The Lancet – Jan 17, 2015

The Lancet
Jan 17, 2015 Volume 385 Number 9964 p201-302
http://www.thelancet.com/journals/lancet/issue/current

Comment
Is the world ready for an Ebola vaccine?
Bruce Y Lee, William J Moss, Lois Privor-Dumm, Dagna O Constenla, Maria D Knoll, Katherine L O’Brien
Summary
The west African Ebola epidemic has motivated efforts to bring an Ebola vaccine to the market as soon as possible. If a candidate vaccine successfully moves through clinical development, a product could be on the market in the next 1–2 years.1–6 Developing an efficacious vaccine will be only part of the process. Post-licensure challenges could impede and even derail an Ebola immunisation programme. We propose seven key challenges to be considered early in Ebola vaccine development that will help stakeholders prepare and allow developers to adjust vaccine characteristics accordingly.

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Comment
Towards evidence-based, quantitative Sustainable Development Goals for 2030
Børge Brende, Bent Høie
Open Access
DOI: http://dx.doi.org/10.1016/S0140-6736(14)61654-8
The success of the Millennium Development Goals (MDGs)1 on health has been due to their being easy to understand, ambitious, and achievable and, therefore, suitable for the purposes of advocacy and political mobilisation. The MDGs have brought quantitative targets and measurement of results—previously the domain of the scientific community—to centre stage for politicians worldwide. The three health MDGs (MDG 4, MDG 5, and MDG 6) have acted as a scorecard to measure progress on health, thus providing an empirical basis for the formulation of policy. For example, this scorecard has made it possible for Norwegian Prime Minister Erna Solberg and her colleagues in the MDG Advocacy Group to provide such strong advocacy for continued efforts to reach the MDGs before the deadline of 2015.

Work on the health MDGs has been based throughout on close collaboration between the scientific and political communities. Politicians have been able to convey documented progress towards the goals to the general public, and voters in both donor and recipient countries alike have been happy to support public funding for these efforts.

The world community is currently negotiating a new set of goals—the Sustainable Development Goals (SDGs)—for the post-2015 period. So far, 17 goals and 169 targets have been proposed by the Open Working Group.2 For politicians this number of goals is far too many. To win popular support for a comprehensive and coordinated effort for development, the goals must be easy to communicate. With regard to health, we have faced the additional challenge of combining three goals into one SDG, with an attempt to put the whole range of health issues under one coherent goal. This process, in turn, has contributed to the present “shopping list” of 13 targets within the Open Working Group proposal for a goal on health (SDG 3): “ensure healthy lives and promote well-being for all at all ages”.

Of course, it is politics that led to such a long list of health targets in the first place, but ultimately it is politics that has to resolve this situation. Politicians have to set priorities. We need a more limited set of goals and targets that are ambitious, easy to understand, and realistic. Importantly, measurement of progress towards the goals and targets must also be possible. To this end, we need contributions from the scientific community.

One plausible way forward is shown in a Lancet study by Ole Norheim and colleagues3 on quantification of the overarching 2030 SDG for health to avoid 40% of premature deaths in each country. In their review of mortality rates and trends in 25 countries, four country income groupings, and worldwide, Norheim and colleagues show that it is possible to consolidate targets in various areas, such as child health (MDG 4), maternal health (MDG 5), major infectious diseases (MDG 6), non-communicable diseases (NCDs), including mental health and injuries, and universal health coverage, under one universal and quantitative health goal. The simplicity of this approach is beautiful. Following this pattern, we could develop a tool to measure convergence in health globally, in line with the principle of universality to which we are all committed.

This approach seems to make sense from a scientific point of view as well. The proposal to set an overall indicator of avoiding 40% of premature deaths in each country is based on trends in mortality rates over the past 40 years and an estimate of what can be achieved by scaling up current cost-effective approaches. This quantification of a goal on health includes the major targets relating to MDGs 4, 5, and 6 and targets on NCDs proposed by the various communities, notably a 25% reduction in premature mortality from NCDs by 2025. This indicator is evidence based and ambitious yet achievable. It is, therefore, a good starting point for future political action and initiative.

Norheim and colleagues’ study3 shows what an important part science could play in the negotiations at the 69th Session of the UN General Assembly. We, therefore, strongly urge the medical community to consider the approach outlined by Norheim and colleagues3 and develop a common position that can enable us to arrive at a single health SDG with a limited number of simple, understandable, and measurable targets. We would also welcome similar approaches for other SDGs by the relevant communities.

We believe that the health SDG could provide the key framework for global health and prosperity. In anticipation of this framework, Norway is already taking concrete action. First, we are taking steps to improve public health in Norway. Our aim is to reduce NCDs, including mental disorders, by 25% by 2025. Second, Norway is working together with partner nations, the UN Secretary-General Ban Ki-moon, and World Bank President Jim Yong Kim to develop financial frameworks both for the current MDGs and for the future SDGs. Third, Norway is actively promoting projects that focus on both education and health, reflecting the aim of the SDG agenda of realising synergies between sectors.

Fourth, later in September, 2014, we will launch a national initiative called Vision 2030 to encourage researchers, commercial actors, civil society, and others to produce innovative ideas that could play a part in achieving the education and health SDGs both in Norway and abroad. Finally, together with partners in global health, Norway will explore ways to accelerate the deployment of innovations that are currently in the pipeline, and how investments can be catalysed to harness these innovations for promoting global health in the longer term.4
With so much left to do in the field of global health, by scientists as well as politicians, there is no time to lose. It is, therefore, vital that we all take action now.
BB is Norwegian Minister of Foreign Affairs. BH is Norwegian Minister of Health and Care Services.

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Comment
Quantifying targets for the SDG health goal
George Alleyne, Robert Beaglehole, Ruth Bonita
Open Access
DOI: http://dx.doi.org/10.1016/S0140-6736(14)61655-X
Summary
The Millennium Development Goals (MDGs) represent the best example of an international commitment to a set of normative principles underpinned by ideals of equity, solidarity, and peace.1,2 The goals achieved universal support because they were ambitious, included indicators that permitted measurement and accountability, and set 2015 for final reporting. The goals institutionalised poverty as multidimensional, and shaped development as beyond economics.3 Criticisms of the MDGs included the omission of many of the concerns of the Millennium Declaration, and the lack of adequate consultation on the process.

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Articles
Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health
Prof Ole F Norheim, PhD, Prof Prabhat Jha, DPhil, Kesetebirhan Admasu, MD, Tore Godal, MD, Ryan J Hum, MEng, Margaret E Kruk, MD, Octavio Gómez-Dantés, MD, Colin D Mathers, PhD, Hongchao Pan, PhD, Prof Jaime Sepúlveda, MD, Wilson Suraweera, MSc, Stéphane Verguet, PhD, Addis T Woldemariam, MD, Gavin Yamey, MD, Prof Dean T Jamison, PhD, Prof Richard Peto, FRS
Open Access
DOI: http://dx.doi.org/10.1016/S0140-6736(14)61591-9
Summary
Background
The UN will formulate ambitious Sustainable Development Goals for 2030, including one for health. Feasible goals with some quantifiable, measurable targets can influence governments. We propose, as a quatitative health target, “Avoid in each country 40% of premature deaths (under-70 deaths that would be seen in the 2030 population at 2010 death rates), and improve health care at all ages”. Targeting overall mortality and improved health care ignores no modifiable cause of death, nor any cause of disability that is treatable (or also causes many deaths). 40% fewer premature deaths would be important in all countries, but implies very different priorities in different populations. Reinforcing this target for overall mortality in each country are four global subtargets for 2030: avoid two-thirds of child and maternal deaths; two-thirds of tuberculosis, HIV, and malaria deaths; a third of premature deaths from non-communicable diseases (NCDs); and a third of those from other causes (other communicable diseases, undernutrition, and injuries). These challenging subtargets would halve under-50 deaths, avoid a third of the (mainly NCD) deaths at ages 50–69 years, and so avoid 40% of under-70 deaths. To help assess feasibility, we review mortality rates and trends in the 25 most populous countries, in four country income groupings, and worldwide.
Methods
UN sources yielded overall 1970–2010 mortality trends. WHO sources yielded cause-specific 2000–10 trends, standardised to country-specific 2030 populations; decreases per decade of 42% or 18% would yield 20-year reductions of two-thirds or a third.
Results
Throughout the world, except in countries where the effects of HIV or political disturbances predominated, mortality decreased substantially from 1970–2010, particularly in childhood. From 2000–10, under-70 age-standardised mortality rates decreased 19% (with the low-income and lower-middle-income countries having the greatest absolute gains). The proportional decreases per decade (2000–10) were: 34% at ages 0–4 years; 17% at ages 5–49 years; 15% at ages 50–69 years; 30% for communicable, perinatal, maternal, or nutritional causes; 14% for NCDs; and 13% for injuries (accident, suicide, or homicide).
Interpretation
Moderate acceleration of the 2000–10 proportional decreases in mortality could be feasible, achieving the targeted 2030 disease-specific reductions of two-thirds or a third. If achieved, these reductions avoid about 10 million of the 20 million deaths at ages 0–49 years that would be seen in 2030 at 2010 death rates, and about 17 million of the 41 million such deaths at ages 0–69 years. Such changes could be achievable by 2030, or soon afterwards, at least in areas free of war, other major effects of political disruption, or a major new epidemic.
Funding
UK Medical Research Council, Norwegian Agency for Development Cooperation, Centre for Global Health Research, and Bill & Melinda Gates Foundation.