In the policy discussions related to hunger, malnutrition, poverty and wellbeing, calorie intake is often the focus. Increasingly, however, micronutrient malnutrition appears to be a critical problem in many developing countries. Women and children are most vulnerable to micronutrient malnutrition due to their elevated micronutrient requirements for reproduction and growth. According to some estimates, nearly three billion people (including 56% of the pregnant and 44% of the nonpregnant women) suffer from iron deficiency anemia (IDA), and one-third of the world's population suffer from zinc deficiency. Twenty percent of the maternal deaths in Africa and Asia are due to IDA. One in every three preschool-aged children in the developing countries is malnourished. Undernutrition, coupled with infectious diseases, accounts for an estimated 3.5 million deaths annually. At levels of malnutrition found in South Asia, approximately 5% of GNP is lost each year due to debilitating effects of iron, vitamin A, and iodine deficiencies alone.
I had been warned—I found it hard to believe—that WHO ministerial meetings can be rather dull affairs of little consequence. Ministers typically take it in turn to read their prepared speeches; their fellow ministers appear to be listening attentively through their headsets but some, it seems, have been known to zap through the simultaneous translation channels in search of lighter entertainment. Speeches aren’t played over the loudspeakers for fear of waking jetlagged ministers from their afternoon naps. WHO is a very considerate organization: it likes to make sure that while on its premises visitors reach “a state of complete physical, mental and social well-being.”
Well I’m happy to report that last week’s ministerial meeting on Universal Health Coverage (UHC)—held in Geneva on February 18-19, jointly organized by WHO and the World Bank, and attended by delegates from all over the world (see map)—didn’t fit the stereotype.
My colleague and (I hope still) friend, Chico Ferreira recently took the trouble to write a comment on my earlier LTD post on measuring inequality of opportunity in the context of human development. Early on in his comment, Chico also paid me the compliment of a being a “clever guy”, which was nice until I read on and found that while he agreed with some of what I said there was a lot he didn’t like. Now Chico is a really clever guy, and this is an area he knows a lot about. So I realize I’m treading on thin ice when I say I’m not completely convinced about his ripostes. But let me take the risk. Chico’s not just super-clever – he’s also very nice. So if the ice cracks and I fall in, I think there’s a good chance he’ll pull me out.
I was asked recently to advise on some ongoing work on human development, equal opportunities, and universal coverage. The work was building on previous work undertaken by the World Bank in its Latin America and the Caribbean (LAC) region that had developed a new index known as the Human Opportunity Index (HOI).
The core idea underlying the HOI isn’t new. The argument is that inequalities are inequitable insofar as they’re the result of circumstances beyond the individual’s control (inequality in opportunity), but not if they reflect factors that are within the individual’s control. The object of the exercise is to separate empirically the two.
In the developing world, a hospitalization is one of the things that families – especially poor ones – fear most. This came through in country after country in the World Bank’s Voices of the Poor exercise. Here are just some examples:
A man from Ghana is quoted as saying: “Take the death of this small boy this morning, for example. The boy died of measles. We all know he could have been cured at the hospital. But the parents had no money and so the boy died a slow and painful death, not of measles, but out of poverty.”
The researchers write that in Lahore, Pakistan, “a father explained that it had taken him eight years to repay debts acquired after he, his wife, and two of their children had been hospitalized.”
There’s nothing quite like a cold shower of shocking statistics to get you thinking. A paper that came out in Health Affairs today, written by my colleague Jishnu Das and his collaborators, is just such a cold shower.
Das and his colleagues spent 150 hours training each of 22 Indians to be credible fake patients. These actors were then sent into the consulting rooms of 305 medical providers – some in rural Madhya Pradesh (MP), others in urban Delhi – to allow the study team to assess the quality of care that the providers were delivering.
A lot of thought went into just what conditions the fake patients should pretend to have. The team wanted the conditions to be common, and to be ones that had established medical protocols with government-provided treatment checklists. The fake patients shouldn’t be subjected to invasive exams, and they needed to be able to be able to credibly describe invisible symptoms.
Editor's warning: The author wrote this post after hitting his head and suffering some memory loss, and the World Bank cannot vouch for the accuracy of everything reported in it.
It was the perfect finale. In the vast high-tech auditorium of Beijing's International Convention Center, the audience jostled in the queue to pose questions to the final plenary panel of the Second Global Symposium on Health Systems Research.
First came an elderly lady from the Indian subcontinent who asked why the panelists were so old. "How can we address the issues of tomorrow with the experts of yesterday? If we're going to be serious about universal health coverage, we need youth!" The crowd -- mostly young -- signaled their approval. A middle-aged gentleman from South Africa tried to engage the panel on the damages inflicted on world nutrition by the global food corporations. Warming to his theme of corporate neocolonialism, land grabs, and genetically modified foods, he invoked the memory of Lenin. "That's Vladimir Lenin", he explained to the crowd, "not John Lennon." "Vladimir who? John who?" wondered the youthful crowd. The chair, the ever-youthful Lancet Editor-in-Chief Richard Horton, whose favored medium is Twitter, asked the gentleman to keep his comments tweet-length. A young woman from Britain's aid agency, DfID, eventually wrestled the mike from Lenin's apologist, and said what was on everyone's mind. "Richard, Dear Leader.", she urged, "Tell us your thoughts. It's you we want to hear!"
Malaria, a life threatening mosquito-borne infectious disease, poses a risk to approximately 3.3 billion people, approximately half of the world’s population. Most malaria cases occur in Sub-Saharan Africa, but they also occur in Asia, Latin America, and to a lesser extent the Middle East and parts of Europe. In 2010, malaria was found in 106 countries and territories, with an estimated 216 million cases and nearly 0.7 million deaths – mostly among children living in Africa. In addition to its health toll, malaria places a heavy economic burden on many countries with high disease rates, with estimates of as much as a 1.3 percent reduction in GDP in those countries.
In my post “Should you trust a medical journal?” I think I might have been a bit unfair. Not on The Lancet, which I have since discovered, via comments on David Roodman’s blog, has something of a track record of publishing sensational but not exactly evidence-based social science articles, but rather on Ernst Spaan et al. for challenging the systematicness of their systematic review of health insurance impacts in developing countries. It’s not that I now think Spaan et al. did a wonderful job. It’s just that I think they probably shouldn’t have been singled out in the way they were.
While we non-physicians may feel a bit peeved when we hear “Trust me, I’m a doctor”, our medical friends do seem to have evidence on their side. GfK, apparently one of the world’s leading market research companies, have developed a GfK Trust Index, and yes they found that doctors are one of the most trusted professions, behind postal workers, teachers and the fire service. World Bank managers might like to know that bankers and (top) managers come close to the bottom, just above advertising professionals and politicians.
Given the trust doctors enjoy, the recent brouhaha over allegations of low quality among some of the social science articles published in medical journals must be a trifle embarrassing to the profession. Here’s the tale so far, plus a cautionary note about a recent ‘systematic review’.