1. Global Public Health Thomas 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 1

2. 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

3. 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

4. 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).

5. 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;

6. 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.

7. 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.

8. 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

9. Global Public Health Problems
Tobacco Use
Obesity
Emerging infectious diseases
Persistent Organic
Pollutants, Climate Change
Hazardous and
Nuclear Waste
Bioweapons

10. 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

11. 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

12. 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

13. 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

14. World Population Growth
Global Travel and
World Population Growth W o r l d P p u a t i n b s ( )
Days to circumnavigate globe Y e 1 8 5 4 3 2 9 6 5 4 3 2 1 5

15. 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)

16. 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.

17. 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.

18. 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.

19. Poverty and Global Health
Poverty and its consequences, including poor nutrition and sanitation, is the major factor reducing years of healthy life in the world

20. The biggest killers of the poor
Source: WHO, 2002

21. 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

23. (Yach, Hawkes et al. 2004)
High BMI
Tobacco
Physical inactivity

24. 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

25. Tobacco Use is a Great Example of a Public Health Problem
Host
Government
and Young People
Agent
Advertising
Movies and Media
Political Influence
Environment
Global Markets
Cognitive Globalization
Information Asymmetry

26. 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.

27. Global Public Health Infrastructure Development
Political commitment
Financing of public health infrastructure
Surveillance
Scientific investigation
Communications
Therapeutics (policy and development)
Critical evaluation of interventions

28. 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.

29. 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