The Chairman’s opening remarks at the Global Health Minders seminar:
INVESTING IN HEALTH – HOW TO DO IT AND WHY?
6 November 2014

Global health has suffered from a serious fatigue lately and has lost some of its virginity somewhere in the West African suburban jungles where a little virus with 7 genes has exposed the entire world to the harsh reality of global health: nobody really cares about global health threats until they turn up in our own neighborhood. Let’s be honest, global health is not having one of its brightest moments this year.

Ebola turned our risk perception of Ebola epidemics upside down just because it spread to urban areas which we haven’t seen before and it managed to cross a couple of borders and all of a sudden it jumped to Europe and across the Atlantic sea.

Some have called the Ebola situation A Chronicle of a well prepared disaster. 10 years of huge investments in global health preparedness have been a complete waste of time and money – most funding was spent in places with no need and no risk or they were just wasted on unprepared health and security systems in low-income countries. In late May 2014 an American team of researchers in Sierra Leone still claimed that they were prepared and in control. This week Ebola cases have re-emerged in Sierra Leone border areas.

Weakened research capacity in those countries, in which diseases are most endemic, may be one of the major factors in their inability to curb, prevent, and treat diseases. Obstacles to strengthening research capacity undermine poorer countries’ health and need action. Threats to strengthening the capacity of health research in low- and middle-income countries (LMICs), such as a lack of research infrastructure and overdependence on donor funding, need more action, as research holds a key to tackling disease.

It was documented, and strongly advised, in the first World development report in 1993, in Brundtlands WHO report form 1999, in Sachs Report from the Commission on Macroeconomics and Health in 2001 and in Sir Michael Marmotts report from the Commission on Social Determinants of Health in 2005: health is a good investment with a fair return rate. However last year in London, this fact was repeated for the fifth time in 20 years when The Lancet launched the latest World development report 2013.

But why do we have to repeat the same analyses, come up with the same evidence and point out the same conclusion every 5 years: health is a good investment that pays off? What is wrong with our research and evidence? Is it boring? Is the evidence too heavy? Or could it be that our minds are not open enough? – that is what we will try to highlight today.

With better analyses of the long term economic effects of investing in health, the message in Lancet’s report was even clearer than the messages of the previous four reports: investing in health has an enourmous pay-off. Yet a lot of high-income countries, like Denmark, no longer support development in the health sector of LIC. Maybe they were just driven by a desire to make a difference and be visible.

Everybody wants to be a catalyst – somebody that initiated something – nobody aspires to be a follower. So new initiatives and initiators are much more abundant in the world than followers that actually transform innovation into action and gets the job done. Decision makers and large donors in global health are no exception to this rule.

Tons of useful experience and interesting evidence has gone down the drain because we all believed that political systems, health organizations and health authorities had brains that would collect and analyze health data and adjust their policy according to evidence. They don’t. Actually they don’t like historical evidence. Experience to politicians is a ticket to a train that has already left. They live to be remembered for a change in policy so they like to reinvent and reshape the same policy over and over again but in the echo chamber of their limited mindset and time frame. Global health challenges don’t have fixed mindsets and their worst enemies are time frames and changing political fashions.

There is no governing body in charge of global health. No overall regulation, no one controlling aid flows, and no one choosing which countries and problems get money and which don’t. Every donor develops their own priorities and policies, and follows them to whatever extent they see fit. Donors, of course, range from tiny faith-based groups and high school fundraising efforts to major foundations like Gates and Rockefeller, government donors and UN agencies. Their levels of skill and competence vary widely.

This causes chaos in accountability and accounting. Nearly one-third of the global health money spent by the very largest donor by far – the US government – is untraceable. There are large gaps in existing health data and comments, surprisingly, discussions about global health financing continue to take place in the absence of a comprehensive system for tracking development assistance for health.

And speaking of counting. Only human beings that are actually counted will count in global health. Donor policies are based on visible, counted and countable humans and their health challenges. But a huge proportion of the world’s population is never counted and therefore never counts. Migrants and refugees constitute over 260 million global citizens often caught as good people in a bad situation in no-man’s land between their country of birth and the recipient country.

Minorities and migrants constitute a lawless and evidence free global health issue. They are vulnerable mobile populations that are dealt with on a global scale mainly based on media reports and fear mongering. Migrants are left in an environment of invisible but tough living conditions. Because they are not counted, or have a common voice, decision makers are not forced, neither legally or morally, to change the situation. But they are many and even if they are regarded by some as illegal or uninvited guests they still interact with the global community, including health risks, human insecurity and at the same time potential for new ideas and new solutions. But if migrant and refugees had a nation and a common voice they would be numerous enough to be entitled to a permanent seat in the Security Council. The internet and social media could be the base for a virtual migrant country with a common voice.

The donors are now so big and rich that they can buy any global health policy they want. Meanwhile WHO budgets have been cut to a third and development agencies have discarded investments in health care leaving the global health dance floor to private enterprise with their affection for changing fashions through extremely short-lived, vertical programmes.

Global health management faces a new problem, by Fidler called “The open-source anarchy”. The forces of open-source anarchy means that States, NGOs and large donors resist global power structure reforms that would limit their freedom of action. Gates foundation for example scores very poor on the aid transparency index 2013.

Reports of shortage of HIV drugs are now piling up as the new large donor players are reorganization their HIV strategy withdrawing funding resulting in failing HIV treatment, drug resistance and a collapse of a short lived global health success. The policy change of central donors has left fragile health systems in some African countries with a massive emerging debt: HIV patients experiencing more and longer spells of drug shortage development extremely expensive drug resistance that require treatment with drugs no African health budget can ever finance.

British DfiD’s decision to leave influential HIV/AIDS campaign in South Africa was called a “Death warrant for South African HIV patients”. Some have argued that the Rockefeller Foundation has played an even bigger role for paradigm shifts in global health than The Gates Foundation but voices are calling for scientists to play a role in contesting and identifying alternatives to the global health philanthrocapitalism of huge donors as Walmart has entered the scene as the latest private donor without prior knowledge of global health.

The uncontrolled bazar of stake holders exposes deficiencies in national public health governance skills, deficiencies that are difficult to address in conditions of open-source anarchy. Governance initiatives on global health are disclosed as weak, powerless and vulnerable.

At the Geneva launch of the 2014 World Disasters Report, published by the International Federation of Red Cross and Red Crescent Societies, with its focus on culture and risk, some issues were taken up that are not often included in reports on disaster management:

How big a role does corruption play in the death tolls that follow earthquakes and buildings collapse? What kind of a boost would it give resilience to disasters if issues like landlessness and caste were tackled? How can you work on disaster risk reduction in a community if you ignore the fact that a large percentage of the female population is being physically and sexually abused?

We introduced user fees in developing countries and 20 years later discovered that it was a disaster. Now we have legalized small scale corruption in health care. Some have called traffic accidents planned murderor a public calculated risk – traffic, as war, has causualties and we have learnt to accept it and live with it. Up to 70 % of hospital expenditure in LIC goes to treatment and rehabilitation of traffic injuries. The victims of traffic accidents are, strange enough, the vulnerable pedestrians and bicyclers that cannot afford to buy a vehicle.

Recent studies have come up with risk factors that compete with our classic ideas of social determinants of health. Loneliness has been shown to shorten life expectancy compared to smoking and it’s twice as hazardous as obesity. Quality of life and alcohol consumption seem to spread in social networks in ways that challenge our usual epidemiological tools and social capital could be a better medicine than school education and wealth together. HIV prevalence fluctuates with food prices, the cocoa market situation, drought periods and access to ART. Social determinants of health act in mysterious ways and often together thereby boosting the negative effects of being poor and illiterate.

Global health in an open world requires an open mind. But not so open your brains fall out…

When I first heard about the world converging by 2035 I was a bit puzzled: does it mean convergence in health risks, social determinants or in treatment opportunities? Will we all become equally poor or rich? Will we all suffer the same illnesses or be exposed to the same discount treatment options because we can’t defend to be globally responsible without sharing what we have?

Einstein’s basic idea was that you can’t solve a problem with the same mindset that created it. Yet, we still try to solve tomorrow’s problems with today’s thinking. The deprived areas in London in 1890 with the highest mortality risk are still 120 years later deprived with the highest mortality risk. We need good data and good open minded thinking to break this vicious circle. But we also need people working on tomorrow’s problems. If everybody 100 years ago had worked only on making better horseshoes who would have done the work leading to cars? We should invest in people that look around corners.

So let us have an open minded discussion today aiming at a new and better mindset than the one that created most of the challenges we face. Let us put the brain and sense back into global health: why and how should we invest in health?

It is therefore a pleasure to welcome our main speaker Gavin Yamey, who is an Associate Professor of Epidemiology & Biostatics at the University of California School of Medicine. Gavin serves on two international health commissions, the Lancet Commission on Investing in Health and the Lancet Commission on Global Surgery. So you seem to be covering all sorts of specialties: social determinants, economy, surgery and statistics. Gavin led the writing of Global Health 2035, the report of the Lancet Commission on Investing in Health, which was published on December 3, 2013.
Morten Sodemann
Chairman, Global Health Minders
www.globalhealthminders.dk