1. The Past, Present and Future of
Global Health Engagement by
Academic Ins=tu=ons
CARLOS DEL RIO, MD
HUBERT DEPARTMENT OF GLOBAL HEALTH
EMORY UNIVERSITY

2. What does the American public
think global health is?

3. Harr, “Defini=ons of Global Health,”
Journal of Public Health Policy, 2008
Ø
Focus
groups
as
forma-ve
research
for
Rx
for
Survival
TV
series
–
to
test
audience’s
understanding
of
the
terms
“global
health”
and
“public
health”.
Ø
Many
people
thought
“public
health”
meant
health
for
poor
people.
Ø
Thought
most
serious
global
health
threats
were
diseases
like
anthrax
and
smallpox.
Ø
Most
knew
that
HIV/AIDS
was
a
serious
problem
but
considered
tuberculosis
and
malaria
to
be
diseases
of
the
past,
and
no
longer
problema-c.

4. History of Global Health
Tropical
Medicine
• self-­‐interest
• colonial
expansion
&
slave
trade
• ID
control:
plague,
yellow
fever,
cholera,
malaria
Interna-onal
Health
• “them”
and
“us”
• paternalis-c?
• smallpox,
malaria,
child
survival,
family
planning
Global
Health
• partnership
• interdependence
• health
&
development
(MDGs)
• systems
~1960
Independence
~2000
Millennium
15th
C
→
Early
20th
C
Scien=fic
developments;
growth
of
capitalism;
increased
speed
of
transporta=on
&
travel

5. History of Global Health
The
bugs:
Plague,
cholera,
Tropical
yellow
fever…
Medicine

6. 20th century wars: WWI & II, Wars of
Independ
ence, Cold War
Ø AUempts
at
interna-onal
coopera-on
to
control
IDs
Ø 1918-­‐9
Flu
pandemic
Ø Vaccine
development
e.g.
1936
Yellow
Fever
–
Rockefeller
Founda-on
as
GH
NGO
Post
WWII:
Ø Par-ally
successful
malaria
elimina-on
Ø 60-­‐70s
Eradica-on
of
smallpox
Ø 1978
Alma
Ata
Declara-on
(PHC)
Ø 1979
Selec-ve
Primary
Health
Care
(GOBI)
Ø 1970/80s
focus
on
child
survival,
family
planning
Ø 1980s
Structural
Adjustment
Ø 1980s
HIV/AIDS
Interna-onal
Health

7. What is global health?
q Interna-onal
health
Ø
Health
prac-ces,
policies
and
systems
in
countries
other
than
one's
own,
stressing
more
the
differences
between
countries
than
their
commonali-es.
It
is
a
concept
more
focused
on
bilateral
foreign
aid
ac-vi-es
than
on
collec-ve
ac-on,
to
disease
control
in
poor
countries,
and
to
medical
missionary
work.
q Global
health
Ø
Health
issues
and
concerns
that
transcend
na-onal
borders,
class,
race,
ethnicity
and
culture.
The
term
stresses
the
commonality
of
health
issues
and
which
require
a
collec-ve
(partnership-­‐based)
ac-on.
Global
Health
Educa-on
Consor-um,
2008

8. Ins=tute
of
Medicine
"health problems, issues and concerns that
transcend na4onal boundaries, may be
influenced by circumstances or experiences in
other countries, and are best addressed by
coopera4ve ac4ons and solu4ons."

9. The
term
“Global
health”
was
first
used
by
the
University
of
California
San
Francisco
in
1999
Since
them
curricula,
programs,
centers,
departments
and
ins-tutes
have
flourished
in
academic
ins-tu-ons
CUGH
(The
Consor-um
of
Universi-es
for
Global
Health)
was
formed
in
2008
and
now
includes
nearly
100
North
American
Universi-es
and
colleges.
A
new
Global
Health
competency
model
recently
developed
by
the
Associa-on
of
Schools
and
Programs
of
Public
Health.
Approximately
1/5
of
US
medical
specialty
residencies
have
global
health
ac-vi-es
Merson,
M.
NEJM
2014

10. Incomplete Transi=ons
Ø Incomplete
transi-on
from
Tropical
Medicine
through
Interna-onal
Health
to
Global
Health
Ø Incomplete
transi-on
from
Bugs
to
People
to
Systems

11. A “brief” ins=tu=onal history of GH
WHO
–
1948
Alma
Ata
Conference
–
1978
World
Bank
–
◦ 1987
–
Financing
Health
Services
◦ 1993
–
Inves&ng
in
Health
(The
DALY)
Public-­‐Private
Partnerships
(PPP)
–
1998
The
Bill
and
Melinda
Gates
Founda-on
-­‐
2000
The
Global
Fund
–
2002

12. Why is there growing interest in global health?
Ø
Sense
of
a
“global
community”
Ø
Changing
demographics
of
U.S.
prac-ces
§ Increasing
immigra-on,
adop-on
Ø
Increasing
travel
to
developing
countries
Ø
Educa-onal
benefits
Ø
Commitment
to
social
jus-ce

14. Summary
Demographic
Na=onal
Data
(and
Source)
Popula-on
(2009
CB
est.)
307,066,550
Popula-on
(2000
Census)
281,421,906
Foreign-­‐Born
Popula-on
(2009
CB
est.)
38,517,234
Foreign-­‐Born
Popula-on
(2000
Census)
31,107,573
Share
Foreign
Born
(2008
CB
est.)
12.5%
Share
Foreign-­‐Born
(2000
Census)
11.1%
Immigrant
Stock
(2000
CB
est.)
55,890,000
Share
Immigrant
Stock
(2000
est.)
20.4%
Naturalized
U.S.
Ci-zens
(2009
Census)
16,028,758
Share
Naturalized
(2009)
41.7%
Immigrant
Admissions
(DHS
2000-­‐2009)
9,105,162
Illegal
Alien
Popula-on
(2008
FAIR
est.)
13,000,000

15. Educa=onal benefits of global health elec=ves for
medical students and residents
Ø
Improve
clinical
diagnosis
skills
Ø
Knowledge
and
training
in
tropical
medicine
Ø
Attudinal
changes
§
Public
health
service,
commitment
to
underserved
popula-ons
Ø
Recruitment
to
residency
programs
Thompson,
et
al.
Academic
Drain,
et
Medicine,
2003.
al.
Academic
Medicine,
2007.

16. “FARMER TOLD ME THAT HE FOUND
HIS LIFE’S WORK NOT IN BOOKS OR
IN THEORIES BUT MAINLY
THROUGH EXPERIENCING HAITI.”
ADDRESSING HEALTH INEQUALITIES AND PROMOTING
SOCIAL JUSTICE IS PART OF OUR MISSION AS
PHYSICIANS
TRACY KIDDER.
MOUNTAINS BEYOND MOUNTAINS.

17. MDG’s – through 2015
1. End
Poverty
and
Hunger
2. Universal
educa-on
3. Gender
equality
4. Child
health
5. Maternal
health
6. Comba-ng
HIV/AIDS,
malaria
and
TB
7. Environmental
sustainability
8. Global
partnership

18. Key Players in Global Health
Ø
World
Health
Organiza-on
and
other
UN
organiza-ons
Ø UNICEF,
UNDP,
UNAIDS
Ø
World
Bank
and
IMF
Ø
Bilateral
–
government
to
government
Ø
NGOs
Ø
Business
and
industry
Ø
BMGF
Ø
Global
Health
Ini-a-ves
(GHI)

20. WHO Challenges
Ø
Limited
funding
Ø
Cons-tuency
–
all
member
na-ons
Ø
Contradic-on
-­‐
loca-on
in
Switzerland,
rich
and
expensive
country,
belies
emphasis
on
poorest
of
the
poor
Ø
Mismatch
between
need
and
alloca-on
of
WHO
resources
-­‐
human
and
financial
Ø
Changing
burden
of
disease
Ø
WHO
deals
with
ministries
of
health

21. Bill and Melinda Gates Founda=on
Ø $34
billion
in
assets
(2009)
Ø Global
health
grants
(1994-­‐2005)
-­‐
$5.1billion
Ø HIV/TB
and
repro
health
-­‐=
$1.45
billion
Ø Infec-ous
diseases
-­‐
$1.1
billion
Ø Global
health
strategies
-­‐
$2.3
billion
Ø Global
health
technologies
-­‐
$211.5
million
Ø Global
health
research,
advocacy
and
policy
-­‐
$109.2
million

22. AIDS
provided
the
founda-on
for
a
revolu-on
that
upended
tradi-onal
approaches
interna-onal
health”
replacing
them
with
innova-ve
global
approaches
to
disease
The
epidemic
disrupted
the
tradi-onal
boundaries
between
public
health
and
clinical
medicine,
in
par-cular
the
divide
between
disease
preven-on
and
treatment.
Disease
advocacy
and
ac-vism
became
main
stream
AIDS
triggered
important
new
commitments
in
funding
of
health
care
in
developing
countries
HIV/AIDS
has
aUracted
remarkable
levels
of
private
philanthropy
and
led
to
new
public-­‐
private
partnerships
that
have
become
a
model
for
funding
scien-fic
research.
AIDS
has
spurred
a
debate
about
the
cost
of
essen-al
medicines
AIDS
incorporated
human
rights
into
the
discourse
Brandt
A.
NEJM
2013

23. The Past, Present and Future of GH and
AIDS
1981
–
First
cases
reported
1983
–
virus
isolated
1986
–
AZT
trial
1993
–
ACTG
076
1996
–
HAART
2000
–
Durban
AIDS
Conference
2001
–
UNGASS
2002
–
Global
Fund
2003
–
PEPFAR

24. HIV/AIDS
Ø
Declared
na-onal
security
threat
by
Clinton
Administra-on
Ø
7,000
thought
to
be
dying
a
day
Ø
Peak
of
epidemic
now
believed
to
be
mid-­‐90s,
but
not
evident
un-l
late
2000s
Ø
Pressures
of
epidemic
&
need
to
roll
out
medica-ons
highlights
fragility
of
health
systems.
Renewed
interest
in
Alma
Ata
Ø
Some
use
AIDS
moneys
to
try
to
build
health
system
(cf.
Farmer
response
to
GarreU)

25. Piot
P,
et
al.
NEJM
2013

26. ART
STOPS
HIV
Transmission
NEJM
Aug
11,
2011

27. Key Global Sta=s=cs
Ø 1.2
billion
people
are
tobacco
users
Ø 370
million
people
live
with
diabetes
Ø 972
million
people
(1
in
4
adults)
have
high
BP
Ø 1
billion
people
are
overweight
Ø 25m
people
live
with
cancer
Ø 32
million
heart
aUacks
and
strokes
globally
/
year
Ø Heart
disease
and
stroke
claim
17.2
million/year
Ø Cancer
kills
7.9
million
people
annually
Ø Diabetes
kills
4
million
people
each
year
Various sources: WHO, IDF, IUC

28. Global death ranks with 95% UIs for the top 25 causes in 1990 and 2010
Lozano et al, GBD Study, Lancet 2012

29. NCD’s: Defini=ons & Condi=ons
• Non-­‐communicable
Diseases
=
– a
disease
which
is
not
infec-ous;
may
result
from
hereditary
or
acquired
lifestyle
factors
– broadly
include
all:
• Cardio-­‐metabolic
(hypertension,
diabetes,
cardiovascular
diseases)
• Cancers
• Chronic
respiratory
disease
(chronic
bronchi-s/emphysema)
• Mental
health
problems
• Injuries

30. NCDs
Ø
Intersec-ons
between
globaliza-on,
urbaniza-on,
poverty
and
health
Ø
Majority
of
deaths
in
LMIC.
Increasingly
problem
of
poor,
rural
areas
of
LMIC:
mechanized
transporta-on,
foods,
rural-­‐urban
migra-on
Ø Impact
people
during
most
produc-ve
years
of
life:
profound
impact
on
economies,
households
Ø Currently,
at
least
300
m.
people
have
diabetes
worldwide
Ø Health
&
public
health
systems:
integrated
models
of
care
for
lifelong
management
of
NCD
condi-ons
Ø Advocacy
and
behavior
change

31. Risk transi=on
WHO
Global
Health
Risks
Report,
2009

32. Changes in Life Expectancy
1900 1950 1980 2000 2030
USA 49.3 68.9 74.1 77.4 81.2
Mexico < 30 50.8 67.4 74.9 80.1
Brazil < 30 50.9 63.3 71.1 77.4
China ≈ 30 40.8 65.5 72.0 77.4
India < 25 37.4 56.6 62.9 72.6
LDCs 40.8 58.8 64.1 71.5
2006
Revision
and
World
Urbaniza-on
Prospects:
The
2005
Revision,
hUp://esa.un.org/unpp,
Wednesday,
March
12,
2008

33. Time of Rapid Economic Changes

34. Diabetes is a huge and growing problem, and
the costs to society are high and escalating
382 million people have
diabetes
By 2035, this number will
rise to 592 million

35. The socially disadvantaged in any country
are especially vulnerable to diabetes

36. Lessons from HIV…..
Ø The search for cause & cure and fight to control the
epidemic has to be global
Ø Strong surveillance systems are key
Ø Prevention must be linked to early diagnosis and
treatment, integrating community and clinic resources
Ø Prevention should integrate behavior and biomedical
approaches
Ø Building advocacy is important
Narayan et al. New Eng J Med. Sept 8, 2011

37. Impact of Global Cooperation and
Annual No of HIV-infected Annual No of AIDS-related Annual Investments on HI/Narayan et al. New Eng J Med. Sept 8, 2011
Investments

38. UN HLM on NCDs, Sept 2011
Ø Only
second
ever
HLM
(first
UNGASS,
2001).
Unlike
AIDS,
not
single
disease
with
few
specific
interven-ons;
less
global
anxiety;
less
social
mobiliza-on.
Ø Whole
of
government
and
whole
of
society
response:
effec-ve
response
beyond
individual
actors
Ø Role
of
interna-onal
trade
&
subsidy
Ø Access
to
essen-al
medicines;
move
health
systems
from
episodic,
fragmented
care
to
con-nuous,
integrated
care.
Ø Need
for
surveillance,
measurable
targets
and
funding

39. Post-­‐HLM
“The
maintenance
of
the
momentum
generated
by
the
UN
Declara-on
will
depend
in
part
on
a
streamlined,
inclusive,
and
democra-c
civil
movement
that
is
proac-ve,
poli-cally
focused,
and
able
to
work
coopera-vely
with
global
and
na-onal
ins-tu-ons.”
“Preven-on
of
NCDs
is
also
inextricably
linked
with
climate
change
and
the
need
for
low-­‐carbon
policies.”
Beaglehole et
NCDs:
celebrating
success,
moving
forward,”
Lancet, 8
October 2011
Beaglehole et
Priority
actions for the
NCD crisis,”
Lancet, April
2011

40. WHO on Post-­‐MDG Agenda
“future
goals
and
indicators
need
to:
be
framed
as
global
challenges
rather
than
aspira-ons
for
developing
countries”
“the
paper
notes:
the
need
to
address
the
emerging
challenge
of
non-­‐communicable
diseases
without
disregarding
other
priori-es”
“The
paper
then
explores
the
poten-al
for
using
universal
health
coverage
in
the
post-­‐2015
agenda
as
a
way
to
accommodate
these
concerns”
International
for
Sustainable
Development,
Identifies
Health Issues
2015
Development
http://
iisd.org/
who-identifies-
key-health-
issues-for-post-
2015-
development-agenda,
October

41. 4 x 4 of NCDs
4
types
of
NCD
priori=zed:
Ø
Cardiovascular
diseases
Ø
Diabetes
Ø
Cancers
Ø
Chronic
respiratory
diseases
4 shared & modifiable risk factors:
Ø Tobacco use
Ø Unhealthy diets
Ø Physical inactivity
Ø Harmful use of alcohol

42. Themes / Paeerns
Ø NCDs
are
highly
prevalent
Ø Common
features
and
common
set
of
RFs
Ø NCDs
exert
major
burdens
worldwide
(death,
disability,
costs)
–
reflects
shiying
epidemiological
paUerns
Ø NCD
burdens
growing
fastest
in
LMICs
(linked
to
globaliza-on)
Ø NCDs
growing
in
low
SES;
perpetuates
poverty
and
stagnates
economic
development
Ø Intersec-ons
with
pneumococcal,
TB,
HIV
Ø Essen-al
to
achievement
of
MDGs
Ø Preventable/avoidable
–
primordial
preven-on
(e.g.,
FCTC)
or
recognize
&
manage
risk
factors
early

43. Key points
Ø The
global
burden
of
disease
increasingly
reflects
the
intersec-ons
between
globaliza-on
and
health:
60%
of
all
deaths
worldwide
due
to
NCDs,
80%
occur
in
LMIC,
with
profound
implica-ons
for
economies
and
health
systems
Ø Addressing
NCDs
key
to
achieving
MDGs
Ø FCTC
a
first:
galvanized
policy-­‐level
support;
progressive
realiza-on
proving
slow
Ø Need
for
civic
mobiliza-on
to
harness
posi-ve
aspects
of
globaliza-on
for
global
good.
HLM
as
galvanizing
force.

44. Obama’s Global Health Ini=a=ve
GHI
commits
“to
address
these
problems
by
tying
individual
health
programs
together
in
an
integrated,
coordinated,
sustainable
system
of
care,
with
countries
themselves
in
the
lead.”
“Improving
the
overall
environment
in
which
health
services
are
delivered…
tackling
some
of
those
systemic
problems
and
working
with
our
partner
countries
to
uproot
the
most
deep-­‐seated
obstacles
that
impede
their
own
people’s
health….”
“We
are
linking
our
health
programs
to
our
broader
development
efforts
to
address
those
underlying
poli?cal,
economic,
social
and
gender
problems…”
SMART
aid:
Integra=on
Coordina=on
Sustainability
Country-­‐led
Leadership
Systems-­‐
oriented
causes

45. Core principles:
Ø
Female
centered
focus
Ø
Strategic
coordina-on
Ø
Mul-lateral
engagement
Ø
Country
ownership
Ø
Strengthening
health
systems
Ø
Monitoring
and
evalua-on

46. Ebola Outbreak in 2014
hUp://onforb.es/Y3YjoG
A.
Vespignani
et
al.
Modeling
projec-on
of
cases
if
spread
con-nues
at
current
rates.
hUp://news.sciencemag.org/health/2014/08/disease-­‐modelers-­‐project-­‐rapidly-­‐rising-­‐
toll-­‐ebola

47. Ebola in 2014 and health systems
Will
the
current
Ebola
outbreak
finally
lead
to
a
real
commitment
to
strengthen
health
systems?

48. Global health is “smart power”
An
integral
part
of
the
government’s
three
pillars
of
foreign
policy:
Ø
Diplomacy
Ø
Development
Ø
Defense
Designed
to
improve
health
while
strengthening
interna-onal
rela-ons
When
the
US
uses
health
as
a
tool
of
diplomacy
it
sends
a
powerful
message
about
its
na-onal
values

50. Global health as public health at its best?
Ø Addresses
socio-­‐contextual
determinants
Ø Interdisciplinary,
systems-­‐oriented,
collabora-ve,
based
in
partnership
Ø Not
squeamish
about
incorpora-ng
clinical
care
Ø Transna-onal
issues,
determinants,
solu-ons;
“without
a
passport”
What
Global
Health
is
going
to
be
is
“a
work
in
progress”.

51. Forces in Public Health
Policy
Environment &
Enforcement
Epidemiology
Needs and
Risks
Science
Effective
interventions
Resources
Human,
Financial,
Infrastructural

52. What does the future hold for GH in
academic ins=tu=ons?
University
administra-ve
and
other
support
services
will
require
addi-onal
exper-se
to
address
the
legal,
financial,
ethical,
technical
and
compliance
issues
inherent
in
working
interna-onally.
Innova-on
in
technology
development
and
delivery
of
health
care
services
will
be
increasingly
more
relevant.
Career
paths
will
need
to
be
beUer
defined
to
keep
the
interest
and
momentum
global
health
Declining
resources
for
global
health
and
shiy
of
resources
more
to
low
and
middle
income
countries.
Need
to
move
from
disease-­‐specific
approaches
to
interdisciplinary
collabora-on
in
discovery
and
delivery
Merson
M.
NEJM
2014

53. Merson
M.
NEJM
2014

54. Educa=on in Global Health
Who
are
we
educa-ng?
For
what
jobs?
What
skills
do
students
need?
Are
they
all
the
same?
(MDs;
MPHs;
PhDs?)
Greater
need
for
leadership
and
management
training

55. Specific skill sets iden=fied
Business
skills:
◦ Project
management
including
budgetary,
strategic
planning
,
cost/benefit
analysis,
organiza-onal
management
and
poli-cal
sensi-vity
Wri=ng
skills:
◦ Scien-fic
and
grant
wri-ng
skills;
persuasive
wri-ng
and
wri-ng
for
diverse
audiences
Interna=onal
development:
◦ Understanding
the
history
and
context
of
the
work
new
graduates
will
embark
on
was
sees
as
cri-cal
need
not
currently
addressed
Language
skills:
◦ While
it
may
not
be
feasible
to
advocate
for
language
requirements
there
is
an
opportunity
to
beUer
provide
opportuni-es
for
students
to
obtain
proficiency
in
a
language
if
needed

56. Word wordle on global health challenges

57. “The ability to empathise with others requires the critical
examination of our individual lives and of our nations’ actions, the
capacity to see ourselves as bound to all other human beings, and
the sensitivity to imagine what it might be like to be a person living
a very deprived and threatened life.”
PLoS Medicine, December 2005

58. Acknowledgements
K.
M.
Venkat
Narayan,
MD,
MSc,
MBA
Mohamed
Ali,
MBChB,
MSc,
MBA
Jeffrey
Koplan,
MD,
MPH
Kate
Winskell,
PhD