Friday, 11 April 2014

The Health of Society

In these exclusive interviews, we speak to Dr. Julio Frenk (Dean of the Harvard School of Public Health, and former Minister of Health of Mexico), Sir Richard Thompson (President of the Royal College of Physicians), Baron Peter Piot (Director of the London School of Hygiene and Tropical Medicine) and Dame Sally Davies (The United Kingdom’s Chief Medical Officer). We talk about the concept of public health, the most important health challenges the world currently faces, and opportunities for the future.

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Vikas Shah, Thought Economics, April 2014

Health,” as defined in the WHO constitution “…is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Given that each and every human on the planet is an almost unimaginably complex system of 37 trillion cells, its unlikely that we will ever reach this utopian goal, but it’s pursuit has amassed some significant victories.

Smallpox has been completely eradicated, leprosy has been virtually eliminated, and polio will be eradicated in the next few years. The antibiotic era has saved countless lives around the world, and vaccinations have prevented tens of millions of deaths and protected hundreds of millions more against disease. In 1900, global average life expectancy was just 31 years, and well below 50 in even the richest of countries. For most of the world now, life expectancy is around 70 years, with rich countries having significant populations over 80 years old.

These are significant successes, but many health challenges still remain. 14 million new cases of cancer are reported every year, and almost 20 million people die of cardiovascular disease. Poor sanitation, lack of access to basic healthcare and other preventable causes also take the lives of tens of millions of people each and every year in the developing world. Our successes have also led to a vast increase in the number of chronic diseases our population must cope with (a bi-product of getting older). More than 35 million deaths each and every year can be attributed to chronic disease, and tens of millions more

Delivering the complex gamut of products and services within healthcare has created a huge industry which employs tens of millions of people worldwide and which is conservatively estimated to be worth at least US$5.5 trillion, just under 10% of the entire world economy.

So how far have we come in public health, and what does the future hold?
In these exclusive interviews, we speak to Dr. Julio Frenk (Dean of the Harvard School of Public Health, and former Minister of Health of Mexico), Sir Richard Thompson (President of the Royal College of Physicians), Baron Peter Piot (Director of the London School of Hygiene and Tropical Medicine) and Dame Sally Davies (The United Kingdom’s Chief Medical Officer). We talk about the concept of public health, the most important health challenges the world currently faces, and opportunities for the future.

Since January 2009, Dr. Julio Frenk is Dean of the Faculty at the Harvard School of Public Health and T & G Angelopoulos Professor of Public Health and International Development, a joint appointment with the Harvard Kennedy School of Government.

Dr. Frenk is an eminent authority on global health who served as the Minister of Health of Mexico from 2000 to 2006. He pursued an ambitious agenda to reform the nation’s health system, with an emphasis on redressing social inequality. He is perhaps best known for his work in introducing a program of comprehensive national health insurance, known as Seguro Popular, which expanded access to health care for tens of millions of previously uninsured Mexicans.

Dr. Frenk was the founding director-general of the National Institute of Public Health in Mexico, one of the leading institutions of health education and research in the developing world. In 1998, Dr. Frenk joined the World Health Organization (WHO) as executive director in charge of Evidence and Information for Policy, WHO’s first-ever unit explicitly charged with developing a scientific foundation for health policy to achieve better outcomes.

Most recently, he served as a senior fellow in the global health program of the Bill & Melinda Gates Foundation and as president of the Carso Health Institute in Mexico City. He is chair of the board of the Institute for Health Metrics and Evaluation at the University of Washington. Dr. Frenk holds a medical degree from the National University of Mexico, as well as a Masters of Public Health and a joint doctorate in Medical Care Organization and in Sociology from the University of Michigan. He has been awarded three honorary doctorates.

He is a member of the U.S. Institute of Medicine, the American Academy of Arts and Sciences, and the National Academy of Medicine of Mexico. In addition to his scholarly works, which include more than 130 articles in academic journals, as well as many books and book chapters, he has written two best-selling novels for youngsters explaining the functions of the human body. In September of 2008, Dr. Frenk received the Clinton Global Citizen Award for changing “the way practitioners and policy makers across the world think about health.

Sir Richard Thompson is the most senior RCP (Royal College of Physicians) officer and leads the RCP on behalf of its fellows and members.

Sir Richard trained in natural sciences and medicine at Oxford and St Thomas' Hospital Medical School. After junior posts in London, he joined Dr Roger Williams in the early days of the liver unit at King's College Hospital, and spent 18 months with Professor Alan Hofmann at the Mayo Clinic. In 1972 he was appointed physician and gastroenterologist at St Thomas' Hospital until his retirement in 2005. He led an active clinical research laboratory for over 30 years, chiefly studying various aspects of nutritional gastroenterology, as well as supervising 30 MD and PhD theses, and publishing over 200 papers.

He was an examiner and censor at the RCP, sat on the Management and Grants Committees of the King's Fund, and for 21 years was physician to HM The Queen.

He was treasurer of the RCP from 2003 until being elected president in 2010. He is a trustee of several charities, was a member of an independent monitoring board of a young offenders institute and is a member of the Ministry of Defence Research Ethics Committee.

Baron Peter Piot is the Director of the School and a Professor of Global Health. In 2009-2010 he was the Director of the Institute for Global Health at Imperial College, London. He was the founding Executive Director of UNAIDS and Under Secretary-General of the United Nations from 1995 until 2008, and was an Associate Director of the Global Programme on AIDS of WHO. Under his leadership UNAIDS became the chief advocate for worldwide action against AIDS, also spear heading UN reform by bringing together 10 UN system organizations.

He has a medical degree from the University of Ghent (1974), and a PhD in Microbiology from the University of Antwerp (1980). In 1976 he co-discovered the Ebola virus in Zaire while working at the Institute of Tropical Medicine in Antwerp, Belgium, and led research on HIV/AIDS, sexually transmitted diseases and women's health, mostly in sub-Saharan Africa. He was a professor of microbiology, and of public health at the Institute of Tropical Medicine, Antwerp, the Free University of Brussels, and the University of Nairobi, was a Senior Fellow at the University of Washington, a Scholar in Residence at the Ford Foundation, and a Senior Fellow at the Bill and Melinda Gates Foundation. He held the chair 2009/2010 "Knowledge against poverty" at the College de France in Paris, and was a visiting professor at the London School of Economics.

He is a Fellow of the Academy of Medical Sciences and was elected a foreign member of the Institute of Medicine of the US National Academy of Sciences, and is also an elected member of the Académie Nationale de Médicine of France, and of the Royal Academy of Medicine of his native Belgium, and a fellow of the Royal College of Physicians. He was knighted as a baron in 1995, and published over 500 scientific articles and 16 books. In 2013 he was the laureate of the Hideyo Noguchi Africa Prize for Medical Research.

Dame Sally became Chief Medical Officer for England and Chief Medical Advisor to the UK Government on 3 March 2010. She retains responsibility for Research and Development, and is the Chief Scientific Adviser for the Department of Health.

Dame Sally is independent advisor to the Government on medical matters, with particular responsibilities regarding Public Health. She provides professional leadership for Directors of Public Health and will lead a public health professional network for those responsible for public health services. She is professional head of the Department’s medical staff and head of the Medical Civil service

Sally has been actively involved in NHS R&D from its establishment and founded the National Institute for Health Research (NIHR) with a budget of £1 billion.

Sally has led UK delegations to WHO summits and forums since 2004 and has played an active role on numerous international committees including WHO Global Advisory Committee on Health Research (ACHR). She has advised many others on research strategy.

Her own research interests focused on sickle cell disease.

Q: What is public health?

[Dean Julio Frenk] Public health is mostly a field for research and inquiry, but it's also an arena for action. The best way to think of public health as to see it tackling the health needs of an entire population rather than individuals (that is mostly what medicine does). I am a physician, but when I went into public health I said that my position was now that society would be my patient.

The essence of public health as a field of action is that it tries to stop problems from happening where possible, and prepares societies for problems that are unavoidable. That's why it requires us to understand the entire population.

Much like medicine where on one hand we diagnose problems, and on the other we prescribe; so too does public health which has two main branches- research and action. One is to understand the health conditions in a population - what are people getting sick from, and why (diseases and their determinants, distribution, risk factors and so on). The other side of public health is to determine how we ameliorate those conditions, how we prevent them, and how we treat them when we cannot prevent them.

In public health we also look at how societies respond to health problems through their public health systems. We look at the diseases affecting societies, and how health systems are structured. When there are big upheavals in this regard such as in the United States with the Affordable Care Act, we- in public health- would study how different methods of financing and delivering healthcare work when compared with others - and this research translates into policy.

[Prof. Dame Sally Davies] Public health goes everywhere. Winslow defined it as 'the science and art of preventing disease, prolonging life, and promoting health through the organised efforts of society'. I think that's a good start, but we have to see the culture and ecosystem of public health in the context of the community (as was pioneered by Prof. Margaret Whitehead in Liverpool). Not only is happiness important to public health, but so is GDP and the environment. It's an immensely broad subject.

Q: What is global health?

[Prof. Peter Piot] Many of our health problems challenges cannot be solved within one specific border. In the old days, we had 'tropical medicine' which was a colonial approach. This led to international-health during the cold-wars which simply meant the health of those far away. Now we have the concept of 'global health' which reflects the globalisation of the world.

The most obvious example of this can be found in the sphere of infectious diseases which- of course- know no borders and therefore need a global approach. Examples can also be found in areas such as chronic disease; especially those driven by global market forces such as smoking.

Q: To what extent should health be considered a human right?

[Prof. Peter Piot] The right to health exists in the constitution of many countries such as Brazil, South Africa and many Latin American countries. What matters however, is how you define health. The concept is always limited by resources which- by their nature- are not infinite. It is also important to understand whether these statements make it a right for everybody. There is a huge amount of health-access inequality around the world.

In most of the world today, for someone's life to be shortened by not having access to healthcare, is considered an important violation of their human rights.

Q: What is the role of the physician in public health?

[Sir Richard Thompson] Every poll suggests that Doctors are at the top of the list of individuals that are most trusted by the population. We impact the health of the population through one to one- doctor to patient- conversations. That is however, a limited number of conversations, and by the nature of the activity- limited to those who are unwell (otherwise they wouldn't come to see us!).

Doctors play a critical role in the public health agenda. They've driven some of the most important policies in this regard such as the various UK Clean Air Acts and tobacco control and alcohol policies. With regard to inequality and economic matters; there is not much that physicians can directly do about health-inequalities themselves, albeit we can influence society to reduce those inequalities.

Physicians, to an extent, are also a bridge between government, private-enterprise and the individual. If you consider pharmaceutical companies and medical instrument makers- we do liaise with them closely and help them to provide the tools we need to do our work. I'm very fond of saying that doctors themselves don't achieve very much... It's the pharmaceutical companies and instrument makers who produce the advances that doctors are then able to apply to patients.

Q: What is the role of the patient and the public themselves in public health?

[Sir Richard Thompson] Society plays an enormously important role in public health. Most medical challenges are highly dependent on the way that patients look after themselves.

If you look at obesity for example- it comes down to the simple fact of whether you are eating more than you need. Even if you have a rare genetic disorder, it still ultimately makes the individual eat more. Much like obesity being caused by overeating, we see that alcohol related conditions are caused by individuals- to a degree- voluntarily drinking the alcohol themselves... and similarly for smoking and drugs.

We would also encourage patients to take more exercise, whether that be direct exercise or through pursuits such as gardening (which is one of the things I'm interested in!). If we could suddenly stop people being obese, we would save a huge-amount of health service costs- even if you consider diabetes alone!

In terms of the future financing of the health system, changing the public's attitudes towards their own lifestyles is the only way we can go- otherwise we shall be overwhelmed with the complications of lifestyle related illnesses.

Q: What are the key public health challenges we are facing today?

[Sir Richard Thompson] The most important growing public health challenge we face today is obesity. We have to change the attitudes within society towards obesity in the manner we have for smoking so that people don't want others to be obese. Changing attitudes so that society thinks it's not good to be overweight is critical; it's about society realising that it's not just unhealthy, but also that it's not something you want others to be. Only if we can produce those changes will we really get a handle on the obesity epidemic.

These are not just issues for the developed-world.. All the problems that we are seeing in the public health arena here such as elderly populations, smoking, obesity and alcohol- are just on the horizon for many countries around the world. I was recently in one of the middle-eastern countries and there was a scientific poster up showing the causes of acute pancreatitis in their country (inflammation of the pancreatic gland). I went up to look more closely, and guess what... the commonest cause found was alcohol... even though the country was meant to be dry.

Alcohol contributes to obesity and other diseases, but also is a major cause of accident and injury around the world.

Smoking remains an enormously important issue. In the developing world, more and more people are now smoking. This doesn't just cause cancer, but has cardiovascular impact, skin impact and more. And these health problems are completely unnecessary. You could make an argument for alcohol as having some social-benefit when you look at the cohesion of people going for a drink, but you cannot make any argument for smoking as being beneficial or important to society. The Army did a study that showed that young people (aged around 17) who smoked did less well in training than those who didn’t; even at this early age, smoking was doing significant damage. Legislation has been effective against smoking. We are close to having a ban on smoking in cars, while and the clean air acts (something) pollution, completely changed hospitals overnight. We no longer saw patients coming in with lung disease and immediately going on ventilators... it was a dramatic change.

It's very difficult to change your genes, but you can change your lifestyle.

Q: What are the key global health challenges we face today?

[Prof. Peter Piot] We still have a huge unfinished agenda. Despite what people may think, the battle with HIV/AIDS is not over- we have over 2million new infections, and 1.6 million deaths per year... Malaria is the same.. and these conditions are particularly prevalent in Sub-Saharan Africa.

On the other hand, our new health challenges are in non-communicable diseases.... obesity, mental-health, diabetes and so on. If you take Asia, the Middle East or Latin America, these are the big risks- and are closely linked to lifestyle and the globalisation of risks. The solutions here are not in new-medications but rather from influencing lifestyles and engaging in structural interventions.

We have tremendous capacity challenges too. Human resource is a big issue in many countries- both in terms of healthcare practitioners, and also service delivery. There are also significant capacity problems in funding strategy and policy... very often most of the money would be absorbed into a big hospital in a capital city, while other communities may suffer. There is also a lack of innovation in delivery. There is no need for many health services to be delivered by a doctor where there is a shortage, and expensive training. One could have far more impact with community based approaches, delivered by people who have fewer skills- but who (with standardised interventions) can certainly engage in chronic care for example.

Q: What are the key challenges and opportunities in the sphere of communicable disease?

[Dean Julio Frenk] If we look at the first pillar of public health, where we understand the distribution, frequency of distribution and determinants of disease in populations; infectious diseases inevitably play large part. In fact, the origins of public health and some of our biggest victories in this arena have been with regards infectious diseases.

It has been estimated that in the United States during the 20th century, life expectancy grew by 30 years. 25 of those 30 were attributable to public health measures and a lot of that was due to public-health interventions such as better sanitation and vaccines. Despite these victories we have not won the fight against infectious diseases. They are a constant part of the epidemiological picture of any society.

Today we have three main challenges with regards to infectious diseases.

Firstly we have to finish what we have started, and deal with the unfinished agenda of fighting those common infections that have been around since almost the beginning of human-kind and which still exact an unacceptable toll of death and suffering around the world. These are common respiratory infections, gastrointestinal disease and vaccine preventable diseases like measles where we have all the technology to stop. Diseases such as malaria and tuberculosis which have been with us for millennia are the real unfinished agenda of public health. We have the knowledge, but we have failed to act.

The second challenge relates to new and emerging infections. The most famous in recent memory is HIV/AIDS which appeared a little over 30 years ago and went on to be the major infectious disease of human history in terms of the number of cases and the number of deaths. Everyday there are new strains of existing bacteria and viruses that emerge. Some of these adopt the form of pandemics such as the 2009 strain of H1N1 influenza; and a lot of them are what we call zoonoses - diseases that start in animas and then mutate into human populations that aren't prepared for them.

The third challenge relates to re-emerging infections. These are conditions which we thought we had eradicated but which are now growing again such as Cholera; which had been eliminated in the Western Hemisphere but is now making a come-back. A big risk in regards to re-emerging diseases is the fact that they may be re-introduced into populations through acts of bio-terrorism. A disease such as smallpox which has been eradicated since the 1970s could be re-introduced into the human population as people born after its eradication would not have been immunised. This would be enormously dangerous.

[Prof. Dame Sally Davies] Early this century as people began to think we had beaten communicable disease and focussed on non-communicable disease, we began to see that many communicable diseases had not gone away such as influenza viruses, zoonoses, and infections such as Ebola.

Antimicrobial resistance (AMR) is of huge concern and is growing, we are moving toward a post-antibiotic era. If you look at the data; at least 25,000 Europeans and 23,000 Americans die each year of antimicrobial resistance- it's equivalent to road traffic accidents and is a figure that will only go up. We have modelled deaths due to antimicrobial resistance for e. Coli septicaemia and the rate doubles from 7-15%, particularly in older people who may have had urinary catheterisation. AMR varies from country to country. The further North in Europe you go, the better controlled the problem is, but it's a real problem. Italy has for example had to close a couple of bone marrow transplant units due to outbreaks of resistant microbes. Modern medicine as we know it, is in the process of changing. We don't have new antibiotics and coincident with this rise in resistance has been a very empty pipeline due to a broken market model for research, development and production of antibiotics and antimicrobials. I have likened this problem to climate change, and continue to do so - this is something we are doing to ourselves as humans that is a problem now, is killing people now, and will only get worse if we do not take mitigating action.

Q: What are the key challenges and opportunities faced by the world in the sphere of non-communicable disease?

[Dean Julio Frenk] Since the beginning of the 20th century (particularly after World War II) we have witnessed the most profound health transition in human history. Through public health measures starting with vaccines and moving on to potent antibiotics and other drugs, we have been able to reduce mortality significantly from infectious diseases. The global epidemiological picture has shifted from one dominated by infectious diseases to one where the dominant causes of disease, disability and death are from non-communicable disease. As a side-note, I don't like calling them 'non-communicable diseases' as defining something by what it is not is not always a good option.

These diseases are mostly chronic and long-lasting. This introduces a big challenge as for the majority of human-history, diseases were a sequence of acute episodes. You were acutely ill and either died or recovered. If you recovered, you went on to experience another episode of disease. With the emergence of non-communicable disease we have gone from having these episodes to having conditions of living. We have changed the way we talk about disease; people say 'I live with diabetes, I live with cancer'.

The major diseases in the non-communicable arena are diabetes, cardiovascular disease, cancer and mental illness. You then have key risk factors, the two that appear to have the most significance are smoking and obesity. We have huge opportunities here. If you look at countries that have introduced tobacco control, you see a corresponding decrease in the number of allied non-communicable diseases such as lung (and other) cancers and cardiovascular disease. This is not just about health policies, but about healthy policies where many sectors work together; for example, raising tax on cigarettes, creating smoke free public and work spaces, forbidding publicity and so on. These are all healthy polices, often formulated outside health departments, but which all account for dramatic drops in disease incidence. Obesity is more complex than smoking as it depends on the intake quality and quantity of food, but also on physical exercise.

Most non-communicable diseases have complex multi-factorial determinants and so require multi-pronged approaches. The other challenge is that because these are diseases of living, and last a long time - they have a huge financial impact on countries in terms of prevention and treatment - and are a major driver to the cost of healthcare around the world.

[Prof. Dame Sally Davies] Obesity is on an upward trend. In our nation and many others... overweight is now the normal weight. The average weight of adults in Britain is above the healthy weight. 77% of parents with overweight children do not realise their children are overweight... 1 in 2 men and 1 in 3 women do not recognise they're overweight... even when we move towards looking at obesity, 1 in 10 men do not realise they're obese. Obesity is associated with high blood pressure, strokes, type II diabetes, cardiovascular disease, sleep apnoea, asthma, post-menopausal breast cancer, colorectal cancer, pancreatic cancer, and many more disease... 90% of obese people will have fatty liver disease which will lead to cirrhoses, it's just awful. We are storing-up problems in our society because of this obesity epidemic. A third of all children and adolescents are overweight, and we risk having a generation of young people who do not outlive their parents. 


Overindulgence in alcohol together with smoking and nicotine addiction are also major issues. Sadly, the United Kingdom is the only country amongst the EU 15 where premature mortality from liver disease is increasing rather than decreasing. This has been due to alcohol, obesity and also viral infections; there is a hidden pool of hepatitis C infections that people are not aware they have got. The binge and over-drinking culture we see is contributing to some very serious liver disease.

Where we consider tobacco, we see use decreasing. I welcome recent announcements to standardise packaging- but I would raise my concern about the use of eCigarettes which are advertised as a 'new way of smoking' they are glamorised by boutiques and have entered culture deeply. This risks addicting young people to nicotine, giving them a route into tobacco... and also risks re-normalising smoking in public places. It's difficult from a distance (for example) to know whether someone is smoking an eCigarette or a real cigarette. While there may be a role for eCigarettes, it's not yet proven that they play a role in nicotine reduction. I would like to see eCigarettes properly regulated for the purpose they set out for, rather than being aimed at young people, children and 'nevers' (people who have never smoked before). I think it's criminal what is happening, and I'm very worried about it.

Q: What is mental health seen as a public health issue?

[Dean Julio Frenk] Mental health is a huge problem and is hugely neglected, it should be a top priority for public health practitioners.

Here at the Harvard School of Public Health, a group of researchers led by Prof Chris Murray designed a new way of measuring the importance of problems. We used to measure the importance of health problems by the number of deaths caused. Precisely because we now have chronic conditions that don't kill people, but allow them to live for long periods, it was determined that number of deaths was an insufficient way of measuring importance. The concept of Disability Adjusted Life Years (DALYs) has since become globally accepted as a way of measuring health problems. This system measures the importance of disease by taking into account premature mortality as before but also degrees of disability. When you run the numbers, you find that mental health becomes the top cause of disability adjusted life years lost around the world. Older measures simply didn't see this as mental illnesses do not directly cause death, they contribute - but other than severe depression that may lead to suicides - they do not directly cause deaths.

Mental illness causes an immense amount of disability around the world and there are three aspects to how we frame it as a public health problem.

Firstly we have to understand the true scale and variety psychiatric diagnoses themselves. Depression affects approximately 10% of the world's population in varying degrees at any given time. You then have significant amounts of people also affected by psychoses and other major psychiatric illness.

Secondly, emotional factors very often contribute to other diseases. Many non-communicable diseases are highly affected by emotion factors. There's a big connection between stress and cardiovascular disease for example. Even infectious diseases show links to the psychological state of people.

We also see this situation reversed quite often, which is my third point. A chronic or serious disease can often trigger mental distress. After the diagnoses of a severe disease, as one can imagine, it can trigger anxiety, depression and so on. When you are treating a patient with HIV/AIDS, Cancer or any other life-threatening condition- mental health becomes a fundamental part of the comprehensive approach to treatment. 


The boundary between mental and non-mental illness is fuzzy and permeable. Mental conditions underlie almost all of the other health conditions you find.

[Prof. Dame Sally Davies] Mental health has to be a priority. 1 in 4 people experience a mental health problem each year. We know that three-quarters of people who start with moderate non-life-threatening mental health disorders that grow to be serious, do so by the age of 18... we know that prevention and early-action can stop people deteriorating... Yet we do not have the services that people need. We do not give the same attention to mental health as physical health. 75% with mental illness receive no treatment at all. 


I am worried too about how people in the workplace with mental health problems can be stigmatised. We need employers to recognise that if people are off-sick with mental health problems, that they need to encourage them back to work and support them - that's immensely important for their long term outcome. With expert input, I am currently writing a Chief Medical Officer's report on public mental health which will be published at some point this summer.

Q: How prepared is the world for health emergencies, and how must we respond?

[Prof. Peter Piot] The world is far more vulnerable to health emergencies than ever before. We have rapid transport and communication of infections. In the old-days, if there was a new strain of influenza or the emergence of a disease like Ebola.... the individual would have had to travel by boat for a few weeks to get to another continent. By then, people were dead or had only infected fellow passengers. Today you take a plane and the next day you can infect people on the other side of the world! We saw this with SARS where there was a big outbreak in Toronto which came from Singapore and Hong Kong.

The production, supply and distribution of food also links to our vulnerability. In the old days, if a farmer had a few chickens that had been infected by salmonella or some virus; it would have been bad for the farmer and his chickens, but not many other people. Today, you have chicken farms with hundreds of thousands or millions of chickens that are sent all over the world. You saw this principle in action during the 'mad cow' disease spread.

We also have much better technology and political infrastructure now which allows us to better handle outbreaks. For example: today, we know usually quite rapidly when there is a new influenza strain coming up which could become an epidemic and we can act- and in the past, there was a slow response and often a cover-up by authorities. A good example is China, which used to respond very slowly to outbreaks with new influenza strains, but now has become very open and responsive.

There are also emerging threats from old diseases. We see a Polio outbreak in Syria and if those people come to Europe where people are no longer protected, it could quickly create a serious epidemic.

There will be new viruses that emerge and challenge humanity, and old problems will always come back. We cannot know what will happen and well, but we can detect early and take measures to respond. If you think back to the beginning of the AIDS epidemic, if we had acted in the 80's like we act now, we would have prevented millions of deaths.

[Prof. Dame Sally Davies] I was impressed when I came into Government, with the exercises that we do to check that we are doing things right... that the whole health system and emergency services work together... we treated those as learning events, and did specific exercises on pandemics and emerging diseases. A lot of exercises were done in the run-up to the London Olympics for example. This is combined with the National Resilience Planning Assumptions and the National Risk Assessments.

We have to keep emergency planning high on our radar. We cannot assume it is done, and we must carry on reviewing and maintaining preparedness.

Q: What is the public health impact of the rising and ageing population?

[Dean Julio Frenk] In public health we are always victims of our own success! It's a great thing that people are living longer. Until World War 2, most deaths in the world happened in young children. Today- with the exception of Sub Saharan Africa- most deaths in the world happen in the elderly, which is the way it should be. We're gradually dying when we reach the biological limit of life, not when social or economic conditions cut life short. This has been an enormous move forward for mankind.

There are two factors to understand here.

Firstly, when we talk of population ageing we mean that the proportion of the population who are ageing is increasing relative to the other segments. For most of human-kind we had population equilibrium where many people were born, but also many children died at early ages; that kept population growth close to zero. With the progress in public health and medicine, infant mortality dropped - and when it dropped, fertility was still high, and we had major population growth - especially in the 20th century. Whenever infant mortality drops however, we find that fertility also drops as couples are more confident that their children will survive and so have fewer children. We then move toward a new equilibrium with low fertility and low mortality. Most of the developed countries of the world are moving towards this.

Secondly, people in general are surviving health conditions more- meaning you get a longer span of life and society has more elderly people. From a public health perspective, we go back to the chronic diseases and conditions we discussed earlier which are more common in this group. It's not just that we have more older people, but we have less working-age young people to support them as fertility has reduced too. The solution is not just to add more years to life, but more life to years. We have to make sure that progress in public health and medicine also means that older people maintain their capacities, and continue to be active and working later in life. What is becoming unsustainable is the old age pension schemes that are simply not sustainable now. We are finding people are spending longer retired, drawing from a pension, as active workers.

[Prof. Dame Sally Davies] We are looking at a future with fewer young people, it's a fundamental change in the balance of the population. As people live longer, we see an increasing number of older people with co-morbidities and a number of long-term conditions linked together. This makes their treatment more complex for the medical establishment.

We will also see an increasing number of people with dementia. This raises significant challenges for the healthcare community, not just with diagnoses... but with management, so that people with dementia are able to cope in their own homes as much as possible, and live good lives.

We also must do more for children. There is a good economic case for investing in prevention, and investing in children. Early stage education and intervention can influence their whole life-course and result in a great return on investment for society.

Q: What are the 'elephants in the room' in the public health arena?

[Dean Julio Frenk] We have huge inequities that still persist globally. We've had this fantastic progress in health, doubling the life expectancy for the 20th century world. This has not however- been distributed equally. As we sit here today, countries like Japan have life expectancy approaching 90, while some African nations have life-expectancies below 40.

We've made huge progress, but there are still 6 million children under 5 who die from totally preventable causes around the world. That used to be 12 million children in 1990- we've cut that in half, but 6 million children dying from unnecessary causes is a huge injustice. 275,000 women every year- one woman every 2 minutes- lose their lives in pregnancy or delivery. That's down from 500,000 but is still an unacceptably high level.

In the 21st century, it is an injustice that we have not managed to get rid of problems for which we have the knowledge to solve. We must drive vigorously to finish the unfinished agenda.

These health inequalities are also a source of great instability in the world. These injustices breed resentment, extremism, and create insecurity for everybody. They are a huge impediment to growth and economic development. If we tackle health inequality, we will make the world safer, more prosperous and fair.

Q: What are the key public health challenges for the future?

[Sir Richard Thompson] Obesity and other unsolved problems such as drugs will remain as future challenges, but the ageing population is where the largest public health expenditure will come from. It is in the later stages of life where most of your healthcare spending will take place, not when you're young- even if you have accidents.

We live in a world where 1 in 300 people born now in the UK will live to 120, and the number of centenarians are going up and up. They put a huge strain not just on the health service, but on community care too. This is the same pattern you see across the world, and is compounded by the fact that families no longer (in general) look after their elderly because there are less young people around to look after those elderly people. The most important thing for many people is to have a pension! In many parts of the developing world, there are no pension schemes; and so people need to have a large number of children to look after them and not become a huge burden on the state. Developing countries must prioritise the development of financial instruments such as pensions to allow people to better look after themselves.

There are worries around the world about antibiotic and drug resistance, but I don't think this will be an enormous problem in the future. As we sit here today we see transplant centres in Europe that have had to close down because they can't treat these resistant bugs; but I believe that as we grow our understanding of the genomes of bacteria and viruses, we will be able to fight them. The problem however, is that there is little or no money for the pharmaceutical companies in developing specialised antibiotics for special patients, which invariably will have limited turnover.. Loose prescribing practices in Southern Europe and elsewhere in the world where antibiotics are available over the counter have led to many of these problems. But hope exists too. If you look at Hepatitis C and HIV, we are at a stage where people are largely treatable- and that has come from innovation from pharmaceutical companies and universities.

Q: Who are the key stakeholders in global health?

[Prof. Peter Piot] There is no doubt that the medical profession are at the core, but it is interesting to see that when we consider global health; it is far more multi-disciplinary than other approaches. Just to give you an example at our school (The London School of Hygiene and Tropical Medicine) we probably have as many economists as clinicians!

You need to have an approach that understands the determinants of health- and that sphere is much larger than simply biological factors or the lack of medical intervention. Since the AIDS movement, attitudes towards conditions changed - and we see that people themselves along with their friends and families- have been key stakeholders in health.

There are a wide range of stakeholders in global health and this has pros and cons. The great thing is that we are able to create a movement with a great variety of resources, but it's also immensely difficult to manage.

Q:What is the role of health and health policies in global development?

[Prof. Peter Piot] In high-income countries, health and healthcare are the largest proportion of government budgets (at least during peace-time). That's not the case in low-middle income countries, though the pressure is there. One has to think of health as a specific budget and policy, but also as a set of enablers that lead to better health- this includes better education, healthy citizens and more.

Globalisation has impacted health in many different ways. Starting with the positives, there is now much faster access to information about health issues... but also new technologies and new drugs are enabling greater reach of medicine into the population. Risks such as smoking are also now globalised.
Particularly at the population level, the whole discipline of health is getting out of the medical!

Q: How do the different stake-holders in public health collaborate?

[Dean Julio Frenk] Public health is everybody's business, and therefore requires a multi stake holder approach. The word 'public' in public health does not mean government. The government has a huge role to play; protecting and promoting the health of the public- but everyone has to be involved. Civil society, private firms, and more.

It is in everyone's interest to have the maximum amount of health in society. It's not just about what's right in ethical terms, but it will guarantee global security and economic prosperity.

Health is one of the only universally shared values. If you look at any major religion, or political ideology- health is placed as a value in and of itself. It offers a great opportunity for collaboration as it's a shared and common objective. Alongside the collaboration between government, civil society and corporations- we have to see collaboration between countries. We live in such an interconnected world that nobody is rich or powerful enough to control the health of their people alone, you need co-operation.

We are in the era of health interdependence and collaboration is the only way we can deal with that.

[Prof. Dame Sally Davies] Public health specialists (be they medical or non-medical) have a significant role to play, but we should not forget the wider arena. CEOs of supermarket chain, celebrity chefs, advertising executives... all these people work in the public health arena and have the responsibility to make decisions with public health in mind. Expert public health leadership is key; particularly where we have communicable disease outbreaks such as the 1854 cholera outbreak in Soho which was managed by Dr. John Snow, who came up with the idea of removing the pump handle on Broad Street! If you read deeply about this outbreak, you find that you needed the social sciences... Dr. Snow needed his friend Rev. Whitehead and all the community links to be able to find the locations of the outbreaks and their context. It wasn't just Snow on his own.

I look at Ipswich recently where they got the whole community... public, private, supermarkets... everybody together to stop selling super-strength alcohol. These people didn't have public health badges, but they made it work! Violent crime dropped!

We recognise this in other areas of life, for example- the Fire Service. They provide strong leadership, but disseminate their skills. Every public building has a nominated lay-person who is the fire-marshall who detect fire hazards, and also help people in emergencies. We need public health experts to reach out and recruit others to help in the battle for 'the public health' that's every single one of us.

Technology will also develop and play a big role. Look at the recent growth in Apps for physical activity, and how powerful social media has been. We have even seen examples were companies developing a wonderful social media campaign that will be launched in 2014 to help adolescents work together to support each other when engaging in what can only be described as risky behaviour, albeit which they may call exploratory... Technology is terrifically exciting. It's not just about big data, it's about safe data and understanding how people can help each other be healthy.

Q: How is policy impacting physicians and health delivery?

[Sir Richard Thompson] We are under-funded, under-doctored, under-nursed and under-bedded compared to our OECD counterparts. In terms of number of beds per capita, we rank at just above Mexico. 


I know it's very expensive, but I think most people would agree that health is worth funding. You only have to get ill yourself to realise that your world collapses once you've got an illness- and we all have friends or relatives who are unwell and using the health service.

The recent reforms we've had in the UK have cost money and disrupted many health organisations. We published the future hospital commission report last year (2013), which looked at ways to improve patient outcomes both in and out of hospital, but, nevertheless, many of the new ideas wouldn't save money. On the whole, unfortunately, you have to invest in healthcare to improve health...

Often you find that government policymakers don't take into account evidence when making broad-decisions. One of the current ideas being floated is telemedicine. The evidence suggests that apart from the case of very remote areas, it rarely works. Evidence also suggests that most patients also want to physically see their doctor to discuss their issues.

It's also important to improve and look after the health of NHS staff. We know quite clearly that happy staff give better care. We must support staff, prevent bullying, encourage them to raise concerns and also encourage them to look after their physical health (for example, to give up smoking).

We are also facing a problem where many doctors are leaving the country where they trained to move to countries where they may perceive the pay and facilities to be better. This creates massive brain-drains in developing countries. I don't know how we will stop this, it's very difficult.

Q: How is technology impacting public health delivery?

[Sir Richard Thompson] The vision that technology will suddenly improve the health service and save money, is wrong. We tried to deploy a national system called Connecting for Health which promised to integrate IT and take the service paperless; it collapsed and cost billions of pounds. It's difficult to include real technology solutions into old hospitals. It's quite clear that certain technologies such as e-prescribing would be beneficial, reducing the number of errors that occur.

There are a number of areas where we have had vast improvements such as technology. It's amazing what goes on in radiology departments now in terms of the quality of images and information they can get, and in terms of reduction in the amount of radiation used.... Similarly in diagnostics! I visited Guys & St. Thomas' Hospital recently and saw huge banks of machines running without human intervention, supporting diagnoses for doctors over the hospital. It's no-longer the person sat at the laboratory bench doing the measurements, we are using technology to increase accuracy, quality and speed.

In terms of the relationship between doctor and patient? ...we mustn't let technology get in the way of that. In terms of allowing x-rays to be read in Australia overnight to avoid waking a radiologist here? those sort of things are important.

We are also working on creating standards in terms of information recording. It would be wonderful if- when a new patient appears- you can get all their information from various centres in front of you instantly. These sort of developments can be empowering when you're handling that patient, and can prevent mistakes and duplication.

Q: What are the most important areas of science and discovery as they relate to global health?

[Prof. Peter Piot] The technology of vaccines is making a huge difference- we now have new vaccines for things like Rotavirus which are becoming just as common as old ones for Measles and so forth. We also have new drugs! If we look at the introduction of antiretroviral therapy... these saved millions of lives. We're now at a stage too where Hepatitis-C will be curable.

The mobile phone, access to big-data, and better sharing of data has also allowed us to have a much better understanding of the challenges and effectiveness of interventions. This is also leading to opportunities in the miniaturisation of equipment... you can now make the diagnoses of an eye problem by putting a smart phone camera in front of the eye... you can now carry around tiny ultrasound machines that transmit data live back to a consultant elsewhere in the world... these are enormous opportunities.

Innovation however depends on political will, funding and people!

Q: What will the next 10-20 years hold for public health?

[Dean Julio Frenk] I am an optimist, and I believe we are seeing the simultaneous operations of a number of revolutions that justify my optimistic view!

First, we have a revolution in life-sciences and genomics. We are understanding the fundamental mechanisms of health and disease, and are translating that into better technology to diagnose, prevent and treat disease.


Second, we have a revolution in communications and information technology. This has a huge impact in the health field. It allows services to be brought closer to people- especially in very poor societies. Mobile platforms are opening opportunities for access to care which never existed before. Technology is also empowering people with greater information on their own health. Providing we can curate and assure the quality of this information, it will have a lot of potential. Patients are co-producers of their own health- they are not consumers. Health is not a good produced by a doctor and consumed by a consumer, health is co-produced by the health-professional and members of the population.

Third, we have a revolution in systems thinking that better allows the understanding of complexity to take place. Health systems have become immensely complex. To give you an idea of scale; health is the largest sector of the largest economy in the world- it accounts for c.18% of GDP of the US economy, around $2.5 trillion. If you look globally; it's around 10% of the world economy, c.$6.5 trillion dollars. It employs 8.5million physicians, 16million nurses and many millions more around this. The revolution in systems thinking, and the management tools that have emanated (such as digital health records) from this will give us better performing health systems.

Fourth, we are at the threshold of a revolution in education. We have a better understanding of how people learn, and communication technologies are empowering this. The spread of education has always been one of the most powerful ways of improving health in populations, and training the healthcare professionals that take care of others. As Dean of a school, I find that tremendously exciting. The appearance of MOOCs will greatly expand access to knowledge around the world. For example, our first 4 MOOCs at HSPH had over 175,000 learners from 110 countries. Access to knowledge will explode- and that's good for health

Finally, we are in the midst of what Michael Ignatieff coined as being the rights revolution. The idea that healthcare is a fundamental human right and not a privilege drives policies to drive universal access. We saw this in the United States recently, we are seeing it in China, Africa and more. When I was the Health Minister of Mexico we really worked hard to try and ensure universal health access for all. It is a human right.

Q: What are the challenges and opportunities in physician education?

[Sir Richard Thompson] The knowledge explosion in medicine has been huge. It's difficult now for a doctor to think of everything when they see a patient, particularly one with a difficult diagnosis. There are some advances such as apps and so on, but it's difficult to hold and contextualise all this information in your mind.


We have historically gone down the route of specialisation to deal with this, but we've probably gone too far. Now, when you're a left-foot doctor... you don't really know anything about the right-foot and so on... We need to support more generalists who are able to make decisions and advice across a broad range of areas that are not within a specialty. Most elderly patients present with several problems wrong with them. They may have experienced a stroke, they may have dementia, they may have diabetes and any number of other problems. Their doctor has to be able to manage these conditions as a system for the whole of their care. 


We have to try and overcome these difficulties by improving standards of education in medicine not just for doctors, but throughout the care system.

Q: What does it take to be a great physician?

[Sir Richard Thompson] You have to have empathy and sympathy. You have to care for people, and you have to have integrity. You have to want to help each patient.

We mustn't forget too that doctors work in teams- more so now than ever before. Physicians work closely with nurses, physiotherapists, technicians and more to get the right outcomes for patients.

Q: What is the relationship between the physician and private enterprise?

[Sir Richard Thompson] The relationship between doctors and drugs companies is important, but it must be transparent and consumers are right to be suspicious of this relationship.

First, we need to know what people are paid. Some doctors are earning hundreds of thousands of pounds a year from drugs companies and device manufacturers. Second, this money shouldn't be going into back-pockets; it should be going into research laboratories or hospitals. All the research should also be published- even negative results- so it can be studied by others later.

It should be clear that people are independent researchers and that they're not being paid by drugs companies to publish, not alter data. I remember when I was doing trials, companies wanted to see the data one month before publishing so they could decide how to handle it. That's perfectly proper- but they shouldn't in any way influence what they are publishing.

Many advances in medicine are dependent on drugs companies and device manufacturers producing new products and innovating.

Q: What would be your advice to the next generation who want to make their future in medicine?

[Sir Richard Thompson] Medicine is a wonderful career. You combine the science and art of medicine, and meet patients from all walks of life... you also know that most (if not all) your patients go home better for having talked with you- and many of them actually cured.

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Medicine and medical anthropology take a necessarily scientific approach to their disciplines, but we cannot forget that these fields are ultimately created, seen and experienced by humans.

To be human is to experience life in relation to how you are…” wrote Ann Hemingway, “your feelings, mood and emotions are all a lens through which you experience the world. Such individual subjectivity is key to our sense of ourselves as human beings. Being human, we live within our bodies; they embody us. We experience the world through them in a positive or negative way… We need to view ‘the body’ in its broader meaning; psychological, environmental, social, spiritual and economic- and our research methods need to enhance this understanding...” (Can humanization theory contribute to the philosophical debate in public health?, 2012)

As human beings, the lenses through which we experience our world are also impacted with bias. One of these, our hard-wired optimism bias tends to make us unaware of our latent vulnerabilities until they manifest.

It seems clear,” wrote Robyn Bluhm “that being sick makes people vulnerable. Not only can even relatively mild, transient illnesses such as colds or flus serve as an unpleasant reminder of the vulnerability of the usual state of health that many of us are fortunate enough to enjoy, but more serious, chronic conditions can force individuals to adapt—or even abandon—life plans or projects, and can also alter their self-conception.” (International Journal of Feminist Approaches, 2012)

Humanity has historically found ways to overcome the vulnerabilities it faces. In early history we overcame our vulnerability from the elements with shelter and clothing… we overcame our vulnerability to lose culture and knowledge with the invention of language and communication… and we overcame the vulnerability of only being able to use our muscles through the invention of mechanisation and industrialisation. Each instance where we overcame created a sense of liberty and progressed us to the next chapter of our story.

As Thomas Jefferson wrote, “Liberty is to the collective body, what health is to every individual body. Without health no pleasure can be tasted by man; without liberty, no happiness can be enjoyed by society.



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Saturday, 8 March 2014

Theatre, Performance and Society

In this exclusive series of interviews, we speak to four world experts on theatre and performance. Sir Howard Panter (Founder of the Ambassador Theatre Group Ltd, Chairman of Rambert Dance Company), Gilles Ste-Croix (co-founder of Cirque du Soleil), Joanna Read (Principal of the London Academy of Music and Dramatic Art - LAMDA) and James Houghton (Director of the Drama Division of The Juilliard School, and Director of New York’s Signature Theatre Company). We discuss the role of theatre and performance in culture, look at the secrets of the performing arts and discuss the future of theatre in the modern world.

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Vikas Shah, Thought Economics, March 2014

Performance is key to human experience. There is not one of us on this planet who hasn’t captivated an audience as a baby with our gurgles, squeaks and steps; nor is there one of us who will fail to move an audience when our shell plays the central role at the spectacle of our own funerals. The intervening period- regardless of its length- is a series of scenes where the protagonist (as self) plays the lead in a tale of joy, tragedy, comedy, farce and errors. The beautiful paradox however, is that in life we are simultaneously the central-actor of our own narrative alongside being the support for hundreds of other stories, and the spectator of millions- perhaps billions more.

This view of life in context of creative culture is shared across the arts. Speaking on literature, Maya Angelou said “We write for the same reason that we walk, talk, climb mountains or swim the oceans- because we can… We have some impulse within us that makes us want to explain ourselves to other human beings… That’s why we paint, that’s why we dare to love someone- because we have the impulse to explain who we are. Not just how tall we are, or thin… but who we are internally… perhaps even spiritually. There’s something, which impels us to show our inner-souls. The more courageous we are, the more we succeed in explaining what we know.” (Thought Economics, October 2012). Speaking on music, Hans Zimmer said, “…If you go to any rave, or any football event, you will find people chanting in a rhythm- human beings do that. We have this sense to participate and organise- Music lets you rediscover your humanity, and your connection to humanity. When you listen to Mozart with other people, you feel that somehow- we’re all in this together….” (Thought Economics, March 2013)

Theatre and performing arts are also hugely important to economies and communities. The US Bureau of Economic Analysis showed that 3.2 percent of US GDP (around US$ 504 billion) is attributable to arts and culture (compared with the entire US travel and tourism industry, which accounts for 2.8 percent of GDP). Alongside this, Americans for the Arts also showed that the arts and cultural industries support over 5.4 million jobs in the US alone. This picture of economic impact and significance is the same in country after country, around the world- and doesn’t even begin to include the intangible- the social capital brought to communities as a result of the existence of arts.

So what is the true relationship of theatre and performance to human society?

In this exclusive series of interviews, we speak to four world experts on theatre and performance. Sir Howard Panter (Founder of the Ambassador Theatre Group Ltd, Chairman of Rambert Dance Company), Gilles Ste-Croix (co-founder of Cirque du Soleil), Joanna Read (Principal of the London Academy of Music and Dramatic Art - LAMDA) and James Houghton (Director of the Drama Division of The Juilliard School, and Director of New York’s Signature Theatre Company). We discuss the role of theatre and performance in culture, look at the secrets of the performing arts and discuss the future of theatre in the modern world.

Sir Howard Panter is a founder, co-owner, joint chief executive and creative director of the Ambassador Theatre Group Ltd (ATG), and Chairman of Rambert Dance Company. In 2010, 2011, 2012 & 2013, together with his wife and business partner Lady Panter (Rosemary Squire), OBE), Panter was named Most Powerful Person in British Theatre by the The Stage in their annual 'Stage 100 list'.

Since 1992, the Ambassador Theatre Group Ltd (ATG) has grown to be the world’s number one live-theatre group with a total of 40 venues in Britain and on Broadway and an internationally recognised award-winning theatre producer with co-productions in New York, across North America, Europe, Asia and Australia. It is also a leader in theatre ticketing services through ATG Tickets (the joint largest ticketing company in the UK) and the Ticket Machine Group (TMG). ATG’s impressive portfolio of West End theatres includes historic buildings such as the Apollo Victoria, Donmar Warehouse, Duke of York’s, Fortune, Harold Pinter, Lyceum, Phoenix, Piccadilly, Playhouse, Savoy, Trafalgar Studio 1 and Trafalgar Studio 2. In New York, ATG owns The Foxwoods Theatre, the largest theatre on Broadway.

Gilles Ste-Croix is the co-founder and artistic guide of Cirque du Soleil. From a group of 20 street performers at its beginnings in 1984, Cirque du Soleil is now a major Quebec-based organization providing high-quality artistic entertainment. The company has 5,000 employees, including 1,300 performing artists from close to 50 different countries. Cirque du Soleil has brought wonder and delight to more than 100 million spectators in more than 300 cities in over forty countries on six continents.

In the late 1970s Gilles Ste-Croix was living in a commune in Victoriaville, Quebec, picking apples to make money. One day he mused that the job would be a whole lot easier if he could attach the ladder to his legs—and devised his first set of stilts. A friend happened to mention the Bread and Puppet Theater in nearby Vermont, which used stilt-walking as the basis of many of its performances. Ste-Croix went to see the company and realized that his apple-picking skills might actually be in demand in the wider world of entertainment.

In 1980, Gilles Ste-Croix and a band of street artists founded the Échassiers de Baie-Saint-Paul and organized a street performance festival called the Fête foraine de Baie-Saint-Paul, which would eventually lead to the founding of Cirque du Soleil with Guy Laliberté in 1984.

In 1984 and 1985, Gilles Ste-Croix designed and performed many stilt acts for Cirque du Soleil. In 1988, he became Cirque's Artistic Director, as well as coordinating a talent search that extended to the four corners of the globe. He was Director of Creation for all of Cirque du Soleil's productions from 1990 to 2000: Nouvelle Expérience, Saltimbanco, Alegría, Mystère, Quidam, La Nouba, "O", and Dralion. In 1992, he directed Fascination, the first Cirque du Soleil show presented in arenas in Japan. He also directed the groundbreaking 1997 dinner/cabaret show Pomp Duck and Circumstance in Germany. In 2000, while continuing to act as a consultant for Cirque du Soleil, Gilles Ste-Croix decided to realize one of his greatest dreams: Driven by his passionate interest in horses, he founded his own company to produce the 2003 show Cheval-Théâtre, which featured 30 horses and as many artist-acrobats under canvas and toured ten cities in North America. Since December 2002, Gilles St-Croix returned to Cirque du Soleil as Vice-President of Creation, New Project Development. In July 2006 he was nominated Senior Vice-President of Creative Content.

Joanna Read is a British theatre director and librettist. In 2010, she became the first ever female Principal of the London Academy of Music and Dramatic Art (LAMDA). LAMDA is the oldest drama school in the UK. Founded in 1861 as the London Academy of Music. It is now regarded as one of the most respected theatre conservatoires in the world.

Read studied Drama at Bristol University from 1986 to 1989, directing her first few productions whilst doing her degree. Having worked on the fringe and at Sheffield in her early years (occasionally in stage management, although she also participated in the Channel 4 Regional Directors Programme), she soon joined the Education team at the Young Vic for a year, and following that became the Head of Education and Participation at the Birmingham Repertory Theatre from 1993 to 1997, where she created a successful and wide-ranging education and outreach strategy and commissioned and directed new writing. She was then Chief Executive and Artistic Director of the Salisbury Playhouse from 1999 to 2007. Under her leadership, the Playhouse became one of the leading regional producing theatres of the last decade. She steered the theatre to a position of financial stability, while also leading a successful major capital development programme. She was then an Associate Director of the Octagon Theatre Bolton from 1997. More recently, she has worked as a freelance director and writer for Edinburgh Festival Theatre, the Young Vic London, the New Vic Theatre in Newcastle Under Lyme, The Watermill West Berkshire Playhouse, The Mill at Sonning and the Watford Palace Theatre, amongst others. As a librettist, her works include a musical version of Charles Dickens' A Tale of Two Cities, for which Howard Goodall composed the music.

James Houghton is a noted administrator, and founding artistic director of New York's Signature Theater Company (1991), he set the company's agenda of single-playwright seasons, with playwrights such as Edward Albee, Horton Foote, John Guare, Bill Irwin, Romulus Linney, Arthur Miller, Lanford Wilson, and others, in residency during the seasons devoted to their works. In addition, Signature has produced 41 premiere works, including 17 premieres, some of them created during two "all premiere" seasons. Houghton is a guest lecturer at numerous colleges and theater programs, including Yale, N.Y.U., Columbia, and the Actors Studio. Has also been a judge and nominator for prestigious awards including the Susan Smith Blackburn Prize, and the PEN/Laura Pels Foundation Award, among others, as well as a presenter and speaker at many panels and symposiums.

James Houghton is the Richard Rogers Director of the Drama Division at Juilliard. A school who’s alumni have collectively won more than 105 Grammy Awards, 62 Tony Awards, 47 Emmy Awards, 26 Bessie Awards, 24 Academy Awards, 16 Pulitzer Prizes, and 12 National Medals for the Arts.

Q: What is theatre?

[Sir Howard Panter] Theatre is a place where one group of people- on stage- tell stories to another group of people who are sitting... usually in an auditorium... usually in the dark... listening to, and watching these stories.

[Gilles Ste-Croix] Since human beings started to gather in groups and communities, they sensed the necessity to transmit their experiences and knowledge- fundamentally- through storytelling. The transmission of these stories, through the ages moved from shamanism to modern forms of art on and off stage.

Theatre is a tool that has existed for thousands of years. I imagine that from the first moments people wanted to transmit their experiences of the hunt, or their father and grandfather. It is both the wish and necessity of human beings to tell stories.

[Joanna Read] Theatre is an art form that brings people together to celebrate, challenge and provoke through the telling of stories.

Theatre is unique, you see transformation right in front of you- created in the moment. In a book; you pick it up, put it down and it remains - similarly with film- but with theatre, what you witness in any given moment is unique and only you and the audience will ever experience that.

[James Houghton] Theatre is a moment of intersection between people where events collide or reveal conflict through storytelling. It is an art-form that always has, and always will be, important and relevant.

I think we have an insatiable appetite to understand our relevance; in context of our human relationships and our existence. Theatre is a moment where we stop our lives long enough to reflect off each other. Ultimately, that leads to context which- in turns- gives perspective on life and circumstances.

Q: What is performance?

[Gilles Ste-Croix] Going in front of an audience- be it small or large- is a performance… you have to captivate people with what you say, do or whatever! This is the basic of performance.

Not everyone can perform. The people who do it have a virtue that they can exploit to get that attention from people. Performance is about having the capability to captivate an audience with whatever means you can; with words, theatre, dance, music and so on.

Sometimes I go to lectures. Somebody can deliver a wonderful lecture with preparedness and experience, but he also captivates me with how it’s delivered.

Q: Why has theatre become such an important art-form?

[Sir Howard Panter] In my imagination this goes back to the time when we lived in caves. I'm pretty convinced that two people, three people or one person sat on one side of a fire, providing the lighting- while a lot of other people sat on the other side of the cave or dwelling... and from time immemorial stories were told by one or several people, to a larger group of people. These stories may have been history, myths or legend.... they may even have been about religion or about grappling with the seasons.

Stories have always been told by live human beings to other live human beings, that's what makes it such an important and enduring form of art in my view.

Q: What is the role of aesthetic and beauty in theatre?

[Sir Howard Panter] The unique selling proposition of theatre is the fact that there are live humans in a space, speaking to other live humans. It's not online, not in a cinema, not on some tablet... it's there. As a member of the audience, you are in the same space as the people who are- in the broadest sense of the word- telling stories.

The very fact that humanity is at the absolute centre of theatre in tangible flesh and blood terms means that there is intrinsic beauty in that art-form because the human form, human voice and human ability to imagine stories (and their repercussions) is the stuff of art!

[Gilles Ste-Croix] The aesthetic and beauty of theatre are very subjective. Performance and theatre can take many forms. It may be a play on the street or- as you saw during the early 19th century- a form of Opera where many forms of art were gathered into a single performance. The aesthetic of the elements of a performance when they are brought together depend on the culture of the people receiving it and where the piece itself is performed. Aesthetic is subjective of the people who want to transmit and also those who receive.

When we play a Cirque du Soleil show I have people asking me, “…so you are French Canadian born, you are producing a show for the USA, you don’t use language, you use jibberish words and music, and people simultaneously get and don’t get it because it plays at many levels…. So how is it when you take the same show to Japan?” – I often relate this back to what the people are as a country. I have seen shows that make the people of Japan cry but the same show in USA or UK would not make people cry… it is a question of sensibility. Japanese people are very sensitive to symbolism… and many of our shows are built on the invocation of symbolism. These images are free to be interpreted by whoever watches them.

The aesthetic and beauty of a piece of theatre lies almost completely in the eyes of the person watching.

[Joanna Read] Theatre doesn't have to be beautiful. Some of the most fantastic and thought-provoking pieces are ugly. There is an aesthetic in the staging and design- which should enhance the stories or design of the production- but it doesn't have to be beautiful.

[James Houghton] The notion of beauty in the theatre is- as in life- defined by the perspective of the viewer. For me, beauty may be defined by other simplicities... stripping away all the white-noise of circumstances and just focussing on human action. That's where I find moments of beauty in theatre, where those absolutely pristine quiet pin-drop moments occur... where the audience, story and artist collide in a moment of truth. These moments of beauty dig deep into an essence.

We each have our own personal aesthetic- but for me the simplicity of storytelling and the collision of human events is where beauty and aesthetic occur in theatre.

Theatre always has, and always will be, important and relevant.

Q: What is the role of spectacle in performing arts?

[Gilles Ste-Croix] Spectacle is largely a question of means, but it also brings an accent to a presentation or to the way of doing a show.

At the beginning of Cirque, we were just a group of street-performers- not great acrobats, so the spectacle was little! As we went along, we were able to add artificial spectacle which was connected to the performance and enhanced with better acrobats- improving the whole experience. Now it would be very hard to go back to 1984 where we were just street-acrobats, people expect and accept spectacle from our performances now.

Q: What is the role of the actor in theatre?

[Sir Howard Panter] The actor is the person who tells someone else's story, he is the messenger of the story; regardless of whether that story was written by a composer, a lyricist or an author. He is the human-conduit to convey the story to the audience. His or her choices are therefore crucial in making that story as vivid as it can be.

[Gilles Ste-Croix] The performer and his performance are the skeleton of our production. We can put muscles over this in the form of costumes and lights… we will add music, light and invoke the emotion of this skeleton by bringing it to life… but the performance is at the centre of all of this.

[Joanna Read] Actors are communicators, storytellers, inventors and commentators. They have many roles in their art, depending on the story they are telling and the genre of the play.

Actors are there to entertain, but also to deliver the story as the writer (or they, themselves) would want.

As an actor, you are an artist. Greatness comes from the quality of the transformation, experience and how they can access and communicate emotion to effect a change in the audience.

[James Houghton] Theatre is an art-form that is meant to be heard. It is a collection of words and moments that are defined by the writer, but ultimately given voice by the actor. For me while it's always story first; the actor is the instrument for those stories coming to life.

We each have our own notion of truth, but the great actors are the ones who make truth the through-line of their work. They are the ones who make the boundary between actor and character invisible- immersing themselves in the story. They are the ones who allow the audience to do the same. A great performance is not full of noise, but full of context and story. The actor must be generous, and give with abandon.

Without the actor, there is no theatre.

Q: What is the role of the audience?

[Gilles Ste-Croix] People decide to buy a ticket, and come to be surprised, moved, entertained, inspired or informed. It is the decision of a consumer to make these steps- they could easily have stayed at home to watch TV.

Live performance with a live audience creates a bond which has existed for thousands of years where a human being meets another, and tells a story.

I once remember going to listen to Pavarotti. I have listened to his music many times at home on a beautiful sound system… but seeing and hearing him sing live moved me like it’s never moved me before. I received that performance like a gift.

Real theatre and real performance exists when you have a meeting of the performer and the audience as receiver.

[Joanna Read] The audience are an active participant, theatre is a relationship between the production and the audience- audiences are not just consuming...

A piece of theatre is not complete until the audience is in the room. The work is changed by the presence of an audience. When you are making work you see rehearsals and so forth, but what the piece becomes when an audience joins the process translates it to another stage.

Whether the audience know it or not, they are active in the process. They clarify things, deny things, join with ideas and more.

[James Houghton] The audience are not passive consumers of theatre, it is a circular relationship.

It is extremely important that an audience and a story become one. You often hear people describe the experience of 'losing themselves' in the story; I- personally- would call it 'finding yourself'.

My guess would be that if you talk to the average audience member or artist, those unique moments that keep us coming back to theatre are relatively rare; yet we keep going. We want that moment where we get so immersed.. where all the people in the audience and the production come together... that is what resonates with us for years to come.

You see this same principle in the fine-arts. Even in the darkest of subjects, art can lift us somehow and reveal something deeply relevant about our human condition.

We are at a place where an entire generation has been introduced to the arts through digital context and theatre is becoming new again. The notion of going into a theatre... a quiet small space with a bunch of real human beings... sitting in a three dimensional experience requiring attention? it's so old, it's new again!

Q: What is the link between theatre and music?

[Sir Howard Panter] Music is generally acknowledged as one of the art-forms that most directly connects with, and stirs, the human emotion. When in theatre- whether it be musical theatre, opera or any form of performance- when emotions are heightened, music together with lyrics creates heightened emotions.

When you get goose-bumps up the back of your neck hearing a song from West Side Story (as it were) it's because the combination of the words, character and music together create a heightened emotional experience.

Music heightens the emotional experience of an audience!

[Gilles Ste-Croix] The performance or performer is dressed up with costumes that create a period or style. The music comes as a layer of emotion to illustrate what the artist was evoking.

Whether we talk of the human voice alone, or musical instruments… the vibrations carry within us and create a layer of emotion – otherwise you are watching TV with the sound off, and what can be more boring than that?

When the music is really deeply connected with the image, it brings another level of engagement for the viewer.

Q: Does theatre have a role 'outside art' in political, social and other struggles?

[Sir Howard Panter] Theatre goes in phases with regard it's Political impact, and sometimes is more at the forefront of social-change than other times. What it should always do is enlighten the audience, and give them an experience which is different to their lives when they came into the performance. Whether it's your perception of a human, social, environmental or any other issue... whether it's the lightest, frothiest farce or the darkest piece of brutalist theatre... it should in some way change and involve the audience's view of the world in which they live.

Q: How does theatre relate to other art-forms?

[Sir Howard Panter] The cross-over between theatre and other art-forms can be wonderful.

Outside my 'day job' I'm the chair of a company called Rambert which is perhaps the leading contemporary dance company in the UK, which comes from a long tradition going back to Diaghilev and so on; and these are all examples of musical theatre with dance! There's been a huge tradition of art-collaboration going back centuries at least. You had Picasso doing back-cloths and Matisse doing costumes in theatre.

Actors often say that their artistic and acting muscles are developed in theatre wherever they end up performing, whether that be in film, TV or elsewhere. Theatre is the place where you develop your real acting skills.

[Joanna Read] Theatre has always been a collaborative art form and has always borrowed and robbed from other arts in order to do its job effectively. Theatre captures and reflects the world and is always informed by the time and culture in which the work is created. The stage, language and many other areas will be informed by the culture of the time. The work of theatre can be a single-playwrights voice or even a wider version of that. Theatre captures and reflects our lives back to us. Every new play is telling the story of our lives and the next generation.

Q: What makes a theatre production great?

[Sir Howard Panter] There is no one single formula to theatre success, needless to say, otherwise we'd all be doing it!

Theatre is a collaborative art-form with writers, producers, directors, lighting designers, costume makers and so on. When all those pieces coincide, and when the performances are great, the lighting is great, the music is great, the design is great.... when all those different creative activities fuse into one emotional and intellectual delivery- that's when great theatre occurs.

I use West Side Story as an example. Bernstein arguably never wrote any music as great as he did for West Side Story, and similarly Sondheim arguably never wrote any greater lyrics. Many say Jerome Robbins also never choreographed anything as great as he did for West Side Story either. At a fundamental level, one could also argue Arthur Laurents never wrote another book as great as West Side Story, a book he based on the work of another genius; Shakespeare - and his play 'Romeo and Juliet'. In this case you have 5 geniuses at the top of their game, and when they came together, they created the masterpiece of West Side Story, which will endure for time immemorial.

Great theatre happens when original creative people come together at the height of their powers in a miraculous concoction.

[Gilles Ste-Croix] Even though we have been in the business for 30 years, the truth is that the concept of what makes a show great is still very fragile.

We must also remember that often we are dealing with theatre which is based on literature and can be the interpretation of a story. Very often I am deceived! If I have read a book, I will create a visual in my mind of that story and often the interpretation I am presented with does not match that.

We are going to launch a show in Montreal, called KURIOS – Cabinet of Curiosities in the Big Top. We have been working on the show for over 3 years but it all comes down to the moment we put the show in front of a live audience to see their reactions to we have perceived in our minds and as members of the production. We need to see how the audience bond with a production, how they breathe with it. That’s what creates the rhythm and determines whether something will become a timeless piece.

We have created some productions that have become timeless and some that have not made it that far…. But in my mind I can think of so many works that have existed for millennia. The works of Shakespeare, Molière, Wagner and so on… they touch and invoke things within us that are universal in their existence. They create images in me that I can recognise myself, something that makes me sit back and say, “ah!

A baby in China, Europe or Canada recognises his mother and calls her “Mummy!” this is something that’s within us, it’s a collective memory. We have to see a show as evoking these basic facets of humanity- both good and bad.

[Joanna Read] A great piece of theatre has relevance.. whether that is to the now and the immediate concerns of an audience... or whether it's a greater universal truth such as love or death or war.. This relevance is then brought alive by the quality of the art... how good the acting is... and more.

[James Houghton] Theatre which becomes timeless digs into the human condition in a way that goes beyond the given circumstances of that piece. Whether you see West Side Story or Shakespeare examining the story of star-crossed lovers; you will see an authentic and genuine human condition- the search for love.

When a story is told with authenticity and honestly; digging into the time and place and human nature, you will create a piece of theatre that becomes timeless. That's true in work which is current, or in work that is set around a particular circumstance or period.

Q: What is the role of education in theatre?

[Joanna Read] At LAMDA, we're training our students to be artists. Art is essential to how we live our lives, it can change-us, inform us and position our lives relative to others. We hold the business of theatre-making and the actors role in that very seriously. There is an obligation and social responsibility to be an actor.

We are training artists not entertainers.

[James Houghton] My greatest hope for the students graduating from the Juilliard graduate division is that we provide them the opportunity to be expressive and more of themselves, and that we give them the tools to express through their work in a manner that is generous, responsible and authentic. We want our graduates to enter the workplace not just prepared for the task at hand, but equipped to produce work that ultimately stems from their core selves... who they are, and their own voice.

Our students want to be great global citizens, they want to respect the form of theatre, they are inspired by the unending possibilities the medium allows. Every year we audition 1500 position for just 18 positions, and I see the heat and passion of theatre being as relevant today as it ever was; and I predict it will be for hundreds of years to come.

Q: What is theatre's economic role?

[Sir Howard Panter] Every single independent tourist review that is written about reasons why people should come to the UK and London starts with heritage/royalty and then immediately moves on to theatre.... Specifically theatre.... not the arts, not entertainment, not shopping, not restaurants... the theatre.

Alongside the fact that theatre employs many people in many diverse and different jobs, it's also a great regenerator of town-centres. If you speak to any government or local-government official that is trying to regenerate cities and towns further, theatres are at the centre. From time to time I get interviewed by an unnamed newspaper about the death of the West End. I always offer to take the journalist around London in a taxi where I can show them boarded up shops, boarded up offices, boarded up factories and boarded up pubs. Funnily enough... I can't find any boarded up theatres!

Theatre is growing globally, and people want it globally. How the work of theatre develop will be a fascinating blend of cultures, it's an incredible opportunity. We currently have three proposals from Shanghai asking us to build, operate and convert theatres as a central core-magnet to retail, residential and other developments. This is alongside conversations we are having in Korea, Hong Kong and more. Around the world, more theatres are being built now than at any other time in history. Theatre will lose the London and New York concentration. Hamburg, Vienna, Melbourne and Sydney are already great theatre cities. Hong Kong is growing into a great theatre destination too. There is also a huge opportunity across Canada and other territories. I see theatre essentially following an upward trajectory in terms of number of cities and venues.

People worldwide now acknowledge theatre is good for society economically and socially.

Q: What does the next 25 years hold for theatre?

[Sir Howard Panter] I think the essential core of theatre.... the unique selling proposition of being there to see it, having to perform in a space... will remain the same.... However what that core is saying and doing will depend on the message and story of the artists of the future.

The activity of theatre has lasted for many thousands of years. As long as human beings have the need to hear stories, and to tell stories, it will remain.

[Joanna Read] We're in very difficult times at the moment in terms of funding. This does however mean that we tend to get better at what we do. The work gets tougher, leaner and better.

I would hope however that regional-theatre funding improves in the future, and we're left with a secure theatre network.

[James Houghton] Theatre is ultimately about conflict between people and circumstances... you can wrap it in a different package and bow, but these principles have remained the same for hundreds of years.

In the off-Broadway scene of the 1960s, you saw a trend of self-generating theatre in store-fronts and unusual venues. They were still going after the essence of theatre, but taking it everywhere. If you look today at the influence of technology in theatre, we are now able to do some of the things we used to do by hand- but more easily... for example, throwing a light cue by computer rather than moving dimmers by hand.

Technology gives us more tools to get to the core event, but ultimately the fierce passion the artist has to reveal the story is what powers the theatre.

Q: What would be your message to the next generation wanting to make their future in theatre?

[Sir Howard Panter] You really have to devote your life to theatre. It doesn't mean you can't have a family and so forth... but it isn't like some activities in life where you can get a healthy work-life balance, as much as we would like to encourage it.

Theatre is your life as well as your work, and if that doesn't fit with you, then theatre isn't right for you.

[Gilles Ste-Croix] Whatever your talent… music, movement, whatever… if you have the drive to continue and develop and become a great performer then you should. It’s a lot of work- my father used to tell me that in life you need a little bit of talent, but lots of hard work.

If you have a little talent, prepare yourself for hard work to develop it, and you may attain greatness; but don’t forget that the road to greatness is long.

[Joanna Read] You should make the work that tells the stories you feel are important to you and your generation. The role of a theatre maker is to tell the stories of our lives.

You should try and grab the whole of the gamut of emotions, it's not just to entertain. The mix and bravery by which you grab those emotions makes theatre exciting.

[James Houghton] You must be fearless and brave. You must be willing to express what you feel, and to do that with thought.

People have a fear of expression, and we must encourage them to do the hard, hard work it takes to overcome this and know they are empowered to make work. All great work comes from this principle, new forms are made, new theatre is created.... When someone stops to write... or stops to raise some money? those are the moments where greatness is created.


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Art is one of the most valuable assets of human society, yet the truth is that while we may attach art to a time and a place; it’s true provenance and relevance remain intangible. We can look at the raw materials (the paint, the instrument…), the composition (the brush strokes, the music) or even the act of consumption (viewing, listing…) – but the thing that we observe only becomes art within us. The phenomenon of art emerges within the intangible mix of experience and cultural inputs that create our mind. A fact not lost on the ancient Greeks who simultaneously originated the concepts of philosophy (the love of wisdom) and theatre (the place for viewing) c.6th century B.C.

In his seminal book ‘Theatre and Everyday Life’, Professor Alan Read notes that “…the theatre is composed of material elements – bodies in action and speech articulated in places, and a receptive audience for that action and speech. The images of other arts are constituted in quite different ways. This engagement has a metaphysical aspect in that the image between the performer and the audience adds up to more than the sum of its various parts. A materialist criticism that does not recognise these ‘metaphysical’ qualities of theatre is lacking critical force. For the ‘beyond physical’, the numinous, the spirit, the aura of art, however it is described is a material response to art not just ideological or ‘imagined’. This ‘something more’ than the thing itself is attested to by too many people without deference to gender, race or class. And to ignore it, as though it will go away, and leave us with the quantified, the material and the manipulable, in the name of dogmatic sectarian objectives, is to impoverish the terms on which theatre might be most valuably and pleasurably thought and practiced. This metaphysics of theatre is what is not seen, beyond the practiced, beyond the mind’s eye it remains unwritten. It is the domain which both makes theatre worthwhile and simultaneously jeopardises its effects. For it is in this hinterland of the undocumented and discreet that the fallacies of theatre are nourished. This ‘something more’ of the image does not disconnect the experience of theatre from its place of performance, nor from the everyday. Theatre remains bound by its context precisely through the unique relationship images create between audience, performer and everyday life.” He adds that, “To value theatre, is to value life, not to escape from it. The everyday is at once the most habitual and demanding dimension of life which theatre has most responsibility to. Theatre does not tease people out of their everyday lives like other expressions of wish fulfilment but reminds them who they are and what is worth living and changing in their lives every day.” (Theatre and Every Day Life, 1993)

The concept of everyday life here is critical. Human beings are cursed with the knowledge of agency. We know without a shadow of a doubt that our immediate experiences are limited simply to ourselves. In many philosophies this is even manifest as the discussion of how one is trapped in the body- able to only experience the substantive world which we have ingested through our limited senses.

With this in mind, we quickly see the real power of theatre. Prof. Erin Hurley describes how, “Theatre allows for and offers vicarious experience: the experience of someone else experiencing something… We know that witnessing another’s actions and emotional experiences can create the same neurological imprint as doing or feeling them oneself. Joseph Roach provocatively recasts the history of theatre in terms of the good of what he calls ‘synthetic experience’, a cognate to vicarious experience. The theatre is a port of entry into another’s life and another kind of living.” (Theatre and Feeling, 2010)

Art is the medium by which we- as human beings- are able to relate to each other. Art allows us to understand things that are more than ourselves, and imagine life through the agency of others. Theatre- as perhaps the most human of all the arts- has the profound ability to engage us immediately in the experience of someone else’s agency- at any point in time, at any place. It breaks down the loneliness of being a self, and allows one to realise that not only are there others- but that the self can be them too.

I regard the theatre as the greatest of all art forms…” wrote Oscar Wilde, “the most immediate way in which a human being can share with another the sense of what it is to be a human being."


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