Dodging the health problems of the poor
-HIV, tuberculosis and malaria have been defined as the diseases causing the most deaths in developing countries. While these remain major health problems and deserve increased attention and resources, an exclusive focus on these diseases has taken the attention away from equally serious problems that are inextricably linked to low life expectancy in many countries. Amongst the poor, malnutrition, maternal and child mortality, and illness related to a lack of proper sanitation are main causes of illness and death. Although there have been advances, more than 7 million children under five years still die every year. In comparison, 3 million die from HIV, says David Sanders, professor at The University of the Western Cape.
Funding for health research mirrors this bias, argues Sanders, who in a recent seminar at the Bergen Resource Centre for International Development challenged the ethical implications of current global health research. Does global health research respond to the needs of developing countries?
The political economy of global health
The straight answer to this question is no, says Sanders. He argues that the discourse on health research is shaped by the broader global discourse, and that complexity has become a new catch phrase to avoid addressing questions of inequality and priorities.
-Global actors claim that health problems are becoming increasingly complex, and that this makes it very nearly impossible to solve issues like the 10-90 gap or even to agree on which matters are most pressing. But blaming complexity can be seen as a retreat from politics, says Sanders.
Even a country like Norway, which has a long tradition of focusing on global health issues, is no different. Only five percent of Norwegian public expenditure on health research is allocated to diseases that account for ninety percent of the global burden of disease, according a report from the Norwegian Health Directorate.
He points to the rapid growth of non communicable disesases in middle income as well as developing countries as a problem that global actors are reluctant to address. In South Africa, about 50 percent of the population is overweight or obese. At the same time a disproportionate number of children are stunted (chronically undernourished). Donors give very little support to researching nutrition issues because that brings them immediately into politics and questions of global and national distribution of resources, including food resources and of ‘free’ trade .
Instead, global health actors and donors tend to focus on technology and development of new drugs, hence choosing an easy response to the dilemmas of global health and inequality. But the focus on a technological approach avoids addressing the political economy of health and the appropriateness of the research agenda.
-There is no question that health technologies workin the experimental and controlled situation, but the system to deliver such technologies often does not. People administer the systems, and we have to expect that things can go wrong. Hence health research needs to becometransdisciplinary , and focus also on issues such as accountability and the political economy of research - which global actors and donors are reluctant to address, says Sanders.
Develop or deliver?
The focus on technology versus deliveryof health services can be illustrated by research and administration of vaccines, according to Sanders. This is a field characterised by heavy global investment, and also a field in which Norway has gained international recognition for the country’s commitment. The average vaccination coverage is now about 70 percent globally. Yet, among the poorest children, the coverage is less than 40 percent.
-Are the heavy investments in vaccines and vaccination properly allocated? Should we primarily focus on developing new vaccines or on the delivery mechanisms for these and even the long-established vaccines? At the moment, many global actors and donors focus on the technological aspects, developing new vaccines and new clinical treatments, ignoring the fact that the actual systems of delivery are flawed, says Sanders.
Intensive research efforts have been put into the development of a vaccine against the rota-virus. The vaccine has been a costly project, and is potentially a great benefit. However, Sanders questions the priorities in regard to childhood diarrhoea.
Many developing countries would be better off with an intensive investment in sanitation and hygiene interventions. The delivery system is flawed. Probably, a lot of the children in need of the rota-vaccine will never get it, he says.
Although there have been great improvements in the treatment of diseases and health problems like HIV and tuberculosis, 30 years of experience in public health and primary health care in Southern Africa has proven to Sanders that the low priority given to basic health problems like malnutrition, maternal and child health continues.
-Actors and donors in health need to look beyond the so-called ‘complexity’ of global health problems if we are to deal with the inequalities in global health and health research. We do not have to be paralysed by trying to understand complexity in order to be much more effective , says Sanders.