Globalization has simultaneously led to immense gains in living standards and fueled extreme frustration by those left behind in its wake. Hundreds of millions of people have been lifted out of abject poverty in emerging economies since the fall of the Berlin Wall in 1989. Yet the ‘triumph of capitalism’ has also coincided with stagnating or declining median family incomes in many advanced economies and even falling US life expectancy in recent years.
Nearly 250 years ago, in The Wealth of Nations, Adam Smith extolled the virtues of economic specialization. Yet he could hardly have foreseen the impacts, positive and negative, of its application worldwide.
Globalization has been a quest for increasingly inexpensive manufacturing processes. This year’s World Development Report, published by the World Bank, described global value chains – the manufacturing of goods in a production process across multiple countries where no one firm specializes in the entire production task – and the impact of such international interactions on growth and economic development. Now, the current pandemic has upended supply chains, impacted the movements of goods and people, and driven a contraction in national economies. Covid-19 is many things, among them a reminder that the wealth of nations is inextricably tied to the health of nations.
It is thus worthwhile reconsidering a World Development Report from almost 30 years ago that related to the impact of health on the economy.
It may seem intuitive now, but the link between health and economic development was not always clear. The World Development Report from 1993, entitled “Investing in Health”, was the first to address health as an economic value proposition. Led by Dean Jamison, a health economist working at the Bank, the report laid the foundations of an econometric model for understanding the fiscal value of healthy lives and the importance of good health to productivity. It introduced concepts that inform what is known as the Global Burden of Disease project, an ongoing assessment of disease states and causes of harm and death in human populations. In particular, it articulated a mechanism for comparing disease states and disability. Prior to these metrics, there was no way of comparing death and disability across countries, settings, or health conditions. What was the cost, in health terms, of the premature death of a 25-year-old laborer from a road traffic crash, and how could that be compared to blindness in a 60-year-old, breast cancer in a 42-year-old, or malaria in a 5 year old?
The technical term for this metric was the Disability-Adjusted Life Year, or DALY, a dry and colorless way to describe the tragedy of premature death and the misery of living with an affliction. If the disease state was debilitating, a breast tumor requiring a mastectomy, or a cleft palate, or a seizure disorder, the DALYs added up. If it happened in a young person, they added up even more. And if life was cut short – from cancer, or injury, or infection – then the complete loss of years of life was also captured by this metric. DALYs are thus a measure of years of life lost to premature death and years lived with disability – that is, years lived in a state of less than perfect health. This econometric assessment of disease burden has allowed countries and health systems to make economically rational and financially influenced decisions on how and where to spend money on health.
One of the early effects of this work was to make a financial case for important public health interventions and prioritize them due to their high value. Vaccines are a classic example – vaccination programs are incredibly cost effective, as they avert a massive burden of disease and premature death. Water, sanitation, and nutritional programs were also identified as high value; when populations had access to clean water and improved food sources (including micronutrients), health and wellbeing increased. Families could contribute to the local economy rather than spending money on treatment or diverting human resources to care for illness and disability.
As public health measures started seeing success, efforts were undertaken to tackle other difficult problems. Programs focusing on health care and health service delivery began gaining traction. Maternal health, HIV, drug resistant tuberculosis, cancers, and cardiovascular diseases were promoted as high-value targets for health investment. Prior to the pandemic, there was increasing optimism amongst public health practitioners that these investments were paying off. Dean Jamison, along with Larry Summers, the former Chief Economist of the World Bank and director of the National Economic Council under President Obama, reported the remarkable improvements in health across countries and settings. The returns were massive, with a projection for a “grand convergence” in health outcomes within our lifetime. It was estimated that deaths from infectious diseases, childhood illnesses, and maternal conditions would drop to nearly universally low levels, “converging” to rates presently experienced by some of the best performing countries for a net benefit of nearly 10 million deaths averted. These were not just extensions of life expectancy – these averted deaths included mothers, children, and laborers who would add to the economic capacities of the poorest countries and improve economic productivity.
Collectively this was all very encouraging, but with the pandemic clobbering the economy, vaccine nationalism and the hoarding of vaccine resources could reverse decades of gains. Countries are poised to begin widespread vaccinations: the US has approved its first two vaccines (from Pfizer/BioNTech and Moderna); the UK commenced vaccinations December 8th. Yet providing vaccine coverage nationally while ignoring the needs of the wider global community will not solve our economic challenges. Local communities may feel better – restaurants and bars that were closed or otherwise limited might open up, and gyms will see increased attendance – but the global community will still be stricken, travel will continue be a challenge, and suspicion will be pervasive.
Many lower income countries made significant public health investments because they were so cost effective. They did this while the US moved in the opposite direction, neglecting core public health interventions and gutting programs that would be needed in a public health crisis like what we now face. We are fortunate to have the resources, both financial and human, to play catch up at extraordinary speed, but that will not bring back the 300,000 dead or reassure a populace that has received mixed messages and is increasingly skeptical of public health messaging. We must ensure that the investments made in public health structures in lower resourced countries are maximized through considered distribution and availability of vaccines at prices that are affordable and at a scale that is achievable.
I am delighted we are starting to vaccinate people in the US. Like many health facilities, Stanford Healthcare, where I work as a surgeon, will begin vaccinating front line health care workers. The plans are well-organized, ensuring coverage while also spreading out timing so entire services lines are not affected simultaneously.* My trauma group, for instance, will not be vaccinated all at once – we cannot afford to all feel rotten at the same time as a result of the natural inflammatory reaction following the injection. But I also know I am spoiled: we have not been crushed (yet) by an overwhelming burden like what was seen in New York or Bergamo, Italy. Furthermore, Stanford has a management system that performs exceedingly well and the financial resources to make sophisticated plans and bulk purchase vaccines.
As I prepare to roll up my sleeve and receive a vaccination when my name is called, I think of colleagues around the world who are toiling away with poor infrastructure, weak management practices, underfunded health systems, and meager resources. And I think back to the promises made and not yet kept by normative bodies, international organizations, funding agencies, ministries of health, and even professionals themselves who have not fully embraced the importance of systematic investments in health services to support economic development and improved financial stability.
If ever there was a time to revisit the premises of that World Bank report from 1993, that time has come. Investments in health must move beyond national or even nationalistic considerations, as this is a tide whose rise truly lifts all boats. It is time to recognize that our material and physical well-being are inseparable. We need to aspire to a health and wealth of all nations.
* While the Stanford Healthcare plans were well organized, that did not prevent them from being tone-deaf: residents and fellows who frequently shoulder the bulk of the clinical work were not prioritized in the first round of vaccinations (unlike staff physicians, some of whom are not encountering COVID+ patients in their daily practice). Stanford Healthcare apologized and has reallocated vaccines to these critical workers.