The Future of Public Health

We now come to the conclusion of this introductory course on global health. Global public health has now a very large mandate in the context of sustainable development. It has grown from the foundations of public health, which itself is not relatively new. Even prior to the 20th Century, public health was deemed to be very important. Many of the important investments in public health, whether in the form of water, sanitation, or healthy nutrition, came about in the centuries preceding what we call as modernity. However in the 20th Century, marked advances in science and technology enabled us not only to understand the links between health and disease much better in terms of what causes disease and how best to protect it, but also to organize health systems around dealing with disease and promoting health. When we look at how the scientific knowledge has helped, we must also recognize that to some extent it started fragmenting our approach to public health. Epidemiology has been a remarkable science which advanced the understanding of the factors that cause disease, whether it is an infectious agent or smoking. However it is in the very nature of epidemiology that we start looking for independent associations which can be attributed to that particular risk factor over and above anything else. And therefore, necessarily we start becoming reductionist in our approach. But we also need to position that reductionist knowledge in a much more holistic context and that is where public health comes in. We have previously separated out different knowledge and practice domains like epidemiology, health economics, behavioral sciences and also to some extent management principles. But now we need to integrate all of them into the discipline of public health and to some extent we have succeeded in doing that in the 21st Century. But we now need to position it in the context of global public health, because global public health has now become a common concern for all of humanity whereas public  health previously did look at what was happening in different parts of the world but confined its actions mostly to national or regional contexts. But when we recognize that the determinants of health now act across geographical boundaries and cause common challenges that have to be faced by the world as a whole, then global public health becomes a very necessary unifying platform and here we need to integrate all of our knowledge in order to address these challenges. So while epidemiology for example provided a very necessary insight into what caused disease, public health provided a better perspective on how a complex system should be addressed, so from linear thinking to complex thinking, a complex system approach, we started having a transition. But global public health now brings in much more dynamics into the picture. It brings in the whole global economic profile of development and distribution of the products of that development. It talks about equity as an underlying value. It shows how economic inequities within countries and across countries can accelerate health inequities. It also shows how global cooperation can advance the common objective of reducing health inequities and protecting people against the spread of disease. So we now need to look at how global health has evolved from public health, how global health is now looking at the determinants of health transition across countries, the varied measure of these determinants, but how they act in concert in order to determine whether countries are going to face a huge burden of disease in one form or the other or whether they can actually telescope the transition by averting much of the disease that could have otherwise occurred. We now have a better understanding of some of the specific problems related to maternal and child health including child under nutrition. We also have a better understanding of the spread of infectious diseases as well as the methods for their control. We recognize the big threat posed by non-communicable diseases, and how these are happening in the context of health transition which again has multiple determinants and driving forces. We have seen how health systems have to be better organized in order to respond to this combination of challenges and how when we talk about health systems we are not only talking about financial protection or health workforce or access to essential drugs and technologies in isolation but we are talking about all of them and again as a combination. And where we now look at the health systems as a platform for universal health coverage, this becomes even more important to look at how universal health coverage can deliver a variety of services needed by the people while providing them adequate financial protection. This again becomes very important in the context of economic development and reducing health inequities which can be perpetuated by ill health which affects the poor people predominantly. So the interrelationship between poverty and ill health is again brought into focus not only in the area of public health at the national level, but in terms of global public health as well. So all of these complex interactions become very integral to our understanding of global health and become the basis for our action. When we really look at how we need to respond to some of these global public health challenges we further realize that we are require an all-of-society approach which brings in multi-sectoral action in order to advance global health by dealing with the multiple determinants which have impact upon health. Those within the health sector as well as those outside of the health sector, whether it’s trade, whether it is urban development, whether it’s agriculture and food systems, all of these will now have to be studied and also motivated to become better aligned to public health objectives. And this is where global public health has to now become positioned in the framework of sustainable development because we cannot really think of sustainable development without having healthy people. But we also can’t think of having sustainable development without a healthy planet and interestingly, we cannot think of healthy people without a healthy planet because environmental degradation will certainly undermine the health of the people and even imperil their very existence. So bringing together all of these elements under the framework of sustainable development is very critical not just because the United Nations wants to call them Sustainable Development Goals but because these are very important goals for humanity itself. But while all of this happens we have to contend with a huge number of social forces and decide how they can actually be driven in favor of public health. We recognize that there are different models of economic development based on ideologies, there are the free market model, there has been the state controlled model, there are people who are looking at blending some of these systems in a mixed economic system as well as in a mixed health system. While all of these debates go on, we must really recognize what works best in favor of global public health. And therefore, we need a vigorous debate on ideas but we also need to embody those debates and a set of fundamental values and global public health actually brings forth global solidarity and partnership as those values. And of course the very underlying value of public health anyway is equity. So when we are really trying to promote equity in all dimensions but use solidarity as one of the motivating forces for moving us toward that ideal of equity, then global public health becomes a very important unifying factor across the world. And therefore, irrespective of some of the ideological struggles that are inevitable, and are likely to take place even in the 21^st Century, we must overcome the struggle of these competing and conflicting ideas and ensure that we have a common blending of values which will triumph over these kind of sectarian ideological battles and those values will have to reflect a commitment to global solidarity, because without that solidarity, we will not be really looking at all of humanity as one family where the concerns and problems of one section will have to be addressed by the whole family together. We must recognize that as we move towards the implementation of the Sustainable Development Goals, health is absolutely pivotal for the economic, social and environmental development and protection. And then we must also ensure that health in turn benefits from equitable development in other sectors. For all of this to happen, the Sustainable Development Solutions Network is providing a unifying platform for looking at sustainable development in all dimensions from all directions. Health and global public health are important components of the mandate of the Sustainable Development Solutions Network. We hope that after this introductory course in global health has set you in motion, you will now become important contributors to global public health and to sustainable development. Therefore, this is not the end of the course. This is the beginning of our partnership to work together for global public health and for sustainable development which are a global public good, and which are important not only for this generation, but for generations to come.

Health and sustainable development- II

This century began with the Millennium Development Goals but after fifteen years moved on to the Sustainable Development Goals, to build up on the gains of the Millennium Development Goals but also to pursue a much more comprehensive agenda of interlinked and inclusive development. Beginning with MDGs, and then subsequently having a strong focus on social determinants of health through the WHO commission on social determinants of health as well as a major thrust towards universal health coverage brought about by the World Health report of 2010 which focused on health financing, particularly as a foundation for universal health coverage, and then also looking at different emerging public health challenges of the 21st Century, the whole area of non-communicable diseases which in September 2011 formed the subject of a UN high level meeting resulting in a political declaration calling for concerted global action to prevent and control NCDs.

All of these in the last fifteen years have coalesced together towards the Sustainable Development Goals, but the clarion call for the SDGs came from the Rio+20 meeting in 2012 where the world pledged that they would work for sustainable development and said that collectively we will create the future we want. Basically at Rio+20 and subsequently through the actions of the United Nations for framing the Sustainable Development Goals three pillars were identified which were economic, social and environmental. Clearly, health is linked to all three of them. But along with this we also need to position another underlying element, if not as a pillar at least as the platform, and that is good governance.

The economic case for linking health to sustainability is very clear. Healthcare costs pushed 100 million people below the poverty line and this was from the World Health Report of 2010 published by the World Health Organization. Catastrophic health expenditures are commonplace not only in lower and middle income countries but also in some of the high income countries, for example in the United States we have seen a fairly large number of uninsured people suffering the problems of either inaccessible healthcare or impoverishing healthcare. Universal health coverage ensures financial protection through risk pooling and reduction of out of pocket spending. Clearly, therefore, there is a case for linking health to the economic development and ensuring that economic inequities do not affect health and also we provide greater health equity through suitable financial pathways like the universal health coverage with built in financial protection.

We also meet to ensure that households avoid spending their disposable incomes on avertable health problems so that that can be spent on other goods and services, improving the welfare of households like nutrition or even to give a fill up to the global economy by spending on other consumer goods. But if you’re spending money on avoidable angioplasties and coronary surgeries and so on, you do not have money to buy other consumer goods and that affects the pace of recovery in a sluggish global economy.

Clearly there is also a social case for linking health to sustainable development. We cannot talk of sustainable development or of health for that matter without talking about gender equality and human rights. They’re intimately linked to health. We recognize that these are important inputs into advancing health of societies and bridging gaps in health equity. So they become fundamental to any concept of sustainable development.

Other social determinants of health like education, social stability, and social networks, all of them are integral to good health. We see the co-dependency of many of these on health of societies so the social case for health is also clearly made.

When we look at the environmental case, while this was not very clear and not explicitly made in the past, we now increasingly recognize that we must place health alongside environment and the overall framework of sustainable development because there are many linked determinants and that framework will allow inter-sectoral policies that promote health as well as improved environmental sustainability simultaneously. For example agricultural sustainability. We can’t think in terms of food and agriculture systems merely as commercial activities because ultimately their purpose is to provide healthy nutrition to every citizen at every stage of life across the world. And if they’re not aligned to health, then clearly we see that agriculture and food systems are failing in their primary objective.

There are other elements as well, like resilient cities. When we talk about resilient cities, we are talking about cities that are not only resilient to climate change but also to natural disasters. We’re talking about promoting active means of transport which will reduce vehicular density, vehicular pollutions, and reduce environmental degradation at the same time protect the lungs and bodies of people and we recognize that air pollution is a major threat to health of people and we need to link that to environmental concerns. And therefore, bringing in the environment and health together into a common platform is very critical to both and that is where sustainable development provides that kind of a linkage.

We also recognize that all of this is not going to happen unless health challenges are seen as something that all of society must respond to, because they cannot be tackled in isolation. We required the engagement of multiple stakeholders, the government, the civil society, academia, the media, the private industry. It has to be an all of society effort for inter-sectoral action to take place because all of these are interlinked goals which can only be advanced by collective action. And at the same time in order to make sure that policies are not misaligned, we need health in all policies. For example, when we look at the non-communicable disease prevention and control plan of the World Health Organization, we recognize that the multi-sectorality implied in that action plan is something that warrants the active engagement of multiple ministries and multiple agencies and unless we link them together we will fail in preventing or controlling NCDs. Similarly even for a number of other areas of health, we need multiple stakeholders to come together. So health in all policies becomes absolutely critical as an important area of advancing health, but in the same time that provides a very smooth passage to sustainable development as the common agenda.

Margaret Chan, the director general of the World Health Organization has said that universal health coverage is the single most powerful concept that public health has to offer. However, there are some questions that have been raised about UHC when we talk about it as a SDG goal. Is it measurable in a comparable way across the world? What are the targets and indicators? Is it related only to financial protection or does it include other health system components? Does it balance vertical equity which is gap filling with horizontal equity which is equality of access? Does it ignore the social determinants of health by focusing only on health sector actions? These are legitimate concerns. But fortunately the global discourse on SDGs over the period when they were actually being debated actively by the global public health and development communities has brought us now closer to a consensus, that UHC needs to have a core component of financial protection but UHC cannot be delivered unless the other elements of health system are strengthened but at the same time health cannot be assured by UHC alone acting through the health sector.

But it has to now bring in actions into other sectors especially on social determinants of health to the fore by ensuring that there is synergy between the health sector actions as well as the actions in other sectors to advance the social determinants of health as well. So we now recognize as we move towards implementation of SDGs that action is required in each of these areas.

Finally there is a big question that had been asked of the SDGs while they were being developed. UHC is of course relevant and must be part of the goal but in the health goal something that we can develop which is applicable to all countries, the MDGs were not applicable to all countries, they were only applicable to the low and middle income countries, so how can we ensure that the new goal in the SDGs is something that all countries subscribe to and become accountable for? So UHC is one where it matters to everybody high or low income. We have seen that. Even countries like the United States still need to address the UHC as an important part of their agenda. Progress on MDGs is also needed but it’s still relevant to low and middle income countries. But non-communicable disease targets are relevant to all countries. They’re a bit more challenging for low and middle income countries where the epidemic is on the upswing rather than for the high income countries where the epidemic has stabilized or is on the downswing. But nevertheless, the whole world faces the challenge of NCDs so we need an income percent goal which combines all of these three elements. So we are really looking at the goal of a healthy planet with healthy people as our ultimate objective and for this it’s been proposed that firstly we must accelerate progress on the health MDGs, we must also reduce the burden of major NCDs and for these we need core enablers which are universal health coverage and access as well as action on social determinants of health. They provide the platform. So if you can combine all of these we have set the goal for health within the SDG context. So we do require what will be the ultimate way the Sustainable Development Goal is worded or interpreted, there are several actions which are needed for implementation. First is to build on addressing the gaps in achievements of the MDGs four, five and six which were the health MDGs or the health Millennium Development Goals. We also need to adopt a life course approach to health promotion, disease prevention and healthcare. We know that human beings live one single life. And therefore their health cannot be segmented and health of one stage of life impacts upon the health at other stages of life. So we need the life course approach.

We also need to increase public spending for health. Allocate at least 5% of the GDP as public financing for health. Without adequate financing health systems will remain feeble, they’ll not be able to deliver on UHC, they’ll not be able to deliver on health as an important part of the sustainable development agenda. And high income countries must do at least .1% of their gross national income as overseas development assistance for health. Of late, we have seen the declining trend in this kind of financial assistance that’s being provided except possibly to the least developed countries. Many of the low and middle income countries need that kind of a continued assistance without which their health systems cannot really be strengthened. So the high income countries must fulfill their social obligation to support other countries through an increased overseas development assistance.

All countries must provide high quality healthcare based on comprehensive primary health services. That is the foundation for good health and therefore a health system must prioritize primary health services.

We must create and support a skilled, adequately resourced workforce for health. We have a global health workforce crisis, particularly reflecting poorly on the health systems of low and middle income countries. We need to create a multi-skilled, multi-level workforce which is competent and motivated to deliver on the UHC and SDG agendas. We must ensure access to essential medicines, vaccines, commodities and technologies using pooled procurement and distribution of quality assured drugs. Whether it is HIV/AIDS or whether it is cardiovascular disease and diabetes, we need essential drugs to be available to all and pool procurement and distribution of quality generics is the way to go. Effectively implement comprehensive tobacco control programs. The Framework Convention on Tobacco Control, this is absolutely critical because tobacco is the major killer even in the 21st Century, it’s expected to kill about a billion people so we have to ensure that people do not die because of tobacco consumption whether it’s active or passive consumption and the various provisions of the FCTC or the Framework Convention on Tobacco Control is implemented in earnest can actually bring down tobacco related mortality and morbidity.

We must align agriculture and food systems to ensure nutritional security. We must align them with health, with a nutritional goal so the population at each stage of life, so our goal must be to deliver caloric adequate but also nutritionally appropriate diets to every citizen on this earth at each stage of his or her life. And that is where agriculture and food systems must deliver.

We must ensure availability of good quality water, sanitation and hygiene reduction and exposure to air, water, light and sound pollution and we must start up pro health policies in all sectors which are conventionally not regarded as part of the health sector but which nevertheless have a profound impact on the health sector.

So when we look at all of these we recognize that when we talk about economic growth, social equity and environmental protection there are a number of factors like urbanization, transportation, air pollution, food and nutrition security, labor productivity, healthcare expenditure, all of these are so interlinked and education, gender, all of these are so intertwined with health that we cannot really tease them apart and that’s why bringing them into the framework of sustainable development is very critical, even for advancing global health.

And we must learn to recognize that some of these connections are not apparent. For example when we think in terms of tobacco, we only think of the one billion deaths that may happen in the 21st Century, bad enough, but we must also recognize that tobacco is also a major cause of deforestation. Therefore it is an environmental threat because in order to cure tobacco leaf, one has to burn wood. For three hundred cigarettes smoked anywhere, someone somewhere has killed a tree. It’s also a cause of air pollution. It exacerbates poverty. It’s a cause of food insecurity. It’s absolutely unacceptable that four million hectares of arable land are now devoted world over for this killer crop than for nutrient crops. It is also a very water intensive crop and therefore, it again is an environmental threat from that point of view by exacerbating the water usage.

So when we think in terms of connection of health with other Sustainable Development Goals, especially environment, the connections really extend beyond the conventional. Similarly when we talk in terms of emerging infectious disease threats, we cannot talk in terms of zoonotic pathogens from wildlife which are now increasing threats whether it’s H1N1 or SARS or H5N1 or avian influenza without recognizing that we are actually creating conditions for this spread by extensive deforestation and by creating a conveyor belt between viruses and vectors from the forestry and the captive veterinary habitat and into the human habitat. Similarly when we are talking about drug resistant pathogens, anti-microbial resistance coming up, whether it’s anti-tubercular drugs or other forms of super bugs, we have to recognize it’s the weakness of the health systems that are really giving rise to this and also the nature of our rapid transportation and modern communication which is also resulting in their spread. So there are multiple areas in which we ought to be able to look at all of health as linked to different areas of human activity and all of those domains are built into the Sustainable Development Goals. In the 20th Century, medicine and nutrition evolved to come under the broad umbrella of public health. In the 21st Century public health must evolve, whether it’s considered as public health within countries or global health across the world must evolve under the umbrella of sustainable development if it has to survive and thrive as an important objective of human development.

Ultimately the thread of human life extends from pulse to the planet, through persons or individuals, through people or communities or populations or nations, health has to be linked ultimately to the overall goal of sustainable development

Health and sustainable development- I

The word development means many things to many people. Mostly people think of it as economic development. Others think of it also as social development. Some would like to think of development only when it is truly inclusive development, when the fruits of development are available to everybody in society. But now we’re also moving on to the concept of sustainable development where development not only happens, but it happens in a manner that is sustainable across generations taking into account the need for planetary health as well as human health and a very balanced economic and social development across the global community.

At the beginning of this century the focus was much more on bridging the huge gaps that existed between the levels of development across the world both in terms of high income and abject poverty and also huge gaps in health equity. So the whole idea was- can we begin the century to try and promote greater equity in terms of development including some of the critical areas of health? But now we are moving on to a period where we are actually beginning to discuss sustainable development as the goal for this century and beyond. Therefore, the Brundtland Commission looked at sustainable development from the point of view of the development not only of the current generations but also the future generations. It titled its report in 1987 as Our Common Future. And sustainable development was defined as one that meets the needs of the present without compromising the ability of future generations to meet their own needs. Therefore it was very important that the inter-generational equity concept was also integrated into the idea of spreading greater equity along with progress in the present day world.

The Millennium Development Goals which were annunciated and adopted by the global community in the year 2000 under the auspices of the United Nations reflected the urge of that time to try and bridge the inequities that were very manifest in the different developmental profiles of the countries. Poverty, ill health, lack of educational opportunities, all of these were clearly reflective of those inequities. So eight goals were designed to end extreme poverty and multiple deprivations with specific targets to be achieved by the year 2015. And these eight goals reflected various areas of developmental concern.

The first one was to eradicate extreme poverty and hunger, the second was to achieve universal primary education, the third to promote gender equality and to empower women, fourth to reduce child mortality especially under the age of five years, the fifth was to improve maternal health, the sixth was to combat major infectious diseases like HIV/AIDS, malaria and other major killers, the seventh was to ensure environmental sustainability, and the eighth was to build global partnerships for development. All of these were considered absolutely essential for altering the developmental gaps that existed across the world.

Three of these Millennium Development Goals directly related to health. Goal four was to reduced child mortality and a specific target was identified for action up to 2015. The target was to reduce by two-thirds between 1990 and 2015 the under five mortality rate, taking 1990 as the base year. Goal five was to improve maternal health with two targets, one was to reduce by three-quarters between 1990 and 2015 the maternal mortality ratio. Target two was to achieve by 2015 universal access to reproductive health recognizing that there was huge gap in the access to reproductive health services in many countries and virtually all across the world. But the whole area of maternal health can not only be reduced to maternal mortality. We also have to look at maternal morbidity issues. That was implicit but not directly measured as a target. Goal six was to combat HIV/AIDS, malaria and other diseases with three specific targets. Target one was to have halted by 2015 and begun to reverse by then the spread of HIV/AIDS across the world. HIV/AIDS was the big specter that was haunting the world at 2000, as the big killer. Target two was to achieve by 2010 universal access to treatment of HIV/AIDS for all those who need it. The whole are of access to essential drugs was becoming a major concern, especially because HIV/AIDS was killing people who could potentially have life saved with access to anti-retro-viral drugs. Target three is to have halted by 2015 and begin to reverse by then the incidence of malaria and other major diseases. These other major diseases were left unspecified but it is very clear that HIV/AIDS, malaria, and tuberculosis are the main areas of focus among infectious diseases at that time.

The other goals also indirectly affected health, even though they did not specify health as their primary objective. Goal one was to eradicate extreme poverty and hunger and we know that ill health is related both to poverty as well as malnutrition. Goal two was to achieve universal primary education and we know that education actually promotes health by improving knowledge and the ability of individuals and communities to take better care of themselves. Goal three was to promote gender equality and empower women. Women have suffered health inequities more than other groups in the society and in every society we have seen unless we promote gender equality and empower women we can not achieve better health indicators not only for them but for their children and for the families of the whole.

Goal seven was to ensure environmental sustainability. For the first time we were bringing in health and environment close together along with other areas of development because we now recognize that unless the environment is also protected, health will suffer.

Goal eight was to develop a global partnership for development, obviously this included partnerships for health as well. So all of the goals in some way or the other related to health, though three of the goals were specifically directed at health related targets.

We have achieved a fair amount of progress on the MDGs by 2014 when the review was conducted it was found that as far as tuberculosis and malaria were concerned, three million malaria deaths were avoided between the year 2000 and 2012. Twenty-two million lives were saved from tuberculosis between 1995 and 2010. About 17,000 fewer children are dying per day. And between 1990 and 2010 there was a 47% reduction in maternal mortality though that has not been uniform across the world. Over 2.3 billion people have gained access to improved water between 1990 and 2012. There’s been a greater enrollment of girls in schools and greater political participation of women. Extreme poverty has been reduced by half between 1990 and 2010. About 50% of the population on less than $1.25 which was the state of affairs in 1990, to 22% of the global population at that level of extreme poverty.

So we have had much to celebrate as a result of the success of the efforts to advance the MDG goals to their targets.  However, the agenda is very much unfinished. In several cases we have fallen short of the targets. For example one in four children are still undernourished. Child mortality from preventable diseases is still a problem. About 800 women die daily from pregnancy related causes. Hunger has declined but still over 800 million people still go hungry all over the world. Nearly one billion people still resort to open defecation. So the ambitious agenda of the MDGs while having achieved several benefits still remains to be pursued in order to attain the targets if not by 2015, soon thereafter.

We have had several learnings from the Millennium Development Goals. They helped to position health very firmly in the development agenda of the world. They helped to focus attention and action on the major health problems of poverty, infectious diseases, under nutrition, as well as maternal and infant mortality because the failing health systems which particularly afflict poor people. They help to mobilize resources to achieve targets. The global community responded by committing more resources, if not in totality for all the MDGs, for selected MDGs of their choice. They helped to create platforms for multiple stakeholder partnerships and they strengthened global monitoring systems by affixing targets and by monitoring progress towards those targets. But having said all that the MDGs also fell short in very many ways.

They covered only the low and middle income countries and excluded the high income countries. So they were not universal in any way. They only focused on a set of countries, the targets, and the implied obligations were only applicable to some of the countries, not all of the countries in the world. They fragmented the health system through vertical programs by directing the programs only at maternal health or child health or TB or malaria or HIV/AIDS, they fragmented the health system and made it weaker in some respects and also created an opportunity cost by which the other programs suffered. Further, even the programs themselves which were the primary focus of the MDGs did not achieve their targets because you can not force fit a vertical program into a weak health system however well-designed the program may be. So we even fell short for example of tuberculosis control and we are seeing the specter of multi-drug resistant tuberculosis coming up.

At the same time the MDGs also segmented by age group. They looked at child mortality, then at maternal mortality, forgetting that adolescent girl in between. They did not look at the elderly, they did not look at the adults who were suffering from non-communicable diseases. They monitored only national aggregate indicators. Now that was helpful to say India or China or Zimbabwe for that matter reduced child mortality or maternal mortality but did it happen across all social groups? Were only certain social groups benefiting from this kind of mortality reduction? And the poorer sections still remained behind? Did the gaps in health equity actually widen even as the aggregate health indicators fell across the country? So that was something that was not really measured at all or not even intended to be measured.

They also measured mortality but not morbidity. It is not just enough to be alive. You are to be alive and healthy so that element of healthy life expectancy was ignored by the MDGs. While these are justifiable critiques of the MDGs, we must recognize that the MDGs have given us a platform to build upon further and that’s the knowledge that we need to transfer as we move across to the sustainable development goals after 2015. Therefore, we need to redefine some of the global health priorities for the period 2015 to 2030 which is the next period the SDG era, and there we need to accelerate the progress on MDGs because they’re not a done deal. Maternal and child health still require our attention, infectious diseases still need concerted action and under nutrition still remains a shameful challenge and we need to act upon them and provide momentum for their progress. At the same time we need to act upon the previously excluded priorities, non-communicable diseases, the number one killer in the world today.

Mental health, the number one contributor to disability in the world today. Injuries and disabilities, adolescent health, health of the elderly, all of these were out of the radar screen of the MDGs. We need to now bring them back into a composite picture of the global health agenda. In terms of the other priorities for 2015 to 2030 we need to create a strong health system platform. The health system needs to become the vehicle for all concerted actions directed at health MDGs or SDGs, because otherwise we will continue to fragment it and fail in our objectives. So we need an integrated delivery of a wide range of health services, we need an emphasis on equity, efficiency, effectiveness and economic viability because when we talk about sustainability we have to talk about also fiscal prudence of how the health system can manage to do all of this without really overrunning the budgets in a very imprudent manner. So we now have to build in all of these elements as well.

We need to implement the universal health coverage as the framework for achieving these goals through actions at national and global levels. We need to enable coordinated multi-sectoral action to influence the social determinants of health. Clearly we know that much of health depends upon actions in other sectors. And the sustainable development goals are addressing some of those other sectors as well, not as separate entities but as synergistic and complementary components of a single unified agenda of SDGs. We need to link health to other elements of sustainable development, not only achieve benefits for each of those elements but to maximize the co-benefits. Health for example benefits education. Sick children can’t gain learning. At the same time, education benefits health, so there are clear co-benefits working together across different SDG and developmental goals. So all of these domains will have to be really brought together and that is wherein the strength of SDGs will come in, including for global health between 2015 and 2030 and beyond that as well. But we do have some optimism when we look at the future.

While we regret that we’ve not been able to achieve some of the MDGs related to maternal mortality or child mortality or infectious diseases by 2015, in terms of their entirety we now know we can substantially bridge the gaps between high income countries and low income countries on those MDGs by year 2035 if we invest wisely and adequately in our health system and specific programs. And here, the Lancet Commission on Investing in Health in 2013 proposed goals that for the under five death rate per thousand live births which is the under five mortality, it can come down to 16 in the low and middle income countries as well as being very close to that in the high income countries now. Similarly, annual AIDS deaths per 100,000 population can come down to eight. Annual tuberculosis deaths per 100,000 population can be brought down to four. Which means the huge gaps that now exist between high income countries and low and middle income countries can be substantially bridged and we can have a grand convergence by year 2035 if we invest properly in the health of these countries and where the global health becomes a priority and a concern and a commitment that everyone shares under the overall umbrella of SDGs.

The threat of antibiotic resistance

REDDY -I’m in conversation with Professor Ramanan Laxminarayan, who is vice president research and policy at the Public Health Foundation of India. Ramanan is a health economist by training, but in the area of public health he has become one of the world leaders in infectious diseases, especially in the area of antibiotic resistance. While many people thought that infectious diseases were only a problem of the 20th Century, in this century antibiotic resistance is now being seen as one of the foremost threats to public health. Ramanan, why is it that antibiotic resistance is being feared so much across by health professionals, policymakers, and even economists? I understand that IMF has now declared it as one of major four threats to global economy.

RAMANAN LAXMINARAYAN: So as, as you know, we’ve had antibiotics only relatively recently, since 1942. Propensity for resistance has always been known. In fact, Alexander Fleming mentioned the possibility of resistance in his Nobel Prize winning lecture. And every antibiotic that has been introduced has been followed by resistance in a space of anywhere between five and ten years. And this is because the use of antibiotics, there are like four strains that are resistant, while killing off the strains that are sensitive. Now all of the antibiotics we have now are dependent on the same 16 or 17 basic compounds from which all antibiotics are derived. And we have not had very much new drug development over the last 25 or 30 years. The huge increase in antibiotic use globally has placed enormous selection pressure for resistance to increase and as a result of this selection pressure in many parts of the world, both developing and developed countries, bacterial infections are no longer responding to antibiotics. This is a much more serious problem today than it was even ten or fifteen years ago. Many of the infections that we used to only see in hospitals are now common even in the community. And because the use of antibiotics truly global, the spread of resistance has also become truly global.

REDDY: What are the reasons for this? I mean bacteria seem to be becoming resistant fairly quickly to antibiotics. And many killer bacteria are now emerging across the world threatening large numbers of people. What are the reasons why this has become such a huge problem now?

LAXMINARAYAN: So the single most important reason for drug resistance is selection pressure which is simply the quantity of antibiotics that we use. Now rising incomes, particularly in low and middle income countries have resulted in a huge scale-up in antibiotic use in places like India, China, the BRICs countries. In fact a paper we published earlier this year showed that total antibiotic consumption in humans has gone up about 36% between 2000 and 2010. And of that increase, three-quarters is just in the BRICs countries. Now this is a good thing because it means that many people who didn’t previously have access to antibiotics now have access to antibiotics. But what is bad is that many of the antibiotics are now being used are very powerful antibiotics that are not necessarily being used by people in rural areas to save lives, these are being used in urban settings by people who can simply afford new antibiotics and have no barriers to purchasing them and therefore go out and buy them. The other trend that is worrying is the worldwide increase in demand for animal protein. This has meant that in places again like India, China, Brazil, that there’s a demand for livestock meat, chicken, pigs, and cattle you know for consumption. And to produce the amount of livestock that is necessary to meet this demand, we have to intensify production which immediately means that antibiotics have become an essential part of that production process, also leading to resistance.

REDDY: Well we have seen that antibiotic resistance is being contributed both among human strains emerging as well as in animals because of profligacy of use of antibiotics. Is it mainly a problem of the prescribing doctors, whether they are physicians or veterinarians? Is it a problem of patients being, using antibiotics irregularly and improperly? Or is it a problem of the regulatory systems which is unable to provide the right guidelines and checks and balances? Or, a combination of all of these?

LAXMINARAYAN: It is a combination of all of these. I think you mentioned that economists have increased interest in antibiotic resistance. You know drug resistance is a lot like climate change in the sense that it involves this idea that each of us, whether we’re patients or a veterinarian or a livestock owner, we don’t take into account the impact that we’re having on overall resistance when we choose to use antibiotics, in much the same way as none of us really thinks about climate change when we decide whether to drive a car or get on an airplane or go somewhere. Now this just means that we use vastly more antibiotics than are necessary or warranted. And at the end of the day no one is really responsible for worrying about the problem as sort of a residual thing. That you know no one is, is in charge of antibiotics. And it’s sort of like this global commons that belongs to everyone like the Earth’s atmosphere or climate, but no one is really responsible for. Therein lies the problem.

REDDY: From you comment it’s very clear that it’s not merely a problem of biology, but also of sociology, of political economy. Now is there that kind of an interdisciplinary learning coming in for multi-sectoral actions to provide the right kind of response to this threat?

LAXMINARAYAN: Sadly not yet. I think we still see antibiotic resistance as primarily a medical problem, driven by prescriptions. It turns out that you know a lot of people worry about you know patients in India for instance getting access to antibiotics without a prescription, just going directly to the shop and buying an antibiotic. It turns out that physicians unfortunately are not very good guardians of antibiotics in the sense that a physician doesn’t necessarily do a better job prescribing antibiotics in the studies that we’ve seen in India for instance than what a shopkeeper might actually provide. All that the physician is doing is acting as a cost barrier to the antibiotic. And therefore we do need that sort of multidisciplinary learning to figure out what drives demand for antibiotics? Why do people behave the way that they do? And in that sense we need the sea change in, in norms with respect to antibiotics, the same kind that we’ve seen with tobacco for instance. You know today it’s no longer acceptable to, to smoke in an office or in a public place but it’s completely acceptable to go demand an antibiotic from your physician whether you’re in the United States or, or in China. And we have made it a different norm with respect to tobacco. We need to change that norm with respect to antibiotics as well, to make people aware of the fact that these are powerful drugs, they have important side effects and should not just be used whenever people have a, a sniffle or a common cold.

REDDY: You convened a major global conference about three years ago. And I know that a number of ministers from several countries also attended that. Is there a global movement building up against this, including the required political will?

LAXMINARAYAN: A number of countries led by the U.K. and Sweden have convened many meetings around the world to help the World Health Organization convene a global action plan to deal with the threat of resistance. And, but this has really increased awareness in many countries. Just early in November of 2014, South Africa convened a large meeting of multiple stakeholders from all of the various sectors to promise to do something against antibiotic resistance. A similar action is underway in many other countries. So there’s never been political awareness of the kind that exists now, but we need to push on in order to really do something to solve the problem. The U.K., the U.S., all of these countries are willing to act, but that is not sufficient because even a few countries misusing antibiotics can have global consequences. DR. REDDY: What’s the role of technology and information systems? The drug resistance index or the online resistance map for instance? How can they advance our action in this area?

LAXMINARAYAN: So one of the reasons why the problem of resistance had not received the traction that it really required was because people could not visualize it, they could not see it, they could not see where resistance was, was increasing, where it was remaining flat because of antibiotic use not going up  And tools like the drug resistance index and also the resistance map have been important for that visual connection to the problem, because people don’t get to see resistance. No one that they know dies of drug resistance in the way that they can understand it. Those tools are very important. I think there is also room for other tools which involve big data and so forth to be able to extract data on antibiotic use as well as resistance to further drive home the importance of dealing with this problem.

REDDY: Across the world there’s a huge scatter of data related to the production of antibiotics, the purchase and utilization of antibiotics and the emergence of resistant patterns and so on. How can big data actually contribute to a better and quicker understanding of this problem?

LAXMINARAYAN: So a great example is the fact that we don’t really have state on drug resistance in most countries, including India for instance, just because to set up a network to do this is, is incredibly expensive. However, many patients do send their blood samples on the advice of their doctor to a lab network. And the lab network will turn back a test result which says, yes, you have a bacterial infection and yes, you may have a resistant pathogen. What we’re trying to do is connect up multiple lab networks which collect thousands of samples every day, not to inform surveillance, they do it just to serve a patient need as a provider. But by connecting up these data we’re able to create snapshots of resistance that are only a week old to be able to inform both prescribers as well as policymakers. And this is possible only because of our ability to link data sets and to make that sort of connectivity possible. It was certainly not possible ten or fifteen years ago. But now these networks of data sets are giving us information that, that is extremely valuable.

DR. REDDY: If you were to make major recommendations to global policymakers in the context of the sustainable development solutions network where we are looking at environment and health and other areas of development together and position antibiotic resistance in that framework, what would those recommendations be?

LAXMINARAYAN: I think the recommendations would be pretty straightforward in the sense that first of all, the main way to deal with antibiotic resistance is to reduce the need for antibiotics which is improved public health, improve vaccinations, improve water and sanitation. These are common goals but particularly important because when we don’t address these, we use too much antibiotics. The second is to phase out whenever possible the use of antibiotics in animals because the benefits of these are not very large but the consequences for resistance is extremely high. The third is to invest in good surveillance. It really doesn’t take a lot of money, it really takes these kind of innovative methods to connect up large data sets, to get a better understanding of the situation to do with resistance and antibiotic use within countries. The fourth is to invest in new tools. We need ne

w antibiotics but we also need other tools like better diagnostics because for instance if we had a diagnostic device that would tell us within 20 minutes whether the patient had a bacterial infection, imagine the amount of antibiotics that we could not use and still make the patient better. And fifth, we need political commitment. This is a problem that is not going away. And as far as we can see, our grandchildren and their grandchildren are still going to need antibiotics. We have not found a good substitute for antibiotics yet. And knowing that the bacteria will always fight back, this is a problem that’s going to stay with us for a very long time.

REDDY: Thank you Ramanan. Bacteria will always fight back, but humans must respond intelligently. If the production and use of antibiotics for human health and welfare has been a product of human intellect, then the growing problem of antibiotic resistance is a problem of our foolishness and how we are using them. So I think antibiotic resistance, while it’s a major public health challenge of the 21st Century is something that can be met with if we take the kind of steps that Ramanan has advised us to take. Thank you.