Sad, But Perhaps Not Shocking

Megan McArdle, whose blog I still read out of some combination of schadenfreude and self-loathing points to an interesting study in PLoS Medicine. I’ll quote the same section from the title that she does:

2,194 households containing 2,592 Ghanaian children under 5 y old were randomised into a prepayment scheme allowing free primary care including drugs, or to a control group whose families paid user fees for health care (normal practice); 165 children whose families had previously paid to enrol in the prepayment scheme formed an observational arm. The primary outcome was moderate anaemia (haemoglobin [Hb] < 8 g/dl); major secondary outcomes were health care utilisation, severe anaemia, and mortality. At baseline the randomised groups were similar. Introducing free primary health care altered the health care seeking behaviour of households; those randomised to the intervention arm used formal health care more and nonformal care less than the control group. Introducing free primary health care did not lead to any measurable difference in any health outcome. The primary outcome of moderate anaemia was detected in 37 (3.1%) children in the control and 36 children (3.2%) in the intervention arm (adjusted odds ratio 1.05, 95% confidence interval 0.66–1.67). There were four deaths in the control and five in the intervention group. Mean Hb concentration, severe anaemia, parasite prevalence, and anthropometric measurements were similar in each group. Families who previously self-enrolled in the prepayment scheme were significantly less poor, had better health measures, and used services more frequently than those in the randomised group.

I have to say I’m a lot less surprised at this outcome than McArdle is, for a few reasons.

First of all, paying for healthcare is not the only variable (and in my mind, though I’m certainly no expert) the primary driver of health outcomes in the third world. Anaemia has many causes, malaria being only one, and infection with the malaria parasite is only a matter of time in Africa if you’re not on anti-malarial medication at all times. From reading the entire study it looks like (quell surprise!) that they did a rather good job of controlling for that kind of thing, but in reading a little further of the 71 anaemic patients at study end 28 had a worm infection and one had a genetic defect. So, on the order of 40% had some cause other than malaria as a plausible cause.

But, secondly, aside from the conditions that can lead to those kinds of health outcomes there are very real non-monetary costs associated with traveling to receive care. If you’re an African peasant and you don’t live within a few miles of a hospital, it costs you a lot simply to go to the doctor even if there is no direct fee. Even if you’re close to a hospital you miss work, and that costs you money, and that matters when you’re poor. A lot. We see that kind of thing here in the US, in San Antonio in particular, and the poor in the US are much better served than the poor in Africa.

A while back I went to a very interesting talk about third-world treatment issues by Paul Farmer of Partners In Health and one of the things he talked about what the multifaceted nature of the problem. Just giving medical care away doesn’t work, just providing clean water doesn’t work, just education doesn’t work…you have to do all these things in some way at the same time. The problems are all connected - people face opportunity costs for medical care, and they don’t understand how modern medicine can help them, and they can’t afford it, and their water is dirty, and they have parasites…it’s a mess. Plus, most of the time, their future is being stolen by some tin-horn dictator with a god complex.

I don’t think the solution is government, and I’m not much on the “social justice” bandwagon, but I do find it immensely troubling that the wealth and beauty of the world passes so many people by solely because of where they were born. I’m all for private charity, and I’m all for real solutions that don’t involve holding a gun to anyone’s head - there must be a way to slowly, with effort, bring the third world into the global economy and let them reap the benefits we do. One small part of that is preventing people from dying of treatable, easily cured diseases.