Public Health Challenges :
The Need for Transdisciplinary
Science
Professor William Powderly
J. William Campbell Professor of
Medicine
Director, Institute for Public Health
• Global health problems are complex and systemic.
• The gross inequalities in health that we see within and
between countries present a challenge to the world.
– The conditions in which people are born, grow, live, work
and age are at the root of much of these inequalities in
health, and these social determinants are relevant to
infectious and non-communicable diseases alike.
• Their resolution requires partnerships transcending the
boundaries between disciplines.
Millennium Development Goals
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower
women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Global partnership for development
Millennium Development Goals
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower
women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Global partnership for development
Millennium Development Goals
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower
women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Global partnership for development
Globalization of Health Challenges
• During the last two decades there has been a
fundamental shift in global patterns of
disease.
• New epidemics of chronic illness are following
in the wake of rapid urbanization and
economic change.
• The epidemiological profile of many LMICs is
becoming similar to that in developed nations.
Main cause of premature death –
worldwide. 1990-2010.
1990
2010
1
Lower Respiratory infections
1
Ischemic Heart Disease
2
Diarrhea
2
Lower Respiratory infections
3
Preterm Birth complications
3
Stroke
4
Ischemic Heart Disease
4
Diarrhea
5
Stroke
5
Malaria
6
Malaria
6
HIV/AIDS
7
COPD
7
Preterm Birth complications
8
Protein-energy Malnutrition
8
Road Injury
9
Tuberculosis
9
COPD
10
Neonatal encephalopathy
10
Neonatal encephalopathy
Source: The Lancet 2012; 380:2095-2128
Global Challenges
• Challenges are interdependent: an improvement in one
makes it easier to address others; deterioration in one
makes it harder to address others.
• Challenges are transnational in nature and
transinstitutional in solution.
– Cannot be addressed by any government or institution
acting alone.
– Need collaborative action among governments,
international organizations, corporations, universities,
NGOs, and creative individuals.
Global Influences on Health
Demographic
and
Health
Social
Changes
Environmental
and Climate
changes
Adapted from McMichael AJ. N Engl J Med 2013;368:1335-1343
Economic
changes
Demographic and Social changes that
influence health
Demographic Changes
• Population Growth
• Aging
• Urbanization
• Increased Mobility
• Family Structure
Social Changes
• Governance
• Institutions
• International codes, treaties
and relationships
• Cultural change and
diffusion
Global economic influences on health
•
•
•
•
•
•
Trade and Capital Mobility
Labor conditions
Wealth creation
Wealth distribution
International financial stability
International Aid
Environmental influences on Health
• Land and water resources
– Use, degradation and depletion
• Energy security and use
• Ecosystem disturbances
• Climate change
– Extreme weather conditions
– Warming
Global Influences on Health
Demographic
and
Health
Social
Changes
Environmental
and Climate
changes
Adapted from McMichael AJ. N Engl J Med 2013;368:1335-1343
Economic
changes
Initial Reports of HIV AIDS
• June 5, 1981: 5 cases of PCP in gay men from
UCLA (MMWR)
Gottlieb MS NEJM 2001;344:1788-91
Emergence of HIV-AIDS
Urbanization
Increased Population
Density
AIDS
War
Mobile populations
Behavioral changes
Transfer of virus from
Chimpanzee and
Monkey
Spatial dynamics of HIV-1 group M spread
Faria et al, Science 346: 56. 2014
Adults and children estimated to be living with HIV2013
Eastern Europe &
Central Asia
North America and Western and Central Europe
2.3 million
1.1 million
[980 000– 1.3 million]
[2.0 million – 3.0 million]
Middle East & North Africa
Caribbean
230 000
[160 000 – 330 000]
250 000
[230 000 – 280 000]
Latin America
1.6 million
[1.4 million – 2.1 million]
Sub-Saharan Africa
24.7 million
[23.5 million – 26.1 million]
Total: 35.0 million [33.2 million – 37.2 million]
Source:
UNAIDS
Asia and the Pacific
4.8 million
[4.1 million – 5.5 million]
Current State of HIV control
Marginalization of
key populations
Adherence to
treatment and
prevention
International Aid
HIV
control
Health priorities of
individual
countries
Discriminatory
Legislation
• 34 million infected people (only 24% on Rx) - 2.5 million newly infected each year
• Marginalization of many populations – women and children, MSM, Drug-users, Mentally
ill
• Financial cost – donor fatigue
• Lack of Adherence and behavioral disinhibition obstacles to sustained effectiveness of
proven interventions
• NEED Vaccine and Cure
“As the HIV disease pandemic surely should have
taught us, in the context of infectious diseases, there
is nowhere in the world from which we are remote
and no one from whom we are disconnected.”
 IOM, 1992
Factors involved in the emergence of
new infections – especially viral
•
Microbial adaptation and change.
–
–
•
Changing ecosystems.
–
•
Mutations or recombination events in pre-existing viruses.
Inter-species transmission (zoonoses)
Climate and weather.
Human demographics and behaviour.
–
–
–
–
War and famine.
International travel and commerce.
Breakdown of public health measures.
Adoption of exotic animals.
Interdependence:
The Shrinking World
• 1 billion people cross international borders
each year or 25/second
– unprecedented vulnerability
– Threats spread faster, further, and non-linear
• Increased threats of global pandemics
– Significant risk in resource-poor countries with
under funded public and animal health systems
– “If the forest is dry enough and dense enough…”
Emergence of Ebola in West Africa -2014
Recent Wars/ Conflict
Distrust in Public
Institutions
Behavioral/cultural
issues enhancing
transmission
Ebola
Virus
Disease
Poorly
Functioning
Public health
infrastructure
International
Indifference
Increased urbanization
Population mobility
Inter-species
transmission
(fruit bats)
Transmission of Ebola
• Individuals are only infectious if they have symptoms of
Ebola.
– No risk of transmission from people who have been exposed to
the virus but are not yet symptomatic.
• Ebola is spreads through direct contact with bodily fluids.
– In the current outbreak, most new cases are occurring among
people who have been taking care of sick relatives or who have
prepared an infected body for burial.
– Health care workers are at high risk
• Need personal protective equipment (PPE) and training to use and
decontaminate it.
• The virus can survive on heavily contaminated surfaces,
– objects contaminated with bodily fluids, e.g., latex glove or a
hypodermic needle, may spread the disease.
CDC Modelling of Epidemic
1,000,000
Best-case scenario
11,000-27,000 cases through Jan. 20
Worst-case scenario
537,000-1.4 million cases through Jan. 20
0
Sept
Oct
Nov
Dec
Jan
Sept
Oct
Nov
Dec
Jan
Ebola – a Global Crisis needing a global largescale, coordinated humanitarian, social, public
health, and medical response
•
•
•
•
Public Health
Medical Science
Classic public health measures (case
identification, contact tracing and
isolation).
Safe and effective interventions
including behavioral changes, developed
in collaboration with the affected
communities.
Appreciation of the culture of the
societies in the affected countries, and
redevelopment of local trust in
governance.
Coordination and real-time, open
sharing of information across diverse
disciplines and with all the players
involved.
• Development of diagnostic
tools, therapies, and vaccines.
• Performance of clinical
research in the midst of care.
• Development of an accepted,
ethical mechanism for
accelerating development and
testing such interventions in
epidemic situations.
Adapted from Farrar and Piot, NEJM 2014
HIV, SARS, H5N1, MERS, Ebola, ………What next?
• Global vulnerability
remains
– Microbial evolution
– Opportunities for exposure
– Human behaviors
• Most countries lack
adequate public health
infrastructure to cope
• Transdisciplinary science
explains but can it
anticipate?
– Better models of
prediction
– Better tools for
surveillance
– Better modes of response
• Critical role for education
– Future leaders
– Current public
Global Challenges – how to respond
The critical aspects of global health
– interaction with policymakers and professionals in
countries at varying stages of development,
– policy development by national and international
organizations,
– questions of funding and prioritization,
– the social determinants of health,
– education, governance and capacity-building,
all take place within a complex political, moral and
philosophical environment.
What can Research Universities do?
• “………..complex political, moral and philosophical
environment”.
• Foster collaboration between academics at their
own institutions, among them biomedical
scientists, social scientists, engineers,
epidemiologists, anthropologists, economists,
psychologists, political scientists and historians.
– Innovative research
– Transformative education
What can Research Universities do?
• Develop cross-national collaborations
addressing the major global challenges
– Manage creatively the tension created by
individual/institutional recognition
• Develop sustainable public/private
partnerships focused on applying innovative
technologies
What Can Research Universities do?
• Develop ethically strong collaborations with
centers in LMICs
– Develop capacity to allow them to identify
leadership, and research/educational capability
– Promote opportunities for short-term and longterm training
– Provide equity in relationships
– Understand and develop innovative approaches to
brain drain
What Can Research Universities do?
• Provide leadership in their own communities
– Tackle the local dimensions of global problems
• Public health, social determinants of disease, food
security and food quality; waste, water and air quality.
– Educate
• Students, faculty, public
Delivering effective Health
interventions over a life course
Health System designed to deliver effective
clinical and public health interventions
Counselling
and Education
Protective
Clinical
Interventions Interventions
- Diet and
exercise
- New therapies
- Vaccinations
- Dissemination
and
implementation
- Micronutient
supplementation
- Smoking
cessation
- Bednets
Based on Frieden TR. Am J Public Health 2010; 100:590
Enabling
Environment
- Legislation for safe
driving
- Smoking restriction
- Public health
Infrastructure
Socioeconomic
Interventions
- Decrease
poverty
- Employment