Associate Dean, Harvard School of Public Health
Although India achieved a historic milestone last year with no new cases of polio, India still accounts for 24 percent of the world’s 1.6 million annual deaths among children under five. This striking contrast in track records only begs the question, If polio can be defeated, why not early-childhood deaths?
The answer is that developing economies can indeed achieve large reductions in early-childhood deaths through the strategic deployment of currently available, low-cost interventions. However, deploying them effectively will require an approach that is radically different from the one employed against polio.
For example, consider the problem of preterm birth, the second leading killer of children under five and the number-one killer of infants worldwide. Two interventions that together could save the lives of well over half a million preterm babies each year are highlighted in Born Too Soon: The Global Action Plan on Preterm Birth, a report published earlier this year by a coalition of health groups with select technical support from The Boston Consulting Group.
The first intervention involves the use of corticosteroid injections during preterm labor. The hormone triggers a rapid development of the lungs, thereby reducing the risk of fatal breathing difficulties following birth. This intervention alone could save an estimated 370,000 lives each year, according to Born Too Soon.
The second intervention is a set of practices known as Kangaroo Mother Care (KMC), which could save an estimated 450,000 lives each year, according to the same report. The genius of KMC—which takes a lesson from kangaroos and other marsupials whose offspring are routinely born at an extremely premature stage of development—is its reliance on the mother’s own body to serve as a low-tech incubator for the provision of critical newborn care. In KMC, mothers are taught to increase the body temperature of their newborns by wrapping the babies to their bare chests. KMC also encourages immediate initiation of breastfeeding, which helps to protect the newborn against severe infections and provides essential nutrients.
But here’s the catch: Despite the availability of these high-impact, low-cost interventions, the task of delivering them where needed is fundamentally different—and in some ways much more difficult—than those involved in polio vaccination.
The polio eradication effort provides a powerful example of the so-called “vertical” approach to disease prevention, in which resources are targeted with laser-like precision on a single disease to achieve a highly-specific goal. The polio campaign relies on large-scale mobilization of volunteers on designated days to provide the oral vaccine to millions of children at a time through a carefully choreographed, centrally managed, highly visible campaign.
In contrast, each premature birth requires immediate and individualized attention, 365 days of the year—not just on designated days. Vast numbers of health workers at the village level need to be trained to promote and apply techniques like Kangaroo Mother Care, and cultural norms need to be changed so that parents of preterm babies understand such practices and support them. Likewise, corticosteroids must be delivered where needed. These things are hard to do without a well-functioning health infrastructure.
That’s why a “horizontal” approach to global health, which cuts across disease-specific categories by strengthening the overall health infrastructure, is favored by many global-health experts. They argue that a single-disease strategy draws essential resources away from the more important “horizontal” approach of strengthening a country’s overall health-delivery system. However, political leaders, funders, and health advocates often find great appeal in the disease-specific approach because it can yield rapid outcomes—measured in millions of lives saved.
The solution may lie in a third way, dubbed the “diagonal” approach. As conceptualized a number of years ago by Jaime Sepulveda, executive director of global health sciences at University of California at San Franscisco, and Julio Frenk, dean of the Harvard School of Public Health, the diagonal approach is neither a linguistic trick nor does it simply split the difference. Its essence is to capitalize on the political appeal of vertical investments by deploying them in smart ways so as to simultaneously build a permanent, high-quality health infrastructure while achieving the stated disease-specific goals. The diagonal approach is built on the realization that many vertical interventions—even if initially very successful—can only get so far before bumping up against problems of procurement, supply chain management, human resource training and management, and the like. Applying the diagonal approach to the problem of preterm births offers the prospect of a rapid reduction in child deaths while permanently strengthening the infrastructure for children’s health.
The ultimate goal, of course, must be prevention of preterm births. However, the current knowledge base for prevention is still quite limited. An analysis published on November 16 in The Lancet by a coalition of global health organizations concludes that even the best available prevention tools can prevent only 5 percent of preterm births in developed countries. Going forward, robust funding for an aggressive research program on causation and prevention of preterm births will be essential.