HEALTH SYSTEMS

By Professor Jeffrey Braithwaite
Centre for Clinical Governance Research in Health

The population clock has ticked over to seven billion. But, it’s more than a mere tick you can hear – it is a very loud warning bell ringing inside your head. Or it should be.

The world’s population has grown slowly for most of human history. It took two million years or so to reach the first billion people on earth, around 1800. Incredibly, it took a mere 12 years to add the latest extra billion which now brings us to seven. That’s 166,667 times faster than our first billion human beings. This rapid acceleration in population growth is largely due to advances in modern medicine, agriculture and industrialisation; including mass food production and processing. Most people no longer die before the age of 40 as they did until a mere century or so ago. We have the know-how and resources to prolong life and to prevent, cure or manage previously untreatable diseases.

But we are facing the grave risk of becoming victims of our own success. The very population growth that such progress has fuelled, now poses a myriad of threats to humanity’s future. It could become a procreation-led disaster.

How can we cope with so many people and maintain a sustainable, healthy planet?

It’s not as though we have been taken by surprise. We have seen this coming for decades but have ignored the problem, ostrich-like. Now, we are closer than ever to a tipping point from which we cannot recover, brought on by environmental degradation, rapid depletion of resources, unjust distribution of the world’s wealth and too many mouths to feed. It would be neglectful, detrimental or just plain stupid to continue to fail to act.

My field of expertise is the delivery of health services. The challenges facing the world’s over nourished, wealthy nations might appear to have little in common with the plight of the struggling masses of the world’s poor. The gap between the world’s rich and poor is widening, and with it the gulf between the potential of modern medicine to deliver ever improving individual health and well being for some of us and the reality of the triple burden of debilitating disease, poverty and hunger for the rest of the world. Yet, we are all threatened by rapid population growth, and demographic change.

The developed world

In the developed world, significant lifespan gains made in recent years may be plateauing as technological and biological limits are reached. Those who enjoy a long life are increasingly likely to have a chronic disease. The ageing population means a rise in dementia, cancer, heart disease and musculoskeletal conditions. Put simply, older people wear out. And there are more and more of them; and they all need to be looked after. Who will provide the care, and who will fund it?

At the same time we are facing a new epidemic of “life style” diseases; the consequence of plenty. Take just one example. Worldwide, more than one billion adults are now obese, as are about 22 million children under five. Obesity shortens lives by eight to ten years and the associated chronic health issues impose huge costs on our health infrastructure. The obesity gap, too, is considerable, ranging from less than five percent of the populations of China, Japan and much of Africa, for example, to over 75 percent in urban Samoa. About 60 percent of Americans and Australians are overweight or obese, and in 1997 the World Health organisation formally recognized obesity as a global epidemic.

In response, our modern health systems are struggling. The costs of dealing with lifestyle diseases – brought on not just by obesity, but drug abuse, tobacco use, alcohol consumption, reluctance to exercise, and the like – are enormous, pushing up health care expenditure to 10 percent of GDP, and more in some countries. The acute and aged care sectors are both stretched and stressed, and not as effective as they should be. Aged patients clog up hospital beds and suffer from multiple conditions simultaneously, or ‘co-morbidities’ in the language of health insiders. At least one in every ten patients will experience an adverse event in a modern hospital, suffering from some sort of healthcare-induced harm.

The developing world

Scarily, that’s not the worst of it by a long shot. In lower income countries, scandalously, most people are still battling to secure the basic conditions for life. Many do not get anything like a fair go – i.e., reasonable health care, a safe water supply and effective sanitation.

Half the world’s population lives in grinding poverty, with an income of less than $2.50 a day. Some 27,000 children die of poverty, virtually invisibly. Not each year, or month, or week. Every day. One every three seconds. Most of us look the other way. Try pausing before reading on for one minute, and twenty children in the third world will have died from preventable illness or starvation.

Global population projections suggest 97.5 percent of population growth to 2050 will occur in developing nations; a trend that will only further widen the health chasm between the haves and have nots. Today, the developing world is home to 84 percent of the world’s population and accounts for 90 percent of the disease burden – but just 12 percent of global health spending. Almost inevitably, then, more poverty, unfairness and death are on the way.

While a child born in Australia is no more deserving of health care, education and water, food and medicines free from contaminants than a child in Ethiopia, our place of birth largely determines our health. Albert Einstein famously said God does not play dice, but someone seems to be dealing the disadvantaged a bad set of cards, every hand.

Being poor and poorly educated makes people sick, and getting sick often makes people poor. Nearly 900 million people in the world do not have access to clean drinking water, let alone a good hospital, midwife, GP or baby health clinic. Much of the world’s disease burden can be directly linked to the conditions of impoverishment like poor sanitation and contaminated water, and for the world’s poor the prohibitively high cost of treatment often puts good health out of reach, even if the most sophisticated medical facility is just next door.

In the 21st Century it should appall us all that such huge discrepancies in basic human rights persist. We have still not made enough progress with malaria, HIV-AIDS and tuberculosis; the “big three” global diseases. Even more neglected are terrible infectious diseases like river blindness, African sleeping sickness, leprosy and Chagas disease, which cause suffering for more than a billion people worldwide. Horrifying but treatable problems like parasitic worms are prevalent in low-and middle-income countries. These major health issues have received little attention from the pharmaceutical industry because of lack of interest or ability to pay the cost of drug development, or fund a supply of existing medicines to alleviate their impact.

Only recently have organisations like the Bill and Melinda Gates Foundation put concerted funding – and large-scale efforts – into these kinds of problem. But there is much more to do. Meanwhile, international trading rules continue to frustrate efforts to provide cheap or reasonably priced drugs to poor countries. This denies millions access to the health the developed world takes for granted.

Internationally, there is already a serious shortage of all kinds of health professionals, and with a growing population this will get worse. At this point the plight of the world’s rich and poor nations collide.

Wealthy societies are already competing for qualified migrants to work in their health systems; systematically stripping the developing world of doctors, nurses and allied health professionals and further widening the global health and well being gap. Fifty-seven of the world’s poorest countries suffer an acute shortage of health professionals; in Africa, for example, there are 2.3 health workers for every 1000 people, compared to 24.8 per 1000 in the Americas, which means 1.3 percent of the world’s health workers are caring for people who experience 25 percent of the world’s disease burden. The world’s capacity to be unfair seems virtually limitless.

Needed: education for everyone, especially women

In an ideal world we would have fewer people with a higher quality of life enjoying better, more equitable, access to the conditions of good health and well being.

The reality is that population models suggest we are heading in the opposite direction, to a peak of nine billion people, or even more. And all the while many of the poor and disadvantaged will be staying poor and disadvantaged. Or going backwards.

Yet the means by which we might constrain population growth range from the unpopular to the infeasible to the inhumane.

Consider the one child policy, which Chinese authorities estimate has prevented 400 million births. Leaving aside the ethical conundrum over whether or not a government has the right to control procreation, and putting aside the harmful social consequences the policy has unleashed such as plight of millions of men who will not be able to find a partner, what are the implications for health?

The policy has been linked to both forced and targeted abortions and female infanticide. Depending on region, there are thirteen more boys born for every hundred girls in China, chiefly because family preferences for a son can be exercised because ultrasound technology revealing the sex of the baby is cheap. This is morally repugnant. But, China is now also facing a “four-two-one” problem. One child is responsible for supporting his or her two parents and four grandparents. Older generations are also more likely to require some government support, a further cost to publicly-funded health systems. And where are the health professionals who are going to care for China’s vast ageing population going to come from?

So, enforced population control is no solution; it violates human rights and throws up new problems. However, is there an alternative?

Experience to date shows that population growth slows voluntarily when the health system provides a mix of better education, especially for women, and access to contraception and medical abortion where needed; but not as a means of favouring sons by aborting female fetuses.

Notwithstanding this, poverty and poor health continue to be important push factors for population growth – as counterintuitive as this might seem. Unless parents can be confident their children will survive into adulthood, they will continue to have large families; especially if their own care into old age will depend entirely on their surviving adult children.

This means creative solutions are needed, but they are neither obvious nor easy. And we have to be mindful not to create, like China, unintended consequences. In essence we need a world-wide, concerted population control strategy based on knowledge not coercion, adequately funded, and led by health professionals, not by governments or religious institutions.

More than anything else we need a really big education campaign, designed by very smart marketing people, providing the best advice. We need to do something of unprecedented difficulty: change the world’s behavior, and persuade people to have fewer or no children. It’s important to rich countries, but downright vital to developing countries. Literally millions of lives depend on it.

What about Australia?

Returning Down Under, we are the driest continent on earth, and more people means more depletion of this scarce resource. We are also famously the lucky country, with plenty of commodities needed by the rest of the world. But where’s the plan for when this all runs out, as it inevitably will one day?

And our carbon footprint is much too large compared with the relatively small population contributing it. A bigger population equates to more pressure on the environment. National climate change and health models suggest Australia is already facing 800,000 more cases of gastroenteritis, a sharp and rapidly accelerating increase in heat related deaths into the tens of thousands from mid century, and a significant movement south of the serious mosquito-borne disease, dengue fever.

Australia’s ageing population curve means we will need one million aged care workers by 2025. How will we fund them, and who is going to do this work, when more rewarding incomes and less burdensome jobs are available in other parts of the economy? Make caring jobs more attractive is the short answer. However, reducing the aged population depending on carers is a more sustainable solution.

If we successfully defused the population time bomb – a big ask – the effects in a couple of generations would be more than merely encouraging.

We (and more importantly, our children and grandchildren) would enjoy cleaner air, a better environment and greater reserves of irreplaceable commodities. We would see less of Australia and the rest of the first world raiding the third world for natural resources, cheap labour and health professionals to provide care for our rapidly increasing numbers of the aged and chronically ill.

So, what do we each have to do? Our population levels have profound impacts on our health. Health systems in all countries must be improved using evidence-based research to cope with increasing populations and to deliver efficient and effective health care. Everywhere, and fairly. This is the responsibility of leaders, policymakers, health professionals and consumers across the globe.

And you, and me. Surely we can make a commitment and take action in rich and poor countries to decelerate population expansion, and thereby improve human health and the health systems that support it, as one coherent, concerted package?

We need to fashion a new social movement for this. I reckon we need a combination of the savvy slickness of Apple’s marketing, the patience of Ghandi’s Indian independence campaign, the determination of the US civil rights movement and the fervour of the Arab Spring uprising.

In truth, nothing less will do, and we are all counting on this. Every one of us. The alternative is not tenable. Keep going at this rate, and there will be an earth inevitably so depleted and unhealthy that it will support none of us.

And after two million years of human existence, that would be the most cataclysmic outcome of all. Exit, Homo sapiens: a drastic solution to the population problem.

I’d rather settle for much smaller populations living in better conditions in the developing world, and vastly fewer people living a fat, inactive, artery-clogging, unhealthy lifestyle in the developed world. For good measure, we could commit to ensuring a fairer distribution of wealth, internationally. And we should toss into the mix good quality, affordable health care for every region and locality, not just for rich folks.

That warning bell inside your head would stop ringing. And surely these are the best humanitarian presents we could give to our fellow human beings.

[i] http://siteresources.worldbank.org/INTHSD/Resources/topics/Health-Financing/HFRChap1.pdf
[ii] http://www.ishib.org/journal/19-1s1/ethn-19-01s1-60.pdf
[iii] http://www.campusreview.com.au/pages/section/article.php?s=News&idArticle=21736

HEALTH SYSTEMS

In the rich world our burgeoning population presents myriad risks to our health – mainly associated with living longer. In the developing world, a child dies every three seconds. Professor Jeffrey Braithwaite explores this dichotomy.

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"We face the grave risk of becoming victims of our own success."