False dichotomies in global health: the need for integrative thinking

The Lancet –  Prof Julio Frenk, PhD; Prof Octavio Gómez-Dantés, MD

During the 20th century, international health was strongly influenced by a set of dichotomies that limited the advancement of the health agenda. In an attempt to force choices, actors in the international arena presented several options to address the dominant health challenges as if they were mutually exclusive. It was a clear expression of a century divided by ideological affections. The list of dichotomies is anything but short: prevention versus treatment, vertical versus horizontal, primary care versus specialised care, infections versus non-communicable diseases (NCDs), knowledge versus action. Unfortunately, the Manichean fixation on false dilemmas continues to pull members of the global health community apart with the re-emergence, in the context of the discussion of the post-2015 sustainable development agenda, of an old and bitter discussion: whether to invest in the social determinants of health or in health care.

The central message of this comment is that, in order to meet the complex challenges of an interdependent world, global health should move, once and for all, beyond those deceiving dilemmas towards integration. The meaning of the word integration, in fact, is related to the ideas of balanced whole and common purpose, which are critically needed in global health in the 21st century.

With the gains made against infectious diseases and increases in child survival beyond 5 years of age, populations all over the world are living long enough to experience the NCDs associated with age. In 2010, 65% of all deaths worldwide (more than 36 million) were attributed to these diseases.1 Around 80% of these deaths occur in low-income and middle-income countries.2

However, in developing nations this transition has occurred while communicable diseases and maternal deaths are still serious threats, thus creating what has been termed a double burden of ill health. In strict sense we should speak of a triple burden, since we should also consider the health challenges related to globalisation, such as pandemics and the health threats associated with climate change, to which developing countries are more vulnerable.3

The increasing prevalence of NCDs has also transformed the whole meaning of illness. Previously, the experience of disease was marked by a succession of acute episodes, from which one either recovered or died. Now, people spend substantial parts of their lives in less than perfect health, coping with a chronic condition. Illness may not always kill us, but it always accompanies us. It has therefore become a condition of living, often stigmatised.

In order to successfully confront these complex epidemiological challenges we need to implement a major shift in global health thinking. An important component of this shift is the abandonment of the dichotomous approach that has polarised the global health community for over half a century.

Probably the first dichotomy that split the international health community apart was prevention versus treatment. The strong concern for personal hygiene and public health prevalent during the 19th century was gradually eclipsed by a growing attention to disease and its care.4 The starting point of this fluctuation towards sickness and health care was the increasing acceptance of the germ theory of disease, inspired by the work and discoveries made by Agostino Bassi, Ignaz Semmelweis, John Snow, Louis Pasteur, and Robert Koch.5 This theory eventually nourished the specific aetiology doctrine,6 which states that each disease has a precise cause and should be treated by confronting the causative agent or, if this is not possible, by focusing on the treatment of the affected parts of the body. In the early 20th century, the hunt for specific germs responsible for all sorts of infectious diseases reached feverish proportions, and so did the search for their cures, incited by the development of new vaccines and the discovery of immune sera and antibiotics. This search was eventually followed by an intense pursuit of the biological, chemical, or physical agents responsible for NCDs, such as cancer, diabetes, hypertension, depression, and others.7 Equally intense was the search for specific cures for these diseases, preferably pharmacological substances that act on the internal milieu, without any regard for the physical and social environment in which those same diseases have their origin.

In the second half of the past century, smallpox eradication and the dramatic success of the global immunisation campaigns shifted the emphasis towards prevention, considered by many not only as a superior but also a cheaper alternative. So for quite a while part of the global community was convinced that in order to control diseases in the developing world it was necessary to put all available resources into stronger prevention programmes.

This is a false dilemma. Health systems require both prevention and treatment, because even if we invest increasing amounts of resources in prevention we will still need to deal with the consequences of risk-factor exposures that have already occurred. The new global health agenda should consider the integration of these two approaches, which are mutually reinforcing, and address what Michael Porter has called the full cycle of care.8 It has been demonstrated, for example, that the treatment of patients with AIDS has enormous impacts in prevention of the spread of this disease. Early detection and treatment of diabetes is also crucial to avoid the complications of this ailment, which require complex and costly interventions that impose enormous financial pressures both on households and health systems. Finally, pain care for cancer, a critical component of the treatment of this disease, has major effects on the quality of life of patients and has proved to be a very cost-effective measure.

Another source of conflict in international health in the 20th century was the divide between vertical and horizontal approaches to the improvement of health. Vertical programmes, which are disease specific and provide very precise services through specialised units, were denounced for ignoring the determinants of health, privileging technical-oriented interventions, and neglecting diseases that demanded complex interventions and extensive, long-term investments. Horizontal interventions, which tackle several problems by strengthening the general operation of health systems, were in turn criticised for being too broad and unable to produce significant results in short periods of time. Without a clear sense of priorities, these horizontal approaches to health care in developing countries also tended to cater to the needs of the better-off.

Global health in the 21st century should integrate vertical and horizontal programmes because we now know that, through what Sepúlveda has called the diagonal approach, we can use explicit intervention priorities to strengthen the overall structure and functioning of health systems.9 An additional advantage of this approach is that these priorities can be used to address the needs of the worst-off, turning them into entitlements that empower vulnerable populations.

A third dichotomy is that related to primary and specialised care. During the last century primary health care was the dominant paradigm in the international health arena and was frequently presented as in conflict with specialised care. This paradigm was also placed within a hierarchical organisational structure and identified with simplicity of problems or resources, or both. In its extreme applications, primary was confused with primitive care, which not surprisingly was reserved for the poorest people.

The global health community should strive to integrate different levels of care through the creation of networks that guarantee the continuity of care, which is crucial for the adequate treatment of most NCDs. The instruments to build these networks lie in a number of revolutions of the 21st century: biomedical, communications, and managerial. In particular, the telecommunications revolution is mobilising cutting-edge innovations that are now available even in the poorest communities, such as mobile phones.

Appropriate technology should no longer be identified with primitive tools. Today a patient may be diagnosed and treated in the first level of care in a rural community by a provider working in a high-specialty hospital of an urban centre. Therefore, a fundamental shift can be launched from the rigid pyramidal structures that have prevailed in the health sector to plastic networks that improve access to all levels of care. A related transformation involves moving beyond health centres, which by definition concentrate human and technological resources, into health spaces, which extend the reach of comprehensive care into schools, workplaces, recreational areas, and the homes of those who live with a chronic condition.10

A fourth dichotomy is that between infections and NCDs. In the 20th century international health was identified with the control of communicable diseases, which were supposed to be characteristic of developing countries. NCDs, by contrast, were practically absent from the global health agenda, under the belief that they would be limited for quite a long time to high-income countries. In the 20th century there was also a general consensus around the idea that infections and NCDs were biologically different.

Reality proved to be a lot more complex. NCDs are now the main cause of death and disability in middle-income countries, and their prevalence is rapidly rising in low-income nations. Infections never disappeared from the developed world, and AIDS and antibiotic resistance were strong reminders of the danger of lowering the guard against communicable diseases. Additionally, ailments originally classified as non-communicable have now been found to have an infectious cause. According to WHO, a fifth of all cancers worldwide are caused by chronic infections produced by agents such as HIV, HPV, and hepatitis B virus.11 Other infections and parasitic diseases are also the cause of other NCDs, such as rheumatic heart disease, Chagas cardiomyopathy, and peptic ulcers. In sum, infectious diseases are not necessarily discrete biological events and the exclusive domain of a primitive stage in the health transition, but rather part of a biological continuum and a shifting component of every epidemiological pattern.12

The former Director General of WHO, Gro Harlem Brundtland, liked to talk about communicated diseases, which are non-communicable in the biological sense of the word, but are transmitted through advertising and sponsorship of unhealthy products such as tobacco, junk food, and carbohydrate beverages. “Our job”, she used to say, “is to immunise people against [these epidemics].”13

In order to meet the challenge represented by NCDs we need to integrate them with communicable diseases in the global health agenda. One of the goals in this regard should be to include health targets related to NCDs common in low-income and middle-income countries, such as hypertension, diabetes, and cervical cancer, in the post-2015 sustainable development agenda.

The fifth false dilemma is that between knowledge and action. In the past century there was an extended belief that international health is mostly an arena for action and that knowledge generation is a long and complicated process that very seldom musters products that can be used to meet the health needs of developing regions. Academic institutions were viewed as isolated communities engaged in pursuits that were disconnected from the everyday world. Health researchers themselves thought that their responsibility ended with the publication of their research results. In turn, decision makers in the health field developed their activities with little concern for the use of evidence in the design and implementation of programmes and policies.

It is precisely in response to this divide that knowledge translation and implementation research were developed: to ensure that use of knowledge stops being a random event and becomes instead a programmed phase of the research process and a central requirement of decision making. In the 21st century we should disseminate the idea that academic excellence should be defined not only as strict adherence to the highest standards of research and education, but also as the undertaking of all possible efforts to translate knowledge into action. In a memorable speech delivered in Mexico City in 2006, Richard Horton stated: “It is not enough to know for the sake of knowing. You and I have a responsibility for acting on our knowledge. Delighting in knowing is an indulgence. Acting on knowledge is an imperative. But that is an imperative we can truly delight on.” (Horton R, The Lancet, personal communication).

The decision-making side of the equation also has a responsibility in this regard. Scientifically derived evidence must guide the design, implementation, and evaluation of programmes by national governments, bilateral aid agencies, multilateral institutions, and civil society organisations.

In recent years, an old divide has re-emerged in the global arena: the dilemma between investing in the social and economic determinants of health or investing in health care. This discussion, associated to the work of the famous physician and medical historian Thomas McKeown, reached great intensity in the 1970s and 1980s. McKeown attributed the decline of mortality and the rise of the world population in the industrialised world from the 1700s to the present to improvements in the overall standards of living resulting from broad economic and social changes rather than to public health or medical interventions.14, 15, 16 This view, however, was refuted by analyses developed in the 1980s by historical demographers.17, 18

Irrespective of its flaws, McKeown’s work had the enormous merit of highlighting the importance of the broad determinants of health. However, it also nourished the appearance of a false rift that has resurfaced in the recent past around the discussion of the post-2015 development agenda.

The allegation that targeted health interventions and socioeconomic policies should be regarded as opposing choices is associated with a limited view of what a health system is supposed to do. Traditionally health systems have been identified mainly with the direct provision of medical and public health services. This is, of course, an essential function. However, in order to provide these services, health systems must perform other enabling functions, such as stewardship, financing, and resource generation.19

The stewardship function includes strategic planning, design of clear and enforceable rules of the game, assessment of health system performance, and coordination within the health sector and with other sectors involved in the generation of goods and services with important health effects. The latter is a stewardship subfunction that is crucial to promote policies to act upon the determinants of health. Examples of such policies are road safety measures to prevent traffic accidents, norms to promote occupational health and prevent work-related injuries, fiscal policies to combat tobacco consumption, and environmental interventions to deal with the health consequences of climate change.

There is an additional component of this stewardship subfunction that has enormous effects on the determinants of health: the expansion of financial protection in health. This kind of protection contributes to the reduction of poverty by avoiding not only direct expenditures and debt to pay for health care, but also the sale of family assets, especially those that have a productive nature, the loss of which reduces future household income. Furthermore, social protection mechanisms for health liberate resources that families previously tended to invest in health care. These resources can now be used to meet other needs, such as nutrition and education, both of which are also considered major determinants of health.

Finally, a properly working health system—which provides high-quality personal and community health services with financial protection—also improves health, and as economic research has shown, good health improves educational performance, increases labor productivity, enhances the investment climate and, by doing all these things, stimulates economic growth, which, in a virtuous circle, in turn improves population health.20

All these facts have contributed to increase the importance of health, which now occupies a central place in the most pressing dimensions of the global agenda: economic development, national security, democratic governance, and human rights. This recognition has been associated with an extraordinary expansion of development assistance for health, which increased from 10·7 billion dollars in 2000, to 28·1 billion dollars in 2012.21

This interest and commitment can only be celebrated by those who have specialised in health matters. It implies the recognition of health not only as a specific sector under the responsibility of specialised ministries of health and international agencies but also as a social objective. As a universally shared value, health is an indicator of the general progress of a society and a reflection of its success in securing equal opportunities for all its members. Because of these broader implications, health indicators are a key component of the Human Development Index and health targets figured so prominently in the Millennium Development Goals. Hopefully, they will also occupy a central position in the post-2015 development agenda.

If health is a social objective more than a specialised field, then its fulfilment demands a broad engagement of all sectors. This means that modern health systems need to mobilise all instruments of public policy to design not only health policy, but also to promote the design and implementation of healthy policies, which act on the major determinants of health.

In conclusion, the complex health needs faced by the global population, increasingly dominated by NCDs, can be addressed only through a comprehensive response that demands solid consensus among all global actors. This response should include upstream interventions to address determinants of health; public health interventions to deal with major risk factors; personal health services to manage infections, maternal health, NCDs, injuries, and mental health problems; and pain control and palliative care. It should also include the identification of priority measures to prevent and treat the most pressing health challenges faced by vulnerable populations in developing regions. Additionally, the design and implementation of this response should be guided by solid evidence.

The global community will be able to advance this comprehensive response only if it leaves behind the dichotomous mindset that has characterised international and global health in the past decades, which tended to emphasise the extremes of the global health situation and disregard its grey areas and its complexities. An editorial on NCDs published in The Lancet stated that we have “an unprecedented opportunity to change the conversation of global health, to rewrite the political manifesto for health”.22 If we are to take advantage of this opportunity, ratified by the approval of the Sustainable Development Goals, we must mobilise the transformative power of integration to address the pressing global health challenges of our times.

Contributors

The general idea of this Viewpoint was conceived by JF and was further developed by both authors, who contributed equally to the writing of the final draft.

Declaration of interests

We declare no competing interests.

Acknowledgments

A version of this Viewpoint was presented at the conference “The Long Tail of Global Health Equity: Tackling the Endemic Non-Communicable Diseases of the Bottom Billion” held at the Harvard Medical School in Boston, MA, USA, on March 2, 2011.

References

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