- Email: [email protected]
Troubled by Ubble
Correspondence
[email protected] World Bank Zambia Country Office, Banc ABC House, Lusaka 10101, Zambia (CC); and Sydney School of Public Health, University of Sydney, Sydney, Australia (JN) 1 2
3
Usher AD. Key donors to reinstate health funding to Zambia. Lancet 2015; 386: 519–20. Central Statistical Office, Ministry of Health, and ICF International. Zambia Demographic and Health Survey 2013–14. Rockville, MD, USA: Central Statistical Office, Ministry of Health, and ICF International, 2014. WHO. Global Health Observatory data repository. http://apps.who.int/gho/data/ view.main.HEALTHEXPCAPZMB (accessed Aug 17, 2015).
Author’s reply In my World Report,1 I pointed out that a range of indicators that had been improving—child mortality, access to drugs, antenatal care, and maternal and newborn health— suddenly declined as a result of what the Zambian Ministry of Health called a “dramatic and acute resource reduction”. As far as I have been able to find out, no one knows exactly what the human costs of this abrupt withdrawal of donor funding from the Zambian health sector were. The Zambian Government’s own annual reviews suggest that the costs were heavy, with disbursements to health-care providers dropping by 40% in 2009–10. The director of the Zambian Anti-Corruption Commission, who investigated the fraud, says there were negative effects on health delivery. The Swedish aid agency Sida, the lead donor in the Zambian health sector before the corruption scandal, also acknowledges the negative effects. Sida never investigated how Sweden’s reaction to the corruption in Zambia affected the life and health of people for whom the assistance had been intended. Given donors’ preoccupation with measuring results, one could well ask why not. Collins Chansa and Joel Negin remarked that government expenditure on health increased during a period stretching from 2 years before www.thelancet.com Vol 386 November 21, 2015
the corruption scandal to 4 years afterwards. Although an increase in domestic spending on health is undoubtedly a good thing, the point of my article was to underline that donors’ zero-tolerance-on-corruption policies can have tragic consequences for beneficiaries. If the corruption occurs in the transport sector and donors freeze their funding, a bridge could go unbuilt or a road left unpaved. In the health sector, it can mean that patients with AIDS do not receive their drugs and babies go without health care. My article was about the dilemma that donors face when they choose to adopt a hard line on corruption. This is not to say that they should not do so. But when they do, they need to be upfront about the fact that their actions have consequences. I declare no competing interests.
Ann Danaiya Usher [email protected] Development Today journal, PO Box 140, 1371 Asker, Norway 1
Usher AD. Key donors to reinstate health funding to Zambia. Lancet 2015; 386: 519–20.
structural forces that fundamentally shape access to social determinants of health. Quiz-takers are likely to believe that epidemiological science has reached essentially individualistic conclusions about how health is produced, and that quiz-takers should also come to these conclusions for themselves. A rapid review of social media confirms this likelihood.3 The known stigmatising effects of such a public representation seem not to have been considered. Nor has the wider policy context, it seems, for, ironically, this so-called public engagement with science unfolded in a context of intensifying austerity across the UK. Austerity measures, affecting individuals who have not chosen (or voted) for them, are among the known and understood causes of premature death, 4 which policy makers at various levels efface every day.5 This tendency, we believe, is something that specialists in the field should be careful not to reinforce in their public engagements. All involved might usefully reflect on their contribution to the so-called impact of this study.
Gideon Mendel for The International HIV/AIDS Alliance/Corbis
*Collins Chansa, Joel Negin
We declare no competing interests.
Troubled by Ubble In their Article (Aug 8, p 533), Andrea Ganna and Erik Ingelsson 1 provided a model to predict premature mortality. Using UK Biobank data, the authors developed a question set that claimed to predict the likelihood of an individual (aged 40–70 years) dying within 5 years. A so-called death quiz storm has ensued on social media. Leaving aside data concerns,2 we query the purpose of turning a predictive population model into a so-called trendable, individualised quiz. We also raise the implications for how, in this case, premature mortality is being represented to the public. The death quiz seems almost actively to efface the political and
*Mhairi Mackenzie, Chik Collins, Gerry McCartney, Marjorie McCrory, Sharon Wright [email protected] Urban Studies, School of Social and Political Sciences, University of Glasgow, Glasgow G12 8RS, UK (MMa, SW); School of Media, Culture and Society (CC), and School of Education (MMc), University of the West of Scotland, Paisley, UK; and NHS Health Scotland, Glasgow, UK (GM) 1
2 3
4
5
Ganna A, Ingelsson E. 5 year mortality predictors in 498 103 UK Biobank participants: a prospective population-based study. Lancet 2015; 386: 533–40. Swanson JM. The UK Biobank and selection bias. Lancet 2012; 380: 110. #ubble. https://twitter.com/hashtag/ubble?sr c=hash&vertical=default13.10pm (accessed June 5, 2015). McCartney G, Collins C, Mackenzie M. What (or who) causes health inequalities: theories, evidence and implications? Health Policy 2013; 113: 221–27. Karanikolos M, Mladovsky P, Cylus J, et al. Financial crisis, austerity, and health in Europe. Lancet 2013; 381: 1323–31.
2055
[email protected] World Bank Zambia Country Office, Banc ABC House, Lusaka 10101, Zambia (CC); and Sydney School of Public Health, University of Sydney, Sydney, Australia (JN) 1 2
3
Usher AD. Key donors to reinstate health funding to Zambia. Lancet 2015; 386: 519–20. Central Statistical Office, Ministry of Health, and ICF International. Zambia Demographic and Health Survey 2013–14. Rockville, MD, USA: Central Statistical Office, Ministry of Health, and ICF International, 2014. WHO. Global Health Observatory data repository. http://apps.who.int/gho/data/ view.main.HEALTHEXPCAPZMB (accessed Aug 17, 2015).
Author’s reply In my World Report,1 I pointed out that a range of indicators that had been improving—child mortality, access to drugs, antenatal care, and maternal and newborn health— suddenly declined as a result of what the Zambian Ministry of Health called a “dramatic and acute resource reduction”. As far as I have been able to find out, no one knows exactly what the human costs of this abrupt withdrawal of donor funding from the Zambian health sector were. The Zambian Government’s own annual reviews suggest that the costs were heavy, with disbursements to health-care providers dropping by 40% in 2009–10. The director of the Zambian Anti-Corruption Commission, who investigated the fraud, says there were negative effects on health delivery. The Swedish aid agency Sida, the lead donor in the Zambian health sector before the corruption scandal, also acknowledges the negative effects. Sida never investigated how Sweden’s reaction to the corruption in Zambia affected the life and health of people for whom the assistance had been intended. Given donors’ preoccupation with measuring results, one could well ask why not. Collins Chansa and Joel Negin remarked that government expenditure on health increased during a period stretching from 2 years before www.thelancet.com Vol 386 November 21, 2015
the corruption scandal to 4 years afterwards. Although an increase in domestic spending on health is undoubtedly a good thing, the point of my article was to underline that donors’ zero-tolerance-on-corruption policies can have tragic consequences for beneficiaries. If the corruption occurs in the transport sector and donors freeze their funding, a bridge could go unbuilt or a road left unpaved. In the health sector, it can mean that patients with AIDS do not receive their drugs and babies go without health care. My article was about the dilemma that donors face when they choose to adopt a hard line on corruption. This is not to say that they should not do so. But when they do, they need to be upfront about the fact that their actions have consequences. I declare no competing interests.
Ann Danaiya Usher [email protected] Development Today journal, PO Box 140, 1371 Asker, Norway 1
Usher AD. Key donors to reinstate health funding to Zambia. Lancet 2015; 386: 519–20.
structural forces that fundamentally shape access to social determinants of health. Quiz-takers are likely to believe that epidemiological science has reached essentially individualistic conclusions about how health is produced, and that quiz-takers should also come to these conclusions for themselves. A rapid review of social media confirms this likelihood.3 The known stigmatising effects of such a public representation seem not to have been considered. Nor has the wider policy context, it seems, for, ironically, this so-called public engagement with science unfolded in a context of intensifying austerity across the UK. Austerity measures, affecting individuals who have not chosen (or voted) for them, are among the known and understood causes of premature death, 4 which policy makers at various levels efface every day.5 This tendency, we believe, is something that specialists in the field should be careful not to reinforce in their public engagements. All involved might usefully reflect on their contribution to the so-called impact of this study.
Gideon Mendel for The International HIV/AIDS Alliance/Corbis
*Collins Chansa, Joel Negin
We declare no competing interests.
Troubled by Ubble In their Article (Aug 8, p 533), Andrea Ganna and Erik Ingelsson 1 provided a model to predict premature mortality. Using UK Biobank data, the authors developed a question set that claimed to predict the likelihood of an individual (aged 40–70 years) dying within 5 years. A so-called death quiz storm has ensued on social media. Leaving aside data concerns,2 we query the purpose of turning a predictive population model into a so-called trendable, individualised quiz. We also raise the implications for how, in this case, premature mortality is being represented to the public. The death quiz seems almost actively to efface the political and
*Mhairi Mackenzie, Chik Collins, Gerry McCartney, Marjorie McCrory, Sharon Wright [email protected] Urban Studies, School of Social and Political Sciences, University of Glasgow, Glasgow G12 8RS, UK (MMa, SW); School of Media, Culture and Society (CC), and School of Education (MMc), University of the West of Scotland, Paisley, UK; and NHS Health Scotland, Glasgow, UK (GM) 1
2 3
4
5
Ganna A, Ingelsson E. 5 year mortality predictors in 498 103 UK Biobank participants: a prospective population-based study. Lancet 2015; 386: 533–40. Swanson JM. The UK Biobank and selection bias. Lancet 2012; 380: 110. #ubble. https://twitter.com/hashtag/ubble?sr c=hash&vertical=default13.10pm (accessed June 5, 2015). McCartney G, Collins C, Mackenzie M. What (or who) causes health inequalities: theories, evidence and implications? Health Policy 2013; 113: 221–27. Karanikolos M, Mladovsky P, Cylus J, et al. Financial crisis, austerity, and health in Europe. Lancet 2013; 381: 1323–31.
2055