Throw it to the wall and hope it sticks!

caplanLast month I attended the Global Health Symposium: Ethics of compassion: Lessons from the Ebola Epidemic in West Africa with Dr. Art Caplan who is the Director of the Division of Medical Ethics at NYU Langone. He spoke on the ethics of compassion in relation to the recent outbreak, especially considering the choices and implications around experimental medications in emergency contexts. It brought forward a lively conversation around who should receive experimental medications first (priority setting) and when they should be used at all (resource allocation).

One of the specific experimental medications was called ZMapp which was manufactured by Mapp Biopharmaceutical, Inc., and given first to infected Americans.  It certainly looked bad that only three Westerners had gotten the drug while most of the people with Ebola are African, said Dr. Caplan.  He felt strongly that a scarce resource shouldn’t be given to whoever is best connected and he added that the drugmaker should clarify its policy.

Mapp Biopharmaceutical Inc., said in a brief online statement it had complied with every request for the drug that had the necessary legal and regulatory authorization.  The company said it provided the ZMapp at no cost in all cases.  Although it didn’t name any countries that requested the drug and didn’t release additional details.  Liberia’s president later said the U.S. planned to deliver sample doses of an “experimental serum” to Liberia later that week to treat Liberian doctors infected with Ebola.

How did the US Government and Mapp Biopharmaceuticals determine Liberia needed the sample doses instead of Guinea or Sierra Leone?  Were the total number of deaths a factor?  As of October 3, 2014, Liberia had 2069 deaths compared to Guinea with 739 and Sierra Leone with 623.  Although, Sierra Leone has had far more laboratory confirmed cases (2179) compared to Liberia (931) and Guinea (739).

Wouldn’t it make sense to send the experimental vaccine to a country that had more confirmed cases with less deaths?  Aren’t there more lives that could be saved in Sierra Leone?  Maybe the reasoning was that the Liberian healthcare system suffered a greater loss compared to the other countries. 

ebola-spreading-in-west-africa.htmlMaybe it was more of an economical determination.  Liberia’s GDP ($2.898 billion in 2103 est.) put it at 184 in comparison to the rest of the world.  Which is far behind number 155 in the world, Sierra Leone ($9.156 billion in 2013 est.), and even further behind number 151 in the world, Guinea (12.56 billion in 2013 est.).  So maybe Liberia with the greatest number of deaths and the weakest GDP made the “powers that be” determine that it was a country closest to collapsing and therefore needed the vaccine.

Dr. Caplan made the comment that when we are in a dire global health situation, such as the one in West Africa, countries should be “giving the stuff out and hope it works”.  In these types of situations, he related administering experimental medications to throwing spaghetti on the wall and hoping it sticks.  Either way, the US and Liberian governments, along with Mapp Biopharmaceutical, and other decision makers should be more transparent in their decision making process.  We have an opportunity to learn a great deal from this entire experience – an experience that is merely a warning of bigger events to come in the future.

The 2 P’s of Priority Setting

Are there ‘too many cooks’ in global health? In other parts of the world, perhaps there aren’t enough. In that vein, based on the perspectives of a political science expert, a ‘social constructionist,’ and a humanitarian/physician, here are the two P’s or “powers” that emerge in their independent discussions on priority setting in global health.

The first “P” in priority setting is the power of institutions. From eradicating polio to fighting Ebola, concerted efforts that are backed by or linked to a powerful organization has a greater potential to influence global health priorities. Jeremy Shiffman, broadly defines “institution” as the “rules, norms and strategies adopted by individuals operating within or across organizations.” He points out that many global health issues out there are endorsed by powerful institutions (e.g. the World Bank, United Nations) who are able to generate resources, implement programs, and that ultimately have negotiating power.

An example of the power of institutions can be observed in the recent press release on the World Bank’s commitment of $400 million to treat and contain Ebola. Using its institutional position, the Bank links the underlying factors of the Ebola crisis as a problem of unequal access to care and income inequality, while also reframing the Bank’s goal to eradicate extreme hunger and poverty by 2015.

This brings us to the second “P” in priority-setting, the power of framing. Given the limited bandwidth of politicians and the public, framing is a powerful tool. Reich, Shiffman, and Farmer allude to the importance of being able to strategically communicate your issue with your audience. A good rule of thumb in framing is suggested by Reich’s expectation of the political calculations involved–weighing the political benefits (feasible and visible) versus the political costs (slow to change, difficult to measure). Paul Farmer provides an interesting use of framing in his narrative about visiting Russian prisons where many young detainees were being left untreated for tuberculosis. Looking back, he had strategically framed his role going into the scenario as a physician, that enabled him and his colleagues to do more for the neglected rights of the prisoners than if they were to embark on their visit in the pure scope of human rights.

The powers of institutions and framing alone are not the only variables to consider in priority setting. However, they provide as important strategies for individuals and organizations in global health to consider in moving their agendas forward.

References:
1. Shiffman J. A social explanation for the rise and fall of global health issues. Bull World Health Organ. 2009 Aug;87(8):608-13.
2. Reich MR. The politics of agenda setting in international health: child health versus adult health in developing countries. J Int Dev. 1995 May-Jun;7(3):489-502.
3. Farmer P. Pathologies of power: rethinking health and human rights.  Am J Public Health. 1999 Oct;89(10):1486-96.

Why does the global health issue with fewer burdens receive the most U.S. global funding?

In the U.S. Global Health Budget Request for 2015, HIV/AIDS accounted for 54% of the total requested $8.1 billion (See Figure 2 Below). (Wexler and Kates, 2014) In addition, the Global Fund requested 17% of the total, which also provides assistance to HIV/AIDS efforts. In 2015, HIV/AIDS incidence has significantly decreased and prevalence has stabilized, so why does it receive the most funding when perhaps it is not the most pressing global health burden? For example, nutrition has only a request of 1%, and yet, malnutrition is possibly the biggest underlying cause of infectious diseases and child mortality globally. In addition, the rise of noncommunicable diseases is becoming the new global epidemic, and it is not even on the 2015 request. What has influenced this priority setting and resource allocation, so that the actual realities of public health burden are basically ignored?

Well, there isn’t a clear answer to this question, but I will offer some possibilities. In the Millennium Development Goals (MDGs), only three goals pertain to health: MDGs 4, 5, and 6. In MDG 6, the first disease mentioned to combat is HIV/AIDS, followed by malaria, and “other diseases” as vague as that is. (UN Millennium Development Goals) The MDGs were composed in 2000 when HIV/AIDS was a much greater global health burden and global security threat with individuals in less developed countries having less access to antiretroviral medications. In 2000, maternal and child mortality were significantly higher; these mortality rates remain a critical issue today, but have been greatly reduced, which is why maternal and child care should have been given a larger request than 9% in the 2015 U.S. budget request. (Wexler and Kates, 2014) It is definitely possible that the MDGs have shaped the budget request for 2015 and in past years because of the great demand to fulfill these goals by the end of 2015. It is also reasonable to guess that HIV/AIDS has received to more funding because it has had more traction throughout its history due to activists, celebrity support (ex. Magic Johnson, Elton John, Alicia Keys, etc.), and specialized funding and organizations such as PEPFAR and UNAIDS, and many more. I don’t think that there are many nutrition or noncommunicable disease activists, or if there are, they definitely don’t have as much ammunition as the people in the HIV/AIDS sector’s corner. Based on this information, there is a need for balance or “harmonization” as Jeremy Shiffman would argue within the U.S. Global Health Budget Request for 2015 between the actual realities of the global health burden that are pressing with the global burdens that are trendy and receive a lot of attention and support. (Shiffman, 2009) This balance can help ensure that global health burdens are reduced and new epidemics be maintained from becoming even larger scale issues.

8564-figure-2

References:

Wexler and Kates, 2014. http://kff.org/global-health-policy/issue-brief/the-u-s-global-health-budget-analysis-of-the-fiscal-year-2015-budget-request/

Millennium Development Goals. http://www.un.org/millenniumgoals/

Shiffman, 2009.  http://www.who.int/bulletin/volumes/87/8/08-060749/en/

Prioritizing Healthcare: Who Receives What, When and How Often?

Investing in healthcare is vital to human social, political and economic development, but how do we prioritize who receives what, when and how often? Priority setting in healthcare is a complex, arduous and often times expensive task for governments, practitioners and beneficiaries.

As the Millennium Development Goals (MDGs) are reaching their end in 2015, the focus is shifting to prioritizing Sustainable Development Goals (SDGs). There are many lessons learned from the last 15 years of working towards achieving the eight MDGs, the shortfalls and the successes, that are being taken into account when formulating the post-2015 agenda for the SDGs. The United Nations Conference on Sustainable Development held in 2012, named the Rio+20, began the process of developing, “action-oriented, concise, easy to communicate, limited in number, aspirational, global in nature, universally applicable to all countries while taking into account different national realities, capacities and levels of development and respecting national policies and priorities.” Well, this sounds great and all, but what does it really mean? How are the SDGs going to produce tangible results if the language of the framework is so wishy-washy?

This is where the Copenhagen Consensus Center comes into the picture. While the SDGs aim to be action-oriented, the Center takes a solutions-oriented approach, “In a world with limited budgets and attention spans, we need to find effective ways to do the most good for the most people”. As with healthcare, prioritizing the SDGs requires consensus on resource allocation, cost-benefit analysis, consideration of efficiency, effectiveness and equity of goods and services and the social, political and economic costs and consequences of implementation. The Rio+20 and the Center take an inclusive approach to prioritizing development issues, however, the Center utilizes evidence and economic analysis to rank international problems that need to be addressed. Understandably, the Copenhagen Consensus Center comes under fire from human rights critics who argue its data-driven approach fails to take into account the ethical aspects of those being most affected by the issues addressed.

However, given limited resources and time constraints, utilizing the Center’s approach for prioritizing exigent healthcare issues could address a greater number of issues and reach a larger portion of the population. The conclusion of the MDGs provides considerable evidence for prioritizing global health challenges in the short- and long-term and utilizing the Copenhagen Consensus Center’s evidence-based approach could prove useful for determining the most cost-effective and efficient global health agenda.

Why is that person healthier than that person?: the roles of acculturation and population health

Why are some people healthier than others? Some determinants lie within socio-economics and other health disparities. Current population health research is focused on the association among race, ethnicity, gender, finances, geography, and even now the theory of acculturation. Acculturation, from a health perspective, is when immigrants come to the United States and their health begins to deteriorate at a faster rate than their U.S. born racial and ethnic counterparts over a certain period of time. This issue of acculturation has been seen in various metabolic conditions such as hypertension, diabetes, obesity, etc. So why does this happen? Social stress for immigrants in a new environment? Lower income per household than in their previous country? Lack of access to decent healthcare? Lack of access to resources for a healthy diet? The socio-economic reasons and health disparities behind it are infinite. The key issue to keep in mind when looking at illness is to look at the illness as a whole and what contributes to it, not just the illness itself. That is why it also so important to acknowledge the population you are dealing with when treating a patient because there are so many other factors at play that are determinants of health. This concept is surprisingly not new. Although the “population health” term was coined in the 1980’s, Hippocrates was thinking and talking about it in Ancient Greece. In On Airs, Waters, and Places, Hippocrates clearly associated the relationship between environment and illness, and how this affects the population. Essentially, it is important to know your population when diagnosing the illness and identifying the health determinants as Hippocrates did. The theory of acculturation is a new and popular trend in research because it is a new way to think about population health and why socio-economics and health disparities play a role in illness. These ideas and questions can ultimately provide some insight into the inequalities of health, but also make us realize that there are extensive possibilities as to why these inequalities exist in the first place.

If Only Ebola Outbreak Originated in U.S.

Well, in a perfect world the Ebola virus would have never reared its ugly head. But ideally, the virus would have been contained at the outset and not spread to cause a global health threat. The virus, first discovered in 1976 in the Democratic Republic of Congo (back then Zaire…oh ineffectual governments, but more on that later), has been a mainstay in the headlines since the outbreak in West Africa earlier this year. As more African countries are imposing quarantines, travel bans and health testing upon entrance into certain countries, the question comes to mind, what would have happened had, say, an American tourist traveled to a remote rainforest and was bit by a fruit bat, contracted the virus and then returned home to Ohio?

_77694455_ebola_apUnfortunately, the virus is outpacing its containment and available treatments; increasing the probability it transitions from an epidemic to pandemic. I’m in Amartya Sen’s corner in wishing that the disease of poverty were communicable. Then, perhaps, maybe the response to the Ebola outbreak would have decreased the death toll. The spread of the virus is just another reminder of the inequity between the societal determinants of health throughout Africa and the U.S.

Let’s look at a snapshot of the countries most severely affected by the virus: Guinea, Sierra Leone and Liberia compared to the United States. The societal determinants of these countries play a large part in the high incidence of poverty and effectually their limited capability to handle the epidemic.

Let’s break this down a bit more…

  • Poverty: The percentage of the population living on less than $1/day in Guinea is 43.4% and 83.7% in Liberia. In the U.S. (poverty measured >$2 a day) was 1.2% in 2011
  • Health Access: In Sierra Leone, there are 0.2 physicians per 10,000 population and 24.2 physicians in the U.S.
  • Cultural behavior: Populations using improved sanitation as of 2011: Guinea 18%, Liberia 18%, Sierra Leone 13%, U.S. 100% (transmission of Ebola linked to families and friends washing bodies of the dead, a common Muslim tradition and practiced widely throughout Africa though uncommon in the U.S.)

The World Health Organization prevention and control measures to contain the outbreak include prompt and safe burial of the dead, identifying people who may have been in contact with someone infected with Ebola, monitoring the health of contacts for 21 days, quarantine the sick to prevent further spread, promote importance of good hygiene and maintain a clean environment. Arguably one of the most important societal determinants of health is the accountability and capacity of governments to address population health, in this case a burden of the responsibility to control the virus falls on these country’s governments. However, because they lack the human and infrastructural resources to do so, multilateral aid has kicked in to fill the gap to prevent a pandemic (though some argue too little too late).

As we can see from a brief glimpse into the disparities in resources between the Ebola-stricken countries in Africa and the U.S., the societal determinants in health of these populations could be correlated to the spread of Ebola and the ability of the governments to efficiently and effectively respond to those living in high-risk areas. Back to the first question: if Ebola first appeared in the U.S. back in March, would it continue to be front-page news as an out-of-control virus that has already taken thousands of lives? Or would it be a public health success story of rapid response and confinement followed by research and development of Ebola treatments? If the disease of poverty were communicable, would the Ebola response in the U.S. be drastically different than the current situation?

Dear DALY: You’re tacky and I hate you

The lovable quote from School of Rock accurately reflects my sentiments of the DALY (disability adjusted life year) and series of Health Metrics in general.

Don’t get me wrong – I believe a system of metrics is quite useful. In theory, they are crucial in keeping a record of health both globally and within our societies. It’s incredibly invaluable to see what exactly is plaguing us today as opposed to a few decades ago. Metrics have the capability of serving as a nice point of reference against which we can determine if anything we’re doing in the public health sector is actually succeeding.

The DALY, while a massive step in the right direction when no alternative was being used, is now sorely obsolete; however, it still remains the standard measurement for the burden of global disease despite decades of backlash for its inaccuracy and misrepresentation.

At its core, the DALY is a numerical value designed to measure the various impacts of disease on people through mortality and morbidity. The potentially healthy years of life lost by diseases are measured, followed by the effects of non-fatal diseases, which are then factored into this ‘black box’ via a disability weight. This weight varies in accordance with an individual’s age – namely, their presumed value to society and position with respect to their ‘peak years of life’.

We can see a massive problem with this metric without having to use too much thought: it necessarily states that the deaths of individuals who are older and/or disabled contribute less to the burden of disease than those of their younger counterparts. This underrepresents diseases and conditions that affect the aging population in more developed countries; and it’s not like we’ve eradicated those afflictions! It’s a significant problem and the DALY, for all intents and purposes, ignores them.

Piggybacking on this notion of misrepresentation, the metrics reported for global health data is wildly inaccurate for most areas of the world that do not contain a vital registration system. Information of deaths and diseases are gathered through surveys and censuses that are incredibly vulnerable to manipulation. If we learned anything from the eight seasons of House, it’s that people lie. They may not even be trying to falsify information – they might simply forget or be unaware of the exact causes of a death in the family. That policy places so much weight on these certainly inaccurate measurements is terrifying. Would you want a physician operating on your body with imperfect knowledge of the actual problem?

Several scholars have made these very criticisms and have even come up with more that are not inherently so obvious. In her section in Reimagining Global Health: An Introduction, Anne Becker and her colleagues bring up two more of these criticisms against the DALY:

The first issue she raises is about the assigned disability weights of diseases. The measurement of disease burden rests on the severity and impact of various diseases, which necessarily relates to the gravity with which we view them. If the top ten most populous countries were suddenly afflicted with a rise in those affected by seasonal allergies, I think it’s safe to say that the world wouldn’t drop everything to find a solution. But that’s just the point: what will elicit such a reaction? What kind of disease and what volume does it need to hit to gain global infamy? The DALY tells us that it should be based on their system of ordering disease severity – one that is wholly arbitrary. A ‘group of independent experts’ is used to determine whether losing an arm is worse than losing a leg. They’re in charge of determining which strain of infection is really worse. While we can argue about the nuances of the science, the final decision is really just a judgement call. There is no indisputable piece of evidence that argues the fine points between what’s number ten on the list of worst diseases and what’s number eleven. Already that undermines the validity of the DALY, which calculates non-fatal diseases against this weighted value to determine global burden.

The darker criticism Becker makes naturally finds itself on the economic side of the debate. According to Becker, the DALY does not account for differences in available resources in a given community. The actual ‘burden’ of diseases and deaths is highly contextual, and will vary rapidly depending on the particular individual and resources of his or her area. While Christopher Murray altruistically defends that a premature death of a person should equally impact the global burden of disease whether he or she was from a developing country or a place like the US, Becker argues that, as unsettling as it is, the deaths are not as alike as we would hope to believe. We like to view ourselves as the apex of human and civil development in a sort of teleological sense of history, but addressing matters on the basis of the idealistic relationships between people may in fact blind us to things we should otherwise be investigating.

The relative burden of a particular disease is highly dependent on who is affected and where they are. It may be useless to keep looking for one catchall metric that will represent everything perfectly. It may instead be more productive to, as Daniel Reidpath puts it in “Measuring health in a vacuum: examining the disability weight of the DALY”, measure burden as it pertains to a particular area. A global, unified measure may not be possible due to the sheer amount of variables that are involved with each individual case.

Any unit of measurement is better than none at all, but an updated method is long overdue. Isn’t it about time we brought health metrics into the 21st century?