The cure for global poverty: Health

Mother and child, Madhya Pradesh, India
Mother and child, Madhya Pradesh, India
Flickr, DFID

Researchers Discover Powerful Cure for Poverty and Inequality – Health

If you could only do one thing to reduce poverty and inequity around the world, say experts in global development, the best thing you could do is reduce the disproportionate burden of disease on those living in the poorest communities.

Improving health, according to a relatively new and perhaps still under-appreciated report written by a blue-ribbon panel, remains the most powerful tool for improving lives and reducing extreme poverty worldwide.

But it’s still a woefully underused tool that, as Humanosphere will report on tomorrow, is actually losing ground on the anti-poverty agenda even as the evidence of its import swells.

Dean Jamison
Dean Jamison

“We have an unprecedented opportunity, unlike any time before in human history, to significantly reduce the level of inequity in the world,” said Dean Jamison, a health policy expert at the University of Washington and, with Harvard University’s Lawrence Summers, one of the lead authors of the report, dubbed Global Health 2035.

“Even in the United States, the single largest cause of poverty is medical expenditures, usually due to some health crisis,” Jamison said. “Europeans have a hard time understanding this, because for the most part they don’t experience medical bankruptcies. But the connection between illness and poverty is also especially the case for the poor in developing and middle-income countries.”

Not everyone agrees, of course, that improving health should be at the top of the anti-poverty agenda.

Some say improving governance, human rights or business development are more powerful means for fighting poverty. Some say we need less targeted efforts and an agenda that emphasizes sustainable development (whatever that means….). The aid and development community, it should be noted, argues about almost everything.

Some of the most popular talking points these days among the anti-poverty expert class can seem a bit odd – pondering whether or not aid works (a question that, stated as such, seems absurd), if giving cash directly to poor people is a good thing (economists have discovered, through carefully conducted trials, that poor people do benefit from having more money … Duh.) and even about what the words ‘aid’ and ‘development’ actually mean.

It can all start to sound to a newcomer or outsider a bit like freshman philosophy class, in which the whole point is for your professor to make you question your assumptions, or your very existence … or if we all see the same thing when we see the color blue. That’s a good thing to do if the goal here is to demonstrate critical thinking or to try to get ‘outside the box’ and be innovative, but billions of people are suffering and dying today.

It’s important to do something now, based on the best evidence we have as to what most reduces suffering and inequity.

And Jamison, Summers and the other development experts who wrote the Global Health 2035 report think the evidence is overwhelming: You can’t get more anti-poverty bang for the buck than can be gotten from the right kind of health improvements.

“Reductions in mortality account for about 11 percent of recent economic growth in low-income and middle-income countries,” the report states. That’s a lot, and yet this accounting is still based on the bizarre metrics of standard economics which usually fails to factor in ‘externalities’ like the quality of the air and water, people’s sense of security or enjoyment of daily life … you know, most of what matters.

When Jamison and his colleagues (many of them economists yet still somewhat interested in reality) wanted to get a more comprehensive view of the impact health improvements have on a person, or population’s, well-being, they turned to what’s known as the ‘full-income’ measure. This includes factoring in trying to measure the intrinsic value of, well, not dying – which they call (because they’re still wonky economists) “VLYs” – Value for additional Life Years.

“Between 2000 and 2011, about 24 percent of the growth in full income in low-income and middle-income countries resulted from VLYs gained,” the report states.

Okay, wow. Again. Unless I misread these folks, they are saying a quarter of all the growth experienced in poor and middle-income countries over the last decade is due to health improvements and, yeah, not dying. Below is a positive-feedback illustration from the report that basically says if people stop getting sick and dying, their productivity increases, kids go to school, the environment wins and the country’s overall GDP goes up. Yes, that seems kinda obvious but experts like charts….

Health GDP
Global Health 2035

This seems like a fairly big deal that the anti-poverty crowd should be celebrating as a clear evidence-based pathway to cutting through all the babble and gobbledygook that now characterizes the debate over setting the next stages for the aid and development agenda.

But it’s not, yet anyway. The Global 2035 report, which was published by The Lancet just before Christmas, got some media attention when it first came out – such as this Guardian story noting that if we increased global health spending annually by $60 billion we could see a ‘grand convergence’ and reduction in the kind of inequality that separates the rich and poor worlds.

Bill Gates later tried to push it at the elite World Economic Forum in Davos. Gates, whose philanthropy helped fund the report, also used it as ammo for his popular but somewhat controversial prediction that most countries would escape poverty by the year 2035. Gates’ optimistic prediction got plenty of media attention, but few media ever even asked why he picked the year 2035 (as opposed to 2030, the consensus finish line for the international community’s next set of Millennium Development Goals, established in 2000 with a target date for accomplishing them in 2015 … which mostly won’t happen).

Humanosphere reported that Gates was focused on the year 2035 because of Jamison, Summers and the Global Health 2035 findings. Yet the report is seldom mentioned, even by some within the global health and development community. Maybe this is because it’s so wonky, has no funny viral video and because the aid and development community isn’t as evidence-based as it likes to think it is.

Or maybe it’s just following the path of its predecessor report, the World Development Report of 1993 – the first (and still only?) World Bank report devoted to examining the relative contribution of health to economic development. Jamison and Summers were lead authors of that report as well, which surprised many by demonstrating in the otherwise dry, drab and statistic-laden lingo of the institution that you can do some amazing things in poor countries simply by getting kids vaccinated, making childbirth safer and such.

Nothing much happened in 1993 or in the years immediately following this revelation. But then, in the late 1990s, this one guy stumbled upon these statistics and things started changing.

“Every page screamed out that human life was not being valued in the world at large,” said Bill Gates, recalling his response to being handed the WDR 1993 report by his then-adviser Bill Foege. The new Bill & Melinda Gates Foundation had found its mission, global health, starting with an emphasis on expanding access to childhood immunizations.

The Global Health 2035 report, which makes an even stronger case for emphasizing health as a primary means of fighting poverty and inequity, awaits its eureka moment. And for no apparent reason, here’s the wonderful Bobby McFerrin singing Don’t Worry, Be Happy.

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About Author

Editor Tom Paulson is founder and lead journalist at Humanosphere. Prior to operating this online news site, he reported on science,  medicine, health policy, aid and development for the Seattle Post-Intelligencer. Contact him at tom-at-humanosphere.org, follow him on Twitter @tompaulson and/or send a comment below.

  • Jonathan Scanlon

    Thanks for bringing the report back to the top of things Tom. I missed it when it came out in December. There’s a lot of good stuff in here. Good new data, new rationale for investing in health, and new policy recommendations.

    That said, I’d dispute your headline an opening lines that state that this is a group of development experts saying that health should be #1 compared to everything else in development. A few people on the commission come from other backgrounds, but the majority of the group are global health experts. There’s nothing wrong with that. I think you should state what this is: a global health commission developed a global health agenda for the next 20 years.

    A group of agriculture experts on a commission would have concluded that agriculture investments should be the top priority in development. When the UN asks citizens what they think should be the priorities for the post-2015 agenda they say education is #1, with health a close #2 (http://www.myworld2015.org/index.html?page=results)

    The Lancet Commission was asked to focus on health. In the “Introduction” section on the second page of the report they acknowledge this. The commission was set up to update the 1993 WDR recommendations, not to consider health as an investment versus agriculture, climate change, human rights, etc.

    From the report: “The Commission aimed to consider the recommendations of WDR 1993, examine how the context for health investment has changed in the past 20 years, and develop an ambitious forward-looking health policy agenda targeting the world’s poor populations.”

    Enough about all that.

    As someone that thinks a lot about US government policy there are some things to consider here. On financing for health, the paper says that low and middle income countries can fund many of the needed increases in health spending with domestic revenue. We should be doing more to help in this area. There’s a lot of good debate at G20 and OECD about tax laws, but a lot of the focus is on OECD countries. The US and others can do more to make sure that American companies are paying what they owe in developing countries. The US can also do more to make public and private finance flows more transparent. Pending legislation like the Foreign Aid Transparency and Accountability Act can help to make our aid transparent. Getting the SEC to actually implement the extractive industry transparency provisions in Dodd-Frank can help.

    Regarding US ODA, there are some recommendations here about targeting our aid. This will be important. The paper calls for increases in aid for health, but the trends show that this is unlikely to happen in the next few years. Some countries are decreasing ODA and others are holding steady. Few of the traditional donor countries are increasing aid at the scale called for in the report. So ODA has to be effective.

  • Aaron Katz

    Ok Tom, but it seems to me a more fundamental question is how does one improve health? I’ll be honest, I haven’t read the report (yet), but many powerful organizations and people seem to think we can obtain huge health gains by providing health care services. I don’t think, in broad brush, that’s true or supported by the evidence.

    A simple analogy: we can build, equip, and staff a clinic in remote Sudan, but if the roads are passable (as many aren’t in the wet season), the investment isn’t going to “improve health.” In this case, it’s probably more effective to pave the roads.

    And Jamison’s argument that health care is the largest cause of poverty I think confuses the data that show that health care is the largest cause of bankruptcies, not the same thing. Health care is no doubt a contributor to financial stress, but poverty is caused by a wide range and depth of factors, from historical racism, to de-unionization, deindustrialization, and wage stagnation, lack of social support systems, etc.

    • http://humanosphere.kplu.org Tom Paulson

      Thanks Aaron,
      I think you and Jon Scanlon are saying similar things – that poverty is not primarily caused by poor health, or lack of access to health services. I agree and am glad to see that we are beginning to incorporate into the ‘humanitarian agenda’ issues of human rights, harmful business practices, political corruption and the like. It’s fair to say Dean Jamison and the other authors of Global Health 2035 are equally happy to see this. That said, the question here is what are best means – the most effective tools – to begin chipping away at the immediate needs. The authors of this report contend, based on their analysis, that improving health can be the most powerful avenue to reduce immediate suffering and inequity. I don’t think they are arguing it is the only thing we need to do, or even that this gets at root causes. They are simply saying it may be cheaper, easier and more effective to, for example, reduce the AIDS death toll in Africa than it will be to ‘improve governance’ or ‘create sustainable development.’ The latter two are probably more important, but also much more difficult and complex. While we debate how to improve governance or even what the hell we mean by ‘sustainable development,’ millions still die or suffer from easily prevented diseases. The point, based on their analysis, is that we still have some low-hanging fruit to pick before we strive for the bigger – and perhaps more important – uh, fruit?

      • Aaron Katz

        I dunno, I still think we’re talking past each other. Yes, if we reduced HIV/AIDS, maternal and infant mortality, malaria morbidity, etc., poor communities would be less poor. But people much smarter than me are debating whether 10 years of investment in MDGs – the health goals of which spurred spending on both health care and traditional public health/prevention – produced more health. That’s the question … HOW to improve health? Is it through health services (medical, preventive) or by improving family income, female education? I don’t think we have to go to vagueries like “good governance” to find non-health actions that would improve health.

      • Aaron Katz

        By the way, you pooh pooh the effectiveness of good governance, etc., and it’s no doubt hard to measure them (conjures up the looking for keys under the lamp post parable), plus the effects are years down the road, but such evidence does exist.

        Here’s an excerpt of a recent study [http://cps.sagepub.com/content/early/2013/12/27/0010414013512601.full?keytype=ref&siteid=spcps&ijkey=qPmuzabskSFkQ] on public budgeting in Brazil:

        “Municipal governments that adopted PB spent more on education and sanitation and saw infant mortality decrease as well. We estimate cities without PB to have infant mortality levels similar to Brazil’s mean. However, infant mortality drops by almost 20 percent for municipalities that have used PB for more than eight years. The evidence strongly suggests that the investment in these programs is paying important dividends.”

        The causal pathway(s) isn’t clear (is it PB, per se, PB via increased sanitation, PB via additional CBO presence, or PB via increased health care spending?), but that shouldn’t make us shy away from thinking hard about investing in such initiatives.

  • Joaquin Gasgonia Palencia

    frequently we view health care from the perspective of our own experiences, which vary quite wildly, as the socio-economic conditions in a remote village as well as its everyday concerns are different from those in the cities. we need to look at these missions through local dynamics and not those of cities from far away.
    the downtime from health problems mean considerable socio-economic losses in these challenged areas because frequently, one’s daily bread is exactly that, daily. thus, if one misses a few “dailies” due to health problems, then, everyday is a period of hunger and more health problems.
    health problems are a major factor on economic well-being in these areas. putting up clinics would solve acute cases but would require some resources in order to ensure a healthier population in terms of better nutrition and work conditions. and we do not need paved roads to access remote communities. all communities are accessible one way or another.