In a feature for Now@NEJM, we ask the authors of the Global Health review article series — all with different backgrounds, experiences, and perspectives — the same set of questions.
Answers from Prabhat Jha, M.D., D.Phil., of the Center for Global Health Research, St. Michael’s Hospital and Dalla Lana School of Public Health, University of Toronto
Dr. Jha is a co-author of the January 2, 2014, article, “Global Effects of Smoking, of Quitting, and of Taxing Tobacco.”
What do you regard as the most significant triumph in global health within the past decade?
The right time frame for BIG changes in global health is not in years, but over 2-3 decades. Good news? Several:
First, in high-income countries, tobacco deaths in middle age have fallen by half or more. This in turn led to vascular mortality rates at ages 35-69 years in Canada falling by 75% since 1975. By contrast, tobacco deaths in low and middle-income countries are rising, mostly due to the lack of tax and non-tax interventions being used widely (Jha and Peto, Jan 2, 2014 NEJM).
Second, child mortality declines are impressive. Worldwide, the risk of dying before age 5 has fallen from 14% around 1970 to 9% around 1990 to about 5% in 2010. Still that means about 7 million child deaths a year (of which 1.5 million occur in India alone). Moreover, the costs of saving a child’s life are getting cheaper (Hum, eLife, 2012). Give real credit to the late Jim Grant from UNICEF who in the 1980s really pushed simple effective interventions to save kids.
Third, widespread use of secondary treatments for infectious disease has substantially altered the trajectory of HIV/AIDS (Piot and Quinn, NEJM 2013) and the expansion of artesunate combination therapies for childhood malaria has had a huge impact. The Affordable Medicines Facility–malaria (AmFm) is a novel financing mechanism to get good high quality drugs worldwide, and does so through a subsidy to private sector delivery (so as to crowd out fake drugs). Sadly, the Obama’s administration did not support the extension of AmFM and this might die a slowly. It should be revived, and indeed used as a model for other drugs.
In the coming decade, which arena of global health do you feel warrants increased attention and awareness?
While its getting cheaper and cheaper to save a kid’s life, the opposite is happening for adult mortality (Hum, eLife 2012). This is in part due to the big tobacco and HIV epidemics, but more generally to the lack of appropriate investment to make adult survival also “cheaper, faster, better.” Top of the list is of course tobacco, and Dean Jamison and Larry Summer’s (Lancet, 2013) recommended a big tax on tobacco as the top priority for global health — as did we (Jha and Peto, NEJM, 2014). Secondly, low cost secondary treatments for vascular disease are highly effective. A simple combination of blood pressure pills, aspirin and statins can reduce the risk of a middle aged person with existing vascular disease dropping dead from a heart attack or stroke or being hospitalized again from 1 in 2 over 10 years to 1 in 6.
Third, the world has started paying attention to direct measurement. Efforts such as the ongoing Indian Million Death Study (Westley, Nature, Dec 5, 2013) have shown the feasibility of low cost, direct evidence on the causes of death, risk factors, and the impact of interventions. This is a welcome alternative from indirect estimates such as the Global Burden of Disease, which rely on econometric models. GBD has actually estimates causes of death for 850 people based on one actual, representative death (Jha, BMC Med, 2014). This is bound to create serious errors. Thus direct measurement of the causes of death is needed.
How can we best harness the revolution in IT to improve health outcomes in the developing world?
IT is a means, not an end. The important things to think about are how low-cost, high impact public health prevention AND treatment approaches plus good measurement (the basic, historic recipe for good public health over the last 200 years) can be applied to a few BIG diseases. Then the use of IT should be thought to catalyze these public health strategies. It’s a mistake, as Bill Gates himself has pointed out to put too much stock in technology before the public health and clinical treatment strategies.
When American physicians think of global health, many are dissuaded from a global health career because they cannot spend a majority of their time abroad. What are other ways for physicians to contribute to this discipline?
The main engine of global health improvements over the last century has been knowledge and technology (broadly defined as drugs, diagnostics, interventions, strategies, epidemiological studies, etc). As Harold Varmus and colleagues point out in the Institute of Medicine Report on global health — these technologies can be produced worldwide and shared worldwide. Thus the old model of “travel medicine” should be thrown out in favour of a shared research and knowledge model. This means that young doctors, epidemiologists, economists and other disciplines can invest in global health careers, and that western Universities should encourage them to do so. But they need to be unafraid to ask big questions and ask what will really make a difference.We are fortunate to be living during an extraordinary time of global health progress. We can envision that in our lifetimes (including a middle-aged hack like me), we might get premature mortality in LMICs to look like that in Canada. The tools to do so are knowledge (lots) and money (lots, but less important than knowledge).