Blog entry by Arif Khwaja
2013 will see the publication of numerous guidelines aiming to improve the outcomes of patients with kidney disease. Whilst there will be heated debate about the merits of the CKD classification system or the setting of lipid targets in CKD, it's striking that major international nephrology organisations such as KDIGO and the ISN generally ignore the major elephant in the room when it comes to global nephrology care - namely the right of all citizens around the world to have high quality care irrespective of their ability to pay for such healthcare.
The argument that nephrology care is expensive and many countries cannot afford such care simply doesn't stand up to scrutiny. For example in oil-rich Nigeria or in booming India, end stage renal disease is simply a death sentence for patients who can't afford care. Despite being the 10th largest economy in the world, data from the WHO shows that the government of India only spends 1.1% of its GDP on healthcare. Tazeen Jafar wrote movingly in the New England Journal of Medicine about the death of a Pakistani tailor in 2006 as a result of developing ESRD secondary to type 2 diabetes - bankrupting his family in process. Yet there is nothing 'inevitable' about such deaths - it is too easy to dismiss these deaths as a consequence of poverty rather than a direct consequence of political choices and priorities made by governments. Again data from the WHO shows that the government of Pakistan chooses to spend only a derisory 0.8% of its GDP on healthcare whilst military spending attracts four times as much funding. In contras there are developing countries that choose to make healthcare a priority. For example, Mauritius has been highlighted by the Nobel prize-winning economist Joseph Stigilitz as a role model for many developing countries - it's government spends 6% of GDP on healthcare and has provided free dialysis for all its citizens since 1997.
The problem of health iniquity is not of course just limited to the developing world and is not just about the amount of money spent on healthcare but how it is spent. 16% of Americans have no health insurance resulting in an estimated 45,000 extra deaths a year and this is despite the US spending an astonishing 17.9% of its GDP on healthcare. Of course it is the poor who suffer with Hispanics and African-Americans being particularly affected. As I pointed out in an earlier blog, lack of funding for long term immunosuppression post-kidney transplantation in Medicare insured patients may partially explain the worse outcomes in those insured by Medicare. Similarly a recent small cohort study of African-American live kidney donors published in AJT showed that at nearly 7 years 15.5% had developed an eGFR<60mls/min/1.73m2 and 5.8% had microalbuminuria. Depressingly 52.4% of those donors that had developed hypertension remained untreated. Whilst these differences in outcomes amongst different racial groups effect in part genetic risk factors for disease, it is likely that access to care may also impact on outcomes. Similarly prior to he 'fistula-first' campaign, American dialysis patients were more likely to be subjected to an arteriovenous graft even though the outcomes were known to be worse with a graft, simply because reimbursement favoured the use of grafts.
I am fortunate to work in the UK where the NHS provides free healthcare for all, irrespective of their ability to pay. The NHS was founded in 1948 and was recently memorably celebrated by Danny Boyle in the opening ceremony of the London 2012 Olympics. Like the BBC and the Open University, the NHS is a brilliant, quintessentially British public institution. Of course it is not perfect and there have been issues with quality of care. Yet its strength is that it is valued, cherished and used by a broad swathe of society irrespective of socioeconomic class. It continues to develop with a relatively sophisticated primary healthcare system that is well placed to deal with the epidemic of non-communicable diseases and is widely recognised as being one of the most efficient, cost-effective healthcare systems in the world. It is worth noting that the inception of the NHS was bitterly opposed by medical organisations such as the BMA which worried about the impact of a publicly funded health system on the salary of doctors, prompting the then Health Secretary Nye Bevan to admit that to get the agreement of doctors he had to " stuff their mouths with gold!"
So while national societies and international organisations such as KDIGO and the ISN do great work to promote nephrology care worldwide it is important that we don't lose sight of the bigger picture - early detection of kidney disease and clinical guidelines count for nothing unless governments fund healthcare appropriately. At the moment governments in both the developing and developed world are getting this wrong and are simply not giving adequate priority to publicly funded healthcare and national and international nephrology societies need to start pushing hard on this issue. Universal access to high quality healthcare is a human right not a privilege - now that really is a message worth promoting on World Kidney Day