UW hosts key players in global health effort

from the Seattle Post Intelligencer

The goal is better coordination

By TOM PAULSON

Not that long ago, Christopher Murray was mostly considered a troublesome "bomb thrower" in the field of global health and development.

Now, Murray and his colleagues at the University of Washington's new Institute for Health Metrics and Evaluation are welcoming hundreds of key players in international health and development to Seattle for a two-day research conference aimed at trying to bring order to the still relatively chaotic and uncoordinated collection of projects aimed at fighting disease and improving health worldwide.

"There's a lot of good work being done out there, but it's being done by many groups who don't talk to each other ... and who often use different yardsticks to assess their efforts," said Murray, director of the institute, which was created last year in large part thanks to a $105 million donation to the UW from the Bill & Melinda Gates Foundation.

Murray's bombs are made of numbers -- statistical analyses of things such as mortality rates, incidence of diseases and the relative effectiveness of health programs. People often don't like his conclusions, because they sometimes challenge working assumptions and conventional wisdom -- not to mention funding priorities and established agendas.

"I remember the first time I met Chris, in 1984, when he came into my office and told me everything I had written about Africa was wrong," said Alan Lopez, a world-renowned expert on international health at the University of Queensland, Australia. "He was indeed a bit of a bomb thrower back then."

Despite this abrupt first encounter, Murray and Lopez soon became collaborators on a project that led to the creation of an entirely new way of evaluating the global burden of disease. They started it on their own time, initially with headquarters in a converted barn in Maine owned by Murray.

Murray, who was then at Harvard University, and Lopez, who worked for the World Health Organization, believed that the standard measures in health -- especially in poor countries -- were wildly unreliable. To begin with, separating mortality rates from nonfatal disease rates seriously skewed the picture. All these government agencies, donor organizations and others working in global health were basically flying blind, Murray and Lopez maintained.

"A good example even today is malaria," Lopez said. "We still don't really know how many people die every year from malaria" -- most estimates range between 1 million and 2 million -- "or if it's increasing or decreasing. We're still quite ignorant about the health conditions of the developing world, but I'd say we're a little less ignorant than we were 15 years ago."

One reason for that improvement is the project Murray and Lopez started in the barn, now known as the Global Burden of Disease. One of this project's creations was a new health metric known as the "disability adjusted life year," or DALY, a method that combines mortality and morbidity rates to provide a more accurate picture of the effect of a disease.

Malaria, for example, doesn't always kill. It disables and weakens many hundreds of millions more people every year, increasing poverty and weakening communities in ways not simply measured by death rates.

"When we came out with this, we were further ostracized and even called unethical," Lopez said. Some complained that their basic numbers assessing how many were afflicted were wrong, he said, while others said it was unacceptable for them to try to quantify -- using the DALY -- the relative value of a life.

"It's still controversial," Murray said. Many of these organizations believe they are doing good and serving the interests of the poor, he said, and so any potential downgrading of a problem's numbers is seen as harming the cause. On the more cynical side, Murray noted, a change in the numbers also can cause a change in funding.

"But we're now well past the era where you can just declare your own numbers," he said. With today's explosion of interest by donors and governments in global health, Murray said, there is also a much greater need for accurate monitoring and assessment of these programs.

Imagine the financial market if companies did not have to report profits and losses or function according to a standard set of rules. That's basically how the field of global health operates today, Murray contended.

After the UW institute's first board meeting and a reception on Wednesday, about 300 participants from all over the globe -- including a former chief of the WHO, the current head of the United Nations AIDS program, World Bank officials, health ministers and experts from Africa, India and others -- will convene to launch the next phase of this work that Murray and Lopez began in the barn in Maine. The British medical journal The Lancet is a co-sponsor of the meeting.

Beyond trying to improve the measurement of disease rates and effects, the next phase of the Global Burden of Disease project aims to establish better methods for assessing disease trends, setting health priorities, determining the effectiveness of disease-fighting programs and judging health care delivery and quality.

"The center for U.S. efforts in global health is now unquestionably in Seattle," Lopez, the Australian, said. "It's great for me, because the flight's much shorter than when I had to go to the East Coast."