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The Global Burden of Disease and its Implications for U.S. Policy

Speakers: Christopher Murray, Professor of Global Health, University of Washington, Director, Institute for Health Metrics and Evaluation, and Jennifer Kates, Vice President and Director of Global Health and HIV Policy, Kaiser Family Foundation
Presider: Thomas J. Bollyky, Senior Fellow for Global Health, Economics and Development, Council on Foreign Relations
February 6, 2013
Council on Foreign Relations


THOMAS BOLLYKY: Good morning. My name is Tom Bollyky. I'm the senior fellow for global health, economics, and development here at the Council on Foreign Relations. It is my pleasure to welcome you here to this event on "The Global Burden of Disease and its Implications for U.S. Policy."

There is a famous quote by the statistician W. Edwards Deming, which many of you with medical and science training will be familiar. And it is: "In God we trust; others bring data." In global health, we've often been forced to rely far too much on divine inspiration for policymaking. For much of the world's population, we have not known what makes them sick, how sick it makes them, and what they die of. Death certificates are lacking. Data are not standardized; diseases often have multiple definitions, making comparisons difficult over time and across countries and regions. Without better data, evidenced policymaking in global health has been difficult, if not impossible.

The question, though, that we're going to focus a bit more on today is that with better data, how and when that evidence should be incorporated into global health policymaking specifically for the United States. And today we are very fortunate to have two speakers who have brought data. In fact, they are two of the best at doing so.

To my left, we have Chris Murray, who directs the Institute of Health Metrics and Evaluation (IHME) at the University of Washington, together with his IHME colleagues and about 500 collaborators from 300 institutions and 15 countries.

They have just completed the landmark 2010 Global Burden of Disease Study, a five-year comprehensive assessment, really the most ambitious ever undertaken on the world's health status and its trends. That study consists of eight papers at 194 pages. It assesses 291 diseases and types of injuries in 187 countries and for 67 different risk factors. The journal The Lancet devoted an entire issue just to this one study, the first time, I believe, they've ever done that. It is a triple-length issue. I'm hopeful those of you who have attended have already picked up a copy. If not, it's available on your way out.

You have Chris's impressive biography before you, so I'm not going to go through it, but it's worth noting that he has actually been a leader at the forefront of this movement to do quantitative assessment of the global burden of disease for two decades and has done this work at the World Bank, at the World Health Organization and at Harvard University, before his current post.

To my far left, we have Jen Kates, who is the vice president and director of global health and HIV policy at the Kaiser Family Foundation, where she has been since 1998. Jen and her colleagues have consistently put out the most rigorous and comprehensive analyses of U.S. budgets and programs. If you're not reading these reports, you should be. I, like many others in the global health field, have relied on Jen and the work of her program extensively, so I'm very pleased at the opportunity to host her here today.

The format of today's talk will go as follows: Chris will speak for 10 minutes first to outline the findings of the report. Given the richness of the data, that will be its own herculean task. Jen will then follow and talk about U.S. health spending for, again, about five or 10 minutes. I will follow up some questions to really kick off the discussion of how the Global Burden of Disease data should start to be incorporated in U.S. policy, what it means for traditional U.S. spending priorities, and what it means for U.S. programs addressing future needs. After that, I will turn it over to the audience for questions and we'll try to leave as much time for that as possible.

Today's event is on the record, which means participants are welcome to use and cite the information at this meeting and attribute it to the speakers who made the comments. We pride ourselves in general on ending events on time at the Council, but today it's particularly important as Chris needs to run to another commitment at the World Bank immediately after this meeting. For those of you who wish to follow Chris like the Grateful Dead today – (laughter) – he's actually speaking at five different events – (laughter) – throughout town, and they will be launching a new report on global health financing at the Center for Global Development around 4:00 p.m. So, if you like, you're welcome to stalk him throughout the day.

If you have cell phones or handheld devices, please turn them off. I'm not sure if they interfere with the sound system, but it's rude to the speakers and it will irritate the rest of us, so if you could turn those off. (Laughter.)

And with that, I turn it over to Chris.

DR. CHRISTOPHER J.L. MURRAY: Well, thank you very much and good morning, everybody. I was shocked to find that so many people would be willing to come out at this time in the morning, especially for those on the West Coast, it's really quite early.

So Tom's already given some of the sort of background of the GBD, about its extent and how broad an attempt it is to quantify health around the world. I won't go through that again. What I'd like to do is first just make it very clear that what I'm talking about is the labor of nearly 500 people, from 50 countries, half of which are developing countries, and it's not just something that I've done or my colleagues at the Institute for Health Metrics and Evaluation have undertaken.

There are five high-level messages that I'd like to emphasize, and then I'd like to add my sort of more personal view around their policy implications for the U.S.

First, the five high-level messages. Health outside of sub-Saharan Africa is changing rapidly, and the change in patterns in health is being driven by four key factors. The first is the demographic transition, both changing age structure but also the change in death rate such that people are dying at much older ages. Second is the systemic shift from the leading causes of death being infectious diseases or neonatal causes or maternal causes to the noncommunicable diseases (NCDs) becoming the major killer. The third is probably less well-known, and that is the very systematic shift towards a larger component of the burden of disease coming from chronic disability than from premature mortality – more on that in a moment. And the fourth key driver is the shift in the profile of risks or risk factors that are characteristic of poor people living in poor communities to behavioral risks such as tobacco and alcohol.

A little bit more on that. The NCD shift, which is one of the more dramatic of the transitions, as shown on this map, and all of this material that I'm showing you is either in the papers or online, where there's interactive tools where you can explore this in a lot more detail. But if you k country, that the fraction of years of life lost that's both premature mortality and years lived with disability, how much is due to heart disease, cancer and the other NCDs?

It turns out that outside of Africa, it's over 60 percent in every country except Haiti, and it's actually over 70 percent in many parts of Latin America, the Middle East, East Asia and Southeast Asia. In sub-Saharan Africa, there are still parts of, for example, West Africa – Niger or Mali or Chad – where the fraction that's due to NCDs is fairly quite small at 10 or 12 percent. So the world outside of sub-Saharan Africa is really quite far in that transition.

The third key message that I mentioned, is the global wave of chronic disability, which needs a little bit of explanation. We've seen huge progress in reducing AIDS-specific mortality globally; therefore, lifespans have increased pretty much everywhere in the world with a few exceptions where there's been a very large HIV epidemic. But everywhere else, life expectancy is going up and that progress is in every single age group.

But if we look at the prevalence of disability by age, it has barely changed. So you have, to contrast, 40, 50 percent declines in premature deaths, with very small, if no declines in prevalence of disability and you immediately ask the question, how is that possible? So the same interventions that we see that are making progress on reducing infectious diseases, heart disease, cancer, shouldn't they also be reducing disability? And the answer lies in this diagram, which basically shows by age what the major causes of chronic disability are, and it turns out that those are mental disorders, substance abuse, somewhat diabetes, musculoskeletal disorders, vision loss, hearing loss, some congenital anomalies, anemia, and then the long-term consequences of injuries.

Now on that list, only diabetes is a major cause of premature mortality. The rest of them really just cause disability. Those prevalences of disability from those causes tend to go up with age. And so as we live longer, there's going to be more volume of that disability that health systems have to deal with. And so that's a pretty important observation.

And I think the tagline there is what ails you isn't necessarily what kills you, and that's the really two sets of diseases we need to think about looking forward. On the risk transition, 20 years ago, the number one risk factor in the world was childhood underweight, and then there were a whole series of other risks characteristic of poor environments, including poor water supply, poor sanitation, micronutrient deficiency, suboptimal breastfeeding. And now in 2010, the leading risk factors globally, in terms of health, disability-adjusted life years are high blood pressure, tobacco, and alcohol.

The first of the ones that affect poor households a lot, which is household air pollution, or indoor air pollution. And then a whole series of diet components, physical activity and obesity. That's a pretty profound change in the key drivers, and that's obviously part of the story around the shift towards NCD.

The fifth message, which is pretty critical on a policy level, is that, although there's been enormous progress in sub-Saharan Africa in reducing child mortality rates, moderate progress in reducing maternal mortality, declines in HIV-related death rates from 2005 and declines in malaria of almost 40 percent from 2004. Despite that, the MDG 4, 5 and 6-related health agenda, child mortality, maternal mortality, HIV, TB, malaria, remain the dominant source of disease burden in sub-Saharan Africa; 60 to 70 percent of all health loss, the burden comes from those NDC-related conditions, and that's no longer true anywhere else. So you have this sort of progress in sub-Saharan African, but still the MDG agenda is really quite central.

Now, just to flag that in The Lancet, the results that we published in December and have been disseminating through online tools are at the global level and for 21 geographic regions. But the analysis is at the country level, and on March 5, we'll be launching the country level results; Bill Gates will be launching them, actually, and many of us there as well. And also at that launch we'll be giving public access to a series of data visualization tools that we think non-technical, non-health specialists can use to explore the findings.

We think this is really important because we think getting these types of quantification of health problems out to a broader citizenship, a broader global audience, is part of using data to transform policy, but it also, I think, heralds a sort of new generation of making data available at the country level in ways that everybody can sort of engage in them.

The other bit of news that'll be announced on March 5th will be that the Burden of Disease will be continuously updated. So rather than doing this every five or 10 years in an enormous effort, it'll be an enormous effort all the time. But I think that's great for everybody else, except those working on it, because we will not have to wait for five years to sort of see where the numbers are changing. So as new data becomes published, the information will be continuously updated.

I'd like to end with six policy implications that I draw from the results. These are my own policy implications and not things that necessarily everybody in the study would agree with.

First is, although it's often hard to prove these things, I think it's very difficult not to make the link between the spending on global health that Jen's going to talk about and the progress that we've seen for child mortality, HIV, malaria, measles -- a dramatic example -- that is documented well in the Global Burden of Disease Study.

I think second observation, if you're a funder focused on the worst-off -- and that's mostly in sub-Saharan Africa -- then the agenda really still remains the MDG 4, 5, 6 agenda because that as we saw is the largest component of the burden of disease, and there are a lot of effective policies available.

On the other hand, if you are an actor or a funder that's interested elsewhere in the world, then I think one of the biggest challenges that I see is that the pace of change in health, in places like Latin America, the mean age of death is increasing almost one year every calendar year. And so that means the types of patients that come in the door of the clinic or the hospital need to be reached by public health programs now is just totally different than 20 years ago, when most of your health professionals were trained and when the structure of your ministry of health was probably set 30 years ago. So I think there's a disconnect between ministries and stewards of health systems and the profiles they actually face and helping them sort of speed up their ability to adapt to rapid epidemiological change, I think, is a really critical task.

The fourth observation is that I think we have been very successful as a global community in coming up with solutions, not necessarily implementing them all, but coming up with solutions for premature mortality – heart disease, cancer, other causes of premature mortality, and infectious diseases, – and we've been moderately successful in rolling them out. But we have nowhere near as much to offer for chronic disabilities, and that's the volume of burden that's growing in absolute numbers pretty much everywhere we look.

I think the risk factor assessment points to some untapped potential for policy action, things like diet, tobacco, blood pressure and alcohol. Certainly tobacco is a very coherent approach on policy, but for diet, I think we're just starting, and there's a lot of potential to do more.

And my last policy observation is given my perceived success of using benchmarking and monitoring to focus global attention on reducing child mortality and maternal mortality and TB, HIV and malaria, I think the burden of disease results and their implications need to play out in how we think about the new goals for post-2015. And I think that if those aren't concrete, measurable and meaningful, then we'll have lost something that's been really quite effective in the MDGs going forward.

MR. BOLLYKY: Great. Jen?

MS. KATES: Good morning, everyone. I want to thank the Council on Foreign Relations and Tom for the opportunity to be here, and also, thanks, Chris and IHME and the entire Global Burden of Disease project, since I too have been waiting for these data and am very excited that they're here. They really are probably the most powerful, policy-relevant data that we all wait for in terms of policy program and implementation.

We didn't coordinate on our remarks at all, but I think you'll see that I was wrestling with some of the same challenges and themes that you see globally that I see for the U.S. So this morning, what I'm going to do is speak a little bit about what I see this as meaning for U.S. policy directions and also give a little update on where the U.S. is on its global health response related to some of this. And I'm going to make five key points.

And the first is that after the decade of global health, which we all generally refer to as the last decade, not this one, U.S. global health investment has begun to flatten and are on the threat of declining. Most of those investments, though, are channeled toward MDGs 4, 5 and 6, towards the communicable diseases that the GBD was focused on change – looking at the changes toward maternal and neonatal nutritional causes.

There is no NCD line in the global health budget, there's no line that says here's what we fund in NCDs that's on these other areas. Most of the funding is channeled towards Africa, and most of the countries are low-income countries, not all, but most. But there are many factors that combine to affect where the U.S. gives its global health support.

I'd say that the fourth point is with the threat of funding decline and the funding envelope, we know, is not expanding, that any discussions about future policy decisions or directions are really about trade-offs and prioritizing, and the risk there because there's tremendous unfinished business. So given this, I see that the U.S. role in responding to or helping to get ahead of some of these trends is less about a traditional role as a donor or health assistant, but much more about its role as a diplomacy agent, as a technical assistance provider, as a researcher. So those are the main points, and I'm just going to show you some data that supports some of the trends here.

This is global health funding by the U.S. government in the last decade and then most recently, and this combines funding for most of U.S. government's global health investment. It doesn't include all, but it's the bulk, and it's the bulk of the ones that we all talk about from a programming perspective that really form the basis of the strategy for the U.S. global health response. And as you can see, the last decade was one of growth, and since the fiscal crisis, there's been a flattening, and I'll talk a little bit about where we are right now, but as I mentioned, there is a high percentage chance it's going to decline.

I also included here what the growth would have been constant, 2001 dollars, and you can also see a similar trend but where the economy has really affected most recent years.

Where is this funding going and where has it gone? This looks at the big bucket sectors of U.S. global health investments over that period, and you can see, as I mentioned, it is really the MDG 4, 5 and 6 areas that Chris discussed. We can see the successes, in large part, because donors like the U.S. and others and recipient countries have really focused a lot of their effort in these areas. HIV has been a big force in that regard here.

Here is that same look just for the last year. This is actually essentially where we are with current funding because those who follow the U.S. budget know that we do not yet have a fiscal year '13 budget, we are operating under a continuing resolution that is slightly different than these levels but approximately these levels.

So this is the current funding portfolio of the U.S. government, about $8.8 billion. And you can see that most of it is going to bilateral HIV, to the Global Fund, which is HIV, TB and malaria, and to the other areas.

A couple of points on this. Maternal and child health is sort of lumped together and includes many of the things that we saw in the Global Burden of Disease project, and what you don't see as easily in the Global Burden of Disease projects is the family planning and reproductive health area, which is another important part of the portfolio.

Another thing I wanted to say and show is where these funding investments are being channeled, and this is a very high level just looking by region, most are to Africa. So it's a combination of reaching the MDG 4, 5 and 6 areas to the places where those are still the big challenges. And we have all of these by country. And now that on March 5th, the country level data is going to be updated, we're going to be doing some analysis with that to try to match how these investments and that burden synch up and where they don't.

So what we've seen is that the spending has begun to flatten, it's likely to decline, that most of the funding is channeled towards the MDG 4, 5 and 6 areas. Most is to sub-Saharan Africa and low-income countries. This is kind of where we are right now.

Fiscal year '13 is operating under a continuing resolution, and if you, even heard the news stories this morning, we're on the verge of having a sequester, which would be an across-the-board cut to all programs at the program level. So that means all of those sectors that we saw – HIV, maternal health, TB, malaria – will get a 5.1 percent cut in March.

Now, it's possible that there'll be some other deal reached. The President sent something to the Hill yesterday, and the Hill said no. But whatever happens, there will be cuts, and the question is what those cuts will be.

And at the same time, and I think it's very timely that the Global Burden of Disease report, has come out because the administration is also finalizing what it's going to release as a fiscal year '14 budget in a very precarious time because we don't have a budget for fiscal year '13; we don't know what the cuts are going to be for fiscal year '13. And developing a budget when you don't know what your current budget is never a fun thing, but it is about prioritizing, and I think the one take-home for me is there's tremendous unfinished business here, and a lot of experts in the field believe that we're really on the verge of being able to see a real turn in HIV, TB and malaria, on child preventable deaths – that's been a huge success, and maternal mortality coming down.

So how does the U.S. position itself given the funding envelope staying the same and given the future trends that we see? And I would say that it's very unlikely that there's going to be a NCD line in congressional earmarks, but you know, who knows? That could happen. But it's more likely that the role that the U.S. plays going forward, in addition to the unfinished business, is through diplomacy, is through its role as a researcher on all the NCDs that we still fight in this country and by providing technical assistance.

And also, as the U.S. is moving much more towards working with recipient countries to help them adapt, take on much more of their own health response, how can those systems that the U.S. has invested so heavily in, through U.S. President's Emergency Plan for AIDS Relief (PEPFAR), through the President's Malaria Initiative, through its maternal child health program, how can they be fitted now, to be able to deal with some of these changes and challenges over time.

MR. BOLLYKY: Great, thanks. I'm just going to ask a couple of quick questions of the speakers and turn it over to the audience.

My first question is for Chris. Dr. Trevor Mundel, the president of global health at the Bill & Melinda Gates Foundation, released a statement on the day that the Global Burden of Disease Study was published. And the statement, paraphrased here, had two basic points.

The first one was that this is an incredibly important piece of work. It shows as you indicated, tremendous progress on foundation investments to address child mortality, diarrheal diseases and immunization programs, but much remains to be done in sub-Saharan Africa.

The second point was that the report also shows a rapid transition to chronic diseases. And this is really important, but we have a strategy and there's a reason why we have that strategy and we're not focusing on these diseases, and this evidence doesn't change that.

My question is not about the Foundation or its strategies or Trevor's statement. It's really about other global health actors who, of course, also have strategies. And there are reasons of political economy or other motivations for those strategies. And you've been at this for a while now, doing this work on the quantitative assessment of the global burden of disease.

Which actors do you see most likely to be swayed by this evidence? And what are the signs that you start to see that happening?

DR. MURRAY: My view on this goes back to just my experience over twenty years plus years on this. I'm somewhat of a policy optimist, because I actually think if you take a long enough view, you find that the evidence on what are people's health problems and what the trends are, does eventually work its way through a diverse set of actors. The HIV/AIDS epidemic came along, there was a lag, but there's been a pretty vigorous global response to the HIV epidemics. When Dr. Derek Yach and I were at the World Health Organization (WHO), I think the evidence about the burden of tobacco that came out from the first Global Burden of Disease Study, was influential in being able to have the Framework Convention on Tobacco Control.

We could go case by case and show – so I think there's a tendency for people to be policy skeptics, that policy isn't influenced by evidence, but that's the short run view. Because I think if you're thoughtful about this, you do want to take your time and look at the evidence and see if the trends that new findings suggest are robust and will they work themselves through to a set of new strategies.

So I think we'll see that. I think that because of the global health investments, because of that line going up on Jen's graph. I think that one of the side effects is that the data on global health is dramatically better, but a side effect is that people have been collecting data all over the place, and we see that in the global burden of disease work, where the quantitative strength of evidence is dramatically better as well the toolkit to do this sort of work.

So I would hold out an expectation that in a five-year time frame, we will see people take on some more of these major shifts.

MR. BOLLYKY: Great. Jen, a related question to you. Many of the macro trends that were revealed in the most current and most comprehensive iteration of the Global Burden of Disease studies have been in evidence for some time, I think since the 1990s. The report released in 1996 talked about the epidemiological shift to non-communicable diseases. And, I want to know what you've seen to reflect these changes in the U.S. government, not just with its budgets, because we focused on budget, but even programmatic efforts that have started to reflect some of the evidence that has become more available for the last two decades.

Is there a sign that this disease shift is being taken up? Because one of the points that I thought was interesting coming from Chris' presentation, is this notion that focusing on the worse off. Many of these middle-income countries, I think three-fourths of the world's population that live under $2 lives in a middle-income country, most of which are not in Africa. What do you see to suggest that U.S. global health programs are starting to shift to the needs of those people?

MS. KATES: I agree. This isn't new, this is confirmation of trends that began, but it really shows how quickly they are happening.

What I've seen is there is U.S. attention to this at the policy level. I think there's always a struggle because attention isn't always going to translate into dedicated funding. And there's a stronger and growing advocacy community in the global health world that wants more funding from the U.S. on NCDs. So that tension comes up.

I think part of the challenge for the U.S. is getting the information out about what it is doing. So for example, the work through the Millennium Challenge Corporation is working with not just the worst off but also other countries on building systems – there's work on NCDs in and going on through the MCC. So that provides an area that hasn't been captured exactly with that lens, but it's there.

USAID is doing some work with partner countries on NCDs. Again, you wouldn't see it identified, but it is there. And then clearly the U.S. National Institutes of Health (NIH) has always played a big role. But it's in the other place where, more recently, the U.S government has stepped into to play more of a diplomatic and leadership role is in the international fora at the WHO and on the high-level forum on NCDs that happened a couple of years ago. That was a very important thing to have the U.S. voice involved in that way.

So I think that there's probably a need to better understand and package what the U.S. is doing across its different areas on NCDs, but recognize that it's going to look very different.

I also think that there are examples to be found in other areas, though they haven't been done systematically, but where for example a PEPFAR investment in a particular country, when you're investing so much in a country and helping to build that system, it's clearly going to enter into lots of different areas, and there are examples where through working with ministries of health and others, incorporating NCDs and/or risk behavior and how personal behavior and education around that has happened.

So to answer your question, I don't think there's been an explicit strategy per se, but there's activity going on and more recently has gone at a higher diplomatic level.

MR. BOLLYKY: Right. Great answer. And I would offer another example out there in support of Jen and Chris's point. In tobacco, the U.S. spends, the last time I looked, was only $6 million out of $8.4 billion devoted to global health in 2010. That said, leveraging funding from the CDC Foundation, the U.S. has established really the most reliable tobacco surveillance system for tobacco worldwide and have offered technical programs that aren't necessarily represented in budget lines.

So that's the last I have to say on this. I want to turn it over to the audience. If you would turn your placards up, I will call you in the order in which I see them. Just state your name and affiliation.


Q: Rachel Wilson from PATH. I had a question about within-country disparities. You're talking about the worst-off by country, but as we're looking at some countries, the disparities in health based on those who are better-off and those who are worst-off in those countries can be very different. And so I'm wondering, thinking about the policy implications and the funding implications of those countries outside of sub-Saharan Africa, when you look at the worst-off in some of those countries, do you see a different picture than when you're aggregating by country?

DR. MURRAY: You know, great question. It's a question that people frequently ask. As part of the study that's being done, we haven't looked at disparities within every country. And I think when you look at studies around disparities, there are obvious ways to do it for maternal and child health because of the demographic health surveys or the mixed surveys, but once you get into the rest of the burden of disease, it's actually really pretty hard.

The good news is that some large countries have already expressed an interest and are already embarking on trying to take the same computational measurements strategy around the burden of disease and applying it sub-nationally, and including some not-so-large but countries with a strong interest, Zambia for example, has a good district information system, and there's a likelihood that district level burden work will be done. China, Brazil, India or other cases where there's some prospect for that. But it's a really important issue for which we're sort of blind on many of the key causes of burden.

MR. BOLLYKY: I next have Jack, then Victoria, then Derek, then Steven.

Q: Thanks. Jack Goldstone, George Mason University. It's a great project, so thank you for all the work putting the data together. I have a question on the divergence between the disability and mortality trends that you discussed. You said mortality's fallen, been greatly affected by interventions, disability not so much. My question is whether that's a product of aggregation or consistence so that in the U.S., we're often told that the baby boomers will be healthy oldsters, we don't need to worry so much, and so is that true so that the growing disability is because people in developing countries that would have died are now surviving and they increase the disability burden, or is it the case that the disability rates are remaining flat even in the rich countries so that as we get the baby boomers aging, we will see a large increase in the volume of disabled in the well-off countries?

DR. MURRAY: Great question, and I think particularly in the U.S. where there's a lot of controversy around this, my view of the evidence is that even here, the prevalence rate, when you look at objective functional measurement aren't really going down much. To put it in contrast, mortality's declined probably 40 percent in the U.S. in any adult female age group and for men, maybe 35 percent in the last two, three decades. And the prevalence of disability's probably declined 5 or 6 percent.

But yes, there's a bit of a decline, and you can trace it to certain conditions. But the declines are coming from cardiovascular disease and cancer, which are actually relatively small contributors. There's almost no evidence that suggests that mental disorders, substance abuse – actually, substance abuse is going up for sure. Diabetes is certainly going up. And then when you look at musculoskeletal disorders, there's really nothing to suggest that they're going away.

We do have some of the benefits of joint replacement, so there is some direct intervention there. But I would say more that what little progress we see is so much smaller than what we're seeing in mortality and just so many more people living into the age groups where the prevalences go up like this. I mean, the bad news is getting old. You start becoming infirm.

MR. BOLLYKY: Great. Next we have Victoria.

Q: Hi. I'm Victoria Kao. I work on food security for the Department of Commerce. I look at trade solutions to global hunger. The question I have is, I think on one of the earlier slides, I noticed that there were breakouts of lack of diversity in food, lack of wide range of necessary nutrients and underlying causes of chronic diseases. This might be really a simple question, but I never had a definitive answer from anyone. Is food insecurity considered on par with all the other chronic diseases in terms of policy, in terms of all the diplomacy that's going on between countries, and do you see a ramp-up of the importance of food, of food security on par with pharmaceuticals and health infrastructures?

DR. MURRAY: I'm certainly somewhat beyond my expertise on answering that, but my impression of what I see from a purely health side is that when food security is invoked, it's usually more on the undernutrition side, so just ensuring, basic provision of sufficient food, so that you don't have child underweight, or even adult underweight, or the micronutrient deficiencies.

If you broaden that to the sort of broader agenda around national food policy, I think what the interesting part of the Global Burden of Disease results is that we've actually got a breakdown for 15 different components of diet, and those results are a little different than the classic message about salt, sugar, and fat. They suggest that one needs a more nuanced approach, that there are some components of diet that are actually really beneficial, not all fat is bad, maybe saturated fat is only as bad as the caloric content that's related to it.

So there are a lot of messages there that are a little bit different than the sort of, for example, the U.N. summit last year's messages on diet, around salt, sugar, and fat, So I think there's huge potential to use that. And if you broaden food security to encompass that, how do you see national diets evolving in the future, I think that's an area that needs a lot of help.

MS. KATES: I would just add that one of the signature initiatives of the Obama Administration is Feed the Future, which in my understanding of it – I'm more familiar with the specific part on the undernutrition but it's much bigger than that. But I think it is a place where it would be worth taking a look to see to what extent some of these issues are being more specifically targeted. But it is working with countries directly and building up their systems and ability to respond and prevent undernutrition going forward and provide security on food, so it gets an opportunity there.

Q: Derek Yach, The Vitality Group. First, congrats, Chris, hugely fantastic achievement.

I just want to raise one comment and then ask a question. I think the comment really is that Tom asked the question which players are attracted by the evidence and most likely to be influenced. And sitting as I do in the private sector, I think we can't negate the fact that the vast majority of spending in health writ large is not by the public sector, and the figures we have up there are interesting but really a tiny fraction of the total spend, and we should really be looking at the total spend and how you can influence it.

I've certainly seen that companies as diverse as those coming from completely different sectors, whether Nike or Novo Nordisk or my past company, PepsiCo, or HUMANA or Wal-Mart or Microsoft – every one of them I know have people who look at this data and already very interested in it, because it's showing the way forward in terms of health care products and services and insurance programs and offerings and so on. The problem I see is that we often don't have enough linkage between what you said is so important- smarter health policies driven by governments to actually align these forces better, to eliminate some of the differences between them.

And on that one specific question, I've seen with interest the growth of the Global Alliance of Chronic Diseases on the research side, the NIH getting involved and so on. And I just wondered, in your discussions with the NIH, how are they responding to this data, if they are responding at all? And how will they globalize a lot of their findings? Because I think you were with them recently.

DR. MURRAY: You know, we had a couple weeks ago a day at NIH, and it was organized around sort of the causes of chronic disability. So the people that work on musculoskeletal disorders and vision loss and hearing loss and mental disorders were obviously very interested, as you might guess, in these findings. And then there were sort of major causes of premature mortality around the NCDs. Then there was Francis Collins and the sort of general NIH discussion, and then one more, the sort of classic communicable, maternal discussions.

And I think in those different parts of NIH, very different types of discussion. But there seems to be an awful lot of familiarity and currency with the Global Burden of Disease results, even though they've only been out for a weeks. So I'm hopeful that they will work their way through their thinking.

If you took the results at face value, you would say, gosh, you know, the NIH has been hugely successful at solutions around heart disease in many aspects; shouldn't we be spending a lot more money on the causes of chronic disability or research going forward, because a number of solutions we've come up with in everything from musculoskeletal to mental disorders, substance abuse, has been much smaller. There's also the element of where is there scientific opportunity.

MR. BOLLYKY: Great. Next we have Steve Morrison.

Q: Thank you. Congratulations. Thank you to both of you for your presentations.

The NCD mobilization has been sort of slow to take shape, and it's been a fragmented movement, and the high-level summit sort of resulted in a further process of deliberation around indicators and the like. And having this powerful new data is terribly important. It leaves a lot of outstanding questions, though, about what does this translate into. I just wanted to make a couple points, one on the U.S. priorities.

I think one of the big outstanding questions is, is this an issue that goes beyond the U.S. Department of Health and Human Services (HHS) that breaks out truly into our diplomacy, and to do what. Because it's not clear yet, if you're the Secretary of State and you're leading health diplomacy, or you are in the Office of Global Health Diplomacy, it's not clear yet what your objective or your goal is in translating all this into diplomacy, and what's the instrument that you're going to look to? Are you going to look to WHO or make a case that WHO needs to really step up its game and we need to be pushing to make sure that's done competently and effectively and showing more leverage and commitment? Is it the World Bank and the International Development Association (IDA) replenishment that's coming up this year, that's where this needs to be situated? Is it in our relationships with the emerging powers, where the demand side and it's got to be in our bilateral exchange with China or our engagement with BRICS? Where's the portal to do what?

And I agree that the NIH is probably the natural place. HHS diplomacy and NIH research agenda – that makes sense; that should be on the table with Congress. That's a very natural fit, and it makes sense. Beyond that, breaking this issue to break out and take on bigger consequences for us – needs to answer that question, I think.

I'd like to hear what you think about, on the domestic side, what does all this mean in terms of this getting translated into a domestic priority that fits within the Affordable Care Act (ACA), other multitude of initiatives that are out there? Because this is as much about us and our society as it is about anything else. And thirdly is the whole trade policy and industry piece and the fact that the beverage and food industry is very much at the center of all of these things that you've talked about. And does this foretell that there's going to be greater clashes and confrontations, or does this foretell that there's going to be greater dialogue and intensification and engagement with business as a top priority moving ahead. Or are we drifting towards greater confrontation and contestation? I think the evidence is very mixed. Congratulations, this is a great contribution.

MR. BOLLYKY: So we have U.S. government's organization on global health, how its priorities get translated into diplomacy, what this means for more domestic policies and what this might mean for trade policy.

DR. MURRAY: I think the first question is a fantastic question. I don't have an answer. I think some of the intersectoral things would naturally fit with IDA at the World Bank. You know, if you think about the links between fine particle (PM 2.5) air pollution and transport investments, that's a natural fit perhaps for the World Bank, so some of the risk factors type interventions are by their nature intersectoral. I think it's a broader issue there, that there is no obvious place within the U.N. system to deal with that in a clear way, and given WHO is very focused, and appropriately focused, on MDG 4, 5 and 6 and probably needs to stay that way to see that agenda through. It's a great question.

On the domestic front, you know, one of our main messages that the world truly is a globe -- and that the patterns of health outside of sub-Saharan Africa are really starting to look quite similar, and because we have country-level results, we think that there's incredibly relevant information for the U.S.

And we've done an exercise with the with the U.K. government of using the Global Burden of Disease results already to benchmark U.K. performance by disease, with what they see as their peer group, Europe, the U.S., Australia, Canada. And it's a very interesting one. They're doing well on some things and terrible on other things. They're the worst in that set for breast cancer, and this was a real shock to them, because they thought they had made a lot of progress, but less progress than everybody else. So I think there's a power to the database and the results to help elucidate new directions for challenges for what we have here at home, and we're hoping that there'll be that type of policy U.S. discussion that perhaps the IOM will host here in Washington. And on trade, I don't see, intrinsically, why there'll be more conflict. If anything, this type of evidence can help make there less conflict around if there's a clear niche for providing products that are going to be health-promoted.

MS. KATES: Two things. I also don't have an answer, Steve, to the first question about how does it spill over outside of HHS, but I think with the new Office of Global Health Diplomacy, and Ambassador Leslie Rowe is here, which is great to have you here. There's opportunity there, clearly, I would see, if a clear goal of the U.S. government, in that office, is to use the diplomatic arm of the government to promote better health goals and also incorporating health into thinking about how the U.S. functions at a country level writ large, not just from its health sector but its mission, then an argument could be made to many countries that part of the move to sustainability and country ownership is in their self-interest. It's not so much about the U.S. pulling back its traditional global health assistance, although that is, over time, part of what will happen; it's also about preparing those countries to get ahead of this curve as much as it can and what the U.S. can bring to bear there.

Secondly, this has, obviously, tremendous implications for the U.S. and the ACA, and I also, separately from this work, do a lot of work on domestic health and the ACA. And the ACA is probably one of the best opportunities this country has, between expanding coverage significantly and incorporating preventive health emphases and benefits into health for the first time writ large, will be poised to be able to take some of these on. But how the U.S. feels about benchmarking itself against other countries in health is sometimes a good strategy, and sometimes it's not so good. So the Institute of Medicine recently did come out with a report that did some of that, and it's instructive. It came out a couple of weeks ago. Obviously, these have lessons at home. The ACA does provide, I think, one of the largest-scale opportunities this country has to tackle these programs in a much more profound way.

MR. BOLLYKY: Great. We have five minutes left, so I'm going to take the last three questions as a group. If you can keep them succinct, we'll have Kimberly, then Matt, then Chris.

Q: Kimberly Reed, International Food Information Council. And thank you for noting behavior is part of the solution, taking a look at that with consumers. But I'm going to ask a question in my personal capacity as a national board member of the Alzheimer's Association. And as we look at 35 million people in the world having dementia, at a cost of $604 billion, and that number doubling every 20 years – and we also see a trend of it in middle- and low-income countries, treatment going from informal to formal sector, and then the cost of that's going to mean on long-term care – just your thoughts on this as we look to NIH hopefully to build support for research.

MR. BOLLYKY: Matt Myers.

Q: I'm just curious to see your reaction, as I listen to you talk about helping health systems, talking about money going to the Global Fund but not talking about the fact that the – as you said, we've switched to a situation where the major cause of the disease are behavioral risk factors across the globe. And there's no way to address those without individual country political will; there is no vaccine we can import. There is no simple technical assistance. Without political will within governments, we'll never succeed.

And therefore – I also didn't hear talk about looking at funding mechanisms that have to come within government because there is no such thing as a "global fund" that will solve the problem of tobacco, alcohol and the other risk factors. So I'd just be curious as to your reaction because my concern is, in this failure of the absence of looking at those issues, we may be raising important issues but missing the core solution.



DR. MURRAY: OK. Certainly in the high-income regions – and if you go online, look at the results of these tools, you'll see Alzheimer's leaping up in the cause list – in a place like the U.K. going up 20 or 30 ranks in 20 years in terms of leading cause of burden. So that's well-documented and hopefully provides good input to those sort of discussions around Alzheimer's. I think – there are issues still about ascertaining bias and are we exaggerating the speed of the increase because we ignored it in the past, but it's still a very big issue.

On the political will issue, in other work, which we're actually releasing the fourth installment of our annual assessment of global health financing, we've been very interested in both what government spend themselves and the relationship between receiving aid and what government spent because there is a crowding out phenomenon that we can document reasonably well so that when you – when you spend money or the high-income countries spend money, ministries of finance are smart and they stake their money and put it somewhere else, to some extent.

The good news on the health finance part is that while development assistance for health is flat-lining, developing countries themselves are spending dramatically more money over time on their own on health programs. And our hope, I think, is getting more country engagement in the use of this information, having policy outreach, having this type of policy discussion. We have, for example, high-level policy discussions in China on the results in April, and a variety of those types of activities and help them use their own rapidly growing resource more wisely.

On the NCDs, there is one really critical message here, which is, I think we have to stop thinking about NCDs as one big bucket. Because the NCDs that were the focus of the U.N. discussion, which is all about premature mortality – and there you're absolutely right, you know; prevention is a great strategy because it's a lot cheaper than cure in most cases. But there is the other component of NCDs, which are these chronic causes of disability where unfortunately musculoskeletal, mental disorders, substance abuse, big volume coming, and we actually currently know very little about how to prevent them. So that's a reflection of we've invested dramatically less in research and knowledge building in those two pieces. But I think the danger of putting the two buckets together is that we then immediately gravitate back to where we have solutions, which is around heart disease, which do need to be implemented and rolled out. They're hugely powerful strategies. But we can't run the risk of ignoring this wave of chronic disability. So we need to come up with ways to prevent them, and we don't have them right now.

MS. KATES: And one thing, which is bringing back to the domestic a little bit because one of the current conversations domestically around HIV has been how that disease, which was very much treated also in this country with an emergency response, with very high mortality in the beginning, is now crossing over into a chronic illness. And many of the challenges that health systems are facing around treating chronic illness and disability-related aspects of poor health are becoming apparent in HIV.

And so there has been increasing attention to how does the HIV response domestically move more into sustainable one as well, and what lessons can it translate into the larger health care system. So it's not just that there are noncommunicable diseases of different types that we have to address and still the communicable diseases; there's going to be a relationship between the two that gets complicated over time. There may be some lessons to be learned from how the domestic health system responds to the increasing need for providing longer-term chronic care to people with HIV in this country.

MR. BOLLYKY: Great. With that, we're going to conclude. I want to remind people that the country-specific data emerging from the Global Burden of Disease report will be out March 5th. I personally think that national governments themselves may be the biggest consumers of this data in terms of it resulting into action. I thought Chris' presentation on the U.S. situation at NIH was fascinating. So I encourage you all to go to the IHME website on March 5th to see that. Kaiser has just put out a report on U.S. global health spending, so you can read more about what Jen has just talked about on their website. And with that, let me ask you to join me in thanking our great speakers. (Applause.)


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