We must value and safeguard human health for a sustainable future
BMJ 2022; 379 doi: https://doi.org/10.1136/bmj.o2699 (Published 11 November 2022) Cite this as: BMJ 2022;379:o2699
- Neena Modi, professor of neonatal medicine1,
- Sonia Bhalotra, professor of economics2,
- Flavia Bustreo, vice chair of the board3,
- Mark Hanson, emeritus professor of human development and health4
- 1Section of Neonatal Medicine, School of Public Health, Imperial College London, UK
- 2Department of Economics, University of Warwick, UK
- 3Fondation Botnar, Basel, Switzerland
- 4Institute of Developmental Sciences and NIHR Biomedical Research Centre, University of Southampton and University Hospital Southampton, UK
Do policy makers value human health? Although the immediate answer may be “yes,” reflection suggests a more nuanced response. During the covid-19 pandemic many policy makers have presented the preservation of health and economic growth as opposing choices. And there have been troubling displays of vaccine nationalism from leaders seemingly unable to comprehend that no one is safe until everyone is protected.
Meanwhile, cultures and religions around the world, supported by legislation, continue to obstruct efforts to improve reproductive health by barring access to contraception and abortion. Earlier this year the United States, in an extraordinary reversal of societal progress, overturned the landmark Roe v Wade ruling and severely restricted access to safe abortion.1
In richer countries people die mainly from preventable physical and mental health conditions, while in poorer countries enormous numbers still also die from treatable diseases. Human health affects quality of life, productivity, the wellbeing of successive generations, and ultimately the economy—but policy does not adequately reflect these realities, and the aim of securing “health in all policies” has not gained sufficient traction.
Life expectancy in many parts of the UK and the US is declining, while the gap between the most and the least affluent is widening.23 Before the covid-19 pandemic, awareness was growing of the rising prevalence of chronic non-communicable physical and mental diseases around the world, with debilitating conditions now responsible for 71% (41 million) of global deaths each year.4 The pandemic also highlighted health inter-relations, as people with non-communicable diseases were more likely to die or experience adverse effects from covid infection.
Equally, conditions during the pandemic resulted in worsening child obesity, as 25.5% of children in school year 6 in the UK are now obese.5 Overweight and obesity in late adolescence or early adulthood, even in apparently healthy people, account for about 60% of the incidence of type 2 diabetes before age 40 and a decrease in life expectancy by as much as 20 years.6 Estimates of the global cost of non-communicable diseases from 2011 to 2025 in terms of lost productivity are in the region of $47tn (£41tn; €46.7tn).7 In comparison, the global cost of climate change in developing countries has been placed at around $1.4tn over an equivalent period.8
Health as human capital
Governments cling to growth in gross domestic product (GDP) as the ultimate measure of success despite widespread and increasing acceptance that this is a flawed measure with serious limitations.910 GDP is a measure of products, outputs, and services that have monetary value even if they damage health, and it does not assign monetary value to activities that improve health. Additionally, GDP does not recognise health as human capital with a valuable future yield. These factors perpetuate the invisibility of activities that contribute to health and wellbeing, and they impede efforts to make health a policy focus. Although many economists accept the need for a new framework, the reliance on GDP persists.
Previously, population health improved as countries became wealthier. Wealth led to more stable food supplies, cleaner water, better housing and education, and therefore less infant mortality, infection, and starvation, with longer lifespans. However, the close link between health and wealth has weakened. The US is one of the wealthiest countries in the world, but it sits near the bottom of the league table for health.11
One reason given for this is that wealth drives health through people’s ability to purchase healthcare. However, current estimates suggest that, overall, healthcare explains only 10-20% of the variance in health in high income settings and about 50% in low and middle income countries.1213 The wide acceptance of “universal healthcare” as a commodity with a cost and a primary solution to the world’s health problems has distracted from investment in health capital. In addition, the World Health Organization’s use of the terms “cost effective” and “best buy” to describe approaches to combat non-communicable diseases14 is a marker of the prevalence of the commodification of health.
Reversing the decline in human health from non-communicable diseases—as well as improving the health of left behind populations who remain disadvantaged by poor nutrition, sanitation, low vaccination rates, and the toll of childbearing—requires a clear focus on prevention. It means rejecting the cries of those who promote healthcare as the principal solution, in what is all too often a self-serving activity because they stand to benefit from the commodification of healthcare. It also means incentivising activities such as parenting and caring, which improve health but all too often impose a financial penalty on the parent or carer. The world needs a framework to safeguard human health by according it value, recognising the long term benefits for individuals and for society. This means replacing GDP with a more nuanced metric, or accepting additional metrics, when making policy decisions.
Mark Carney, former governor of the Bank of England, has acknowledged a need to measure “value”15; the WHO Council on the Economics of Health for All, led by the economist Mariana Mazzucato, has called for rejection of “the pathological obsession with GDP”16; and the BMA has highlighted the need to recognise the value of health.17 As the world struggles to recover from covid and faces new challenges with the cost of conflict, the cost of living, and the continued spectre of climate change, now would be a good moment to make the case for valuing health.
Footnotes
Competing interests: NM reports current grants outside the submitted work from the National Institute for Health Research, the Medical Research Council, Health Data Research UK, Shire Pharmaceuticals, Chiesi Pharmaceuticals, the European Health Data Evidence Network, and March of Dimes. NM is a member of the Nestlé Scientific Advisory Board but accepts no personal remuneration for the role. NM is immediate past president of the BMA, immediate past president of the UK Medical Women’s Federation, past president of the UK Royal College of Paediatrics and Child Health, and president elect of the European Association of Perinatal Medicine. NM is patron of Keep Our NHS Public and HealthProm and is a trustee of the charities TheirWorld, the David Harvey Trust, Action Cerebral Palsy, and the Academy of Medical Sciences. The views expressed are her own.
SB reports current grants outside the submitted work from the European Research Council under the European Union Horizon 2020 research and innovation programme, the Economic and Social Research Council, the Italian Social Security Institute, the Sexual Violence Research Initiative, the National Bureau of Economic Research, the Ministry of Science Chile, Innovations for Poverty Action, and the Swedish Research Council. SB is a member of the international advisory board of Academics Stand Against Poverty.
FB chairs the Governance and Ethics Committee for the Partnership for Maternal, Newborn and Child Health, hosted by the World Health Organization, and the advisory board of the United Nations Institute of Global Health. She co-chairs the Lancet Commission on Gender-Based Violence and Maltreatment of Young People. The views expressed are her own.
MH reports grants outside the submitted work for the British Heart Foundation, the European Union Horizon 2020 LifeCycle Programme, and the Royal Society. He chairs the Knowledge and Evidence Working Group for the Partnership for Maternal, Newborn and Child Health, hosted by the World Health Organization. The views expressed are his own.