An Optimist’s View of Global Health Achievement

Remarks by Tim Evans, Dean, Bangladesh Rural Advancement Committee (BRAC) University

First, in keeping with the dream theme of this meeting, I’ll take a deliberately aspirational view of the 21^stcentury in health and describe indicative prospective achievements. Second, as a Dean of a school of public health, I’ll examine the role Universities might play both in contributing to these results through their research and education missions.

My optimistic view is based on the successful translation of the shared values. While the intrinsic value of health as a special good has been masterfully articulated by Professor Sudhir Anand, I posit two values related to health – equity and security – that are critical for forging convergence and mobilizing actions for health in our increasingly globalized and interdependent world.

Dr. Bill Foege – former CDC Director, leader of the Task Force for Child Survival and former Rockefeller Board member – summed up the 20^th century in health in four words: Spectacular Progress, Spectacular Inequities! Projecting forward a hundred years, I would hope a similar summing up for health might be expressed as “Spectacular Equity, Spectacular Security.”

Let’s consider first what a century of achievement in global health equity might look like?   Fundamentally, it would mean transcending the tendency of health systems towards greater inequities in health outcomes – what Julian Tudor Heart famously called the Inverse Care Law — and learning how to systematically “break” the Law…the Inverse Care Law!

Across the life course breaking the inverse care law would yield the following outcomes by 2113:

• All first trimester terminations of pregnancy are gender-blind and the world’s two most populous countries (India and China) achieve normalization of sex ratios at birth;
• Maternal mortality declines to such a low level that differences in rates across countries cannot be reliably measured and the World Health Assembly debates whether it should be declared “controlled”; “eliminated”; or “eradicated”.
• Improvements in gender equity in health are of such magnitude that the New York Review of Books publishes an article in 2090 entitled “Zero missing women”, on the centenary of Amartya Sen’s 1990 article entitled “100 million missing women”.
• Early child development, recognized as the most effective intervention for life-long adult health, is tailored to the contextual realities and needs of urban populations in every city on every continent be it Beijing, Bangkok, Brisbane, Bamako, Berlin, Baltimore or Bogota.
• Adolescent and early adult engagement programs facilitate the transition to employment and stem a pandemic of substance abuse, violence, suicide and depression among disenfranchised youth.
• Risk factors for chronic diseases including tobacco use and obesity are declining at similar rates for the wealthy and the poor in all countries as manufacturers of cigarettes and junk food withdraw from the market due to regulation, taxation and class action suits.
• Inter-professional health teams facilitate home and work-based delivery of primary and secondary prevention, rehabilitation and palliation for acute and chronic illness across countries and socio-economic strata;
• Equity-impact assessments are integrated into decisions on priorities for technology development and the assessment criteria for the inclusion of new diagnostics, devices and drugs in health benefit packages.
• Gains in equity are so great that Hans Rosling’s Gap-Minder is renamed “Gap-Finder!”

In terms of Spectacular Security, outcomes might include:

• A “one-world health” system for pandemic threats ensures 24/7/365 capacity for rapid detection and speciation of new bugs as well as development of, and access to vaccines/drugs to minimize the health, social and economic consequences of disease outbreaks;
• A specialized field of global health diplomacy that values the health of future generations known as “Carpe Centuria” –– has brokered a dozen inter-governmental, multi-stakeholder agreements ranging from new laws to conventions to codes of conducts for critical security threats such as climate, water, energy and food;
• All countries have health financing systems that minimize direct payment for health care for all citizens at home and abroad and eliminate health care expenditure as a cause of household impoverishment;
• Official development assistance for health ended 50 years ago and was replaced by a global family of solidarity and re-insurance funds for health that all countries contribute to and can access as needed to overcome financing shortfalls;
• Check-lists other “safety” innovations in health care provision relegate “medical errors” from a “leading” to a “extremely rare” cause of death;
• New artificial kidneys that are cheap and easily implanted eliminate the illegal and exploitative trade in kidneys
• All individuals have living wills that guarantee dignified end-of-life care that respects individual choice

What is the role of the University in achieving this dream for global health?

In his commencement address to students at Harvard University in 2006, Bill Gates said that “reducing inequity is the highest human achievement.” And the development economist Paul Collier in his best selling book the Bottom Billion said – “although the plight of the bottom billion lends itself to simple moralizing, the answers do not!”

The university thus has an important leadership role in marshaling knowledge through both research and education to achieve this dream for global health equity and security in the 21^st century. Leadership in research involves charting new knowledge frontiers related to priority topics or issues as well as establishing new types of information systems, disciplines and fields that are more responsive to the nature of global health equity and security challenges.

Perhaps the most important science frontier in health relates to the brain. Described by many as the key to health in the 21^st Century, there are a slew of health problems in which the brain is central – the dementias, movement disorders, mental illness etc. that are accentuated with aging societies. The brain also mediates a fascinating array of socio-economic and environmental threats and opportunities with both acute and long-term impacts i.e. early childhood stress and risk of chronic illness later in life. In addition, the insights from Nobel-laureates Kahneman and Tversky related to “thinking fast and slow” revealing the fallacies of “rational” thinking, together with powerful brain function imaging and computation are beginning to unveil how to harness the potential, and minimize the pitfalls, of the 100 billion neurons that constitute the human CPU.

A second closely related frontier relates to the IT revolution in health. In Bangladesh, opportunities are emerging for continuous, life-long, portable electronic health records based on unique biometric identifiers assigned at birth as part of a universal vital events and health information system. If this can be done in Bangladesh, why can’t it be done globally? Why couldn’t every newborn be assigned a Global Health Identification Number – or GHIN? Think of the equity and security implications of counting every life, or making every life count!

The knowledge of what determines health has grown exponentially and spans the bio-physical including genomes/proteomes to the cognitive and behavioral, to the social structural and environmental.  And just as the Rockefeller Officer, Warren Weaver catalyzed the emergence of molecular biology in the 20^thcentury, there is a similar opportunity ahead to combine molecular epidemiology with population demographics and global economics and create a new hybrid discipline entitled “EPIDEMONNOMICS”. EPIDEMONNOMICS could shed fundamental insights on the diverse range and interactions of health determinants through multi-level trans-national research where the global sampling frame comprises a cool 10 billion individuals!

In addition to this “GHIN and EPIDEMONOMICS” cocktail, an exciting new field of health systems research is on the knowledge frontier menu for the 21^st Century. To effectively prepare or respond to a global pandemic; AND to scale-up interventions to save mothers and children from preventable mortality  AND to provide effective secondary prevention in the community for hypertension, diabetes and high cholesterol–requires a level of functioning of systems for health that is all-too-often missing. Learning to do better and achieving breakthroughs in systems performance and innovative models of care is whetting the appetite of a growing group of researchers and practitioners from diverse disciplinary backgrounds and contributing to securing the scientific foundations of the field. In 2113, a review of the last century of Nobel Prizes in medicine will identify a third of the prizes granted to teams of researchers from non-OECD countries that have pioneered transformative solutions to health systems shortfalls in performance, e.g. models of long-term community care.

Just as the knowledge agenda related to research needs leadership, so too does the education agenda related to health professionals. On the 100^th anniversary of the landmark Flexner Report on medical education in 2010, the Report of the Global Commission on Health Professional Education for the 21^stCentury, recommended a set of “instructional” and “institutional” reforms to achieve transformative and inter-professional education for equity in health. These broad recommendations are helping to re-set the direction and revitalize the relevance of health professional education globally.

In following-up in Bangladesh, we have reformed our MPH around a “praxis” theory of knowledge for public health. “Praxis” is defined by Paulo Freire in his book “Pedagogy of the Oppressed” as “reflection and action upon the world in order to transform it.” Our hope is that, working with other interested institutions from around the globe, we can establish a set of global standards for global public health education that raise the bar on competencies required to break the law on inverse care and re-define the courses and degrees that steer us in a better direction for greater equity and security in health in this century.

However, education is so much more than supplying new curricula and pedagogic methods in good functioning institutions. Rather than bore you with the details of our “pedagogic oppression”, I thought it might be more interesting to hear from students/the future leaders themselves – as they constitute the next generation of leaders for global health equity and security. Unfortunately, 20^th century technology has conspired against me. Were you able to hear the voices of our future leaders, I’m sure you would be impressed by their borderless and optimistic vision of the future. They are inspired by a wide range of 21^stcentury opportunities to learn that include:

•  Going to the people public health is meant to serve, to learn from them
•  Learning from one another in a class-room of students that is truly international
• Transcending disciplinary and professional silos in the common pursuit of knowledge to solve problems
•  Working in “dream” teams in a relentless pursuit of greater equity and security in health
•  And above all having fun.

Clearly the spirit of sacrifice and service that Mr. Rockefeller hoped for, nearly a century ago at the inauguration of the Peking Union Medical College, is alive and well in the 21^st century not only in Bangladesh but elsewhere.  Further 100-year investments to “grow the people” and thus nurture future generations of leaders will set us on the right course to realize the centennial dream of spectacular equity, spectacular security.