HTA connections

9 Aug

In our blog at AQuAS, we have spoken about the European EUnetHA project, of the arthroplasty registry of Catalonia, of the paradigm shifts in acute stroke care and of melatonin.

Let us begin with EUnetHA, a European project made up of different institutions working towards joining forces and methodologies to avoid duplicities with the aim of providing, adapting and sharing useful knowledge for health systems. When we speak of HTA, we are basically speaking about assessment.

Emmanuel Giménez highlighted that in a world of constant change a robust system is needed in terms of method which is at the same time agile and which can adapt to the speed of innovations.

“The identification and prioritisation of products to be assessed (the Horizon Scanning system), as well as the balance between innovation and divestment, are also extensively discussed subjects and under continuous debate”

Marta Millaret focused on the aspect of communication and dissemination in a project because although doing is important, explaining and sharing what is being done is equally so.

“Involvement in dissemination means getting the people that work on a project to disseminate both their work and their project at the same time. In this way, everyone stands to gain”

We continue with the Arthroplasty Registry of Catalonia, a tool of the health system with an impact on a large part of the population.

In an interview with Olga Martínez and Xavier Mora, aspects of the suitability and prognosis of arthroplasties were discussed, and in particular, they shed light on the value of registries.

“Arthroplasty registries can help detect models of prosthesis with a malfunction, both in the short and long term, and identify the patients who have received these implants”

Precisely this summer, two reports from the AQuAS have been published thanks to the registries.

We wanted more so we held a second interview with Olga Martínez and Xavier Mora. On this occasion, we put the spotlight on the materials used in making prostheses.

“The new European legislation passed in 2016, regarding implants used in health, aims to increase the supervision of the industry by implementing stricter norms and regulations including the obligation of clinical assessment, while at the same time fostering innovation in this field”

Moving on to another subject. Knowledge advances, which has implications in medical practice. An example is this text by Sònia Abilleira which shows a paradigm shift forcing one to rethink organised systems of care for people with acute stroke.

“This recentralising tendency in carrying out endovascular treatment contrasts with the decentralisation which was done in its day to ensure an adequate access to thrombolytic therapy which by nature needs to be administered in the first 4,5 hours after the onset of symptoms”

To finish this journey, a 100% current topic: melatonin. Joan MV Pons shared his thoughts after an assessment report.

“New physiological actions of this hormone are discovered every day which means that it almost acquires the quality of a “miraculous molecule” due to its ubiquity and the number of activities in which it takes part (antioxidant, neuro-protector, anti-cancerous, immunomodulation, etc..).”

What do these initiatives, all so different from each other, have in common? The answer is assessment. Wherever, with the will to identify, analyse and use knowledge of better quality using the best methodology available while considering the context in all its complexity. This is no mean feat!

The impact of research in retrospect

26 Jul

It was last autumn, with cooler temperatures than this mid summer’s, that we published some interesting reflections by Ramon Gomis on biomedical research in Catalonia  mentioning the CAPRIS programme (Advisory Board in Research and Innovation Policy) and the ICREA programme (Catalan Institute of Research and Advanced Studies).

These questions marked the start of a powerful reflection by Núria Radó about nursing research where the aspects of participation and impact of research were combined (multifactorial), and where the aspect of involvement came into play. All of this in the context of SARIS (The Health Research and Innovation Assessment System) and PERIS (Strategic Plan for Research and Innovation in Health 2016-2020).

Doing research and publishing on this research are actions which often go hand in hand, be it in scientific contexts (articles, communications at congresses) or in informative contexts (the traditional media  or  social networks).

In this study we saw an analysis of the critical tone of news about medical innovations published in the daily written press. These are the generous reflections by Gaietà Permanyer on the reservations of a doctor when publishing in newspapers or books of a non-professional nature, of the concepts of patient autonomy, of informed decisions and health literacy, and of how everything fits together, to ideally arrive at balanced information in non-specialist media.

We continue highlighting publications. However, we are now focusing on scientific publications and the impact that can be derived from two very different but inspiring subjects:

On the one hand we saw the phenomenon known as “the sleeping beauties of science” thanks to Joan MV Pons and the case of a discovery (published) by Francis Mojica (25 years ago) which has been key in the development of the CRISPR genome editing technique..

“Sleeping Beauties is also said of those scientific articles which seem to go by unacknowledged until someone comes to their late rescue and gives them the recognition they deserve”

On the other hand, two days before the start of spring, we had the collaboration of Ernest Abadal from Newcastle who explained the altmetrics and the strengths and weaknesses of systems (traditional and not so traditional) in the assessment of the quality of a scientific publication.

“From 2010, people started talking about altmetrics, a set of indicators (for example, how often an article is shared, its re-dissemination, the comments it has generated, mentions (likes), etc…) that measure the presence of a publication in social and academic networks, which complement citation indexes considerably”

The aspect of involvement also comes up here:

“From a researcher’s perspective, it is clear that at present publishing an article in a journal is not enough and one needs to be fully involved in its dissemination in social networks and also in academic networks so as to give visibility to the contents published”

We end this journey on the assessment and impact of research with Ion Arrizabalaga with the challenge of measuring involvement in this context.

“Participation of the actors in research is a key element in research to transform and generate impact in society”

If you would like to read more about participation and research, we recommend reading these two documents published at AQuAS:

“Me sube la melatonina”

28 Jun
Joan MV Pons

Well, let’s say that in Juan Luis Guerra’s merengue song (1990), it was bilirubin that was on the rise:

Me sube la bilirrubina
¡Ay! Me sube la bilirrubina
Cuando te miro y no me miras
¡Ay! Cuando te miro y no me miras
Y no lo quita la aspirina
¡No! Ni un suero con penicilina
Es un amor que contamina
¡Ay! Me sube la bilirrubina

It is evident that it is something difficult to treat, but who cares, it could also have been serotonin, dopamine or noradrenaline. After all, love alters everything and things would rhyme just the same. Whatever the case, if there is one thing that should best be avoided, it is a rise in bilirubin, because one can end up jaundiced or, as they said in the past, with an excess of bile.

What is true is that melatonin starts increasing in all of us when it begins to get dark, before going to sleep, following a circadian rhythm set by our hypothalamic biological clock. The pineal gland, where Descartes thought there was a connection between the mind and the body, where he placed the soul, segregates this hormone that induces sleep and thus, works better when restful sleep eludes us, that is, when there is a delay in the onset of sleep.

New physiological actions of this hormone are discovered every day which means that it almost acquires the quality of a “miraculous molecule” due to its ubiquity and the number of activities in which it takes part (antioxidant, neuro-protector, anti-cancerous, immunomodulation, etc..).

Melatonin, which is mostly obtained synthetically, is marketed as a drug (prolonged-release tablets of 2 mg) and as a nutritional or dietary supplement (doses of less than 2 mg). This difference, we are talking about 0.02 mg, is in itself a little surprising and even more so bearing in mind that there is only one drug with melatonin but on the other hand, there are numerous supplements that contain melatonin (on its own or in combination with other products). The requirements, in one case or another, are very different. While there are countries in which melatonin is marketed on its own or as dietary supplements, in others it is only found as a drug which requires a doctor’s prescription, and in Europe both situations exist. In Spain, a medical prescription is needed but it is not a publicly funded drug and as a supplement, as mentioned before, there is a wide range of products.

As a drug, it is authorised by the European Medicines Agency (EMA) in people aged 55 or over and in treating primary insomnia for a limited period of time. The EMA considers that melatonin is effective albeit with a small effect size in a small fraction of the population but with a more favourable safety profile than other hypnotic drugs.

It is known that as one gets older the secretion of this hormone decreases and yet all clinical practice guidelines or recommendations in the approach to insomnia primarily advise sleep hygiene measures followed psychological interventions. Nevertheless, the data of pharmacological consumption shows an increase in prescriptions of hypnotic drugs and sedatives, especially those derived or related to benzodiazepines.

The EMA has asked for more studies on melatonin at a paediatric level despite the fact that there is data which seems favourable in children with an attention-deficit hyperactivity disorder or with autistic spectrum disorder where sleep hygiene and psychological interventions have failed.

The report “Exogenous melatonin in the treatment of sleep disorders: efficacy and safety” drawn up by the AQuAS talks of these and other related subjects, mentioning the wide range of para-pharmaceutical products that contain melatonin.

 

As a dietary supplement or a drug, there are unequal demands by regulatory agencies in Europe (food safety, drugs) in terms of its authorisation for marketing. It is a known fact that the variability in the quality of a product, its formulation, dosage and combinations in supplements and so on, in part explain the heterogeneity between studies observed in some meta-analyses, also contained in the report.

Post written by Joan MV Pons.

In memory of professor Joan Rodés

12 Jan
Joan MV Pons
Joan MV Pons

With his passing away, Dr Joan Rodés (1938-2017) will be remembered by many people in person, and in many fields, for those who had the good fortune to know him as a doctor, researcher, manager and assessor (of politicians), as his was a life full to the brim. No matter which professional activity he took part in, and with the responsibilities he took on throughout his life, he left his mark and the accolades expressed these days are a clear demonstration of this.

To AQuAS (originally AATM), Joan Rodés has been an exceptional figure and I say this without any rhetoric whatsoever. When the Agency was created in 1994, he presided its scientific board of assessors and at the end of 1999, when the institution became known as Catalan Agency for Health Tecnology Assessment and Research (CAHTA), in Catalan Agència d’Avaluació de Tecnologia i Recerca Mèdiques (AATRM), he presided its Administrative Board, a position that he held till 2010. It was in that period (2000-2006) that, due to my responsabilities within the Agency as Managing Director, I was able to get to know this great personality more closely, very much a big strong fellow (in Catalan, a homenot) was Joan, as Josep Pla would say. At that time, we saw each other often, and I had frequent exchanges with him, aside from the more or less termly meetings of the Administrative Board. I did this in that minute office of the haematology services and later in that of the General Manager at the Hospital Clinic.

No matter what the position he occupied, he was always watchful -very much so- of events at the Agency, being a great facilitator of its duties. It was like this, without a doubt, because with Joan Rodés there was no need to convince him of the importance of informing well about decisions taken in the health services, using the most updated and precise knowledge that was available, not only that regarding the benefits and risks to health of medical interventions, but also in terms of its economic, ethical and social impact. For him and I quote his words literally from the AATRM Newsletter, 10 years of the Agency, of November 2004:

“critical assessment and continued learning are basic tools that need to be maintained and improved, not only by the Agency, in its everyday activity, but also by all the multiple actors and stakeholders in the health system (professionals, managers, politicians and citizens) that wish to continue sustaining this element of such importance for our social well-being”

I said this because of his role of facilitator as highest representative of the Agency giving constant support to the activities it carried out, but also because of his extensive experience and network of relationships that contributed to giving strength to many initiatives that were then being undertaken, especially in the field of research and its assessment. I was able to discuss this with him on many occasions at a later date, and I never once perceived an interventionist or managerial attitude; quite the opposite, always with a laissez-faire approach where each one had to do their assigned task (the technicians and managing director of the Agency, the scientific board and the administrative board) while facilitating that of others.

It has always been a great pleasure for me -a privilege better said- to have maintained contact at dinners and get-togethers, even during the last period in which his respiratory illness worsened, but he would still go to IDIBAPS from time to time despite this. I cannot end without saying that during those times when we would talk about any and everything (medicine, science, politics, society, the past, present and future) we had a really good laugh. Then as now that you have left us, you are and will very much be in my thoughts.

Post written by Joan MV Pons

agencia-2004-ca
Joan Rodés presiding an Administrative Board of AATRM in 2004

A medicine of excesses

27 Oct
JoanMVPons
Joan MV Pons

Joan MV Pons has published an opinion article in the Diari de la Sanitat where he gives his report on the congress of Preventing Overdiagnosis which was held in Barcelona last September.

Some of the subjects of the congress have been repeated and expanded on year after year such as that of polypharmacy this time round, centering on the need for sensible deprescription, selections made and the overdiagnosis resulting from early diagnosis interventions.

The article highlights the as yet incipient nature of this international initiative but which is becoming more and more of interest: in Barcelona, there was an increase of 30% in the number of presentations given comparing to the year before and more than 500 people registered and, needles to say, English speakers predominating. The role of AQuAS in this current which aims to appease the medical hyperbole in which we find ourselves immersed is also highlighted.

Article

The “perfect” health system

20 Oct
Joan MV Pons
Joan MV Pons

Mark Britnell is an international expert in health systems having held several senior positions in the NHS and currently provides consulting services for several countries. With this wealth of experience, Britnell wrote a book in 2015 with the inspiring title of, In search of the perfect health care system (1). In it, Britnell examines the dilemmas facing governments, the global challenges such as demographic, epidemiological, technological and economic transitions, as well as the more specific cases facing each country.

A significant portion of the book, more than half, is dedicated to examining individual countries grouped by continent: the Asian region including Australia (with large countries from Japan, China and India, to small densely populated enclaves such as Singapore and Hong Kong) Africa and the Middle East (just three very different examples such as Qatar, Israel and South Africa), Europe (from Portugal to Russia via the Nordic countries, Germany, Italy, France and the English) and the Americas (from the north; Canada, USA and Mexico and the south, such as Brazil). Too bad that the section on the Iberian Peninsula only speaks of our western neighbours (the eastern side but a general walk through).

There is no questioning that Britnells’ knowledge has been acquired first hand, given his worldwide expertise in conferences and consultancy. As the author mentions, he is often asked which country has the best health care system? Since the WHO report, Health systems: Improving performance (2), published in 2000, several country rankings have been published according to the assessment of their health systems using a variety of methodologies and outcomes. The table below serves as an example.

pons-comparison-health-systems

Nowadays, rankings proliferate as can be seen in universities and research institutions/centres. The indicators may be different, but it seems that one may always end up finding the most favourable ranking for them. Catalan public universities are a good example, given that centre advertises their position – besides that of excellence in comparison to other universities which are not necessarily British –  in the ranking system which makes it stand out to a greater degree that other Catalan universities.

Britnell, getting back to our point, after so many rankings, lectures and consulting, make a proposal on what the best health system might be by taking the best areas from the different countries. If the world could have a perfect health system, it would have to possess the following characteristics:

–    Universal healthcare values (UK)
–    Primary health care (Israel)
–    Community services (Brazil)
–    Mental health and welfare (Australia)
–    Promoting health (Scandinavian countries)
–    Empowerment of patients and communities (certain African nations)
–    Research and development (USA)
–    Innovation and new ways of doing things (India)
–    IT and Communication technologies (Singapore)
–    The capacity of choice (France)
–    Funding (Switzerland)
–    Care for the elderly (Japan)

References

(1) Britnell M. In Search of the Perfect Health System. London (United Kingdom): Palgrave Macmillan Education; 2015.

(2) The World Health Report 2000. Health systems: improving performance. Geneva (Switzerland): World Health Organization (WHO); 2000.

(3) Where do you get the most for your health care dollar?. Bloomberg Visual Data; 2014.

(4) Davis K, Stremikis K, Squires D, Schoen C. 2014 Update. Mirror, mirror on the wall. How the performance of the U.S. Health Care System Compares Internationally. New York, NY (US): The Commonwealth Fund; 2014.

(5) Health outcomes and cost: A 166-country comparison. Intelligence Unit. The Economist; 2014.

Post written by Joan MV Pons.

Perspectives on Preventing Overdiagnosis

15 Sep

Preventing Overdiagnosis Barcelona 2016We continue drawing inspiration from the Preventing Overdiagnosis Congress (in Twitter: #PODC2016), which is due to take place this coming week. There are many issues in play that we must take into consideration and we will try to demonstrate just some of those here.  Joan MV Pons in this post reflects on the public health measures implemented over the past centuries which have had a role in the history of overcoming poverty and increasing life expectancy after reading the book by Nobel Prize winning Economist Angus Deaton.

Without detracting from developments made over time, in this post Andreu Segura comments on the futility of medicine and of procedures with unrealistic expectations regarding the benefits. Segura mentions the report “To err is human” and the estimation made by Barbara Starfield concerning mortality caused by adverse side effects of medicine. At the same time, the author mentions the very specific case of prescribing preventive measures and how these have evolved over the years.

It is not a straightforward task, but thanks to this post by Cari Almazan, it is easy to understand exactly what is being referred to when we talk about overdiagnosis. Almazan takes us on a journey from the origins of the concept itself through to some current examples and discusses the challenges we face in the future in this area, which begins with a good communications strategy.

No es fácil pero gracias a este post de Cari Almazan resulta fácil entender qué significa y qué no significa sobrediagnóstico. Almazan propone un recorrido por los orígenes de este concepto pasando por algunos ejemplos actuales y planteando algunos retos de futuro en este ámbito, empezando por una buena estrategia de comunicación.

The concept of overdiagnosis is equivalent to diagnosing a disease that does not present symptoms throughout a person’s life and, meanwhile, the treatment and monitoring the patient is subject to in order to treat the disease can be more harmful and fail to produce any benefits.

The interest of working along the lines of diagnosing less can be seen on an individual and population-wide level. On an individual level, overdiagnosis is associated with the negative effects of unnecessary labels, such as the effects of radiation and false positives and false negatives as a result of unnecessary diagnostic tests and therapies (surgery or medication). On a population-wide level we are talking about the opportunity cost derived from wasting resources that might have been allocated to preventing and treating diseases.

That said, we can ask ourselves what the primary care professionals think. In this regard we find some interesting pointers in this post by Johanna Caro where we can see the principal results of a survey of GPs and paediatricians post by Johanna Caro Mendivelso where we can see the principal results of a survey of GPs and paediatricians. One of the most striking results of the survey is the fact that around 80% of physicians surveyed find themselves in the position of making a decision whether to request an unnecessary test or prescribe unnecessary treatment at least once the week.

The interest in the impact that this issue can have is growing significantly. For this reason, Preventig Overdiagnosis will be a brainstorming session which will enable us to design strategies and make decisions to address the fallout from overdiagnosis and overtreatment. We think that this new topic for debate is increasingly present in both our professional and personal lives.

johanna-caro-cari-almazan
Johanna Caro Mendivelso and Cari Almazan, members of the Essencial Project team, participating in the Preventing Overdiagnosis.

Ioannidis and the industry: a persistent distortion

7 Apr

John PA IoannidisJoanMVPons is a scientist and professor originally from Greece, currently working at Stanford (Meta-research Innovation Center – METRICS) who is, undoubtedly, among the most prolific authors of medical scientific literature.

Some of his papers, alone or in collaboration, have had a great impact. Who does not remember the one entitled “Why most published research findings are false?”. Nowhere in his large output will you find trivialities, and he recently came to Barcelona to speak about defective research and even about the waste of resources this implies. But we will leave the latter topic for another occasion.

The paper by this author I want to comment on is the one written in collaboration entitled “Undue industry influences that distort healthcare research, strategy, expenditure and practice: a review” published in 2013 in European Journal of Clinical Investigation.

One might think that all has been already said about the (bad) influence of drug and health care products industries. There is even a literary body or genre in biomedical scientific publications exclusively devoted to this topic. And books abound, too. All that could be said has been said. Well, actually it hasn’t. Undue influence, such as biases, is far more subtle than we think. It is often hard to tell how, similarly to interest conflicts in biomedical research or in prescription practices, the one who does it refuses any influence, since science could not admit it, as its own deontology doesn’t. Fools!

What is interesting about this paper is its review nature, not only for the number of papers gathered, but because it provides a more integrated (re)view of the different elements upon which industry acts, or is allowed to act. It should be noted that the interests and profit of the drug and health care products industry are quite legitimate, but it clearly shows some specifics that put it aside from other manufacturing industries, and not just because its important investment in R+D+i. It is believed to be one of the most profitable industries, possibly due to its large margins, but also because human diseases and ailments are here to stay, even though their end –which both the poor and the rich want to delay– is ultimately inescapable.

Ever since I learned it, I am very fond of a quotation by George W Merck (1894-1957) who for 25 years chaired the drug company that bears his family’s name (1925-1950). As this visionary man said: “We try to remember that medicine is for the patient. We try never to forget that medicine is for the people. It is not for the profits. The profits follow, and if we have remembered that, they have never failed to appear. The better we have remembered it, the larger they have been.“ I wonder what he would think of it now.

Coming back to Ioannidis and his paper, there he follows the outline of how this (bad) influence acts, and the main elements –which changed with time– upon which it exerts its distorting effect, although not as an exclusive factor. Governments, as with other industries also regulated by them, play an essential role.

Evidence based medicine - Clinical practice guidelines - Medical practice

Post written by Joan MV Pons.

Animal (non-human) testing

18 Feb
Joan MV Pons
Joan MV Pons

It is striking that there are more data on the animals used in experimentation than on humans (patients or not) who take part in clinical trials. Certainly, in both cases, the regulations are stern and there are different organisms which ensure the safety of participants in experimentation.

Recently data on the experimental use of animals in Spain were published. Overall, the number of applications has been over 808,827 throughout 2014: 526,553 rodents (mostly mice), about 190,354 fish (more than a third were zebrafish) 44,169 birds and 23,881 rabbits, to name the most used animal species. It should be noted that a quarter of those, and despite being mostly mice, are genetically modified animals. The vast majority (75%) are used for what is called basic research and translational and applied research.

Informes anuales de la utilización de animales en la investigación y docencia

Is this too many or too few? What are the latest trends? Despite recent changes in the way we collect information, data show an increase over previous years, which does not seem to quite support the principles that should inspire animal testing, which were collected by the Royal Decree 53/2013, the so-called 3 Rs replacement, reduction and refinement.

Aside from quantity, quality also is important and there is a remarkable lag in  initiatives to improve data collection and reviews of experimental studies compared to human clinical research. We are referring to the CAMARADES (Collaborative approach to Meta-analysis and Review of Data in Experimental animal Estudies), which is essential before starting a new study, and the ARRIVE guidelines (Animal Research: Reporting In-Vivo Experiments) to improve the design and publication of animal experimentation, and ultimately, to reduce the risk of biases.

One might wonder, how many biomedical research funding agencies, in their peer review process, call or require the use of these guidelines when assessing projects involving animal experimentation? Surely we could also discuss the implementation of the guidelines CONSORT (Consolidated Standards of Reporting Trials) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) in the case of clinical trials in humans.

It seems clear that the higher the risk of bias, the more overestimation of effects,  thus it is not surprising that the subsequent proposals for translating this into human experimentation end up being disappointing.

The field of neuroscience is full of such cases of failed transfer, usually for involving imperfect animal models, or less than careful study designs and too prone to bias.

A recent paper by Malcolm R. Macleod from the Centre for Clinical Brain Sciences, University of Edinburgh, published in PLoS Biology, insisted on those qualitative aspects often found in animal research. It also underlined that reporting the risk of bias is not related to the journal’s impact factor, which again emphasizes this measure as a poor indicator of the quality of research.

Post written by Joan MV Pons.

The Great Escape

21 Jan
Joan MV Pons, Head of Evaluation AQuAS
Joan MV Pons

A few days ago, Anna Garcia-Altés in a previous post referred to the Nobel Prize in Economics, which Alfred Nobel never granted – that was awarded in 2015 to Angus Deaton and his work on inequality. This is not the subject that I wish to talk about today but another that also features in the recent book from this Nobel proze winner which is titled “The Great Escape” (The Great Escape). Yes, just like the movie, set in a German camp for prisoners of war starring Steve McQueen and recalling a real fact of World War II. Unlike reality, the book predicts a better ending. For Deaton, the greatest escape in human history was in overcoming poverty and ageing.

For centuries, those who did not die at a young age could face years of misery. Beginning in period called the Enlightenment, with its scientific revolution and subsequent later industrial revolution, some people in certain countries began to escape this meagre fate.

Meanwhile, germ theories founded in the late nineteenth century surpassed the paradigm of the miasma theory in explaining contagious diseases. The key was and still is scientific knowledge and its dissemination. This point in history marks the extraordinary increase in life expectancy, initially for the better-off and then for the rest of the population.

This higher life expectancy, manifested especially in the developed countries, is largely due to the remarkable reduction in infant mortality and, more recently, to the epidemiological transition to chronic non-contagious diseases, the improvement in life expectancy in adulthood (increased life expectancy ≥ 50 years from 1950), but without a substantial improvement in longevity. Deaton shows us all this with data and graphics.

To illustrate it, Deaton mentions the progress in combating smallpox with a vaccination of smallpox (initially using matter from infected people and later the much safer vaccine Edward Jenner introduced in 1799). The public health measures introduced in the last few hundred years, including sanitation, water supply, nutrition and better hygiene, have led to a significant reduction in infant mortality.

Here, it was due to not only the knowledge but also the determination of the authorities in improving the conditions of the population. The improvement in life expectancy in adulthood is explained largely by reducing cardiovascular mortality through diagnostic and therapeutic advances in this field.

As mentioned before, we witnessed not only increased life expectancy but also a significant increase in the world population, an authentic explosion starting in the second half of the twentieth century. Malthusian alarms re-emerged but they were fortunately overcome by improvements in agricultural productivity, without excluding initiatives – for better or worse – for controlling the birth rate in developing countries; again, examples of scientific knowledge and its dissemination.

Deaton is very critical about the operating methods in which help flows from developed countries to developing countries. From the times of imperialism and colonization where (natural) resources were moved from poor countries to rich ones (Nineteenth century) and since the end of World War II we’ve also seen a flow of resources from developed countries to developing countries.

This external help, whether from governmental or NGO sources and despite the illusion that might it create if it continues as usual, may end up doing more harm than good. There’s no shortage of examples in the book of wasted resources by governments and corrupt politicians, granting donations or grants to countries (government to government) without these ever reaching the people. Not to mention situations where these grants are part of the geopolitics of the former colonies or contemporary powers.

Contrary to what an engineered hydraulic vision (communicating vessels) may show, we must invest in projects and programs that promote conditions for economic development to make external aid unnecessary, as is the reality in Africa, where paradoxically, the more external help yields the least growth in GDP per capita.

Health aid, without underestimating its achievements (vaccination campaigns, infrastructure construction, drugs against HIV / AIDS, mosquito nets), continues to be in most cases, vertical health programs with a very specific focus. This contrasts with the horizontal programs aimed at strengthening local health care systems, especially a good network of primary and community care.

Often foreign aid and the development of local capacity are not aligned; on the contrary, often one damages the other. Rich countries’ subsidies to their agriculture – consider the famous European PAC – is detrimental to farmers in poor countries where most of the workforce still works the land. There are more effective ways to help.

(It notes that another Nobel laureate in economics, Robert Fogel (1926-2013), had already written about the great escape in “The Escape from Hunger and Premature Death, 1700-2100” (2004), Deaton and had revised appointment. Thank Anna Garcia-Altés to call me about this)