Bill Gates calls it the most beautiful graph he has ever seen. He used it in his first annual letter to the public as the founder of the Bill and Melinda Gates Foundation.¹ He showed the graph in an infamous talk at the TED conference where he released mosquitoes into the audience so that the audience could “see what it feels like” (these mosquitoes didn’t carry malaria)² and to kick off the foundation’s Living Proof campaign, which seeks to publicize the impact of US investments in global health.³ You may have guessed by now that the graph does not depict the meteoric rise of Microsoft stock or the doubling of processing power every two years, the phenomenon known as Moore’s Law in computer science, or even the percentage of homes that own a desktop computer. Rather, it shows that over the past fifty years we have cut the number of children dying in the world by half from 18 million in 1960 to fewer than 9 million today.

Unfortunately, global health doesn’t have too many graphs like this one and not because the field hasn’t made an impact. From 1990 to 2007, development assistance for health has grown by $16.2 billion⁴ funding antiretroviral drugs to fight the HIV/AIDS epidemic, insecticide treated bednets to prevent malaria, and vaccinations for diphtheria, tetanus, and pertussis. Many of the health interventions the United States funds are having a positive impact, but some are wasting money or worse draining resources from the areas of health that desperately need them. As outrageous as it sounds, we often can’t tell the difference. The reason we do not have a beautiful graph for, say, maternal mortality or malaria is that we don’t have the data.

The most important thing the United States can do to improve global health over the next 15 years is to invest in the measurement of global health problems, the evaluation of their potential solutions and the scale-up of the interventions that work. The United States should initiate this strategy by strengthening health surveillance and vital registration in developing countries. US investments in global health must fund both the development of the infrastructure required to monitor health and the training of a new army of healthcare professionals that knows how to set priorities for their communities, design interventions to address the diseases that cause the most suffering, monitor the outcomes of those interventions, and make improvements based on the best evidence available.

The British physicist Lord Kelvin once wrote, “If you cannot measure it, you cannot improve it.” Health is no exception. Formulating effective policy requires some basic information. It requires, at a minimum, knowing what people die from, but we often don’t know even that. Dr. Philip Setel, an anthropologist at the University of North Carolina, writes in an article entitled “The Scandal of Invisibility: Making Everyone Count by Counting Everyone” that “most people in Africa and Asia are born and die without leaving a trace in any legal record or official statistic.” In the long-term, the United States must build the capacity of developing countries to collect, manage, and analyze death certificates. Death registration systems provide the gold standard data on causes of death. As an interim solution, since training healthcare workers and building the necessary infrastructure to manage the death certificates takes time, US investments can also go towards conducting verbal autopsies, or surveys that ask the families of the deceased to report on the symptoms their relative experienced before death. The data from these surveys gives us some of the little evidence we have about the most common causes of death in those parts of Africa and Asia where no legal record exists. USAID has helped fund the Demographic and Health Surveys, which have provided the data needed to track progress towards the United Nations Millennium Development Goal (MDG) to improve child health. By strengthening health surveillance and death registration, the United States can provide the world with the data needed to not only track progress towards and beyond the MDGs for HIV/AIDS, malaria, TB and maternal health, but also to inform how best to achieve our global health goals.

With American financial support and technical guidance, ministries of health in the developing world can soon employ a cadre of physicians, epidemiologists, and public health practitioners with the skills needed to monitor the health of their country. Another beautiful graph would be one, created by an in-house epidemiologist trained in workshops sponsored by the CDC, that depicts the success of a retooled donor-funded program which only started to have its intended effect after the ministry of health evaluated it, found it was not working, and adapted it to better fit the local environment. The impressive declines in child mortality over the past fifty years should make us optimistic for the next fifty. Nevertheless, we must do more than merely sustaining the declines of the past. To realize a Moore’s Law of health, like halving child mortality every two decades, the United States must pioneer the science of global health. By investing in the capacity of developing countries to measure health and evaluate interventions, the United States will ensure its discovery of the most important thing it can do to improve global health.

Sources

1. http://www.gatesfoundation.org/annual-letter/Pages/2009-bill-gates-annual-letter.aspx
2. http://www.ted.com/talks/bill_gates_unplugged.html
3. http://www.gatesfoundation.org/livingproofproject/Pages/impatient-optimists-speech- introduction.aspx
4. Ravishankar N, Gubbins P, Cooley RJ, Leach-Kemon K, Michaud CM, Jamison DT, Murray CJL. Financing of global heatlh: tracking development assistance for health from 1990 to 2007. The Lancet 2009; 373: 2113-24.