I’ve spent the last two days at the Global Health Council Conference in Washington DC participating in numerous presentations about the current and future state of global health, writ large. The focus of this year’s conference has placed significant emphasis on including non-communicable diseases (NCDs) in the agenda. These diseases include: diabetes; cardiovascular diseases; renal (kidney) disease; cancers; vision, hearing and dental issues; among others. They have generally not been the focus of the global health, which has emphasized infectious diseases (IDs) like HIV, TB, and malaria. The argument for the change is two-fold: (1) that there has been wide-spread success in the treatment of IDs and resources are now available for other things, and (2) that the incidence of NCDs is high and growing as countries become more developed in terms of urbanization and must be treated equitably.
As a reminder, I’m not a doctor. However, I have spent significant time in the field focused particularly on programs to address HIV and nutrition. While I am a strong advocate for social justice, these arguments concern me and I am worried about the implications of stating that we’ve succeeded against infectious disease and the changes in the global health system that will happen as we ‘move on’ to address non-communicable disease.
I have been shocked to learn that we have achieved such success in the care and treatment for infectious disease. One panelist said, “we should be joyous” about the achievements to date with regard to HIV and that instead of seeing poor people in African countries sick and dying they were now “laughing and waiting in line for treatment”. Certainly things are better than they have been, but the continent has not been transformed in such a dramatic way. While in many countries people are now being tested and treated for HIV, according to the 2009 figures from UNAIDS, there are 33.3M people living with HIV, 2.6M new infections per year and 1.8M AIDS related deaths per year. Only 5M people are receiving treatment. While these numbers are moving in the right direction, nowhere near the number of people who need care and treatment are receiving it and the epidemic continues to grow. Is this a success about which to be joyous? I don’t think so. And if the HIV community doesn’t allow itself to celebrate the successes, it’s only because there is much work left to do.
That isn’t to say there haven’t been amazing advances and things for which individuals, organizations and the community should be proud. The reduction in prices of drugs; implementation of treatment standards for adult, pediatric and PMTCT (prevention of mother to child transmission); and establishment of national lab systems are all to be heralded. But, there have been failures as well and we must learn from both in order to keep improving the services and systems that are being built now. And, we must anticipate some issues which are likely to come.
We’ve already seen that donor fatigue is leaving the financial resources required for continuous provision of the drugs required for treatment short. As the number of people on treatment increases (which is a good thing) and people live longer (also a good thing), the cost of HIV treatment programs increases. Unfortunately, donors (the multilateral and bilateral agencies including the Global Fund, USAID, UNICEF and many others) aren’t willing or able to increase their funding. The economic crisis, issues of health care in their own countries and the idea that we have had such success against HIV are no doubt contributing to this. And while some of these external forces are beyond the control of those of us in the global health community, the messaging is not. We must be mindful of the way we communicate about the progress that has been made.
This isn’t to say that we shouldn’t also be addressing NCDs and there are some interesting and provocative approaches being suggested to do so. The one that makes most sense to me at the moment is to take a diagonal approach in which systems are built around the patient. According to Felicia Knaul of the Harvard Global Health Equity Initiative, this approach allows the money and resources to follow the patient and not force the patient to fit into a system. It also requires integration of vertical disease issues across horizontal programs that include health care, poverty reduction and social service programs. It’s complicated, but it makes sense philosophically. There is a lot more to consider as this is practically applied, especially since complexity goes against the general approach to public health which favors simplicity.
As at most conferences, I leave with more questions than answers. And while I am so proud of them for the extraordinary efforts, I implore my colleagues to be careful about the language they use to describe successes to date. So much has been accomplished, but there is a long road ahead. And while some new and interesting ideas have surfaced, in their application we will likely see some success and some failure and we must share both in order to make more and more progress. If we consider the scientific method, each failure is progress toward proving or disproving a hypothesis, bringing us closer to truth and ultimately solving the problem at hand.