CMAJ • June 7, 2005; 172 (12). doi:10.1503/cmaj.1050072.
© 2005 CMA Media Inc. or its licensors
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
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Letters
Correspondance

Global IDEA

Prabhat Jha*, David Brown{dagger}, Nico Nagelkerke{ddagger}, Arthur S. Slutsky§ and Dean T. Jamison

Centre for Global Health Research, St. Michael's Hospital, University of Toronto, Toronto, Ont.;* Canadian Imperial Bank of Commerce, Toronto, Ont.;{dagger} United Arab Emirates University, Al-Ain, United Arab Emirates;{ddagger} St. Michael's Hospital, University of Toronto, Toronto, Ont.;§ Fogarty International Centre, National Institutes of Health, Bethesda, Md.¶

Health determinants are not necessarily health interventions. Interventions need to be practicable (i.e., widespread use is possible) and affordable. We agree with David Moore and his colleagues that universal primary education has social returns beyond its impact on child and maternal survival. However, safe housing, sanitation and food subsidies are more costly and less practicable than are public health interventions.1

As we have recently reviewed,2 research and the diffusion of knowledge have improved public health interventions (which differ from the more narrowly defined "medical" interventions), making them more efficacious and cheaper, which means that they are more cost-effective. Thus, mortality fell more rapidly in the 20th century than it fell in the 19th century. Access to vaccination and treatment of respiratory infections and diarrhea explain more of the decline in child mortality in India since 1975 than do differences in income growth or education.3,4 In rural Senegal, recent mortality decline can be traced to specific interventions, even in the absence of universal safe water, sanitation or housing.5 Smoking controls and changes in saturated fat intake have decreased adult mortality in Poland.6(Declines in mortality due to tuberculosis before 1950 are a riddle. Although these declines were not due to antimicrobials, it is unclear if better living standards were responsible. Less well studied cofactors for tuberculosis may well have played a role.7)

Interventions based on "egalitarian principles" or "social determinants of health" strike us as romantic but impracticable notions. To quote Kingsley Davis from 1956,8

[It] seems clear that the great reduction of mortality in underdeveloped areas since 1940 has been brought about mainly by the discovery of new methods of disease treatment applicable at reasonable cost [and] by the diffusion of these new methods ... The reduction could be rapid because it did not depend on general economic development or social modernization ... Though in the literature on public health there is still great lip service paid to the necessity of general economic improvement and community welfare in the control of disease, the truth is that many scourges can be stamped out with none of this...

References

  1. Jha P, Mills A. Improving health of the global poor. The report of Working Group 5 of the Commission on Macroeconomics and Health. Geneva and London: London School of Hygiene and Tropical Medicine; 2002.
  2. Global IDEA Scientific Advisory Committee. Health and economic benefits of an accelerated program of research to combat global infectious diseases [editorial]. CMAJ 2004;171(10):1203-8.[Free Full Text]
  3. Measham A, Rao K, Jamison DT, Wang J, Singh A. Reducing infant mortality and fertility, 1975-1990: performance at all-India and state levels. Econ Political Wkly (India) 1999;34 (22): 1359-67.
  4. Jha P. Avoidable mortality in India: past progress and future prospects. Natl Med J India 2002;15 (Suppl 1):32-6.
  5. Pison G, Trape JF, Lefebvre M, Enel C. Rapid decline in child mortality in a rural area of Senegal. Int J Epidemiol 1993;22(1):72-80.[Abstract/Free Full Text]
  6. Zatonski W, Jha P. The health transformation in Eastern Europe after 1990: a second look. Warsaw: M. Sklodowska-Curie Memorial Cancer Center and Institute of Oncology; 2000.
  7. Nagelkerke NJS, DeVlas SJ, MacDonald KS, Rieder HL. Tuberculosis and sexually transmitted infections. Emerg Infect Dis 2004;10:2055-6.
  8. Davis K. The amazing decline of mortality in underdeveloped areas. Am Econ Rev (Pap Proc) 1956; 46(2):305-18.




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