71
Commentary Global Health Leadership A Continuing US Challenge ALFRED SOMMER, MD, MHS, Baltimore, Maryland
Presented in part at the Annual Meeting of the Institute of Medicine, Washington, DC, October 14, 1991. M y original intent was to describe the United States' role in global (read "foreign," principally Third World) public health. * Even brief reflection suggests the myopic cast of this traditional formulation. Most global problems are exactly that: affecting even our own society in real and direct ways, particularly in remote, underserved, rural areas and decaying inner cities. Serious problems may be more prevalent in but are not limited to developing countries. Furthermore, these are problems of health; they are "public" only in the sense that society needs to recognize their existence and collectively invest in their solution, whether this requires more biomedical research, a new and more effective health care delivery system, or nutrition education.
Global Health Priorities The single overarching global health priority is maximizing quality years of life at a cost society can afford. The operative terms are "quality years," not just "life," and can afford, not merely being "willing" to afford. Major global (universal) health issues include, among others, the following: * Tobacco and other substance abuse; * Environmental pollution; * Infectious pandemics, including the acquired immunodeficiency syndrome (AIDS); * Population growth; and * Women's health. Central to them all are the organization and use of health resources, from basic and applied research through prevention and cure. No country is entirely satisfied with its health system. There is no country in which all disease that could be prevented is being prevented or where services and care are not rationed (only whether it is spread more or less evenly across economic and ethnic strata). In the United Kingdom's National Health Service, for example, patients queue two to three years for the "elective" removal of a blinding cataract, a cataract that can be removed the same day in the private sector. Every country is casting about for a better solution. If there is a single mission uniquely within the purview of public health, it is the rational allocation of health resources. Global health priorities also include issues that are nearly universal, involving the poorer four fifths of the world's pop*See also "Eight Years and Counting-What Can Americans Do?" by A. Velji, page 84 of this issue.
ulation. The most immediate priority is closing the gap between potential health, available from the judicious application of existing, appropriate technology, and the present state of unnecessary ill health. The poorest 30 countries suffer nationwide infant mortality as high as 172 per 1,000 live births, compared with less than 10 per 1,000 in the most fortunate 30, and a life expectancy as low as 42 years, compared with over 75 years.1 That gap largely reflects the consequences of poor individual and collective hygiene, malnutrition, and the failure to prevent and manage childhood infections. The gap is not fixed by poverty or a lack of sophisticated curative technology. There is a strong correlation between a country's gross national product (GNP) and the life expectancy of its citizens (Figure 1).2 Most gains in life expectancy, however, are achieved within the first $1,000 GNP. A number of poor but deter80
45
40
0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 GNP per Capita Figure 1.-Life expectancy is graphed against the per capita gross national product (GNP) for different countries around the world. Countries circled in the upper left-hand side have achieved relatively long life expectancy at relatively low levels of per capita GNP (redrawn from UNICEF data2).
mined countries have narrowed their health gap even as their income gap has widened.'l China, with a per capita GNP of only $300, has a life expectancy of 70 years; Costa Rica and Jamaica, with less than a tenth our per capita GNP, share with us a 75-year life expectancy (Table 1). Sri Lanka, with a per capita GNP of only $400, has a lower infant and under-S mortality than sections of Washington, DC. It is clearly not a matter of how much is spent but how it is spent. Much of the improvement in health can be traced to other,
(Sommer A: Global health leadership-A continuing US challenge. West J Med 1992 Jul; 157:71-73) From the Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland. Reprint requests to Alfred Sommer, MD, MHS, Dean, Johns Hopkins School of Hygiene and Public Health, 615 N Wolfe St, Ste 1041, Baltimore, MD 21205-2179.
a
72
COMMENTARY
TABLE 1.-Infant Mortality and Life Expectancy in Relation to Gross National Product (GNP) Infant Life Expectancy Mortality, per 1,000 live births at Birth, years
GNP, $US
Country
China .............. Jamaica ............ Costa Rica .......... United States ........
290 940 1,600
18,500
31 18 18 10
70 74 75 75
structural changes. A reasonable argument can be made that the coming of the railroad, which made possible the movement of food from surplus to deficit areas, had as great an effect on health in India as did the introduction of western medicine. In many cultures there is a direct correlation between the level of literacy, particularly of women, and childhood mortality. We should not forget that measles mortality declined dramatically in the United States long before there was a measles vaccine (Figure 2), and tuberculosis virtually disappeared long before the introduction of effective chemotherapy. 16
c
.2
r
86 o
L
w
lZ
1& 1 1 &
Measles
vaccine
not introduced
(D
until
-
1965
0
1900
1910
1920
1930
1940
1950
1960
Figure 2.-The graph shows the death rates for measles in the United States before the introduction of the measles vaccine.
Organizing Public Health How should public health organize to meet these challenges at home and abroad? By recognizing the centrality of its mission and the need to leverage effects by working closely with other health professions, by strengthening the competence of public health professionals here and abroad, and by being proactive in developing and implementing scientifically sound health policies. Traditional boundaries limit our vision and impact. The interface between public health and medicine should become virtually seamless. "Public" and "private," "health" and "medicine," "preventive" and "curative" are artificial and divisive barriers. All countries, including the United States, are converging on a health care system that is very much public. All curative services are meant to prevent something, whether it is death prevented by cardioversion in a tertiary care emergency department, or earlier in the disease process, a change in life-style meant to prevent the development of coronary artery disease in the first place. Who is responsible for clinical trials, technology assessment, or quality assurance: the clinician who measures individual outcomes, the epidemiologist who designed the study, or the statistician who analyzed the results? Public health is not a profession in the traditional sense of possessing a common body of knowledge. Rather, its practitioners, from many professional backgrounds, are distin-
guished by their common agenda: to maximize health through a scientifically based, efficient, effective, and equitable use of resources. Public health is also distinguished by the breadth of its view, from the root cause of a problem through its prevention and cure. It is no accident that the scientific symposium celebrating the 75th anniversary of the founding of the Johns Hopkins School of Hygiene and Public Health is entitled "From Cell to Society." As a thoughtful public health professional expressed it, "typhoid fever is not, as some clinicians seem to believe, simply a manifestation of chloramphenicol deficiency" (Adetokunbo 0. Lucas, oral communication, May 1991). Modem public health requires the orchestrated collaboration of a wide variety of specialists possessing a common public health orientation. At times these will include varying permutations and combinations of clinicians, epidemiologists, engineers, basic and applied researchers of every hue, and front-line field workers delivering the messages, vaccines, micronutrients, condoms, and care. If effective public health emanates from the collective input of diverse specialists, we must reorient our academic agenda. While there will always be a need for MPH generalists, as there is for family practitioners, new leadership for practicing public health professionals is needed. This will require a Flexnerian revolution, producing leaders versed in a specific public health specialty, steeped in independent analytic thought, possessing a public health orientation, and having at least rudimentary exposure to biotechnology and to sick people. It positively frightens me to think that health care legislation is being written by MPH graduates who may never have cared for a sick patient. A modern engineer does not design a new car or plane without having first traveled in an existing model. Finally, the "new" public health, both academic and professional, must be more willing than ever to translate research results into scientifically based policy initiatives and, where necessary, challenge the more egregious political pressures hindering reform. US society has transformed its use oftobacco products. This has been a health triumph of the first order. But official US aid and trade policies conspire to export the problem to developing countries. We share this common cause with our colleagues overseas. Role of the United States Although it ill-behooves us to preach a rational use of health resources given our dismal record in this regard, the United States is otherwise uniquely qualified to provide leadership in responding to international health issues: through training, training, and more training; through basic laboratory research; and by supporting-intellectually and financially-those who return abroad, thereby creating and sustaining productive and effective indigenous public health proficiency and local health awareness. The American capacity for training public health professionals for academic and programmatic leadership is unrivaled. By themselves, our 24 schools of public health provide the wide diversity of disciplines in which specialists need to be trained. Given the severely constrained resources of most developing countries, the obstacles our graduates face on returning home require all the problem-solving capability they can muster. The ability to recognize, define, and attack a problem is far more important to future success than is the rote
THE WESTERN JOURNAL OF MEDICINE * JULY 1992 *
157 *
1
memory of public health facts. The road to the world's most successful coordinated health project, eradicating smallpox, was littered with discarded solutions: Mass vaccination failed to reach those who most needed it and was supplanted by surveillance and containment, which established an effective cordon sanitaire around infective cases; and just when vaccine availability threatened to become a bottleneck, introduction of the highly efficient bifurcated needle effectively quadrupled the reach of the vaccine supply.3 A public health professional cannot function efficiently in isolation. Effectiveness requires a critical mass of professionals. US policy should encourage the training of a multidisciplinary, complementary group of public health professionals from each region. In turn, they should seek opportunities to work with like-minded personnel from their local ministries of health and academic institutions. Collaboration among health agencies, government organizations, and academic institutions is invaluable for developing local political commitment. In addition to training, this country has unsurpassed facilities for conducting basic laboratory research that can overcome old and new obstacles. Developing countries rarely provide hospitable environments for sophisticated molecular biology. On the other hand, developing countries represent unsurpassed field laboratories for identifying major obstacles to attaining health, for determining the effectiveness of new biologic agents, and for conducting essential applied research.2 It is a two-way street: New therapeutic agents for AIDS, and possibly an effective vaccine, are likely to issue from research laboratories of wealthier industrialized countries, but the epidemiology and natural history of AIDS are being foretold from field studies in Africa. Contributions are sometimes circular: John Black Grant, trained at the thennew Hopkins School of Hygiene and Public Health, spent the next 15 years working in China, where he inspired people like C. C. Chen to develop and refine community-based primary health care,4 a model that might be brought back with good effect to help solve the health crises of our own rural areas and inner cities. Field needs and laboratory research drive one another. The Expanded Programme for Immunization is an attempt to immunize the world's children and thereby prevent millions of unnecessary deaths and disabilities annually. Despite having attained its goal of vaccinating 80% of the world's children against six major childhood diseases, available vaccines require injections, cold chains, and multiple booster shotspractical obstacles to the most effective, sustainable result. But the infrastructure capable of providing vaccines to young children has stimulated a new initiative, based on modern
73
immunology and recombinant DNA technology, to produce
a children's vaccine that is meant to provide prolonged immunity against a host of agents and from a single oral adminis-
tration.
Foreign graduates of US institutions provide a skilled group of professionals with whom to collaborate. Such North-South dialogue enriches us all. American faculty and students gain hands-on experience with Third World problems and bring critical technologic bottlenecks back to the US for laboratory study. Our Third World colleagues gain fresh insight and stimulation that help maintain and enhance their skills, contribute to their health professional interest and expertise, and thereby strengthen their ability to conduct essential operational research. They also add to their international recognition and their local credibility. Indonesian scientists with whom I began collaborating on vitamin A deficiency research and control more than a decade ago now hold major health research and policy leadership positions, charting Indonesia's future and bringing invaluable experience to international advisory committees. Conclusion The great global health priority is to maximize quality years of life for all. This requires attacking universal problems and the nearly universal health gap of developing countries-and neglected rural and inner-city populations of the western world-through appropriate research and the organization of resources in the most imaginative, effective, efficient, and equitable way. Public health disciplines and the public health approach, strongly linked to other professions, are central to sustained success. The United States is uniquely blessed with institutions and organized intellectual resources for training the academic and professional health leadership needed to chart rational directions and create much-needed political will. Flexnerian academic reform is critical to create a more vigorous and rigorous science-based professional public health environment at home and abroad. US collaboration, intellectual and financial, is essential to the global maturation of public health capacity and effectiveness, in both the academic and professional arenas. REFERENCES 1. UNICEF: The State of the World's Children, 1990. New York, NY, Oxford University Press, 1990 2. Commission on Health Research for Development: Health Research: Essential Link to Equity in Development. New York, NY, Oxford University Press, 1990 3. Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID: Smallpox and Its Eradication. Geneva, Switzerland, World Health Organization, 1988 4. Chen CC: Medicine in Rural China. Berkeley, Calif, University of California Press, 1989
Commentary Global Health Leadership A Continuing US Challenge ALFRED SOMMER, MD, MHS, Baltimore, Maryland
Presented in part at the Annual Meeting of the Institute of Medicine, Washington, DC, October 14, 1991. M y original intent was to describe the United States' role in global (read "foreign," principally Third World) public health. * Even brief reflection suggests the myopic cast of this traditional formulation. Most global problems are exactly that: affecting even our own society in real and direct ways, particularly in remote, underserved, rural areas and decaying inner cities. Serious problems may be more prevalent in but are not limited to developing countries. Furthermore, these are problems of health; they are "public" only in the sense that society needs to recognize their existence and collectively invest in their solution, whether this requires more biomedical research, a new and more effective health care delivery system, or nutrition education.
Global Health Priorities The single overarching global health priority is maximizing quality years of life at a cost society can afford. The operative terms are "quality years," not just "life," and can afford, not merely being "willing" to afford. Major global (universal) health issues include, among others, the following: * Tobacco and other substance abuse; * Environmental pollution; * Infectious pandemics, including the acquired immunodeficiency syndrome (AIDS); * Population growth; and * Women's health. Central to them all are the organization and use of health resources, from basic and applied research through prevention and cure. No country is entirely satisfied with its health system. There is no country in which all disease that could be prevented is being prevented or where services and care are not rationed (only whether it is spread more or less evenly across economic and ethnic strata). In the United Kingdom's National Health Service, for example, patients queue two to three years for the "elective" removal of a blinding cataract, a cataract that can be removed the same day in the private sector. Every country is casting about for a better solution. If there is a single mission uniquely within the purview of public health, it is the rational allocation of health resources. Global health priorities also include issues that are nearly universal, involving the poorer four fifths of the world's pop*See also "Eight Years and Counting-What Can Americans Do?" by A. Velji, page 84 of this issue.
ulation. The most immediate priority is closing the gap between potential health, available from the judicious application of existing, appropriate technology, and the present state of unnecessary ill health. The poorest 30 countries suffer nationwide infant mortality as high as 172 per 1,000 live births, compared with less than 10 per 1,000 in the most fortunate 30, and a life expectancy as low as 42 years, compared with over 75 years.1 That gap largely reflects the consequences of poor individual and collective hygiene, malnutrition, and the failure to prevent and manage childhood infections. The gap is not fixed by poverty or a lack of sophisticated curative technology. There is a strong correlation between a country's gross national product (GNP) and the life expectancy of its citizens (Figure 1).2 Most gains in life expectancy, however, are achieved within the first $1,000 GNP. A number of poor but deter80
45
40
0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 GNP per Capita Figure 1.-Life expectancy is graphed against the per capita gross national product (GNP) for different countries around the world. Countries circled in the upper left-hand side have achieved relatively long life expectancy at relatively low levels of per capita GNP (redrawn from UNICEF data2).
mined countries have narrowed their health gap even as their income gap has widened.'l China, with a per capita GNP of only $300, has a life expectancy of 70 years; Costa Rica and Jamaica, with less than a tenth our per capita GNP, share with us a 75-year life expectancy (Table 1). Sri Lanka, with a per capita GNP of only $400, has a lower infant and under-S mortality than sections of Washington, DC. It is clearly not a matter of how much is spent but how it is spent. Much of the improvement in health can be traced to other,
(Sommer A: Global health leadership-A continuing US challenge. West J Med 1992 Jul; 157:71-73) From the Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland. Reprint requests to Alfred Sommer, MD, MHS, Dean, Johns Hopkins School of Hygiene and Public Health, 615 N Wolfe St, Ste 1041, Baltimore, MD 21205-2179.
a
72
COMMENTARY
TABLE 1.-Infant Mortality and Life Expectancy in Relation to Gross National Product (GNP) Infant Life Expectancy Mortality, per 1,000 live births at Birth, years
GNP, $US
Country
China .............. Jamaica ............ Costa Rica .......... United States ........
290 940 1,600
18,500
31 18 18 10
70 74 75 75
structural changes. A reasonable argument can be made that the coming of the railroad, which made possible the movement of food from surplus to deficit areas, had as great an effect on health in India as did the introduction of western medicine. In many cultures there is a direct correlation between the level of literacy, particularly of women, and childhood mortality. We should not forget that measles mortality declined dramatically in the United States long before there was a measles vaccine (Figure 2), and tuberculosis virtually disappeared long before the introduction of effective chemotherapy. 16
c
.2
r
86 o
L
w
lZ
1& 1 1 &
Measles
vaccine
not introduced
(D
until
-
1965
0
1900
1910
1920
1930
1940
1950
1960
Figure 2.-The graph shows the death rates for measles in the United States before the introduction of the measles vaccine.
Organizing Public Health How should public health organize to meet these challenges at home and abroad? By recognizing the centrality of its mission and the need to leverage effects by working closely with other health professions, by strengthening the competence of public health professionals here and abroad, and by being proactive in developing and implementing scientifically sound health policies. Traditional boundaries limit our vision and impact. The interface between public health and medicine should become virtually seamless. "Public" and "private," "health" and "medicine," "preventive" and "curative" are artificial and divisive barriers. All countries, including the United States, are converging on a health care system that is very much public. All curative services are meant to prevent something, whether it is death prevented by cardioversion in a tertiary care emergency department, or earlier in the disease process, a change in life-style meant to prevent the development of coronary artery disease in the first place. Who is responsible for clinical trials, technology assessment, or quality assurance: the clinician who measures individual outcomes, the epidemiologist who designed the study, or the statistician who analyzed the results? Public health is not a profession in the traditional sense of possessing a common body of knowledge. Rather, its practitioners, from many professional backgrounds, are distin-
guished by their common agenda: to maximize health through a scientifically based, efficient, effective, and equitable use of resources. Public health is also distinguished by the breadth of its view, from the root cause of a problem through its prevention and cure. It is no accident that the scientific symposium celebrating the 75th anniversary of the founding of the Johns Hopkins School of Hygiene and Public Health is entitled "From Cell to Society." As a thoughtful public health professional expressed it, "typhoid fever is not, as some clinicians seem to believe, simply a manifestation of chloramphenicol deficiency" (Adetokunbo 0. Lucas, oral communication, May 1991). Modem public health requires the orchestrated collaboration of a wide variety of specialists possessing a common public health orientation. At times these will include varying permutations and combinations of clinicians, epidemiologists, engineers, basic and applied researchers of every hue, and front-line field workers delivering the messages, vaccines, micronutrients, condoms, and care. If effective public health emanates from the collective input of diverse specialists, we must reorient our academic agenda. While there will always be a need for MPH generalists, as there is for family practitioners, new leadership for practicing public health professionals is needed. This will require a Flexnerian revolution, producing leaders versed in a specific public health specialty, steeped in independent analytic thought, possessing a public health orientation, and having at least rudimentary exposure to biotechnology and to sick people. It positively frightens me to think that health care legislation is being written by MPH graduates who may never have cared for a sick patient. A modern engineer does not design a new car or plane without having first traveled in an existing model. Finally, the "new" public health, both academic and professional, must be more willing than ever to translate research results into scientifically based policy initiatives and, where necessary, challenge the more egregious political pressures hindering reform. US society has transformed its use oftobacco products. This has been a health triumph of the first order. But official US aid and trade policies conspire to export the problem to developing countries. We share this common cause with our colleagues overseas. Role of the United States Although it ill-behooves us to preach a rational use of health resources given our dismal record in this regard, the United States is otherwise uniquely qualified to provide leadership in responding to international health issues: through training, training, and more training; through basic laboratory research; and by supporting-intellectually and financially-those who return abroad, thereby creating and sustaining productive and effective indigenous public health proficiency and local health awareness. The American capacity for training public health professionals for academic and programmatic leadership is unrivaled. By themselves, our 24 schools of public health provide the wide diversity of disciplines in which specialists need to be trained. Given the severely constrained resources of most developing countries, the obstacles our graduates face on returning home require all the problem-solving capability they can muster. The ability to recognize, define, and attack a problem is far more important to future success than is the rote
THE WESTERN JOURNAL OF MEDICINE * JULY 1992 *
157 *
1
memory of public health facts. The road to the world's most successful coordinated health project, eradicating smallpox, was littered with discarded solutions: Mass vaccination failed to reach those who most needed it and was supplanted by surveillance and containment, which established an effective cordon sanitaire around infective cases; and just when vaccine availability threatened to become a bottleneck, introduction of the highly efficient bifurcated needle effectively quadrupled the reach of the vaccine supply.3 A public health professional cannot function efficiently in isolation. Effectiveness requires a critical mass of professionals. US policy should encourage the training of a multidisciplinary, complementary group of public health professionals from each region. In turn, they should seek opportunities to work with like-minded personnel from their local ministries of health and academic institutions. Collaboration among health agencies, government organizations, and academic institutions is invaluable for developing local political commitment. In addition to training, this country has unsurpassed facilities for conducting basic laboratory research that can overcome old and new obstacles. Developing countries rarely provide hospitable environments for sophisticated molecular biology. On the other hand, developing countries represent unsurpassed field laboratories for identifying major obstacles to attaining health, for determining the effectiveness of new biologic agents, and for conducting essential applied research.2 It is a two-way street: New therapeutic agents for AIDS, and possibly an effective vaccine, are likely to issue from research laboratories of wealthier industrialized countries, but the epidemiology and natural history of AIDS are being foretold from field studies in Africa. Contributions are sometimes circular: John Black Grant, trained at the thennew Hopkins School of Hygiene and Public Health, spent the next 15 years working in China, where he inspired people like C. C. Chen to develop and refine community-based primary health care,4 a model that might be brought back with good effect to help solve the health crises of our own rural areas and inner cities. Field needs and laboratory research drive one another. The Expanded Programme for Immunization is an attempt to immunize the world's children and thereby prevent millions of unnecessary deaths and disabilities annually. Despite having attained its goal of vaccinating 80% of the world's children against six major childhood diseases, available vaccines require injections, cold chains, and multiple booster shotspractical obstacles to the most effective, sustainable result. But the infrastructure capable of providing vaccines to young children has stimulated a new initiative, based on modern
73
immunology and recombinant DNA technology, to produce
a children's vaccine that is meant to provide prolonged immunity against a host of agents and from a single oral adminis-
tration.
Foreign graduates of US institutions provide a skilled group of professionals with whom to collaborate. Such North-South dialogue enriches us all. American faculty and students gain hands-on experience with Third World problems and bring critical technologic bottlenecks back to the US for laboratory study. Our Third World colleagues gain fresh insight and stimulation that help maintain and enhance their skills, contribute to their health professional interest and expertise, and thereby strengthen their ability to conduct essential operational research. They also add to their international recognition and their local credibility. Indonesian scientists with whom I began collaborating on vitamin A deficiency research and control more than a decade ago now hold major health research and policy leadership positions, charting Indonesia's future and bringing invaluable experience to international advisory committees. Conclusion The great global health priority is to maximize quality years of life for all. This requires attacking universal problems and the nearly universal health gap of developing countries-and neglected rural and inner-city populations of the western world-through appropriate research and the organization of resources in the most imaginative, effective, efficient, and equitable way. Public health disciplines and the public health approach, strongly linked to other professions, are central to sustained success. The United States is uniquely blessed with institutions and organized intellectual resources for training the academic and professional health leadership needed to chart rational directions and create much-needed political will. Flexnerian academic reform is critical to create a more vigorous and rigorous science-based professional public health environment at home and abroad. US collaboration, intellectual and financial, is essential to the global maturation of public health capacity and effectiveness, in both the academic and professional arenas. REFERENCES 1. UNICEF: The State of the World's Children, 1990. New York, NY, Oxford University Press, 1990 2. Commission on Health Research for Development: Health Research: Essential Link to Equity in Development. New York, NY, Oxford University Press, 1990 3. Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID: Smallpox and Its Eradication. Geneva, Switzerland, World Health Organization, 1988 4. Chen CC: Medicine in Rural China. Berkeley, Calif, University of California Press, 1989
