Category Archives: Equity

Related to the fairness of distribution of goods, opportunities, and processes.

Does global health need a ‘red team’?

Looking at population health, time-series data it is easy to imagine that everything is getting better and better. What is more, as your eye tracks the line into some imaginary future, it is easy to believe that things will continue to get better and better.  It is a soothing balm to the more insidious thought, that doom awaits us around every corner.  In the world of stock pickers and equities experts, the balm is the Ying of the bull to the Yang of the bear. Hope versus despair.

The late Hans Rosling has done more to ground people in that hopeful view of the future than any other person.  The gapminder website, his creation, provides clear, firm evidence of global improvements in health and well-being across a wide range of outcomes.  As you follow the motion picture trends, countries improve. Some occasionally collapse, horribly. Then they recover. And on average, all improve.  Poverty, life expectancy, education, the infant mortality rate — it does not matter what you focus on, the world has been getting better and better

Figure 1 is a quick snapshot of this improvement in life expectancy from 1915 and 2015. In both years, higher national wealth was associated with better life expectancy.  In 1915, a country with a GDP/capita (adjusted for inflation and price) of $1,000 had a life expectancy of 30 years. In 2015 a country with a GDP/capita (adjusted for inflation and price) of $1,000 had a life expectancy of 60 years.

 

Figure 1. The left and right panels show the countries’ life expectancy in relationship to the GDP/capita (adjusted for inflation and price) 100 years apart. In 1915 a country with a GDP/capita of $1000 had a life expectancy around 30 years. In 2015 it was around 60 years — a difference of about 30 years. Source: Gapminder

In contrast, in the middle of the 18th Century, life expectancy was similar across all countries, without regard to national wealth. Little had changed by the middle of the 19th Century. Sixty years later (1915), there was a strong association between national wealth and life expectancy; and over the next 100 years, things became much better for everyone.

Will this continue?

Let’s hope that it will.  There are however significant threats visible on the horizon — and I would argue that Global Health needs a strong Red Team to make plain that dreadful prospect, often and forcefully. And as the Red Team argues their side we should hope fervently that they are utterly and comprehensively wrong! We should nonetheless listen to the arguments and not glaze over or dismiss them as we would Cassandra.

Red Teams arose in the US military and intelligence communities. They were there to argue against self-satisfied complacency. If the majority view was purple, they argued orange, if Winter, then Summer. Their purpose was to find the weaknesses in the status quo. One of the most extraordinary examples of the power of a contrarian view was the Millenium Challenge 2002, in which Paul van Riper showed that a demonstrably weaker force (the Red Team) could be devastatingly effective against the powerful (Blue Team) when they were prepared to play outside the constrained paradigm of accepted norms.

In Global Health the situation is, of course, entirely different — we do not battle each other, but we do struggle with (and against)  nature and the environment.  What is not different between Intelligence agencies and Global Health agencies is that views become entrenched. The Philosopher of Science, Thomas Kuhn, described the entrenchment of scientific ideas in terms of normal science: “the regular work of scientists theorizing, observing, and experimenting within a settled paradigm or explanatory framework”. These “settled paradigms” can permit significant new developments, but they brook no serious opposition (only tinkering at the margins). They are the VHS manufacturer to the plucky Betamax.

“Beta what?”, I hear you ask, and the point is made.

Global Health has large, powerful groups that are in danger of playing a form of technocratic hegemony — Global Health, normal science.  It’s incremental, unabrasive, and potentially wrong or ineffectual. Some of the possible threats to global health are well known, and if we focus only on those related to climate change and population growth the following is a reasonable starting list:

The global expansion of humans over the past 10,000 years was made possible by the growth of agriculture, which in turn was made possible by a stabilisation in the climate about … 10,000 years ago.  Our current success is again a product of agricultural developments. Paul Ehrlich, in his 1968 book The Population Bomb wrote a Malthusian tale of global starvation.  His prediction failed to take account of Norman Borlaug’s green revolution, and the development of semidwarf wheat, which saw grain yields triple in the 1960s and 1970s. The predicted cycle of devastating starvation was averted.

Success in the past, unfortunately, does not tell us anything about the future. Timely science then does not predict timely science now. Although Borlaug’s work saw Ehrlich’s predicted threats displaced in time, towards the end of his Nobel Prize acceptance speech, Borlaug said:

Malthus signaled the danger a century and a half ago. But he emphasized principally the danger that population would increase faster than food supplies. In his time he could not foresee the tremendous increase in man’s food production potential. Nor could he have foreseen the disturbing and destructive physical and mental consequences of the grotesque concentration of human beings into the poisoned and clangorous environment of pathologically hypertrophied megalopoles. Can human beings endure the strain? Abnormal stresses and strains tend to accentuate man’s animal instincts and provoke irrational and socially disruptive behavior among the less stable individuals in the maddening crowd.

We must recognize the fact that adequate food is only the first requisite for life. For a decent and humane life we must also provide an opportunity for good education, remunerative employment, comfortable housing, good clothing, and effective and compassionate medical care. Unless we can do this, man may degenerate sooner from environmental diseases than from hunger.

So far, the international, multilateral approach to a possibly gloomy future is to seek hope — it does, after all, spring eternal.  We will reduce greenhouse gas emissions, tackle global poverty through economic growth, and increase food production. We will not need to tackle population growth, nor will we have to make do with less. We write about planetary health, but we do not develop strategies for a planet that is less human-friendly tomorrow than it is today.

I hope that global health and well-being will improve well into the future, well past my life and I hope well past that of my children, (and their children, …). In case it does not, I would like to think that there is a Global Health Red Team that does not just echo gloomy news in the halls of power, but argues for and develops strategies suitable for the world in which we are all worse off.  What should our goal be in that worse off world?  Is it a global goal, an equitable goal of mutual pain, or is it a “My Country First”, Shakespearean tragedy of the commons?

There is an ironic twist to the use of Red Teams in the US military that may have some bearing on their use in Global Health.  In the Millenium Challenge 2002 when the Red Team devastated the Blue Team in the first few days of a fortnight-long exercise, the judges reset the clock. They hamstrung the Red Team, and then let everything play out in a way that would ensure that normal (military) science came out unscathed.

Global Health needs to be intellectually braver.

 

Who will guard the journals? Gender bias in the “Big Five” medical journals.

Journals, by which I mean Editors, have shaped modern science, particularly in medicine. The publication policies of journals now direct the kinds of ideas that are acceptable, how to present the ideas and the ethical frameworks that should govern data collection, authorship, treatment of participants, and data sharing. Journals will refuse to publish a paper if they are not satisfied that the authors have fulfilled those requirements. The journals have become both arbiters and gatekeepers of sound scientific practice. A recent journal issue on conflicts of interest appearing in the Journal of the American Medical Association (JAMA) is a case in point (2 May 2017).

Editors will also self-publish encyclicals of good conduct, laying down the rules of engagement for the future. The JAMA editorial supporting the recent special issue is such an example. When the journals involved are at the top of their fields, these views reverberate. In medicine, the Big Five journals in general and internal medicine are the New England Journal of Medicine (NEJM), Lancet, JAMA, British Medical Journal, and Annals of Internal Medicine. When the Editors speak, the field listens. Their role is revelatory. It is an imperfect conduit of nature’s voice whispered to researchers in their labs and clinics.

The rules do not, unfortunately, prevent the publication of bad science. The Autism-MMR paper in the Lancet is an excellent example of bad science slipping into the field. In general, however, failures of science lie at the feet of the scientists. The journals rise above it. A retraction here, a commentary there, and the stocks or pillory of peer humiliation are kept for the authors.

It is easy when criticism can be deflected, and laid at the feet of authors. What, however, should the response be when researchers identify a bias in the Big Five journals? Bias in medicine is a serious issue. It indicates a skew in the published science – a tendency to emphasise one kind of science over another or the promotion of one interest over another. It carries risks into the future of skewing practice and funding.

In 2016, Giovanni Filardo and colleagues identified a gender bias in first authors of research articles published in the Big Five. The journals were more likely to publish articles with a man as a first author than a woman. The most biased journal was NEJM. You will not have read about the research in that journal, however, because they rejected the paper when it was submitted. Unfortunately, the bias in the gender of published first authors is not a local, journal issue. The bias has a larger and more insidious career effect. Women are less likely to be in the prestigious position of the first author in prestigious Big Five journals, and ceteris paribus they are disadvantaged in funding applications, job applications, receipt of awards, and recognition.

My co-authors and I recently published an investigation of gender bias in clinical case reports. You may be unsurprised to learn that clinical case reports are more likely to be about men. Apparently, clinical cases about a man are just more interesting than a clinical case about a woman. All but one of the investigated journals showed a gender bias, and the most biased journal was NEJM.

Of course, journals can and should reject research papers that are not relevant or deficient in quality. And our paper may have been both. The fact that a journal like the NEJM should have rejected two recent papers that identified the journal as being the most gender-biased among the Big Five begins to look like an avoidance of criticism.

If there is a tendency to avoid self-reflection, particularly in an area as important as bias in science, then the editorial decisions begin to have much greater significance, and at least a whiff of hypocrisy. The origins of a bias may be authorial. A greater proportion of articles written by men than women are submitted to the journal; a greater proportion of clinical case reports about men rather than women are submitted to the journal. The Editors are in a position to correct the submission bias, just as they vigorously correct other biases. The Big Five would have acceptance rates below 10%; they presumably have a bias towards higher rather than lower quality science. We are suggesting that in exercising their Editorial judgment they could include factors they have (presumably) hitherto not noticed in their own behavior. They might find it easier to explain these editorial shifts if they based it on scientific research published in their own journals. At the very least it indicates that the issue is taken seriously.

This article was co-written by Daniel D Reidpath and Pascale Allotey

Would you give knee surgery to the FAT MAN?

I do understand your plight, Mr Smith.  An arthritic knee can be extremely painful.  And you say it’s so bad you can’t even walk from the living room to the kitchen.  That’s actually very good news!  Yes, yes … awful … but terribly good news. If you can’t walk to the kitchen, you can’t eat. If you can’t eat you’ll lose weight.  And the faster you lose weight, the sooner we’ll schedule your knee surgery.

On 15 March 2017, Dr David Black, NHS England’s medical director for Yorkshire and the Humber, sent a letter of praise to the Rotherham Clinical Commissioning Group (RCCG).  The RCCG had decided to restrict the access to smokers and “dangerously overweight patients” of hip and knee surgery.  The letter was leaked, and it has triggered, according to the Guardian, “a storm of protest.”

The title of this blog is a play on David Edmond’s book, Would you kill the fat man, an exploration of moral philosophy and difficult choices about the valuation of human life. The RCCG’s decision intrigued me. It was essentially a decision about rationing a finite commodity — healthcare. In a world of plenty, rationing healthcare is a non-question.  In the real world, however, in a world of shrinking healthcare budgets and a squeezed NHS, resources must be allocated in a way that means some people will receive less healthcare or no healthcare.  Fairness requires that the rules of allocation are transparent and reasonable.

While you ponder, whether you would give knee surgery to the FAT MAN, I have a follow-up question.  Would you want to see a doctor who would deny you knee surgery because of some characteristic of yours unrelated to whether you would benefit from knee surgery?

I am sorry Mrs Smith, today we decided not to offer clinical services to women, people under 5’7″, or carpenters. We need to cut the costs of our clinical services, and by excluding those groups, we can save an absolute bundle.

I have heard it said of the doctor, academic and human rights advocate, Paul Farmer, that he would regularly re-allocate hospital resources from Boston to his very needy patients in Haiti.  He used to raid the drug stocks of a Boston hospital, stuff them in his suitcase and fly them back to his patients in Haiti.  I have no idea if the story is true or not. It does mark, however, one of the great traditions of medicine.  The role of a doctor is to advocate vigorously for the health (and often social) needs of the patient.  The patient actually in front of them.  The one in need.  Because, if your doctor will not advocate for your health needs, who will?  This is why all the great TV hospital dramas show a clash between the doctor and the hospital administrator.  Administrators ration.  Doctors treat.  The doctor goes all out to save little Jenny, against all odds.  The surly hospital administrator stands in front of the operating room, hand outstretched and declares (Pythonesque): “None shall pass.”

Under the current NHS system of clinical commissioning groups, there are family doctors who are simultaneously trying to make rational decisions about the allocation of limited resources to a population, and trying to be the best health advocates for the patient in front of them.  That screams conflict of interest. If you live in the catchment area of the RCCG and want my advice, check out which doctors are part of the RCCG.  If your doctor is one of them, change doctor immediately. Treating you, advocating for your health interests is what you need and should want.  Unfortunately, if she is part of the RCCG when she is treating you, you are not her principal concern.  Run(!) assuming of course that you don’t need knee surgery.

Should smokers and overweight people receive knee surgery?  Let’s start with smokers.  Why would you not want to treat a smoker?  It is difficult to come up with arguments that are not so outrageous that they are embarrassing to make. But I won’t let personal embarrassment get in the way of stating the top two silly arguments that came to mind:

  1. Smoking is a disgusting habit and anyone who smokes deserves all the pain they get?
  2. Smokers won’t live as long as non-smokers, so the investment in surgery to reduce pain and improve mobility in smokers will not have the net benefits to society as the same investment in non-smokers.

The arguments for restricting the surgery to people who are not overweight are similarly cringe-worthy.  There are also clinical reasons for prioritising the overweight.  The load on joints resulting from increased weight creates greater wear-and-tear and, the broader inflammatory processes that obesity triggers also seem to increase the risks of osteoarthritis — affecting hands as well as knees.  [See for example, here and here].

I can’t find the RCCG’s arguments for restricting access to knee surgery for smokers and people who are overweight, but prima facie it looks a lot like a variant of victim blaming.

Full disclosure.  I am all for the rational allocation of resources.  I think smoking is a disgusting habit. I am overweight and trying to do something about it.  I also think that the arguments for resource allocation need to be more explicit about the social values upon which they are often implicitly based.

Inequality of life expectancy between countries

A colleague of mine recently asked me if I knew of a citation for the narrowing in life expectancy between high-income countries (HICs) and low- and middle-income countries (LMICs).  I didn’t.  But the question did get me thinking.  Was there a narrowing between country-level life expectancy?  Probably … maybe … I didn’t know.

There are some very nice resources on life expectancy. I particularly liked Max Roser‘s post on the Our World in Data website.  None of the things I found, however, seemed to tackle the question of “the narrowing” in quite the way I wanted.  A longer search may have solved the problem, but it seemed just as easy to grab some data and have a look for myself.  While my colleague asked about a narrowing in the life expectancy gap according to the World Bank’s income classification (i.e., between HICs and LMICs), my interest was piqued by the broader question of the inequality in life expectancy between countries.

I decided to use the GapMinder data.  For a “quick and dirty” look it suited my purposes, it’s readily available, and the googlesheets R-package makes it trivial to access the data for re-purposing.  To simplify things, I calculated the deciles of life expectancy for the available countries in the gapminder data from 1870 to 2016.

I started with 1870 because in the years prior (from 1800) the gapminder data show nine largely unvarying parallel lines.  Around 1870 you can see that the life expectancy of the top (9th decile) improve rapidly, moving away from the pack of the lowest performing (90%) of countries.  The divergence continues until the beginning of World War I, when life expectancy in the 9th decile countries begin to decline as Europe started to implode. There is a sharp drop for life expectancies in all countries in 1918 marking the appearance of “Spanish Flu“.  After 1918 life expectancy in deciles 6-9 all start to improve, taking a dip for World War II; and then after World War II, life expectancy in all the deciles began to improve.  The overall pattern is one of narrow and low life expectancies in 1870.  Increasing disparity between the 1st and the 9th deciles, peaking around 1950, and then there is a gradual narrowing.

I find it quite difficult to make those kinds of visual comparisons, so I calculated a simple measure of inequality, the difference in years between the life expectancy of the 9th-decile countries and the life expectancy of the 1st-decile countries.

This 9th/1st decile gap (mis-named in the graph titles) in life expectancy is much, much clearer.  There is a relatively steady increase in the inequality, peaking around 1950.  There is then a steady decline in the inequality until the 1990s (when it increases again) and begins to decline again in 2000.  The narrowing inequality is, thus a relatively recent phenomena.  In 2016 the difference between the life expectancies in countries of the 9th- and the 1st-decile was 20.1 years.   In every year prior to 1909, the inequality was even lower.  Of course the life expectancies were also much lower.  In 2016 the life expectancies were 81.4 (9-th decile) and 61.3 (1st-decile), in 1909 they were 46.2 (9th-decile) and 26.0 (1st-decile).

The data extraction and plotting with the R-code is posted as a “gist” on GitHub.

Caveats

The data are not without their problems, for one, they are derived from multiple sources (some better than others).  Another obvious problem is that a “country” is not static over time.  Countries come and go and their borders change. To ask then about the life expectancy of a country is not straightforward.  Imagine a country with significant regional disparities in life expectancy, and that country is then divided into two independent states along those same regional lines.  Simply by division, an inequality in life expectancy arises.  I did not try to discuss this, nor to weight the analysis by the population size of the country. On the gapminder site you can find details of the data sources.

Finally the difference between the 9th-decile and the 1st-decile is only one among many ways to measure and understand inequality.