Category Archives: Equity

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

Globalisation and health

The past has already been written and the accolades distributed. We now need to decide whether the next century is going to be good or bad for our health, and the role of globalisation in helping us to determine our destiny. People living in failed states do not enjoy utopian, anarchic freedom. They die young. Healthy populations need the goods and services of society to be shared in a broadly inclusive fashion. They need health systems that can respond rapidly and flexibly to emerging disease. They need environments that support human life.

The zombie apocalypse is our least likely but most entertaining future. [image from proprofs.com]

70,000 years ago our ancestors took their first steps out of Africa. With those steps they initiated the binding link between globalisation and health. The difference between then and now is a matter of temporal and geographical scale. Then, nothing moved faster than a walking pace. Now, a person can traverse the globe in 24 hours. A city thousands of kilometres away can be destroyed in 30 minutes. An idea can be everywhere in seconds.

The technological advances of the last century have been kept pace by extraordinary improvements in human health. Average life expectancy barely moved until the beginning of the last century, and over the next hundred years, it doubled. In 2016, the global average life expectancy was 71.4 years of age. We had achieved the biblical entitlement of three score and ten years promised in Psalm 90. The improvements in health were achieved because of globalisation. Reductions in poverty. Improvements in food supply. Advances in healthcare. Sophisticated infrastructure was delivering clean water and carrying away waste. Those advances have also been accompanied by large inequalities in health outcomes and significant environmental degradation.

I suggest there are three broad intersections between globalisation and health. First, there is the real (and sometimes imagined) disease outbreaks: Ebola or the Zombie apocalypse. Infectious disease, however, is only one part of the health and globalisation relationship. The second, very modern concern is the interconnection between our global activities and environmental change, and by extension the impact on human health. The final idea is our relationships with each other, and how these relationships can shift, and the effect the changes may have on the availability of health supporting resources.

I sketched these ideas out in a 3,000 word essay in early 2017 at the invitation of the Editors of “Vaguardia dossier” a Spanish language, Catalan magazine. Many people (including myself) cannot read the published, Spanish version, but you can get the slightly rough, English language preprint here.

Reidpath DD, Globalización y salud [Globalisation and health]. Vanguardia dossier. 2017; 65:76-81

Fat on the success of my country

When I first visited Ghana in the early 1990’s, there was a very noticeable relationship between BMI and wealth. Rich people were far more likely to be overweight and obese than poor people. That visit took place about ten years after the 1982-1984 famine. Some of the roots of the famine lay in natural causes resulting in crop failure and some lay in local and regional politics, and it was small children that bore the brunt of it. Less than ten years after the famine it was perhaps unsurprising to see that (on average) the thinnest were the poorest, and the fattest were the richest.

Working in Australia in the early 2000s, however, there appeared to be exactly the opposite relationship. It appeared that the poorest were more likely to be overweight or obese and the wealthiest, normal weight. This observation was certainly borne out at an ecological level when my colleagues and I found an unmistakable relationship between area level, socioeconomic disadvantage, and obesogenic environments — fast food chain “restaurants” were more likely to be found in poorer areas.

So which is it? Are the poor more likely to be overweight and obese, or is it the rich? One of the challenges in working out this relationship is that it appears to be different in different countries. Neuman and colleagues conducted a multi-level study of low-and middle-income countries (LMICs) looking at this very problem using DHS Survey data. They found an interaction between country-level wealth, individual-level wealth, and BMI. Unfortunately, the study was limited to LMICs because the DHS surveys do not operate in high-income countries. While it would be tempting to extrapolate the interaction into high-income countries, without the data, it would just be a guess.

We don’t have the definitive answer, but a recent paper by Mohd Masood and me, based on his PhD research, provides some nice insights into the issue. We were able to bring together data from 206,266 individuals in 70 low-, middle- and high-income countries using 2003 World Health Survey (WHS) data. The WHS data are now getting a little old, but it is the only dataset we knew of that provided BMI and wealth measures from a sample of all countries, using a consistent methodology, all measured over a similar period of time.

Mean BMI of the five quintiles of household wealth in countries ranging from the poorest to the richest (GNI-PPP). [https://doi.org/10.1371/journal.pone.0178928]

The analysis showed that as country-level wealth increased, mean BMI increased in all wealth groups, except the very wealthiest group. The mean BMI of the wealthiest 20% of the population declined steadily as the wealth of the country increased. In the wealthiest countries, the mean BMI converged for the poorest 80% of the population around a BMI of 24.5 (i.e., near the WHO cut-off for overweight of 25). The wealthiest 20% had a mean BMI comfortably below that, around 22.5.

It is obviously not inevitable that as the economic position of countries improves, everyone except the very richest put on weight. There are thin, poor people and fat, rich people living in the wealthiest of countries. Nonetheless, the data do point to structural drivers creating obesogenic environments. My colleagues and I had argued, at least in the context of Malaysia, that the increasing prevalence of obesity was an ineluctable consequence of development. The development agenda pursued by the government of the day decreased physical activity, promoted a sedentary lifestyle, and did nothing to moderate the traditional fat rich, simple carbohydrate diet associated with the historically rural lifestyle of intensive agriculture.

We really need more data points (i.e., a repeat of the WHS) to try and tease out the effect of economic development on obesity in the poorest to the richest quintiles of the population. I would suspect, however, that countries need to think more deeply about what it is they pursue (for their population) when they pursue national wealth.

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