Epic Measures
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Summary

Moneyball meets medicine in this remarkable chronicle of one of the greatest scientific quests of our time—the groundbreaking program to answer the most essential question for humanity: how do we live and die?—and the visionary mastermind behind it.

Medical doctor and economist Christopher Murray began the Global Burden of Disease studies to gain a truer understanding of how we live and how we die. While it is one of the largest scientific projects ever attempted—as breathtaking as the first moon landing or the Human Genome Project—the questions it answers are meaningful for every one of us: What are the world’s health problems? Who do they hurt? How much? Where? Why?

Murray argues that the ideal existence isn’t simply the longest but the one lived well and with the least illness. Until we can accurately measure how people live and die, we cannot understand what makes us sick or do much to improve it. Challenging the accepted wisdom of the WHO and the UN, the charismatic and controversial health maverick has made enemies—and some influential friends, including Bill Gates who gave Murray a $100 million grant.

In Epic Measures, journalist Jeremy N. Smith offers an intimate look at Murray and his groundbreaking work. From ranking countries’ healthcare systems (the U.S. is 37th) to unearthing the shocking reality that world governments are funding developing countries at only 30% of the potential maximum efficiency when it comes to health, Epic Measures introduces a visionary leader whose unwavering determination to improve global health standards has already changed the way the world addresses issues of health and wellness, sets policy, and distributes funding.

Published: HarperCollins on
ISBN: 9780062237521
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INTRODUCTION

Counting Everything When Everything Counts

What you don’t know can kill you—A genius and a madman—The human side of scientific revolutions.

We are told we live in the age of Big Data. From hedge funds to Internet search algorithms to baseball sabermetrics, numerical analysis—on an unprecedented scale—guides more and more of our decisions. As I write, you can pay $99 for a personalized genome service—23andme—that uses a saliva sample to provide one million points of data from your DNA, to tell you about your ancestry and warn you about your propensity for certain diseases (though the health warnings have been suspended by directive of the United States Food and Drug Administration). Another $99 and you can buy a wearable device like the Fitbit, which tracks your every move—even how well you sleep.

But basic information about what actually kills people and makes them sick is trickier to tabulate. In 2010, approximately 53 million people died worldwide, and, for all but a fraction, no one knows definitively why. In 147 of 192 countries, reliable death certificates—often any death certificates—don’t exist, and, even in rich nations, health records have many missing pieces. Consider these basic questions: In the United States, one of the wealthiest countries in the world, does life expectancy vary depending on where you live? How different are the causes of illness and injury for men and women? Do Americans spend more time suffering from job-related accidents or outdoor air pollution, from drug abuse or not eating enough fruit? Incredibly, no one has really known. And yet efforts to help everyone in danger are stymied if we don’t know who is getting sick and dying, and why.

Health, to date, has generally been counted in two crude ways: length of life and cause of death. These measures are very poor reflections of how we all actually live—mere epitaphs, not biographies. If you are anemic, arthritic, deprived of sight, or depressed, you are very far from perfect health, but you may live just as long as other people, and something else will likely kill you. That no one dies from a migraine doesn’t mean headaches don’t have consequences. That there are no pink ribbons for low back pain doesn’t mean it doesn’t hurt and cost days at work. Chronic conditions like these drive a huge and growing proportion of private and public health spending—and, of course, of human suffering. If we want to improve how we live as well as how we die, we need to know the full measure of our diseases and disabilities—what doesn’t kill us as well as what does.

Ignorance is expensive. Between 1990 and 2010, international development assistance for health—medical aid money—more than quintupled from $5.8 billion to $29.4 billion a year. And that’s minuscule compared with what countries and individuals spend on themselves. At last count, annual total health spending worldwide was $7 trillion—10 percent of the global economy and growing. But is that money being spent on the health threats that really cause the most suffering, or only on what seem to be our worst problems? Are billions of lives at risk and trillions of dollars being wasted because of priorities based on faulty information?

Everyone wants the world to move in a healthier direction. But what we need is a map. And if no accurate, sufficiently extensive map exists, someone needs to create one.

This book is the story of a huge independent effort, years in preparation, to do nothing less than chart everything that threatens the health of everyone on Earth, and make that information publicly available to doctors, health officials, political leaders, and private citizens everywhere. The quest has engrossed the time and talent of thousands of people around the world, from computer programmers to village interviewers. Chris Murray, the originator and now leader of the project, has been called a genius and a madman: a Harvard-trained physician who no longer practices medicine but is trying to treat the world’s 7 billion people, an Oxford-educated economist who doesn’t follow the stock market but is believed by some to hold the key to one of the largest segments of the international economy. You might also say he is a very smart guy who has found a way to channel an obsession with detail, a prodigious appetite for hard work, and an unusual kind of global compassion into the monumental task of surveying, comparing, and combating all the illness and injury, fatal and disabling, that burdens each and every human being. That is the study’s name, in fact: the Global Burden of Disease.

Global Burden is a concept, a quantity, and an ongoing project—a comprehensive, comparable measure of almost everything wrong with everyone everywhere. Its numbers can be broken down by person, place, ailment, and consequence—what kills us, what makes us sick, and what shortens our pain-free years of life. It can identify the probable top killers of newborn children in Angola or of middle-aged men in the United States, the worst causes of pain and suffering for teenagers in Egypt or for elderly French women, and the global toll of everything from asthma to suicide to chronic neck pain. It is not a static document, but an evolving report, in ever greater detail, that has already released a trove of more than 650 million results. These may provide more powerful ammunition in the fight against unnecessary suffering and needless death than any other invention in the history of public health. The basic principles of a medical practitioner apply to the 7 billion as well as to the individual patient. First, diagnose. Then prescribe.

What are the world’s health problems? Who do they hurt? How much? Where? Why? Forget what you think you know. With a truly all-encompassing view of life and death, we can see for the first time if Europe is healthier than America, or Iowa than Ohio, or you than your neighbor. And then in what ways. And how people are responding, with specific details everyone else around the world can try to emulate.

The question then becomes not what stops us from living better, but how far and how fast are we willing to improve?

I first met Chris Murray in January 2012. The project he described was one of the largest scientific exercises ever attempted. It was as complex and controversial as the first moon landing or the Human Genome Project. It was extremely expensive, insanely ambitious—and almost done.

Murray himself was fascinating: blunt, often abrasive, hyperenergetic, supremely confident, yet fiercely collaborative. As his colleagues would all attest, he has always been a person who likes to argue, and he seemed to operate on the assumption that scientific progress relies on picking fights. He was also intellectually generous, invigorated by the push and pull of other people’s ideas and willing to listen to any serious proposition, no matter the source.

Soon that list of outside ideas included the notion that I be allowed to watch as he and his team scrambled to complete the latest, most significant stage of an effort that had started more than twenty years before.

Murray agreed. He set no restrictions on my questions, whom I talked to, or what I saw, and had no control over what I wrote. This was brave, perhaps even reckless—he had made prominent enemies, he had personal secrets, and his project might well fail—but it was also in character. The longer I observed Murray, the more the question of personality interested me. Before meeting him I had considered myself a lively person of above-average stamina. Follow him for just twenty-four hours, though, and I required a week afterward to recover. For fun, he raced sailboats, skied on virgin slopes reached via helicopter, and mountain-biked across forest and desert. He was at once personally reserved and, categorically, an extrovert: Basically, I am only capable of creative thought when I am interacting with others, he said to me. But if he was convinced you were wrong, he paid no attention to what you said, no matter who you were or how exalted your position. Do good work that matters was one of his personal mottos. Another was Everything everyone tells me is a lie until I can verify it’s the truth.

We can’t wait for a better map of what’s ailing us, Murray said—and we don’t have to. New methods of analysis and new powers of computation make it possible to unite previously scattered points of information in revelatory ways. One use of the discipline of Big Data, much chronicled by the media, is taking almost-infinite stores of knowledge and reducing them to a single answer (think Google). Another, relatively neglected by reporters, is taking extremely sparse data and ingeniously stitching them together to construct a provably reliable big picture. A third is finding and correcting errors in the information we already have. Murray’s claim was to have mastered all of the above in service of the most essential question of all: how to measure—and improve—how we live and die. And everyone, everywhere was included—now and for all time.

This was a tall order, but, when Murray made the case, the impossible seemed not only possible but necessary. It’s not acceptable, he said, not to know what people die from around the world. It’s not acceptable to count only rich countries or only causes that have a spokesperson. It’s not acceptable to ignore nonfatal conditions or to let the powers that be decide what’s important without outside oversight or public input. And it’s simply shortsighted to take just what we already know and then see what it tells us. Instead we have to decide what we need to know and then go out and get that information.

This is what Murray and his colleagues have done, and continue to do. If you have ever read that the U.S. health system is ranked 37th in the world, that famous (to some, infamous) figure comes from their studies. Whether identifying tuberculosis as the leading infectious killer of adults at a time when most global health programs focused only on diseases of children, or revealing in which U.S. counties men and women live longer than their counterparts in Japan (and in which they die earlier than in Syria), their work makes headlines and resets the priorities of national and international health organizations. They have shown the wealthiest couple on Earth a way to invest their fortune for global good. And they may help any of us, anywhere, know what really hurts us and what will best improve our health.

The people transforming our knowledge of life and death are not saints. They are very much human beings, albeit extraordinary ones. They boast human virtues and they suffer human flaws. Saying that the way we measure health is broken and that you can fix it requires a conviction, drive, and focus that almost all of us would find inconceivable. It means making enemies of good people who stand in your way or who you believe are wrong or wrongheaded. It means overcoming politics and embracing competition—for money, for power, for priority.

How the Global Burden of Disease study came into being—and what it can tell us already—is an epic tale. It encompasses wars and famines, presidents and activists, billionaires and billions of people worldwide living in poverty. It shows the human side of scientific revolutions—and of revolutionary scientists: their mistakes and setbacks as they happen, their personal foibles and frustrations, how they face critics and rivals, and if and how they can ever claim success.

But even revolutions have small beginnings. This one started more than forty years ago, in a Land Rover crossing the Sahara Desert.

PART I

Who Dies of What

CHAPTER ONE

Murray, Murray, Murray, and Murray

The navigator—A childhood memorizing maps—Do you have some water?Medicament—A deadly puzzle—Both skeptic and true believer.

March 1973. The Sahara.

There was no road, and certainly no GPS. Forward motion meant following a dusty track. Occasionally, through the haze, the family had seen a lone gazelle or a few people on camels. Every now and then they had discovered a village. For the last three days, however, they had encountered no one but themselves. Drought and daytime temperatures touching 120 degrees Fahrenheit made the area almost uninhabitable. Now, at four in the afternoon, they came to a split in the track and didn’t know which way to go.

John, hair white, his bald spot susceptible to sunburn, wearing professorial black-framed glasses, drove one dark green Land Rover. Anne, an athletic redhead, accompanied him or Nigel, their seventeen-year-old son, who drove the other. Luggage, tents, bedding, food, a cookstove, and other supplies for the trip lined every free inch of the vehicles’ interiors. In the backseats, Megan, fourteen years old, and Christopher, ten, couldn’t touch their feet to floors packed with flat-sided five-gallon metal jerry cans. The ones with water were still full, though sloshing, the children heard. The ones with gas, already partly empty, seemed to make a louder sound. Let them accidentally clank against each other and they might echo ominously.

The adults conferred about which trail to follow. Megan, who wanted to be an anthropologist, passed the time imagining what it would be like to live where they were going. Chris, the family navigator, brushed overgrown brown bangs from his eyes and studied yet again the only map of their terrain.

Drawn by French surveyors at a scale of 1 centimeter to 40 kilometers, the map depicted the desert in mustard yellow. Every morning and evening, before breaking camp or bedding down for the night, the boy ran to lead his father and older brother in unfolding it for reference atop the hood of a Land Rover. Tiny symbols—an X, an empty square, a stick-figure house—marked possible stops for gas, repairs, and primitive lodging. Eau bonne à 5 m—good water at 5 (or 15 or 35) meters—little notes suggested along the route. Of the unmarked trails they followed, Chris read: Suitable only for cross-country vehicles and certain types of truck. To use them a guide or means of land navigation is necessary. Traveling with only one car inadvisable.

Chris, dressed in a short-sleeve collared shirt and shorts, was noticeably thin, all knees and elbows; at home, in Golden Valley, Minnesota, his parents had tried to fatten him up with eggnog and ice cream. His energy and diligence, however, made his presence larger. Knowing where you were was a big thing, he would say years later. Crossing the Sahara, it’s a matter of life and death. Now, carefully double-checking their whereabouts, he calculated that their next fuel stop was not for five hundred kilometers.

The family decided to drive left. Sweating, they spent an hour traversing rough chunks of rock, down into a valley or gorge. Then dunes, nearly liquid in the heat. Standing at the edge of an escarpment, the Murrays could see no more track below them. They went back, exploring the other side. Finally, the path was pure loose sand. Wrangling sand ladders, six-by-two-foot metal boards, full of holes, under buried tires, they returned to the original split.

In England, John, the intellectual, had bought a compass. Now Chris berated him for not using it. Instead, as the sun set, they prepared to wait as long as necessary for a fellow traveler of whom they could ask directions. A guide—which was supposed to be Chris’s job. He made some pretty nasty comments, John defended himself decades later. But we didn’t know what the sand was like. If we had gone off, we could have been lost in it.

This was how the Murray family arrived in Africa. The hard part was yet to come.

Chris Murray spent his entire childhood memorizing maps. His parents were both New Zealanders—the most travel-mad people on Earth. John was a cardiologist. Anne was a microbiologist. They had even met in motion—as students in 1943 on a train back to the University of Otago following a school break. In the 1950s, a stint together at the Mayo Clinic and then the offer of a professorship for John at the University of Minnesota brought them to the United States.

Exploration became the family passion. Winters, John and Anne packed Chris and his three older siblings—Linda, Nigel, and Megan—on car trips to the new ski resort of Vail, Colorado. Summers, they drove to southern California, where they camped on the beach. To see as much country as possible, the Murrays traveled one summer through Yellowstone and the Tetons; another summer to Oregon and down the Pacific coast; and a third year through Colorado. To save money en route, John drove late into the night, stopping the car by the side of the road where he set up cots for everyone to sleep on. Anne, who had grown up on a remote dairy farm, taught the children to embrace the adventure of unfamiliar places. She wanted to see over the next hill and around the next bend—always, John says.

By the mid-1960s, Linda, Chris’s eldest sibling, had graduated from college and started work as a flight attendant for Pan American Airlines. A job benefit allowed family members to fly on standby anywhere in the world for only 20 percent of the normal fare. Suitcases packed, sleeping in airports if necessary, the Murrays took off every chance they could, visiting Thailand, Turkey, Lebanon, Egypt, and India. Once the family flew to Nairobi, rented a minivan camper, and spent a month touring Kenya, Uganda, and Tanzania in a big circuit. Then, inspired by seeing the Omar Sharif movie The Horseman, Anne decided they should go to Afghanistan. More than four decades later, Chris, the baby, would still recall the blue lakes of Band-e Amir, the 120-foot-plus sandstone Buddhas of Bamiyan (later destroyed by the Taliban), and a giant pile of skulls he was told were remnants of Genghis Khan’s rampage through the region seven and a half centuries earlier.

In 1973, John was granted a sabbatical for the next academic year. He suggested that the Murrays spend it in South Africa, home of the cardiac surgeon Dr. Christiaan Barnard, who had performed the first successful human heart transplant. Nigel, now a high school senior, refused. Emphatically. Even though his father meant to spend the year in basic research, not politics, the long-haired teenager would not live in a country ruled by apartheid. Megan, a high school freshman, and Chris, a fourth grader, agreed. If the family had an entire year free ahead of them, they should serve people in need directly, the children said. Make themselves useful. Weren’t there millions around the world desperate for medical attention?

Anne, inspired, started planning. She just loved the desert and everything about it, John says of their earlier trips. The radical change—from being a farm girl, then lab worker, and, finally, stay-at-home mother in suburban Minneapolis—to the life of adventure. Through their local church, Westminster Presbyterian, Anne contacted people at Church World Service. They said a new hospital had been built in sub-Saharan Africa, in eastern Niger, then and now one of the poorest countries on Earth. Could the Murrays help there?

The family sat at the kitchen table, three children and his wife lobbying John. That’s a good idea, Nigel, Megan, and Chris said. Why don’t we do that?’

We can make a contribution to humanity, Anne said. A small one. Nothing grand. Work together as a family, do something collectively.

Fine, John said. Maybe the challenge would be good for them. His father had come to New Zealand from Lebanon at the age of five or six, and had gone door to door selling matches for pennies. Neither of his parents had graduated from high school. Cabaret-style restaurateurs, they paid for his medical education by singing duets as they sold roast dinners to American GIs. It frustrated him that none of his kids, growing up in prosperous suburbia, seemed particularly motivated students. They wanted to spend a year working in Niger? If anything can change your life dramatically, he thought, this is it.

The family raised money, flew to England, and stayed in Oxford while gathering supplies for the year ahead. They bought the Land Rovers on discount direct from the factory in Solihull. They went by ferry from Southampton to France, drove south into Spain, and crossed over into Africa from near Gibraltar.

Then it was into the world’s largest desert.

The Sahara covers an area of some 9.4 million square kilometers, almost equal to Europe, or more than thirteen Texases. In three directions, water determines its borders: the Mediterranean to the north, the Atlantic to the west, and the Red Sea to the east. Southward, the desert ebbs into the Sahel, a semiarid region long known for greater moisture, and is therefore much more populated. But as John, Anne, Nigel, Megan, and Chris drove slowly south hundreds of kilometers to Niger’s capital, Niamey, and then east another 1,300 kilometers to their assigned hospital, in the town of Diffa, near Niger’s borders with Chad and Nigeria, the heat and drought never abated. People would wave down their Land Rovers. They were begging. At first, the Murrays thought they wanted money. Well, money was useless. Do you have some water? the family was asked instead. Can I have some water for my baby?

They arrived in Diffa, a district capital, in early April. One to two thousand people lived here, most in straw-roofed mud huts. The hospital, really a little clinic, donated by Italians, was easy to spot: two long, low one-story prefab buildings, the only modern structures in a very unmodern town. One building, outpatient services, held a waiting area, examining rooms, a lab, and a pharmacy. The other building, a hospital ward, had ten beds each for men and for women, plus nurses’ quarters, a surgical suite, and an operating room. All were empty.

There was housing for an electrical generator that had not yet come. A water tower with no water. A supply room with almost no supplies.

Outside people gathered in the sand. The patients.

The Murrays asked to meet other staff: doctors, nurses, administrators. A government official appeared. It turned out that another doctor who had arrived previously had taken one look at the setup and left.

The family was furious. It’s no good to us, John said. We can’t operate in this situation. Or could they? Brought all the way from Minneapolis and bolted to the Land Rovers were their own generator and portable electric cardiograph machine, an old microscope and basic stains for lab work, and medical supplies to last perhaps two weeks. He conferred with Anne a world away from their comfortable kitchen table. She’d wanted an adventure? Now she had one. If they stayed, John would be the chief—and only—physician. Anne and Megan, the fourteen-year-old, would be nurses. Nigel, the seventeen-year-old, would fix equipment and man the lab. And Chris, the ten-year-old? I was the pharmacist and run-around boy, he explains.

Or they could go back all the way they’d come.

We asked ourselves, can we operate this hospital without water and without electricity? John remembers. We decided we could.

A little doctor’s house sat beside the clinic, surrounded by thin bushes and pink-and-white flowering portulaca. Unfortunately, it had been built without windows, only air conditioners. Like the clinic itself, these probably appeared as a great advance for Africa on the balance sheets of Italian aid. Without electricity, however, they were a worthless encumbrance. Except when it rained, which was very seldom (the Sahelian drought was the worst in twenty years), the family camped outside. They threw up sheets for privacy, dropped mosquito nets, and unfolded little cots they folded up again and put away come morning. Waking up, they saw the bed nets above them. They immediately put on boots, checking first for scorpions.

Centuries ago, Lake Chad covered the entire area, but the drought and dry climate had shrunk this shallow water body to a fraction of its former size, pushing the closest access a torturous hundred-kilometer trek east. A single well in the town square, a thousand feet deep, sustained everyone. Local food, in short supply, was the past year’s millet, ground to powder. Every morning, Chris heard a rhythmic pounding as women mixed the millet with spices and water to the consistency of porridge.

People heard the hospital had opened. And a doctor was offering medical care. They walked days and nights to have themselves, their children, or their elderly relatives treated. John went to the local prefect and asked permission to use the well. This agreed to, Nigel was sent over every morning with the Land Rovers. Laboriously, he filled the family’s jerry cans and a donated 200-liter drum. Then, since the Murrays lacked working radios or an ambulance service, the teenager roamed the area, distributing water as necessary and picking up people too ill to make the trip on their own. Megan, meanwhile, greeted patients in morning rounds with her mother. As directed by her father, she dispensed medication, IVs, shots, or stitches. Every day, they had to sweep the floors of sand and dust. Every three days, they swabbed them. As far as electricity was concerned, the family was helpless. What little fuel they had went to run the generator during key procedures. Otherwise, cool came from shade and nightfall, and light from the sun. If we finished what we were doing in the hospital, we’d attend my dad, Megan says. They held flashlights while he was doing routine surgery.

Chris, too young at first to provide direct care, briefly attended the local school. The experience was a disaster. Bookish and bright, more like his academic father than any other sibling, Chris loved brainteasers and playing board games like Risk. Neither prepared him for the strictures of learning in a one-room hut. Nobody spoke any language he knew. Any student who did anything wrong got beaten. He contracted hepatitis A, a fever-causing virus transmitted in food, and lost almost 40 percent of his already-meager body weight, dropping from 89 to as few as 54 pounds before stabilizing. Chris suffered terribly, says John. We were desperate. They drove 725 kilometers south and west to Kano, a major city in northern Nigeria, for supplies and fresh food. Chris’s skin was bright yellow. It took all his effort, he would remember later, not to fall down outside the main hotel.

When he recovered, his parents gave Chris the job of organizing the clinic’s precious few medical supplies. In the dry, dusty-smelling room, he witnessed his father make frantic phone calls, requesting necessary equipment and basic drugs such as penicillin. A shipment was on its way, they were told. A paper voucher followed: medicament, it read. French for medicine. Wonderful. Chris and his family waited eagerly for weeks. At last a full truck lurched across the horizon.

They pulled down the flaps. There were no drugs. What filled the pickup instead were hundreds, even thousands, of cans of marmalade. All of them had gone bad somewhere. It was ludicrous—"a moment from the