The standard approach to defining the global health challenges is to use some formulation of Abdel Omran’s epidemiological transition or what is known also as the health transition and show that the progression is inevitably from famine and pestilence through the stage of receding pandemics to the predominance of the chronic degenerative noncommunicable diseases globally. It is these last which have occupied most of my attention recently and the major four are heart disease, cancer, diabetes and chronic respiratory disease and there is clear evidence that they represent an ever growing challenge globally. The data are impressive. These four are responsible for about two thirds of all global deaths, the great majority of which occur in low and middle income countries. It is a myth that they affect only the elderly as about one quarter of these deaths occur in persons below the age of 60. The economists tell us that in the next two decades they will cost the world about 30 trillion dollars, and if mental health is added the figure rises to 49 trillion dollars. I was one of the first to use the term tsunami to describe them some five years ago at a conference in Alexandria, Egypt, to paint the image of an impending disaster of apocalyptic dimensions.
But I will take a different approach here, and frame them in a personal context, as I am old enough to appreciate the manner in which the challenges to global health have changed. There have been massive changes not only in the basic health problems, but also in how we have addressed them. When I was born in Barbados, 80 years ago, the infant mortality in my little country was about 300 infant deaths per 1000 live births so I had about a 1 in 3 chance of seeing my first birthday. And this was the situation throughout most of the poor world in which famine and pestilence indeed made life for many nasty, brutish, and short. But I survived and went to medical school in Jamaica and learned about the diseases that were common to the poor countries. I saw the leeches applied to suppurating wounds, I learnt to herald the crisis and the lysis of the fever as signs of recovery from typhoid and I could describe in detail the manifestations of yaws. I witnessed the euphoria that attended the early use of penicillin and the hubristic enthusiasm that at last man had got the better of the germs. Myocardial infarcts hardly existed and when they did occur, were almost always fatal.
In my lifetime I have seen the infections recede and the chronic disease take their place. About 1 in 7 adults in Barbados is diabetic and it has garnered the reputation of being the amputation capital of the world because of the frequency of amputations of lower limbs affected by diabetes. There have also been changes in the manner in which we have addressed the changing pattern of disease. There have been epidemiological as well as political changes. We have passed from the stage in which the nation states, accepting their pristine responsibility to protect their citizens within their territorial boundary and ever conscious of the need to preserve trade and commerce depended on quarantine to keep the pestilence out. This passed to the stage in which they were concerned with addressing disease at its point of origin and now we are accepting that for self interest as well as for laudable humanitarian reasons the nation states must address diseases collectively. However, such is the nature of national sovereignty that while the borders of our nations are permeable to the vectors of disease, principal among them being information or propaganda that comes often unbidden and unregulated to all people, the site of corrective action is national. This interconnectedness that is the essence of globalization is for me the first major challenge in global health. How do we address on a global scale the problems that affect all the world’s people and still preserve national agency? How do we build the bridge between the knowledge of the global dimension of disease and the capacity of the nation state to respond? How can we achieve global action to address those diseases that are really impatient of national confinement?
The solution is essentially a political one and the world has agreed to create structures in which global consensus can be reached on the manner in which these problems can be tackled. The obvious one is the World Health Organization, one of whose underappreciated major functions is to provide a forum for socializing governments into collective action. But it has become clear that some of these problems have such political ramifications outside of health that they need to be addressed in a global political forum. Thus health is entering the global political arena.
Perhaps the first health problem to attract such attention was HIV/AIDS because of the infectious nature of the disease, because it represented the toxic cocktail of sex, blood, and death, and also was the focus of health activism on an unprecedented scale. Thus, HIV was addressed at the level of the Security Council and was the first health issue to come before a special session of the United Nations General Assembly. It is noteworthy and perhaps an indication of the health transition that the second set of health problems to be addressed at this level was the four main noncommunicable diseases. This progression is important as the declarations from this level indicate quite clearly that these problems have to be addressed at the level of the state, and not only by the government. There has to be involvement of the private sector as well as civil society. This recognition of the need for a pluralist approach to addressing health problems is an important aspect of the new challenge.
The Political Declaration on NCDs from the UN General Assembly sets out a number of commitments for all parts of society. It emphasizes personal behavior as fundamental for primary prevention, but we know that this will not be sufficient and there has to be a change in the enabling environment which is within the purview of government. But importantly, it spelled out the role for the private sector and industry as important supporters of national efforts to control these diseases. It calls specifically on the private sector to “contribute to efforts to improve access to and affordability of medicines and technologies in the prevention and control of noncommunicable diseases”
I will not describe in detail the approaches to be taken in dealing with these diseases, but I wish to emphasize two of the common risk factors which for me present perhaps the gravest challenge of all. I refer first to tobacco use which is associated with a plethora of diseases and not only the NCDs. I fear tobacco because of the powerful financial interests behind it and the capacity for those interests to corrupt our social systems. But I fear obesity as much or more. I can envision a world in which our technologies control or prevent many of the diseases that are upon us now or are likely to come, but I confess to a deep angst over the tendency of the world to get fatter and fatter and to be comfortable with the notion that our appetites increase with eating. As distinct from tobacco, there is no single identifiable enemy—there are many enemies. As Ilona Kickbush puts it succinctly “Obesity will be a test case for the 21st century public health as was the introduction of water and sewage at the end of the 19th century.”
For the kind of care needed for these and indeed all chronic conditions there must be partnership between the individual, the community, and the primary secondary and tertiary levels of institutional care. There must be partnerships among the various sectors and agencies of government. While the health sector is the one to which the public looks for health and healthcare, the healthy state depends always on the inputs from other sectors of government. But equally important is the partnership among the parts of the state. The partnership of the various parts of the state I prefer to call intersectoral partnership or cooperation as opposed to the partnerships within the government agencies which I prefer to label multisectoral cooperation or partnership. The rules of engagement are fundamentally different. In the case of the intersectoral partnership in which the private sector is involved there are usually more formal contractual arrangements. The principal/agent type of arrangement which obtains between government and civil society may not be appropriate for the contractual arrangements between government and the private sector. The role of government is obviously to provide public goods and set the regulatory framework essentially through its basic functions of regulation, taxation, and legislation. Civil society, which is by no means a homogeneous entity can still be envisaged as the conscience of society and can perform the activist role that no other section of the state can. So what should be the role of the private sector and business, which by definition under the kind of societal arrangement in which we live, has to be concerned with the efficient production of goods and services. It has a responsibility to be profitable even in the face of discharging its corporate social responsibility or perhaps we should say now while seeking shared value.
In the case of the production of medicines and technologies there is good evidence of a predilection for addressing the chronic disease market. Three years ago I had the opportunity or misfortune to chair a WHO Expert Working group on “Research and Development Coordination and Financing” and while there was controversy about some of the recommendations, some of the data on the distribution of R&D for the noncomunicable diseases was of interest. One section of our report said:
“While the results were tentative and the relative share of research and development funding by disease cannot be generalized, they showed a consistent 2:1 ratio in research and development funding allocated to noncommunicable diseases as compared with communicable diseases across sectors. And of all the projects in development in 2008 by the 10 pharmaceutical industries with the highest revenue 84% were related to noncommunicable and 16% to communicable diseases.”
I know that innovation in the production of treatments and technologies is the major theme for your conference and there is little I can tell you about the mechanics of innovation or the requirements to transform inventions into innovations. But there are two dimensions that have interested me recently. The innovations we need for the management of the global health challenges are not only in the realm of traditional technologies. We also need innovations in terms of processes to address for example the chronic care of individuals. Chronic continuous care will assume ever greater importance because of our ageing populations and because of the increasing prevalence of the NCDs which I mentioned above. The latter is an example of the urgent need for a rethink of the processes that are necessary in many of the developing countries. Studies have shown that the major problem for the secondary prevention of the chronic diseases is certainly not the price of first line drugs, most of which except for cancer drugs are off patent and therefore price is not the barrier to wide coverage with these drugs. The essential problem is one of access and there is urgent need for the systems and processes that can assure access to these drugs where they are needed. I find it difficult to accept the simplistic view that corruption is the main reason. There is need for a more systematic examination of the problem of access and devising innovative country specific processes to overcome them.
But my interest also stems from another of my other responsibilities. I am Chancellor of the University of the West Indies and have been concerned that the progress of our small countries which with one exception cannot count on profitable extractive industry will depend on knowledge work. Essential to this is the need for innovation. I have been taken by the thesis of Henry Etzkowitz that there is a triple helix of innovation, with the three strands being government, business, and academia. Government supplies the regulatory framework, the ideas and inventions come from academia which is well suited because of the flow through of bright students, and enquiring faculty to produce the ideas that can be the basis of innovation. It is business that supplies the entrepreneurship and the venture capital that brings these products to the market as innovations. To quote from “The triple helix of innovation” by Henry Etzkowitz:
“The University is the generative principle of knowledge-based societies, just as government and industry were the primary institutions in industrial society. Industry remains a key actor as the locus of production, government as the source of the contractual relations that guarantee stable interactions and exchange.”….. “The competitive advantage of the university over the other knowledge-producing institutions is its students. Their regular entry and graduation continually bring in new ideas, in contrast to the research and development units of firms and government laboratories that tend to ossify, lacking the flow-through of human capital that is built into the University.”
This interests us from the developing world. I do not see this interaction between business, certainly not the pharmaceutical business, the university and government in fomenting innovation in my part of the world. It is a challenge I would extend to you, that you explore how the academy from the developing world can join with you and government for the innovation both of processes and technologies that are applicable to the coming challenges of health. I will admit that this is not a universal view. There will still be those who would prefer that the University stick to its pristine roles of teaching and research and this new approach runs the risk of prostituting the search for knowledge that is essentially of instrumental value.
One of my favorite books is John Bunyan’s “The Pilgrim’s Progress” and let me quote from a comment by Mr Valiant for Truth which is relevant to my travel to get here.
“Though with great difficulty I have got hither, I do not repent me of all the trouble I have been at to arrive where I am.”
George Alleyne is the director emeritus, Pan American Health Organisation.
This blog is adjusted from a speech given by George Alleyne in Geneva, Switzerland, 30 October 2012.