Global Public Health Thomas E. Novotny, M.D., M.P.H. University of California, San Francisco Global Public Health Thomas E. Novotny, M.D., M.P.H. University.

Global Public HealthThomas E. Novotny, M.D., M.P.H.

University of California, San Francisco

Global Public HealthThomas E. Novotny, M.D., M.P.H.

University of California, San Francisco

Public Policy and Biological Threats

IGCC/AAAS Wye River Biosecurity Workshop

August 15, 2006

Definitions

• Public Health: “the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community effort”– Institute of Medicine, The Future of Public

Health– Core Function No. 1: Prevent epidemics and

the spread of disease

Unique Features of Public Health

• Basis in social justice concepts

• Inherently political nature

• Dynamic, ever-expanding agenda

• Grounding in the sciences

• Prevention is prime strategy

• Link with governance—national or multi-national

Historical Perspective

• Conflicting value systems of public health and wider community;

• Often takes outbreak, disaster, or other tragedy to implement public health strategies;

• Little attention paid to financing core public health functions (pure public goods).

Essential Public Health Practices

• Monitor health status to identify community health problems;

• Diagnose and investigate health problems and health hazards in the community;

• Inform, educate, and empower people about health issues;

• Mobilize community partnerships to identify and solve health problems;

• Develop policies and plans that support individual and community health efforts;

Essential Public Health Practices, continued

• Enforce laws and regulations that protect health and ensure safety;

• Link people with needed health services and assure the provision of care;

• Assure a competent health workforce;• Evaluate effectiveness, access, and quality of

health services;• Research for new insights and solutions to

health problems.

Global vs. International Health

• Global Health: problems, issues, and concerns that transcend national boundaries and may best be addressed by cooperative actions.

• International health: bilateral foreign aid activities, specific disease control projects in developing countries, and direct medical assistance.

Globalization and Public Health

• National governance challenged by globalization

• Global trade expansion opens markets to all legal products

• Transnational approaches needed on global health issues

• Both temporal and spatial dimensions

Global Public Health Problems

Emerging infectious diseases Persistent Organic

Pollutants, Climate Change

Hazardous and Nuclear Waste

Bioweapons

Tobacco UseObesity

What are emerging infectious diseases?

• Diseases whose incidence in humans has increased in last 20 years or threatens to increase in future, usually due to demographic or environmental factors

Institute of Medicine, 1992

Examples of emerging and reemerging infectious diseases

• Ebola virus• HIV• Hepatitis C• Sin Nombre Virus

(hantavirus)• Influenza A(H5N1 and

H7N7) • SARS coronavirus• Legionella pneumophila• Escherichia coli O157:H7• Cyclospora cayetensis

• Borrelia burgdorferi• Vibrio cholerae O139

Cholera• Dengue fever• Diphtheria• Meningococcal

meningitis• Monkeypox• Rift Valley fever• Yellow fever

Why are they emerging?

• Global travel• Globalization of food supply and central

processing of food• Population growth, increased urbanization, and

crowding• Population movements due to civil wars,

famines, and other man-made or natural disasters

• Irrigation, deforestation, and reforestation projects that alter the habitats of disease-carrying insects and animals

Why are they emerging?

• Human behaviors, such as intravenous drug use and risky sexual behavior

• Increased use of antimicrobial agents and pesticides, hastening the development of resistance

• Increased human contact with tropical rain forests and other wilderness habitats that are reservoirs for insects and animals that harbor unknown infectious agents

W orl

d Popu

l ation

in

billi

ons

(

)

at

Days

to c

ircu

mnavig

ate

glo

be (

)

Year1850

0

400

350

300

250

200

150

100

50

2000

0

1900 19 50

1

2

3

4

5

6

Global Travel andWorld Population Growth

Antimicrobial resistance

• Worldwide problem

• Dramatic increase in antimicrobial-resistant community-acquired and nosocomial pathogens

• Major risk factors: Antimicrobial use (misuse - human and vet) Infection control practices (noncompliance)

Current International Efforts at Infectious Disease Control• Improve surveillance efforts;• Develop international standards and

guidelines for disease reporting and control;

• Strengthen international research;• Disproportional concern with techno fix• Encourage national governments to

improve public health systems.Source: World Health Assembly. Communicable diseases prevention and control: new,emerging, and re-emerging infectious diseases. WHO Doc. WHA 48.13, May 12, 1995.

International Health Regulations

• Established under WHO in 1951: ‘Sanitary and quarantine requirements and other procedures designed to prevent the international spread of disease;’

• Lack of compliance almost universal;

• Revisions (1995): Surveillance, response, increased number of diseases covered.

International Health Regulations

• Intended to protect industrialized world commercial investments and armies

• Global infectious disease spread through mobility, war, etc

• Major effort to protect economies through control of Infectious Diseases and subsequent bad publicity.

Poverty and its consequences, including poor nutrition and sanitation,

is the major factor reducing years of healthy life in the world

Poverty and Global Health

The biggest killers of the poor

Source: WHO, 2002

Non-Communicable Diseases

“Chronic diseases are the largest cause of death in the world. In 2002, the leading chronic diseases – cardiovascular disease, cancer, chronic respiratory disease, and diabetes –

caused 29 million deaths worldwide.”

Yach et al, JAMA 2004

(Yach, Hawkes et al. 2004)

High BMIHigh BMI

Tobacco

Physical inactivity

The Issues in Non-communicable Diseases

• A chronic disease pandemic, growing rapidly in developing countries (cancer, DM, obesity, CVD)

• Insufficient public health focus or funding• Complex set of interrelated factors• Risk factors and diseases can be reduced• Needs innovative solutions• Requires multiple stakeholder involvement• Needs a catalyst for global action• Already lots of evidence for effective interventions

Tobacco Use is a Great Example of a Public Health Problem

Agent

Advertising

Movies and Media

Political Influence

Environment

Global Markets

Cognitive Globalization

Information Asymmetry

Host

Government

and Young People

Framework Convention on Tobacco Control

• First health treaty to be negotiated under auspices of World Health Organization;

• Agreement by consensus at 2003 World Heath Assembly (190 countries);

• So far, 168 have signed, 137 ratified; • Depends on ratification and developing national

policies in accordance with obligations;• Advertising ban, warning labels, misleading

information on labels, taxation, clean-indoor air policy, liability, smuggling controls, etc.

Global Public HealthInfrastructure Development

• Political commitment

• Financing of public health infrastructure

• Surveillance

• Scientific investigation

• Communications

• Therapeutics (policy and development)

• Critical evaluation of interventions

Shaping Global Health:Civil Society, the State, and

Academia• Highly credible scientific evidence

(especially surveillance);

• Public health advocacy;

• Enforceable and enforced sensible public health laws and governance;

• Health diplomacy.

References

• Institute of Medicine. The Future of Public Health. Washington DC: National Academy Press, 1988.

• Fidler DP. International Law and Infectious Diseases. New York: Oxfod University Press, 1999.

• Grad FP. The Public Health Law Manual, 2nd Edition. Washington DC: American Public Health Association, 1990.

• Hong Kong Department of Health. A Briefing on SARS in Hong Kong, 16 April 2003.

• Isaacs SL, Schroeder SA. Where the public good prevailed—lessons from success stories in health. The American Prospect, June 4, 2001.

• Turnock BJ. Public Health: What It is and How It Works. Gaithersburg, Maryland: Aspen Publishers, Inc., 2001.

• World Bank. Public Health In Eastern Europe and Central Asia—A Decade of Experience In Transition. (In Press), April 15, 2003