Global Health Commissions

The health and wellbeing of children now and in the future depends on overcoming new challenges that are escalating at such speed as to threaten the progress and successes of the past two decades in child health. The climate emergency is rapidly undermining the future survival of all species, and the likelihood of a world in which all children enjoy their right to health appears increasingly out of reach. A second existential threat that is more insidious has emerged: predatory commercial exploitation that is encouraging harmful and addictive activities that are extremely deleterious to young people’s health.

After more than a decade of major achievements, the AIDS response is at a crucial juncture, both in terms of its immediate trajectory and its sustainability, as well as its place in the new global health and development agendas. In May, 2013, the UNAIDS–Lancet Commission—a diverse group of experts in HIV, health, and development, young people, people living with HIV and affected communities, activists, and political leaders— was established to investigate how the AIDS response could evolve in a new era of sustainable development.

Sexual and reproductive health and rights (SRHR) are essential for sustainable development because of their links to gender equality and women’s wellbeing, their impact on maternal, newborn, child, and adolescent health, and their roles in shaping future economic development and environmental sustainability. Yet progress towards fulfilling SRHR for all has been stymied because of weak political commitment, inadequate resources, persistent discrimination against women and girls, and an unwillingness to address issues related to sexuality openly and comprehensively. As a result, almost all of the 4·3 billion people of reproductive age worldwide will have inadequate sexual and reproductive health services over the course of their lives.

Viral hepatitis is a major threat to public health and a leading cause of death worldwide. Each year, viral hepatitis kills 1.34 million people, which is comparable with deaths due to HIV/AIDS, malaria, and tuberculosis. With the advent of highly effective prevention measures and treatments, global elimination of viral hepatitis is a realistic goal; all WHO member states have committed to a global reduction in hepatitis-related deaths by 65% and new infections by 90% by 2030. This Commission sets out to appraise the current global situation and to identify priorities—for countries, regions, and globally—to accelerate efforts towards these ambitious targets.

Liver disease in the UK stands out as the one glaring exception to the vast improvements made during the past 30 years in health and life expectancy for chronic disorders such as stroke, heart disease, and many cancers. Mortality rates have increased 400% since 1970, and in people younger than 65 years have risen by almost five-times. Liver disease constitutes the third commonest cause of premature death in the UK and the rate of increase of liver disease is substantially higher in the UK than other countries in western Europe. More than 1 million admissions to hospital per year are the result of alcohol-related disorders, and both the number of admissions and the increase in mortality closely parallel the rise in alcohol consumption in the UK during the past three decades.

The sustainable development goals (SDGs) have marked a new era in global development-to strive towards a healthier, fairer, and safer world by 2030. Improving the health and well-being of the world’s people is at the core of the SDGs and attaining universal health coverage is central to those health-related goals. But even in the short time since their endorsement, there are immense and growing challenges to achieving them. The global HIV/AIDS response is not immune to this changing landscape and there are signs that the response is faltering.

The lack of global access to pain relief and palliative care throughout the life cycle constitutes a global crisis, and action to close this divide between rich and poor is a moral, health, and ethical imperative. The need for palliative care and pain relief has been largely ignored. Yet, palliative care and pain relief are essential elements of universal health coverage (UHC).

The causes of antibiotic resistance are complex and include human behaviour at many levels of society; the consequences affect everybody in the world. Similarities with climate change are evident. Many efforts have been made to describe the many different facets of antibiotic resistance and the interventions needed to meet the challenge. However, coordinated action is largely absent, especially at the political level, both nationally and internationally.

Tuberculosis was declared a global emergency by WHO in 1993. Then, about a third of the world’s population was infected with the bacteria that cause tuberculosis, and the disease was responsible for an estimated 3 million deaths each year. Today, around a quarter of the world’s population has a tuberculosis infection, which causes about 1·6 million annual deaths, making it the leading infectious killer of our time. Although progress has been made in reducing the global burden of tuberculosis in the past 25 years, it has occurred at a frustratingly slow rate. Declines in tuberculosis mortality are not keeping pace with reductions in deaths from other infectious diseases of global importance such as HIV and malaria, and the world is not on track to meet targets set out in the Sustainable Development Goals and the WHO End TB Strategy.

Collectively, China, India, and Russia account for around 40% of the world's population, experience 46% of all new cancers worldwide, and account for 52% of cancer deaths globally. However, a sizeable gap exists between disease burden and the ability of these countries to afford effective control measures, and considerable sociopolitical, cultural, and environmental factors further complicate the situation. In this Commission, and in linked Comments, a multidisciplinary team of health-care professionals, policy makers, and others address the challenges to providing cancer care in these countries and identify the critical steps needed to effect change

This Commission is the first ever detailed appraisal of the role of culture in health, bringing together voices from different fields, including anthropologists, social scientists, and medics. Experts review health practices as they relate to culture, identify and assess pressing issues, and recommend lines of research that are needed to address pressing issues and emerging needs. The Commission examines three overlapping domains of culture and health: cultural competence, health inequalities, and communities of care. With reference to these domains, the Commission shows how inseparable health is from cultural perceptions of wellbeing.

The prevalence of Alzheimer’s disease (AD) and other age-related dementias is increasing dramatically with ageing populations worldwide. No treatment is yet available to halt or reverse the underlying pathology of established AD—the most common cause of dementia—and the economic and societal burdens of dementia threaten to become overwhelming as more people live into old age.

The burden of cancer is growing rapidly, and the disease is becoming a major challenge for all developed countries. This is not simply due to an increase in absolute numbers or need for optimised treatments, rather it relates to the unsustainable rate of increase in expenditure on cancer within health-care systems. What are the drivers and solutions to the so-called cancer-cost curve in developed countries? How are we going to afford to deliver high-quality and equitable care? In this Commission and the linked Comments, expert opinion from health-care professionals, policy makers, and cancer survivors has been gathered to address the barriers and solutions to delivering affordable cancer-care in high-income countries.

The number of people with diabetes in sub-Saharan Africa has increased very rapidly in the past three decades. Many people are unaware that they have the disease, leading to a high prevalence of complications and premature mortality, even in people of working age. Weak health systems in the region that are ill-prepared to treat complex chronic diseases are already struggling to cope with diabetes and other non-communicable diseases. The challenge of diabetes faced by sub-Saharan Africa is enormous, and will get rapidly worse if effective measures are not taken. 

“Practices for the management of individual patients in settings with a high tuberculosis burden are not sufficient to prevent the emergence, amplification, and spread of drug-resistant tuberculosis” is one of the key messages from The Lancet Respiratory Medicine Commission, led by Keertan Dheda from the University of Cape Town, South Africa. The Commission focuses on multidrug-resistant, extensively drug-resistant, and incurable tuberculosis, and highlights the growing burden of disease, its implications for patient management, as well as social and legal aspects. The authors also provide practical solutions for tackling emerging resistant cases—an exponentially increasing concern in high-burden countries.

Essential medicines are crucial to satisfy the priority health-care needs of the population, promote health, and achieve sustainable development.

Food systems have the potential to nurture human health and support environmental sustainability, however our current trajectories threaten both. The EAT–Lancet Commission addresses the need to feed a growing global population a healthy diet while also defining sustainable food systems that will minimise damage to our planet.   

Surgery is a fundamental modality for both curative and palliative treatment of most cancers in countries across all income settings. Yet, the global debate on cancer has mainly focused on prevention and medication, with little narrative directed towards surgery. The Lancet Oncology Commission on Global Cancer Surgery highlights cancer surgery as an integral partner in national cancer control plans as a means of addressing the overlooked role of curative surgery in cancer care. The Commission critically examines the state of global cancer surgery and the variable needs and interdependencies of surgery with other cancer treatments, such as radiotherapy. It explores the link between the needs, gaps, and opportunities and directed changes in policy to drive improvements in cancer surgery research, education, and systems of care across all income settings.

Prompted by the 20th anniversary of the 1993 World Development Report, a Lancet Commission revisited the case for investment in health and developed a new investment framework to achieve dramatic health gains by 2035. Our report has four key messages, each accompanied by opportunities for action by national governments of low-income and middle-income countries and by the international community.

Although health outcomes have improved in low-income and middle-income countries (LMICs) in the past several decades, a new reality is at hand. Changing health needs, growing public expectations, and ambitious new health goals are raising the bar for health systems to produce better health outcomes and greater social value. But staying on current trajectory will not suffice to meet these demands. What is needed are high-quality health systems that optimise health care in each given context by consistently delivering care that improves or maintains health, by being valued and trusted by all people, and by responding to changing population needs.

Nearly 3 billion people worldwide are exposed to the threat of household air pollution (HAP) every day from the use of solid fuel for cooking, heating, and lighting. HAP is a major contributor to global figures for morbidity and mortality, with major effects on respiratory symptoms and disease. This first Commission of The Lancet Respiratory Medicine discusses the toxic effects of HAP in low-income and middle-income countries, ways to measure pollution, and solutions to tackle the problem. While a linked Comment reminds readers that HAP can also occur in high-income countries.

This Lancet Group Commission advocates global reform of the care of separated children through the progressive replacement of institutional provision with safe and nurturing family-based care. It provides essential information on both the global scale of institutionalisation and its physical, social, and mental health consequences. It presents a pragmatic roadmap for carefully managed change.

A major new Commission from The Lancet and the International Society of Nephrology calls for the elimination of preventable deaths from acute kidney injury by 2025. This ambitious goal is practical and achievable according to leading medical experts. In contrast to high income countries, acute kidney injury in low and middle income countries is mainly a community-acquired disease that affects young and previously healthy individuals. Using peritoneal dialysis, acute kidney injury could be managed for as little as US$150 per patient.

Almost two-thirds of global deaths due to liver disease in 2015 occurred in the Asia-Pacific region. This Commission examines the burden of liver diseases in the Asia-Pacific region, with an in-depth review of the epidemiology and aetiology of liver disease across 11 countries and territories. Although viral hepatitis remains the most common cause of liver disease in the region, the contribution of alcohol-related liver disease and non-alcoholic fatty liver disease is rapidly increasing. The Commission concludes with suggestions for priority areas for action to tackle changing landscape of liver diseases in the Asia-Pacific region.

A Lancet Commission highlights a call from 20 professional and academic leaders for major reform in the training of doctors and other healthcare professionals for the 21st century. Changes are needed because of fragmented, outdated, and static curricula that produce ill-equipped graduates. The Commission argues for major reform across the entire medical education system, in order to produce competency-led curricula for the future.

The largest generation of adolescents and young people in human history (1·8 billion) demands more attention and action. Adolescents and young adults face unprecedented social, economic, and cultural change. The Lancet is dedicated to creating discussion around this critical topic by publishing the best research to lead to better lives for all. Adolescence is generally thought to be the healthiest time of life, and young people have therefore attracted little interest and too few resources. The 2016 Lancet Commission concluded that investing in adolescents will yield a triple benefit—today, into adulthood, and the next generation of children.

Non-communicable diseases, including cancer, are rapidly becoming the leading health-care problem in middle-income and low-income countries. In Latin America and the Caribbean, current cancer control plans vary widely between countries in this region, are largely reactionary to treating advanced cancers, and strongly favour a wealthy and educated minority. In this Commission and linked Comments, expert opinion from a multidisciplinary team of health-care professionals, policy makers, and others address the challenges to providing cancer care in this region and report on the critical steps that are required to reduce the rapidly rising human and economic burden of cancer in Latin America and the Caribbean

Psychological treatments occupy an important place in evidence-based mental health care. Now is an exciting time to fuel treatment research: a pressing demand for improvements is poised alongside new opportunities from closer links with sister scientific and clinical disciplines. The need to improve mental health treatment is great; even the best treatments do not work for everyone, treatments have not been developed for many mental disorders, and the implementation of treatments needs to address worldwide scalability. Psychological treatments have yet to benefit from numerous innovations that have occurred in science, particularly those that have emerged in the past 20 years, and arguably vice versa. This Commission, in association with mental health charity MQ, comprises ten parts that each outline an area in which an expert panel of authors sees substantial opportunity and scope for advancements that will move psychological treatments research forward.

By almost any measure, human health is better now than at any time in history. Life expectancy has soared from 47 years in 1950–1955, to 69 years in 2005–2010, and death rates in children younger than 5 years of age have decreased substantially, from 214 per thousand live births in 1950–1955, to 59 in 2005–2010. But these gains in human health have come at a high price: the degradation of nature’s ecological systems on a scale never seen in human history. A growing body of evidence shows that the health of humanity is intrinsically linked to the health of the environment, but by its actions humanity now threatens to destabilise the Earth’s key life-support systems.

Sepsis is a common and lethal syndrome: although outcomes have improved, mortality remains high. No specific anti-sepsis treatments exist; as such, management of patients relies mainly on early recognition allowing correct therapeutic measures to be started rapidly, including administration of appropriate antibiotics, source control measures when necessary, and resuscitation with intravenous fluids and vasoactive drugs when needed.

The World Health Organisation estimates that nearly one million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research.

Collaboration between The Lancet and University College London, UK, has resulted in the second UCL Lancet Commission report. The report analyses how health outcomes are part of the complexity of urban processes, drawing attention to the part that urban planning can and should play in delivering health improvements through reshaping the urban fabric of our cities.

Cancer kills more than 100,000 children each year, and yet 80% of paediatric cancers are curable with currently available interventions. Notably, the majority of these deaths occur in low‐income and middle-income countries where children have poor access to health services. It is crucial that as countries transition to universal health care, childhood cancers are recognised as a priority for inclusion in benefits packages. Yet no reliable data are available in low-income and middle-income countries on the current and future burden of childhood cancer; on cost of effective interventions; on current coverage levels for diagnostic, treatment, and care services; or on the cost, feasibility, or health and economic benefits of scaling-up effective coverage. There is an imperative for a comprehensive study to estimate the number of new cases, survival with and without treatment, the number of deaths without additional investments to scale up health services and treatment for children with cancer, and to develop an investment framework to establish an evidence-based case for investing in effective interventions to address childhood cancer.  In a new Commission from The Lancet Oncology, Rifat Atun, Carlos Rodriguez-Galindo, and colleagues provide a comprehensive analysis to develop an investment case for funding management and control of childhood cancer.

The Lancet and the American University of Beirut have together established the concept for a Commission on Syria: Health in Conflict. The aim of the Commission will be to describe, analyse and interrogate the calamity before us through the lens of health and wellbeing. With this Commission, we aim to examine five priority areas: health of people inside Syria; health of refugees and host communities; health systems, which includes the pillars of health professionals, delivery, infrastructure, and transition to rebuilding; challenges of the international response to the crisis particularly health-related international law violations and humanitarian aid design and delivery; and policy options and next steps, including those that can strengthen the role of global health in conflict and health more broadly. The Commission will develop concrete recommendations to address the unmet current and future health needs.

Collaboration between The Lancet and Imperial College London, UK, has resulted in a new Commission, which examines how medical technology should best be used to improve health in low- and middle-income countries. The report concludes that in many cases, medical technology—almost exclusively developed in rich countries—is simply inappropriate for use in poorer nations.

Decades of progress in the care of people with cystic fibrosis mean that patients are living longer, healthier lives than ever before. However, the disease continues to limit survival and quality of life in high-income countries, and many patients in low-income and middle-income countries do not have access to integrated multidisciplinary care or affordable therapies. With a growing population of adult patients, widespread genetic testing for the diagnosis of cystic fibrosis, increased recognition of patient populations of non-European descent, and the development of potentially life-changing therapies that target the underlying cause of cystic fibrosis, an unprecedented opportunity exists for improved health outcomes. The Lancet Respiratory Medicine Commission, led by Scott Bell and Felix Ratjen, reviews the latest research advances and identifies challenges and opportunities for progress in the care of patients globally.

Obesity is still increasing in prevalence in almost all countries and is an important risk factor for poor health and mortality. The current approach to obesity prevention is failing despite many piecemeal efforts, recommendations, and calls to action.  This Commission following on from two Lancet Series on obesity looks at obesity in a much wider context of common underlying societal and political drivers for malnutrition in all its forms­ and climate change. The Commission urges a radical rethink of business models, food systems, civil society involvement, and national and international governance to address The Global Syndemic of Obesity, Undernutrition, and Climate Change. A holistic effort to reorient human systems to achieve better human and planetary health is our most important and urgent challenge.

A decade on from the 2007 Lancet Series on global mental health, which sought to transform the way policy makers thought about global health, a Lancet Commission aims to seize the opportunity offered by the Sustainable Development Goals to consider future directions for global mental health. The Commission proposes that the global mental agenda should be expanded from a focus on reducing the treatment gap to improving the mental health of whole populations and reducing the global burden of mental disorders by addressing gaps in prevention and quality of care. The Commission outlines a blueprint for action to promote mental wellbeing, prevent mental health problems, and enable recovery from mental disorders.

The global burden of disease amenable to surgical intervention, such as trauma, cancer, and complications from childbirth, is substantial and growing. Despite this, there are currently gross disparities in access to safe surgical care worldwide. Surgery is an integral, indivisible component of a properly functioning health system, and all people should have access to safe, high-quality surgical and anesthesia care with financial protection when needed. The purpose of The Lancet Commission on Global Surgery is to make this vision a reality by embedding surgery within the global health agenda, catalysing political change, and defining scalable solutions for provision of quality surgical and anesthesia care for all.

For decades, pollution and its harmful effects on people’s health, the environment, and the planet have been neglected both by Governments and the international development agenda. Yet, pollution is the largest environmental cause of disease and death in the world today, responsible for an estimated 9 million premature deaths.

Leading global health and development institutions continue to view non-communicable diseases (NCDs) predominantly through the lens of epidemiological transitions, wherein NCDs are best understood in terms of ageing, urbanisation, lifestyle choices, and affluence. This narrow framing is expressed through the so-called 5 x 5 model, favoured by WHO, of five diseases (cardiovascular disease, cancer, diabetes, chronic respiratory diseases, and mental ill-health) and five risk factors (tobacco use, unhealthy diets, physical inactivity, harmful use of alcohol, and air pollution), and is enshrined in Sustainable Development Goals target 3.4 on reducing NCD mortality.

Despite large gains in health over the past few decades, the distribution of health risks worldwide remains extremely and unacceptably uneven. Although the health sector has a crucial role in addressing health inequalities, its efforts often come into conflict with powerful global actors in pursuit of other interests such as protection of national security, safeguarding of sovereignty, or economic goals. This report examines power disparities and dynamics across a range of policy areas that affect health and that require improved global governance: economic crises and austerity measures, knowledge and intellectual property, foreign investment treaties, food security, transnational corporate activity, irregular migration, and violent conflict.

Law is crucial for protecting the health and wellbeing of society. This Lancet–O’Neill Institute Commission on Global Health and Law shows how law can be a powerful tool in advancing global health. The Commission provides seven recommendations to implement to advance global health with justice.

In 2000, 189 countries signed up to the Millennium Declaration—a global commitment to halve extreme poverty and achieve equitable and sustainable development for all. The agreement led to the creation of a historic framework revolved around eight goals: the Millennium Development goals (MDGs), which centre on targets around poverty, education, gender, health, environment, and global partnerships—to be met by 2015.

Africans can be proud of many successes in health such as longer life expectancy, reduced maternal and child mortality, and greater control of HIV and malaria epidemics. However sub-Saharan Africa faces the well known challenges of conflict, urban and rural exclusion, environmental degradation, and brain drain.

Increasingly, people leave the countryside to pursue better opportunities in cities. Nowhere has urbanisation been more rapid and pronounced than in China. This Lancet Commission, led by Tsinghua University in Beijing, examines the particular challenges and opportunities for health in China’s cities, with regard to health risks, health promotion, environmental health, and health-care delivery. For cities to be active participants in China’s aspiration as an ecocivilisation, there needs to be increased participation in health-related activities by stakeholders, with fuller integration of health into all civic policies. From this dialogue should come shared goals that are assessed regularly, and research on interventions to improve health for people who live in cities.

With one billion people on the move or having moved in 2018, migration is a global reality. International migration has increased to 258 million, and the numbers of refugees and people displaced by conflict, natural disasters, and climate change are at their highest levels: 22 and 40 million, respectively. Despite negative political narratives, migration is not overwhelming high-income countries—instead, it takes place mostly between low-income and middle-income countries and most people are migrating for work. By and large, migration is a positive and diverse experience. But migration has also become a political lightning rod. 

Traumatic brain injury (TBI) is a public health challenge of vast, but insufficiently recognised, proportions. TBI is the leading cause of mortality in young adults and a major cause of death and disability across all ages in all countries. In high-income countries, the number of elderly people with TBI is increasing, mainly due to falls, while in low-income and middle-income countries, the burden of TBI from road traffic incidents is increasing.

Girls' and women's health is in transition and, although some aspects of it have improved substantially in the past few decades, there are still important unmet needs. Population ageing and transformations in the social determinants of health have increased the coexistence of disease burdens related to reproductive health, nutrition, and infections, and the emerging epidemic of chronic and non-communicable diseases (NCDs). Simultaneously, worldwide priorities in women's health have themselves been changing from a narrow focus on maternal and child health to the broader framework of sexual and reproductive health and to the encompassing concept of women's health, which is founded on a life-course approach. This expanded vision incorporates health challenges that affect women beyond their reproductive years and those that they share with men, but with manifestations and results that affect women disproportionally owing to biological, gender, and other social determinants.