Del-Rio- The-Past-Present-and-Future-of-Global-Health-2010-10-01
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The Past, Present and Future of Global Health Engagement by Academic Ins=tu=ons CARLOS DEL RIO, MD HUBERT DEPARTMENT OF GLOBAL HEALTH EMORY UNIVERSITY
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Transcript of Del-Rio- The-Past-Present-and-Future-of-Global-Health-2010-10-01
The Past, Present and Future of Global Health Engagement by Academic Ins=tu=ons CARLOS DEL RIO, MD HUBERT DEPARTMENT OF GLOBAL HEALTH
EMORY UNIVERSITY
What does the American public think global health is?
Harr, “Defini=ons of Global Health,” Journal of Public Health Policy, 2008
Ø Focus groups as forma-ve research for Rx for Survival TV series – to test audience’s understanding of the terms “global health” and “public health”.
Ø Many people thought “public health” meant health for poor people.
Ø Thought most serious global health threats were diseases like anthrax and smallpox.
Ø Most knew that HIV/AIDS was a serious problem but considered tuberculosis and malaria to be diseases of the past, and no longer problema-c.
History of Global Health
Tropical Medicine
• self-‐interest • colonial
expansion & slave trade
• ID control: plague, yellow fever, cholera, malaria
Interna-onal Health
• “them” and “us” • paternalis-c? • smallpox, malaria, child survival, family planning
Global Health
• partnership • interdependence • health & development (MDGs)
• systems
~1960 Independence
~2000 Millennium
Early 20th C 15th C →
Scien=fic developments; growth of capitalism; increased speed of transporta=on & travel
History of Global Health The bugs: Plague, cholera, yellow fever… Tropical
Medicine
20th century wars: WWI & II, Wars of Independence, Cold War
Ø AUempts at interna-onal coopera-on to control IDs Ø 1918-‐9 Flu pandemic Ø Vaccine development e.g. 1936 Yellow Fever – Rockefeller Founda-on as GH NGO
Post WWII: Ø Par-ally successful malaria elimina-on Ø 60-‐70s Eradica-on of smallpox Ø 1978 Alma Ata Declara-on (PHC) Ø 1979 Selec-ve Primary Health Care (GOBI) Ø 1970/80s focus on child survival, family planning Ø 1980s Structural Adjustment Ø 1980s HIV/AIDS
Interna-onal Health
What is global health?
q Interna-onal health Ø Health prac-ces, policies and systems in countries other than one's own, stressing more the differences between countries than their commonali-es. It is a concept more focused on bilateral foreign aid ac-vi-es than on collec-ve ac-on, to disease control in poor countries, and to medical missionary work.
q Global health Ø Health issues and concerns that transcend na-onal borders, class, race, ethnicity and culture. The term stresses the commonality of health issues and which require a collec-ve (partnership-‐based) ac-on.
Global Health Educa-on Consor-um, 2008
"health problems, issues and concerns that transcend na4onal boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by coopera4ve ac4ons and solu4ons."
Ins=tute of Medicine
The term “Global health” was first used by the University of California San Francisco in 1999
Since them curricula, programs, centers, departments and ins-tutes have flourished in academic ins-tu-ons
CUGH (The Consor-um of Universi-es for Global Health) was formed in 2008 and now includes nearly 100 North American Universi-es and colleges.
A new Global Health competency model recently developed by the Associa-on of Schools and Programs of Public Health.
Approximately 1/5 of US medical specialty residencies have global health ac-vi-es
Merson, M. NEJM 2014
Incomplete Transi=ons Ø Incomplete transi-on from Tropical Medicine through Interna-onal Health to Global Health
Ø Incomplete transi-on from Bugs to People to Systems
A “brief” ins=tu=onal history of GH WHO – 1948 Alma Ata Conference – 1978 World Bank – ◦ 1987 – Financing Health Services ◦ 1993 – Inves&ng in Health (The DALY) Public-‐Private Partnerships (PPP) – 1998 The Bill and Melinda Gates Founda-on -‐ 2000 The Global Fund – 2002
Why is there growing interest in global health?
Ø Sense of a “global community” Ø Changing demographics of U.S. prac-ces
§ Increasing immigra-on, adop-on
Ø Increasing travel to developing countries Ø Educa-onal benefits Ø Commitment to social jus-ce
Summary Demographic Na=onal Data (and Source) Popula-on (2009 CB est.) 307,066,550 Popula-on (2000 Census) 281,421,906
Foreign-‐Born Popula-on (2009 CB est.) 38,517,234
Foreign-‐Born Popula-on (2000 Census) 31,107,573
Share Foreign Born (2008 CB est.) 12.5%
Share Foreign-‐Born (2000 Census) 11.1%
Immigrant Stock (2000 CB est.) 55,890,000
Share Immigrant Stock (2000 est.) 20.4%
Naturalized U.S. Ci-zens (2009 Census) 16,028,758
Share Naturalized (2009) 41.7%
Immigrant Admissions (DHS 2000-‐2009) 9,105,162
Illegal Alien Popula-on (2008 FAIR est.) 13,000,000
Educa=onal benefits of global health elec=ves for medical students and residents
Ø Improve clinical diagnosis skills Ø Knowledge and training in tropical medicine Ø Attudinal changes § Public health service, commitment to underserved popula-ons
Ø Recruitment to residency programs
Drain, et al. Academic Medicine, 2007. Thompson, et al. Academic Medicine, 2003.
ADDRESSING HEALTH INEQUALITIES AND PROMOTING SOCIAL JUSTICE IS PART OF OUR MISSION AS
PHYSICIANS
“FARMER TOLD ME THAT HE FOUND HIS LIFE’S WORK NOT IN BOOKS OR IN THEORIES BUT MAINLY THROUGH EXPERIENCING HAITI.”
TRACY KIDDER.
MOUNTAINS BEYOND MOUNTAINS.
MDG’s – through 2015 1. End Poverty and Hunger 2. Universal educa-on 3. Gender equality 4. Child health 5. Maternal health
6. Comba-ng HIV/AIDS, malaria and TB 7. Environmental sustainability 8. Global partnership
Key Players in Global Health
Ø World Health Organiza-on and other UN organiza-ons Ø UNICEF, UNDP, UNAIDS
Ø World Bank and IMF Ø Bilateral – government to government Ø NGOs Ø Business and industry Ø BMGF Ø Global Health Ini-a-ves (GHI)
WHO Challenges
Ø Limited funding Ø Cons-tuency – all member na-ons Ø Contradic-on -‐ loca-on in Switzerland, rich and expensive country, belies emphasis on poorest of the poor Ø Mismatch between need and alloca-on of WHO resources -‐ human and financial Ø Changing burden of disease Ø WHO deals with ministries of health
Bill and Melinda Gates Founda=on
Ø $34 billion in assets (2009) Ø Global health grants (1994-‐2005) -‐ $5.1billion Ø HIV/TB and repro health -‐= $1.45 billion Ø Infec-ous diseases -‐ $1.1 billion Ø Global health strategies -‐ $2.3 billion Ø Global health technologies -‐ $211.5 million Ø Global health research, advocacy and policy -‐ $109.2 million
Ø AIDS provided the founda-on for a revolu-on that upended tradi-onal approaches to “interna-onal health” replacing them with innova-ve global approaches to disease
Ø The epidemic disrupted the tradi-onal boundaries between public health and clinical medicine, in par-cular the divide between disease preven-on and treatment.
Ø Disease advocacy and ac-vism became main stream
Ø AIDS triggered important new commitments in funding of health care in developing countries
Ø HIV/AIDS has aUracted remarkable levels of private philanthropy and led to new public-‐private partnerships that have become a model for funding scien-fic research.
Ø AIDS has spurred a debate about the cost of essen-al medicines
Ø AIDS incorporated human rights into the discourse
Brandt A. NEJM 2013
The Past, Present and Future of GH and AIDS 1981 – First cases reported 1983 – virus isolated 1986 – AZT trial 1993 – ACTG 076 1996 – HAART 2000 – Durban AIDS Conference 2001 – UNGASS 2002 – Global Fund 2003 – PEPFAR
HIV/AIDS Ø Declared na-onal security threat by Clinton Administra-on Ø 7,000 thought to be dying a day Ø Peak of epidemic now believed to be mid-‐90s, but not evident un-l late 2000s Ø Pressures of epidemic & need to roll out medica-ons highlights fragility of health systems. Renewed interest in Alma Ata Ø Some use AIDS moneys to try to build health system (cf. Farmer response to GarreU)
Piot P, et al. NEJM 2013
ART STOPS HIV Transmission NEJM Aug 11, 2011
Ø 1.2 billion people are tobacco users Ø 370 million people live with diabetes Ø 972 million people (1 in 4 adults) have high BP Ø 1 billion people are overweight
Ø 25m people live with cancer Ø 32 million heart aUacks and strokes globally / year
Ø Heart disease and stroke claim 17.2 million/year Ø Cancer kills 7.9 million people annually Ø Diabetes kills 4 million people each year
Key Global Sta=s=cs
Various sources: WHO, IDF, IUC
Lozano et al, GBD Study, Lancet 2012
Global death ranks with 95% UIs for the top 25 causes in 1990 and 2010
NCD’s: Defini=ons & Condi=ons
• Non-‐communicable Diseases = – a disease which is not infec-ous; may result from hereditary or acquired lifestyle factors
– broadly include all: • Cardio-‐metabolic (hypertension, diabetes, cardiovascular diseases) • Cancers • Chronic respiratory disease (chronic bronchi-s/emphysema) • Mental health problems • Injuries
NCDs Ø Intersec-ons between globaliza-on, urbaniza-on, poverty and health Ø Majority of deaths in LMIC. Increasingly problem of poor, rural areas of LMIC: mechanized transporta-on, foods, rural-‐urban migra-on
Ø Impact people during most produc-ve years of life: profound impact on economies, households
Ø Currently, at least 300 m. people have diabetes worldwide
Ø Health & public health systems: integrated models of care for lifelong management of NCD condi-ons
Ø Advocacy and behavior change
Risk transi=on
WHO Global Health Risks Report, 2009
Changes in Life Expectancy
1900 1950 1980 2000 2030 USA 49.3 68.9 74.1 77.4 81.2
Mexico < 30 50.8 67.4 74.9 80.1
Brazil < 30 50.9 63.3 71.1 77.4
China ≈ 30 40.8 65.5 72.0 77.4
India < 25 37.4 56.6 62.9 72.6
LDCs 40.8 58.8 64.1 71.5
2006 Revision and World Urbaniza-on Prospects: The 2005 Revision, hUp://esa.un.org/unpp, Wednesday, March 12, 2008
Time of Rapid Economic Changes
Diabetes is a huge and growing problem, and the costs to society are high and escalating
382 million people have diabetes
By 2035, this number will
rise to 592 million
The socially disadvantaged in any country are especially vulnerable to diabetes
Lessons from HIV….. Ø The search for cause & cure and fight to control the epidemic has to be global
Ø Strong surveillance systems are key
Ø Prevention must be linked to early diagnosis and treatment, integrating community and clinic resources
Ø Prevention should integrate behavior and biomedical approaches
Ø Building advocacy is important
Narayan et al. New Eng J Med. Sept 8, 2011
Narayan et al. New Eng J Med. Sept 8, 2011
Annual No of HIV-infected cases Annual No of AIDS-related deaths Annual Investments on HI/AIDS
Impact of Global Cooperation and Investments
UN HLM on NCDs, Sept 2011 Ø Only second ever HLM (first UNGASS, 2001). Unlike AIDS, not single disease with few specific interven-ons; less global anxiety; less social mobiliza-on. Ø Whole of government and whole of society response: effec-ve response beyond individual actors
Ø Role of interna-onal trade & subsidy Ø Access to essen-al medicines; move health systems from episodic, fragmented care to con-nuous, integrated care. Ø Need for surveillance, measurable targets and funding
Post-‐HLM “The maintenance of the momentum generated by the UN Declara-on will depend in part on a streamlined, inclusive, and democra-c civil movement that is proac-ve, poli-cally focused, and able to work coopera-vely with global and na-onal ins-tu-ons.” “Preven-on of NCDs is also inextricably linked with climate change and the need for low-‐carbon policies.”
Beaglehole et al., “NCDs: celebrating success, moving forward,” Lancet, 8 October 2011
Beaglehole et al., “Priority actions for the NCD crisis,” Lancet, April 6, 2011
WHO on Post-‐MDG Agenda “future goals and indicators need to: be framed as global challenges rather than aspira-ons for developing countries” “the paper notes: the need to address the emerging challenge of non-‐communicable diseases without disregarding other priori-es”
“The paper then explores the poten-al for using universal health coverage in the post-‐2015 agenda as a way to accommodate these concerns”
International Institute for Sustainable Development, “WHO Identifies Key Health Issues for Post-2015 Development Agenda, http://uncsd.iisd.org/news/who-identifies-key-health-issues-for-post-2015-development-agenda, October 2012
4 x 4 of NCDs 4 types of NCD priori=zed: Ø Cardiovascular diseases Ø Diabetes Ø Cancers Ø Chronic respiratory diseases
4 shared & modifiable risk factors: Ø Tobacco use Ø Unhealthy diets Ø Physical inactivity Ø Harmful use of alcohol
Themes / Paeerns Ø NCDs are highly prevalent Ø Common features and common set of RFs Ø NCDs exert major burdens worldwide (death, disability, costs) – reflects shiying epidemiological paUerns Ø NCD burdens growing fastest in LMICs (linked to globaliza-on) Ø NCDs growing in low SES; perpetuates poverty and stagnates economic development Ø Intersec-ons with pneumococcal, TB, HIV Ø Essen-al to achievement of MDGs Ø Preventable/avoidable – primordial preven-on (e.g., FCTC) or recognize & manage risk factors early
Key points Ø The global burden of disease increasingly reflects the intersec-ons between globaliza-on and health: 60% of all deaths worldwide due to NCDs, 80% occur in LMIC, with profound implica-ons for economies and health systems Ø Addressing NCDs key to achieving MDGs
Ø FCTC a first: galvanized policy-‐level support; progressive realiza-on proving slow Ø Need for civic mobiliza-on to harness posi-ve aspects of globaliza-on for global good. HLM as galvanizing force.
Obama’s Global Health Ini=a=ve GHI commits “to address these problems by tying individual health programs together in an integrated, coordinated, sustainable system of care, with countries themselves in the lead.”
“Improving the overall environment in which health services are delivered… tackling some of those systemic problems and working with our partner countries to uproot the most deep-‐seated obstacles that impede their own people’s health….”
“We are linking our health programs to our broader development efforts to address those underlying poli?cal, economic, social and gender problems…”
SMART aid: Integra=on Coordina=on Sustainability Country-‐led Leadership Systems-‐oriented Root causes
Core principles: Ø Female centered focus Ø Strategic coordina-on Ø Mul-lateral engagement Ø Country ownership Ø Strengthening health systems Ø Monitoring and evalua-on
Ebola Outbreak in 2014
hUp://onforb.es/Y3YjoG
A. Vespignani et al. Modeling projec-on of cases if spread con-nues at current rates. hUp://news.sciencemag.org/health/2014/08/disease-‐modelers-‐project-‐rapidly-‐rising-‐toll-‐ebola
Ebola in 2014 and health systems
Will the current Ebola outbreak finally lead to a real commitment to strengthen health systems?
Global health is “smart power”
An integral part of the government’s three pillars of foreign policy: Ø Diplomacy Ø Development Ø Defense
Designed to improve health while strengthening interna-onal rela-ons When the US uses health as a tool of diplomacy it sends a powerful message about its na-onal values
Global health as public health at its best? Ø Addresses socio-‐contextual determinants Ø Interdisciplinary, systems-‐oriented, collabora-ve, based in partnership Ø Not squeamish about incorpora-ng clinical care Ø Transna-onal issues, determinants, solu-ons; “without a passport”
What Global Health is going to be is “a work in progress”.
Forces in Public Health
Policy Environment &
Enforcement
Science Effective
interventions
Epidemiology Needs and
Risks Resources Human,
Financial, Infrastructural
What does the future hold for GH in academic ins=tu=ons? University administra-ve and other support services will require addi-onal exper-se to address the legal, financial, ethical, technical and compliance issues inherent in working interna-onally. Innova-on in technology development and delivery of health care services will be increasingly more relevant. Career paths will need to be beUer defined to keep the interest and momentum in global health Declining resources for global health and shiy of resources more to low and middle income countries. Need to move from disease-‐specific approaches to interdisciplinary collabora-on in discovery and delivery
Merson M. NEJM 2014
Merson M. NEJM 2014
Educa=on in Global Health Who are we educa-ng? For what jobs? What skills do students need? Are they all the same? (MDs; MPHs; PhDs?)
Greater need for leadership and management training
Specific skill sets iden=fied Business skills: ◦ Project management including budgetary, strategic planning , cost/benefit analysis, organiza-onal management and poli-cal sensi-vity
Wri=ng skills: ◦ Scien-fic and grant wri-ng skills; persuasive wri-ng and wri-ng for diverse audiences
Interna=onal development: ◦ Understanding the history and context of the work new graduates will embark on was sees as cri-cal need not currently addressed
Language skills: ◦ While it may not be feasible to advocate for language requirements there is an opportunity to beUer provide opportuni-es for students to obtain proficiency in a language if needed
Word wordle on global health challenges
PLoS Medicine, December 2005
“The ability to empathise with others requires the critical examination of our individual lives and of our nations’ actions, the capacity to see ourselves as bound to all other human beings, and the sensitivity to imagine what it might be like to be a person living a very deprived and threatened life.”
Acknowledgements K. M. Venkat Narayan, MD, MSc, MBA
Mohamed Ali, MBChB, MSc, MBA
Jeffrey Koplan, MD, MPH
Kate Winskell, PhD
