Non-communicable diseases (NCDs) and the poorest billion
15 September 2020
Obscene inequalities. Myths. Changes in government systems. "They tied me up and wanted to kill me."
The Lancet NCDI Poverty Commission released a new report today on addressing NCDs and injuries (#NCDIs) among the world's poorest 1 billion people (depicted in map below).
One myth debunked in today’s presentation introducing the report is that people think NCDs, including heart disease, asthma, diabetes, cancer, mental health, and injuries, are not a problem in developing countries.
Another myth is that development aid has met health needs of the world’s poorest. As the graphic with 4 charts below shows, while funding for HIV and maternal and child health has reached $7B per year, funding for NCDs in the poorest billion countries is barely on the chart, i.e., barely $1M. Due to the focus on acute issues, a pregnant woman with HIV will get appropriate treatment while one with diabetes will not.
“A child with rheumatic heart disease is doomed,” one speaker said. Similarly, the man with psychosis, quoted at the top, was attacked and tied up by his community members; he is now receiving treatment, saying “I didn’t know I could recover.”
The years of healthy life lost due to NCDIs in the poorest billion is "obscene", as the Health Loss Transition graphic below shows: 22 years for someone with epilepsy, 13 years for rheumatic heart disease, and 20 years for non-Hodgkin lymphoma. The international investment focus has been on health promotion at the community level (left side of Global Action Plan best buys grid below), while a much wider scope of interventions are needed (right side of grid), including district hospitals and health centers to treat chronic diseases.
As the funding gap graph below shows, even in the best of circumstances with a 6% increase in per capita GDP growth, the amount of funding for health care financing available would only be around $50 per capita—compared to the $84 needed for essential universal health coverage (EUHC).
More poor people are dying due to NCDs during #COVID19 due to lack of access to medical care, loss of income and higher COVID-19 risk due to having an NCD. Pakistan responded by making millions of dollars available to provide “half the country” with a $75 income supplement; people were told to send their national ID number by SMS, so government officials could verify their eligibility and send the funds.
COVID-19 has brought such positive changes in government systems and collaboration between health care entities that can be harnessed going forward. In addition, health care systems need to re-orient from acute to chronic care.
#LancetNCDIPovertyCommission #NCD #health #healthcare #socialjustice #poverty
How to promote public policy
2 September 2020
My favorite quote so far from today's Public Health Schweiz's conference (#SPHC2020):
Facts alone cannot win political debates. Facts do not conquer hearts.
As Fritz Sager (#UNIBE) explained, too often scientists think the public will be swayed by facts.
He suggests that when working with policy administrators (i.e. bureaucrats*), researchers need to:
- explain what problem they're trying to solve, focusing on what part of that problem they're addressing (can't solve COVID; can work on changing people's behavior)
- identify people causing the problem as targets of the proposed policy
- identify policy proposals that may change the target group's behavior so they no longer cause the problem.
- providence evidence of the intervention's effectiveness
It reminds me of engineering: Engineers need to build the best bridge possible--in the time frame and within budget limits; thus it likely won't be the perfect bridge, but it will be quite satisfactory. Policy proponents need to adopt the same attitude of finding solutions that will actually be adopted, even if they're not the perfect or complete solution. The vote for 2 weeks of paternity leave (rather than 4) and the mostly-ban on smoking in SBB stations (rather than a complete ban) are good examples of advocates supporting a partial solution as a first step.
Advocates also tend to get bogged down with details--exactly how many people, divided by subcategory, experience a problem. Advocates are passionate about the cause and care about those details. But as explained in today's presentation, researchers, data analysts and scientists need to understand their audience, including the reality that their audience does not think the way they do.
Two efforts in America to explain progressive, liberal concepts to conservative or uninterested audiences:
For example, conservatives might say spending to combat climate change is too expensive. Progressives can respond:
What costs too much is what we’re doing now. 1,300 counties [in the US] have been declared disaster areas due to drought, losing billions of dollars in crops, exports and income. This year’s wildfires have cost us billions more in firefighting and emergency aid. Clean energy is practical, affordable and inexhaustible—it’s the fastest growing energy sector around the world. America has the know-how to power our economy with clean energy—if we break Big Oil’s grip on Washington.
To promote needed programs, fair policies and new solutions, researchers and advocates need to learn how to present their ideas effectively and work with their audience.
*as a former state government employee, I think of "bureaucrat" as a good word -- it represents people slogging through changes in administration and political winds to get the work done serving the public.
Public Health Priorities part 3: the US CDC
29 July 2020
This posting is a brief excerpt of my third article on public health priorities, on funding for the US CDC.
The US Centers for Disease Control and Prevention (US CDC) is the largest player in the disease control world. The US CDC’s total annual budget for federal FY20 was $7.9 billion, or 0.04% of the country’s US $21.7 trillion (T) GDP and 0.2% of its US $4.9T federal budget. By comparison, the World Health Organization’s 2019 budget was US $2.2 B.
The US CDC spends approximately 11% of its budget on infectious disease identification and response and 59% on “regular” diseases, such as #NCDs, #HIV, birth defects and injury prevention.
How should the funding pie be split?
One way to answer these policy questions analytically is to look at health care spending. If the major drivers of health costs can be better managed, then more funds will be available for other health (and non-health) services.
According to the US CDC, chronic and mental health conditions account for 90% of the $3.5 trillion (T) in annual health care spending. Chronic diseases include heart disease, lung diseases, stroke, diabetes, kidney disease, as well as cancer and Alzheimer’s Diseases and Related Disorders (ADRD). To the extent chronic diseases are preventable, then money spent changing people’s behavior (including to stop smoking, eat healthier, exercise more, use sunscreen and drink less alcohol) will see a good return on investment (ROI). Yet only 16% of the US CDC’s budget in FY20 is for chronic disease prevention. See Figure 4.
But motivating behavior change is hard. The truth campaign has been effective in reaching teenagers through anti-smoking ads. Community Health Workers (#CHWs) are another effective strategy in convincing people to adopt healthier behaviors and adhere to treatment regimens.
Is the US CDC underfunded?
Figure 6 shows the US CDC budgets for FY10, FY15 and FY20. Although the total budgets for FY10 (US $8.3 B, in FY20 $) and FY20 (US $7.9 B) are not so different, funding gaps and program shortages are chronic. A few examples:
The overall pandemic-related funding has decreased 17% from FY10 to FY20 (see Figure 7).
What is the “right” amount of funding to spend on identifying, preventing, and responding to infectious disease epidemics? By contrast, how much money “should” be spent preventing chronic, long-term diseases that bring long-term health costs?
There are no easy answers.
#CDC #chronicdisease #HIV #publichealth #underfunding
30 June 2020
How can the fossil fuel, waste management and agriculture sectors decrease methane? A science policy symposium from the Climate and Clean Air Coalition (#CCAC) last week provided policy experiences and recommendations from experts.
What is methane?
Methane (CH4) is a greenhouse gas (#GHG) that is more efficient at trapping radiation (heat) than carbon dioxide (#CO2); it warms Earth 84 times as much as CO2 does over a 20-year period. Methane also contributes to the formation of ozone (#O3), which further impacts health, causes more than a million premature deaths and decreases the crop yields as well as their nutritional quality. Methane, including the ozone it produces, is responsible for 40% of the global temperature increase, according to CCAC.
Where does methane come from?
#Methane is emitted naturally by wetlands but over half of methane emissions come from three main human activities, or anthropogenic sources:
Because human activity causes so much methane to be emitted, it is within our capabilities to reduce the emission rate.
How exactly does farming cause methane?
The majority of agricultural methane is emitted by livestock. When ruminants such as cows, sheep and goats digest food in their rumens (stomach), the food is fermented and methane is produced; the animals then release the methane by exhaling, farting and burping. The United Nation’s Food and Agriculture Organization (FAO) estimates that livestock emit 3.1 Gigatons CO2-equivalent of methane per year, a number that is rising due to increasing demand for beef worldwide.
Rice cultivation is another source of methane. The water in the rice paddies blocks oxygen from reaching the soil; this enables methane-emitting bacteria to grow. The longer the paddy is kept flooded, the more the bacteria builds up.
Yes. Research has linked the beginnings of agriculture and forest clearing in Eurasia 8,000 years ago to higher CO2 levels and the start of rice cultivation based on an increase in methane 5,000 years ago. It is estimated that the gases emitted by early farmers caused approximately 1 – 2°C increase in global temperatures, enough to stop glaciers in northern Canada. Similarly, the abandonment of farms in Europe during outbreaks of the Bubonic Plague led to reforestation and subsequent decreases in CO2.
How do we reduce methane in agriculture?
Technical solutions and know-how for reducing methane produced by farming exist. Mitigation solutions include:
As CCAC points out, technical measures are not sufficient to reduce methane enough to meet the 1.5°C reduction target.
That means a demand-side solution is equally important: Decreasing the demand for meat products.
This 20 minute CCAC video provides a more detailed discussion of the three anthropogenic sources of methane: https://www.youtube.com/watch?v=mBjesciLrLE
Funding for Disease Control (Part 2)
25 June 2020
This posting is an excerpt from my second article in the Public Health Priorities series, Funding for Disease Control.
Disease management is suddenly a household topic due to COVID-19. But what are the normal priorities of the World Health Organization (WHO) and other disease control organizations.
How much funding is available for disease control?
The US CDC is the largest disease control organization in the world, with an annual budget of US $7.5 B. Figure 2 shows how the US CDC’s budget dwarfs the other organizations.
The WHO comes next in size, with an annual budget of $2.2 (based on a 2-year budget of $4.4 B). The WHO’s budget in 2018-2019 was only 29% of US CDC’s budget.
The Indian National CDC has a budget of over $1 M, followed by PAHO with $676 M. The European CDC has a budget one-tenth the size ($65 M), while the Africa CDC started with a budget of $7 M and 20 staff, though its 2020 budget is $13 M, or one-fifth of the ECDC’s.
How should global disease control funds be spent?
The WHO reported 57 million (57 M) deaths worldwide in 2016. The top causes, representing 54% of all deaths, were: heart disease, stroke, pulmonary disease, diabetes, lung cancer, Alzheimer’s, tuberculosis, diarrheal diseases, and road injuries.
Should these figures guide priorities? What about during the COVID-19 pandemic? Some might argue that the entire budget of the WHO and other organizations should be turned over to COVID-19 health care services and vaccine development.
On the other hand, what about less common issues, such as preventing birth defects? Or less well-known issues, such as improving water sanitation (WASH) so people do not get cholera (which can kill a healthy adult within hours), diarrhea or typhoid? Increasing vaccinations for measles, mumps and rubella (MMR) to prevent future illnesses and health care costs as well as enable people to work and earn an income? Identifying effective treatments for Alzheimer’s to improve quality of life for millions in their older years?
You can read more about ROIs for measles, polio and COVID-19 as well as the amount of funding allocated for pandemic-related activities in my article Funding for Disease Control.
Mental illness and the criminal justice system
Jun 3, 2020
Recidivism dropped from 80% to 25%. Arrests have fallen from 118'000 to 56'000 a year. Jails are closing.
The Miami-Dade (Florida, US) Criminal Mental Health Project (CMHP) works with people who have committed crimes and have a mental illness, under the premise that jail is the last resort. Rather than making mental illness a crime, an issue I discussed in my EU Public Health Week presentation. the program guides people through treatment plans, therapy, and job searches. The police, prosecutors and judges work together to help the accused recover and regain their lives.
A new documentary, The Definition of Insanity, takes viewers through the courtroom, following a peer counselor and several cases for 18 months.
Accodring to the CMHP, 17% of inmates have a serious mental illness, costing taxpayers $50 million a year. Defendants with a serious mental illness (SMI) or an SMI and substance use disorder, are diverted to a community-based treatment and support system.
The two components of the program are pre-booking, where Crisis Intervention Team (CIT) training teaches officers to de-escalate situations and understand that someone with a mental illness may not be able to respond to directions from the police, and post-booking, where pepole awaiting trial are served. Clients are provided with community-based transition plans to help them be successful in the community.
More on the documentary: https://www.kpbs.org/news/2020/apr/13/definition-insanity/?mc_cid=d5154ce380&mc_eid=9f9021aba4
You can also read more about the program at: https://www.jud11.flcourts.org/Criminal-Mental-Health-Project
For another similar project that helps inmates access needed services in the community, see: https://commed.umassmed.edu/news/2019/12/17/commonwealth-medicine-collaborates-massachusetts-initiative-providing-community (Full disclosure: I worked on this program)
We need more such solutions so our social problems - ones that are effective for those involved, save money, and produce better results for society.
19 May 2020
COVID-19 has focused attention on global public health organizations such as the World Health Organization (WHO). What exactly is public health? What do public health organizations usually focus on? What are their capabilities during an infectious disease emergency?
Part 1 of this series focuses on why public health is important. Part 2 looks at the funding for disease control organizations such as the WHO and the European Center for Disease Prevention and Control (ECDC) as well as how to make policy decisions about health programs. Part 3 goes more in depth into the budget of the US Centers for Disease Control and Prevention (US CDC) as an example of historical and current budget priorities.
What is Public Health?
Public health is the concept of improving infrastructure for a common good. Infrastructure may be regulatory (seatbelts, occupational health agencies) or physical (sewer systems, health clinics, bed nets).
Public health is also about equity. Everyone benefits from health-oriented rules (no smoking in workplaces), infrastructure (clean water; emerging disease identification and warning systems), and discoveries (vaccines).
Public health discoveries
Tu Youyou identified the ancient traditional Chinese use of a plant called sweet wormwood to fight fevers, a symptom of malaria; she and her team extracted a substance, artemisinin, which is used today to fight malaria. She and colleagues won the Nobel Prize in the category “Physiology or Medicine” in 2015.
Public health initiative: The WHO recommends artemisinin-based combination therapy for malaria.
Yet: The WHO estimates there were 228 million cases of malaria and 405,000 deaths in 2018, due to lack of insecticide-treated nets and sufficient medical care.
Life without Public Health
What would the costs be, both for health care as well as societal costs to businesses, trade, and families due to death and injuries, without public health initiatives?
Three health issues provide good illumination into the importance of public health efforts: life expectancy, maternal mortality and smallpox.
Until the 1900s, the average life expectancy in Europe was around 40 years. A major driver of the low life expectancy was high infant mortality. In Switzerland in 1876, 27% of deaths were of children under one and another 8% were in children 5 and under; each age group over five represented only about 1% of deaths for the year.
Figure 3: Swiss Life Expectancy
Infectious diseases were historically the main drivers of infant mortality, including pneumonia, influenza, and diarrheal diseases. In France, approximately one-third of babies died before age one in the 1700s, until improvements in birthing techniques and smallpox vaccinations reduced the infant mortality rate to one in six infants by 1850; however urban crowding and the spread of epidemics like cholera increased infant mortality again (as did the custom of giving babies to wet nurses in the countryside who nursed and cared for them).
To learn more about maternal mortality, smallpox and disease control, download my article.
Stay tuned for parts 2 and 3, which will be available in the upcoming weeks.
The public health advertisements in the slideshow were collected by the World Health Organization.
 The Human Mortality Database. https://www.mortality.org/hmd/CHE/STATS/Deaths_1x1.txt (accessed April 2020)
 Institut national d’études démographiques (INED). “Infant mortality in France”. https://www.ined.fr/en/everything_about_population/demographic-facts-sheets/focus-on/infant_mortality_france/
18 February 2020
Taken from my article on social determinants of health:
Sicker people cost more in health care resources. How do we equitably pay for their care? It would be immoral (not to mention illegal in many places) to charge people premiums based on their actual costs. One solution is using risk adjustment so payments reflect costs more closely; risk adjustment (RA) can be used by the government (paying insurers) or by an insurance company (paying medical providers).
In Switzerland, mandatory health insurance (MHI/Grundversicherung) companies with higher-risk members receive money from a fund paid into by companies with lower-risk populations. However, the risk adjustment calculation used to redistribute the money is based on only a few factors: age, gender, stays in a hospital or nursing facility and pharmaceutical cost group (PCG) for issues such as diabetes, depression, and cancer.
There is another set of factors that impact a person’s health care costs and health outcomes: social determinants of health (SDH).
Health is impacted by several inter-related drivers, each of which can have a positive or negative (or neutral) effect. A person’s biology (genes), access to medical care and lifestyle choices obviously help determine their health status. But so do their physical environments and social/economic characteristics, or SDHs, such as education level, employment opportunities, access to needed services and housing security. For example, it’s easier to maintain a healthy diet when fresh fruits and vegetables are both available in your local market and are affordable.
The World Health Organization (WHO) has made SDHs a key focus area to improve health equity worldwide. The University of Bern’s Institute for Social and Preventive Medicine (ISPM) social determinant research on young men found differences in the health behaviors of people from the Swiss, French, and Italian-speaking parts of Switzerland. Around the world, government agencies, private insurers, accountable care organizations (ACOs) and even individual medical practices are beginning to include social determinants of health in their assessments of patients.
In America, the state of Massachusetts’ public health insurance agency, MassHealth, began incorporating SDHs into their risk adjustment strategy in 2016. The formula to include SDHs includes unstable housing, disability, relationships with other state agencies, serious mental illness (SMI), and substance use disorders.
The Swiss Smarter Healthcare National Research Programme (74 NRP), part of the Swiss National Science Foundation (SNSF), is also funding new research into the social inequalities in the provision of in-patient care. The research study aims to link medical and socio-economic data so that determinants can be identified regarding use of inpatient care for chronic diseases as well as health outcomes.
Of course, using SDHs is not necessarily a cure, as researchers recently found, to their surprise. As reported in the New England Journal of Medicine, a hospital program that sent a team of nurses, social workers and community health workers to “superutilizers” after their discharge resulted in a hospital readmission rate not statistically different from that of the control group.
Nevertheless, SDHs are a powerful tool to address underlying causes of people’s health problems. By capturing and using social determinant data, medical providers have the opportunity to improve their patients’ health and quality of life. When health care costs consequently decrease, that is an even better win-win outcome.
For more details, including examples of SDH use by health care providers and how to incorporate SDHs into your practice, read the full article on social determinants of health.
11 February 2020
What are you willing to sacrifice for the environment? Your time? Money? Convenience? Choice?
If environmentally-friendly options were as cheap, convenient and attractive as non-sustainable choices, we'd be choosing the better options without a fuss. Instead, we need to engage in thought experiments as we make decisions.
I was faced with the sustainability dilemma for a 3-day conference in Belgium - a short 1+ hour flight from my home in Zürich, but a 7 - 9 hour train ride away. Should I go? Is the conference so necessary to me professionally that it justifies a flight? Do I want to spend an entire day traveling there and another traveling back?
I posit that we should review our choices from the following dimensions:
How much more will the environmentally-friendly option cost?
Your limit may differ from mine, but if a conventional item costs CHF 100, then I think I can afford CHF 110 or CHF 120 for the environmentally-friendly version. Would I pay CHF 150? It might depend on the situation or product.
How much more time will the sustainable version take?
For me, the choice was between a very short flight and a whole day (or overnight) of travel.
Do you have fewer options with the sustainability? Only one cereal brand, one color shoe, no veal (typical meat production is incredibly cruel to animals in the US, where standards are shockingly lower than in Europe)?
It may not be your favorite color/style/brand, but it's a bearable sacrifice.
Similar to time, how much more effort will it take? Think of your time as an investment--once you know where to buy the sustainable product, you won't need to research that product again.
If I need a particular vegetable for a meal I'm planning to cook but the supermarket only offers it in plastic packaging (for broccoli? or bananas? really?) or styrofoam, then I don't buy it. I'm annoyed, definitely. But I can cook something else. Plastic and styrofoam don't biodegrade, period.
I think of it as the freedom to or option to (support sustainability) rather than restrictions from (having it my way when I want it). I freely choose.
Focus on items that have a big impact on the environment; maybe you'll choose to spend your extra time or money on those choices.
You may have heard the joke about the tailor who says: You can have it cheap and quick but not good or good and quick but not cheap or cheap and good but not quick. Sometimes you will have to pay more for sustainable options, be it in time, energy, variety, or money. But women who have to walk miles to find water or firewood, farmers whose crops don't grow because of climate change -- they don't have easy options. We do.
So what did I do about the conference? The cost difference between flying and the train wasn't a determining factor. Time and convenience were, but the environment won out. I decided to sacrifice my time and spent the Sunday before the conference traveling by train. My husband and I then combined my business travel with our vacation, and he flew to Belgium Wednesday night after work (yes, an imperfect solution). We then took the train back to Switzerland the following Monday (another time and vacation-day sacrifice) so at least we were spending the day together.
Would I make that same decision again? Yes, easily. Was it perfect? Not when our train to Paris was late and we missed our connection. But we were put on another train an hour later--not a huge inconvenience.
Nor am I bothered that my husband flew -- it was clearly impractical for him to take the train (we didn't consider an overnight trip because we had to change trains 4 times). A solution doesn't have to be perfect to be good. Maybe sometimes you buy the more expensive bio fruit and sometimes not. Sometimes you take the bus to work instead of driving or order fish instead of beef. You don't have to do it every time in every situation.
Where are your limits? Engage in a thought experiment next time you're choosing to spend money. How can you interact with the marketplace differently? And what dimensions do you use for your decision-making?
26 January 2020
ADLs are the daily self-care activities we do every day without thinking -- getting out of bed, showering, getting dressed, going to the bathroom, feeding ourselves (#Selbstpflege in German). For someone with decreased mental or physical capacity, the ability to perform ADLs determines the level of care they need. #ADLs are measured both for home and institutional care settings (#nursing facilities, #rehabilitation).
As the chart shows, a person can perform an ADL completely or mostly independently; need supervision or help of varying levels; or be completely dependent on assistance. (Graph is from my co-presentation at the 2016 interRAI conference while working at the University of Masschusetts Medical School's Health Law & Policy Center.)
There are multiple tools available to assess clients' ADLs, including interRAI (shown in the graph) and the EPa-CC (ergebnisorientiertes PatientenAssessment), and the Enhanced Barthol Index (#EBI), as well as home-grown systems developed by governing agencies, hospitals, or other providers. Each software system typically has a specific survey for different care settings, such as home care, emergency room, and long-term care (Pflegeheim/nursing facility), and for specialized populations such as children. But all will have the same types of core questions about a person's ability to perform ADLs. (For an interesting study comparing EBI and EPa, click here.)
For home care settings, additional information is critical: can the person manage the intellectual activities of living independently, including cooking, shopping for groceries, getting to and from community locations, cleaning the house and paying bills. These are called Instrumental Activities of Daily Living, or #iADLs. They answer the question of whether it is safe for the person to be living at home.
Someone might need help with ADLs, iADLs, or both, and a disability in one area does not necesarily hinder the person's ability to live at home. The type and duration of support they receive should be tailored to the identified needs. For example, a client who needs help showering might need a home care worker twice a week for a couple of hours, while someone else might require assistance every morning to get out of bed, get dressed, and prepare for the day. A client might need a second level of support to do household chores, but those needs can sometimes be met through informal care or volunteers, such as a son or daughter who takes charge of their parents' bills, a cleaning service, or a neighbor who takes the person shopping once a week. I've also heard of volunteer programs that send (verified) volunteers to the homes of elders once a month to help them sort through, understand, and pay their bills. Someone with severe ADL limitations might still have the intellectual capacity to manage their own household, while another, able-bodied person with dementia has a different set of needs.
As you will hear repeatedly in these blogs, I'm a big believer in collecting and using data. Next week, I'm going to the 2020 interRAI Conference, where I will learn more about specific ways interRAI's data is used and adapted to better serve clients.
What ADL index system do you use? What strengths and weaknesses do you feel it has? How does your organization, or the organization serving your loved on, use the data? Is your loved one able to get all the care they need? Feel free to share your thoughts on this topic in the Comments section.