The Global Risks Report 2020 - Abstracted Chapter: False Positive Health Systems under New Pressures - Zurich Insurance

The Global Risks Report 2020 - Abstracted Chapter: False Positive Health Systems under New Pressures - Zurich Insurance
The Global Risks
Report 2020
Abstracted Chapter:
False Positive
Health Systems under New

                     Insight Report   15th Edition
    In partnership with Marsh & McLennan and Zurich Insurance Group
The Global Risks Report 2020 - Abstracted Chapter: False Positive Health Systems under New Pressures - Zurich Insurance
The Global Risks
Report 2020
15th Edition

Strategic Partners
Marsh & McLennan
Zurich Insurance Group

Academic Advisers
National University of Singapore
Oxford Martin School, University of Oxford
Wharton Risk Management and Decision Processes Center, University of Pennsylvania
The Global Risks Report 2020 - Abstracted Chapter: False Positive Health Systems under New Pressures - Zurich Insurance
Health Systems under New Pressures

                                     REUTERS/BENOIT TESSIER
The Global Risks Report 2020 - Abstracted Chapter: False Positive Health Systems under New Pressures - Zurich Insurance
The institutions and approaches that have until   against some of humanity’s biggest killers.
now enabled health progress across the world      Meanwhile, new vulnerabilities threaten to undo
are straining under gathering pressures and       the dramatic gains in wellness and prosperity
seem outmatched against new risks.                that health systems have supported over the
                                                  last century. Non-communicable diseases
Health systems around the world are at risk of    (NCDs)—such as cardiovascular diseases
becoming unfit for purpose. Changing societal,    or mental illness—have replaced infectious
environmental, demographic and technological      diseases as the leading cause of death.
patterns are straining their capacity. Vaccine    As existing health risks resurge and new
hesitancy and drug resistance are undermining     ones emerge, humanity’s past successes
progress against pandemics, making it             in overcoming health challenges are no
increasingly difficult to land the final blow     guarantee of future results.

The Global Risks Report 2020 - Abstracted Chapter: False Positive Health Systems under New Pressures - Zurich Insurance
The slowing of                                                  However, strained health systems are leading
                         health progress                                                 to worrying trends. Gains in lifespan and
                                                                                         healthspan (the number of years spent in
                         Global investments in health in recent                          good health) seem to be slowing in both
                         decades have yielded substantial gains to                       developed and developing countries.4 For
                         both longevity and quality of life. Over the                    example, recent data published by the
                         long history of our species, the average                        Centers for Disease Control and Prevention
                         life expectancy at birth for people in most                     shows that US life expectancy declined in
                         societies ranged from 20 to 50 years. Since                     2017 for the third year in a row, the longest
                         1950, this has improved significantly—to                        sustained drop for a century—since the
                         72 years globally,1 of which 63 years on                        combined effects of World War I and a global
                         average are lived in good health, free of                       influenza pandemic.5 In Singapore, although
                         disease or disability (see Figure 6.1).2                        life expectancy has increased since 1990,
                                                                                         people are spending more of their lives in
                         Many factors have contributed to this                           sickness.6 Disparities in health outcomes
                         success: scientific breakthroughs; better                       persist within and across countries. A baby
                         hygiene, sanitation and nutrition; health                       born in Hong Kong can expect to live for
                         policies and investments made possible                          85 years, versus just 52 years in the Central
                         by prosperity; international cooperation;                       African Republic (Figure 6.1).7 Meanwhile,
                         and individual choices. Vaccines illustrate                     rich-poor health gaps are growing in
                         this point: after germ theory took hold in                      countries including the United Kingdom
                         the late 19th century, scientists developed                     and the United States.8
                         vaccines for many deadly infectious
                         diseases including smallpox, measles,
                         polio, pertussis, diphtheria, tetanus and                       Pressures on health systems
                         tuberculosis. Smallpox—once among the
                         deadliest diseases—was the first to be                          Gathering pressures are straining health
                         eradicated by national programmes and                           systems on many fronts. In this section, we
                         international cooperation in surveillance and                   discuss long-standing challenges as well as
                         containment, reinforced by people’s trust                       the next generation of health pressures that
                         in health systems and their willingness to                      health systems are now confronting.
                         be vaccinated. Coordinated immunization
                         programmes continue to prevent millions of                      Familiar foes
                         deaths annually.3                                               There is no guarantee that health systems
                                                                                         will continue to improve health, and clear
                                                                                         signs of strain are apparent. Despite historic,
                                                                                         hard-won success against diseases such
                                                                                         as smallpox, some of humanity’s most
Life Expectancy at Birth, 1967–2017                                                      formidable global health threats still linger—
                                                                                         and other threats, thought to have been
                                                                                         quashed, are resurgent.
80                                                                                       Persisting pandemics. Thirty years ago,
75                                                                                       polio was endemic in 125 countries,
70                                                                                       causing 350,000 clinical cases per year.
65                                                                                       After an extraordinary international effort
60                                                                                       and US$20 billion in investment, today
55                                                                                       there are 99.9% fewer cases and polio
                                                                                         remains endemic in only Afghanistan,
                                                                                         Pakistan and possibly Nigeria—where
                                                                                         geopolitical challenges have complicated
                                                                                         eradication.9 Polio could potentially be
     1967                                                                  2017          eradicated in the next four years—but the
                                                                                         estimated cost to make that happen would
     Central African Republic      World       Hong Kong                                 be another US$4.2 billion.10 The last mile is
                                                                                         proving the hardest, for reasons including
Source: World Bank Open Data,, accessed 15 December 2019.   persistent political instability and community

74    False Positive
The Global Risks Report 2020 - Abstracted Chapter: False Positive Health Systems under New Pressures - Zurich Insurance

                                                                              33 years:
                           resistance—which often stems in part
                           from a perception that investments in polio
                           eradication come at the expense of other
                           health priorities.11 Letting up is not an option
                           because the short- and long-term benefits
                           of eradicating this enduring scourge would
                           be massive.
                                                                              widest gap in life expectancy
                                                                              between countries
                           Similar stories can be told about HIV/AIDS,
                           tuberculosis and malaria. After years of
                           remarkable progress as a result of sustained
                           political commitment and funding via               also recently saw the world’s largest
                           the Global Fund, ambitions to end these            measles outbreak, affecting over 200,000
                           epidemics by 2030 are being undermined             people in less than a year.16 The resurgence
                           by factors such as diseases’ increasing            of measles is a symptom of complacency
                           resistance to drugs.12                             and recklessness.

                           Vaccine hesitancy. The World Health                Antimicrobial resistance (AMR). As
                           Organization (WHO) considers reluctance or         measles and other infectious diseases
                           refusal to vaccinate to be among the top 10        strain health systems by siphoning off
                           threats to global health.13 Growing vaccine        limited resources and attention, overuse of
                           hesitancy has led to outbreaks of measles          antibiotics poses a direct threat to health
                           worldwide, including in developed countries        and healthcare. AMR makes antibiotics
                           where it had largely been eliminated.14            less effective at treating illnesses. Surgeries
                           New York City spent US$6 million in 2019           that have become routine, infections we
                           responding to a completely preventable             now think of as easily treatable, and some
                           measles outbreak.15 Making fewer headlines         common illnesses could again become life-
                           than the massive Ebola outbreak in the             threatening.17 The WHO estimates that AMR
                           Democratic Republic of Congo, that country         could result in 10 million deaths by 2050.18

                                                                                                                           The Global Risks Report 2020   75
The Global Risks Report 2020 - Abstracted Chapter: False Positive Health Systems under New Pressures - Zurich Insurance
Global health security risks.                                   Serious as these risks are, it can be argued
                              Considerable progress has been made                             that health systems nonetheless have a
                              since the Ebola epidemic in West Africa in                      blueprint to mitigate them, and success
                              2014–2016, but health systems worldwide                         requires only adequate attention. The same
                              are still under-prepared for significant                        cannot be said for new health risks.
                              outbreaks of other emerging infectious
                              diseases, such as SARS, Zika and MERS.                          Emerging Risks
                              A recent first-of-its-kind comprehensive                        Longevity, lifestyle and climate changes
                              assessment of health security and                               are transforming disease burdens. Health
                              related capabilities across 195 countries                       systems need new infrastructure, resources
                              found fundamental weaknesses around                             and skills, but in many parts of the world
                              the world: no country is fully prepared                         they are failing to adapt—even as healthcare
                              to handle an epidemic or pandemic.19                            spending soars to unsustainable levels.
                              Meanwhile, our collective vulnerability
                              to the societal and economic impacts of                         Non-communicable diseases (NCDs).
                              infectious disease crises appears to                            As populations grow, age and urbanize,
                              be increasing.20                                                NCDs and mental disorders have replaced
                                                                                              infectious diseases as the leading threats to
                                                                                              health and health systems worldwide. Once
                                                                                              considered diseases of the rich world—
                                                                                              linked to low-quality diets, little exercise and
Top Global Causes of Death, 2017                                                              the use of tobacco and alcohol—chronic
                                                                                              and degenerative conditions are now a
     Non-communicable diseases
                                                                                              global epidemic (see Figure 6.2). They
                                                                                              account for 41 million deaths each year, of
     Communicable, maternal, neonatal and nutritional diseases
                                                                                              which 85% are in low- and middle-income
                                                                                              countries, where people might grow old
                                                                             % of total
                                                                                              and ill before they become rich.21 By 2030,
           Cardiovascular diseases                                               31.8%        the WHO expects this figure to increase by
                                                                                              11 million, reaching 52 million in total, and
                          Neoplasms                                              17.1%        deaths from infectious diseases to decline by
                                                                                              7 million.22 Depression and anxiety disorders
      Chronic respiratory diseases                                                7.0%
                                                                                              are on the rise—they increased by 54%
                Respiratory infections
                                                                                              and 42% respectively from 1990 to 2013,
                    and tuberculosis                                                          according to WHO data.23 Currently 700
             Neurological disorders                                               5.5%        million people worldwide are estimated to
                                                                                              have a mental disorder.24
     Diabetes and kidney diseases                                                 4.7%
                                                                                              While infectious diseases and pandemics
                   Digestive diseases                                             4.2%
                                                                                              pose an acute threat to human life, NCDs
                       Maternal and
                                                                                              have a gradually crippling effect on the
                   neonatal disorders                                                         well-being of individuals and societies.
                 Unintentional injuries                                           3.2%        Besides causing enormous physical and
                                                                                              psychological suffering, the four leading
                    Enteric infections                                            3.2%        NCDs—heart disease, cancer, diabetes
                        Self-harm and                                                         and respiratory diseases, along with mental
                interpersonal violence                                                        illness—could have cost the global economy
                    Transport injuries                                            2.4%
                                                                                              an estimated US$47 trillion (in treatment and
                                                                                              lost productivity) over the 2010s and 2020s.25
                         Other NCDs                                               2.1%        Dementia is expected to cost a further
                                                                                              US$2 trillion by 2030,26 as each year brings
             HIV/AIDS and sexually
                                                                                  1.9%        10 million new cases.27 NCDs and mental
              transmitted infections
                                                                                              disorders are difficult to prevent and treat as
         Other infectious diseases                                                1.5%
                                                                                              they stem from varied and complex causes,
                                                                                              develop slowly, and often co-exist with other
Source: IHME (Institute for Health Metrics and Evaluation), Global Burden of Disease Study
                                                                                              chronic conditions. Effective interventions
2017,       need to target both individuals and

76     False Positive
The Global Risks Report 2020 - Abstracted Chapter: False Positive Health Systems under New Pressures - Zurich Insurance
Dementia affects 10 million more
  people each year

populations, overcoming entrenched habits
and commercial interests. Even in richer
countries, the medical and social care costs
of NCDs could bankrupt health systems.

NCDs could also disrupt societal cohesion:
growing health inequalities could widen
economic inequalities, earlier onset among
younger people could stifle the economic
growth necessary to fund care for older
people, and ageing electorates could prioritize
spending on pensions and healthcare over
other issues such as education, infrastructure
and climate resilience.

Climate change health effects. The
WHO deems climate change to be “the
greatest threat to global health in the 21st
century”.28 Human-induced climate change
is already impacting the health of millions
and challenging health systems globally.29 It                                                REUTERS/VALENTYN OGIRENKO

affects the quality of the air we breathe and
both the quality and quantity of the water        Demand–capacity mismatch. As more
we drink and the food we eat. Air pollution is    people live for longer with increasing health
already costing the world more than US$5          and social care needs, and as new drugs
trillion from decreased productivity every        and technologies are developed, surging
year.30 Extreme weather conditions are            demand and expectations are stretching
putting populations around the world at risk      current approaches to financing care. Health
of food and water insecurity. Today’s children    expenditure growth is outpacing inflation in most
face a future of increasingly serious climate-    countries.35 It has reached an unsustainable
related hazards: less nutritious crops, air       18% of GDP in the United States,36 resulting
pollution exacerbated by burning fossil           in an increasing transfer of financial risk from
fuels, rising average temperatures and other      insurance companies to individuals through
weather-related disruptions to livelihoods.31     rising premiums, co-pays and deductibles;
                                                  and in bipartisan anger over drug prices,
Climate change also exacerbates the               hospital bills and out-of-pocket spending.
incidence of infectious diseases. Warming
temperatures are expanding mosquito-              Most health systems continue to focus on
friendly habitats beyond the tropics,             reactive care in hospitals—detecting and
spreading diseases such as malaria, dengue,       treating disease—and give too little attention
yellow fever, West Nile virus and Zika into       to NCD prevention and control. They have
new regions. In 2015, the El Niño effect          yet to adapt their infrastructure to combine
allowed Zika to spread from Brazil to the         online, remote and retail care settings to
rest of South America.32 In 2012, the United      improve information, screening, treatment
States logged a record 5,500 cases of West        and support for patients and carers.
Nile virus and an increase of 70% in dengue       Health systems—and governments more
fever.33 By 2080, extreme global warming          broadly—will also need better health policies,
could expose a billion people to mosquito-        regulations and promotion strategies to
borne diseases in previously unaffected           reduce environmental and lifestyle risk
regions such as Europe and East Africa.34         factors of NCDs.

                                                                                               The Global Risks Report 2020   77
Workforce limitations. Most health systems
                      are training and retaining too few doctors,
                      nurses and other health workers. For
                      example, the UK National Health Service
                      has an estimated 94,000 unfilled vacancies
                      in hospital and community services37—
                      almost 8% of its total workforce—and
                      risks an exodus due to burnout and low
                      morale.38 Disparities persist across countries,
                      regions, care levels and areas of medicine.
                      Nearly half of the world’s population lives in
                      countries with over 100,000 people for every
                      psychiatrist.39 Even in the United States,
                      with 10.8 psychiatrists per 100,000 people,
                      almost half of those currently practising are
                      expected to retire soon.40 The brain drain
                      of health workers places further strain on
                      poorer and rural parts of the world.

                      New breakthroughs, new risks
                      Transformative technologies, medicines
                      and insurance that could vastly improve the
                      reach and quality of healthcare are on the
                      horizon—but they also bring new risks and         ultimately make it possible for everyone—
                      trade-offs for health systems and societies.      even in currently fragile, over-burdened
                                                                        health systems—to access high-quality,
                                                                        consistent, affordable, timely and
                                                                        convenient care.

US$                                                                     But new technologies also raise risks,

2 million:
                                                                        including risks of compromising patient
                                                                        safety and privacy, as well as introducing
                                                                        bias. Errors by individual health workers
                                                                        affect only their patients, whereas the
                                                                        consequences of AI errors could unfold
cost per patient of recent cell                                         at a whole new scale. Since training data
and gene therapies                                                      sets in health often skew white and male,44
                                                                        AI could fail to spot symptoms or devise
                                                                        effective treatment plans for everyone else.
                                                                        These outcomes will be tough to predict or
                      Disruptive technologies. Over the                 avoid because AI’s black-box nature makes
                      centuries health systems have embraced            it difficult to understand how it reaches
                      many innovations, sometimes without               conclusions—making it hard to spot bias.
                      waiting for them to be proven safe and            Health data are especially vulnerable to
                      effective. Healthcare providers and payers        cyberattacks,45 with risks of individuals being
                      are already using today’s emerging                identified even from anonymized data (see
                      technologies—machine learning and artificial      Chapter 5, Wild Wide Web).
                      intelligence (AI), sensors, digital therapies,
                      telemedicine and so on—to support both            Pharmaceutical revolution. Highly complex,
                      clinical and operational decisions: to triage     specialized new drugs promise radically better
                      symptoms,41 interpret diagnostic tests,42         treatment for devastating diseases—but they
                      create personalized treatment plans43             come at exorbitant prices. For example, three
                      and predict re-admissions at a hospital or        recently launched cell and gene therapies
                      epidemics in a population. Combined with          cost up to US$2 million per patient. Over
                      human capacity, these technologies could          the next few years, between 15 and 30 new

78   False Positive
could lead to rewards and incentives for
                                                   people to live healthier lifestyles, but if
                                                   unchecked by regulation, it could also
                                                   potentially put insurance beyond the reach of
                                                   people judged to be higher risk for genetic,
                                                   environmental or behavioural reasons.

                                                   In some jurisdictions, steps have already
                                                   been taken to mitigate this risk in response
                                                   to the concerns of people who have taken
                                                   predictive genetic tests for certain diseases.
                                                   In 2018, the UK Government, together with
                                                   the Association of British Insurers (ABI),
                                                   consolidated existing agreements on the use
                                                   of genetic information and created the Code
                                                   on Genetic Testing and Insurance. Given
                                                   the rapid advances taking place in genetic
                                                   research, this Code will be reviewed every
                                                   three years to consider the technical, ethical
                                                   and societal implications of insurability.
                                                   Among other principles, the Code commits
                                                   insurance companies to treat applicants for
                                                   insurance fairly and not require or pressure
               REUTERS/YVES HERMAN/ILLUSTRATION    any applicant to undertake a predictive or
                                                   diagnostic genetic test.47
million-dollar drugs are expected to enter
the market, mostly for cancer.46 New pricing
models—such as multi-year payments                 Ubiquitous risks of a weak
contingent on patient outcomes—are starting        health system
to emerge to address the high costs and risks
of these treatments.                               Good health is the foundation for societal
                                                   well-being and a dynamic and prosperous
But health systems are finding it difficult to     economy.48 Health systems form part of
adapt amid questions over who should pay,          countries’ critical infrastructure: they are
how high a price can be justified, and what        vital to security, resilience and growth.
can be given up to afford new therapies. As        At the population level, health underpins
people’s expectations rise, unequal access         productivity. Well-functioning health systems
to better therapies could deepen health            enable countries to respond to, and recover
inequalities within and across countries,          from, natural and human-made disruptions.
eroding trust in health systems and societal       Weak systems let pathogens and diseases
cohesion. In the longer run, if (or when)          spread because they fail to address fake
gene-editing technologies become available         news about healthcare and preventive
to enhance physical, cognitive or behavioural      care, psychological responses of fear and
capabilities, these could result in a society of   despair, and lack of compliance with health
genetically enhanced haves and the merely          professionals’ requests.49
natural have-nots.
                                                   Like climate change, health risks pose an
Risk pools of one. Health insurance looks          expensive and expanding transnational
set to be transformed by big data and              challenge. Around the world, health systems
analytics. As with in-car devices used by car      need to take a critical look at the fitness of their
insurers to reward responsible drivers with        current approaches and institutions if we are to
lower premiums, health insurers can (with the      maintain the progress of the last century and
consent of customers and the appropriate           tackle emerging threats. When health systems
levels of data security), capture, store and       fail to mitigate vulnerabilities and adapt to
analyse personal health and behavioural data       changing contexts, they increase the likelihood
from wearable—and eventually implantable—          of economic crises, political instability, social
devices. Personalized risk assessment              ruptures and state-on-state conflict.

                                                                                                   The Global Risks Report 2020   79

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82   False Positive
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