Ladies and gentlemen, with the help of the little handout you will find before you I am going to inflict a “good news, bad news” presentation on you about the state of global health.
 
First, the good news.

In terms of health progress, the Twentieth Century was an extraordinary success. Life expectancy estimates underscore the remarkable progress that humanity achieved:

• In 1900 the planetary lifespan was probably somewhere around 30 years: the typical human being at that time could expect at birth to live no more than 3 decades.
• By the year 2000, worldwide life expectancy at birth had risen to something like 65 years--over twice the level 100 years earlier.
• Since our species’ life expectancy probably never averaged much below 20, even in prehistoric times, this means that three-quarters of all health progress ever attained took place during the past century.

And it is not just averages that increased. Over the past century, ladies and gentlemen, health conditions around the world have become much more equal. This important fact often goes unappreciated, but it is powerful and apparent, and is plainly evident when we consider the world’s changing patterns in age-at-death.

Look at my first chart, please. (See figure one) This compares Sweden’s age-at-death patterns for men in 1861 and 1999. In 1861, male life expectancy in Sweden was about 45; in 1999, it was over 75. In 1861, over a quarter of Sweden’s males died before the age of 10--and only 23 percent of them made it to age 70. In 1999, less than 1 percent of them died before age 10--and over three-fourths lived to 70, or beyond.

The areas under the red and the blue curves on the chart are identical--each tracks the fate of 100,000 typical men. But you can readily see that higher life expectancy also means a much more equal distribution of lifespans--and this holds true not just for Swedish men, but for every global population.

We are nowadays used to hearing people talk about the “Gini coefficient” when discussing income inequality--but we can use that statistical measure to discuss death-age inequality, too.  If we do, we will see something quite noteworthy. Here please look at my second chart. (See figure two) Although we do not have the data at hand to calculate the precise Gini coefficient for the world for 1900 and 2000 with respect to death age, available data from contemporary populations from around the globe permit us to approximate those quantities tolerably well. 

Those data demonstrate that the relationship between a people’s level of life expectancy and their degree of inequality in death-age is strong and regular, irrespective of income level, culture or ethnicity. Those same data suggest, moreover, that the “Gini coefficient” concerning this fundamental indication of global health inequality has probably fallen by over two-thirds over the past century. Such a revolutionary reduction in death-age inequality marks a signal improvement in the human condition--although, ironically, it is one that has gone almost entirely ignored despite its immediate importance to everyone alive today.

This is the good news. Now for the bad news.

Although health progress in the Twentieth Century was utterly unprecedented in both scope and scale, progress today is by no means universal. Quite the contrary: for the first time since World War II, there are now many dozens of countries suffering sustained and often significant reversals in life expectancy.

If you look at my next chart, you will see in fact that the US Census Bureau currently expects that over 40--over 40--countries from all over the planet--Africa, Eurasia, the Western Hemisphere, and the Pacific--will register a lower life expectancy at birth in 2010 than they did back in 1990. (See table one) For each of these societies, we are talking here about the prospect of twenty years’ worth of retrogression in national health conditions. The afflicted countries listed in that chart, incidentally, currently have something like 700 million inhabitants--they account for over a tenth of the human population.

There are diverse reasons for these health setbacks, but the single most important one of them is the global HIV/AIDS pandemic. In the places where AIDS is raging most rampant, its health and mortality consequences are very much akin to total war. We can see this from the next chart, which compares the upsurge in male mortality for France during the Second World War, and in Zimbabwe since its gruesome AIDS explosion. (See figure 3)

The AIDS crisis is not only reducing life expectancy in much of the world today--it is also making national, and potentially also international, health conditions much more unequal again, as they were in the all too recent past.

But how to deal with the AIDS onslaught in the poor world--where the epidemic is overwhelmingly located today? Here we come to more bad news: for as you will see from the next chart, the cost-benefit calculus for our existing treatments and therapies for AIDS is completely unforgiving for poor people. (See table 2)

Table 2 offers illustrative but not unreasonable estimates for the cost of prolonging an HIV-victim’s life by a single year through a HAART regimen--“highly active anti-retroviral therapies”, more informally known as “drug cocktails”. As you can see, if the medications are sold at deeply discounted generic prices--say, the Indian CIPLA group’s offer of $600 per patient per annum--extending an adult life by a single year will cost over $3000.  Even if the medication is given away for free, the cost will be over $600, since HAART treatment necessarily requires a certain amount of attendant health personnel services. 

As you will readily appreciate, there are still many places in the world today where per capita income is not yet as high as $600 per year (much less $3000 a year). In all such places, it will be exceedingly difficult to justify the general use of HAART regimens financed through local resources. 

But even if outside donors were to supply the funds for such AIDS relief, HAART interventions still look like a problematic health care choice. This is because there remain vastly more cost-effective channels through which to extend life in low-income areas: these include, for example, malaria control programs, clean water connections in rural areas, immunization programs, and some tuberculosis therapies. (See table 3) When we compare the cost of extending life for a year through HAART with alternative uses of funds for other poor people’s health problems, we see that AIDS interventions cost dozen, hundreds, or possibly even thousands of times as much.[1]

To be sure: the computations in Table 3 should be understood as illustrative--there are margins of error attached to all these numbers, and some of them may be large. Altering assumptions about “discount rates” and other parameters would correspondingly change the computed results. None of these changes, however, would lop a few “zeros” off the cost of extending an AIDS patient’s life by a year--and that is what would be necessary to make HAART treatment for adults “competitive” with other health programs for low-income populations. 

Ladies and gentlemen, we must regard these unpleasant realities as fundamentally unacceptable--because these are realities we can alter. We can change the realm of the possible here--and we must resolve to do so, through further medical research and health innovation. Above all else, it is research and development--especially in the pharmaceutical area--that promises the potential for recasting the cost-benefit calculus for HIV/AIDS treatment for low-income populations. To grasp this potential, of course, we must maintain a climate, for both business and universities that is conducive to and propitious for research and innovation. Only by encouraging further medical advances can we hope to protect against these new threats to global human health--and it is the promise of such medical advances that offer us the greatest hope for promoting the honorable and indeed noble goal of global health equality.

Thank you very much.    

Note

1. Please note that we are discussing HAART treatment for adults here--HAART for children (for prevention of mother to infant HIV transmission) could promise a much more favorable cost-benefit calculus.

Nicholas Eberstadt is the Henry Wendt Scholar at AEI.