The Editorial: The complexity of health requires an expansion of the areas covered by public health agencies
Ed note: This post comes to us from our PLOS Blogs friend Dr Travis Saunders. Travis Saunders has a PhD in Human Kinetics at the University of Ottawa. His research focuses on the health impact of physical activity and sedentary behaviour. He blogs regularly about both on his blog, Obesity Panacea.
I came across an editorial in Maclean’s this weekend which was both surprising and disappointing (and at times condescending). The gist of the editorial was that public health agencies like the World Health Organization (WHO), Centers for Disease Control and Prevention, and Public Health Agency of Canada, should focus on infectious diseases (Ebola, smallpox, SARS, etc), rather than chronic diseases (heart disease, diabetes, cancer, etc).
I like Maclean’s, and read it regularly. In fact, I was disappointed specifically because their science and medical coverage is so consistently excellent. The now-retired Science-Ish column, written by current Vox contributor and Knight Science Journalism Fellow Julia Belluz, was a fantastic model of high profile science/medical communication. Health feature writer Kate Lunau is also great. Everything I know about Polish democracy, I owe to Maclean’s political writer Paul Wells. So while Maclean’s is typically a great, evidence-based read, this editorial was neither.
Let me begin by saying that I’ve been appalled at how slow the response to the Ebola epidemic has been. Before I get to the editorial, I would like to urge everyone to consider donating to Medecins sans Frontieres, who are coordinating much of the Ebola response. There’s no question this is an important health issue that demands attention. However, I fail to see how prioritizing focus on infectious diseases over the long term at the expense of chronic disease will improve health (especially in developed nations).
Ok, now to my complaints. Below are my arguments, along with excerpts from the editorial (emphasis mine throughout).
Ebola vs cigarettes
From the editorial:
More than 4,500 Africans have died of Ebola to date. The number of new infections is doubling every month. Health facilities in hot-zone countries Guinea, Liberia and Sierra Leone are overwhelmed and understaffed. And while Canada has so far been lucky in avoiding infection, on Sunday, U.S. President Barack Obama mustered the Pentagon into the fight after the botched response by civilian authorities left the American public nervous. Meanwhile, the head of the World Health Organization (WHO)—the UN body meant to provide leadership during international health emergencies—has bigger things on her mind.
Last week, as the Ebola crisis deepened, the director-general of the WHO, Margaret Chan, was in Moscow hosting a conference on tobacco control. “Yes, Ebola is truly an issue of international concern,” she told the Wall Street Journal. “But tobacco—if we put the evidence on the table—tobacco control is still the most cost-effective and efficient way of reducing unnecessary diseases and deaths arising from using such harmful products.” The conference concluded with an agreement on the necessity for ever-higher tobacco taxes. (Canada and the U.S. boycotted the assembly because of sanctions against Russia.)
Ebola may be scary, but cigarettes are scarier.
While diseases like Ebola are terrifying, the death tolls are still relatively small compared to chronic diseases, even in many developing countries. Smoking is the # 1 preventable cause of death worldwide, and is responsible for roughly 17% of deaths in Canada. So quite frankly, it does make sense for the WHO and other public health agencies to discuss ways to reduce tobacco related deaths, even while the Ebola response is ongoing.
Let’s put this in perspective. So far, 4,922 people have died worldwide from Ebola. In Canada alone, 37,000 died in 2011 due to tobacco use. An astounding 480,000 Americans died in 2010 from tobacco related deaths. Put another way: tobacco kills more people than Ebola every three days. So yes, cigarettes are scarier than Ebola, at least in terms of their ability to kill.
And that’s just cigarettes. As chronic diseases account for an ever greater percentage of deaths worldwide (68% of all deaths worldwide are due to chronic disease in 2012), it seems reasonable that public health agencies give them increased attention. By any objective measure, reductions in smoking rates, and related reduction in tobacco-related deaths are an unmitigated public health success story.
Change of focus, or lack of funding?
As Maclean’s illustrated in their cover story last week, the WHO’s inability to deal with the Ebola outbreak isn’t due so much to their focus on chronic diseases like obesity, as to the fact that their funding has been diminishing for years. From that cover story:
The WHO has failed to provide that leadership, [Kelley Lee, a global health professor at Simon Fraser University] explains, for a “perfect storm” of reasons: an ineffective WHO African regional office, political and economic instability in the area and, most of all, because it doesn’t have the money it needs to do its job. The WHO’s regular budget has promised “zero real growth” since the 1980s, only increasing spending to account for inflation. It tightened its belt further in the late ’90s and froze the budget in absolute terms.
In contrast to their article above, the editorial implied that the reason for the spread of Ebola was because of “mission drift” towards a focus on chronic diseases. From the recent editorial:
Unfortunately, this sort of bizarre mission drift is not unique to the WHO. Public health officials around the world have succumbed to a similar preference for tackling issues of personal choice, the free market and political causes apparently inspired by the Occupy movement. The predominant public health fixation in developed countries these days is the so-called obesity epidemic and the alleged need for food taxes, along with other intrusive measures, such as New York’s failed Big Gulp soda ban, to correct this situation.
The mandate of any public health organization is to promote health. Period.
If your goal is to promote health/reduce the risk of disease, then it makes sense to focus on whatever factors are linked to disease… be they viruses, behaviours, or income. At some times and locations it will make sense to focus on infectious diseases, at others on chronic diseases. As discussed below, there are some countries that need to focus on both simultaneously.
The only real argument against focusing on all disease, and all causes of disease, is that some people object ideological grounds, in the absence of data. But there isn’t a strong case to be made in terms of evidence. The Social Determinants of Health framework has shown that the environment you are exposed to have direct impacts on your health – the neighbourhood you live in, the people you associate with, your family structure, all of these can impact health in a multitude of ways. Health is not exclusively at the mercy of bacteria or viruses. This was nicely illustrated in an article published in Macleans in 2013, which included this extremely informative infographic:
And now the most confusing portion of the editorial
Last year, Toronto’s activist public health office chastised ABC TV for adding actress Jenny McCarthy, a vaccination critic, to the cast of its talk show The View. It is apparently necessary to remind public health officials that their mandate (and competency) does not include individual food choices, income disparity, trade, agricultural policy or network programming decisions.
This year has shown a tremendous spike in the number of measles cases in the US (see image below). Most of the infected individuals were unvaccinated. Thus, the reason that public health agencies objected to Jenny McCarthy getting a daily television platform is that she is the standard bearer of the anti-vaccine movement. Even if public health agencies focused primarily on infectious diseases as the editorial suggests, it would still make sense for them to publicly oppose her views, and to advocate against giving her a prominent daily platform on network TV. While we cannot stop the network from hiring her, we can be outspoken critics of the dangerous views she represents, and ensure that the public understands that her views do not represent the mainstream, and in fact represent a dangerous alternate reality.
Chronic diseases are a considerable (and increasing) burden, even in developing nations.
While the leading causes of death and disease in Africa are mostly infectious in origin, their role has been decreasing, while the role of chronic diseases has been increasing. Between 1990 and 2010, the disease burden of diabetes in sub-Saharan Africa increased by almost 90%. Only HIV/AIDS saw a greater increase in disease burden than diabetes over this period. The burden due to stroke and heart disease also saw increases of more than 30% during that period, while the disease burden due to respiratory infections, diarrheal diseases and malnutrition all decreased by 15-35%. This is not to say that infectious diseases have been vanquished – HIV and malaria remain the top causes of death and disease in Sub Saharan Africa – but developing nations have the unenviable task of addressing high rates of infectious disease while also seeing increasing levels of chronic disease; a situation referred to as the “double burden” of disease.
The line between infectious and chronic diseases is blurring.
We’re now finding out that several types of cancer (cervical, throat, etc) are linked to viruses, and are therefore in some sense an infectious disease (so too is obesity, and other disease-virus links are likely to follow). At the same time, advances in medications have led some to suggest that HIV is essentially a chronic disease, since it can be managed more or less indefinitely with proper medications (a key characteristic of chronic diseases is that they are long lasting, typically with no true “cure”). If public health agencies were to focus primarily on infectious diseases, would cancer be included? Only those that are specifically linked to viruses? What about HIV? Would that be too much “mission drift”? Or should we only focus on diseases that are dominating the news cycle at any particular point in time?
Chronic diseases are much more complicated than infectious ones. We know what causes Ebola, smallpox, and HIV. While it’s not necessarily easy to prevent or cure these diseases, at least the process is itself relatively simple. Contrast that with the risk factors for obesity in the above graphic (a similar graphic could be made for heart disease or diabetes). With a chronic disease it’s often difficult to even determine the key risk factors, let alone agree on the best methods of treatment or prevention.
I know that many people are ideologically opposed to public health agencies focusing on chronic diseases. Chronic diseases are seen as being due to “lifestyle”, while infectious diseases are seen as something outside of our control. Unfortunately there’s little evidence to support that view, and even less evidence that focusing our efforts on infectious diseases will result in better health or longevity in Canada or abroad.