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Global health – The next generation

Written by Peter Hotez, MD, PhD, dean of the National School of Tropical Medicine at Baylor College of Medicine; and keynote speaker for 2015 Global Health Week

Peter Hotez

We are coming to the end of an incredible 15-year period of expansion in promoting global health. Beginning with the launch of the Millennium Development Goals (MDGs) in 2000 there was an extraordinary burst of activity devoted to reducing child mortality; improving maternal health; and combating AIDS, malaria and other diseases. These goals were partly achieved through massive overseas development assistance (ODA) and bilateral and multi-lateral initiatives mostly involving the United States and the other Group of Seven countries, in addition to the Bill & Melinda Gates Foundation. The dollar amount easily exceeded one billion dollars.

For example through Gavi, the Vaccine Alliance, many childhood vaccine preventable diseases decreased by 50% or more, while through the Global Fund to Fight AIDS, Tuberculosis, and Malaria, together with the US President’s Emergency Plan for AIDS Relief and other programs we’ve seen a 30% reduction in malaria cases and deaths, and similar reductions in deaths from HIV/AIDS. For the “other diseases” component of the MDGs we are also seeing big decreases in the prevalence of some key neglected tropical diseases (NTDs) including lymphatic filariasis, trachoma, onchocerciasis, and yaws, to the point where we can realistically talk about the elimination of these diseases as public health problems. A key message is that ODA can work and save lives if it is backed by good governance and accountability.

Students of the health professions have a broad array of options if they are considering a global health career.

It is imperative that we not lose our momentum on reducing the impact of these important infectious diseases. This means continuing to expand drug, vaccine, and bednet coverage, but it also means programs of research innovation to foster the development of new drugs, diagnostics, and vaccines. Washington University in St. Louis has been at the forefront of conducing strategically important research to allow us to this point. For example Dr. Gary Weil developed an essential diagnostic that made the elimination of lymphatic filariasis a realistic target, Drs. Dan Goldberg’s and Steve Beverly’s fundamental research on malaria and leishmaniasis, respectively, facilitated the discovery and development of new antiprotozoan drugs, and Dr. Mark Manary’s efforts to develop peanut butter derivatives is alleviating hunger in Africa and elsewhere. At our Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development in Houston we are working to develop new vaccines for NTDs.

As a result of these gains we can now visualize some important new global health trends. They include the rise of non-communicable diseases (NCDs) among the poor, such that heart disease, cancer, chronic lung disease and diabetes are becoming as important as infectious diseases in Africa, Asia, and the Americas. These findings now suggest that students of the health professions have a broad array of options if they are considering a global health career. For example a new Lancet Commission on Global Surgery highlights the urgent need for qualified surgeons, anesthesiologists, and obstetricians to enter the global health arena. We are also only now realizing a massive burden of global mental health issues such that we will need a new generation of neurologists, psychiatrists, psychologists, and social workers committed to global health issues. For example, findings from the Global Burden of Disease Study (GBD 2013) indicate that in terms of disability-adjusted life years (DALYS), unipolar depression is as important as HIV/AIDS!

To achieve the Sustainable Development Goals we’re going to have to look beyond biomedicine and better embrace the social sciences — political science, sociology, economics — law, business, engineering, and really almost all fields of intellectual endeavor.

Much of the current discussion about NCDs in developing countries revolves around interventions to improve lifestyle and stop bad habits such as smoking and alcohol intake, while implementing legislation to tax harmful substances like tobacco. A new Lancet Commission on Investing in Health, also known as Global Health 2035, is looking at these big picture interventions.  However, we are also finding lots of neglected causes of NCDs. For example much of the heart disease in Latin America is actually due to Chagas disease –an NTD. Similarly much of the urologic and renal disease in Africa results from urogenital schistosomiasis, and so forth. Therefore, controlling and eliminating NTDs should become front and center to the NCD debate.

Still another important new trend is our somewhat paradoxical finding that most of the world’s neglected diseases and global health problems actually occur in wealthy economies. Today (with some important exceptions) most of the world’s NTDs, including helminth and protozoan infections are found among poor people who live in the group of 20 (G20) nations. Also, about one-half of the AIDS, tuberculosis, and malaria occur within the G20, and most of the NCDs. We find that our current framework of global health now focused on less developed countries has “morphed” to a situation in which the poverty found in G20 nations such as Argentina, Brazil, Mexico, China, India, Indonesia, and South Africa account for the neglected diseases. We are also finding neglected disease and poverty in the United States (especially Texas) and in Europe. I have given a new name – blue marble health – to describe this new paradigm and framework and will discuss its potentially useful policy implications.

Finally, we are seeing conflict and war in Africa and in the Middle East reverse important global health gains. Ebola virus infection arose out of West Africa due to its failed post-conflict infrastructure, and for similar reasons I predict we will soon see additional catastrophic epidemics arise out of ISIS occupied conflict zones. Increasingly we recognize that social determinants like conflict and poverty are going to send us back in time due to these global health reversals. We are about to replace the MDGs with a new set of 17 Sustainable Development Goals (SDGS) that will better consider such social determinants as well as climate change, the oceans, and the environment.

To achieve the SDGS we’re going to have to look beyond biomedicine and better embrace the social sciences — political science, sociology, economics — law, business, engineering, and really almost all fields of intellectual endeavor. This conclusion makes me excited to visit Washington University in St Louis, a comprehensive world class institution that could become an important and powerful ally in achieving the Sustainable Development Goals!