A premature mortality target for the SDG for health is ageist
2015; Elsevier BV; Volume: 385; Issue: 9983 Linguagem: Inglês
10.1016/s0140-6736(15)61016-9
ISSN1474-547X
AutoresPeter Lloyd‐Sherlock, Shah Ebrahim, Martin McKee, Martin Prince,
Tópico(s)Health disparities and outcomes
ResumoOle Norheim and colleagues' Article (Jan 17, p 239)1Norheim OF Jha P Admasu K et al.Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health.Lancet. 2015; 385: 239-252Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar provides a robust empirical study of the effects of a reduction in mortality in people younger than 70 years. Although this analysis is itself perfectly valid, the ethical principles on which it is based are deeply troubling. Specifically, the concept of premature mortality—which has come to the fore in debates about non-communicable diseases and about the 2030 Sustainable Development Goals (SDGs)—has the potential to undermine the cherished, fundamental principle of health as a universal right for all. Put simply, the Article1Norheim OF Jha P Admasu K et al.Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health.Lancet. 2015; 385: 239-252Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar tells policy makers, particularly in low-income countries, that people aged 70 years and above do not matter.A chronologically exclusive premature mortality target sends out a strong signal that years lived beyond a given age, such as 60 years or 70 years, are intrinsically less valuable than those of a younger person. This misconception builds on a flawed tradition in health-care priority setting, which includes an explicit bias against older people (as opposed to people of so-called economically and socially productive ages). These issues have been recognised (even if not fully overcome) in the Global Burden of Disease estimates, which account for disability and are at least based on the maximum life expectancy at each age, even though an upper age limit is set out.2Murray CJL Vos T Lozano R et al.Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2197-2223Summary Full Text Full Text PDF PubMed Scopus (6188) Google Scholar Consequently, the approach proposed by Norheim and colleagues1Norheim OF Jha P Admasu K et al.Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health.Lancet. 2015; 385: 239-252Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar would be a retrograde step. Moreover, by focusing only on mortality, the authors also neglect the effect of age-related, chronic morbidity on sustainable development.These bias matter because evidence exists from many low-income and middle-income countries (LMICs) that public investment has been channelled towards the existing Millennium Development Goal targets that are focused on maternal and child health and HIV, thereby reducing the available resources for other interventions.3Fukuda-Parr S Yamin AE The power of numbers: a critical review of MDG targets for human development and human rights.Development. 2013; 56: 58-65Crossref Scopus (25) Google Scholar As such, any SDG based on premature mortality will drain resources from services of relevance to older people—services that are already woefully inadequate in many countries. Older people have higher rates of common disorders that are amenable to prevention and management than younger people. A health-care system that gives adequate priority to older people would contribute more to the achievement of targets to reduce overall mortality and morbidity than a system that only focuses on younger people who are at intrinsically lower risk.Although perhaps not Norheim and colleagues' intention, setting a premature mortality target for the SDGs will inevitably reinforce the ageist bias that pervades many aspects of health-care decision making. Evidence from high-income countries suggests that this bias remains strong in areas such as cancer treatment.4Lawler M Selby P Aapro MS Duffy S Ageism in cancer care.BMJ. 2014; 348: g1614Crossref PubMed Scopus (49) Google Scholar No studies of ageism in LMICs have been published, which in itself shows the low priority afforded to older people.Norheim and colleagues1Norheim OF Jha P Admasu K et al.Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health.Lancet. 2015; 385: 239-252Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar suggest that any specific premature mortality commitments should be supplemented by a general commitment to "improve health care at all ages". The vague framing of this objective would, however, be insufficient to provide a specific steer for policy makers unless supported by targets that include people throughout life—including those in old age. Norheim and colleagues claim that the health gains of extended provision for younger age groups will trickle down to the old to the benefit of all. However this hope glosses over the specific barriers that many older people have to face to access health services, especially in low-income countries.5Prince MJ Wu F Guo Y et al.The burden of disease in older people and implications for health policy and practice.Lancet. 2015; 385: 549-562Summary Full Text Full Text PDF PubMed Scopus (1014) Google Scholar For example, levels of detection and management of diseases such as diabetes and hypertension are often lower for older people than for younger age groups.5Prince MJ Wu F Guo Y et al.The burden of disease in older people and implications for health policy and practice.Lancet. 2015; 385: 549-562Summary Full Text Full Text PDF PubMed Scopus (1014) Google ScholarPolicy makers have to make choices, and these choices are most demanding in settings of scarce resources. Rather than design targets that explicitly exclude important population groups, would a policy that focuses on the key risk factors that contribute to easily prevented mortality in people of all ages not be better? A case in point would be a global target to increase hypertension control rates to 20%.In their discussion,1Norheim OF Jha P Admasu K et al.Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health.Lancet. 2015; 385: 239-252Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar the authors observe that "in old age death is inevitable". Death is an inevitable part of life, but that does not mean we should set policy priorities that explicitly exclude those people who are often in the greatest need and face the most hardship.We declare no competing interests. Ole Norheim and colleagues' Article (Jan 17, p 239)1Norheim OF Jha P Admasu K et al.Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health.Lancet. 2015; 385: 239-252Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar provides a robust empirical study of the effects of a reduction in mortality in people younger than 70 years. Although this analysis is itself perfectly valid, the ethical principles on which it is based are deeply troubling. Specifically, the concept of premature mortality—which has come to the fore in debates about non-communicable diseases and about the 2030 Sustainable Development Goals (SDGs)—has the potential to undermine the cherished, fundamental principle of health as a universal right for all. Put simply, the Article1Norheim OF Jha P Admasu K et al.Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health.Lancet. 2015; 385: 239-252Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar tells policy makers, particularly in low-income countries, that people aged 70 years and above do not matter. A chronologically exclusive premature mortality target sends out a strong signal that years lived beyond a given age, such as 60 years or 70 years, are intrinsically less valuable than those of a younger person. This misconception builds on a flawed tradition in health-care priority setting, which includes an explicit bias against older people (as opposed to people of so-called economically and socially productive ages). These issues have been recognised (even if not fully overcome) in the Global Burden of Disease estimates, which account for disability and are at least based on the maximum life expectancy at each age, even though an upper age limit is set out.2Murray CJL Vos T Lozano R et al.Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2197-2223Summary Full Text Full Text PDF PubMed Scopus (6188) Google Scholar Consequently, the approach proposed by Norheim and colleagues1Norheim OF Jha P Admasu K et al.Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health.Lancet. 2015; 385: 239-252Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar would be a retrograde step. Moreover, by focusing only on mortality, the authors also neglect the effect of age-related, chronic morbidity on sustainable development. These bias matter because evidence exists from many low-income and middle-income countries (LMICs) that public investment has been channelled towards the existing Millennium Development Goal targets that are focused on maternal and child health and HIV, thereby reducing the available resources for other interventions.3Fukuda-Parr S Yamin AE The power of numbers: a critical review of MDG targets for human development and human rights.Development. 2013; 56: 58-65Crossref Scopus (25) Google Scholar As such, any SDG based on premature mortality will drain resources from services of relevance to older people—services that are already woefully inadequate in many countries. Older people have higher rates of common disorders that are amenable to prevention and management than younger people. A health-care system that gives adequate priority to older people would contribute more to the achievement of targets to reduce overall mortality and morbidity than a system that only focuses on younger people who are at intrinsically lower risk. Although perhaps not Norheim and colleagues' intention, setting a premature mortality target for the SDGs will inevitably reinforce the ageist bias that pervades many aspects of health-care decision making. Evidence from high-income countries suggests that this bias remains strong in areas such as cancer treatment.4Lawler M Selby P Aapro MS Duffy S Ageism in cancer care.BMJ. 2014; 348: g1614Crossref PubMed Scopus (49) Google Scholar No studies of ageism in LMICs have been published, which in itself shows the low priority afforded to older people. Norheim and colleagues1Norheim OF Jha P Admasu K et al.Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health.Lancet. 2015; 385: 239-252Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar suggest that any specific premature mortality commitments should be supplemented by a general commitment to "improve health care at all ages". The vague framing of this objective would, however, be insufficient to provide a specific steer for policy makers unless supported by targets that include people throughout life—including those in old age. Norheim and colleagues claim that the health gains of extended provision for younger age groups will trickle down to the old to the benefit of all. However this hope glosses over the specific barriers that many older people have to face to access health services, especially in low-income countries.5Prince MJ Wu F Guo Y et al.The burden of disease in older people and implications for health policy and practice.Lancet. 2015; 385: 549-562Summary Full Text Full Text PDF PubMed Scopus (1014) Google Scholar For example, levels of detection and management of diseases such as diabetes and hypertension are often lower for older people than for younger age groups.5Prince MJ Wu F Guo Y et al.The burden of disease in older people and implications for health policy and practice.Lancet. 2015; 385: 549-562Summary Full Text Full Text PDF PubMed Scopus (1014) Google Scholar Policy makers have to make choices, and these choices are most demanding in settings of scarce resources. Rather than design targets that explicitly exclude important population groups, would a policy that focuses on the key risk factors that contribute to easily prevented mortality in people of all ages not be better? A case in point would be a global target to increase hypertension control rates to 20%. In their discussion,1Norheim OF Jha P Admasu K et al.Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health.Lancet. 2015; 385: 239-252Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar the authors observe that "in old age death is inevitable". Death is an inevitable part of life, but that does not mean we should set policy priorities that explicitly exclude those people who are often in the greatest need and face the most hardship. We declare no competing interests. Supplementary Material Download .pdf (.07 MB) Help with pdf files Supplementary appendix Download .pdf (.07 MB) Help with pdf files Supplementary appendix Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for healthModerate acceleration of the 2000–10 proportional decreases in mortality could be feasible, achieving the targeted 2030 disease-specific reductions of two-thirds or a third. If achieved, these reductions avoid about 10 million of the 20 million deaths at ages 0–49 years that would be seen in 2030 at 2010 death rates, and about 17 million of the 41 million such deaths at ages 0–69 years. Such changes could be achievable by 2030, or soon afterwards, at least in areas free of war, other major effects of political disruption, or a major new epidemic. Full-Text PDF Open AccessA premature mortality target for the SDG for health is ageist – Authors' replyThe Millennium Development Goals (MDGs) for health, adopted in 2000, targeted substantial reductions by 2015 in a few MDG-selected causes: mortality in children younger than 5 years, maternal mortality, and mortality from HIV, tuberculosis, and malaria. The World Health Assembly resolution on non-communicable diseases (NCDs), adopted in 2012, targeted a 25% reduction from 2008 to 2025 in NCD mortality at ages 30–69 years.1 Full-Text PDF
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