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

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 Tobacco Use Obesity Emerging infectious diseases Persistent Organic Pollutants, Climate Change Hazardous and Nuclear Waste Bioweapons

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

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

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

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 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 Host Government and Young People Agent Advertising Movies and Media Political Influence Environment Global Markets Cognitive Globalization Information Asymmetry

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 Health Infrastructure 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