I’m always surprised that the LSHTM gives me the privilege of returning to talk about the shifting landscape of funding and how to help assure that it is spent well and to benefit Africa’s future. As I met the Zoom room full of bright, engaged students (many of whom are living the challenges of adequate funding daily in countries such as Uganda, Nigeria, Kenya, and Cameroon) I was struck by how fast the familiar old world of advocacy died, and how urgent it is that we build a new one.

My perspective is shaped by 35 years as a policy and communications consultant working across the continent. I have seen the era of the “Great Man” advocacy, where we simply tried to bend the ear of a US President or a billionaire philanthropist. We look back at those days with rose-tinted glasses: the billionaires and rich-country leaders were fickle and their focus was often on getting recognition or a seat at the top table, not on the real need. Even when they did try to assess the real needs, it was usually through the uninformed eyes of over-priced management consultants whose only knowledge of Africa came from airport VIP lounges. The billionaires were also shockingly bad at effective advocacy for something as obviously cost effective as health spending.

In any case, those days are over. If we want to secure the future of health in Africa, our work to influence policy must evolve to meet a much harsher, more complex fiscal reality.

The Shifting Foundation of Global Health Funding

We have seen a fundamental failure in advocacy around health funding. The data released by the OECD reveals a stark trend: the era of expanding bilateral aid is ending. Total Official Development Assistance (ODA) is contracting, and 96% of that decline is driven by just five donors: Germany, the UK, Japan, France, and most significantly, the USA.

The US alone is responsible for three-quarters of the global decline in health funding. While Germany has technically become the largest provider of ODA for the first time in history, even it is cutting budgets, albeit in an attempt to become more efficient. Meanwhile, traditional multilateral ODA, money flowing to the WHO or the World Food Programme for example, is shrinking less than bilateral grants, but the overall pie is getting smaller.

The good news is that the World Bank and regional development banks such as the African Development Bank (AfDB) are stepping in to fund some health projects. There are questions over “additionality”: are these institutions really funding things that private equity or other lenders to states would not? And there are frequent criticisms that the banks have failed to create funding buckets for innovative models such as low-cost private-sector primary care. However, there are real successes. The AfDB in particular has said loudly and clearly that economic growth depends in large measure on better health and has encouraged governments and funding agencies to invest accordingly.

The Rise of the America First Bilateral Accords

US funding has not disappeared: it has shrunk and mutated into the America First health policy. This administration is moving away from broad global initiatives toward strict bilateral health accords between the US and individual African countries. These are not just funding agreements; they are ideological and strategic contracts that come with significant strings attached.

Under these accords, the US makes a five-year commitment with a clear “exit strategy”: funding is front-loaded but tapers off to zero, forcing national governments to take on “ownership.” While national ownership sounds positive, the requirements are often demanding.

The focus is what you would expect from an administration with an ideological focus derived from Project 2030. It is on maternal and child health (and, yes. The State Department often says that it is the health of children “born and unborn”) and infectious disease.

These accords also require African countries to share pathogen data and specimens with the US within five days of an outbreak. This creates a parallel data mechanism to the WHO and, more importantly, seeks to capture what one of the post-graduate students called, “the new oil.” Africa holds 80% of humanity’s genetic diversity. In an era of genetic medicine, this data is a massive national asset. Several students at LSHTM rightly pointed out that countries like South Africa and Kenya see this as a key resource to be traded for R&D investment, not just given away for a few years of HIV funding. Africa is also developing national health databases that can be used to assess and model the impact of interventions and, as when the continent pioneered payments from mobile phones, it is less encumbered with antiquated existing systems and threatened vested interests.

Most alarmingly to me, these accords are sometimes tied to non-health issues. We’ve seen Zambia refuse to sign because the US tied HIV funding to access to critical minerals and mining data.

One Path Forward: the Accra Reset

The Accra Reset sets out to be a roadmap for this new era. It aims for 55% of health spending to be domestic by 2030, funded in part through “sin taxes” on sugar-sweetened beverages and tobacco. Other means of national funding include surcharges on profitable data transactions and health solidarity funds. Its organisers say that these taxes will raise £750 million in 2026 in six countries alone. I think that’s a high estimate, but there is real money there.

The Accra framework is, though, delusional in thinking that out-of-pocket health can be reduced over the next five years. The AfDB projection is that the private health market in Africa will explode. This is not necessarily bad news for health equity: much of the growth will come in highly efficient fixed-cost private primary care models targeted to working people (although, admittedly, rarely to the bottom of the pyramid or the working poor). These models can be valuable ways to give fast access to innovation and convenient, timely provision of sexual and reproductive health services.

Recommendations for the New Advocate

Given this backdrop, I suggested that these elite advocates do the following.

1. Make Health Explicitly Political

We often hear that health should be non-political. This is a mistake. Non-political subjects are boring and ignored. We need health to be the subject of election campaigns, impassioned debates and social media memes. When health becomes a political must-have, politicians make promises they can be held to. We want people shouting about health in the streets of Accra, Nairobi, and Lagos.

2. Frame Health as a Capital Asset, Not a Cost Centre

We must stop arguing for funding based solely on morality. We need to speak the language of Finance Ministers. According to the World Bank and the AfDB, health is a growth engine.

• ROI Data: For every $1 spent on malaria treatment, the economy gets $35 back. For paediatric immunisation, it’s $20. For SRHR, the returns are less often quantified rigorously but similarly massive because they enable women to enter the workforce and stay productive.
• Preventative Care as Infrastructure: Just as investing in robotics improves productivity, investing in the health of a citizen from birth to age 65 creates a stock of human capital that belongs on a national balance sheet, as the World Bank has now recognised.

3. Build Alliances with FBOs

Faith-Based Organisations (FBOs) provide roughly 30% of healthcare in Africa. The America First plan prioritises them, in part because it plays well to US domestic audiences and, in part, because they are efficient and embedded in communities. While we may disagree with some FBOs on abortion or family planning for unmarried youth, they have incredible national reach. As one student noted, a Pentecostal church in Nigeria aiming for a branch every 15 minutes of walking distance is a more powerful delivery network than any government programme. We must engage them to improve quality and advocate for rights within their frameworks.

4. Harness the Power of Media and Social Media

We can’t forget about media, especially in Africa where so many people are still dependent entirely on TV and local radio and where online and offline newspapers are declining less slowly.

Increasingly, though, we must go where the people are — which is social media. During the lecture, students raised concerns about medical influencers spreading misinformation or misogyny. My response: then we must flood the zone. We need to train responsible influencers. When Joe Fazer, a bodybuilding influencer with about 30 million followers produces content about health equity, he can mobilise a generation we will never reach through traditional policy papers.

Overall, we are in a time of great opportunity and serious danger. The transition from aid to co-investment is the only way to escape the whims of Washington or Berlin. We must be like the “trained revolutionaries” Lenin spoke of — professionals who know how to stir up movements and demand that our governments prioritise health not because a donor asked them to, but because their own citizens demand it.

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I believe in making it very difficult for people to refuse vaccines. There’s enough of the libertarian about me that I wouldn’t actually strap them down and inject them, but I’m fine with school districts making parents write out their conscientious objections to children being immunised or with sports clubs requiring adult proof of immunisation before people can join. What I or you think is, though, beside the point. Much of the US is walking away from cajoling and compulsion and there’s great pressure in Europe for similar change. We can either go on moaning about how we wish the world hadn’t changed or we can respond effectively.

Before the current US Administration began rewriting vaccine recommendations, one in six US parents wasn’t following them. We used to joke that vaccine-preventable diseases in the West had become diseases of children of the over-educated middle classes who shopped at Whole Foods and did naked yoga classes; vaccine refusers now are still more likely to be white, but they skew to being conservative, very religious, and young. Recommendations actually reduced uptake in this group because most have a deep distrust of the Federal Government and its agencies.

Formal vaccine refusals in Poland more than doubled from 2017 to 2022 and reached over 87,000 in 2023, a 1685% increase since 2003; measles cases surged 10x in early 2024 due to falling rates. Ireland, where I live, has the third-lowest childhood vaccine coverage rate in the OECD.

There are bright spots too, Italy for example, and the battle is far from lost. But the mistrust now endemic to the United States is coming to Europe.

High-handed US and European experts

You can understand confusion, if not mistrust. About half of parents in the USA did not vaccinate their children for flu in the past year, compared with 41 percent who said they had done so, a Washington Post / Kaiser Family Fund poll found. Coverage started declining after 2019. In 2016, the US CDC said that the nasal flu vaccine used in children provided “no measurable benefit” (injectable vaccines for adults were, as usual, highly effective). In the same year, Public Health England said that the same vaccine (produced by a British company in a British factory) was 58 percent effective. Canada followed the UK, saying that its population was very different to the USA! It’s very unlikely that both the Americans and the Canadians were right — despite those obvious population differences…. Few journalists covered the story — I suspect because no-one wanted to be accused of promoting vaccine scepticism. The vaccine is now recommended again in the USA.

Few American paediatricians and even fewer nurses would have been able to explain this to parents because no-one ever bothered to give the professionals an explanation. What do we think doctors told parents who asked why a vaccination was recommended then was not and then was again? British parents who did a web search (this was pre-Chat GPT, remember) might have asked why their children were getting an apparently ineffective vaccine and would have met equally bemused stares from their health providers. Did anyone brief social media influencers or health journalists? Of course not, who do they think they are? What impudence…

I know some of those involved and I’m sure that there was no subterfuge and nothing sinister going on; the answer is likely to be dull and involve methodology and surveillance systems.

This is the way we all used to approach treatment discussions 40 years ago — the doctor told you what to do, you thanked him (it was nearly always a him) and you did it. Questions were a sign of disrespect, of even psychological illness. I was recently treated by a Russian dentist, now practising in Ireland, who was shocked and outraged when I questioned his recommendation to use antibiotics prophylactically; if he had been Irish, he would have been completely used to it.

Nonsensical recommendations in developing countries

Vaccine hesitancy looks a bit different in France. Those least likely to have their children vaccinated tend to be more educated, high users of the internet for information and to have lower trust in health authorities. Those who refuse vaccines for themselves tend to be at the lower end of the social hierarchy with less education and fewer financial resources. Many are ​immigrants and descendants of immigrants, and residents of French overseas departments. Both are probably likely to know about the vaccines which Western experts recommend for children in the developing world, including in Francophone countries.

I remember doing a policy interview with the health minister of a large Indian state. I was trying to find out what he might pay for an effective TB vaccine. “But”, he said, “we already have a TB vaccine. Why do I need a new one?” His top civil servant was sitting behind him and frantically gesticulating to me to try to stop me explaining that the BCG vaccine, given to almost every Indian newborn, may do nothing to prevent TB infections and, at best, may make the disease less severe in some of the children who contract it. It is, though, very good at causing severe side effects. No developed economy uses it; almost every poor one does.

I’m ashamed to say that I did not explain BCG as clearly as I should have to the minister. He was the norm, not the exception, in that series of policymaker interviews: few of those making decisions about TB vaccine policy had ever been given a thorough, honest briefing about the limitations of the vaccines their expert advisers recommended. None of the parents, of course, were ever told about any of these reservations.

There might also be a case for the current practice of giving many children in Africa and Asia a vaccine that sometimes causes polio, instead of preventing it, although I doubt it. The risks of a child contracting polio from the live-attenuated oral vaccine are probably underestimated when they’re presented to politicians and policy influencers. Hardly any parents who bring their children forward for these vaccines are told about the risk or the rationale for continuing to use them, rather than the perfectly safe inactivated vaccine used throughout the rich world.

Is it any wonder that those with insight into the developing world are sceptical? The real wonder is that vaccine confidence is still so high in Africa and Asia. That probably comes from everyday encounters with the tragic consequences of infection by vaccine-preventable illnesses, an experience blessedly denied to most Americans and Europeans.

What we need to do now

The road ahead has been cleared for us. Thirty years ago, I went out with a trainee doctor at the Royal College of Surgeons in Ireland. He was upset one evening because he had been berated by his tutor for telling an older patient that she had cancer — it had been agreed with the family that she would be told that she had a “growth” to avoid upsetting her. At least she found out: King George VI of the United Kingdom sent his daughter, Princess Elizabeth, on a world tour in 1952 because neither he nor she had been told that he had lung cancer and that it was terminal. He never saw her again. These stories shock us now because honesty, realism and communication are taken for granted in what we tell patients who are ill. These principles need to be the new basis for what we tell people who are healthy and want to stay that way.

First we need a change in attitude. Whether to be immunised or not is a decision that people will take — actually, a series of decisions. We don’t need to think about whether we like the concept or not, it is the way things increasingly are. We have to get ordinary people used to making good decisions, just as they do about other life issues such as house buying or insurance or continuing education. Ordinary people are not property experts or risk analysts or trained evaluators of course offerings, but they mostly make reasonable choices. They can do the same thing with vaccines.

Then, we need to communicate much more. Vaccine producers are free to talk to the public about recommended vaccines in many countries; where they are not, they need to be allowed to. Then they need to accept their responsibility to speak often, clearly and loudly. They are the experts on the vaccines they produce and they must tell potential recipients or the parents of recipients about the benefits and disadvantages. Of course, they need to do it in an honest and balanced way. They will be more successful if they communicate in partnership with professional organisations, charities and respected consumer groups. They can be transparent: they have a commercial interest in getting people to accept vaccines but a legal responsibility to set out all the factors in deciding whether to or not. It’s like banks selling mortgages and car dealerships selling warranties.

Researchers and healthcare providers need training in communication and answering questions. They need to be much better at helping policy makers to make decisions about vaccines. Today, too few vaccines are reimbursed and many are offered only to some of those who would benefit from them. In many countries, it is still too hard to get vaccinated and even where rules have changed, practices have not — look at Poland, for example. Politicians and public officials can unleash vaccines so that they can do even more to boost productivity, growth and wealth in society.

Those same scientific and medical experts need to be much better at talking to people who are making decisions about immunisation. Research tells us clearly what helps the right decision, but too few professionals follow the evidence. The most powerful prompt to action is a trusted health professional saying, “I would like you to do this”. Setting a good example works wonders too, but too few health professionals have had all of the vaccines recommended for them.Communication can change all of this.

The vast majority of social media influencers want to give good advice and powerful motivation but no-one talks to them — after all, we want people to follow the guidelines, not think, don’t we? For example, have you seen Dr Mike Varshavski take on 20 vaccine sceptics at once? Thirty million people probably have over various platforms and he’s brilliant. Industry and professionals need to work with influencers who specialise in women’s issues, childhood, workplace effectiveness and, of course, health. Look at this from Dr Ahmed Ezzat — his videos on RSV reduced calls to the emergency services by 25% — and just think what he can do for vaccines.

Journalists are discouraged from writing pieces about vaccine decisions — “just tell people to follow expert recommendations”. Many, consequently, avoid writing about vaccines. We need to treat these journalists as powerful allies in helping lay people to make important decisions with lifelong implications for their risk of developing chronic illnesses. It’s the way that property developers treat journalists who write about houses,

Honestly, I still think it would be simpler and still ethically correct to just nudge almost everyone into getting immunised but that is not an option in many places now and, given the global market in ideas, won’t be one anywhere soon.

Parents get things right

Asia should encourage us. Many parents save and spend to get their children the best vaccines. The state often provides old tech or nothing, so middle-class parents take their children to private clinics for the best protection and pay full price for it. Of course, it’s not fair to poorer children and it is crazy public policy given that population sizes will plunge across Asia over the next 30 years so every child, whether middle class or not, is a precious national resource. Still, it shows that individual families can and do make better decisions than health policy makers when the routes of communication are open and used well.

The post We Have to Earn Better Vaccine Coverage Rates appeared first on Medika Life.

Many private-sector investors are considering health in Africa. Maybe that’s no surprise; the African Development Bank says the Continent could almost double its GDP if health were better. Robert Appelbaum, though, thinks that many are interested in what Africa might export as well as the potential unlocked at home.

Appelbaum has advised multinational pharma companies through the most difficult episodes of the past three decades including the disputes over HIV medicines patents and the transfer of technology to African producers. He also provides legal and business counsel to billionaires who are household names. “Today, investors are looking at the African Continental Trade Agreement (AFCTA) and the commercialisation of African drugs and devices for use across the world,” he told me. “The AFCTA is making Africa into a legitimate manufacturing hub for the full gamut of manufacture from API [active pharmaceutical ingredients] through to fill and finish, whereas in the past we have been in the business of fill and finish,” he added.

The day before we spoke I had been to see the Biomedical Research Institute at Stellenbosch. It houses a network of 26 BSL-3 — highly secure — laboratories to handle infectious diseases samples. There are probably a third as many BSL-3 labs at Stellenbosch alone as there in all of China. The Biobank in the same facility has space for up to seven million samples and provides an exceptionally rapid way of looking back at the evolution of disease outbreaks. It was designed to allow another seven million to be stored when needed. To give an idea of how massive this is, the largest biobank in China can hold 10 million samples and the largest human biobank in Europe can keep 20 million. Maybe the most impressive statistic is that the Stellenbosch institute was completed for about €65 million, a fraction of what it would have cost in Europe.

Cost is not Africa’s only advantage: it has the kind of frugal innovation that hard-pressed European and American health systems need. “There is a huge amount of work taking place — more in devices and technology than in drug discovery. Africans are very innovative at creating for ourselves what does not already exist,” Appelbaum said. These are exactly the areas in which slow first-world innovation is holding back medicine: commissions on antimicrobial resistance assumed point-of-care diagnostics would by now have been able to differentiate between viral and bacterial illnesses and between different kinds of infectious bacteria. They cannot.

Pre-history gives Africa another advantage. As humans spread across the globe from Africa, we lost genetic diversity. It’s said that today there is more genetic diversity within Mozambique than between people in South Asia and people in Europe. In that vast genetic storehouse are hidden undiscovered clues to resisting and treating disease — clues that can be transformed into prevention, diagnosis and treatment by health innovators. As Africans have more access to health services, those genetic assets and liabilities will become more and more evident and accessible. This is a key aspect of the African Human Genome project and of South African agreements with commercial entities such as Illumina and MGI.

To spot the real life implications of these genetic patterns, to find population clusters and to identify possible genetic outliers, a country needs easy, secure access to massive numbers of records. The United Kingdom sees this as a competitive advantage for its four national health services while France’s La poste, the nation’s post office, is bringing together over 40 million patients’ referrals, visit reports and test results. These and other developed world efforts, though, are having to retrofit national analytical frameworks onto multiple old data systems and to pry data loose from academics and care systems with strong proprietorial instincts. African countries are building new national data systems from the bottom up with integration and analysis as part of the original design. Appelbaum thinks that Africa may again leapfrog over Western competitors, just as it did by introducing modern mobile telephony and mobile payment systems while legacy system owners slowed down adoption in Europe and the Americas.

Many think that Oracle has already honed in on the opportunity. It has partnered with the Tony Blair Institute to introduce vaccine tracking systems in Ghana, Rwanda and Sierra Leone and to promote them Continent-wide. Given the vast effort that Oracle continues to put into developing a nationwide repository of health records in the USA and the Gulf states, many see its efforts in Africa as a test run for much broader and more ambitious national health databases. African countries are not waiting. Kenya’s Afya Yangu platform is already operational in a third of the nation’s counties and provides portable individual records including medical history, prescriptions, lab results, and appointments for three million users. South Africa faces some of the same challenges as Europe in unifying or supplanting existing systems but its Health Patient Registration System has registered over 57 million patients across more than 3,000 facilities as a foundation for portable electronic health records. Africa’s health data is a vast opportunity which governments will need to use as the basis for investment.

Private sector health investors are indispensable to Africa, Appelbaum thinks. In the US and Europe, they find far more R&D than governments and foundations combined; that must be the pattern in Africa if the Continent is to not just meet its own health needs but to develop innovations for the world.

The post Why Sophisticated Investors Really Care about Health in Africa appeared first on Medika Life.

The NEJM paper shows that hypertension care delivered at home by community health workers (CHWs) delivers better results than care delivered through a clinic. It is reporting on interventions in rural South Africa. The team that did the research comes from the University of KwaZulu Natal and Harvard. Do not, though, expect to see people in Massachusetts benefit from the findings any time soon.

In the most sophisticated community model in South Africa, 83 percent of trial participants had their blood pressure under control after six months, an outcome that was sustained after a year. In that model, patients were seen by a nurse with decision-making authority; they were given an automated blood pressure monitor that sent regular messages to an app used by the nurses; CHWs — lay health workers who live in the communities where they work — helped patients use the machines and delivered medicines that the nurses had prescribed. The nurses got reminders about regular review of readings, prompts from a national management protocol and suggestions about prescribing updates. Medicines were sent automatically to the CHWs, who delivered them to patients.

In the world’s most expensive healthcare system, about 60 percent of Americans with hypertension knew they had it in 2024. About half of them were taking treatments and about 20 percent had their hypertension under control. Unsurprisingly, heart disease and stroke are the leading causes of death in the United States and hypertension is a major risk factor for both.

In a 2010 report, over 40 percent of Americans with hypertension were managed by internists, who now earn over $250,000 a year on average, although about one in eight were managed by cardiologists, with an average salary of about $420,000. A Journal of the American Medical Association paper in late 2024, reported that, “70% of adults with uncontrolled hypertension who were aware of their condition reported taking antihypertensive medication.”

Crudely — and I appreciate that we shouldn’t compare data from very different sources and different populations — Americans are about a quarter as likely to have successful treatment of their hypertension as are rural South Africans in this pilot. The Americans pay a fortune; the SA government pays very little, but uses technology wisely. This should not come as a surprise. It follows closely the track record of the two countries in treating HIV.

In 2022, 90% of South Africans living with HIV knew they had it; 91% of those aware of their status were on effective treatment (highly-active antiretroviral therapy or ART); and 94% of those on ART were virally suppressed. Suppression means that the virus cannot be detected in the person being treated; that the disease is unlikely to progress; and that it is virtually impossible to transmit it to another person. South Africa’s success is mostly the result of good community care, efficient delivery of medicines to convenient pickup points and strong leadership. It is doing well, especially given the vast number of its citizens living with HIV, but most of its neighbours are doing better.

The US Centers for Disease Control do not report data in the same format, but in 2023, only 67% of Americans living with HIV were virally suppressed. About a quarter received no medical care at all that year. A US government webpage lists at least 10 kinds of professionals who may make up an HIV care team. Almost all will include an infectious disease doctor, who earns about $250,000 a year, a bargain in American terms.

I could keep giving examples — open heart surgery in a production line model for under $2,000; one-stop breast care clinics to diagnose early-stage breast cancer and manage it; AI-powered skin lesion analysis by CHWs. All deliver better results at a fraction of the cost. We should also not just pick on the USA as a comparator: France and Germany don’t do much better. Worst of all, some of these examples are over a decade old but entrenched medical interests have stopped advanced economies from adopting models of frugal innovation that would improve quality of life and avoid premature deaths.

There are examples in the other direction. For example, about 90 percent of children with cancer survive at the very best treatment centres in the USA; fewer than 20 percent do in some low-income countries. (A coalition involving St Jude Children’s Research Hospital, the WHO and partners are working on exactly this) The patterns are not so stark in adult cancers and neurological diseases, but also clearly favour the advanced economies. However, risk stratification based on big data, standardised treatment protocols and the rapid introduction of some new diagnostics all seem likely to happen faster in middle-income countries than outside centres of excellence in high-income ones.

There is little appetite to take on the vested interests in most countries and concern over making so much current investment redundant. For example, many GPs in Ireland, where I live, won’t rely on validated smartwatch readings to monitor blood pressure because all have bought devices that patients take home for 30 hours and that inflate a cuff every hour.

Change will accelerate rapidly from here on. The innovators will come from middle-income countries without our sunk investment or our abundant human resources. If we, in the advanced economies, want to be early adopters or even part of the early majority, we’ll need to be more willing to disrupt entrenched and dysfunctional systems.

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President Trump’s executive order could result in higher US medicines prices because big data will allow payments to be linked more closely to the real value a medicine delivers.

President Trump’s executive order is short on specifics but Bloomberg says that he will direct the US Trade Representative and the US Department of Commerce to take action on “unreasonable or discriminatory policies that suppress drug prices overseas.” Trump is also asking the Department of Health and Human Services to “facilitate direct drug sales to consumers at lower prices paid abroad.”

Pharmaceutical companies look as if they are charging more in the US than in the rest of the world for medicines protected by patents; sometimes they are not. Recently, I was with a client’s US and European commercial teams. With some trepidation, the UK GM announced the price he had negotiated with NICE, the British pricing authority. It was less than half the US list price but, the US general manager said that it was higher than the average price the company actually received in the US. The difference was skimmed off by what economists call “rent seekers” — companies that add no value but are able to add fees or a mark up. These parasitical pharmacy benefits managers and insurers are politically well connected and it has proved very difficult to cut them out of the US supply chain.

Does the US want medicines priced the way they are in the rest of the world?

The American system, beyond big federal programmes, relies on prices that are set through these one-on-one negotiations with various actors who can permit or block access for patients. In most of the rest of the rich world, medicines prices are set for almost all prescriptions through a system of health technology assessments (HTAs). These HTAs typically rely on some mix of assessing the true incremental value of a new medicine and estimating the savings that it could generate in other parts of the health system.

In the UK, for example, NICE typically considers a medicine cost-effective if its incremental cost-effectiveness ratio (ICER) falls between £20,000 and £30,000 per quality-adjusted life year saved (QALY). Interventions below £20,000/QALY are generally approved, while those above £30,000 require additional justification. It may accept ICERs up to £50,000 per QALY for severe conditions such as cancer or neurological illnesses or where it is difficult to measure the benefit exactly. In theory, a QALY equates to one year of life in perfect health. Two years at about 50 percent of perfect health (measured according to criteria such as pain, mobility and self-care) would be one QALY, for example.

Irish agencies require hospitals to consider the broader impact of drug choices on the entire healthcare system, including potential savings from reduced admissions or procedures. Most other countries factor these elements into decisions too. A 2015 study of 15 rich countries concluded that new medicines launched between 1982 and 2015 had saved about five times as much in averted health system costs as they had cost.

If those HTA criteria were applied widely in the US, prices would be much higher than they are in Europe. In the US, life expectancy is growing faster than healthy life expectancy — Americans are sicker for more of their lives than are most people in the world, so the cost of mitigating that poor health will be higher. There is a wealth of information in the International Longevity Centre UK’s Healthy Ageing & Prevention Index. American healthcare costs are much higher than they are anywhere else in the world, so the savings achieved by medicines will be even more impressive.

The real economic benefits of new medicines

What none of the HTA systems yet take into account are the wider societal benefits of prevention and treatment — it is often seen as too complicated. As Professor Rifat Atun and others wrote recently, “an important but often-overlooked mechanism is the benefit of health investments on the broader economy through influences on supply and demand across various other sectors of a country’s economy.”

“Adult immunisation programmes across ten countries and four vaccines showing that [these programmes] offset their costs multiple times through benefits to individuals, the healthcare system, and wider society,” a 2024 paper from the Office of Health Economics reported. “In particular, benefit-cost analysis of the same vaccines showed that adult vaccines can return up to 19 times their initial investment to society, when their significant benefits beyond the healthcare system are monetised,” it concluded

Most health spending is on older people. They, on average, spend more of their income than do younger people so they are disproportionately important drivers of economic growth. They also provide a very large proportion of volunteer hours that enable younger people, especially women, to work more. As experts at Germany’s pioneering WifOR Institute said recently about cancer treatments in Germany, “health investments [are a] driver of economic stability and growth.”

The US is the world’s biggest economy so it realises more benefits from innovative medicines than other countries do. These benefits are getting easier to measure and quantify too: big data means we can track prevention and treatment success and its knock-on impacts throughout the economy more easily month by month.

Obstacles to the executive order

Is this executive order meant to effect change or to distract from other developments? It is too early to say.

Congress may not agree to government taking a role in setting prices outside Medicare and Medicaid, but those still account for about 40 percent of US medicines spending. The Biden Administration initiated negotiation for some medicines for federal programmes and that could probably be extended by executive action.

It is easy to talk about enabling Americans to buy medicines from abroad but that requires the consent of the countries from which they are buying. Canadian or British prices are negotiated based on different health system costs and economic benefits; it is unlikely that foreign governments will want to make it easier for Americans to take advantage of negotiations that do not reflect their own circumstances or choices about healthcare provision and prevention.

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Pharmaceuticals have been spared so far from the growing trade war between the United States and many other nations. But that run of fortune may soon be coming to an end as President Trump said recently that the United States will announce a “major” tariff on pharmaceutical imports “very shortly.” While we do not know what the delay in implementing other tariffs means for the threatened tariffs on pharmaceuticals — those on automobiles, for example, are going ahead as planned — the implications of tariffs on pharmaceuticals could have a dramatic impact on multiple areas throughout the US and global healthcare ecosystem.

Tariffs on medicines will, of course, increase prices for US patients. But, as with many other aspects of the fast-moving trade war, this one is likely to have unintended consequences as well. We think that companies should prepare now with an eye to mitigating problems and be prepared to communicate the ramifications of tariffs on health-related areas to diverse audiences, from regulators and policymakers to health providers and patients.

The most likely knock-on effect is on patents and other intellectual property (IP). The US has traditionally protected IP belonging to American companies and the global IP system by threatening trade retaliation against countries that do not respect IP. Those threats may now ring a bit hollow, especially among the countries most well-positioned to capitalize on erratic US policies on biopharma IP.

China

The semi-official Global Times reported on April 9 that China might consider “investigating the intellectual property benefits of US companies operating in China.” China has responded robustly to tariffs of 145% on most of its exports to the US. Vice-President J.D Vance’s characterisation of Chinese as “peasants” may complicate trade negotiations, making it very difficult for the Chinese government to seek conciliation instead of escalation.

As our colleagues have already pointed out, China sees a vast opportunity in the US’s exit from global health. China’s thriving biotech and life sciences sector wants to do more to supply South Asia, Africa, and Latin America. Its COVID vaccines were deployed across the world, but China is positioning its vaccines industry to meet routine and pandemic needs.

The 14th Five-Year Plan (2021–2025) explicitly prioritised biotechnology as a strategic sector for national development, aiming to position the country as a global leader in the bioeconomy by 2035. The Healthy China 2030 and Made in China 2025 initiatives have prioritised development of medical R&D and manufacturing, both in small molecules and biologicals. The government uses subsidies, financial incentives, public-private partnerships, and talent recruitment programmes to foster biotech innovation. High-tech science parks and innovation hubs have been established in regions such as Shanghai and Shenzhen to strengthen industrial capabilities. China is particularly focusing on synthetic biology, gene editing, stem cell research, brain science, and regenerative medicine.

There is an obvious synergy here. China may well relax IP protections for US-based companies, while maintaining its strengthened domestic IP regimen. At its most basic, this would allow Chinese producers to export biosimilars and generic copies of small molecules still protected by patents in the US and EU. Probably more significant would be the shortcuts it might allow Chinese developers in producing new therapeutics and vaccines that build on established American discoveries.

India

In 2022, almost half of US generic medicines came from India. New tariffs could dramatically affect the affordability of medicines within the USA.

India is, for now, not responding to tariffs of 26% on most of its other exports and is putting its hopes on a bilateral trade agreement (BTA) to be concluded by the third quarter of 2025. It may happen, but because presidential authority to conclude trade agreements has expired, the agreement would require Congressional approval and that is usually a fraught process. Absent a BTA, India will look for leverage and, to encourage a BTA’s progress, it may seek to apply pressure in the meantime. In this, India’s government has an advantage: it can leave action to India’s sophisticated civil society sector and the country’s activist courts.

India has long been on the US Priority Watch List for intellectual property (IP) protection and enforcement because of rumbling disputes over administrative and legislative issues. However, India’s generics industry has largely been forced to respect IP on medicines since the early years of this century. That could change without any provocative action by India’s government.

India has recently taken steps to expedite the approval of new treatments based on registration by stringent regulatory authorities such as the EMA and the FDA. Based on these approvals, ordinary Indians can import medicines for personal use. This probably has an untested implication for patents.

India’s Supreme Court has long held that a patent can only be valid in India if the patent holder is “working the patent” in the country; practically this means that a medicine discoverer has to have taken some reasonable steps to make its treatments accessible to Indian patients. The slow pace of approvals in India — and the option of submitting for approval later than in other countries — has meant that developers could control application of this doctrine in the past. Courts might now say that there are few good reasons for a delay in availability in the country and that failure to provide access in these circumstances could invalidate a patent.

India’s government can honestly say that it is powerless to control the courts and fairly helpless to resist activism around patents — look, for example, at the scholarship and training on India’s ever-excellent SpicyIP website. A new trade agreement with the US, when applied fully, could reinforce IP protection but, in its absence, the government can say with some justification that it would have trouble getting any new legislation on pharma IP through the two chambers of Parliament.

As with China, a more subtle threat may come from India’s emerging R&D-based vaccines and medicines industry. The job of developers is much easier if they can use the trade secrets of established rivals.

Ireland

The pharmaceutical industry may have some relief because it holds so much of its intellectual property in Ireland. This is a very sore point for the Trump Administration, but could mitigate the danger from any future moves by China, India and other countries to “investigate US intellectual property benefits”: no-one wants a trade war with the EU as well as the US.

Ireland has, however, been a laggardly partner to the pharma industry. It has been slow to adopt the EU’s United Patent Court (because doing so requires a referendum in Ireland). More seriously, it is one of the slowest countries in Europe to grant access to new medicines. This does not create a legal hazard for patent holders but it does weaken the country’s moral and public relations case, especially because Ireland’s delays are partly the result of policies that favour inefficient national generic producers.

Impact of IP threats

Weakening intellectual property may offer short-term improvements in access, but has many long-term risks.

Generics from India, in particular, are associated with much higher risks to patients than medicines produced in Europe, Israel, Jordan or North America. We don’t yet know enough about generics from China.

It is intellectual property that powers innovation. Developing new drugs is a high-risk, costly endeavour, often requiring billions of dollars and over a decade of research. Strong IP protections, such as patents, allow companies to recoup these investments by granting them exclusive rights to market their products for a defined period. This exclusivity ensures that innovators can profit from their discoveries without immediate competition from generics or imitators. Strong IP frameworks also encourage partnerships between pharmaceutical companies, universities, and research institutions and enable the sharing of expertise and resources, accelerating the development of new treatments while safeguarding proprietary knowledge.

What can companies do?

The evolving global trade outlook is changing by the day, and sometimes by the hour, so it is important to have one or more internal task forces with public affairs experts and consultants in China, India and Latin American markets with some similar dynamics — Brazil, Colombia and Mexico, in particular. Having an internal and an external perspective with clear lines of communication with expert advisors is very important in our current trade climate because different people know different things in fast-changing scenarios. There needs to be a different task force in Ireland, a country that will likely come under unaccustomed scrutiny.

Access planning may be the best mitigation for many of the risks. It is important in India for obvious reasons. It may be important in other countries as part of a response for moves by generic producers elsewhere.

Communication with policymakers and influencers matters more than ever. Policy responses will happen in a far more condensed time frame than they usually do. Having open channels may make all the difference, as well as having a tested protocol in place that allows companies to rapidly distinguish and mitigate misinformation before it influences policy direction. There are many consultancies and advisers with expertise, but it is important to include ones who have worked on intellectual property as well as trade.

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Filippo Maria Stefania of Generali thought consent would always be needed, but it would become a cultural norm. “A decade ago, if you took a picture of your main course in a restaurant, the owner would come out to ask what was wrong,” he said. Agreeing to share health data with insurers and providers will be part of an overall move toward individuals taking more responsibility for their health. That cultural shift will be supported by incentives, discounts, and nudges based on behavioral economics.

The technology is ready. Inge Thijs, a remote clinical monitoring coordinator, explained that a hybrid care system is already in place for heart failure patients in northwestern Belgium. They tend to have repeat admittances to the hospital. Health professionals can intervene before hospital care is needed by tracking measurements such as the build-up of fluids. This not only improves patient outcomes but also reduces the financial burden on the healthcare system. Belgium has a new pathway for reimbursement of M Health, and one of the first areas to be considered was heart failure.

The same technology can be used for rehabilitation after major surgery, reducing hospital stays while improving outcomes — data clearly show that patients recover better at home.

Elie Lobel, the CEO of RDS, a company that develops biosensor technology that can be worn comfortably at home, said that just discharging patients a day or two early can make an enormous difference to hospitals’ viability. Most hospitals in Europe are paid for the procedure performed, not the days spent in the hospital, and most have waiting lists. Discharging each patient even a little earlier will control costs and improve access.

Technology may also make prevention more cost-effective and better targeted, said Todor Jeliaskov, the CEO of In Heart. At the moment, for example, most implanted defibrillators – designed to restore the regular rhythm of the heart after an abnormal heartbeat – are never used. Large data sets may predict who should receive them better than current clinical guidelines can. Those same data sets may be able to target patients most at risk for a blood clot in the heart; these clots cause about a third of strokes, many of which can be prevented by medicines if health systems can identify who needs treatment.

This progress depends not just on wearables and sensors to collect data but on massive computational power to detect patterns unrelated to the disease. Some of these digital biomarkers will seem improbable: in multiple sclerosis, for example, symptoms of depression are predictive of a disease flare-up. It may well be that speech patterns or subtle shifts in activity can warn of cardiovascular problems. Risk factors may be synergistic, too, Dr Nathan Malka said. As a cardiologist, he could never accumulate the data to see which risk factors might augment others, but quantum computer power can unveil these patterns.

Remember the human factor, cautions care coordinator Inge Thijs. The same patients reluctant to come to clinics in hospitals are resistant to home rehabilitation monitoring and help. The technology will require health professionals who can turn its findings into advice that patients will follow. This transition may not be easy, and it’s important to acknowledge and address these concerns to ensure a smooth integration of digital monitoring in healthcare.

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The global population is ageing. This has long been a trend in Western nations. However, many developing countries are now witnessing a similar societal shift. This will profoundly affect our economic well-being (as I wrote about here) and security and cohesion (as I wrote about here) unless countries focus much more on the health of older people. Health systems must adapt to this new reality, or we will all face dire health and economic burdens in the future.

Adult vaccination is a key area where we are simply not keeping up with shifting dynamics. Pneumococcal disease is a prominent example. Pneumococcal disease is a name for any infection caused by bacteria called Streptococcus pneumoniae, or pneumococcus. Pneumococcal infections can range from ear and sinus infections to pneumonia, meningitis and bloodstream infections[1].

We have made great strides when it comes to pneumococcal disease prevention. However, there is a lot of work that needs to be done to improve protection through vaccination, most prominently among the adult population.

Paediatric pneumococcal vaccination had been introduced in 155 WHO Member States by the end of 2022. Though coverage rates vary considerably by region, the global third dose coverage was estimated at 60%[2]. This is contrasted sharply by the situation regarding adult vaccination. Despite WHO recommendations, only 31 countries currently include adults in the pneumococcal vaccination schedule. Coverage rates are often lacking in countries with a programme in place, and the implementation is suboptimal.

It has been estimated that between 2004 and 2040, the economic burden of pneumococcal pneumonia will increase by US $2.5 billion per year[3]. A global burden of disease study on lower respiratory tract infections (LRTIs) indicated that in 2016, a total of 2,377,697 deaths occurred from LRTIs in people of all ages. Of these, close to half, or 1,080,958 deaths, occurred in adults over 70 years of age[4]. Streptococcus pneumoniae was the leading cause of LRTI morbidity and mortality globally, causing more deaths than all other etiologies combined in 2016. As the population ages, the at-risk group is increasing. Despite nearly half of current deaths already being associated with older adults, adult pneumococcal vaccination remains a low priority for policy makers in most countries. This is a major mistake.

Health system recommendations are not the only issue. Perceptions and visibility of the pneumococcal vaccine also limit uptake where they are available. One assessment suggests that the two most cost-effective adult vaccines are flu and pneumococcal[5], but the pneumococcal vaccine uptake is much lower. A survey conducted by the International Longevity Centre (ILC)[6] found that in adults over 50 across a number of European countries, 94% had heard of the flu and COVID-19 vaccines. Still, only 42% had heard about the pneumococcal vaccine. This lack of knowledge translated directly into uptake rates. Flu vaccine uptake was 59%, 85% got the COVID-19 vaccine, while only 18% got the pneumococcal vaccine. “We know that knowledge is a key driver for vaccination…when people aren’t aware a vaccine exists, they won’t get it,” said Arunima Himawan, Senior Health Research Lead, ILC, UK.

Need for policy prioritisation and igniting longer-term thinking amongst decision-makers

Scientists working in the field of pneumococcal disease and immunisation feel that a key challenge is convincing policymakers to implement strategies within their five-year election cycles. This focus on reelection often favours spending on the immediate and the concrete rather than on prevention policies which will pay off over decades.

“Now, how can we make the same argument for adults? I think the argument is beginning to emerge in the concept of healthy ageing and living, and there are dividends in this. Healthier populations result in higher economic productivity and more societal cohesion. I think these are the things we need to be framing to policymakers,” said Dr Sipho Dlamini of the University of Cape Town, South Africa.

Policymakers make the same errors in value calculation over and over again. Officials calculate value in the short term without looking at the associated costs. The narrative must shift from thinking of pneumococcal vaccination as just preventing hospitalisations directly from the illness.

Many of the longer-term effects of pneumococcal infection are delayed and masked. Myocardial infarction risk is significantly elevated following a bout of pneumococcal infection[7]; however, due to the delay or a focus on the immediate issue of the myocardial infarction, the diagnosis of the infection may not occur. Without clear visibility of an issue, and a lack of data, there is no immediate political incentive to address it.

The relationship between viral and bacterial infections is another matter that must be highlighted. In many instances, a viral infection may be an instigator of a secondary infection from a bacterial pathogen.

Antimicrobial resistance (AMR) brings enormous costs — even in 2013, the US Centers for Disease Control and Prevention estimated that antimicrobial resistance added $20 billion to direct healthcare costs in the United States alone and a further $35 billion in loss of productivity annually. Vaccines reduce antibiotic use and this slows AMR, especially in life-threatening illnesses such as pneumonia where clinicians are reluctant to postpone treatment until lab results on bacterial susceptibility are available.

If a policymaker wishes to implement longer-term strategies, they must be reelected. It is vital, therefore, to have evidence-based information available to them. To justify the immediate expense of vaccination campaigns, they also need immediate rewards that alert the electorate or their superiors to their far-sighted decision-making. This might come from social media posts or press events with heads of NGOs and professional societies or through recognition in international comparisons.

Productivity as an incentive for vaccination

Productivity may be a critical narrative focus for adult immunisation. Politicians, in the face of an ageing society, are more interested in getting older people to stay in work.Employers may fund vaccination too to keep an older workforce engaged and productive.

Population demographics across the globe are aligning to effectively make it a necessity for adults to work into older ages. The world’s median age has been projected to increase from 31 to 36 by 2050. Europe is projected to have the oldest median age, at 47 years[8]. A considerable, and ever-increasing proportion of the population will fall into the over-65 category. Keeping these individuals healthy and productive will be essential to the economy.

Businesses must also be persuaded of the merits of adult vaccination, as they both directly benefit from them, and can also be one of the most powerful advocates for changes in government policy. “The reason that Rotary was so successful in their polio campaign was that they had so many business leaders there who could influence governments and had access,” said Michael Moore, former member of the ACT Legislative Assembly of Australia and Former District Governor, Rotary.

Younger workers also benefit, as they will not be taking time off work to care for their older family members.

Delivering the data to policymakers

A very small proportion of health budgets is earmarked for preventative health, and less specifically for immunisation and even less for adult immunisation. According to ILC UK, if preventative health spending increases by just 0.1% of GDP, it could unlock a 9% increase in annual spending by people aged 60 plus and an additional 10 hours of volunteering[9].

Data may not be enough; we need charismatic individuals. Australia is a clear example of the benefits of having a champion to rally around. Professor Ian Fraser, one of the inventors of the HPV vaccine, had a significant impact on the uptake of the vaccine by the government and was named Australian of the Year. Having a well-known, trusted advocate can be invaluable in providing policymakers with support.

Clear messaging, confidence, and convenience

Often unclear messaging permeates where vaccines are available, and this can have an impact on coverage rates. South Africa has provided a case study on how to address this. A group from a number of medical disciplines met with the aim of producing a simple-to-use guide. “The idea is that you produce a one-stop document. So any clinician anywhere, whether it be a GP or other specialist can say, I’ve got a haematology patient, how should I give vaccination? And the document is there.” said Dr Sipho Dlamini. This massively simplified the process and allowed for standardisation, overall improving access. It also meant that cardiologist, rheumatologists, diabetologists and others could be reassured that their own colleagues had endorsed the guidelines.

Confidence and awareness play important roles in the acceptance of vaccination. However, convenience is a factor that is often overlooked. “Older adults may need to rely on their children and their schedules to be able to take them to get the vaccines. That can make a very big difference,” said Lois Privor Dumm, Johns Hopkins Bloomberg School of Public Health.

A documented success story is the availability of vaccines through pharmacies. Pharmacists are a well-trusted source, but they’re also convenient, and many people are used to going to their pharmacy much more regularly than a general practitioner.

If we are to convince both policymakers and the public that adult vaccination for illnesses such as pneumococcal disease is a necessity, the narrative must shift. The health of older adults has an impact on the entire community. Vaccination has a significant positive economic impact on the productivity of older adults, the people who are taking care of older adults and the people who rely on older adults for childcare. Much like childhood vaccination, life course immunisation is an investment opportunity that will pay dividends for years to come and improve the health of the population.

[1]https://www.cdc.gov/pneumococcal/index.html#:~:text=Pneumococcal%20%5Bnoo%2Dmuh%2DKOK,to%20help%20prevent%20pneumococcal%20disease.

[2] WHO Immunization Coverage https://www.who.int/news-room/fact-sheets/detail/immunization-coverage

[3] Wroe PC, Finkelstein JA, Ray GT, et al. Aging population and future burden of pneumococcal pneumonia in the United States. J Infect Dis. 2012;205(10):1589–1592. doi: 10.1093/infdis/jis240

[4] Anderson R, Feldman C. The Global Burden of Community-Acquired Pneumonia in Adults, Encompassing Invasive Pneumococcal Disease and the Prevalence of Its Associated Cardiovascular Events, with a Focus on Pneumolysin and Macrolide Antibiotics in Pathogenesis and Therapy. Int J Mol Sci. 2023 Jul 3;24(13):11038. doi: 10.3390/ijms241311038. PMID: 37446214; PMCID: PMC10341596.

[5] Leidner AJ, Murthy N, Chesson HW, Biggerstaff M, Stoecker C, Harris AM, Acosta A, Dooling K, Bridges CB. Cost-effectiveness of adult vaccinations: A systematic review. Vaccine. 2019 Jan 7;37(2):226–234. doi: 10.1016/j.vaccine.2018.11.056. Epub 2018 Dec 4. PMID: 30527660; PMCID: PMC6545890.

[6] https://ilcuk.org.uk/european-pneumococcal-vaccination-a-progress-report/

[7] Ohland, J., Warren-Gash, C., Blackburn, R., Mølbak, K., Valentiner-Branth, P., Nielsen, J., & Emborg, D. (2020). Acute myocardial infarctions and stroke triggered by laboratory-confirmed respiratory infections in Denmark, 2010 to 2016. Eurosurveillance, 25(17). https://doi.org/10.2807/1560-7917.ES.2020.25.17.1900199

[8] https://www.imf.org/en/Publications/fandd/issues/2020/03/infographic-global-population-trends-picture

[9] https://ilcuk.org.uk/major-conditions-strategy-time-to-act-on-prevention/

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Three Ways to Adapt

We might get very lucky: artificial intelligence might take over a higher proportion of all work as the labour force shrinks and as lots of old people need more and more services. We might, but that is not what has happened in any previous technological revolution, as I explain below. AI may, though, solve the only problem that policymakers do worry much about: health could become more affordable.

There are only a few large areas of the world where the number of births is still well above two per couple. The young from those areas may need to move to places where many couples are having one child or none. Indeed, there may be a global competition for increasingly rare youth resources. It will require a radical shift in thinking about culture.

Neither of these mitigation approaches will be smooth or easy, so we need now to be focussed on making every child we have as healthy and productive as she can be. We also need to think about how to keep the disenchanted elderly at work: they are mostly able to work for longer but prefer racking up debts for the next generation while they enjoy an unsustainably long retirement.

The ageing world will soon come to dominate discussions about who pays what for health and much else. Those who think about it now will be best able to respond to the panic when it comes.

How we got here

Over the past fifty years, we have worried too much about overpopulation and not enough about shifting dynamics.

Fear of the consequences of overpopulation dates back at least to the Reverend Thomas Malthus, who started to publish his theories in 1798. Malthus argued that, however much technological progress might improve supply, exponential population growth would eventually exhaust the world’s resources. Scholars still argue about where he was right and where he was wrong, but he certainly did not foresee our current reality of few children.

The big error in Malthus’s thinking was that population growth would be exponential until crises caused it to plunge. Malthus was thinking mostly about famine;  Neo-Malthusians later pointed to an ecological collapse.  In the second part of the last century, the rise in the world’s population looked terrifying. The Earth’s population was estimated at three billion in 1960; by 1975, it was four billion; by 1987, it was five billion.  Today, it is eight billion, and the UN estimates that it will peak in 2086 at about 10.4 billion (another reputable forecast has a lower and earlier peak). That bolus of people in the second part of the twentieth century is the reason we now have such a rapid shift in the average age on the planet. When I first started working in the field in the late 1980s, some still thought Malthus might have had a point and that the spurt might be a long-term trajectory.

The shortcomings in Malthus’s reasoning were obvious, albeit in hindsight. Europe’s population growth was long over, and its pattern would be replicated in most of the world. The most charismatic of those who explained the process was Hans Rosling, a professor of international health at the Karolinska Institute in Sweden. Rosling’s key theory was mainstream, but he explained it much better than most demographers. (I can’t begin to do justice to his genius as a communicator – have a look). “Only by raising the living standards of the poorest can we check population growth,” he said. Specifically, child survival was key to lowering the number of children that each couple decided to have. As parents see their children surviving and as women gain access to economic opportunities, population growth screeches to a halt. Rosling’s powers of persuasion about the ties between survival and a lower birth rate were a large part of what got Bill and Melinda Gates to focus so relentlessly on child health.

For the great self-regulating mechanism to work, couples, especially women, need to have the ability to make their own choices about how many children to have and when –  a choice about fertility is also a fundamental human right for women. That means access to a range of family planning methods. A coalition of the fanatical, the misguided, and the evil have worked tirelessly since the 1950s to stop women from being able to make choices about their fertility.

The extraordinary sight of Vatican officials plotting with fundamentalist Islamists, African dictators and deluded radical feminists was, for me, the most abiding memory of the 1994 Cairo International Conference on Population and Development. (The Vatican thought its sincerely held beliefs should be imposed by law. The radical Islamists thought something similar. The dictators convinced themselves that large, poor, unhealthy populations would be a route to power. I never understood what possessed the radical feminists into believing that unplanned pregnancies would advance the rights of women)

Had the advocates of universal access to voluntary family planning won the day, hundreds of millions of women would have led better, happier lives and more children would have reached their potential in a manner that was often impossible in families too big for parents to support. Then and since, international efforts have had only limited success in meeting the gaps in family planning services

Had they done better, the global population would peak at a lower level, the demographic cliff edge would be less shear, and the climate crisis would be less severe. A decade ago, we worked with the Hewlett Foundation to promote policies based on voluntary family planning as one of the most cost-effective ways to mitigate climate change. I don’t think I have ever been so vilified or ostracised (and I was the head of communications for an AIDS charity in 1983!) No one was suggesting that women be forced to have fewer children, but that is how the debate was often heard.

The Cairo conference, those Hewlett-funded researchers and others working for women’s reproductive human rights have lived in the shadow of China’s coercive family planning policies and the short-lived attempts of Mrs Indira Gandhi and her son to bring those policies to India in the late 1970s.

I escorted a group of Western journalists to China in the mid-1990s as part of a Rockefeller Foundation-funded project on reporting population issues. The reporters asked about punishments, fines and forced abortions for women who had more than one child. Our hosts at the State Family Planning Commission told us, “You have misunderstood. The state is happy to provide all health, education and food to the first child; families are simply asked to contribute to the costs of further children.” The officials were lying.

The draconian one-child policy brought China’s population growth down very fast, but it entailed massive social pressure and frequent abusive treatment of couples who tried to have second or, heaven forbid, third children. Fines, exile to rural areas and even forced abortions were common as overzealous local officials tried to meet national targets. It has also left China with a plummeting number of people entering the workforce in the years ahead.

We find ourselves in a world of extremes: some women are still forced to have more children than they want, while it is only in the past few years that most Chinese women have had the freedom to have larger families. Booming economies have led to falls as fast as China’s in countries with no hint of coercion. The net effect will be a fundamentally unbalanced world.

If each couple has, on average, 2.1 children, the population will remain stable. Globally, couples had 2.3 children on average in 2022. Both India (2.0) and China (1.2) are below the replacement level, as is most of Europe and all of North America. The native-born population is falling precipitously in countries and regions including the Canary Islands (0.98), Hong Kong (0.8), Italy (1.3), Japan (1.3), the Republic of Korea (0.9), Singapore (1.0) and Ukraine (1.3). Countries such as Hungary and Russia have introduced policies of social pressure and incentives to boost the birth rate, with limited success, as both are still well below the replacement level. Countries with high immigration do better in the short term, but the immigrants seem soon to conform to the fertility patterns of the native-born.

Nineteen of the 20 countries with the highest birth rates are in Africa (the exception is Afghanistan). Several countries in West Africa face very fast-growing populations: couples in Niger, for example, still have 6.7 children per couple. Even well-organised and relatively prosperous Senegal still has a total fertility rate of 4.3. Most of the countries with high population growth, though, are very troubled: the Central African Republic, Chad and Somalia, for example.

By 2100, one estimate suggests that China’s population will have fallen from 1.4 billion to 732 million; South Korea’s population will have halved. Nigeria will have risen from 206 million people to 791 million. Nigeria, already densely populated, cannot support 800 million people; China probably cannot function with 700 million; South Korea, almost certainly, cannot support itself with 24 million. By then, over a quarter of the world’s population will be aged over 65.

This older world will need help. The two most likely external sources are artificial intelligence taking the place of many human workers and immigrants taking the place of ageing ones. Help from within will involve making the most of all of the human resources in mature economies.

Can AI save Europe, China and Korea?

“You should worry more about the clerical, white-collar jobs than the physical [jobs]. A large number of them will get replaced. So the question is: ‘What jobs do you create to replace those?’” said IBM’s chairman and chief executive Arvind Krishna at the World Economic Forum in 2023. Respectfully, I don’t think he needs to worry

The Industrial Revolution, which began in England at the end of the eighteenth century, brought a massive shift from an economy centred on production in family units to a system based on salaries and factories. Blacksmiths and seamstresses did badly, but most became mechanics or machine operatives; some earned less, but many earned more. Many had to move to new regions. The Industrial Revolution happened alongside a steady rise in population, but there appears to have been little long-term mass unemployment.

Imagine the reaction if you had told someone in the 1950s that there would soon be very few ledger clerks, shorthand typists or local bank managers, but there would be lots of personal trainers, baristas and app developers.

The history of technological breakthroughs is that new jobs and needs replace those that are lost. Out-of-work lawyers will find jobs we haven’t imagined yet. So we can’t rely on AI to make up for Korea’s 50 per cent drop in population.

There is likely to be one particularly important reshuffling of work. “When you get to medical school, all the complex math concepts, physics, and organic chemistry goes out the window. If there was one way to explain medical school, it was rote memorization.” wrote Kevin Jubbal, MD in 2016. These recall and matching skills are exactly the ones that AI will make redundant. AI has already been shown to be better than British GPs at diagnosing and treating bacterial infections and better than Indian health professionals at spotting early-stage leprosy. AI is better than pubic health doctors at predicting which populations are at high risk of heart disease and better than many oncologists at predicting which cancer patients will have a recurrence. A wholly autonomous surgery robot outperformed American human surgeons in suturing as early as 2016.

Soon, AI will be better at almost everything doctors do other than talking to patients, and most doctors are not nearly as good at that as nurses. The average American physician earned about $350,000 per year in 2022. Hospital and clinic services account for about 60% of US healthcare spending (while prescription medicines account for about 11%). We will still need hospitals, but they will be much cheaper to staff and run.

Technologies and medicines should become more expensive as the research required becomes more intensive, but AI may come to the rescue there too, with more efficient identification of targets and treatments and with more intelligent patient selection. Healthcare is likely to get much more affordable in the AI era

What About the Workers?

The shortage of workers will be exacerbated because each of us expects to work less and less.

Most of us are working many fewer hours than we used to and for a smaller proportion of our lives. In 1870, the average German worked 3,285 hours per year (yes, that’s about 63 hours a week for every week of the year); in 2017, she worked 1,354 hours. Americans had less of a decline – from 3,096 to 1,757 hours.  We also have much longer retirements: in 1870, there was no paid retirement for most (the first state payments for older people were introduced in Germany in 1889). By 1950, Americans received social security at age 65; by 2020, it was by 66. Average American life expectancy in 1950 was just over 68; by 2020, it was over 79 years.

The trend has accelerated since COVID. Many late fifty-somethings seem to have tried retirement and liked it; others are less able to work because of long waiting lists for hospital treatment or because they are worried about lack of care should they contract COVID. In the United Kingdom in 2022, there were almost 400,000 more economically inactive adults aged 50 to 64 years than in the pre-pandemic period (out of a total population in that age group of about 11 million). 

The closest historical parallel to fewer workers and shorter working lives may be the black death in Europe and West Asia in the fourteenth century. Between 30 and 50 per cent of the population died in wave after wave of the bubonic plague – over about the same period that Korea’s population will halve. The remaining workers soon realised the power that they had. It was the beginning of the end of feudal servitude in many places. Despite the best efforts of governments, answering to their rich patrons, wages rose and working conditions improved dramatically. The precedent is bad news for some major retailers and a delivery company that we won’t name because I don’t want my packages to start disappearing..

In the fifteenth century, education became more common and access to healthcare did seem to increase in most places, although it’s far from clear that was a good thing – bleeding and cupping probably did little for productivity. Today, we have the means to make much better use of the people we have, whatever jobs they end up doing.

Health is heavily determined early in life. Over the past twenty years, we have made remarkable progress in preventing diseases of childhood that can impair for life the children who survive them. Some of that progress is now being lost to Luddite anti-vaxxers whose malign influence is reaching from North America and Europe to Africa and Asia, and because of irrational constraints on access to care – infant deaths actually rose in the United States in 2022. Every human life has inherent value, but every child now has unprecedented economic value. We should be spending much more on their health. As societies, we must also find effective ways to stigmatise and marginalise the, often well-educated and persuasive, fantasists who look back with nostalgia to stone-age societies where people in their thirties were considered unusual survivors.

Older people have to work longer. This is not simple: witness the riots in Paris occasioned by the suggestion that the retirement age should rise very gradually. Older people are much more likely to vote than younger ones, so politicians listen to them. And, except for the political élite, most of the old seem not to want to work into their seventies.

The British Office of National Statistics looked at why those over 50 did not come back to work after COVID. Many of those findings can guide broader policies on keeping the mature productive.

Around one in five of the non-returners said they were waiting for medical treatment; this rose to 35% for those who left their previous job for a health-related condition. The UK health system is particularly dysfunctional but this statistic hints at a much more important economic issue: there is a longevity dividend if we keep older people healthy. As the International Longevity Centre UK has shown in an impressive and fascinating series of reports, “We know that countries that invest more in health see more people working, spending and volunteering and that investment in prevention drives a return. Spending just 0.1 percentage points more on preventative health can unlock an additional 9% in spending by older consumers and an average of 10 additional hours of volunteering across the G20.” (Here is a link to the India report. Those for other countries are on the same website. Here’s a link to something I wrote on the subject in 2022)

Healthy older people do not just work, they spend. Across the G20, which contains many emerging economies with young populations, 56% of total spending in 2015 came from families over 50.

For all the British over 50s, those who had left work and those who had stayed, flexible working and reasonable adaptation were key to staying employed. Those in their seventies probably do not want to work 40 hours a week; they might well want to work for 15, though. Does the job description for a 20-year-old shelf stacker have to be the same as that for a 75-year-old? Probably not, although age may not be the only reason to customise job requirements: in a time where people are scarce and AI is pervasive, maybe every job requirement should be tailored to the health, interests, capabilities and aspirations of every individual.

Among those currently in work, active employer support seemed an important factor in their decision to stay. Again, AI means that this will not require tripling the HR department.

We should note a few paradoxes in the British data that don’t seem wholly idiosyncratic. Those aged 50 to 59 were more than twice as likely to report mental health problems and disability issues as those aged 60 to 69. Part of that is because some of those in their sixties were going to retire anyway, but part is probably culture.  As someone who grew up in the 1960s and 70s, I know the downsides of a “just get on with it” attitude to pain and distress, but maybe we’ve gone too far in the opposite direction.

Big institutional employers seem to do a much better job of supporting older workers than hospitality or personal services firms. This is counter-intuitive. It should be much easier to have flexible, adapted work patterns in a hair salon than in a local authority. Maybe smaller employers are too worried about inadvertently breaking rules on age discrimination or creating grounds for action by an employee who feels disadvantaged. If so, this should be relatively easy to fix.

The Populist Nightmare

We can keep people employed more flexibly and longer but most societies will need workers and some Africans, especially West Africans, are not going to be able to survive in their home countries. Africans will need to migrate, and the rest of the world will thank them.

My undergraduate degree comes from an Alabama university that was, at the time, the late Governor George Wallace’s pet project (Governor Wallace is the one who barred the entrance to a university to stop the first Black student from coming in and set police dogs on civil rights marchers). Our required reading didn’t quite parallel Harvard’s. In political science, we were assigned Jean Raspail’s racist dystopia, The Camp of Saints. In it, Indians set sail for Europe and seized it – at the time, the scare was about birth rates in India. Africans from the north invade apartheid South Africa, and the Chinese invade Russia. Although it was first published in 1973, the book has had a surprisingly long-lived popularity, with Steve Bannon and Viktor Orbán among its fans. It is the inspiration for many populist memes about the demise of Western civilisation.

Among the book’s many flaws is the idea that Europe has always been stable, white and homogenous. Roman emperors were often North Africans or Middle Easterners. This is, in fact, the longest period in recorded European history in which Western Europe has been at peace. The last mass movement of millions of Europeans happened in living memory when ethnic Germans fled large sections of Eastern Europe after the Second World War. North America is even more turbulent, and the conflict over its transition from Native American (actually, mostly invaders from Siberia) to European and African was still going on at the end of the nineteenth century. For most of history, wars were the main business of states; invasions and enslavement were the main way of sorting out population imbalances.

Raspail is dead, so I’ll risk saying it: there aren’t really many, if any, French people. In Roman times, France was inhabited largely by Celtic tribes who were displaced and assimilated by invaders from the East. The Bretons are Cornish people, displaced by the Saxon invasions of the British Isles. The “Normans” who conquered England were actually Vikings who had come to France only decades before – the same Vikings went on to conquer swathes of Europe: the Kingdom of Sicily was largely run by blond, blue-eyed courtiers.

Even Raspail’s adherents aren’t actually “European”: Orbán’s ancestors arrived in Hungary from central Asia about 1500 years ago. I’ll spare you the rest of the history lesson; the point is that people have always moved to find land, jobs or simply new vistas.

People are moving, and more will move. We may be competing for them to come. The likelihood is AI will not create pools of the unemployed; in most of the world, the population will shrink and age very fast; and we will mostly decline to do what our ancestors did and work until two or three years before we die. Only Africa will have the people we need to staff our security forces, our care homes, our leisure industries and everything else that machines cannot do. Now, we have to figure out how to make this reality as welcome as it should be.

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In October of 1983, I was in my fourth month as the first communications director of the Gay Men’s Health Crisis (GMHC) in New York. If we weren’t then, we would soon be the largest AIDS service organization in the United States. I had been in New York for less than a year, working on morning drive at a news and talk radio station. Fresh from years in Alabama and Georgia, my naÏvety knew no bounds.

For us, then, AIDS was an emergency. We thought we were fundraising and counselling and managing politicians to get past a crisis. It soon became clear that the numbers were vast and the crisis would become a fact of life and death for affected communities across the world. More chilling still, AIDS had been present in humans since the early part of the twentieth century but, because only Africans were dying, no-one had even noticed.  

By October of 2023, the twin miracles of pharmaceutical discovery and global political will had turned HIV into a manageable chronic condition, but I had become much more world weary about the crisis ever concluding.  I moderated a panel that month at the World Health Summit in Berlin and left it thinking that the world really could achieve the UNAIDS goal of ending AIDS as a public health threat by 2030. 

The triumph of hope

“Sixteen years ago, I landed in Lilongwe and, on the way from the airport, there were roads full of coffin makers… I’ve been back and I’ve seen what happens when there is a commitment of resources and the will to fight AIDS,” Dr Mamadi Yilla, the Deputy Global AIDS Coordinator for Multisector Relations at the U.S. Department of State, told the panel. My moment of hopelessness came standing on the Thai – Burmese border sometime around the turn of the century and wondering how people caught up in fighting, without reliable access to primary care could ever be treated with the new highly active antiretroviral therapies.

Despite the coffins and the insurrections, we are within grasp of the current 90-90-90 global targets: ninety percent of those infected knowing their status, 90 percent of them on treatment and 90 percent of them with undetectable viral load. “Being hopeful is what has carried us through the last 30 years,” said another panel member, Christine Stegling, the Deputy Executive Director for Policy at UNAIDS. It was naïve and almost foolish hope but it changed the world

To understand how vast the accomplishment is, appreciate that minimal success in HIV is defined as 90 percent being on treatment effective enough to remove any trace of the virus; in Europeans being treated for hypertension, at least 40% do not control their high blood pressure. Those Europeans have no stigma, no supply chain interruptions, no systemic lack of primary care and very few side effects, yet they are four times as likely as a typical African with HIV to be incapable of controlling their life-threatening illness

We will need more resources and more political will to reach the remaining ten percent. The technological innovations coming will be especially important in the areas where the challenges are toughest. “The places that we’re getting to late are the ones with the most need,” said panellist Janet Dorling, Senior Vice President, Intercontinental Region and Global Patient Solutions at Gilead.  “They’re often the ones with the most people at the most risk…But with partnerships we can do things differently,” she added. 

About 4,900 women a week are still contracting HIV and 4,000 of those are in Africa, Dorling said. Reaching them is complicated by the baked-in inequity around women’s access to healthcare in Africa, panellist Florence Riako Anam said. She is the co-Executive Director of the Global Network of People Living with HIV – GNP+. 

Five countries are on track to remove AIDS as a public health threat by 2030, while 16 more are almost there, Stegling reported. The disproportionate share of national and donor resources required to achieve 100-100-100 goals should, I think, be seen as justified. “Everything about the HIV response is a model. This HIV response has taught us about how we serve vulnerable people whatever the threat impacting them” Yilla said

The incredible world waiting for us

The key role in reaching the end of AIDS as a threat will come from people living with it. “The ultimate goal for us is to be undetectable [have an undetectable amount of the virus in the bloodstream] because we will live long healthy lives… but also because the science tells us that if we’re undetectable, there’s zero risk of transmission… We must now use the confidence of the science to shift how we talk about HIV,” Riako Anam said. 

Science and innovation will be vital too. One innovation, Stegling said, tends to become transiently fashionable – the focus of all attention – while others are neglected, often those for women. Then the pack moves on.  “They take one thing and bold it, while forgetting everything else,” Riako Anam agreed. 

Innovation can not only prevent infections and improve quality of life; “innovation can help combat barriers and inequity,” Dorling said, but cautioned that it had to be innovation centred on those living with or vulnerable to HIV. Without transformative, multi-sector partnerships, the panellists concluded, new technologies and approaches would still come to Africa a decade late.

Scientific progress means that there is “an incredible world waiting for us”, Yilla said. Digital practitioners in Lusaka are already using telemedicine to deliver expert care through remote clinics. Digital technologies and AI could transform many aspects of care, she thought. But, she added, that progress in discovery had to be accompanied by progress in policy. Several panellists discussed a wave of bad policies on issues such as criminalising same-sex partnerships and any sexual relationships at all for people living with HIV and AIDS. “Bad policy will undermine the gains we have made in HIV,” Stegling warned. 

There is “a growing global numbness to pain,”  Riako Anam said. It is made worse by those too young or too forgetful to remember how things were twenty years ago in the boom time for coffin makers. “There is a whole generation who don’t know what 2003 was like and some of these people are making decisions,” she added. “They don’t remember what people with HIV looked like then.”

I remember clearly the skeletal, lesion-covered bodies of the early years of the epidemic. I also remember the hopelessness that set in as the scale of the epidemic became clear. This panel reminded me that I have, throughout the forty years since, underestimated the power of hopeful people to change the world. The threat is now almost over. 

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