Taking Stock of Health in 2013
Another fascinating year in public and global health has passed. We are riding the whirlwind of multiple transitions that impact health, including:
- An aging population.
- Widespread health illiteracy.
- Increasing levels of dementia and mental illness, with ever-expanding public and private costs. Mental health must be integrated into healthcare delivery.
- Changes in the burden of disease and an epidemiological shift from infectious diseases associated with underdevelopment to chronic diseases associated with longevity and urban lifestyles.
- Malnutrition linked not only to famine and starvation, but also to high-calorie, low-nutrient diets in the developed world. As Margaret Chan, Director-General of the World Health Organization, commented recently, “It is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda, and Big Alcohol.” The enormity of the problem is illustrated by the fact that the food industry is three times bigger than the tobacco industry. Fast food advertising in 2012 was $4.6 billion; energy drinks another $281 million.
- New and re-emerging diseases evolving to become drug resistant.
- Stubborn global inequalities in access to food, sanitation, vaccines and health care. For every eight people in the world today, one still goes to bed hungry, and despite advances in biomedical technology and capacity to enhance the quality of health care and prevention, the poor and disadvantaged suffer a vastly disproportionate burden of illness and disease.
Infectious diseases (especially HIV/AIDS) continue to pose a major threat to health, particularly in our interdependent and interconnected world. Moreover, the threat posed by infectious diseases will grow, as up to 2 billion people are projected to be living in dense urban slums by 2030.
Noncommunicable diseases such as diabetes, heart disease, stroke and cancer are now the leading case of death in the world. Described as the invisible epidemic, there is no single cure or cause for NCDs, but the common modifiable risk factors include poor diet, obesity, and inactivity. Poor education and low incomes are associated with rising NCDs in both developed and developing countries, and poor and disadvantaged populations have the highest rates of NCDs in high-income countries.
Exciting research continued apace in 2013. For example: we are rapidly expanding our understanding of the many roles that the microbiome plays in human health and disease; work is underway on a method to quickly identify antibiotics that can treat multidrug-resistant bacteria; a study suggests that sleep helps restore the brain by flushing out toxins that build up during waking hours; and a malaria vaccine was found safe and protective in an early-stage clinical trial.
Delivering basic vaccines remains one of the top priorities of the Bill and Melinda Gates Foundation. Bill is passionate about giving 22 million children who do not have access to lifesaving vaccines a healthy start to life. “We live in a world where we have the power to correct this injustice. We have the knowhow to produce effective vaccines, make them affordable, and deliver them to the children who need them.” He cites the invaluable part played by emerging country vaccine suppliers, who have become leaders in supplying the world with high-quality, low-cost vaccines, calling them “our most valuable partners in global health.”
The visionary and inclusive approach of the Gates Foundation is instructive. Many social factors play decisive roles in determining the health of individuals and communities, and solving social dilemmas and addressing the many social determinants of health requires multi-stakeholder perspectives.
In the United States, inequality has finally emerged as a focus of debate, where too many citizens live in economic fear. This reality is a product of such government actions as the recent failure to extend the Emergency Unemployment Compensation program, cutting off in the New Year 1.3 million people who had been receiving assistance. This shameful decision will affect jobless workers in every state, with an estimated 4.9 million workers missing jobless benefits by the end of 2014. Similar examples abound.
Public health will be among the casualties of such misgovernance, and will serve as a reminder that healthier lifestyles are a responsibility not just of individuals but also of societies as a whole. It should come as no surprise that trust in Congress among U.S. citizens dropped from 42% in 1973 to 10% in 2013. And in the face of frequent consensus in narratives and perspectives for many stakeholders, the issue is often not lack of awareness as much as lack of voice; too many conversations are closed to too many people.
The power of organizations that benefit from the status quo often outweighs desires for reform. Vested interests employ thousands of lobbyists in Washington to help members of Congress “understand the issues.” The pharmaceuticals and health products sector spent $171 million on lobbying in 2013, the agribusiness sector bestowed $111 million, and the food and beverage industry paid lobbyists $21 million. Meanwhile, the vegetables, fruits, and tree nut industry spent $3 million, and a pharmaceutical partnership contributed $112,500 to lobbyists to “fight chronic disease.”
Trust is an essential component of effective policymaking because it bestows legitimacy, and facilitates greater public willingness to abide by decisions and proposals made by politicians. A good example of broken trust is anxiety about the consequences and motivations of large-scale vaccination programs.
Disillusionment and skepticism underlie the increasing difficulty of governments to engage in conversations about values-based principles that transcend more populist, day-to-day political agendas, and strive to articulate a broader vision for society. Nevertheless, as Bill and Melinda Gates demonstrate, we cannot try to solve social dilemmas in isolation, as if politics, economics, technology, education, hunger, unemployment, science, depression, health system disparities, and power differentials are all disconnected from each other.
Happy New Year anyway, with a final word later in the week.
— Michael Lytton, AJPM Blog Editor