Looking at population health, time-series data it is easy to imagine that everything is getting better and better. What is more, as your eye tracks the line into some imaginary future, it is easy to believe that things will continue to get better and better. It is a soothing balm to the more insidious thought, that doom awaits us around every corner. In the world of stock pickers and equities experts, the balm is the Ying of the bull to the Yang of the bear. Hope versus despair.
The late Hans Rosling has done more to ground people in that hopeful view of the future than any other person. The gapminder website, his creation, provides clear, firm evidence of global improvements in health and well-being across a wide range of outcomes. As you follow the motion picture trends, countries improve. Some occasionally collapse, horribly. Then they recover. And on average, all improve. Poverty, life expectancy, education, the infant mortality rate — it does not matter what you focus on, the world has been getting better and better
Figure 1 is a quick snapshot of this improvement in life expectancy from 1915 and 2015. In both years, higher national wealth was associated with better life expectancy. In 1915, a country with a GDP/capita (adjusted for inflation and price) of $1,000 had a life expectancy of 30 years. In 2015 a country with a GDP/capita (adjusted for inflation and price) of $1,000 had a life expectancy of 60 years.
In contrast, in the middle of the 18th Century, life expectancy was similar across all countries, without regard to national wealth. Little had changed by the middle of the 19th Century. Sixty years later (1915), there was a strong association between national wealth and life expectancy; and over the next 100 years, things became much better for everyone.
Will this continue?
Let’s hope that it will. There are however significant threats visible on the horizon — and I would argue that Global Health needs a strong Red Team to make plain that dreadful prospect, often and forcefully. And as the Red Team argues their side we should hope fervently that they are utterly and comprehensively wrong! We should nonetheless listen to the arguments and not glaze over or dismiss them as we would Cassandra.
Red Teams arose in the US military and intelligence communities. They were there to argue against self-satisfied complacency. If the majority view was purple, they argued orange, if Winter, then Summer. Their purpose was to find the weaknesses in the status quo. One of the most extraordinary examples of the power of a contrarian view was the Millenium Challenge 2002, in which Paul van Riper showed that a demonstrably weaker force (the Red Team) could be devastatingly effective against the powerful (Blue Team) when they were prepared to play outside the constrained paradigm of accepted norms.
In Global Health the situation is, of course, entirely different — we do not battle each other, but we do struggle with (and against) nature and the environment. What is not different between Intelligence agencies and Global Health agencies is that views become entrenched. The Philosopher of Science, Thomas Kuhn, described the entrenchment of scientific ideas in terms of normal science: “the regular work of scientists theorizing, observing, and experimenting within a settled paradigm or explanatory framework”. These “settled paradigms” can permit significant new developments, but they brook no serious opposition (only tinkering at the margins). They are the VHS manufacturer to the plucky Betamax.
“Beta what?”, I hear you ask, and the point is made.
Global Health has large, powerful groups that are in danger of playing a form of technocratic hegemony — Global Health, normal science. It’s incremental, unabrasive, and potentially wrong or ineffectual. Some of the possible threats to global health are well known, and if we focus only on those related to climate change and population growth the following is a reasonable starting list:
- How to sustain a planet with a population of 7.51 Billion people (2 June 2017);
- How to sustain a planet with a projected 50% growth in population to 11.2 Billion by 2100;
- (Re-)Emerging infectious diseases;
- Climate change affecting food production, habitable regions, water, and disease spread;
- War, [and more war]
- Growing inequity with its associated health hazards
The global expansion of humans over the past 10,000 years was made possible by the growth of agriculture, which in turn was made possible by a stabilisation in the climate about … 10,000 years ago. Our current success is again a product of agricultural developments. Paul Ehrlich, in his 1968 book The Population Bomb wrote a Malthusian tale of global starvation. His prediction failed to take account of Norman Borlaug’s green revolution, and the development of semidwarf wheat, which saw grain yields triple in the 1960s and 1970s. The predicted cycle of devastating starvation was averted.
Success in the past, unfortunately, does not tell us anything about the future. Timely science then does not predict timely science now. Although Borlaug’s work saw Ehrlich’s predicted threats displaced in time, towards the end of his Nobel Prize acceptance speech, Borlaug said:
Malthus signaled the danger a century and a half ago. But he emphasized principally the danger that population would increase faster than food supplies. In his time he could not foresee the tremendous increase in man’s food production potential. Nor could he have foreseen the disturbing and destructive physical and mental consequences of the grotesque concentration of human beings into the poisoned and clangorous environment of pathologically hypertrophied megalopoles. Can human beings endure the strain? Abnormal stresses and strains tend to accentuate man’s animal instincts and provoke irrational and socially disruptive behavior among the less stable individuals in the maddening crowd.
We must recognize the fact that adequate food is only the first requisite for life. For a decent and humane life we must also provide an opportunity for good education, remunerative employment, comfortable housing, good clothing, and effective and compassionate medical care. Unless we can do this, man may degenerate sooner from environmental diseases than from hunger.
So far, the international, multilateral approach to a possibly gloomy future is to seek hope — it does, after all, spring eternal. We will reduce greenhouse gas emissions, tackle global poverty through economic growth, and increase food production. We will not need to tackle population growth, nor will we have to make do with less. We write about planetary health, but we do not develop strategies for a planet that is less human-friendly tomorrow than it is today.
I hope that global health and well-being will improve well into the future, well past my life and I hope well past that of my children, (and their children, …). In case it does not, I would like to think that there is a Global Health Red Team that does not just echo gloomy news in the halls of power, but argues for and develops strategies suitable for the world in which we are all worse off. What should our goal be in that worse off world? Is it a global goal, an equitable goal of mutual pain, or is it a “My Country First”, Shakespearean tragedy of the commons?
There is an ironic twist to the use of Red Teams in the US military that may have some bearing on their use in Global Health. In the Millenium Challenge 2002 when the Red Team devastated the Blue Team in the first few days of a fortnight-long exercise, the judges reset the clock. They hamstrung the Red Team, and then let everything play out in a way that would ensure that normal (military) science came out unscathed.
Global Health needs to be intellectually braver.