What can we learn from previous pandemics and from the response to COVID-19 so far?

In spite of being the most foreshadowed global catastrophe in recent history, the COVID-19 pandemic has managed to catch all of us by surprise. Comparisons with the 7 December 1941 attacks on Pearl Harbor, and with the destruction of the World Trade Center by terrorists on 11 September 2001, are instructive. Following those attacks, and after a careful, investigative study of a broad range of signals and human intelligence, it was possible to reach the conclusion that they were foreseeable but that the pertinent signs had not been recognized, and that a sufficiently recognizable pattern therefore did not emerge in time to allow for mitigating action. This is different than the present case in important respects, but, as we shall see, it is also the same. History repeats itself in a different form

The time dimension in measurements of population health

As recently attested by the Millennium Declaration (United Nations, 2000), the health of populations is a concern for both governments and civil society: three of the eight Millennium Development Goals are defined in terms of health objectives. It is therefore reasonable to enquire what it means when we claim population health improves or declines. We should also know how to measure such changes. Since the Millennium Declaration does not answer these questions, we infer that concern for population health on the part of governments and civil society is not necessarily accompanied by clear concepts regarding its definition and measurement. Nevertheless, substantial technical progress on population health measurement has been made recently (see, for example, Murray and Lopez, 1996). In addition, there is a substantial body of older work on life expectancy and related measures (for an overview, see Keyfitz and Caswell, 2005). Life expectancy, in addition to being one of the oldest population health measures, might also be the only one to have successfully established itself in popular and political conceptions. As we argue in the following, this very success conceals subtle technical points that have confounded, at least to some degree, further developments in population health measurement

Malaria intervention scale-up in Africa : effectiveness predictions for health programme planning tools, based on dynamic transmission modelling

Scale-up of malaria prevention and treatment needs to continue to further important gains made in the past decade, but national strategies and budget allocations are not always evidence-based. Statistical models were developed summarizing dynamically simulated relations between increases in coverage and intervention impact, to inform a malaria module in the Spectrum health programme planning tool.; The dynamic Plasmodium falciparum transmission model OpenMalaria was used to simulate health effects of scale-up of insecticide-treated net (ITN) usage, indoor residual spraying (IRS), management of uncomplicated malaria cases (CM) and seasonal malaria chemoprophylaxis (SMC) over a 10-year horizon, over a range of settings with stable endemic malaria. Generalized linear regression models (GLMs) were used to summarize determinants of impact across a range of sub-Sahara African settings.; Selected (best) GLMs explained 94-97 % of variation in simulated post-intervention parasite infection prevalence, 86-97 % of variation in case incidence (three age groups, three 3-year horizons), and 74-95 % of variation in malaria mortality. For any given effective population coverage, CM and ITNs were predicted to avert most prevalent infections, cases and deaths, with lower impacts for IRS, and impacts of SMC limited to young children reached. Proportional impacts were larger at lower endemicity, and (except for SMC) largest in low-endemic settings with little seasonality. Incremental health impacts for a given coverage increase started to diminish noticeably at above ~40 % coverage, while in high-endemic settings, CM and ITNs acted in synergy by lowering endemicity. Vector control and CM, by reducing endemicity and acquired immunity, entail a partial rebound in malaria mortality among people above 5 years of age from around 5-7 years following scale-up. SMC does not reduce endemicity, but slightly shifts malaria to older ages by reducing immunity in child cohorts reached.; Health improvements following malaria intervention scale-up vary with endemicity, seasonality, age and time. Statistical models can emulate epidemiological dynamics and inform strategic planning and target setting for malaria control

What Counts in Economic Evaluations in Health? Benefit-cost Analysis Compared to Other Forms of Economic Evaluations

Economic evaluations are increasingly popular, both in the field of global health as well as in purely domestic settings. However, the proliferation and use of economic evaluations by members of multiple publics, many of whom are non-economists, creates misunderstandings as well as strategic opportunities. In this extended essay, Lauer and colleagues develop a critical analysis of economic evaluations that is intended to clarify concepts and terms, and thereby to enable a diverse community of users, performers, and commissioners of economic analyses in health to better understand and use such studies. The authors pay particular attention to cost-effectiveness analysis, long the mainstay of economic evaluations in health, and to benefit-cost analysis. The article starts by noting that economic evaluations in health (EEHs) take a number of typical forms, although all involve a comparison of inputs and outcomes, either of which may or may not be market-traded goods. They call a particular choice of inputs and outcomes a ‘table of accounts’. They argue that the notion of a table of accounts provides a useful way to understand the methodological diversity of EEHs, one which subsumes more established but also more restrictive terminology (e.g. the notion of ‘study perspective’). Lauer and colleagues present tables of account for a number of commonly used EEHs. They then discuss at length benefit-cost analysis, a distinctive form of EEH that has recently attracted substantial attention in the form of so-called ‘investment cases’ in healt

Cost effectiveness of strategies to combat chronic obstructive pulmonary disease and asthma in sub-Saharan Africa and South East Asia: mathematical modelling study

Objectives To determine the population level costs, effects, and cost effectiveness of selected, individual based interventions to combat chronic obstructive pulmonary disease (COPD) and asthma in the context of low and middle income countries

Deaths and years of life lost due to suboptimal breast-feeding among children in the developing world: a global ecological risk assessment

Abstract Objective We estimate attributable fractions, deaths and years of life lost among infants and children ≤2 years of age due to suboptimal breast-feeding in developing countries. Design We compare actual practices to a minimum exposure pattern consisting of exclusive breast-feeding for infants ≤6 months of age and continued breast-feeding for older infants and children ≤2 years of age. For infants, we consider deaths due to diarrhoeal disease and lower respiratory tract infections, and deaths due to all causes are considered in the second year of life. Outcome measures are attributable fractions, deaths, years of life lost and offsetting deaths potentially caused by mother-to-child transmission of HIV through breast-feeding. Setting Developing countries. Subjects Infants and children ≤2 years of age. Results Attributable fractions for deaths due to diarrhoeal disease and lower respiratory tract infections are 55% and 53%, respectively, for the first six months of infancy, 20% and 18% for the second six months, and are 20% for all-cause deaths in the second year of life. Globally, as many as 1.45 million lives (117 million years of life) are lost due to suboptimal breast-feeding in developing countries. Offsetting deaths caused by mother-to-child transmission of HIV through breast-feeding could be as high as 242 000 (18.8 million years of life lost) if relevant World Health Organization recommendations are not followed. Conclusions The size of the gap between current practice and recommendations is striking when one considers breast-feeding involves no out-of-pocket costs, that there exists universal consensus on best practices, and that implementing current international recommendations could potentially save 1.45 million children's lives each yea

Cost-effective interventions for breast cancer, cervical cancer, and colorectal cancer : new results from WHO-CHOICE

Background: Following the adoption of the Global Action Plan for the Prevention and Control of NCDs 2013-2020, an update to the Appendix 3 of the action plan was requested by Member States in 2016, endorsed by the Seventieth World Health Assembly in May 2017 and provides a list of recommended NCD interventions. The main contribution of this paper is to present results of analyses identifying how decision makers can achieve maximum health gain using the cancer interventions listed in the Appendix 3. We also present methods used to calculate new WHO-CHOICE cost-effectiveness results for breast cancer, cervical cancer, and colorectal cancer in Southeast Asia and eastern sub-Saharan Africa. Methods: We used "Generalized Cost-Effectiveness Analysis" for our analysis which uses a hypothetical null reference case, where the impacts of all current interventions are removed, in order to identify the optimal package of interventions. All health system costs, regardless of payer, were included. Health outcomes are reported as the gain in healthy life years due to a specific intervention scenario and were estimated using a deterministic state-transition cohort simulation (Markov model). Results: Vaccination against human papillomavirus (two doses) for 9-13-year-old girls (in eastern sub-Saharan Africa) and HPV vaccination combined with prevention of cervical cancer by screening of women aged 30-49 years through visual inspection with acetic acid linked with timely treatment of pre-cancerous lesions (in Southeast Asia) were found to be the most cost effective interventions. For breast cancer, in both regions the treatment of breast cancer, stages I and II, with surgery ± systemic therapy, at 95% coverage, was found to be the most cost-effective intervention. For colorectal cancer, treatment of colorectal cancer, stages I and II, with surgery ± chemotherapy and radiotherapy, at 95% coverage, was found to be the most cost-effective intervention. Conclusion: The results demonstrate that cancer prevention and control interventions are cost-effective and can be implemented through a step-wise approach to achieve maximum health benefits. As the global community moves toward universal health coverage, this analysis can support decision makers in identifying a core package of cancer services, ensuring treatment and palliative care for all

Cost effectiveness analysis

Cost-effectiveness analysis (CEA) is a form of economic evaluation concerned with efficiency: that is, with achieving the most for the resources ( “value for money”). For example, imagine that you have billions of dollars to allocate to global health and have to decide how to spend it. Or, you are a minister of health who wants to rationalize the use of your budget. Or imagine you are the head of an agency mandated to improve human health, and you need to know what strategies to recommend. The primary aim of this chapter is to show that, in each of these cases, you ought to know something about CEA if you want to achieve your objectives. Fortunately, a number of excellent standard accounts are available (Jamison, 2009; Sculpher et al., 2017). So rather than retrace well-trodden ground, this chapter offers a complementary approach intended to respond to the needs of non-economists. It also offers a novel perspective on CEA that should be of interest to specialists. A related aim of the chapter is to explain why – in spite of its relevance – CEA remains underused for problems like those mentioned above, and misused in many cases where it is applied. We attempt to show therefore both why CEA is often appealed to and why its basic principles remain opaque

Cost effectiveness of strategies to combat breast, cervical, and colorectal cancer in sub-Saharan Africa and South East Asia: mathematical modelling study

Objective To determine the costs and health effects of interventions to combat breast, cervical, and colorectal cancers in order to guide resource allocation decisions in developing countries

Star Formation in Quasar Disk

Using a version of the ZEUS code, we carry out two-dimensional simulations of self-gravitating shearing sheets, with application to QSO accretion disks at a few thousand Schwarzschild radii, corresponding to a few hundredths of a parsec for a 10^8 solar-mass black hole. Radiation pressure and optically thick radiative cooling are implemented via vertical averages. We determine dimensionless versions of the maximum surface density, accretion rate, and effective viscosity that can be sustained by density-wave turbulence without fragmentation. Where fragments do form, we study the final masses that result. The maximum Shakura-Sunyaev viscosity parameter is approximately 0.4. Fragmentation occurs when the cooling time is less than about twice the shearing time, as found by Gammie and others, but can also occur at very long cooling times in sheets that are strongly radiation-pressure dominated. For accretion at the Eddington rate onto a 10^8 solar-mass black hole, fragmentation occurs beyond four thousand Schwarzschild radii, r_s. Near this radius, initial fragment masses are several hundred suns, consistent with estimates from linear stability; final masses after merging increase with the size of the sheet, reaching several thousand suns in our largest simulations. With increasing black-hole mass at a fixed Eddington ratio, self-gravity prevails to smaller multiples of r_s, where radiation pressure is more important and the cooling time is longer compared to the dynamical time; nevertheless, fragmentation can occur and produces larger initial fragment masses. We also find energy conservation is likely to be a challenge for all eulerian codes in self-gravitating regimes where radiation pressure dominates.Comment: 34 pages, 8 figures. Submitted to Ap