THE GLOBAL ECONOMIC, HEALTH & SOCIAL IMPACTS OF AGEING POPULATIONS

PREAMBLE: On June 25, 2009, the Economist published "A slow-burning fuse: A special report on ageing populations”, drawing significantly from recently released estimates from the International Monetary Fund (IMF). The Economist report is available online at http://www.economist.com/specialreports. It begins with a focus on rapid aging trends in rich countries, and affirms that low-income countries are only a few decades behind. For a direct link to the report, go to http://tinyurl.com/kw7bvh

We selected this topic for the August issue of Global Perspectives not only because of its importance world-wide, but also because – in our teaching, publishing and advisory roles – we (among others active in the population health sciences) have been stressing the relevance and impact of ageing to the health of populations for over two decades. By way of historical interest, the following references to two early publications are listed:

White F, The Environment of Medicine in the 21st Century: implications for Preventive and Community Approaches. Canadian Medical Association Journal 1987, 136: 571 75.
White F, Prevention of Disease and Promotion of Health An Overview of Medical Education in Canada, Association of Canadian Medical Colleges. ACMC Forum, 1987, XX, 2:1 3,6.

We are pleased to note that appropriate attention is finally being given to these demographic forces and effects by widely established media sources such as the Economist. Their ability to present the phenomenon in common (non-technical) language, placing it in the perspective of the global financial crisis (that affects everyone), and then highlighting what the future may hold, should be a wake-up call to governments around the world: to come to grips with the policy and fiscal implications.

What we reflect below is a précis of some key points; interested readers should consult the complete article which includes several charts to illustrate the main observations.

REVIEW OF “A slow-burning fuse”
The special report places the current deep recession, trillion-dollar rescue packages and burgeoning job losses within an even more sobering perspective. It contemplates the longer term consequences of demographically ageing populations: the prospects of slow growth, lower productivity, rising public spending and labour shortages.

In June 2009 the IMF released its estimates of the impact of the current financial crisis. The costs will be huge: the fiscal balances of the G20 countries will likely deteriorate by 8 % of GDP in 2008-09. However, they also noted that in the longer term these costs will be dwarfed by age-related spending. Between now and 2050, it predicted that “for advanced countries, the fiscal burden of… ageing-related costs” will be about 10 times greater than this, mostly due new spending on pensions, health and long-term care.

The report notes that the rich world’s population is ageing fast, and that the poor world is only a few decades behind. According to the UN’s latest biennial population forecast, the median age for all countries is due to rise from 29 years now to 38 years by 2050. At present just under 11% of the world’s 6.9 billion people are over 60. Taking the UN’s central forecast, by 2050 that share will have risen to 22% (of a population of over 9 billion), and in the developed countries to 33% (see the Economist’s chart 2). Put another way, in the rich world 1 person in 3 will be a pensioner; nearly 1 in 10 will be over 80. This is a relentless development that in time will have vast economic, social and political consequences. By about 2020, barring huge natural or man-made disasters, demographic changes are much more certain than other long-term predictions (even climate change).

So what is making the world so much older?
There are two long-term major causes, plus a “temporary blip”.

The first major cause is that people everywhere are living far longer than they used to: in 1900 average life expectancy at birth for the world as a whole was only around 30 years, and in rich countries under 50. The figures now are 67 and 78 respectively, and still rising. We agree with the Economist that this is something to be grateful for - especially since older people these days also seem to remain healthy, fit and active for much longer.

A second, and much larger, cause of the ageing of societies is that people everywhere are having far fewer children (declining fertility rates), so that younger age groups are too small to counterbalance the growing number of older people. This trend emerged first in developed countries and is taking place now in poor countries too. In the early 1970s women across the world were still, on average, having 4.3 children each. The current global average is 2.6, and in rich countries only 1.6. In many less developed countries the rates are still in the range of 3-6, but steadily falling. The UN predicts that by 2050 the global figure will have dropped to just 2 (2.1 is often taken as the level for zero population growth, independent of migration), so by mid-century the world’s population will begin to level out. The numbers in some developed countries have already started shrinking. As the report argues, this will certainly turn the world into a different place.

The temporary blip that has magnified the effects of lower fertility and greater longevity is the baby-boom that arrived in most rich countries after World War II. The timing varied slightly from place to place, but in North America it covered roughly the 20 years from 1945. The first “baby boomers” are now approaching retirement. For the next 20 they will swell the ranks of pensioners, and lead to a decline in the working population.

In richer parts of Asia e.g, Japan, South Korea, Taiwan, populations are already old and will become even older. Europe is split: Germany, Italy and Spain now have tiny families and are therefore ageing fast, whereas France, Britain and most Nordic countries have more children which keeps them younger. In eastern Europe, and particularly in Russia, birth rates are low and life expectancy has also taken a knock. North America, due to a resilient birth rate and high immigration, will remain fairly youthful by mid-century.

In most developing countries, although birth rates are dropping, populations will remain relatively young for decades yet. But in the longer term demographic dynamics will cause poorer countries to age too. Before then, the absolute numbers of older people will swell substantially, simply because these countries are so populous. The current total of 490m over-60s, will more than triple by 2050. Since most poor countries have little or nothing in the way of a state-funded welfare net, those numbers will be hard to manage.

Alone among developing countries, China is already ageing fast. For the past 30 years it has been keeping a tight lid on population growth: not quite the “one-child policy”, as it is often called (the average number of children per woman was closer to 2), the population will peak at about 1.46 billion in 2030 and then decline. Although China has seen stupendous economic growth in recent years, it will be challenged by the cost of absorbing the cost of this rapidly ageing population.

The report also addresses the macroeconomic impacts: “as more people retire, and fewer younger ones take their place, the labour force will shrink, so output growth will drop unless productivity increases faster. Since the remaining workers will be older, they may actually be less productive.” The implications for financial markets also receive comment in the report, along with speculations regarding the potential for declining standards of living related to such issues as reduced savings rates, and asset depletion. The OECD estimates that over the next three decades the age-related decline in the labour force could cut growth in its member countries by a third compared with the previous three decades.

Envoi:The following two paragraphs are quoted verbatim, as they seem to sum up the implications not only for health but also for social policy:

“For the public finances, an ageing population is a huge headache. In countries where public pensions make up the bulk of retirement income, these will either swallow up a much larger share of the budget or they will have to become a lot less generous, which will meet political resistance (and remember that older people are much more inclined to vote than younger ones). Spending on health, which in most rich countries has been going up relentlessly anyway, is likely to grow even faster as patients get older. And because of a huge increase in the number of over-80s, a lot more money, and careful thought, will be needed to provide long-term care for them as they become frailer.

What can be done? As the IMF puts it, 'the fiscal impact of the [financial] crisis reinforces the urgency of entitlement reform.' People in rich countries will have to be weaned off the expectation that pensions will become ever more generous and health care ever more all-encompassing. Since they now live so much longer, and mostly in good health, they will have to accept that they must also work for longer and that their pensions will be smaller.”

Source: A Special Report on Ageing Populations - A slow-burning fuse. Jun 25th 2009 Economist.com. http://www.economist.com/specialreports/displayStory.cfm?story_id=13888045

FAMILY PLANNING & REPRODUCTIVE HEALTH FALL OFF GLOBAL DEVELOPMENT RADAR

WASHINGTON, June 30, 2009. On the eve of the 20th anniversary of World Population Day, the World Bank and the United Nations Population Fund (UNFPA) warned that family planning and other reproductive health programs vital to poor women had fallen off the development radar of many low-income and donor country governments and international aid agencies.

These programs, they said, were vital to boost women’s economic and social well-being, especially during the current global economic crisis, and to reduce endemic poverty and high numbers of maternal and infant deaths.

”The global economic downturn has taken a wrecking ball to growth and development in poor countries worldwide, and has become a development emergency for women because invariably they’re the first to suffer when economic crises strike”, said Joy Phumaphi, Vice President for Human Development at the World Bank, and a former Health Minister for Botswana. “Even before this crisis began, family planning and reproductive health had fallen off the radar of low-income countries, aid donors, and development agencies with the result that we’ve lost precious time in helping women get access to these vital health services, and helping countries get on a faster track to reducing poverty.”

Delivering a keynote address at the World Bank to mark the 20th anniversary of World Population Day, UNFPA Executive Director Thoraya Obaid said that investing in women was a smart choice during a time of global economic crisis and cutbacks in health budgets worldwide.

“The sad and shocking truth is that maternal mortality represents the largest health inequity in the world, and of all the Millennium Development Goals, MDG 5 to improve maternal health is lagging the farthest behind. And with the financial crisis and the reduction in budgets for health, this goal will be even harder to realize. It is not a lack of knowledge that is hindering progress; it is a lack of political will to protect the health and rights of women.”

New preliminary World Bank figures show that while official global developmentaid for health soared from US $2.9 billion in 1995 to US $14.1 billion in 2007,roughly a five-fold increase in 12 years, aid for population and reproductive health had increased much more modestly during the same period, from $901 million in 1995 to $1.9 billion in 2007. In the 35 highest-fertility countries in Africa, Asia, and the Middle East, aid for women's family planning and reproductive programs started at $150 million in 1995 and increased to $432 million in 2007, while overall aid for health in these 35 countries went from $915 million in 1995 to $4.9 billion in 2007. Support for population and reproductive health programs has significantly declined as a percentage of overall health aid, from about 30 percent in 1994 to 12 percent in 2008.

According to UNFPA, more than 500,000 women die each year during pregnancy and childbirth from mostly preventable and treatable medical problems. For every woman who dies, another 20 women suffer injuries and disabilities that can last a lifetime and rob them of livelihoods and physical well-being. Of all regions, Africa has the world’s highest rates of maternal mortality, at least 100 times those in developed countries.

Also speaking at the World Bank on behalf of the Obama Administration, Margaret Pollack, Acting Deputy Assistant Secretary, Bureau of Population, Refugees, and Migration, U.S. Department of State, said that falling birth rates cannot be achieved through better health programs alone and that better education for girls, equal economic opportunities for women, and fewer households living below the poverty line are also vital.

"We have seen time and time again that investing in women is an investment in families, communities, and societies. It is, in other words, an investment in our future. The United States is engaged and committed, and we look forward to working in partnership to ensure a world in which women are healthy, respected, and their rights are protected."

During the second half of the 20th century, world population more than doubled to reach 6 billion, an astonishing 3 billion increase in population in just 40 years. Although this rate has now slowed to 1.2 percent a year, an additional 75 million people are being added every year this decade. The world’s population could reach up to 9 billion by 2050, with the majority likely to live in the world’s poorest countries.

A recent World Bank report, Population Issues in the 21st Century: The Role of the World Bank, notes that family size can also greatly affect women’s jobs in the workplace. One cross-national survey suggests that the percentage of women in the labor force is directly related to national birth rates. For example, in Bolivia, there were strong links between women using contraception and having jobs outside of the home. In the Philippines, the average income growth for women with 1-3 pregnancies was twice that of women who had been pregnant more than seven times. The globe’s highest birth rates are found in Sub-Saharan Africa, where average fertility remains above five children per woman.

”The low status of women often poses a barrier because in many societies, women lack the power to make their own decisions about using contraceptives or using other reproductive healthcare”, says Joy Phumaphi of the World Bank. “Educating girls, improving economic opportunities for women, while giving them control over the design, management, and oversight of reproductive health programs, are very important ways to encourage better access to these essential health programs.”

Source: Press Release No: 2009/450/HD Washington, June 30, 2009.
For further information: World Bank Contact in Washington: Phil Hay (202) 473-1796 Cell (202) 409 2909 phay@worldbank.org UNFPA Contact in New York: Omar Gharzeddine (212) 297-5028 gharzeddine@unfpa.org

ACTING ON CLIMATE CHANGE TO PROTECT HUMAN HEALTH

PREAMBLE: Following on from our May issue (scan down, directly below), which devoted its space to the predicament of indigenous peoples in the face of climate change, for this June issue we decided to donate our space to dissemination of another statement on climate change, this time from the UK-based Climate and Health Council whose message is that ‘Climate Change is the biggest global health threat of the 21st century’.

This message is part of a campaign to elict support for action from the global health community, leading up to the United Nations Climate Change Conference (COP15) in Copenhagen, December 7-18, 2009 (for more information: http://www.en.cop15.dk/ ).

As the editors of the British Medical Journal and Lancet have stated, as co-chairs of the Climate and Health Council:

“Over the coming months it is crucial that all those involved in the negotiations are made aware of this campaign, of the growing body of health professional consensus, and of the importance of the message.”

They appeal for a broader-based communication strategy, and Pacific Health & Development Sciences Inc. is pleased to add its voice to this effort.

TACKLING CLIMATE CHANGE, PROTECTING HEALTH
The essence of the Climate and Health Council position is this.

1. For all those involved in negotiations to control climate change, it is important to understand that mitigating climate change can have the immediate and beneficial effect of improving public health and reducing health inequalities. These health arguments have a particular, and so far unrealised, force. They should be set alongside the powerful arguments that “climate change is the single biggest global health threat of the 21st century” (Lancet May 16th)

2. In particular, the policies that are needed to reduce greenhouse gas emissions will also bring about immediate reductions in heart disease, cancer, obesity, diabetes, mental illness, road deaths and injuries, and air pollution through promoting substantially increased physical activity (e.g. walking and cycling) and much improved diets (less meat, fat and sugar, more fruit and vegetables). Not only will overall health be improved but there is good evidence that such action will contribute to minimising the gap in health between rich and poor, promoting more biodiversity and a more sustainable food system – both important additional determinants of a just and sustainable society.

3. The evidence for this being true, important, and possible comes from health professionals, a sector of society in which the public places trust, who are firmly calling for substantial action on behalf of their families, their patients and the public, and which is showing itself foursquare behind the need for action. Health professionals are amongst those who are at the front line in enabling the enormous behavioural and social changes which will be necessary if we are to achieve a transition to a low carbon economy and lifestyle.

4. These arguments are rooted in notions of equity and social justice and must occupy a much more dominant position in the minds of the negotiators in the run up to, and at, Copenhagen than they have at previous UN Climate Change conferences.

Reference: Climate and Health Council is part of a registered charity Knowledge into Action. www.climateandhealth.org

INDIGENOUS PEOPLE'S GLOBAL SUMMIT ON CLIMATE CHANGE

PREAMBLE: Indigenous peoples from 80 nations gathered for a summit on climate change in Anchorage, Alaska, April 20-24, 2009. “Leading the Way,” organized by the Inuit Circumpolar Council (ICC), an international organization representing Arctic Inuit nations, convened some 400 participants to exchange ideas and set strategies for responding to global warming.

The Indigenous Peoples' Global Summit on Climate Change was also designed to help strengthen the communities’ participation in and articulate recommendations to the December UN conference in Copenhagen, at which a successor agreement to the Kyoto protocol will be negotiated. The Summit concluded Friday, April 24 with the signing of the Anchorage Declaration and action plan.

Says Sam Johnston of Tokyo-based United Nations University, a Summit co-sponsor: "The rich and detailed insights of Indigenous Peoples reflects and embodies a cultural and spiritual relationship with the land, ocean and wildlife. The world owes it to both the Indigenous Peoples and itself to pay greater heed to the opinions of these communities and to the wisdom of ages-old traditional knowledge."

Source: Adapted from: United Nations University, Institute for Advanced Studies. Press Release April 20, 2009. http://www.unutki.org/default.php?doc_id=145

INDIGENOUS PEOPLES AT WORLD SUMMIT SHARE CLIMATE CHANGE OBSERVATIONS, EXPERIENCE, TRAIDITIONAL COPING TECHNIQUES
With the first climate change-related relocation of an Inuit village already underway, some 400 Indigenous People and observers from 80 nations convened in Alaska for a UN-affiliated conference April 20-24 to discuss ways in which traditional knowledge can be used to both mitigate and adapt to climate change.

Hosted by the Inuit Circumpolar Council, the Indigenous Peoples' Global Summit on Climate Change was also designed to help strengthen the communities' participation in and articulate messages and recommendations to the December UN climate change conference in Copenhagen, at which a successor agreement to the Kyoto protocol will be negotiated.

The Summit took place in Anchorage, about 800 km east of the Alaskan village of Newtok, where intensifying river flow and melting permafrost are destroying homes and infrastructure, forcing 320 residents to relocate to a higher site 15 km west, at an expected financial cost in the tens of millions of dollars.

While the move will be financed in part with government funds that would have been spent maintaining the existing village and on periodic emergency evacuations, NGOs say the relocation of Newtok marks an Arctic milestone - the first official casualty among six Alaskan Inuit settlements in urgent need of relocation, including Shishmaref (pop. 560), Kivalina (pop. 377), where autumn storm waves are no longer contained by shore-fast ice, which used to form in September but in recent years has appeared only in December or even January. Dozens of similar settlements are considered threatened.

At the Summit, Indigenous Peoples from every world region shared observations and experiences of early impacts in their part of the planet, as well as traditional practices that could both ease climate change and help all humanity adapt to its anticipated consequences.

With scientific experts now predicting that the effects of climate change will be more severe and appear even faster than previously believed, Indigenous Peoples presented the Summit with new observations of changes, including:

Papua New Guinea: Indigenous People are being forced to relocate due to a combination of population growth and the inundation of coastal land due to sea level rise.

Borneo: The Dayak have documented climate variations based on observations of bird species, rising water levels, and the loss of traditional medicinal plants;

Mexico: Highland Mayan milpa farmers have a shortened rain season, unseasonal frost and unusually large daytime temperature changes, forcing them to find alternative sources of irrigation and crop variations;

Andean Region: Temperature changes in the Andean region have had a drastic impact on agriculture, health and biodiversity, evidenced by an increase in respiratory illnesses, a decrease in alpaca farming and a shortened growing season. In some areas where Indigenous People depend on Alpine flora for medicines, grazing and food, the growing season could be cut in half should the loss of glaciers continue and agriculture become dependent solely on rainfall;

Kenya: Protracted droughts are killing livestock on which the Samburu People depend for food and economic survival;

Nepal: Intense rainfall and droughts have become common, having severe crop effects.

"Indigenous Peoples have contributed the least to the global problem of climate change but will almost certainly bear the greatest brunt of its impact," says Patricia Cochran, Chair of both the Inuit Circumpolar Council and the April Summit.

"Indigenous Peoples are on the front lines of this global problem at a time when their cultures and livelihoods in traditional lands are already threatened by such trends as accelerating natural resource development stimulated by trade liberalization and globalization."

At least 5,000 distinct groups of Indigenous Peoples have been identified in more than 70 countries, with a combined global population estimated at 300-350 million, representing about 6% of humanity.

Their traditional knowledge contributes to understanding climate change - observations and interpretations by Indigenous Peoples of changing Arctic sea ice, for example, has proven important across a wide range of economic and scientific interests. Traditional knowledge of fire, meanwhile, is helping to create more effective strategies for year round forest management and reducing the risk of killer wild fires.

Interestingly, in a world first, the aborigines of Western Arnhem Land (in north-west Australia) have used traditional fire practices to reduce greenhouse gas emissions. As a result, they have sold $17 million worth of carbon credits to industry, generating significant new income for the local community.

Over millennia, Indigenous Peoples have developed a large arsenal of practices of potential benefit in the climate change context, including:

• Traditional methods of shoreline reinforcement, land stabilization and reclamation;
• Protecting watersheds with Indigenous farming techniques; and
• Fostering biodiversity and the growth of useful species through planting, transplantation, and weeding techniques, the benefits of which have often gone unappreciated outside Indigenous communities until traditional peoples are relocated or their practices restricted.

Traditional drought-related practices used to hedge against normal climate variation include:

• Sophisticated small dam systems to capture and store rainfall;
• Temporary migration;
• Planting diverse varieties of crops simultaneously; and
• Using alternative agricultural lands, food preservation techniques, hunting and gathering periods and wild food sources as required.

Among new Indigenous climate change adaptation efforts presented at the Summit:
Honduras: With increasing hurricane strikes and drastic weather changes, the Quezungal people have developed a farming method which involves planting crops under trees so the roots anchor the soil and reduce the loss of crops during natural disasters.

East Cameroon and Congo: The Baka Pygmies of South East Cameroon and the Bambendzele of Congo have developed new fishing and hunting methods to adapt to a decrease in precipitation and an increase in forest fires;

Guyana: Indigenous peoples have adopted a nomadic lifestyle, moving to more forested zones in the dry season, and are now planting manioc, their main staple, in alluvial plains where, previously, it was too moist to plant crops.

Indigenous Peoples most at risk

According to the International Union for the Conservation of Nature, the number of Indigenous Peoples most likely to be impacted to climate change requires additional research. However, those at greatest risk from expected extreme climate change-induced events such as sea level rise and crop-damaging droughts reside in:

• The Arctic,
• The Caribbean
• The Amazon
• Southern Chile and Argentina,
• Southern Africa,
• Pacific islands and other island states,
• Along the Asian coastline
• Across Australia

Beyond temperature flux, climate change is expected to alter the timing, frequency and intensity of precipitation, the direction and intensity of winds, waves, ocean currents and storm circulations, the volume of rivers, and the ranges of plants and animals.

UNU researchers say the greatest number of people will be affected by climate change through more frequent drought and spreading desertification, by rising sea levels that inundate coastal communities, through the expanded range of diseases like malaria and dengue fever, and by the disappearance of glaciers, which will stunt the usual supply of water in areas such as the Indian subcontinent, where more than 2 billion people will reside by 2050.

Source: Adapted from: Press Brief 20 April 2009: Indigenous Peoples at World Summit to Share Climate Change Experience. http://www.unutki.org/default.php?doc_id=144

GLOBAL ECONOMIC CRISIS AND THE MILLENNIUM DEVELOPMENT GOALS

PREAMBLE: For this issue we have selected a recent UN News Release that addresses global consequences of the greed and corruption in the financial industry. While almost all people have been affected by the economic crisis, the World Bank states that the crisis is set to drive 53 million more people into poverty in 2009, seriously threatening the prospect of achieving the Millennium Development Goals.

ECONOMIC CRISIS TO DRIVE MILLIONS INTO POVERTY IN 2009
13 February 2009 – The spreading global economic crisis is set to trap up to 53 million more people in poverty in developing countries this year on top of the 130-155 million driven into poverty in 2008 by soaring food and fuel prices, bringing the total of those living on less than $2 a day to over 1.5 billion, according to the World Bank.

The new forecast highlights the serious threat to achieving the United Nation's Millennium Development Goals (MDGs), which aim to slash poverty, hunger, infant and maternal mortality, and lack of access to health care and education, all by 2015. Preliminary estimates for 2009 to 2015 forecast that an average 200,000 to 400,000 more children a year may die if the crisis persists, making a total of 1.4 to 2.8 million over the period.

“The global economic crisis threatens to become a human crisis in many developing countries unless they can take targeted measures to protect vulnerable people in their communities,” World Bank President Robert B. Zoellick said on the eve of the Group of Seven (G7) finance ministers' meeting of leading industrial countries in Rome on Saturday, which he will attend.

“While much of the world is focused on bank rescues and stimulus packages, we should not forget that poor people in developing countries are far more exposed if their economies falter. This is a global crisis requiring a global solution. The needs of poor people in developing countries must be on the table.”

New estimates for 2009 suggest that lower economic growth rates will trap 46 million more people on less than $1.25 a day than was expected prior to the crisis, for a total of an extra 53 million trapped on less than $2 a day, on top of the 1.37 billion before the current crises.

A World Bank policy note issued in the run up to the G7 meeting reports that almost 40 per cent of 107 developing countries were highly exposed to the effects of the crisis and the remainder were moderately exposed, with less than 10 percent facing little risk.

It is critical for exposed countries to finance job creation, delivery of essential services and infrastructure, and safety net programmes for the vulnerable, according to the note, entitled The Global Economic Crisis: Assessing Vulnerability with a Poverty Lens.

Yet three quarters of these countries cannot raise funds domestically or internationally to finance programmes to curb the effects of the downturn. One quarter of them also lack the institutional capacity to expand spending to protect vulnerable groups. The note urges financial support in the form of grants and low or zero interest loans for these countries.

Mr. Zoellick recently called for the establishment of a Vulnerability Fund in which each developed country would devote 0.7 per cent of its stimulus package to aid poorer countries set up safety net programmes, invest in infrastructure, and support small and medium-sized enterprises and microfinance institutions.

Source: UN News Service. http://www.un.org/apps/news/story.asp?NewsID=29897&Cr=financial&Cr1=crisis

LEADERSHIP AND MANAGEMENT OF HEALTH ORGANIZATIONS – 7 QUESTIONS

PREAMBLE: When this issue was first posted on March 16, we attempted to test a 7-day polling function offered by Google. Our trial topic was “health leadership and management”. However, interest in the poll was insufficient, so we removed the questions from our sidebar on March 23. We also reconstructed the material that now follows, to be consistent with this decision.

Given the role of poorly prepared leaders and managers in the global financial crisis, it is possible that a similar crisis may be developing in health organizations.

As a “backgrounder” we supply extracts from an Opinion piece in the Globe and Mail, in which Henry Mintzberg, Cleghorn Professor of Management Studies, McGill University, took aim at “America’s monumental failure of management”. His focus on the global financial crisis and the contribution of US management teaching, including that of Harvard University, stimulated our interest in reflecting on current approaches to health leadership and management and the potential for similar failures.

Reference: Minzberg H. Globe and Mail p A11, March 16, 2009 http://www.theglobeandmail.com/servlet/story/RTGAM.20090313.wcomintzberg16/BNStory/specialComment/home

Comment: One of our concerns is that the current fashion of promoting leadership studies among health professionals early in their career development may be at the cost of first building their management skills; if so, this will eventually adversely impact the managerial competence of their organizations.

BACKGROUNDER
In his critique of American leadership and management training practices, Minzberg states: “American management is still revered across much of the globe for what it used to be. Now, a great deal of it is just plain rotten - detached and hubristic. Instead of rolling up their sleeves and getting engaged, too many CEOs sit in their offices and deem: They pronounce targets for others to meet, or else get fired.”

Further on he addresses “hubris on a massive scale” from which we extract the following:
“Management is a practice, learned in context. No manager, let alone leader, has ever been created in a classroom. Programs that claim to do so promote hubris instead. And that has been carried from the business schools into corporate America on a massive scale."

Minzberg then comments on the iconic Harvard Business School which, according to its MBA website, is ‘focused on one purpose - developing leaders.’ He states: "At Harvard, you become such a leader by reading hundreds of brief case studies, each the day before you or your colleagues are called on to pronounce on what that company should do. Yesterday, you knew nothing about Acme Inc.; today, you're pretending to decide its future. What kind of leader does that create?"

He notes that Harvard prides itself on how many of its graduates make it to the executive suites. He states: “Learning how to present arguments in a classroom… helps. But how do these people perform once they get to those suites? Harvard does not ask. So we took a look.” He then summarizes a study he carried out with a colleague Joseph Lampel:

“Joseph Lampel and I found a list of Harvard Business School superstars, published in a 1990 book by a long-term insider. We tracked the performance of the 19 corporate chief executives on that list, many of them famous, across more than a decade. Ten were outright failures (the company went bankrupt, the CEO was fired, a major merger backfired etc.); another four had questionable records at best. Five out of the 19 seemed to do fine. These figures, limited as they were, sounded pretty damning. (When we published our results, there was nary a peep. No one really cared.)”

OUR SEVEN QUESTIONS ON HEALTH LEADERSHIP AND MANAGEMENT
These questions were composed by the authors of this blog, and required only “yes” or “no” responses, a format that we recognized would severely limit the scope of the exercise. As already noted, responses were insufficient to form a basis for any comment or interpretation, so we removed the poll from this issue on March 23, and offer the same seven question (below), but now with our own commentary.

Introduction: A wide range of educational institutions (with varying capacities in health, leadership and management, from modest to substantial) have a major impact on the preparation of leaders and managers for the health field, yet health systems everywhere are creaking under the strain of expanding need and constrained budgets. We suggest therefore that the time has surely come to examine some related questions regarding leadership and management in the health sector.

The Seven Questions:

1. Like GM, are some health care organizations now “too big to fail”? COMMENT: We believe that this is very much so, and that examples exist at every level, from the World Health Organization to any number of health service entities within countries. What looms large are issues of accountability.

2. Is too much emphasis now being given to “leadership” training for health organizations at the expense of basic management skills? COMMENT: We are aware of numerous instances where individuals have been inside-tracked into leadership training, without having first gone through the process of learning much about health organizations from working within them.

3. Noting a trend towards recruiting CEOs for large health organizations from outside the health system, based on their success in unrelated fields e.g, food, energy, tourism, are such CEOs adequately prepared for the health context? COMMENT: This is a definite risk in political cultures that are more oriented towards cost containment than positive health outcomes.

4. Do such CEOs give enough philosophical commitment (comparable to that of the health professionals they lead) to health goals and objectives? COMMENT: We believe that there is a risk here, and one that needs to be studied. Just how well can "leaders" from outside health identify with health goals, or will business models dominate to the detriment of evidence based services?

5. With such CEOs is there a greater risk of remote leadership with an easy exit out of health in the event of failure? COMMENT: To the extent that health services are viewed as a business, we believe that there is a risk in relation to this trend; while career mobility and sourcing talent are important recruitment considerations, there are also downside risks in relation to loyalty to a health mission e.g, consider the greed and irresponsibility in the financial industry that has surfaced over the past year.

6. Are “leaders” of health organizations receiving disproportionate compensation, driven more by the size of their operating budgets than consistency with evidence of efficacy and positive outcomes, while extolling teamwork and sustainability? COMMENT: We dont know the answer to this, but it is a serious question: if more transparency were to apply to senior levels of the health enterprise, it would be easier for everyone to know.

7. Do teachers of health leadership and management in tertiary education institutions have sufficient health leadership and management experience to relate their teaching to reality? COMMENT: There are many exceptions, but also many people engaged in education and research into health leadership and management have a "product" to promote, not necessarily real experience on how that product actually works.

Disclaimer: The foregoing questions and comments are not cited from any of Minzberg's work, but were stimulated by his opinion piece. We accept responsibility for our exercise, and hope that it may provoke interest in the future of health leadership and management.

CLIMATE CHANGE AND THE EXPANDING GLOBAL REACH OF DENGUE FEVER

PREAMBLE: We selected dengue fever for this issue because both principals of PacificSci developed this disease while visiting the island of Trinidad in the West Indies in December 2008. Characterized by headache, muscle and joint pains, spiking fever; and (in one of us) a petechial (hemorraghic) rash, the other of us was admitted to hospital for dehydration and a major fall in platelet count (20,000; normal = 150,000-400,000). We tested positive to an IgM laboratory test, indicative of acute infection. We returned to Canada in mid-January and are convalescing.

Given the incubation range for dengue fever, typically 4-7 days, it is likely that we were exposed within 24 hours of entry into Trinidad, either on arrival at Piarco airport, or subsequently at a residential area on the north-west boundary of Port of Spain. Although the Ministry of Health maintains a mosquito control programme at the airport, an active epidemic of dengue fever had been reported by the media for several weeks in adjacent communities to the east of Port of Spain; locally employed baggage handlers could have served as a reservoir. Initially downplayed by the Ministry of Health (according to media reports), the Pan American Health Organization records 2,366 cases including deaths by the 37th week of in 2008 in Trinidad, which translates to well over 3000 cases by year end.
Source: http://www.paho.org/English/AD/DPC/CD/dengue-cases-2008.htm

Since the late 1970s dengue fever reemerged as an expanding public health problem in the Caribbean basin. Because the situation now involves co-circulation of three serotypes, the threat to personal and public health has actually heightened because a primary infection does not immunize against subsequent infection from another strain; to the contrary, it sets up a complex immune response that may result in serious disease e.g, dengue hemorrhage fever and dengue shock syndrome. This threat is compounded by climate change which is having the effect of both extending the range of the mosquito vector and also the length of the mosquito breeding season.
[See: accompanying articles below for more details].

Although there has been plenty of warning about this increasing threat, diminished priorities for public health e.g., education and mosquito abatement, plus deteriorating infrastructures e.g, drains and ditches which trap fresh water (ideal for mosquito breeding), have exacerbated the impact of this condition in many countries. Concerns for the potential impact on tourism have contributed to insufficient recognition by the political establishment, an inappropriate response because ultimately this disease will become more firmly established, and affected countries will become globally recognized as endemic for the disease. The major risk is of course for the people of the affected countries, especially those who live in heavily mosquito afflicted areas. The adequacy of the health care system in many instances may not be sufficient to cope with epidemic surges; clearly therefore the appropriate response is to refocus on prevention.

PRIOR WARNINGS OF GEOGRAPHIC EXPANSION AND INCREASED SEVERITY - HAVE THEY GONE UNHEEDED?
Over a decade ago [1], mathematical models simulating climate change projected that rising global temperatures will increase the range of mosquitoes that transmits the dengue fever virus, even then considered the most serious viral infection transmitted in man by insects, whether measured by number of infections or the number of deaths.

Researchers used three different models to show that dengue's epidemic potential increases with a relatively small temperature rise. The higher a virus's epidemic potential, the fewer mosquitoes are necessary to maintain or spread dengue in a vulnerable population. Most predicted areas of encroachment were temperate regions that border on endemic zones, places where humans and the primary carrier, the mosquito Aedes aegypti, often co-exist, but where lower temperatures until then limited transmission.

Global warming would not only increase the range of the mosquito but would also reduce the size of Ae. aegypti's larva and, ultimately, adult size. Since smaller adults must feed more frequently to develop their eggs, warmer temperatures boost the incidence of double feeding and increase the likelihood of transmission. In addition, the time the virus must spend incubating inside the mosquito is shortened at higher temperatures. Shortening the incubation period can mean a potential higher transmission rate of disease.

NOTE: The foregoing study was co-funded by the U.S. Environmental Protection Agency, the National Institute of Public Health and Environment (RIVM) (the Netherlands), and the Center for Medical, Agricultural, and Veterinary Entomology of the U.S. Department of Agriculture.

According to a recent report [2], published by the US Centers for Disease Control and Prevention, dengue is expanding in tropical and subtropical regions and is now the most frequent arboviral disease globally, with an estimated annual 100 million cases of dengue fever, 250,000 cases of dengue hemorrhagic fever, and 25,000 deaths (a 1% fatality:case ratio). Dengue has been reported in >100 countries, and 2.5 billion people live in areas where it is endemic.

Increasingly reported in travelers, dengue is a major international public health concern because of the expanding geographic distribution of the virus and competent mosquito vectors, increased frequency of epidemics, co-circulation of multiple virus serotypes, and emergence of dengue hemorrhagic fever in new areas.

References:
1. Science Daily Mar 10, 1998 http://www.sciencedaily.com/releases/1998/03/980310081157.htm
2. Wilder-Smith et al in the January 2009 issue of Emerging Infectious Diseases http://www.cdc.gov/EID/content/15/1/8.htm

MORE GLOBAL NEWS ON DENGUE FEVER
The situation as experienced described in our preamble is by no means limited to the Caribbean basin. A report published in Time magazine in 2007 reveals – among other things - that denial and inertia regarding dengue fever is widespread. Political leadership clearly has been insufficient in many countries to respond adequately to this threat. The following is extracted from a TIME Magazine report in 2007 (citation below):

“Across Southeast Asia, doctors and public-health officials are grappling with alarmingly high dengue-infection rates. Cambodia and Vietnam reported double the cases this year (2007) compared with (the prior year), and more than 400 deaths; Thailand and Burma each recorded roughly a third more cases in 2007. The World Health Organization (WHO) says this is the fourth consecutive year of unusually high rates in the region — and doctors are worried that global warming may be partially to blame.

That's because the mosquito that infects most people with dengue, the striped Aedes aegypti, does better in warm, wet weather. Regions experiencing rising temperatures and longer rainy seasons are seeing large outbreaks year after year, and what has previously been thought of as a tropical disease is popping up in more temperate regions. Nepal and Bhutan saw their first cases in recent years, as did isolated spots such as Easter Island. Today, an estimated 2.5 billion people live in areas where dengue is endemic. The WHO expects millions more will be added in coming years. ‘Dengue is an evolving situation,’ says Dr. Jai Narain, director of communicable diseases for the WHO in Southeast Asia. ‘A lot of people say climate change will impact [the disease] somewhere down the line. But it already is.’

Weather isn't doing the job alone. As more and more people migrate to cities, they create additional opportunities for the mosquito to spread the virus. The problem is particularly acute in developing countries, where inadequate utilities mean residents must store water in jars and tanks — prime breeding grounds for the Aedes aegypti. Increasing air travel is also a factor as infected fliers spread the disease quickly worldwide. ‘It's simplistic to suggest that the increasing outbreak is solely caused by climate change,’ says Simon Hales, a senior research fellow at New Zealand's University of Otago. ‘But those who would suggest that it has nothing to do with it are equally misguided.’ Hales estimates that if global warming advances as predicted by the U.N., more than half the world could be dengue country before the end of this century.

Lacking vaccines or effective treatments [Ed Note: neither option exist for dengue, which has not received adequate attention to this needed research and development], public-health officials are battling the disease with old-school tactics: pest control and education. But fumigation campaigns are too expensive for many Asian governments to carry out effectively; it's also difficult to regularly send out health officials to remind communities to keep their homes dry and water supplies clean. Even wealthy Singapore, a model of dengue control, was floored by an outbreak in 2005. Reported cases went down the following year, but are back up again slightly in 2007. ‘That's a kind of warning to us," says Hales. "As the temperature continues to increase, it gets progressively more difficult to prevent the disease from spreading — even with the best technology.’

Health-care professionals are trying to raise global awareness of the threat. In Cambodia, for example, more funding goes to controlling avian flu, a disease that affects far fewer people but has a higher fear factor worldwide. Health organizations such as the U.S.-based Centers for Disease Control and Prevention are stressing the link between climate change and disease, hoping to get more money to fight mosquito-borne illnesses.

‘This is a critical moment,’ says Dr. Maria Neira, director of the WHO's program on public health and the environment. ‘If the public pressure is maintained, the politicians will act accordingly. Waiting for dengue fever to burn itself out may be the only option for individuals who catch the disease, but that's a lousy prescription for the planet.’ “

Source: Krista Mahr Thursday, Dec. 06, 2007 TIME MAGAZINE http://www.time.com/time/magazine/article/0,9171,1691616,00.html