Sunday, 7 March 2010

Global Health

In this interview, we speak to Sir Richard Feachem, who is Professor of Global Health at both the University of California, San Francisco, and the University of California, Berkeley, and Director of the Global Health Group. Sir Feachem was also the founding Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has saved over 4.9 million lives globally. We discuss the key issues facing health in the developed and developing world, strategies to eradicate some of the most prevalent conditions, and the future of global health.

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Vikas Shah, Thought Economics, March 2010

That human persons are flourishing” said Thomas Pogge (in his 2002 book, ‘World Poverty and Human Rights) “…means that their lives are good or worthwhile, in the broadest sense. Thus, the concept of human flourishing, as I understand it, marks the most comprehensive 'all in' assessment of the quality of human lives. It is broader than many other concepts including pleasure, wellbeing, welfare, affluence and virtue.

What Mr. Pogge realised was that for humanity to flourish (in both a philosophical and physical context) presupposes at least elementary levels of stability in diverse areas such economics (at a basic level, the ability to participate within an economy), politics and law (a framework which supports rather than suppresses, provides at least the basic levels of protection and freedoms), environment (the ability to subsist agriculturally, find water, shelter, safety from threats, and not fall victim to environmental conditions) and community (the existence of, and ability to interact with, other humans). Once these ‘elementary criteria’ (often referred to as basic human rights) are fulfilled, human beings can begin to flourish in other senses; intellectually, artistically, technologically, and so forth.

At the core of all these factors of human success is the core presupposition not discussed above, which is that humans are healthy, and able to participate in society. Many of the greatest commentators on life have realised this. “It is health,” said Mahatma Gandhi, “that is real wealth and not pieces of gold and silver.” A view supported by such statesmen as Benjamin Disraeli who said, “The health of the people is really the foundation upon which all their happiness and all their powers as a state depend” and even philosophical commentators such as Samuel Johnson, who stated, “To preserve health is a moral and religious duty, for health is the basis of all social virtues. We can no longer be useful when we are not well.

Humanity has also experienced a profound period of growth, in number (population), capability (technology) and mobility against a backdrop of economic ‘development’. These changes have exacerbated the spread of diseases (as humans are more mobile, and have greater variety of interactions), and created other health challenges (as health issues are compounded by poverty, or somewhat paradoxically created by wealth).

In this exclusive interview, we speak to Sir Richard Feachem, and discuss the key issues facing health in the developed and developing world, strategies to eradicate some of the most prevalent conditions, and the future of global health.
Sir Richard Feachem is Professor of Global Health at both the University of California, San Francisco and the University of California, Berkeley, and Director of the Global Health Group at UCSF Global Health Sciences. He is also a Visiting Professor at London University and an Honorary Professor at the University of Queensland.

From 2002 to 2007, Sir Richard served as founding Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria and Under Secretary General of the United Nations. During this time, the Global Fund grew from scratch to become the world's largest health financing institution for developing countries, with assets of US $11 billion, supporting 450 programmes in 136 countries. Previously, Sri Richard was Director for Health, Nutrition and Population at the World Bank (1995-1999) and Dean of the London School of Hygiene and Tropical Medicine (1989-1995). Professor Feachem holds a Doctor of Science degree in Medicine from the University of London, and a PhD in Environmental Health from the University of New South Wales. In 2007 he was awarded an Honorary Doctorate in Engineering by the University of Birmingham. He is a Fellow of the Royal Academy of Engineering and an Honorary Fellow of the Faculty of Public Health Medicine of the Royal College of Physicians and of the American Society of Tropical Medicine and Hygiene. In 2002 he was elected to membership of the Institute of Medicine of the US National Academy of Sciences. Sir Richard was knighted by Her Majesty Queen Elizabeth II in 2007.



Q: Looking at the core conditions of HIV/AIDS, Malaria and Tuberculosis. What are the economic, political and social challenges contributing to the continued growth and spread of these conditions? And what are the measures which are in-progress, and needed to move towards eradicating or managing these conditions?

[Sir Richard Feachem]HIV/AIDS, TB and malaria are among the largest health challenges faced by low and middle income countries today. In addition, these three major killers form the focus of the Global Fund to Fight AIDs, Tuberculosis and Malaria. At this point the similarities end. It is necessary to discuss these pandemics individually, because their specifics are very different.

HIV/AIDS is the greatest pandemic in human history. It is chronic pandemic, in the sense that its rise and fall is measured in decades. The known part of this pandemic is now three decades old, and it has several decades still to run. We have been remarkably successful in rolling out anti-retroviral therapy to those who need it, and therefore prolonging the life of millions of individuals in the developing world, who would otherwise die. We have been much less successful in prevention or in gaining a full understanding of the dynamics of transmission and the reasons for the large differences in infection rates among different populations.

The key challenges for the next decade are twofold. First, continuing to increase the level of international and domestic investment, both in antiretroviral therapy and in more successful and better designed programs of prevention. The second priority lies in designing and implementing effective prevention programs. We are not good at doing this today and we do not fully understand how to increase our effectiveness. The discovery of an effective HIV vaccine is the nirvana for all our efforts to prevent AIDS.

Turning to tuberculosis, there are two key dimensions. First, it is the handmaiden of HIV. As HIV worsens, so does TB. TB is the most common cause of death of HIV positive people in the developing world. Second, because we have so vigorously rolled out tuberculosis treatment programs, in some countries with great success, we have fuelled a rising pandemic of multiply drug-resistant (MDR) TB and extremely drug-resistant (XDR) TB. These forms of TB are steadily growing and will continue to do so. We are scientifically naked in front of this threat. We do not have the diagnostics to quickly detect an MDR or XDR case. Once detected, we do not have the drugs to effectively treat the patient at reasonable cost, and we do not have a TB vaccine. This is an area where major investments in basic science and laboratory research are urgently needed in order to bring us a new generation of improved tools and technologies for confronting this rather scary threat.

For malaria, the news is extremely good. Roughly 100 countries in the world have already eliminated malaria (most of them since the Second World War). Of the 100 countries in the world that still have endemic malaria, 39 are in the process of eliminating while the remaining 61 are making steady progress with their control programs. Numerous countries, even in the tropical heartland of malaria, have halved their morbidity and mortality rates since the beginning of this century. Challenges ahead of us are to maintain and, if possible, to increase successful investments in this field. In addition, we have to be ever vigilant about emerging resistance in the parasite populations to the drugs and emerging resistance in the mosquito populations to the insecticides. We can never prevent this resistance; we can only postpone it. Eventually, we will need new drugs and new insecticides.

Q: Looking at life expectancy, can you discuss the differences in life expectancy based on where one is born? How can be prevented?

[Sir Richard Feachem] The world experiences, on a daily basis, a zip-code lottery (or postcode lottery) with regard to the expectancy of life and the expectancy of health. Roughly speaking, a child born today in a very poor country can expect to live about 40 years, while a child born today in a wealthy country could expect to live about 80 years. These numbers come from national averages, and if you contrast life expectancy between a child born in the poorest communities in the poorest countries with a child born in the wealthiest communities in the wealthiest countries, the gap between the fortunate and the less fortunate is even wider. The reasons for these differences are well-known and, in most cases, the solutions are also well-known and have been effectively used in many places. The well-managed and large-scale implementation of known interventions would greatly close the life expectancy gap between the wealthy and the poor. The challenge is to finance this work and to deliver it effectively. Even with today’s resources, strengthening the management and delivery of programs can still have great impact.

Q: What are the key challenges facing the developed and developing world with regards human nutrition?

[Sir Richard Feachem] We are in the midst of a pandemic of eating too much (the overweight and obesity pandemic) and a pandemic of not having enough to eat (the under nutrition and hunger pandemic). Roughly 1.6 billion people in the world are affected by the first pandemic and roughly 1 billion people in the world today are affected by the second pandemic. Both numbers are rising rapidly. Curiously, 52% of the world’s population resides within countries where these pandemics co-exist on a significant scale. The solutions to the two pandemics are very different. The pandemic of hunger is related to poverty, the equitable distribution of food, and rising food prices. The epidemic of obesity is related sedentary lifestyles and the skill of the food industry in producing unique combinations of fat, sugar and salt, which override our appetite mechanisms and cause us to consume far too many calories. A single super large combo meal at any popular hamburger outlet will contain a full day’s worth of calorie intake. When one sees such meals being purchased and eaten, one wonders whether the individual concerned is going to consume only water for the next 24 hours. Unlikely!

Q: What impact are global topics such as conflict, climate change, the global economic slowdown and mobility playing in global health?

[Sir Richard Feachem] The global economic slowdown has huge implications for global health. Global health benefited from a rising tide of investments in recent years, which has now abruptly come to an end. The major global health investors, such as the Global Fund to Fight AIDS, TB and Malaria, find that their income is plateauing and may even start to decline. This provides a fundamental challenge to their business model and their ability to support the high quality applications that they continue to receive in large numbers. Significant reengineering is required in the face of this reality, combined with a major movement towards smart investment and not just more investment.

Conflict is and always has been a huge enemy of global health. Diseases surge forward in times of conflict and painstakingly developed public health programs can be destroyed in weeks. In addition, conflicts create refugees and migrants, who typically experience worsening health and epidemics linked to the squalor of their temporary living conditions.

The global warming and global health relationship is more nuanced and subtle. There may be gains and there may be loses through gradual increases in temperature and shifting patterns of rainfall. What is clear is that extreme climatic events, which appear to accompany global warming, are greatly hazardous to health and typically produce acute setbacks and epidemics together with longer term undermining of carefully designed and implemented public health programs.

Q: What role does philanthropy play in providing solutions to health challenges globally and organisations such as The Global Fund? Can you explain the need and premise behind health-systems initiatives (PPiP)?

[Sir Richard Feachem] In recent years, philanthropy has played important and influential role in global health. This has been led by the Bill and Melinda Gates Foundation which has significantly changed the global health landscape. Global health is now a field in which, rather than having a monopoly of ideas and initiatives coming primarily from the WHO, we have a competitive plurality of initiatives and investments coming from a variety of public and private organizations. Provided there is not duplication and wastage of effort, this competitive plurality is a good thing and has greatly stimulated the intellectual and investment landscape in global health.

New mechanisms for financing global health, especially the Global Fund, have shown that the modalities used since the end of Second World War can be greatly improved upon. The Global Fund has embraced a number of radical innovations which have set new standards in the business of aid. The leading innovations implemented by the Global Fund have been:

1. To let the demand side rule and to separate the business of finance from the business of designing and implementing programs;

2. Disbursement on the basis of independently validated performance;

3. Financing both public and private actors on the basis of the quality of ideas and the success of implementation of those ideas; and,

4. Extreme web-based transparency to allow citizens in both donor and recipient countries to track every detail of every grant.

Another major arena of active debate concerns the role of private actors (in Europe, referred to as NSAs; non-state actors) in health systems strengthening. Most developing countries start from a position where half or more of all health care delivery is done by disorganized and unregulated private providers and is paid for out-of-pocket. A major movement is underway to conscript private investment, skill, and energy into the achievement of public policy goals, by forming long-term public-private partnerships between government and the private sector. Much of the innovation in this area is coming from the developing countries themselves rather than from debating rooms in Geneva, London or Washington. This local innovation provides the beginnings of a way out of decades of health systems neglect and the lack of access to high quality services experienced by most people in low and lower-middle income countries.

Q: How are investment markets playing a role in these challenges?

[Sir Richard Feachem] Innovation in the financial market place is playing an increasing role in global health. We already have bond issues to support global vaccination programs, and advance market commitments to promote research and development investments in new drugs and vaccines targeted at priority diseases of the developing world. Big pharma companies are working on patent pools. Organizations such as the Clinton Health Access Initiative are negotiating highly favourable prices for large volume supply of HIV and malaria products for the developing world. And so on and so on. This will continue.

Q: What are the key technological developments which will impact global health?

[Sir Richard Feachem] This falls into two domains. Biomedicine and biotechnology on the one hand, and everything else on the other. The rapid progress in molecular biology and biochemistry will continue to accelerate the pace at which new drugs, diagnostics and vaccines targeted at major health problems in the developing world will become available. The challenge then is to make these new products quickly accessible to poor people in remote parts of poor countries. We are getting better at doing that, but we still have a long way to go.

The other domain of technical innovation will be, simply put, everything else. Prominent in the everything-else space will be information technology of many kinds. Already cell phone technology is being used for surveillance, data reporting, remote diagnosis, tracking the movements of people who might carry malaria across borders, and much more. Satellite based mapping technology is also rapidly improving our ability to track health and disease spatially, down to the level of the individual house. This kind of intelligence can be extremely helpful in the fight against infectious diseases and in responding effectively to outbreaks and pandemics.

Q: Is enough attention also being directed towards the development of treatments for orphan diseases?

[Sir Richard Feachem] There are two kinds of orphan diseases. First are the very rare diseases of wealthy people in wealthy countries. For this category, there is explicit legislation providing substantial incentives for research and product development. These incentive structures have worked very well in North America, Europe, and Japan, for example. The other kind of orphan diseases are the common diseases of poor people in poor countries, which are not also experienced by rich people in rich countries. For these diseases, there is also a profitability risk for anyone contemplating a research and development investment. We have seen much less ingenuity in designing incentive structures for this second group of orphan diseases. For HIV/AIDS, this has not mattered because it is a disease both of poor people in poor countries and of wealthy people in wealthy countries. Profitability is ensured by the second category of patients and new products, appropriately priced, can also benefit the first category. This is not true of the so-called neglected tropical diseases or conditions such as malaria. We need to improve incentive structures for this category. The rise of a research-base pharmaceutical industry in countries like Brazil, China, India and South Africa will not make this problem go away. These companies will be subject to the same incentive structures as their competitors in North America and Europe and their boards will equally favour research and development directed towards chronic disease of wealthy people (or well-insured people) in rich countries. Because a new drug is developed and manufactured in India does not mean that it is more likely to address the needs of the 700 million poor Indians rather than the 300 million middle-class Indians. Again, much more ingenuity around incentive structures is required to unleash the full potential of the pharma and biotechnology industries to tackle the biggest of global health problems.

Q: What does our experience with the first year of the H1N1 pandemic tell us about challenges and opportunities in global health?

[Sir Richard Feachem] It tells us a great deal. H1N1 (swine flu) has let us off the hook by being such a mild virus with such a low case fatality rate. H1N1 does have one of the two properties we fear; namely it is very easily transmitted from one human to another. H1N1 spread to 120 countries in the first 10 weeks after the index case in Mexico, and this wasn’t due to flying pigs! This was people getting on airplanes. Fortunately (to put it mildly), H1N1 does not have the second property which we fear, namely high virulence and a high tendency to make infected people severely ill or to kill them. By contrast, H5N1 (bird flu) does have this second property but lacks the first property. When a virus begins to spread which has both of these properties, humankind is in big trouble.

H1N1 has shown us that we lack the ability to identify new pandemic strains quickly or to contain them. Global spread is therefore assured. The challenges are: how to collaborate?, how to cope?, and how to respond globally once the cat is out of the bag?

How did we do? In national terms, some countries did quite well. In global terms, we failed miserably. The 30 OECD member countries pre-bought pretty much the total drug and vaccine production capacity of the small numbers of companies in Europe and North America that make the drugs and the vaccines. The only exception is China, which created its own H1N1 vaccine manufacturing capacity and bought it for its own people. The remaining 170 non-OECD countries were left out in the cold. They made no vaccine and there was little vaccine to be bought, even if they could afford it. Dr. Margaret Chan at WHO worked hard to persuade the wealthy countries to donate 10% of their pre-purchased vaccines to the low- and middle-income countries. This was better than nothing, but a token contribution. 10% of the population of the 30 most wealthy countries is roughly 2% of the population of all other countries. Even if all of this 10% contribution had been made and effectively distributed to where it is most needed, its contribution to attenuating the pandemic would have been minor at best.

Ironically, history then overtook us and we found that the mildness of the pandemic, and the fact that, in the United States and elsewhere, the major vaccine supplies arrived after the peak of the pandemic, meant that demand for the vaccine collapsed and many wealthy countries have been left holding large amounts of vaccine that they cannot use for their people at home. A scramble is therefore underway to give or sell this vaccine to other countries that may have need for it.

If there were a Government of the World, one of its first duties would be to create a CDC for the world (Centers for Disease Control and Prevention). A sensible leadership at CDC would work to optimize the rapid production of vaccine in the face of a flu pandemic and to allocate that vaccine in a way that would cause maximum attenuation of the global spread and impact of the pandemic. Such an allocation of available vaccine would look nothing like what we have seen through this winter in the northern hemisphere.

What H1N1 has shown us is that, despite the heroic efforts of WHO, the world is very far from the point of international collaboration that can allow globally optimal responses to global threats. In other words, we have a failure to address a prominent global public good, or put the other way, to redress a prominent global public bad, namely a potentially devastating pandemic. When the current northern winter is behind us, we should gather internationally to debate and discuss this experience and struggle to create new and better systems. A highly virulent and easily transmissible flu virus will emerge. We just do not know where and when.


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It is also important at this stage to address the issue of whether healthcare is a basic human right, and whether it is the responsibility of governments to provide universal healthcare for their citizens. Interviewed in October 2009, Professor John Harris (Lord Alliance Professor of Bioethics at the University of Manchester) stated, “I think access to healthcare is very important. I tend not to use the language of rights if I can avoid it, except to add rhetorical force to what I say. The better way to look at it is not as a human right because you then have the problem that if a particular society doesn’t have the resources to deliver healthcare, are they denying human rights to their people? Well, not if they can’t generate the resources. For some African countries, for example, the available money for healthcare per capita, is something like ten dollars and you can’t deliver a comprehensive healthcare system on that sort of funding. What is an entitlement, and what is very important is firstly that we should care for other people if we can (including care for their health). This is one of our basic moral duties, partly the duty of beneficence (the duty to do good and not harm), and partly the rule of rescue (that if someone is in need of healthcare, they are in need of rescue) and a good person will try to rescue someone if he or she can. So rather than think of it in terms of rights, we have very strong moral reasons to provide healthcare to the best standard we can. That standard will vary from society to society.

To put this in a macro-context, a report by the World Health organisation (The World Health Report 2008 - primary Health Care -Now More Than Ever) states, “Globalization is putting the social cohesion of many countries under stress, and health systems, as key constituents of the architecture of contemporary societies, are clearly not performing as well as they could and as they should … People are increasingly impatient with the inability of health services to deliver levels of national coverage that meet stated demands and changing needs, and with their failure to provide services in way that correspond to their expectations. Few would disagree that health systems need to respond better – faster – to the challenges of a changing world.

The identification of ‘globalisation’ as a driver by the WHO is important. Societies, in general, wish to be fair and decent. The advent of global free-market capitalism has created a great deal of perceived liberty in the industrialised countries who have most benefited from it, but this capitalism has brought costs, including (as A.C. Grayling identifies), “…environmental damage, crippling third world debt, untenable disparities between rich and poor, and the destructive effect upon communities of turning people into commodities and social relations into market transactions.” Grayling also identifies humbling facts including, “…Mexico’s richest man has more money than the poorest seventeen million of his countrymen put together, and the annual debt repayments of many poor countries far exceed what they can spend on health and education.

Capitalism has, though, given us huge innovation across all fields of human experience from transportation, to medicine, communication, and more. Alongside these innovations has come our ability to interact as a society, understanding the plights of those in need in our communities, and elsewhere in the world. While defenders of free-markets assert that markets themselves will remedy their inequities in time, the fact remains that while greed and human nature play a part in economics, intervention is necessary by us, as participants in society, to remedy the disparities and plights which exist.

For global policy makers, this presents immediate and necessary challenges to their incumbent policies. To take paradigm from Thomas Pogge, “One's human right to adequate nutrition, say, should count as fulfilled when one has secure access to adequate nutrition, even when such access is not legally guaranteed. Legal rights can be, and often are, an effective means for realising human rights, but such legal rights need not, however, have the same content as the human right they help realise. Depending on the context, the best way of realising a human right to minimally adequate nutrition may not be legal rights to food when needed, but rather some other legal mechanisms that keep land ownership widely dispersed, ban usury or speculative hoarding of basic staples, or provide childcare, education, retraining subsidies, unemployment benefits, start-up loans. And non-legal practices - such as a culture of solidarity among friends, relatives, neighbours, compatriots - may also play an important role.

To contextualise these thoughts for global-health, we can see that the challenges faced will not simply be remedied by the creation of drugs, or techniques for managing conditions. A wider approach is necessary, creating policies which focus on health issues in all facets of human experience, from education about health issues (not solely for children, but even adults), through to political and economic frameworks for the delivery of care, and strategic involvement from commercial and sovereign partners to fund these great challenges.

The importance of health cannot be understated. Whatever measure we use, whether it be political, economic or otherwise, we come down to the fact that society is made of participants who need health to flourish, and regardless of our race, colour, background or nationality, we share the same DNA, meaning that health becomes the core of our collective experience, and part of our collective responsibility to remain acutely aware of.

As A.C. Grayling allows me to conclude, “Health is not an end to itself; it is the principal instrument for the enjoyment of life”.

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