King Holmes, MD, PhD: Present and Future Challenges in Global Public Health, Interscience Conference on Antimicrobial Agents and Chemotherapy, Sept. 12, 2009.

1. Present and Future Challenges in Global Public Health September 12, 2009 ICAAC King Holmes

3. Under-standing Global Health – The Acronym Pandemic EB EC EFC EPGH EU FAO FCA FCTC FDI FTA GAP GATS GATT GAVI GBC GDP GFATM GHG GHI GHP GIIC GPA GPGH GOARN GPPP H8 HAART HAI HIC HIV HR IAVI IBFAN ICC IFF IFF(Im) IFM IFPMA IGM IGO IGWG IHG IHP IHR ILO ILSI IMF INFACT INGOs IP IPC IPR ISO LFA LMIC LN LNHO LRCS MAP M&E MDGs METAG MOPH MRA MSF NAM NCD NGO NHG ODA OECD OHIP OR PASB PEPFAR PHC PHM PR PROPER PRSP R&D RBM RF SARS SOP SPHC SPS SPT Stop TB SWAp TAC TB TBT TNC TNPC TPRM TRIPS UIA UK UN UNAIDS UNDP UNESCO UN-HABITAT UNICEF UNFPA US USAID WDR WFPHA WHA WHO WIPO WTO AFAS AIDS AMC ARISE ART ARV ASEAN BAT CAFTA CCM CCS CD CDC CEO CHBC CHGA CIPIH CMH CODEX COMESA COP CSDH CS CSO CSR DAC DALY DDR DFID DPAS DNDi

7. Cover of "The Economist", Dec. 13-19, 2003 .

8. GLOBAL BURDEN OF DISEASE (DALYS) 1990 2020 Lower Respiratory Infection 1 Ischaemic heart disease Diarrhoeal Disease 2 Depression Perinatal 3 Road Traffic Accidents Depression 4 Cerebrovascular Ischaemic Heart Disease 5 COPD Cerebrovascular 6 Lower Respiratory Infection Tuberculosis 7 Tuberculosis Measles 8 War Road Traffic Accidents 9 Diarrhoeal Disease Congenital Diseases 10 HIV Malaria 11 Perinatal Disease COPD 12 Violence Falls 13 Congenital Iron-deficiency anemia 14 Self-inflicted injury Protein calorie malnutrition 15 Bronchial and Lung Cancer

9. Top causes of death in low- and Allocation of U.S. global health aid by middle-income countries, < 70 y.o. (2001). category (average for 2004-2008).

12. Disease Control: More Specific Key Investment Priorities (Copenhagen Consensus, 2008) *20% of cancer world-wide is due to infection Priority Area Benefit/Cost Annual Benefit 1. Tuberculosis : Appropriate case finding and treatment 30:1 30  10 6 DALYs 2. Heart attacks : Low cost acute management 25:1 4.5  10 6 DALYs 3. Malaria : Prevention and ACT Rx 20:1 20  10 6 DALYs 4. Childhood infections : Vaccine coverage 20:1 20  10 6 DALYs 5. Cancer*, heart disease, other : Tobacco taxation 20:1 20  10 6 DALYs 6. HIV : “Combination prevention” 12:1 22  10 6 DALYs 7. Injury, difficult childbirth, other : District hosp. surgical cap. 10:1 30  10 6 DALYs

13. Land Area Each territory's size on the map is drawn according to its land area. The land area of each territory is shown here. The total land area of these 200 territories is 13,056 million hectares. Divided up equally that would be 2.1 hectares for each person. A hectare is 100 metres by 100 metres. However, population is not evenly spread: Australia's land area is 21 times bigger than Japan's, but Japan's population is more than six times bigger than Australia's.

14. “ My wife died a few months ago. Very probably from malaria because she had a lot of fever and was also vomiting. But she never went to a health center. Because of the lack of money.” Révérien, 2004 Malaria Deaths Territory size shows the proportion of worldwide deaths from malaria that occur there.

15. &quot;I would like to invite all of us to re-affirm our commitment to Stop TB, and thereby gift our children a tuberculosis-free world.&quot; Samlee Plianbangchang, 2004 Tuberculosis Cases Territory size shows the proportion of worldwide tuberculosis cases found there.

16. “ I have come to the conclusion that HIV/AIDS is not entirely about death. People die and will continue to die for one reason or the other. AIDS is also about the living.” Kiiza Ngonzi, 2004 HIV Prevalence Territory size shows the proportion of all people aged 15-49 with HIV (Human Immunodeficiency Virus) worldwide, living there.

19. Threat of Pandemics

20. World Air Traffic Flow Chart 35,000 Routes - 2002

25. Yang Y, et al. The transmissibility and control of pandemic influenza A (H1N1) virus. Science (In ScienceXpress: 9/10/2009) Influenza Pandemics

26. The Chronic Disease Agenda The Lancet Vol. 370 Number 9603 December 8-14, 2007

27. S. Nishtar. Integrating a new public health order. Lancet 2007;370:1901

28. T. Gaziano et al. Scaling up interventions for chronic disease prevention. Lancet 2007;370:1939-46 Key messages:

29. The Indian Polycap Study (TIPS). Lancet 2009;373:1341-51 Effects of a polypill (ASA, statin, antihypertensives) (Polycap) on risk factors in middle-aged individuals without cardiovascular disease (TIPS): phase II, double-blind, randomized trial. Indian Polycap Study (TIPS)

30. Climate Change: mitigation and adaptation “Fiddling while the globe burns” D. Weston 2009

32. Kibera - in Nairobi, Kenya - the largest slum in Africa – crowding, poor water, poor sanitation, poor nutrition. Commonest course of childhood fever = typhoid

33. &quot;Everyone here wakes up in anger. People find it very hard and it is getting worse. Day in, day out, poor people from all over Africa arrive in this place, still seeing Lagos as the land of opportunity.&quot; Daga Tola, 2006 Slum Growth Territory size shows the proportion of all extra people to start living in slums between 1990 and 2001, that live in slums in that territory.

34. Lancet 2009;373:1693-1733

35. Global Health: What Do Developing Countries Need? Work Force Capacity Medicine (> 30 specialties, Primary health care) Public Health Specialists (5-10 specialties) Nursing Pharmacists & Pharmacy Techs Dentists Social workers Community Health Workers Equitable allocation of funding across Education, Health, Poverty, and Infrastructure Sectors Health Leadership, Management, Policy Health leadership, management training Integrated Health Systems Development Public Health Systems Tertiary Hospitals District Hospitals Health Centers Health Posts Certified Laboratory System Access through Roads & Transportation Logistics & Supply Chain Management Financial & Material Resources Reversal of structural adjustment policies Salaries for public sector health care workers Pharmaceuticals Equipment Diagnostics Adequate, Safe Water & Sanitation Nutrition – adequate, safe food supply Housing – especially in emerging mega cities Adaption to climate change Information Systems Etc., Etc., Etc., Etc.

37. Fraction of African-born physicians residing and working abroad in 2000

38. &quot;Hundreds of thousands of African doctors need to be trained ... Nobody worries about it. There’s a rich part of the world that only cares about oil, diamonds, minerals, forests, gas, cheap labour ...&quot; Fidel Castro, 2001 Territory size shows the proportion of all physicians that work in that territory. Physicians Working

39. “ [they] are also being poached by industrialized countries. There are more nurses from Malawi in Manchester than in Malawi …&quot; Glenys Kinnock, 2005 Nurses Working Territory size shows the proportion of all nurses that work in that territory.

42. Core Global Public Health Functions Functions ( ½ CD-related) Program areas 1) Surveillance Vital records, surveys & epidemiology Surveillance: disease, risk factors, lab 2) Environmental health Water & sanitation, air, nutrition & food, injury, smoke, toxics, vectors 3) Outbreak/ID detection, Contain specific diseases (HIV, STI, TB), investigation, control risk communication 4) Immunization Vaccine policy, delivery, production, coverage 5) Non-communicable diseases Tobacco, food & nutrition, exercise, cancer, screening, alcohol, mental health 6) Clinical care/case mgmt. Direct provision of services, QI & access 7) Health education Inform & educate public & providers 8) Emergency prep & response Outbreak detection; planning; mass immunization & prophylaxis, isolation

43. Public Health Spending Territory size shows the proportion of worldwide spending on public health services spent in that territory. This spending is measured in purchasing power parity.

44. Stefano Bertozzi Namibia PEPFAR Implementation Meeting

46. Enormous Potential for Improved Efficiency and Effectiveness through Strategically Integrated Collaboration

52. Trends in growth in number of University-based GH programs 300% increase btn 1995 and 2008 From Breyette Lorntz, University of Virginia, GHEC

56. A global demand for high quality distance education >400,000 hits/month ~14,000 visitors/month from 140 countries ~6 minutes per visit >1000 archived, recorded training sessions Bob Bollinger MD, MPH

57. New East African High Band Network

58. “ Show me the money!” Cuba Gooding: Jerry McGuire New Resources

59. Ravishankar N, et al. Lancet 2009;373:2113-24. By disease Financing of global health: tracking development assistance for health from 1990-2007.

60. President’s Global Health Initiative Budget (millions) 5/5/09 FY 09 enacted FY 10 budget 6 year total (09-14) PEPFAR 6,490 6,655 (HIV & TB) Malaria 561 762 $51B GH Priorities 1,135 1,228 $12B GHI Total 8,186 8,645 $63B

61. Why some global health issues attract attention & resources (e.g., HIV/AIDS), while others (e.g., pneumonia, diarrhea, seasonal influenza, malnutrition) do not Social constructionism ; Framing: a “problem” claim (based on severity and neglect) a “solution” (tractability) claim Building “institutions” to carry the torch: e.g., OAR, UNAIDS, PEPFAR, Global Fund, GAVI Emerging examples: NTD; newborn survival; CUGH Shiffman J. A social explanation for the rise and fall of global health issues. Bull WHO Org 2009;87:608-13.

62. Collins says global health is one of his top priorities New NIH Director Dr. Francis Collins singled out global health as one of five areas he wants to focus on during his tenure, citing it as an example of &quot;soft power&quot; the United States cannot afford to pass up. …… a chance to be more of a “doctor to the world” than a “soldier to the world”…..

63. NHLBI funds Global Centers of Excellence on Chronic Diseases, and collaborates with UnitedHealth Group ~$35M NHLBI UHG Fogarty Center Bangladesh X X X China X X X Guatemala X X X India (Bangalore, N. Delhi) XX XX XX So. Africa X X X Argentina X X X Mexico X X Peru X X US-Mexico Border X Tunisia X

64. New Horizons for a Health America: Fragmentation to Integration The Commission on US Federal Leadership on Health and Medicine: Changing Future Direction – April, 2009. A New Vision for Global Health: Develop Long-term Strategies: - “Marshall Plan” for Global Health use Marshall Plan model to coordinate single disease initiatives with broader health infrastructure strengthening. - Streamlines and synergies US investments across Federal Agencies (PEPFAR, USAID, HHS) and international health organizations (get photo from Bob Martin Lab talk) - Implement Health in All Policies in international development and foreign affairs: Global Health Advisor in Department of State

66. Bill and Melinda Gates Foundation commitments and disbursements from 1999-2007 Financing of global health: tracking development assistance for health from 1990-2007. Ravishankar N, et al. Lancet 2009;373:2113-24.

67. Rockefeller Foundation Ariel Pablos-Mendez Transforming Health Systems in Africa and Asia - $100M Initiative Health leadership development Harnessing the private sector Interoperable eHealth Systems Initial Launch – Rwanda, Ghana, Vietnam

69. Initiative to Strengthen Health Research Capacity in Africa Wellcome Trust, DFID, IDRC Vision: African-led health research that reduces burden of disease and improves health on the continent Mission: Includes enabling research and translating research into policy and practice through capacity development Wellcome Trust support ($48,795,174.76 USD) aims to boost Africa’s research capacity: 86 institutions in 7 consortia.

70. Public – Private Partnerships PPP CPDD GSK GNF NITD DNDI MMV

71. INFECTIOUS DISEASE INSTITUTE Merle Sande Warner Greene

73. Mark Kline, MD

75. Clinical Facilities

77. ASM International Ambassadors Program International Mentoring Program International Grants & Fellowships International Affairs

78. ICAAC STUDENTS ON THE MOVE ICAAC International Culinary Arts Academy Cebu 96 P. Del Rosario Extension Streets, Cebu City, 6000 PHILIPPINES www.icaac.net

79. Development: Old and New Perspectives OLD: ↓ Poverty +  Infrastructure ->  Education ->  Health Dean Jameson, 2008  Infrastructure NEW:  Health  Education ↓ Poverty Development

81. Summary: Global Health - 2009 Many Problems - 5 major GH agendas Many Needs & Challenges - workforce, infrastructure, health systems, economy, population, climate change Many New Opportunities - Academia, technologies, resources, partnerships, strategies We are beginning to make a difference We can make a much bigger difference if we work together, strategically, and systematically

83. Many People are Making a Difference in Global Health Haile Debas Mark Kline Jimmy Whitworth Elaine Gallin Marcel Tanner Jaime Sepulveda Tachi Yamada Warner Greene L. Mpanga Sebuyira Roger Glass Nelson Sewankambo Ariel Pablos-Mendez Peter Piot Anne Johnson Richard Hayes David Mabey Alex Coutinho Tim Brewer Michele Barry Stephano Bertozzi Mike Cohen Chris Elias Kathy Neuzil Ruth Nduati Dorothy Mbori-Ngacha Patricia Garcia Tom Quinn Amy Hagopian Steve Gloyd Judy Wasserheit Emmanuela Gakidou Dean Jamison Steve Lim Bob Bollinger Bob Black Bill Foege Ann Downer Waafa El-Sadr Judd Walson Grace John-Stewart Mike Merson Jeff Koplan Chris Murray Elizabeth Nabel Jerry Keusch MOH Tedros Paul Farmer Eric Goosby Quarraisha Abdool Karim