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Proof of Success

Saving lives through global interventions

By JESSICA CURRY

Anyone who doubts that large-scale public health interventions are possible should pick up Millions Saved: Proven Successes in Global Health. Confronting skepticism that money for health programs in developing countries is "money down a rat hole," Ruth Levine and the What Works Working Group decided to compile a book that features successful global health interventions. To be considered, the interventions had to be large in scale, affecting a national, regional or global population, cost- effective, address an important public health problem, have lasted at least five years and have had a positive impact on health that could be attributed to the program. ....Nominations were solicited from hundreds of health experts from around the world, and after studying the submissions, Levine and the What Works Working Group selected 17 cases that best exemplify success to be featured in the book. The cases include eradicating smallpox, eliminating measles in southern Africa, preventing iodine deficiency disease in China and reducing guinea worm in Asia and sub-Saharan Africa. Levine spoke to Chicago Life about saving millions of lives through health interventions and what we can do to help.

What's the purpose of Millions Saved? We had two goals. One was to try to address the chronic skepticism--I don't know if you feel it in Chicago, but we feel it in Washington--that money for development assistance is money down a rat hole. We knew that wasn't actually true, and it wasn't a complete story. Our hope was to tell a story that would address that skepticism. The other part was that we're facing some really big challenges now--HIV/AIDS, child mortality in Africa and malaria. Maybe there's something we can learn from previous successes in health. When we were doing this work and saw the combination of factors that were in place that brought about these successes, it's striking how few of those are often in place in international health programs.

What is the combination of factors that leads to success? The building blocks include a combination of money, technical consensus and management expertise. An example is in the HIV/AIDS prevention world--there really isn't a technical consensus that's broadly shared about what the best approach is. Without that you find a lot of missed opportunities for achieving success.

You describe the six "wows" that emerged from the study of the cases. Which one surprised you the most? Maybe it was the one about the effectiveness of governments. A lot of work these days focuses on the potential role for the private sector to deliver some key types of health services. But in almost all of the instances, the real work was done by public sector agencies, and it was a reminder to me that public health is a core function of government. When public health programs succeed, it's because governments are doing their job.

Which project did you find to be most remarkable? One that I learned the most from and I did find remarkable was the tobacco control case in Poland. What was striking was how addressing the problem of high-level tobacco use really required taking advantage of a political moment. When Poland was opening its democracy, the power of the tobacco industry was reduced.

How can midwives, even more so than doctors, save lives during childbirth in some developing countries? The use of professional midwives can reduce maternal mortality more than the expansion of physician services can. I think that particularly in Sri Lanka, which is primarily a rural country, what counts is to have trained individuals available on the spur of the moment near where the women live. One thing is the proximity, and the other thing is, just from a economic perspective, trained midwives are much less expensive than trained doctors.

Looking at the severe case of guinea worm in Sudan, is successful intervention possible in an unstable political environment? It's possible, but much more difficult. There've been some really great studies done on the health costs of civil conflicts. It's estimated that for every one death directly associated with war, there are five other deaths from infectious disease, failure in the health system, inability to get drugs to areas of conflict and so forth.

Is it still true that AIDS and tobacco are the only two major causes of death rising worldwide? Yes, the numbers on malaria are always sort of equivocal because the diagnosis is so challenging. I think that still holds though in terms of what people will sign their name to.

Why is smoking on the rise in developing countries? A central reason is that incomes are on the rise in developing countries, and tobacco is marketed very heavily. There's been a compensation on the part of tobacco companies--as they've lost ground in industrialized countries, they've redoubled their marketing efforts in the developing world.

Which diseases could be eradicated? There are actually, sadly, very few disease that have characteristics that lend themselves to eradication. I think there's hope that guinea worm could be. Certainly smallpox was. There's hope that polio can be and potentially leprosy.

What do you think about preparedness for a potential outbreak of a long-gone disease like smallpox? It really is a paradox when you consider eradicating a disease, which is a huge accomplishment. There are lots of benefits of eradication, but the one big downside is that you've created a biological threat of immense proportions because we lose our immunity. I think the only clear policy implication is a strong public health system and good epidemiological surveillance.

Which global health issues do you think need the most attention? My personal view is that there are three that merit more attention than they're getting. AIDS is not on the list, not because it's not important, but because it's getting a lot of attention. The first one is child health. There are so many ways to prevent and treat inexpensively the major diseases that are killing kids around the world. I think we've gotten distracted from that challenge by HIV/AIDS. If you look, for example, at the USAID budget, which is my tax money and your tax money, the amount of resources going for child health has either remained stagnant or declined in recent years. It's painful to see that because the potential to save kids' lives is so much greater. There's a whole set of immunizations with the newer vaccines along with the traditional ones. There are various treatments for diarrheal disease. These are very inexpensive, feasible interventions, but the resources aren't there right now. Second, there some key women's health issues. There's been some transfer of resources away from family planning and reproductive health. The third issue is non-communicable diseases, chronic diseases like diabetes, heart disease and so forth, which are really rapidly on the rise in developing countries. There's a window, demographically and in terms of the health conditions, of about 15 to 20 years where preventative measures can be taken.

Geographically, where do we need to focus our attention? I think on the women's health, it's really South Asia, India, Nepal, Pakistan, Bangladesh and many countries in sub-Saharan Africa. These are the places where 99 percent of maternal morality occurs. With respect to the chronic disease challenges, the most attention probably needs to be given to China. Between the smoking, the pollution, the graying population, the emerging affluence and the change in diet, they're going to have a huge challenge in front to them. And when China has a challenge, the world has a challenge. We're going to have to get used to thinking of them as central to our future.

If people reading want to take action to improve global health, to which organizations would you direct them? A good one in the United States is the Global Health Council, which has lots of public information and a good website. There's also an organization called the U.S. Coalition for Child Survival. For donating money, [I recommend] UNICEF, the Global Alliance for Vaccines and Immunizations and the Global Fund to Fight AIDS, Tuberculosis and Malaria. All accept individual contributions and are doing great work.

Published: August 01, 2006
Issue: Fall 2006