Major diseases: A (majorly) big-picture view

by Anjali Sastry on November 1, 2008

We had only a very short time–some 60 minutes–to start learning about major diseases in our class this week. As I told students, they way we see it, this class puts to the test the notion that an excellent manager knows something about the limits of his or her own knowledge, is skilled in drawing on others, and is always working to link and connect ideas and information, test hypotheses, and make the most of others’ experience and expertise in new and effective ways. Our students cannot learn as much about, say, HIV AIDS treatment, the Ugandan political system, or the lives of a given set of patients as our hosts, partners, and domain experts already know. So our job is to learn from them as effectively as possible.

To that end, we started looking at major diseases and health conditions that some of our student teams will encounter. We started with a very big-picture view, asking: what are the major diseases that impose the highest costs? We ended up talking about how one measures the cost of a given cause of death, and got talking about DALYs, or disability-adjusted life years, a standard measure for the cost to society of a given disease or health condition. Students wanted to know more about some of the methodological issues: the WHO site on the Global Burden of Disease is the best place to start. Here you’ll see the source of my graphs (the 2004 update), more data and reports, and links to academic papers that discuss some of the questions we touched on.

The readings we assigned for this class offer a useful starting point for anyone interested in the big picture. For self study, start here:

The World Health Report 2008 critically assesses the way that health care is organized, financed, and delivered in rich and poor countries around the world. The WHO report documents a number of failures and shortcomings that have left the health status of different populations, both within and between countries, dangerously out of balance.

The World Health Atlas is an interactive site that opens a window into the health of people around the world. The data are a few years old, but are nicely presented and worth exploring.

Global Health Opportunities: The Global Health Council worked with expert advisors to highlight four health focus areas: Child Health; Reproductive Health; HIV/AIDS; Infectious Diseases. This site presents the Global Health Opportunities 2008 on Priorities and U.S. Investments, in a very useful section-by-section format.

The online module Global burden of disease: Magnitude and measures is a nicely-produced resource to look through. Click on the icon at the lower right for a guide through the materials. Its learning goals:  Causes of Mortality; How Deaths are defined; Methods to generate health values; Summary Measures of Population Health; Global Burden of Disease Project; the Disability-Adjusted Life Year (DALY) and its criticisms; Mortality and DALYs projected to 2030.

BIO Ventures for Global Health, an organization dedicated to harnessing the resources of the biotechnology industry to create new medicines for neglected diseases of the developing world, produced its BVGH Global Health Primer last year.

Up next: Stay tuned for a post on the other part of our introduction to major diseases.

{ 4 comments… read them below or add one }

Susan Zawaski November 6, 2008 at 10:56 am

When trying to click through the link for “Global burden of disease: Magnitude and measures” there is an error in the page. Thus, I found this abstract which also provides projections of global disease to 2030.

Projections of global mortality and burden of disease from 2002 to 2030.
Mathers CD, Loncar D.

Evidence and Information for Policy Cluster, World Health Organization, Geneva, Switzerland. mathersc@who.int

BACKGROUND: Global and regional projections of mortality and burden of disease by cause for the years 2000, 2010, and 2030 were published by Murray and Lopez in 1996 as part of the Global Burden of Disease project. These projections, which are based on 1990 data, continue to be widely quoted, although they are substantially outdated; in particular, they substantially underestimated the spread of HIV/AIDS. To address the widespread demand for information on likely future trends in global health, and thereby to support international health policy and priority setting, we have prepared new projections of mortality and burden of disease to 2030 starting from World Health Organization estimates of mortality and burden of disease for 2002. This paper describes the methods, assumptions, input data, and results. METHODS AND FINDINGS: Relatively simple models were used to project future health trends under three scenarios-baseline, optimistic, and pessimistic-based largely on projections of economic and social development, and using the historically observed relationships of these with cause-specific mortality rates. Data inputs have been updated to take account of the greater availability of death registration data and the latest available projections for HIV/AIDS, income, human capital, tobacco smoking, body mass index, and other inputs. In all three scenarios there is a dramatic shift in the distribution of deaths from younger to older ages and from communicable, maternal, perinatal, and nutritional causes to noncommunicable disease causes. The risk of death for children younger than 5 y is projected to fall by nearly 50% in the baseline scenario between 2002 and 2030. The proportion of deaths due to noncommunicable disease is projected to rise from 59% in 2002 to 69% in 2030. Global HIV/AIDS deaths are projected to rise from 2.8 million in 2002 to 6.5 million in 2030 under the baseline scenario, which assumes coverage with antiretroviral drugs reaches 80% by 2012. Under the optimistic scenario, which also assumes increased prevention activity, HIV/AIDS deaths are projected to drop to 3.7 million in 2030. Total tobacco-attributable deaths are projected to rise from 5.4 million in 2005 to 6.4 million in 2015 and 8.3 million in 2030 under our baseline scenario. Tobacco is projected to kill 50% more people in 2015 than HIV/AIDS, and to be responsible for 10% of all deaths globally. The three leading causes of burden of disease in 2030 are projected to include HIV/AIDS, unipolar depressive disorders, and ischaemic heart disease in the baseline and pessimistic scenarios. Road traffic accidents are the fourth leading cause in the baseline scenario, and the third leading cause ahead of ischaemic heart disease in the optimistic scenario. Under the baseline scenario, HIV/AIDS becomes the leading cause of burden of disease in middle- and low-income countries by 2015. CONCLUSIONS: These projections represent a set of three visions of the future for population health, based on certain explicit assumptions. Despite the wide uncertainty ranges around future projections, they enable us to appreciate better the implications for health and health policy of currently observed trends, and the likely impact of fairly certain future trends, such as the ageing of the population, the continued spread of HIV/AIDS in many regions, and the continuation of the epidemiological transition in developing countries. The results depend strongly on the assumption that future mortality trends in poor countries will have a relationship to economic and social development similar to those that have occurred in the higher-income countries.
PMID: 17132052 [PubMed – indexed for MEDLINE]

What is most striking to me is that depressive disorders and heart disease are in the projected top three. HIV/AIDS is a terrible epidemic and the due research, attention, and policy has been, and needs to continue to be, given to this disease. However, current policy and research funds are not prioritized for mental health. Furthermore, less than 10% of worldwide health research is devoted to diseases that account for 90% of the global burden of disease.

Better tools and methodologies are needed to define priorities in health research investments. A multidisciplinary approach is needed to address all perspectives. However, the projection above provides good baseline analytics to begin setting the (expected) most prevalent diseases as priorities.

Anjali Sastry November 8, 2008 at 6:59 pm

Susan, thanks for the resources and comments. The mismatch between the need and funding in global health is a real issue for the entire field, and it’s good that you point this out. What struck me in our second two class sessions was how many organizations may be starting with HIV AIDS treatment and then developing with a broader model of health in mind. But how far does this take us towards addressing mental health and heart disease?
We fixed the link, by the way; the Global Health Education Consortium had changed its urls. It’s a site also worth visiting: http://globalhealthedu.org

Fernando Garcia Migliaro November 9, 2008 at 3:36 pm

The money is there, are we using it properly?

There is no doubt that the developed world has turned conscious about the urgent needs that developing countries have in all kind of aspects, including health. This awareness has been translated into an increased amount of money offered by private donors for different programs focused in specific health issues; and Africa has been in the top of the list. But this structure, private donor giving money for a specific health program, results in an inefficient usage of this scarce resource.

Obviously money is more than welcome, I would say more than necessary in order to improve Africa’s health services quality, but the fact that this money is coming from private donors puts a lot of restrictions to the final destination of these funds. It is common to see funds that are tied exclusively to the treatment of a particular disease in a certain region. But doing so is really effective? Does it worth to spend money in such an specific target when more basic things such as nutrition, running water, education, primary care, etc, are really precarious?

Offering ART drugs for AIDS treatment is definitely a huge help for citizens in these Regions, but is this the best way to help them? Is their life quality being improved? Having such specific targets results in actions that bring short-term solutions. People is helped to overcome this specific problem, but the root of the problem is not being tackled, so in the near future we will need more money to solve the same problem.

People that are offering their money are in their right to ask for specific and measurable results in order to assure a that funds are used properly and to promote their actions to attract more donors. It is necessary to find the way to convince these donors to offer their money without so many restrictions. In that scenario it will be easier to use that money to coordinate projects with a broader focus supported by public policies. It will be difficult to offer donors the tangible results that they may expect in the short-term, so it is mandatory to start thinking in building their trust in long-term projects before requesting a change in their funding policies. We don’t want to lose this funding inertia that has been developed in the last decade.

For a more detailed vision on this matter I suggest to read “The Challenge of Global Health”, by Laurie Garrett (From Foreign Affairs, January/February 2007). (http://www.foreignaffairs.org/20070101faessay86103/laurie-garrett/the-challenge-of-global-health.html)

Nga Phan November 30, 2008 at 4:56 pm

Fernando — I agree with the view that the financial resources are there but they perhaps are not utilized in the most optimal ways. One issue you mentioned is that fact that often times these funds are highly restrictive, but another issue is the competitiveness in securing funds on a long-term basis for areas that NGOs and private donors may not have an interest in.

The increased competitiveness of securing funds for a social organization is what motivates Surgeons OverSeas (a flagship program of Society of International Humanitarian Surgeons (SIHS) — a non-profit organization with 100 member surgeons who desire to practice in developing nations — to explore a cross subsidization revenue model. The idea here is to identify a customer base that would be willing to pay for the improved surgical care provided by well-trained, experienced, and board-certified U.S. surgeons to enable the poor to have access to the same quality of care.

I see monumental benefits for an organization to not have to constantly worry about getting money to keep an organization going but have the freedom to focus on delivering health care. A self-sustained organization can go a long way in addressing the medical needs of the underprivileged. A success story that we learned in class is the Aravind Eye Hospital in India.

One thing to keep in mind for our project in Sierra Leone is not to lose sight of the primary focus, which is to improve surgical care for the local population who can’t afford it.

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