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 the first of three measures included in the Human Development Index, a leading indicator of development which assesses countries on life expectancy, education and per capita national income and produces annual rankings.

Over the life of the Millennium Development Goals, many nations were able to extend the life of their citizens and life expectancy at birth rose from 65 in 1990 to 71 in 2015 ( Global Burden of Disease). The rates of increase 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 masked deep regional inequalities.  Today, average life expectancy is just 60 years in sub-Saharan Africa; 66 in South Asia; 72 in Eastern Europe; 75 in South East Asia; 79 in North America, 81 in Western Europe and 83 in the Asia-Pacific.  All 23 of the countries with life expectancy at birth below 60 years are in Africa, but there are also differences across African regions with life expectancy at 58 in the central region, 61 in the western and eastern regions and 64 in the south. Further, as life expectancy hovers around 50 in many of the 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 from 2000 to 2011.  According to this analysis, reductions in early death trigger a range of positive development forces including declining fertility rates (as more children survive, parents have fewer children), a growing working age population (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). GlobalHealth 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.

16 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 16 million people die before they turn fifty each year; including 6.3 million children under five years of age (Global Burden of Disease). Surprising to some, 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 accidental injuries, heart disease and cirrhosis. 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 20 million whose lives are cut short every year.

The majority (60%) of early deaths occur in just twenty countries, including India, Nigeria, China, Pakistan,  the Democratic Republic of Congo, Indonesia, Ethiopia, Bangladesh, Brazil, Tanzania, Russia, the United States, Uganda, Philippines, Mozambique,  Kenya, Afghanistan, Mexico, Angola, and Sudan. Four countries – India, China, Nigeria and Pakistan – together account for more than 6 million early deaths, or almost one half of the global total. In many of these countries early deaths represent a large proportion of overall deaths, above the global average of 29%, and far above Japan’s 3.4% – the world’s best. For example, in Nigeria, home to the world’s third largest concentration of early deaths, 79% of all deaths occur among people under fifty. In  Afghanistan it’s 62%, Ethiopia 56%, Sudan 52%, Pakistan 48%, India 35% and China 16%.

Screen Shot 2016-03-21 at 9.33.00 PM

TARGETING THE LEADING CAUSES AND RISKS OF EARLY DEATH

A handful of causes account for the vast majority (over 80%) of early deaths, including newborn, accidental injuries, heart disease, pneumonia, cancer, AIDS, malaria, diarrhea, diabetes, congenital birth defects, tuberculosis, malnutrition, cirrhosis, violence and deaths in pregnancy and childbirth.  The causes of death vary by age and gender. Children aged under 5 are much more likely to die from newborn causes and infectious diseases (especially pneumonia, diarrhea and malaria). In contrast, accidental injuries are the leading causes of death for children aged 5 to 14, where deaths from drowning, falls, fire, and road accidents dominate.  Injuries are also the largest cause of deaths among 15 to 49 year olds, but deaths from self-harm and violence almost equal deaths from road accidents in this age group. The other leading killers for this group are heart disease, cancer, AIDS and tuberculosis. The leading causes of death for men and women under fifty are very similar, but accidental injuries, heart disease and violence claim many more male lives. For females, AIDS is also one of the top five killers causing an estimated 500,000 deaths and deaths in pregnancy and childbirth is also a major killer, claiming 300,000 lives.

The Lancet reports the leading global risk factors for death as 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, child underweight, household air pollution, suboptimal breastfeeding, iron deficiency, high blood pressure and alcohol use dominate, while in South Asia, household air pollution, tobacco smoking, high blood pressure, child underweight and poor diet are the top five risk factors. The leading risk factors for death among females are high blood pressure, household air pollution, obesity, tobacco smoking (includes second-hand smoke) and diabetes; while tobacco smoking, followed by high blood pressure, alcohol use, poor diet and household air pollution dominate among males. Once again these risk factors by gender change according to geography.

REDUCING EARLY DEATH: A NEW DEVELOPMENT PRIORITY

Many of the 16 million early deaths are preventable with low cost, high impact interventions including contraception, vaccines, human milk, devices (e.g. bed nets, rapid diagnostic tests), therapeutic foods and supplements, and medicines (e.g. antiretrovirals, artemisinin-based combination therapies, oral rehydration salts and zinc, and antibiotics). Others require higher cost interventions especially diagnosing and treating heart disease, cancers, and newborn birth complications. Substantial behavior changes relating to diet, alcohol and tobacco use, and cooking practices are required to reduce the leading risk factors for death and the evidence suggests where these are made alongside investments to improve the education of girls and women of reproductive age, large gains are possible. Chris Murray and colleagues found that half of the reduction in child deaths since 1970 is due to increases in the education of women of reproductive age, and a recent WHO study reported that factors outside the health system (especially education, women’s incomes and political representation, access to clean water and sanitation, poverty reduction and economic growth) are responsible for half of the reduction in child deaths since 1990. When it comes to reducing deaths from accidental injuries, much more work needs to be done on effective interventions, especially in the area of reducing deaths from road traffic accidents which are projected to increase rapidly alongside the urbanization that is occurring in many of the countries with the weakest road infrastructure and transport safety policies.

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 3.4% 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 lifespan 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 to these challenges. In many low-income countries newborn deaths, injuries, and infectious diseases will dominate, while in higher income countries, cancers and heart disease 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 deaths, governments and other stakeholders should invest heavily in prevention by reducing population exposure to the major risk factors, especially high blood pressure, household air pollution, tobacco and alcohol use and poor diet.

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 of healthcare delivery because this is ultimately what will drive populations to seek health care enabling population-wide health improvements and the achievement of global 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 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 death under the Sustainable Development Goals and support the reframing of national and international health investments to target 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 the risk factors associated with them.  The UN should reinforce the 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 death (e.g. newborn, accidental injuries, heart disease, pneumonia and cancer) and risk factors (e.g. high blood pressure, tobacco smoking, household air pollution, poor diet and alcohol use), 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 constant improvement. These flagship initiatives should serve the populations with the largest concentrations of early deaths.

A final note. This analysis has focused only on early death and not on disability.  Behind the statistic of 16 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 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.