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The Borders of Policy

What if global health solutions depend on "them" being less – rather than more – like "us?"

The New Physician November-December 2013

As industrialized countries try to solve emerging health care problems in the developing world, many experts believe that "our" solutions may not be the right fit. Student Editor Luke Messac looks at how the health priorities of industrialized nations often fundamentally differ from those of the countries we're trying to help.

Michael is a new father. He is the star goalie on his local soccer team in rural Malawi. He works construction at a religious mission near his home for less than $2 per day. At the hospital on a July afternoon, Michael is asking for powerful drugs, but he cannot find them.

Michael's reasons are entirely legitimate. A few days ago at work, a boulder fell onto his leg when an earthen wall collapsed. His boss drove him to the nearest rural hospital where clinicians performed an X-ray and found a non-displaced mid-shaft fracture of the femur. He was prescribed acetaminophen, a mild analgesic, and sent home. Yet each night he was kept awake by unremitting pain. When Michael returned to the hospital a few days later for a cast, he reported this pain but was given only a refill of acetaminophen.

A growing body of literature attributes the travails of Michael and millions of other patients to the global health establishment's fixation on American problems. Global treaties limiting access to opioid analgesics were written largely at the behest of American and European policymakers trying to stem their own epidemics of abuse. But the stringent conditions on importation, distribution and prescription set by these treaties make pain management difficult in poor countries like Malawi. Whereas in the United States a patient with a femoral fracture is likely to receive codeine, oxycodone or hydrocodone to help treat pain, Michael and similar patients in poor countries receive only weak analgesics like acetaminophen.

A number of critics point to a pattern of dominance by the "Global North" in global health priority-setting, a pattern that includes not only treaties limiting access to opioid analgesics, but American advisers who favor fees in health clinics and influential conferences where almost all attendees hail from North America and Europe.

PAIN CONTROL AND GLOBAL HEALTH IDEOLOGY

Even as advocacy movements have helped expand access to lifesaving AIDS medications and decrease child mortality worldwide, untreated pain remains a global problem awaiting a response. According to the World Health Organization, 5.5 million cancer patients and 800,000 trauma patients around the world go without treatment for moderate or severe pain each year.

In many ways, the institutions of global health have only made the problem of untreated pain worse. "The general sentiment – that we need to be very careful about prescribing opioids because of addiction and the risk for abuse – has impacted not only clinical practice in North America but also global health policy," argues Nicholas King, an ethicist and epidemiologist at McGill University in Montreal.

King and others point to global conventions, such as the 1961 United Nations Single Convention on Narcotic Drugs, as culprits. The conventions establish regulatory agencies like the International Narcotics Control Board, ostensibly with the dual mission of stanching the flow of illicit drugs while facilitating access to medically indicated opioid analgesics. But, King explains, "since their inception [these agencies] have focused steadfastly on the prohibition side and not on the promotion side."

Health officials and politicians in the United States, Canada and – to a lesser extent – Western Europe have long been concerned with abuse of opioid analgesics like morphine and codeine. So when the diplomats met to write these conventions, representatives of these countries insisted on tight controls in importation and prescribing privileges. While such rules might appear reasonable given enough trained physicians and ample resources to store and transport drugs securely, in poor countries these regulations were often prohibitively expensive.

The result is a world divided between the pain relief haves and have-nots. According to the International Narcotics Control Board, in 2010 the United States accounted for more than 99 percent of global consumption of hydrocodone, 80 percent of global consumption of oxycodone, and 55 percent of global consumption of morphine. Meanwhile, according to the World Health Organization estimates, morphine and other strong opioids are unavailable in over 150 countries. So while trying – and failing – to stop the abuse of painkillers in the United States, American health officials helped create another crisis outside their borders.

MAKING THEM PAY: AMERICAN HEALTH ECONOMICS AND USER FEES

Michael and other patients with untreated pain are not alone in suffering the adverse effects of American preoccupations. For the past half-century, health economists in American universities have argued in favor of point-of-service fees – that is, charges paid at each clinic visit. For insured patients in the United States today, these fees take the form of co-payments at checkups or sick visits.

Since the 1980s these fees have also become common in low-income countries. A 2010 survey of 50 "high-mortality" countries found only six that did not charge point-of-service fees at public sector facilities. Health economists have argued that these fees are necessary to prevent excessive, unnecessary use of scarce health resources by patients who are not especially sick.

In 1968 a young graduate student named Mark Pauly, now a professor at the University of Pennsylvania, wrote a comment in the American Economic Review arguing that overconsumption by insured patients was not a moral failing, but rational economic behavior. "I thought that was an old-fashioned explanation that deserved to be trotted out and looked at," explained Pauly in a telephone interview in July 2013. "You don't necessarily need morality to explain why people change their behavior when insurance covers care." Co-payments were necessary, Pauly argued, to help control health care utilization and, by implication, to keep insurance premiums reasonably low.

Pauly's paper became one of the foundational documents in the then-young field of American health economics. His subsequent work provided a large part of the intellectual foundation for insurance co-payments and deductibles, as well as the system of mandates and subsidies enacted with the Affordable Care Act – better known as "Obamacare" – in 2010.

Yet Pauly is one of the first to contend that his moral hazard argument is not universally applicable. He notes that multiple studies in East Asia have found that people don't overuse health care when it is free at the point of service. The reason is not bewildering, either: People think their friends and family would disapprove of such selfish consumption of scarce resources.

Meanwhile, in communities so poor that any fee would hinder access to care altogether, Pauly believes concerns about moral hazard are misplaced. After all, he explains, "if you are thinking of a country where everyone is living at the level of bare subsistence, there's not much point in talking about voluntary insurance." In fact, such a hypothetical is not terribly far from reality in some places. In Malawi, for instance, 82 percent of the population lives on less than $2 per day.

Yet for decades, health advisers at the World Bank and other international institutions invoked moral hazard while promoting point-of-service fees, even in the absence of insurance schemes and often in terribly impoverished places. Due in part to the imposition of user fees, every year 100 million people around the globe are pushed into poverty by out-of-pocket health payments, according to the World Health Organization.

WHO'S INVITED TO GLOBAL HEALTH GET-TOGETHERS?

Why should American concerns with drug abuse and health care overuse have become so influential in global health? Medical anthropologist Johanna Crane, author of Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science, points to representation at international meetings as one reason. [*] The Consortium of Universities for Global Health (CUGH) includes dozens of the largest academic medical centers in the United States and Canada, as well as "international institutional members" from Latin America, Africa and Asia.

The CUGH annual convention is an influential gathering in global health, where members discuss their work, plan for the future, and even agree upon a "common definition of global health." Yet even though the meetings are intended to strengthen global health "partnerships," most attendees hail from the United States and Canada. At the inaugural CUGH meeting in 2008, Crane notes, only four of the 50 invited participants were from resource-limited settings.

Crane argues that the priorities of North American academics and funding agencies are reflected in research performed by such partnerships. "In Uganda, I have interviewed physician-researchers who are involved in internationally funded research projects, often with an HIV focus, and they enjoy those projects," Crane explains. "But I sometimes ask them, what would you research if it were up to you? And they say, 'I would love to do a project on campylobacter [a common form of bacterial dysentery], but nobody is funding that. It's not of global interest; it's only of local interest, so I can't get any funding to do that even though it's something that affects a lot of our patients.'"

Crane admits that even if Ugandan physicians gained a greater voice in global health meetings, it would simply expand the circle of influence to a greater number of scientific elite. It would not necessarily give greater voice to the poor, or advance the cause of equity.

BRINGING LESSONS HOME

The basic premise of many global health endeavors is that challenges facing poor countries can be addressed by bringing them "up" to American standards. For many recent developments in global health, especially the scale-up in access to antiretroviral drugs for AIDS, this model has proved lifesaving for millions. But discontent over stringency of narcotics control and the fixation on moral hazard reveal that while the rest of the world may demand access to modern medicine's diagnostics and therapeutics, there is little desire to replicate American health policy.

In fact, prominent voices in global health have long argued that the American example is not the answer, but instead has many lessons to learn from the innovations wrought in the Global South. These innovations have achieved results that American health systems have not.

In the early 2000s, some American experts claimed poor patients in poor countries could not follow demanding regimens. But in 2001, a paper in the Bulletin of the World Health Organization reported on a program using paid community health workers to deliver AIDS treatment in rural Haiti that achieved rates of adherence higher than those documented in American cities.

Rwanda, a low-income country less than two decades removed from one of the 20th century's deadliest genocides, has in the last eight years instituted a national community-based health insurance program that today covers over 90 percent of the population. In 2013, a Rwandan is more likely to enjoy the health and financial benefits of health insurance than an American.

In Mexico, a conditional cash transfer program called Oportunidades has, since 2002, paid millions of families to send their children to school, health clinics and nutrition programs. In the program's first decade, researchers have documented increased school enrollment (particularly for girls), decreased incidence of illness, and reduced rates of child stunting. Mexico's model has inspired similar programs in many places, including the Opportunity NYC program in New York City.

In Haiti, Rwanda and Mexico, health outcomes improved when health care systems became less – rather than more – like America's. The health care system in the U.S. generally does not involve large cadres of paid semi-professional community health workers, comprehensive national health insurance, or conditional cash transfers.

Some in public health have called these examples of "frugal innovation." But Dr. Paul Farmer, co-founder of Partners in Health and chair of the Department of Global Health and Social Medicine at Harvard Medical School, objects to the term. "Frugal innovation makes it sound like necessity is the mother of invention. Oh, really? What if you have a femoral fracture? Or even worse, what if you have acute leukemia? You think that frugal innovation is going to be helpful? Just the opposite is true."

Indeed, though none of these programs compare to the expense of the American health care system, each requires significant funding. The Haitian community health workers are trained and paid for their work, and though the cost of antiretroviral medicines has fallen precipitously, it still far outstrips the capacity of Haitian peasants to pay. For its part, the Rwandan health insurance program requires subsidies for millions of people. Mexico's cash transfer program demands funding for the cash payments and administration.

From these experiences, with the failure of American ideas and the success of programs designed elsewhere, leaders in global health glean two lessons. First, there is a need for greater resources to fund programs to achieve equitable access to proven interventions. King and Farmer agree that a better pain control regime will demand increased resources to procure drugs, train providers and study best practices to expand access.

The second lesson is that American health policy is far from ideal, and may not be worthy of export. Some institutions that previously promoted health care user fees to raise revenues and combat moral hazard have reversed their positions. In the 1990s the World Bank was one of the foremost proponents of point-of-service health user fees. In June 2013, the bank's president, Dr. Jim Yong Kim, publicly called for the "elimination or sharp reduction of point-ofservice payments."

But for patients like Michael, untreated pain continues unabated. The immediate cause of his pain might have been the boulder that broke his leg, but the reasons for his weeks of agony were legion. The perennial absence of resources discouraged national policymakers' efforts to procure drugs and train providers. Doctors and nurses became accustomed to the absence of opioid analgesics in their clinics and inured to their patients' cries of pain. International treaties written to appease Americans' concerns with abuse rendered importation impractical.

American fears may have helped prolong Michael's pain, but his condition is far from incurable. King, for one, sees a roadmap toward a world with less pain: "You need to have health professionals set [pain control] as a priority, you need to train them in a manner that allows them to achieve that priority, and you need to provide them with the resources that they need in order to put the training into effect." It's not the world's most complex problem. But for Michael it is a worthy one.

Luke Messac, an M.D./Ph.D. student at the University of Pennsylvania, is TNP's student editor. His graduate research focuses on the history of social medicine in the United States and the history of health economics in southern Africa. This article was written with support from the Pulitzer Center on Crisis Reporting.

 [*] Editor's note: This sentence has been changed from the originally published text to reflect the correct full title of Johanna Crane's book, Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science.