Self-contained health programs directed at infectious diseases such as HIV, TB, malaria have wrought miracles, saving lives and enhancing prosperity. But a new challenge is looming globally, as subtle as climate change.
No self-contained ‘vertical’ programs work for non-communicable disease: here we need health systems that span conditions and facilities, linking hospitals to general practice and community services for a wide variety of patients and conditions, from chronic heart disease to mental illness.
Investment in health systems that address these needs is necessary (though not sufficient) for enhancing future productivity.
Thomas Bollyky, a journalist with the Council on Foreign Affairs in Washington DC, has written a challenging essay in the latest issue of the council’s regular publication Foreign Affairs. Entitled ‘Health without Wealth’, he addresses what he terms “the worrying paradox of modern medical miracles”.
“For the first time in recorded history,” he states,
“Bacteria, viruses, and other infectious agents do not cause the majority of deaths or disabilities in any region of the world.” This infamy now belongs to chronic illness.
Bollyky takes an historical view of how the vast improvements of the past century in health occurred, seeing “government-mandated measures—such as milk pasteurization, laws against overcrowded tenements, and investments in clean water and sewage treatment systems—and better social norms around hygiene, childcare, and girls’ education.” as the infrastructure on which control of communicable diseases was built in America and Europe.
By these means half of the improvement in life expectancy in developing countries between World War II and 1970 was due, Bollyky claims, not to antibiotics and immunization, but to education, sanitation, and improved local oversight of public health playing large roles.
These public health measures had a strong relationship with prosperity. They occurred because governments invested in water and sewers and much else. In return, a healthier workforce contributed to prosperity.
Big cities, the engines of innovation and achievement, became increasingly affluent because of rising productivity and were able to complete the circle of public health investment leading to societal economic benefit.
But with rising life expectancy due to programs addressing, say, malaria and HIV and child immunisation, latter-day prosperity has failed to materialise. Often paid for by outside agencies they do not automatically lead to greater productivity or expansion of the local health services. Rather than community-wide health uplift, vertical programs addressing specific illnesses often using drugs to good effect (think HIV) have succeeded in saving lives. But if those lives cannot find a job, then what?
The ‘what’ appears to be unemployment and poverty, leading to a rapid rise in frequency of chronic illnesses familiar to us in economically advanced nations such as Australia. Changes in food supply, increasing availability of tobacco, and housing shortages accrue and in that setting chronic disorders flourish and a new generation of peri-urban slums develop.
In Australia we enjoy the ability to treat these conditions and we have succeeded in pushing many of them into the senior years.
But think back to the 1950s and 60s when our therapeutic abilities were much less and where death from heart attack and stroke was common among middle aged men. That is how it is in many less economically developed nations now – a huge loss of productive workforce in middle age.
Bollyky states that deaths from hypertensive heart disease among people under 60 “have increased by nearly 50 percent in sub-Saharan Africa in the past 25 years. In 1990, heart disease, cancer, and other noncommunicable diseases caused about a quarter of deaths and disabilities in poor countries. By rising to 80 percent 2040.
The remedy, Bollyky suggests is a more comprehensive approach to aid, ensuring that investments help countries to improve their health-care systems, make their cities more livable, and that “enable their companies to employ more people more productively.” These are the social determinants of health and prosperity.
While our preventive approaches to chronic illness in Australia could do with more money, we can be thankful that we have health care that enables us to cope with chronic ailments, especially through general practice. We spend generously on health care for altruistic and economic reasons. We reap the benefits. But in less developed economies expenditure is lower and chronic illness flourishes untreated and affluence is scarce.
Many less developed nations spend about $30 per person on health care each year. “In comparison, the United Kingdom spends $3,800 per person on health care, and the United States spends $5,400.
“So great is the disparity that in 2014, the governments of all 48 sub-Saharan African countries together spent less on health care ($93 billion) than the government of Australia did ($95 billion).”
So while we consider what to do about our local concerns, there is room to advocate to even the most hard-headed financial conservatives that spending on health care and enjoying prosperity are two sides of the same coin. And this applies across the world as we face the era of chronic illness
Stephen Leeder is Emeritus Professor of Public and Community Medicine at University of Sydney