PREVENT EARLY DEATH

LIFE EXPECTANCY AND HUMAN DEVELOPMENT

It was Amartya Sen who championed the idea that human development could be measured by increases in human life span. The basic idea is that a life cut short is a great injustice – perhaps the greatest injustice of all – and that being able to live a long life is a critical measure of development. Martha Nussbaum further underscored the value of a long life by making it the first of her “Ten Central Capabilities”:

Life. Being able to live to the end of a human life of normal length; not dying prematurely or before one’s life is so reduced as to be not worth living.

Life expectancy at birth is also the first of three measures included in the Human Development Index, which was created to emphasize that people and their capabilities should be the ultimate criteria for assessing the development of a country, not just measures of economic growth.

In recent decades, many nations have been able to extend the life of their citizens. Life expectancy at birth rose from 65 in 1990 to 72 in 2016, according to the World Health Organisation. Increases in some low and middle income countries (e.g. China) were more than twice as fast as high income countries over comparable periods. But this global progress masks deep regional inequalities. Today, average life expectancy is 61.2 years in Africa, 69.1 years in the Western Pacific, 69.5 years in South East Asia, 76.8 years in the Americas, and 77.5 years in Europe. All 15 of the countries with life expectancy at birth below 60 years are in Sub-Saharan Africa.

There are also differences within Africa, where life expectancy ranges from 58 in the center to 64 in the south. Further, as life expectancy hovers around 50 in many of the HIV/AIDS-affected countries (e.g. Lesotho and Swaziland) but rises into the high 60’s in several countries in the east (e.g. Rwanda and Kenya), the gaps in Africa are widening. The highest performing country in the world and the “frontier” for life expectancy is Japan, where the average citizen lives to 83 years.

An outstanding analysis of the contribution of increasing life expectancy to economic growth and development, GlobalHealth 2035, found that annual increases in life expectancy added 1.8% to annual GDP for all low and middle income countries between 2000 to 2011.  Reductions in early death trigger a range of positive development forces, including declining fertility (as more children survive, parents have fewer children), growing working age populations (and greater productivity), rising savings rates (as people plan for longer lives), increasing foreign investment, and falling healthcare costs (as populations thrive, at least in the short term before the costs of aging set in). Global Health 2035 concludes that, “this new understanding of the economic value of health improvements provides a strong rationale for improved resource allocation across sectors”.  Their conclusion is clear – nations should be investing more in health relative to other sectors, and investing in ways that increase life span.

14 MILLION LIVES CUT SHORT, EVERY YEAR

It is largely because of the spotty progress in increasing life expectancy at birth that we live in a world where an estimated 14 million people die before they turn fifty each year; including 5 million children under five years of age, according to the Global Burden of Disease. Men and boys make up 60% of early deaths, with gender gaps widest for 15 to 49 year old men. Of the total 2.7 million extra male deaths, 2.2 million occur among 15-49 year olds, largely due to excess male deaths from road injuries, heart disease, and interpersonal violence. If we add in the estimated 1.4 million unborn females who are victims of sex selection every year (largely in China and India), the gender gap shrinks but is not eliminated. If we include female deaths from sex selection during pregnancy and the estimated 2.6 million stillbirths that occur every year we have a population of 18 million whose lives are cut short every year.

The majority of early deaths occur in just ten countries, including India, China, Nigeria, Pakistan, Indonesia, the Democratic Republic of Congo, Ethiopia, Brazil, Russia, and Bangladesh. Four countries – India, China, Nigeria, and Pakistan – account for 5.7 million early deaths, or 40% of the global total. In many of these countries early deaths represent a large proportion of overall deaths, above the global average of 26%, and far above Japan’s 3.2% – the world’s best. For example, in Nigeria, home to the world’s third largest concentration of early deaths, 77% of all deaths occur among people under fifty. In the Democratic Republic of Congo it is 62%, in Ethiopia 48%, in Pakistan 42%, in Bangladesh 33%, in India 30%, and in Indonesia 28%.

A handful of causes account for the vast majority of early deaths, including pneumonia, road injuries, HIV/AIDS, heart disease, diarrhea, preterm birth, malaria, birth trauma, self-harm, and congenital defects.  The major causes of death vary by age and by gender. Children aged under five years are much more likely to die from newborn causes and infectious diseases (especially pneumonia, diarrhea, and malaria).

Infectious diseases are also leading causes of death among children aged five to 14 (especially malaria, typhoid, HIV/AIDS, pneumonia, diarrhea,  and meningitis), but road injuries and drowning are also big killers.

HIV/AIDS is the largest cause of death among 15 to 49 year olds, but deaths from road injuries, self-harm, and interpersonal violence are also a major problem. Other leading killers for this group include heart disease, tuberculosis, and stroke. The leading causes of death for men and women under fifty are similar, but road injuries, heart disease, and interpersonal violence claim the lives of many more young men. For females, death in pregnancy and childbirth is also a major killer, claiming 230,000 lives.

The leading risk factors for death before 50 years include high blood pressure, tobacco smoking, household air pollution, poor diet, and alcohol use. Obesity, diabetes and child underweight are also major risks. Leading risk factors vary by geography and by gender. For example, in Sub-Saharan Africa, low birth weight/short gestation, child growth failure, unsafe sex, unsafe water, and poor sanitation are leading risk factors for early death.  In South Asia, low birth weight/short gestation, high blood pressure, ambient air pollution, child growth failure, and high cholesterol are the top five risk factors.

The leading risk factors for early death among females are low birth weight/short gestation, child growth failure, unsafe sex, ambient air pollution, and household air pollution. In contrast, low birth weight/short gestation, alcohol, smoking, child growth failure, and high blood pressure are the leading risks for early death among males.

REDUCING EARLY DEATH: A NEW DEVELOPMENT PRIORITY

Many of the 14 million early deaths are preventable with low cost, high impact interventions including contraception, vaccination, devices (e.g. condoms, bed nets, rapid diagnostic tests, pulse oximetry), therapeutic foods and supplements, and medicines (e.g. antiretrovirals, artemisinin-based combination therapies, oral rehydration salts/zinc tablets, antibiotics, and oxygen). Others require higher cost interventions, especially diagnosing and treating heart disease, preventing newborn deaths, and suicide. Substantial behavior changes relating to diet, alcohol and tobacco use, sexual practices, and cooking norms are required to reduce the risks of early death. Reducing the risks of ambient air pollution will ultimately require changes to industrial, agricultural, transport, and urban policy, and are likely to be very challenging in economies that are transitioning from low to middle income status. Deaths from road injuries are projected to increase rapidly in countries with weak road infrastructure and limited transport safety policies.

The evidence suggests where investments in health interventions are made alongside investments to improve the education of girls and women of reproductive age, large gains are possible. Fully half of the reduction in child deaths since 1970 has been due to increases in the education of women of reproductive age, according to a study by Chris Murray and colleagues. Women’s education was also found to be critical to child mortality declines, alongside access to clean water and sanitation, poverty reduction, and economic growth, according to a recent WHO study.

Accordingly, all countries should make reducing early deaths (<50 years) the focus of their national health goals by maintaining early deaths at <30% of all deaths by 2020 and <15% by 2030. For countries already at these levels, targets of <15% and <7% should be set with Japan’s rate of 3.2% as the ultimate goal. This focus on reducing early deaths is supported by a recent Lancet study which concluded that, “reducing premature deaths is a flexible target that can be pursued in different ways in different countries, according to their mortality patterns and resources,” and by the Copenhagen Consensus, which has consistently argued that investing in increasing lifespans is the most cost-effective development investment in the world today.

National health plans and programs should target the leading causes of early death in their respective countries, and invest in the most cost-effective solutions targeted to the most vulnerable populations. In many low income countries infectious diseases, newborn deaths, and road injuries, will dominate the causes of early death, while in higher income countries, non-communicable diseases and self-harm will dominate. In countries where stillbirths and sex selection are major challenges, reductions in pregnancy termination related to sex selection and preventing stillbirth should be national health priorities.

In addition to investing to improve the diagnosis and treatment of the leading causes of early death, governments and other stakeholders should invest heavily in prevention by reducing population exposure to the major risk factors, especially low birth weight/short gestation, child growth failure, unsafe sex, alcohol use and smoking, high blood pressure, air pollution, and poor diet (especially obesity and cholesterol).

Finally, we need to invest in solutions that go beyond a single disease or intervention to better integrate the financing and delivery of the products and services with the greatest impact on reducing risk and death among the populations where early deaths are concentrated. We need to aim for the vision outlined by Jim Kim, Paul Farmer and Michael Porter in “Redefining Global Health Care Delivery”, where the creation of “patient value” is the endgame because this is ultimately what will drive populations to seek health care enabling population-wide health improvements and the achievement of health goals.

Solutions also need also to address the underlying political, economic, and social causes of early death. As the majority of early deaths occur in countries where people struggle on low incomes, where government is often dysfunctional, where markets are not strong and where women are disempowered, specific health interventions need to be delivered in the context of broader reforms to encourage economic growth and rising incomes, to build stronger democracies and markets, and to empower women.

REFRAMING GLOBAL HEALTH PRIORITIES TO FOCUS ON EARLY DEATH

The United Nations, its agencies, and development partners should reinforce this focus on reducing early deaths under the Sustainable Development Goals, and target national and international health investments to the leading causes and risk factors associated with early death. The UN should encourage and incentivize, where necessary, country investments in the highest-impact, most cost-effective interventions that can prevent, diagnose, and treat the leading causes of early death and ameliorate the risk factors associated with them. The UN should support national prioritization of the populations with the largest burdens of early deaths. 

To model the much-needed integration in the financing and delivery of the products and services with the greatest potential to reduce early deaths, the UN, its agencies, and partners should establish flagship multi-sector initiatives in each of the leading causes of early death (e.g. infectious disease killers, road injuries, heart disease, newborn causes, and self-harm), and risk factors (e.g. low birth weight/child growth failure, unsafe sex, alcohol and tobacco use, air pollution, and obesity/diet), to demonstrate how the integration of financing, policy development, and program delivery can accelerate reductions in early deaths and put population health on a trajectory of convergence with the highest performing countries. These flagship initiatives should disproportionately benefit the populations with the largest concentrations of early deaths in each of the causes/risks.

A final note. This analysis has focused only on early death and not on disability. Behind the statistic of 14 million early deaths lie hundreds of millions of episodes of sickness, many of which leave children and young adults with lifelong disabilities. Action to prevent early deaths and to reduce the risk factors associated with them will also reduce this heavy burden of sickness and disability that prevents so many from reaching their full potentials and acts as a barrier to national economic and social development.