[Reprinted: The Lancet, 10-17-2020]
What strategies should governments adopt to improve the health of their citizens? Amid the COVID-19 syndemic it would be easy to focus attention on global health security—at a minimum, strong public health and health-care systems. WHO has based its global health strategy on three pillars: universal health coverage, health emergencies, and better health and wellbeing. The indispensable elements of robust public health and health care are well known and endlessly rehearsed—a capable health workforce; effective, safe, and high-quality service delivery; health information systems; access to essential medicines; sufficient financing; and good governance. But has the gaze of global health been too narrow? Have health leaders and advocates been missing the most important determinants of human health?
The latest report of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 raises uncomfortable questions about the direction global health has taken in the 21st century. On the one hand, the news seems good. The health of the world’s population is steadily improving. Global life expectancy at birth increased from 67·2 years in 2000 to 73·5 years in 2019. Healthy life expectancy has increased in 202 of 204 countries and territories. In 21 countries, healthy life expectancy at birth increased by more than 10 years between 1990 and 2019, with gains of up to 19·1 years. The estimated number of deaths in children under 5 years decreased from 9·6 million in 2000 to 5 million in 2019. Indeed, the falls in rates of age-standardised disability-adjusted life-years since 1990 have been the largest for communicable, maternal, neonatal, and nutritional diseases—and progress has been fastest in the past decade.
But GBD also reveals, once again, that health depends on more than health systems. The strong correlation between health and the socio-demographic index—a summary metric of a country’s overall development based on average income per capita, educational attainment, and total fertility rates—suggests that the health sector should consider redefining its scope of concern.
GBD 2019 also offers a revised theory of the demographic transition, delineating seven separate stages. A particular innovation is the idea of late-transition and post-transition stages, disaggregated for migration status. 35 countries, largely in sub-Saharan Africa and the Middle East, are in mid-transition, with falling birth and death rates (as of 2019, no countries were in the pre-transition stage). Countries such as Brazil, China, and the USA are in the late-transition stage, with death rates plateauing, while birth rates continue to decrease. The final post-transition stage is when the birth rate is lower than the death rate and natural population growth is negative—as seen in Japan, Italy, and Russia. An important and overlooked influence on these demographic stages is migration. 17 countries, including Spain, Greece, and many eastern European countries, are in “a precarious state”—in the post-transition stage, with net emigration. Here, policies are needed to lessen the social and economic effects of an increasingly inverted population pyramid—encouraging immigration could be one way to help.
None of these arguments should suggest that universal health coverage and global health security are irrelevant to health. As the GBD 2019 authors argue, some countries have longer life expectancies than their stage of development would predict. These overperforming nations—such as Niger, Ethiopia, Portugal, and Spain—probably have superior public health and health-care policies. What GBD 2019 does suggest is that the global health community needs to radically rethink its vision. An exclusive focus on health care is a mistake. Health is created from a broader prospectus that includes the quality of education (primary to tertiary), economic growth, gender equality, and migration policy.
This conclusion is immediately relevant to national strategies to address COVID-19. Although attention should be given to controlling community transmission of severe acute respiratory syndrome coronavirus 2 and protecting those most vulnerable to its consequences, success will require a more capacious strategy. COVID-19 is a syndemic of coronavirus infection combined with an epidemic of non-communicable diseases, both interacting on a social substrate of poverty and inequality. The message of GBD is that unless deeply embedded structural inequities in society are tackled and unless a more liberal approach to immigration policies is adopted, communities will not be protected from future infectious outbreaks and population health will not achieve the gains that global health advocates seek. It’s time for the global health community to change direction.