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.
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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