改善全球健康的最佳藥物？ 減少不平等

新冠疫情大流行阻礙了改善公共衛生的進展。如果不解決健康問題的根本社會和經濟原因，它可能會完全停滯。

社論/2023 年 7 月 11 日/《自然》

一道帶刺鐵絲網將南非約翰尼斯堡郊區亞歷山德拉與其富有的鄰居桑頓隔開。

圖片來源：Dean Hutton/Bloomberg/Getty

    過去幾年對世界衛生保健系統來說並不輕鬆。 當聯合國於 2015 年制定可持續發展目標 (SDG) 時，大多數人都沒有意識到席捲全球的流行病的威脅。

    在標誌著可持續發展目標 2030 年最後期限已過半的一系列每週社論中，《自然》雜誌依次審視了 17 個目標中的每一個目標。 毫不奇怪，在實現第三點——「確保健康的生活，促進各年齡層所有人的福祉」——方面的進展充其量是步履維艱。 但這並不意味著當世界領導人九月份齊聚紐約評估實現可持續發展目標的進展時，該目標中包含的目標應該降低。 相反，應該透過更加關注導致全球疾病和殘疾的經濟、社會和權力不平等來加強健康目標——研究人員必須在實現這一目標方面發揮自己的作用。

    聯合國的健康和福祉目標涵蓋廣泛，包括將孕產婦死亡率降低至目前的三分之一、將道路交通事故減少一半以及消除結核病和瘧疾等疾病的流行。 在 COVID-19 大流行之前，出現了一些令人鼓舞的進展跡象。

實現可持續發展目標的進展

    從 2015 年到 2021 年，接受評估的 200 個國家中有 146 個國家有望實現每 1,000 名活產嬰兒死亡人數低於 25 人的可持續發展目標。 一項使用 2020 年數據的研究預測，到 2030 年，世界衛生保健工作者短缺將從 1,500 萬減少到 1,000 萬（M. Boniol 等人，BMJ Glob. Health 7, e009316; 2022）。 這將在一定程度上實現可持續發展目標，即大幅增加低收入國家的衛生保健勞動力。甚至在大流行之前，人們就越來越擔心一些以前看起來很有希望的領域的進展開始趨於平穩。 孕產婦死亡率從 2000 年到 2016 年有所下降，但在可持續發展目標制定後的五年內相當穩定。 根據 2020 年 2 月的最新統計，該數字仍約為 2030 年可持續發展目標（即每 10 萬名活產兒中有 70 名孕產婦死亡）的三倍左右。

但隨後疫情爆發，奪走了數百萬人的生命，造成數百萬人殘疾，並擾亂了全世界的醫療保健系統。 影響既有直接的，也有間接的。 隨著世界領導人對這一流行病的關注，全球結核病服務支出下降了 10%，從 2019 年的 60 億美元下降到 2021 年的 54 億美元； 同一時期，結核病死亡人數從 140 萬人增加到約 160 萬人。 與瘧疾相關的死亡人數增加了 12%，從 2019 年的 558,000 人增加到 2020 年的 627,000 人。2019 年至 2021 年，兒童白喉、破傷風和百日咳疫苗接種率下降。

降低孕產婦死亡率的雄心勃勃的目標

教育也受到了這一流行病的影響：來自社會經濟背景不利的兒童在學習中比來自高收入家庭的兒童經歷了更多的挫折（B. A. Betthäuser et al. Nature Hum. Behav. 7, 375–385 ; 2023）。 一些國家的學校長期停課意味著一些兒童提前離開教育系統。 人口外流對健康和福祉的全面影響可能在多年內都不會成為人們關注的焦點。 例如，對於女孩和年輕女性來說，受教育時間越長，懷孕率和愛滋病毒感染率往往會降低。

可持續發展目標的衛生目標始終雄心勃勃，但它們可以為制定國家策略和分配資源以改善健康和福祉成果並消除差距提供基礎。 良好的健康不僅僅取決於生物學；它還受到環境、機會、經濟和歧視的影響。 COVID-19 大流行暴露了這種影響，富人和窮人在結果、治療可用性和疫苗分配方面存在廣泛差異。 但倫敦大學學院的公共衛生研究員莎拉•霍克斯表示，隨著疫情的緩解，公眾對健康問題社會決定因素的討論逐漸失敗。「我們似乎已經繼續前進」，她說。 「人們集體喪失了對事情有多糟糕的記憶」。

必須在可持續發展目標的背景下恢復這一討論。 更多的研究人員需要研究健康的經濟和社會決定因素，例如幫助填補阻礙有效行動的數據空白。 許多國家仍然沒有按性別、種族或是否是難民來區分醫療保健統計數據。 如果沒有這些信息，就很容易掩蓋不平等及其原因。

但為了真正解決全球健康和福祉問題，各國政府必須努力減少經濟不平等，不僅是國家之間的不平等，而且是國家內部的不平等。 這意味著既要增加提供醫療保健所需的資金，又要減少導致健康不良的貧困、歧視和暴力。

新冠疫情會迫使公共衛生部門面對美國嚴重的不平等嗎？

五月，世界衛生組織發布了一份報告，列出了改善全球健康所需的經濟改革。 這份題為「人人享有健康」的報告提出了一系列經濟措施，例如改革對富裕個人和跨國公司的稅收，並呼籲在流行病和自然災害期間允許低收入國家減免債務。

它還呼籲從根本上重新闡述我們對健康和福祉的看法：不要將其視為在緊縮時期要削減的支出，而是將其視為對國家未來經濟和福祉的投資。 這是一個必須被聽到和理解的呼籲。 最終，除非世界領導人願意接受減少不平等所必需的經濟改革，否則我們將沒有機會實現可持續發展目標的健康目標。

自然 619, 221 (2023) ；doi：https://doi.org/10.1038/d41586-023-02251-y

The best medicine for improving global health? Reduce inequality

The COVID pandemic knocked back progress towards improving public health. Without addressing the underlying social and economic causes of ill health, it could completely stall.

EDITORIAL / 11 July 2023 / Nature

A barbed wire separates Alexandra, a suburb of Johannesburg, South Africa, from its wealthy neighbour, Sandton.

Credit: Dean Hutton/Bloomberg/Getty

The past few years have not been easy on the world’s health-care systems. When the United Nations set its Sustainable Development Goals (SDGs) in 2015, the threat of a pandemic sweeping the world would not have registered with most people.

In a series of weekly editorials marking the halfway point to the SDGs’ 2030 deadline, Nature is looking at each of the 17 goals in turn. It is no surprise that progress towards number 3 — “Ensure healthy lives and promote well-being for all at all ages” — has been stuttering, at best. But that does not mean that the targets embedded in this goal should be lowered when world leaders gather in New York City in September to assess progress towards achieving the SDGs. Instead, the health goal should be strengthened by increasing focus on the economic, social and power inequities that drive disease and disability worldwide — and researchers must play their part in making that happen.

The UN’s health and well-being targets cover a wide territory that includes reducing maternal mortality to one-third of current rates, halving road-traffic accidents and ending epidemics of diseases such as tuberculosis and malaria. Before the COVID-19 pandemic, there were a few encouraging signs of progress.

Progress towards the Sustainable Development Goals

From 2015 to 2021, 146 countries out of 200 evaluated were on course to meet the SDG target of fewer than 25 deaths per 1,000 live births. One study using data from 2020 projected that the world’s shortage of health-care workers would fall from 15 million to 10 million by 2030 (M. Boniol et al. BMJ Glob. Health 7, e009316; 2022). This would have gone some way towards meeting the SDG target to substantially increase the health-care workforce in low-income countries.

Even before the pandemic, there was growing concern that progress was beginning to level off in some areas that previously looked promising. The rate of maternal mortality, which declined from 2000 to 2016, was fairly constant in the five years after the SDGs were established. At the last count, in February 2020, it was still around three times the SDG target of 70 maternal deaths per 100,000 live births by 2030.

But then the pandemic hit, taking millions of lives, leaving millions of people living with disability and disrupting health-care systems worldwide. There were indirect, as well as direct, effects. With world leaders focusing on the pandemic, global spending on tuberculosis services dropped by 10%, from US$6 billion in 2019 to $5.4 billion in 2021; over the same period, deaths from tuberculosis rose from 1.4 million to about 1.6 million. Malaria-associated deaths rose by 12%, from 558,000 in 2019 to 627,000 in 2020. Childhood vaccination rates against diphtheria, tetanus and pertussis fell between 2019 and 2021.

Ambitious goal to slash maternal deaths in jeopardy

Education was also affected by the pandemic: children from disadvantaged socio-economic backgrounds experienced more setbacks in their learning than did those from higher-income ones (B. A. Betthäuser et al. Nature Hum. Behav. 7, 375–385; 2023). Prolonged school closures in several countries meant that some children left the education system early. The full ramifications of that exodus on health and well-being might not come into focus for years. For girls and young women, for example, pregnancy and HIV rates tend to decrease the longer they stay in education.

The ambition of the SDG health targets was always lofty, but they can provide a foundation for formulating national strategies and allocating resources to improve health and well-being outcomes and counter disparities. Good health is not just down to biology; it is affected by the environment, opportunity, economics and discrimination. The COVID-19 pandemic laid such influences bare, with widespread disparities between rich and poor people in terms of outcomes, treatment availability and vaccine distribution. But public discussion of the social determinants of health fizzled out as the pandemic eased, says public-health researcher Sarah Hawkes at University College London. “We seem to have moved on,” she says. “There has been a collective memory loss of just how bad it was.”

That discussion must be revived in the context of the SDGs. More researchers need to be studying the economic and social determinants of health, to, for example, help fill the data gaps that hinder effective action. Many countries still do not separate health-care statistics by sex, ethnicity or whether someone is a refugee. Without this information, it is too easy to gloss over inequities and their causes.

But to truly address global health and well-being, governments must work to reduce economic inequality, not just between nations but also within them. This means both shoring up the funding needed to provide health care and reducing the poverty, discrimination and violence that contribute to ill health.

Will COVID force public health to confront America’s epic inequality?

In May, the World Health Organization released a report that laid out the economic reforms needed to improve global health. The report, entitled ‘Health for All’, set out a range of economic measures, such as the reformation of taxes on wealthy individuals and multinational corporations, and called for allowing debt relief for low-income countries during pandemics and natural disasters.

It also called for a fundamental reformulation of how we perceive health and well-being: not as an expenditure to be chopped during times of austerity, but as an investment in a country’s future economy and well-being. That is a call that must be heard and understood. Ultimately, we will not stand a chance of meeting the SDG health targets unless world leaders are willing to embrace the economic reforms necessary to reduce inequality.

Nature 619, 221 (2023)

doi: https://doi.org/10.1038/d41586-023-02251-y