On Health Priorities, BRICS Countries, and Equity

This issue of AJPH includes a provocative article entitled “The 20 Most Important and Most Preventable Health Problems of China: A Delphi Consultation of Chinese Experts,” by Wu et al. (p. 1592). From an initial list of 205 prominent Chinese medical practitioners and scientists who were invited, 70 completed the two rounds of a Delphi process, which led to two rankings: the 20 health problems that they thought would be the most important and the 20 most likely to be preventable. When the two lists were pooled, the final 20 problems included “9 noncommunicable diseases, 4 communicable diseases, 2 unhealthy behaviors, and 2 forms of environmental pollution, plus depression, road injury, and contamination of food with pesticides, antibiotics, and hormone residues.” The list thus consists of an interesting mix of diseases (including hypertension, diabetes, and several cancers), several habits such as smoking and poor dietary practices, and environmental hazards.

GLOBAL BURDEN OF DISEASE

The authors compare their list with the Global Burden of Disease (GBD) ranking of causes of lost disability-adjusted life years (DALYs) for China in 2010. (A 2016 updated list of DALYs is now available, but there are minor changes relative to the 2010 rankings; http://www.healthdata.org/china.) The GBD list results from a combination of national data on morbidity and mortality with extensive modeling based on risk factors that are likely to affect disease frequency and severity. One would not expect complete agreement between the two rankings, because the Delphi process also considers preventability, and it is not restricted to diseases but also includes risk factors such as behaviors and environmental conditions. Nevertheless, both rankings are dominated by noncommunicable diseases. The most remarkable differences are the four osteomuscular conditions included in the GBD (lower back pain, neck pain, osteoarthritis, and other musculoskeletal problems), none of which appeared in the Delphi process, and the inclusion in the latter of four communicable diseases (hepatitis, HIV/AIDS, tuberculosis, and lower respiratory infections), of which only respiratory infections appear in the DALYs ranking. The GBD also produces separate rankings of risk factors, of which the top 10 include behaviors such as poor diets and smoking, and environmental exposures including air pollution and occupational hazards. Occupational hazards is not included in the Delphi listing, nor is the consumption of alcohol or drugs, which is ranked fifth according to the GBD. A detailed comparison of both approaches is beyond the scope of this editorial, but it is important to register the greater emphasis of the Chinese experts on environmental and food contamination, compared with the importance given by the GBD of nonfatal conditions leading to disability.

BRICS

As in the other BRICS (Brazil, Russia, India, China, and South Africa) countries, the burden of disease in China is dominated by noncommunicable diseases and, to a lesser extent, by road injuries. However, there are some important differences, including the larger burden of interpersonal violence in Brazil and South Africa, of HIV/AIDS and other infections in South Africa, of alcohol-related conditions and self-harm in Russia, and of communicable diseases and undernutrition in India (http://www.healthdata.org). The relative share of noncommunicable diseases has been increasing steadily in all five BRICS countries, signaling the need for increased efforts and funding to tackle this major epidemic currently affecting middle-income countries.

DELPHI-TYPE EXERCISES’ LIMITATIONS

Priority making includes a fair amount of subjectivity. It requires not only data on disease frequency and severity, but also assessments of preventability, feasibility, cultural appropriateness, and costs. Delphi-type exercises, if properly conducted, have a role in this process by tapping into expert opinion. Such exercises also have limitations. As the study shows, the responders’ rankings varied according to their backgrounds, so future assessments should strive to include broader representativeness across the health field. Also, given the traditionally high response rates achieved by epidemiological studies in China, it is a bit disappointing to learn that experts were not nearly as responsive as the general population.

This also raises a major issue. Although expert opinion is certainly valuable, communities must also play a key role in defining priorities. First launched in my home city of Pelotas, Brazil in 1983, “participatory budgeting” is a process that allocates a proportion of the governmental budget for health and other sectors according to direct popular vote. The process became widely known when it was adopted in Porto Alegre, and later in many other cities in Brazil and abroad.¹ In Porto Alegre, about 20% of the total budget has been typically allocated on this basis. Notwithstanding the major advantages of participatory budgeting, I am left with the impression that projects and initiatives strongly lobbied for in the social and mass media—and which end up receiving the most votes—are often specialist curative units in hospitals instead of preventive projects at the community level.

SOCIAL DETERMINANTS OF HEALTH

Lastly, I note the lack of discussion on the social determinants of health. When addressing risk factors, both the Delphi process and the GDB are restricted to proximate determinants such as smoking or dietary intake. There is no attempt to quantify, or to even mention, the “causes of the causes,” to use Michael Marmot’s terminology.² Given the existence of data on morbidity and mortality by socioeconomic position or by proxies such as education, it is perfectly possible to estimate the impact on health of reducing disparities. For example, an individual-level meta-analysis of 48 cohort studies from seven high-income countries showed that “low socioeconomic status was associated with a 2.1-year reduction in life expectancy between ages 40 and 85 years, compared to 0.5 years for high alcohol intake, 0.7 years for obesity, 3.9 years for diabetes, 1.6 years for hypertension, 2.4 years for physical inactivity, and 4.8 years for current smoking.”^3(p1229)

There is no reason why similar exercises could not be carried out in BRICS countries, even though less data may be available than in high-income countries. Obviously, information on social determinants depends not only on what data are collected but also on the analytical interests of researchers. There is growing evidence on the importance of socioeconomic, ethnic, and geographical inequalities in the health of Chinese people,^4,5 yet equity does not seem to be a major issue in health research coming from China. A PubMed search for articles on human participants in the five BRICS countries—including the search terms equity, inequal*, inequit*, or socioeconomic—showed that only 1.0% of articles on China had such an index term, compared with 5.5% in Brazil and 4.8% in South Africa. Russia (2.0%) and India (2.5%) came in between.

PRIORITY MAKING

Summing up, priority making must be informed by hard data, but community priorities and expert opinion also have a role. Addressing not only the proximate causes of ill health but also the causes of these causes will contribute to improving health not only through interventions within the health sector but also in society as a whole.