The Vicious Cycle of Winners and Losers

Ask any Public Health Practitioner what the biggest public health success story is and they will mention the eradication of smallpox. Across the globe, this accomplishment is seen as the biggest contribution public health brought onto society and a sort of proof-of-concept that illness can be dealt with even before onset. Yet if you ask the Public Health Community what the current most pressing public health concern should be, you will never get consensus. Infectious disease connoisseurs will bring forward the re-emergence of infectious diseases, chronic disease experts will point to the majority of top 10 leading causes of death (in the US) as being chronic. HIV/AIDS researchers will underline the fact that HIV/AIDS can lead to other infectious/chronic diseases, yet diabetes researchers could state the same.

At a recent departmental gathering, I had an interesting conversation with a former guest lecturer in one of my epidemiology classes who repeated something I’ve heard over and over again. His concerns resonated with me, and, as a future public health practitioner, they are my concerns as well. The professor spoke of waves of great funding leading to great outcomes, then followed by waves of decreased funding or changed objectives, defeating the purpose. This vicious cycle of wins and losses looks like this:

  1. Prevalence/incidence for disease X is measured as x/100,000 population.
  2. Funding is secured to decrease incidence/prevalence of disease X.
  3. Money is spent, resources are allocated and prevalence/incidence of disease X sees a hit. 
  4. Once the effect is seen, funding administrators now look for the next big thing to donate to. Therefore, disease X stops receiving as much funding, in favor of disease Y.
  5. While disease Y prevalence/incidence begins decreasing, less funding for disease X means less resources allocated, and a potential increase in prevalence, thus defeating the purpose of spending all that money to begin with.

I hope that by now you are seeing where I’m trying to get at. As soon as a potential “threat” is cleared (incidence decreases), there is this assumption that we are in the black. That, somehow, a quick burst of spending/research will last a lifetime of disease elimination. Yet, as soon as funding diminishes, all the efforts put into decreasing the amount of disease get wasted.

To put it in a different way: since one can’t really measure something that does not exist (public health initiatives aim at preventing disease), there is never a stable continuity of funding as priorities get shifted once a disease is deemed within acceptable limits (endemic). And as soon as disease Y is within limits, disease Z will come along. Then X again, then Y, then Z….get it?

A clear example would be Malaria in South East Asia. When looking at funding trends for anti-malaria programs from 1999 to 2004 (Figure 3), we can see a substantial decline in 2001 and 2002. Now look at some incidence and death data (Malaria Trends in South East Region 2000-2010). Both the number of new cases and the number of deaths have seen some variability with an increasing trend (especially beginning 2004). Obviously we can’t necessarily assume that funding reported by one organization directly correlates with prevalence data reported by another organization. However, assuming that when funding is received, the budgeting process, disbursement, the implementation and evaluation of programs etc. could take much longer than a year or two, changes seen in 2004 could stem from funding lost in 2001.

The professor also mentioned that he had drafted and published a letter with the intent to stir up conversation and get administrators on board. To his surprise, the funding commissions didn’t give it much attention and neither did his colleagues. I assume its because everyone is so fed up with the bureaucracy of grant writing/receiving that they are willing to accept the status quo.

So how do we break the cycle of winners and losers? If we are to repeat the smallpox victory with a future bug, how do we determine which research is more important and which intervention is more crucial? And who will be the loser in order for a winner to prevail?

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