. Twenty three countries that have halved child deaths have widening inequity, sometimes meaning no improvement for the poorest.  New technologies are always likely to increase inequity because they benefit the better off first. But there are countries—like Niger—that despite very unfavourable conditions have both halved child deaths and reduced inequity.

UNICEF is now putting an emphasis on reducing inequity, and one of the tools it is using goes under the sexy name of “Marginal budgeting for bottlenecks.” This recognises that there are many steps necessary for providing a service to a group, and there may be fall off at each step, meaning that what is finally delivered may provide no benefit and even do harm.

Bottleneck analysis starts with “availability.” Are drugs, vaccines, supplies, and health workers available? Next is “accessibility.  Are the drugs accessible to local communities, or must they pay? Are staff actually present in remote clinics? Often not. Then there is “utilisation.” Do people come to the clinics? Chopra described clinics in the Congo with staff but no patients.  People may not come because they have to work or for cultural reasons. Finally, what about “quality?” People might, for example, be vaccinated with dirty needles and suffer harm.

I’d never heard of bottleneck analysis, but clearly it is very relevant to services for people with NCD. I’ve tracked down the original document and will share it with my colleagues.

Conferences are rightly criticised for consuming carbon, wasting time, and generating hot air rather than action, but there will surely always be a place for face to face meetings—and maybe conferences with a wide agenda are ultimately more valuable than those with a narrow focus especially if they promote learning across boundaries.

Competing interests: RS spoke at the meeting and had his expenses paid. He travelled first class on the train, but a combination of booking well in advance and his senior railcard meant that this was much cheaper than an open standard class return. He was given free wine and an indifferent piece of quiche on the train. He’s a fellow of the Royal College of Physicians of Edinburgh and an enthusiast for all things Scottish,  particularly whisky and his wife.