Building Health Partnerships Between
Developed-Developing Country Universities
Is Academia Relevant to Global Health?
Gerald T. Keusch, M.D.
Associate Provost and Associate Dean
for Global Health, Boston University
Organization of presentation
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Health disparities - scene setting
Where have we come from?
Where are we now?
Where are we going
Partnerships
Intended and unintended consequences
Health disparities are quantitative
Health disparities are also qualitative
Populations with Equal Access to Health Care
SOURCE: Gomes and McGuire
Unequal Treatment, Confronting Ethnic
and Racial Disparities in Health Care
National Academy of Sciences, 2001
Global health disparities are even greater…
Life expectancy at birth by world region, 2001
Area
Total
Males
Females
World
67
65
69
Developed countries
75
72
79
Less developed countries
64
63
66
Africa
54
52
55
Asia
67
65
68
Latin America and Caribbean
71
68
74
Europe
74
70
78
North America (U.S. and Canada)
77
74
80
SOURCE: Population Reference Bureau. 2001 World Population Data Sheet.
Washington, DC: Population Reference Bureau, 2001.
related to poverty…
80
Life Expectancy (Years)
1990
1960
70
About 1930
60
About 1900
50
40
30
0
5,000
10,000
15,000
20,000
25,000
Income Per Capita, 1991 International Dollars
related to particular diseases…
and not getting better for those at the
very bottom of the barrel.
Population
1997-9
(Millions)
Ave. Annual
Income per
Capita ($)
Life
Expectancy
(y)
Infant
Mortality
/1000 Births
Least
Developed
Countries (38)
643
$
296
49
103
Other Low
Income
Countries (23)
1,777
$
538
61
60
High Income
Countries
858
$23,335
77
6
WHO Macroeconomics Report, 2001
Given these realities, what would
you want in your fortune cookie?
Its why its called a fortune cookie!
Where have we come from?
A century of medical science.
Successes in the 20th Century •
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Imaging, X-ray to MRI
Immunology, a new science
New vaccines, from polio to HPV
Eradication of an ancient pathogen
Behavioral risk factors – tobacco, diet
Pathology to molecular/cellular biology
Receptors, signaling, molecular cross-talk
Genetic sciences and the human genome
Omics, systems biology, bionics, designer meds
A century of medical science:
Disappointments of the 20th century
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Increasing disparities in health
Failure to use available technology
Increasing disparities in health research
Knowledge doesn’t equal problem solving
More people affected by neglected diseases
Rise of a for profit pharmaceutical industry that must
focus R&D on the business bottom line
 Impact on access, availability, affordability,
appropriateness, acceptability
 Excessive attention to life-style drugs
 Inattention to neglected tropical diseases
The Dilemma of Public Health
 Public health is the art and science of making sure
nothing happens
 When nothing happens, nobody notices
 Politicians worry when nothing happens – “nothing” is a
political vacuum
 When asked to pay for nothing they balk
 When they pay and nothing happens they get mad
 When they balk or they get mad the public health
system suffers…until something happens
 When something happens, everybody is blamed,
especially the public health system and its “failed”
leadership who “mislead” the politicians
No wonder expenditures on public
health are so low (data from the U.S.)
<5%
Public Health
Other Health
Where are we now?
The present global context:
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Poverty: billions live on less than $2/day; health
expenditures are woefully inadequate.
Population: > 6 billion and growing.
Environment: Continuing degradation, climate
change, pollution and disease spread.
Civil Society: Civil and foreign wars, genocide,
displaced persons, refugees and migration, failed
states.
Health: 95% of global disease burden is in the
developing countries and local expenditures are
grossly inadequate.
Research: > 90% of $$ is for first world diseases so little
is spent on disease affecting the majority – too much
oriented to highly technical, expensive drugs,
diagnostics or devices.
But, growing recognition of the
importance of global issues
 Globalism as the 21st century theme
 The response to a changing world
 The social conscience of students
 Health as a key global concern
 Health is the basis for development
 Health as a human right
 Health as a security issue
 Centrality of health to international policy
 Core aspiration of all nations
 Role of health in “soft” diplomacy
The Essential Premise: There are many sectors
but just one, health, is central to all others
ECONOMICS
BUSINESS
POLITICS
HEALTH
AGRICULTURE
CIVIL SOCIETY
ARTS AND
CULTURE
A Definition of Global Health: New Field or
New Name? Koplan, J.P. et al, for the
Consortium of Universities for Global Health
Global health is a field of study, research
and practice that places a priority on
improving health and achieving equity in
health for all people worldwide. Global
health emphasizes transnational health
issues, determinants and/or solutions;
involves multiple disciplines within and
beyond the health sciences and promotes
interdisciplinary collaboration; and is a
synthesis of population-based prevention
with individual level clinical care.
Where are we going?
Unless things change dramatically
what will happen in the 21st century?
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More old, more young
More poor, more hungry
More crowding, more pollution
More degradation of environment
More discrepancy in access to resources
More resentment, political instability, violence
More social disruption, failed states, terrorism
How can health be improved and disparities
reduced in developing countries?
 Figure out what the problems are
 Applied as well as basic and translational research
 Can involve students as well as faculty
 Get into the field, in facilities and the community
 Identify potential solutions
 Facility or community based
 Be sure they are culturally appropriate
 Implement interventions
 Funding/staffing
 Capacity building
A transforming publication for university
global health programs
The most important unanticipated
finding in the 1993 World Development Report
(according to Dean Jamison, lead author)
Increased scientific knowledge has accounted for
much of the dramatic improvement in health that
has occurred in this century—by providing
information that forms the basis of household and
government action and by underpinning the
development of preventive, curative, and
diagnostic technologies… Because the fruits of
science benefit all countries, internationally
collaborative efforts, of which there are several
excellent examples, will often be the right way to
proceed.
What do universities do?
What is their role in society?
Universities have four critical roles
• Education – (including education of the public
at large), but this may be relegated to 2nd
place in some research intensive institutions
• Research – generation of new knowledge
• Service – translation and application of
knowledge in society
• Policy – inform the political sector, influence
decision making
Education: responsibility of the
university as the Academy
• Teach global literacy – business students need to understand
the magnitude of disparities in health, science students need
to understand the practical value of their work, all students
need to know about the real world
• Make global studies a required part of the core curriculum
• Contribute to improvement of K-12 education in science and
technology
• Promote public access to the health literature
Encourage publication in open access journals
Find venues to publish work that doesn’t work
Speak in plain language to the public
Research: knowledge creation –
upstream, downstream or all stream?
• Embrace a global culture of science with high ethical
standards, open and free communication, concern for
global public goods
• Reduce barriers between academic faculties and
promote interdisciplinary research
• Connect basic and applied research within the research
culture
• Reward applied research productivity by faculty through
recognition, support, academic promotions
• Establish thoughtful socially relevant intellectual property
policies and licensing terms: knowledge as a global public
good
Appropriate university engagement
in service and policy development
• Contribute to capacity building in science, clinical medicine,
and public health
• Support training of developing country health workers in a
manner that does not lead to emigration
• Work more directly with international agencies to improve
health and health capacity in developing countries
• Promote the good side of globalization, correct the bad
• Enter national policy decision making process to insure that
evidence is used effectively
University Consortium for Global Health
National Academy of Science/Institute of Medicine
Advocacy
Building Health Partnerships
Between Developed and
Developing Country Universities
Sustainable, Effective
Building ^ Health Partnerships
Between Developed and
Developing Country Universities
What are the essential features of
sustainable effective partnerships?
Traditional
Business model
Innovative
PH model
The new governance paradigm
Robert Klitgaard, President Claremont Univ.
From “layer cake” (tasks taken on separately
by different sectors) to “marble cake” (cross
sectoral partnerships). In research we call it
interdisciplinarity
There are three key questions:
 What’s in it for me (my institution)?
 What will my partner contribute?
 What will it cost me?
Three essential features:
1. Trust
2. Trust
3. Trust
Three essential attitudes:
1. Respect
2. Respect
3. Respect
These create the three essential enabling
features for successful partnerships:
1. Relationships
2. Relationships
3. Relationships
Who your “ambassadors” are
does really matter.
What can academics do?
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Improve access to information, globally – publish in
open access journals
• Develop sustained collaborations with developing
country scientists for training, research, and improving
clinical services
• Advocate for “better” (more enlightened) tech transfer
policies – understand IP and TT
• Organize and become vocal advocates for
appropriate assistance to developing countries for
capacity building and service
 Canadian version of the newly announced Obama
initiative in Global Health
 Work with IRDC – an inherently good agency
Science for Humanity
What can institutions do?
Value applied research in career development,
e.g. work on rapid low-tech low-cost diagnostics
Create new mechanisms for risky research:
Professorships of Failed Experiments
Intended consequences
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Progression to integrative partnership model
Capacity improvements
Managerial competence
Good governance – transparent, fair, ethical
Meaningful health benefits
Learning lessons become bidirectional
Unintended consequences
 Neocolonialism – control issues
 Introduction of inappropriate technology
 Displaced concern – e.g. from local problems
to hosting international students
 Cultural clashes
 Facility based focus
 Research dominance – leadership roles,
authorship/presentation of data
Can we deliver what we promise?
McGill Partner
“I think I can make you very happy if I can get funded.”
Today…
Backslide tomorrow?
Personal/institutional persistence and focus