King Holmes, MD, PhD: Present and Future Challenges in Global Public Health

Present and Future Challenges in Global Public Health September 12, 2009 ICAAC King Holmes

Global Health

Tropical Medicine -> Geographic Medicine -> International Medicine -> International Health -> Global Health

Global health implies global interdependence for health

A broad field that seeks to enable all disciplines to work effectively globally: to understand and solve problems that cause greatest GH morbidity and mortality; and to reduce GH disparities.

Under-standing Global Health – The Acronym Pandemic EB EC EFC EPGH EU FAO FCA FCTC FDI FTA GAP GATS GATT GAVI GBC GDP GFATM GHG GHI GHP GIIC GPA GPGH GOARN GPPP H8 HAART HAI HIC HIV HR IAVI IBFAN ICC IFF IFF(Im) IFM IFPMA IGM IGO IGWG IHG IHP IHR ILO ILSI IMF INFACT INGOs IP IPC IPR ISO LFA LMIC LN LNHO LRCS MAP M&E MDGs METAG MOPH MRA MSF NAM NCD NGO NHG ODA OECD OHIP OR PASB PEPFAR PHC PHM PR PROPER PRSP R&D RBM RF SARS SOP SPHC SPS SPT Stop TB SWAp TAC TB TBT TNC TNPC TPRM TRIPS UIA UK UN UNAIDS UNDP UNESCO UN-HABITAT UNICEF UNFPA US USAID WDR WFPHA WHA WHO WIPO WTO AFAS AIDS AMC ARISE ART ARV ASEAN BAT CAFTA CCM CCS CD CDC CEO CHBC CHGA CIPIH CMH CODEX COMESA COP CSDH CS CSO CSR DAC DALY DDR DFID DPAS DNDi

Major Global Health Agendas

Present and Future Challenges

Emerging Opportunities

Global Health

How many global health priorities can hold our leaders attention simultaneously?

3?

4?

The global communicable disease agenda (HIV, TB, malaria, NTD, EID, ARI, diarrhea) already has 7 main subagendas.

Five Global Health Agendas

Communicable diseases agenda : the unfinished (and unfinishable) agenda: HIV/AIDS, TB, malaria, NTD, EID, ARI, diarrhea

MCH and RH disparities agenda : the unfinished (but more finishable) agenda

Accidents, injury, violence, war : Permanent structural (policy-driven) prevention agendas: 8 th Western Regional International Health Conference Seattle, April 23-25, 2009: Global Health and War

Chronic disease agenda : Aging, nutrition-obesity, diabetes, tobacco smoking, cardiovascular diseases, cancer, mental illness…..

The future “ECO-Health” agenda : Climate change, over-population, migration, environment, & health

Cover of "The Economist", Dec. 13-19, 2003 .

GLOBAL BURDEN OF DISEASE (DALYS) 1990 2020 Lower Respiratory Infection 1 Ischaemic heart disease Diarrhoeal Disease 2 Depression Perinatal 3 Road Traffic Accidents Depression 4 Cerebrovascular Ischaemic Heart Disease 5 COPD Cerebrovascular 6 Lower Respiratory Infection Tuberculosis 7 Tuberculosis Measles 8 War Road Traffic Accidents 9 Diarrhoeal Disease Congenital Diseases 10 HIV Malaria 11 Perinatal Disease COPD 12 Violence Falls 13 Congenital Iron-deficiency anemia 14 Self-inflicted injury Protein calorie malnutrition 15 Bronchial and Lung Cancer

Top causes of death in low- and Allocation of U.S. global health aid by middle-income countries, < 70 y.o. (2001). category (average for 2004-2008).

A Balanced Global Health Agenda

How can we promote investment in research and public health programs in communicable diseases, while promoting a balanced, sustainable global health agenda?

10 Best Buys for Health

Prevent neonatal mortality

Ensure healthier mothers and children

Promote good nutrition

Reduce deaths from cardiovascular disease

Stop the AIDS pandemic

Stop the spread of tuberculosis

Control malaria

Combat tobacco use

Reduce fatal and disabling injuries

Ensure equal access to high-quality health care

*Items in red have an infectious basis

Disease Control: More Specific Key Investment Priorities (Copenhagen Consensus, 2008) *20% of cancer world-wide is due to infection Priority Area Benefit/Cost Annual Benefit 1. Tuberculosis : Appropriate case finding and treatment 30:1 30  10 6 DALYs 2. Heart attacks : Low cost acute management 25:1 4.5  10 6 DALYs 3. Malaria : Prevention and ACT Rx 20:1 20  10 6 DALYs 4. Childhood infections : Vaccine coverage 20:1 20  10 6 DALYs 5. Cancer*, heart disease, other : Tobacco taxation 20:1 20  10 6 DALYs 6. HIV : “Combination prevention” 12:1 22  10 6 DALYs 7. Injury, difficult childbirth, other : District hosp. surgical cap. 10:1 30  10 6 DALYs

Land Area Each territory's size on the map is drawn according to its land area. The land area of each territory is shown here. The total land area of these 200 territories is 13,056 million hectares. Divided up equally that would be 2.1 hectares for each person. A hectare is 100 metres by 100 metres. However, population is not evenly spread: Australia's land area is 21 times bigger than Japan's, but Japan's population is more than six times bigger than Australia's.

“ My wife died a few months ago. Very probably from malaria because she had a lot of fever and was also vomiting. But she never went to a health center. Because of the lack of money.” Révérien, 2004 Malaria Deaths Territory size shows the proportion of worldwide deaths from malaria that occur there.

"I would like to invite all of us to re-affirm our commitment to Stop TB, and thereby gift our children a tuberculosis-free world." Samlee Plianbangchang, 2004 Tuberculosis Cases Territory size shows the proportion of worldwide tuberculosis cases found there.

“ I have come to the conclusion that HIV/AIDS is not entirely about death. People die and will continue to die for one reason or the other. AIDS is also about the living.” Kiiza Ngonzi, 2004 HIV Prevalence Territory size shows the proportion of all people aged 15-49 with HIV (Human Immunodeficiency Virus) worldwide, living there.

Estimated % of global population coverage *However, S. Lim et al. Evidence of over-reporting of vaccine average since GAVI began. Lancet 2008;372:2031-46.

Environment : Clean water Sanitation

Vaccines* : Polio, measles, DPT3 HBV H. influenza B

Micronutrients : Vitamin A Iodine sufficient Fluoride sufficient

DOTS for TB

Modern contraception

Insecticide-treated bed nets

Safe blood

Tobacco abatement policies

0% 20% 40% 60% 80% 100%

Neonatal sepsis

ARI

Diarrhea/ORS

Measles

Malaria

HIV/AIDS

Child Health < 5 y.o.

Prevent tetanus

Essential childhood vaccine coverage

Nutrition, including micronutrients

Safe water

Bed nets

Major causes of death Prevention

Threat of Pandemics

World Air Traffic Flow Chart 35,000 Routes - 2002

Global Infectious Diseases in Humans: The Importance of Animal to Human Transmission

335 newly emerging infectious diseases from 1945 to 2004

Of newly emerging pathogens, 75% are zoonotic

Yang Y, et al. The transmissibility and control of pandemic influenza A (H1N1) virus. Science (In ScienceXpress: 9/10/2009) Influenza Pandemics

The Chronic Disease Agenda The Lancet Vol. 370 Number 9603 December 8-14, 2007

S. Nishtar. Integrating a new public health order. Lancet 2007;370:1901

T. Gaziano et al. Scaling up interventions for chronic disease prevention. Lancet 2007;370:1939-46 Key messages:

The Indian Polycap Study (TIPS). Lancet 2009;373:1341-51 Effects of a polypill (ASA, statin, antihypertensives) (Polycap) on risk factors in middle-aged individuals without cardiovascular disease (TIPS): phase II, double-blind, randomized trial. Indian Polycap Study (TIPS)

Climate Change: mitigation and adaptation “Fiddling while the globe burns” D. Weston 2009

The Future: Climate Change, & Global Health

Changing patterns of infectious diseases

Food safety and security

Water and sanitation

Shelter and human settlements

Extreme events (heat, flood, drought)

Population, migration, mega cities & slums – outgrowing the built environment

Adapted from: Costello A, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 2009;373:1693-1733.

Kibera - in Nairobi, Kenya - the largest slum in Africa – crowding, poor water, poor sanitation, poor nutrition. Commonest course of childhood fever = typhoid

"Everyone here wakes up in anger. People find it very hard and it is getting worse. Day in, day out, poor people from all over Africa arrive in this place, still seeing Lagos as the land of opportunity." Daga Tola, 2006 Slum Growth Territory size shows the proportion of all extra people to start living in slums between 1990 and 2001, that live in slums in that territory.

Lancet 2009;373:1693-1733

Global Health: What Do Developing Countries Need? Work Force Capacity Medicine (> 30 specialties, Primary health care) Public Health Specialists (5-10 specialties) Nursing Pharmacists & Pharmacy Techs Dentists Social workers Community Health Workers Equitable allocation of funding across Education, Health, Poverty, and Infrastructure Sectors Health Leadership, Management, Policy Health leadership, management training Integrated Health Systems Development Public Health Systems Tertiary Hospitals District Hospitals Health Centers Health Posts Certified Laboratory System Access through Roads & Transportation Logistics & Supply Chain Management Financial & Material Resources Reversal of structural adjustment policies Salaries for public sector health care workers Pharmaceuticals Equipment Diagnostics Adequate, Safe Water & Sanitation Nutrition – adequate, safe food supply Housing – especially in emerging mega cities Adaption to climate change Information Systems Etc., Etc., Etc., Etc.

Skilled Work Force for Global Health

Estimated shortage of almost 4.3 million doctors, midwives, nurses & support workers worldwide

Fraction of African-born physicians residing and working abroad in 2000

"Hundreds of thousands of African doctors need to be trained ... Nobody worries about it. There’s a rich part of the world that only cares about oil, diamonds, minerals, forests, gas, cheap labour ..." Fidel Castro, 2001 Territory size shows the proportion of all physicians that work in that territory. Physicians Working

“ [they] are also being poached by industrialized countries. There are more nurses from Malawi in Manchester than in Malawi …" Glenys Kinnock, 2005 Nurses Working Territory size shows the proportion of all nurses that work in that territory.

Brain Drain vs. “Skill Flow:” Best Practices

Improve incentives to serve those in need : e.g., WWAMI model.

Innovate in education finance : e.g., foreign subsidies for training in migrant-sending countries.

Match training to local needs : e.g., use locally relevant curricula

Remove domestic barriers to service providers : e.g., license NPs.

Support regional centers of excellence : e.g., U.W.I. in the Carib.

Support temporary return by skilled emigrants ? Mexico, Ethiopia.

Michael Clemens : Center for Global Development 2009

Public health requirements for rapid progress in global health

TR Frieden and KJ Henning

Global Public Health 2009;4:323-37

Core Global Public Health Functions Functions ( ½ CD-related) Program areas 1) Surveillance Vital records, surveys & epidemiology Surveillance: disease, risk factors, lab 2) Environmental health Water & sanitation, air, nutrition & food, injury, smoke, toxics, vectors 3) Outbreak/ID detection, Contain specific diseases (HIV, STI, TB), investigation, control risk communication 4) Immunization Vaccine policy, delivery, production, coverage 5) Non-communicable diseases Tobacco, food & nutrition, exercise, cancer, screening, alcohol, mental health 6) Clinical care/case mgmt. Direct provision of services, QI & access 7) Health education Inform & educate public & providers 8) Emergency prep & response Outbreak detection; planning; mass immunization & prophylaxis, isolation

Public Health Spending Territory size shows the proportion of worldwide spending on public health services spent in that territory. This spending is measured in purchasing power parity.

Stefano Bertozzi Namibia PEPFAR Implementation Meeting

Enormous Potential for Improved Efficiency and Effectiveness through Strategically Integrated Collaboration

Mead Over: Prevention Failure: The Ballooning Entitlement Burden of US Global AIDS Treatment Spending, & What to Do About It

US reneges on implied commitment to treat those now on ART

We fail to prevent new infections from swelling ranks of those needing ART

We harm the health care of those without HIV

Potential for serious failure, if:

New Opportunities

Explosion of interest from academia

New technologies

New resources from governments, foundations

Public – private partnerships

Professional organizations go global

New strategies

Trends in growth in number of University-based GH programs 300% increase btn 1995 and 2008 From Breyette Lorntz, University of Virginia, GHEC

Consortium of Universities for Global Health (CUGH)

59 N.A. universities meeting at NIH on Monday

University Presidents’ Statement : BU, UC, Duke, Emory, Hopkins, McGill, Stanford, UW: ….“We urge policy makers and health-related foreign assistance programs to use the resources and global health expertise of our universities to deliver high quality, evidence-based, cost-effective and sustainable assistance to partner nations. We stand ready to do so. We welcome other universities to join and support the CUGH.”

New Technologies and Tools

Biotechnology

New vaccines – rotavirus, HPV

New diagnostics - rapid tests: malaria, syphilis - centralized NAATS (mailing swabs from PHCs to central labs)

Information technology - distance learning - surveillance

Generic and FDC pharmaceuticals – HIV, malaria, TB

A global demand for high quality distance education >400,000 hits/month ~14,000 visitors/month from 140 countries ~6 minutes per visit >1000 archived, recorded training sessions Bob Bollinger MD, MPH

New East African High Band Network

“ Show me the money!” Cuba Gooding: Jerry McGuire New Resources

Ravishankar N, et al. Lancet 2009;373:2113-24. By disease Financing of global health: tracking development assistance for health from 1990-2007.

President’s Global Health Initiative Budget (millions) 5/5/09 FY 09 enacted FY 10 budget 6 year total (09-14) PEPFAR 6,490 6,655 (HIV & TB) Malaria 561 762 $51B GH Priorities 1,135 1,228 $12B GHI Total 8,186 8,645 $63B

Why some global health issues attract attention & resources (e.g., HIV/AIDS), while others (e.g., pneumonia, diarrhea, seasonal influenza, malnutrition) do not Social constructionism ; Framing: a “problem” claim (based on severity and neglect) a “solution” (tractability) claim Building “institutions” to carry the torch: e.g., OAR, UNAIDS, PEPFAR, Global Fund, GAVI Emerging examples: NTD; newborn survival; CUGH Shiffman J. A social explanation for the rise and fall of global health issues. Bull WHO Org 2009;87:608-13.

Collins says global health is one of his top priorities New NIH Director Dr. Francis Collins singled out global health as one of five areas he wants to focus on during his tenure, citing it as an example of "soft power" the United States cannot afford to pass up. …… a chance to be more of a “doctor to the world” than a “soldier to the world”…..

NHLBI funds Global Centers of Excellence on Chronic Diseases, and collaborates with UnitedHealth Group ~$35M NHLBI UHG Fogarty Center Bangladesh X X X China X X X Guatemala X X X India (Bangalore, N. Delhi) XX XX XX So. Africa X X X Argentina X X X Mexico X X Peru X X US-Mexico Border X Tunisia X

New Horizons for a Health America: Fragmentation to Integration The Commission on US Federal Leadership on Health and Medicine: Changing Future Direction – April, 2009. A New Vision for Global Health: Develop Long-term Strategies: - “Marshall Plan” for Global Health use Marshall Plan model to coordinate single disease initiatives with broader health infrastructure strengthening. - Streamlines and synergies US investments across Federal Agencies (PEPFAR, USAID, HHS) and international health organizations (get photo from Bob Martin Lab talk) - Implement Health in All Policies in international development and foreign affairs: Global Health Advisor in Department of State

Foundations

Bill & Melinda Gates

Rockefeller

Doris Duke

Wellcome Trust

Bill and Melinda Gates Foundation commitments and disbursements from 1999-2007 Financing of global health: tracking development assistance for health from 1990-2007. Ravishankar N, et al. Lancet 2009;373:2113-24.

Rockefeller Foundation Ariel Pablos-Mendez Transforming Health Systems in Africa and Asia - $100M Initiative Health leadership development Harnessing the private sector Interoperable eHealth Systems Initial Launch – Rwanda, Ghana, Vietnam

Doris Duke Foundation – Africa Health Initiative Implementation Research for Health Systems Strengthening

$44M to 4 partnerships to strengthen health systems

Mozambique: HAI/UW

Rwanda: Brigham and Women’s Hospital

Tanzania and Ghana: Columbia U/Mailman School

Zambia: UAB

Elaine Gallin

Initiative to Strengthen Health Research Capacity in Africa Wellcome Trust, DFID, IDRC Vision: African-led health research that reduces burden of disease and improves health on the continent Mission: Includes enabling research and translating research into policy and practice through capacity development Wellcome Trust support ($48,795,174.76 USD) aims to boost Africa’s research capacity: 86 institutions in 7 consortia.

Public – Private Partnerships PPP CPDD GSK GNF NITD DNDI MMV

INFECTIOUS DISEASE INSTITUTE Merle Sande Warner Greene

Mark Kline, MD

The “Achilles Heel” of Global Efforts to Combat Infectious Diseases Laboratories – time to end the neglect by DRWG members Andrew Ramsay and Emma Back

Berkelman R, Cassell G, Specter S, Hamburg M, Klugman K. The "Achilles Heel" of Global efforts to Combat Infectious Diseases. Clinical Infectious Diseases 2006; 42: 1503.

Petti CA, Polage CR, Quinn TC, Ronald AR, Sande MA. Laboratory Medicine in Africa: A Barrier to Effective Care. Clinical Infectious Diseases 2006; 42: 377-82.

Bates I, Maitland K. Are Laboratory Services Coming of Age in Sub-Saharan Africa? Clinical Infectious Diseases 2006; 42: 383-4.

Okeke IN. Diagnostic Insufficiency in Africa. Clinical Infectious Diseases 2006; 42: 1501-2

Muula AS, Maseko FC. Medical Laboratory Services in Africa Deserve More. Clinical Infectious Diseases 2006; 42: 1503.

Clinical Facilities

ASM International Ambassadors Program International Mentoring Program International Grants & Fellowships International Affairs

ICAAC STUDENTS ON THE MOVE ICAAC International Culinary Arts Academy Cebu 96 P. Del Rosario Extension Streets, Cebu City, 6000 PHILIPPINES www.icaac.net

Development: Old and New Perspectives OLD: ↓ Poverty + ⁭ Infrastructure -> ⁭ Education -> ⁭ Health Dean Jameson, 2008 ⁭ Infrastructure NEW: ⁭ Health ⁭ Education ↓ Poverty Development

A Strategic Approach to Global Health for 21 st Century

HIV vs. other comm. disease -> Develop synergies in doing both

Communicable disease vs. non- -> Develop strategic workforce communicable disease vs. leadership, policy, and systems injuries strengthening as essential components of all major health programs; bundle ID interventions with complementary interventions in “packages”

Health vs. Poverty Reduction vs. -> Promote cross-sectoral inter- Infrastructure vs. Education dependence in development (IDID)

Avoid Conflict on: Instead:

Interagency turf battles -> Set targets for joint interagency projects, reward successful collaborations

Summary: Global Health - 2009 Many Problems - 5 major GH agendas Many Needs & Challenges - workforce, infrastructure, health systems, economy, population, climate change Many New Opportunities - Academia, technologies, resources, partnerships, strategies We are beginning to make a difference We can make a much bigger difference if we work together, strategically, and systematically

Many People are Making a Difference in Global Health Haile Debas Mark Kline Jimmy Whitworth Elaine Gallin Marcel Tanner Jaime Sepulveda Tachi Yamada Warner Greene L. Mpanga Sebuyira Roger Glass Nelson Sewankambo Ariel Pablos-Mendez Peter Piot Anne Johnson Richard Hayes David Mabey Alex Coutinho Tim Brewer Michele Barry Stephano Bertozzi Mike Cohen Chris Elias Kathy Neuzil Ruth Nduati Dorothy Mbori-Ngacha Patricia Garcia Tom Quinn Amy Hagopian Steve Gloyd Judy Wasserheit Emmanuela Gakidou Dean Jamison Steve Lim Bob Bollinger Bob Black Bill Foege Ann Downer Waafa El-Sadr Judd Walson Grace John-Stewart Mike Merson Jeff Koplan Chris Murray Elizabeth Nabel Jerry Keusch MOH Tedros Paul Farmer Eric Goosby Quarraisha Abdool Karim