Universal Health Coverage I

The Human Right to Health

Good health stands at the very center of sustainable development. It is one of the most important goals of humankind, in and of itself. And good health is also vital for everything else we hold dear. It’s vital for economic development through a productive workforce through the ability of children to not only survive disease, but also to flourish, to learn to make their way through school.

911For the ability of a community to be able to undertake economic activities or to attract investment. So health has always been  regarded as central to basic human rights, basic human needs, and to the aspirations of ending extreme poverty. It’s notable that in the millennium development goals, for example, of the eight goals about ending extreme poverty in all its forms, three of the goals, absolutely centrally, are about health. MDG-4 is about reducing child mortality. MDG-5 is about reducing maternal mortality. And MDG6 is about controlling the mass, killer epidemic diseases like AIDS and malaria. And one can absolutely say that, all of the other goals as well, ending poverty and hunger, having children in school, gender equality, a safe natural environment. Are also goals in which health plays an important role.

Both as a determinant of outcomes and also, as one of the main objectives. It’s also an area where there’s progress. And the science of public health breakthroughs in modern medicine and breakthroughs in other areas, such as in food production or in clean water from safe infrastructure in urban areas, have contributed to important gains. But we know that the challenges of achieving health for all as it’s often called, or universal health coverage, when we see a picture of this young child, sick with malaria and remember that hundreds of thousands of children like this one, will die, of malaria unless the control measures that are effective and accessible are actually implemented. We’re reminded of the kind of challenge that we still face. Millions and millions of children, especially in the very poor countries, die each year of utterly preventable, or treatable causes that could be ended.

912These lives could be saved. Children who are dying today, or are left with lifetime disabilities could, with proper organization of our response, have happy lives and safe lives, that would give them the opportunities that of course, they want and we yearn for on their behalf. Since the beginning of the United Nations itself, the priority of health has been clear. And in the Universal Declaration of Human Rights back in 1948 it was already made clear that health is a human right, a part of our basic needs. As we know about the basic declaration, those were rights, are not the kind of rights that can be achieved all at once. They are to be progressively realized. But time is going, and we could move faster. When the World Health Organization was created as well, right in its central constitution, in 1948, it was declared that health the highest attainable standard of health, is a fundamental human right. Quote without distinction of race, religion, political belief, economic or social condition. Health for all, universal health coverage. One of the really notable global efforts to achieve health for all started in 1978 in Alma Ata now called Almaty Kazakhstan. When world health officials, the health ministers from around the world gathered and made a very important Alma Ata declaration. That called for health for all by the year 2000, a notable specific objective dated for 22 years after that event. Unfortunately, when the year 2000 came, it wasn’t health for all. Unfortunately, it was pandemics for many, many parts of the world almost contrary to the aspirations two decades earlier. The AIDS pandemic was running rampant millions and millions of people infected with the HIV virus. More then 20 million, millions dying every year. Malaria which is a tropical killer disease had risen tremendously in in number of infections and in number of deaths. Because the first line medicine used in Africa to treat malaria had lost its efficacy the parasite had become drug resistant to chloroquine and so 2000 was very bleak for malaria with a surging death toll.

The year 2000 was also bleak for tuberculosis another horrific scourge of humanity that claims millions of lives each year. With tuberculosis there was a surge partly riding on the HIV/AIDS pandemic, because immuno compromised individuals suffering from AIDS died in very large numbers from tuberculosis infection. There was also as with malaria, the crisis of drug resistance and new lethal very difficult to treat strains were spreading of what we called then, multidrug-resistant TB, tuberculosis bacteria that were resistant to way wide spectrum of traditional medicine. And this also became extreme multi drug resistant TB when even the rescue medicines lost their effectiveness as the bacteria continued to evolve resistance. In other words the year 2000 did not meet the hopes and aspirations of the health ministers who had assembled in 1978, nor did it fulfill the promise of the Universal Declaration of Human Rights, nor the Constitution of the World Health Organization. So, it was notable that in the year 2000, the Millennium Development Goals put three of the eight goals so centrally on health and took up the challenge of fighting these scourges that were spreading malaria, TB, AIDS, and other killer diseases. We’ve made a lot of progress since then. The distance from 2000 till now is a period of tremendous progress. It rekindles for us the hopes of 1978. Indeed we see within reach the possibility of truly honoring the commitment to help as a basic human right. Now health like education is a merit good. Remember that a merit good is a good that should be accessible very broadly or universally in the population. Health is considered to be such a good not only because it’s so vital for individuals that we feel from a moral and ethical point of view that everybody as human beings deserves access to health. But very practically, health is a merit good, because untreated disease is a threat for society and a threat that spills over to the rest of a population when an epidemic is left to fester and to spread. Think of the devastation that comes when a highly communicable disease races through a countryside, races through a continent, as AIDS has done. The death tolls that can result in the cost to the whole community are huge. We’ll see other reasons as well why government has a necessary leadership role, not only to ensure widespread coverage, but to ensure the efficiency and, the results orientation of the health care system. Now when we look at the actual experience, in health, this is like economic development itself, one of the real achievements of the modern era. Back in the industrial revolution, worldwide life expectancy was perhaps 35 years.

913Of course, we don;t have the, records to establish with precision, a world wide number. But something around the order of 30 to 35 years of life expectancy is a reasonable estimate. This does not mean that people were dying at the age of 30 or 35. It means that a newborn on average would reach, an age of 30 or 35 taking in to account that a very large number of deaths would occur within the first month after birth or the first year or the first five years. Once individuals reached an age of 20 or 25 or 30 there would be a chance, a good chance that they might reach 55, 60, 65. So life expectancy at birth is a measure that is made at the start date of life, just at the time of birth. And from there, to estimate statistically how long on average an individual can expect to live within the society. Now from 35 years in, 19, 1800 or so. By the time we got to 1950, just after World War II, there had been some gains in the average in the world. But remember, how much of the world was still mired in poverty and also in the aftermath of war. It’s estimated that during the five year period 1950 to 1955, worldwide life expectancy was perhaps around 46 years. That’s the average as estimated by the United Nations, but if you look at this graph that divides the world according to high income developed regions developing regions and the least developed countries. You can see that, for the developed regions of the world, life expectancy, in the period 1950 to 1955, was somewhere around 65 years already. Of course much lower still around 35 years in the least developed countries. Probably quite close to the health conditions that had existed at the start of the Industrial Revolution. We see from this curve though that the world has made progress and every category of country has made significant progress. By today, world life expectancy is perhaps 70 years, twice the life expectancy, roughly, at the start of the Industrial Revolution.

914This is one of the great achievements of modern humanity, one of the great achievements of modern science and of economic development. But one also sees the continuing large discrepancies between the high income and the low income world. In the high income, life expectancy is, almost 80 years. Whereas in the least developed countries, you can see from the graph,that life expectancy is, is still 60 years or even less. In other words roughly a 20 year, two decade gap in in life expectancy between the richest and the poorest countries. This gives us a, a measure of how much we have to do. Most of the causes of death in the poor countries are in some sense caused by poverty itself, suggesting that from a medical and public health point of view, these deaths are preventable. These diseases that are causing these deaths are treatable in many cases. In this interesting graph that you’re looking at we put on the horizontal axis the per capita income of countries. And on the vertical axis, the life expectancy at birth. And you see, in this graph, a rising curve. Richer countries, naturally, have a longer life expectancy. You also see in comparing the fitted curve for 1975 and for the year 2005, the two shown here with the dotted line for the earlier year, that the whole curve linking income and life expectancy has shifted up. This means that during that 30 year interval, at any given level of income, one expects a longer life in the more recent years.

Now why would that be? The answer is technological improvement, better ways to prevent disease. Better ways to treat diseases, that, that, occur, nonetheless. And the result is that even at the same income level year after year there is an improvement of health that comes from a rise of the productivity of our public health and medical systems, as well as of other parts of our economic life. 915For instance, the literacy and awareness of people themselves, so that they can pursue health seeking behaviors more ably, or they can use their mobile phones to call for emergency help, and this is one of the reasons why life expectancy rises. Now, what I find extremely pertinent about this graph is the very steep part of the curve at very low income. This means that when countries are very poor, small increments of income going from $1,000 per year to $2,000 per year leads to very steep gains of life expectancy. Those gains later on level off so that increases of income say from $25,000 per person per year to $26,000, the same absolute increase, would have a quite small effect on the average life expectancy. Whereas that gain at the very low levels of income have a massive increase. This is to be expect. There are, diminishing benefits of added income to many things including to happiness, but also to human health. But what’s important about this curve, in my view, is, it says that even small increases of income, or I would also argue, small increases in the amounts that we are able to invest in health, can have huge benefits for the level of health. One of the themes that I want to emphasize is that very low cost investments in poor settings can have huge effects on saving lives on extending life expectancy on extending the quality of life and the health of, of people during their lifespans.

916Not surprisingly, when you look at a world map such as this one, showing the mortality rates of under 5s. Meaning, for every thousand births the number of those children out of a thousand who will die before their fifth birthday. We see that the under five mortality rate is by far the highest in tropical Africa. And next is in south Asia. Those are our two locations we constantly see as being the epicenters of the challenge of extreme poverty. And much, much lower under five mortality rates in the other parts of the world. So our challenges in health are heavily focused in the poorest countries. And, that means geographically they’re heavily concentrated in two regions of the world, Sub Saharan Africa and South Asia. The next graph shows you another asp, very crucial aspect of health and this is maternal mortality. This is measured as the number of deaths related to pregnancy of, of women for every 100,000 live births. And so the numerator of this fraction, number of deaths in pregnancy, typically at childbirth, but it could also be pregnancy related has a huge variation between rich countries where very, very few women, thank goodness, die of pregnancy related causes. Compared with countries in the poorest regions, and poorest of all in tropical Sub-Saharan Africa, where maybe 1,000 woman die for every 100,000 births, an astounding risk of death due to pregnancy. Those numbers are coming down. We see that, that the maternal mortality rate in the developing regions is falling sharply. It was around 440 deaths per 100,000 live births back in 1990. And now below 250 deaths per 100,000 live births as of 2010. We see that in the high income regions, the developed regions, the numbers are very, very small, a few deaths per 100,000 live births. The reasons for death in rich and poor countries differ. But for one basic reason, the poor die of the same reasons that the rich die. They die of cancer, they die of cardiovascular diseases, they die of metabolic disorders, say, related to diabetes. But they also die of conditions that rich people no longer die of, mainly communicable diseases such as children dying of measles, or children dying of malaria, or children dying of other kinds of infections which would not kill their counterparts in the rich world. But do kill the children in the poor countries because the children are hungry, they’re undernourished. And one basic principle of health, is that under-nutrition leads to immuno-suppression. What does that mean? Under-nutrition leads to a camping down of the immune system, the ability to resist infectious diseases and so poor kids die of diarrhea or respiratory infections that would not kill a child in a rich country better nourished. But do carry away millions of children, into death in the poorest countries. The disparities between rich and poor and across ethnic groups, another kind of inequality that we’ve examined can apply within countries as well. The United States, we know being the most unequal of all the high income countries for reasons that we’ve discussed, also has very high disparities in life expectancy. This is a map showing the measure life expectancy across counties of the United States and we see that the Northeast seaboard of the United States. Say Boston or New York City have quite high life expectancies, but in the deep south of the United States, in Alabama, in, in Mississippi, in Georgia, in Louisiana life expectancy is several years less. And we also know that minority groups in the United States, especially the African American community, has many years less of life expectancy compared to the white, non Hispanic Americans. And so these gaps cross class lines. They cross racial lines and they have geographic counterparts as well related to ethnicity, race, and perhaps at least some direct effects of geography as well. To measure the variation over time and across countries in health we use a number of statistics. The life expectancy at birth is an example. Under five mortality, another example. Maternal mortality rate, a third example. Infant mortality rate, which is out of a thousand newborns the numbers who will die before the first birthday. There’s also a very important concept that I want you to know because it’s widely used and very useful called DALYs. DALYs is the acronym for Disability Adjusted Life Years. The idea is that a normal lifespan is 80 years, according to the calculations of DALYs[1]. If an adult dies at age 60, this is 20 lost life years. If that adult is sick between age 55 and 60 and not enjoying healthy years even in those final five years of life, that’s an added penalty for disability. Paralysis, blindness, the loss of a limb, other kinds of disabilities can be translated into a partial loss of a life year by making an assessment how much healthy life is lost by the particular disability. What DALYs calculate in any population is on average the number of lost life years plus the number of lost years to disability add up those two components from death and disability and you get dis you get disability adjusted life years. The DALYs. And these DALYs are used to understand the varying disease burdens across the world. An example of this is this rather complicated chart, but a very, very important one. Every bar on this chart is for a distinct region of the world. At the top is the high income countries. Next Europe and Central Asia. At the very bottom bar, of the chart, is Sub-Saharan Africa. What is being shown here, are the disability adjusted life years lost to disease per population. So a large bar means that there’s a lot of lost life years, either to death or to disability. And we see that Africa has, by far, the highest disease burden, and the high income world, not surprisingly, the lowest disease burden. But this bar in each grouping is divided by colors in a quite interesting way. Those colors refer to different disease categories. So take the dark blue, which is most to the left of each of the bars. That is the amount of loss of life years due to HIV/AIDS. We can classify all of the diseases into a few categories and then measure the disability adjusted life years lost to that particular set of conditions, and group that in a category. What do you see when you do this? Very, very important to note this, Sub-Saharan Africa, for example, has by far The highest disease burden of AIDS. This is not surprising. The very epicenter of the AIDS pandemic is in Sub-Saharan Africa. Now compare the bar for Sub-Saharan Africa with the bar at the very top for the high-income countries You can’t even see that the sliver for HIV/AIDS. That doesn’t mean,uh, of course that there are, is no, death and disease from HIV/AIDS in the high income world, of course there is. But it means that the burden of the disease per person in the population is very, very low compared to the massive burden in Sub-Saharan Africa. And look at the part of that bar for  Communicable disease. You have to scrunch your eyes and see a tiny little sliver. Well why is that? It’s because in the high-income world the communicable and parasitic diseases like malaria, like measles, like diphtheria or typhoid are virtually gone, almost not heard of. Many of these diseases are completely and successfully prevented by immunizations. Others are treated by antibiotics. People, and mainly young children in the case of sub-Saharan Africa, suffer these diseases in the poorest countries, but not in the richest countries. And that’s good news in the sense that it means we have tools already to shrink the bar of DALYs, of the disability adjusted life years, in sub-Saharan Africa and in south Asia. So that the disease burden can get under control. So that life expectancy can rise. So that the quality of life lived is higher, and so that a healthy population can also play it’s part in in more dynamic e-, and more inclusive economic development. Let’s see how we can attack the those disease burdens by now going on to look in more detail at the nature of the diseases, and what can be done about them.

[1] http://vizhub.healthdata.org/gbd-cause-patterns/

Pedro Pereira Leite

Researcher and professor. He had his PhD. on museology in 2011, with the title “Muss-amb-ike Homeland: The commitment on musicological process”, that was published in 2011. In 2012 he finishes a Post-PhD Research on "Biographical Glances: The intersubjectivity poetry on museology, at Lusófona University (Lisbon). Presently he is working in his Post PhD. Research about: “Global Heritages" with the aims to build a network on local cognizance and memory manager has a tool to build the will of action in 3 different communities, linked by past communed heritages.” He works at CES. He participates on different Research network, presented papers in national and international conferences, and had published books on research subjects.

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