Professor Karen Day: Global health policy and malaria from 1980 to the present
Professor Karen Day, Dean of Science and Professor of Population Science at the University of Melbourne, recently gave a speech to Newman College about global health policy over the past 40 years. She described some remarkable successes in improving global health through initiatives like the Millenium Development Goals, and also about the challenge of maintaining this momentum in the current global political climate. Below is a transcript of her speech.
In my lecture this evening I will discuss three major changes in global health policy over the past 30 years and the impact of key players: The United Nations, the World Health Organisation, the rise of Non-Governmental Organisations, Bill Gates and Donald Trump. I will use malaria as a case study to review the impact of these three policy changes.
To set the scene for this lecture let me tell you about my career, as being a scientist has undoubtedly influenced my thinking about my practice in global health.
As I student I walked across the road to the Walter and Eliza hall Institute to do an honour’s project. Little did I know that this short journey across Royal Parade would change my life. I became the first student in a Tropical Medicine Research Programme set up by Sir Gustav Nossal after he returned from a sabbatical at the World Health Organisation, where he met the Adetokunbo Lucas , Director of the newly formed Tropical Diseases Research Program (TDR) at the World Health Organisation. Adidi Lucas encouraged him to get his researchers engaged with applying modern molecular technologies to study “great neglected diseases” such as malaria.
I trained in this Program as a basic scientist, becoming a microbiologist. Later I trained in population science in Papua New Guinea and Oxford, becoming an epidemiologist (someone who studies patterns of infection and disease in communities).
My career spanned the various aspects of scientific endeavour in global health:
- I created technical solutions to problems of global infectious disease in the lab by inventing drugs, vaccines and diagnostic tests for parasitic diseases like malaria and worm infections
- I did operational research to evaluate these technical solutions
- I implemented and evaluated control programs on a national and global scale
Having been a global health practitioner for over 30 years, I have seen enormous changes in this field, but three key policy milestones in my view changed the face of global health during my career by leading to a greater flow of both dollars and interest.
Policy milestones in global health
- Health as part of development
Instead of development being seen as just building roads, dams and bridges, an economic value was placed on a having a healthy community. This was done with health metrics, which were being used to measure the economic impact of disease. By measuring the global burden of disease with health economic metrics, in particular the disability adjusted life year, or DALY , and using big data from WHO databases, Chris Murray (a geographer form Oxford and Harvard) and Alan Lopez (a demographer from Australia working at WHO in Geneva) created a framework to show which diseases had the greatest economic impact and which countries had the greatest burden of disease. For the first time, chronic diseases causing morbidity that reduced lifelong productivity of an individual were on the radar. Previously, only mortality (death) due to disease was counted, and as this largely occurred in young children the burden of disease was restricted to childhood infectious diseases such as pneumonia and malaria.
As a consequence, development dollars came to health.
- HIV pandemic led the world to think about global rather than international health
The spread of the HIV viruses from West Africa to the rest of the world because of globalisation changed the view of global health. We moved from talking about international health to global health in the 1990s at the height of the HIV pandemic, when it became clear that microbes did not recognise national boundaries.
Here it’s worth pointing out the difference between global and international health , and indeed public health.
- Global Health – an area for study, research, and practice that places a priority on improving health and achieving health equity for all people worldwide
- International Health – focuses on the health issues, especially infectious diseases, and maternal and child health in low-income countries.
- Public Health – health of communities
Greater interest in global health compared to international health again led to a greater flow of dollars to global health in both R&D and program implementation
- United Nations Millennium Development Goals (MDGs)
In 2000, this policy initiative set specific targets, including health targets, to be achieved by 2015. There were eight goals, with four directly related to global health (in bold):
- To eradicate extreme poverty and hunger
- To achieve universal primary education
- To promote gender equality
- To reduce child mortality
- To improve maternal health
- To combat HIV/AIDS, malaria, and other diseases
- To ensure environmental sustainability
- To develop a global partnership for development
The UN describes the MDGs as “a powerful framework for tackling poverty [that] have galvanized national, regional and global efforts towards promoting human development”.
African countries were identified as having shown “considerable commitment in the pursuit of the Goals and have pursued bold and innovative strategies in order to scale up progress towards their achievement”.
I had the opportunity to be a global health researcher working in New York post 9/11. This was a time when global efforts were focussed on achieving the millennium development goals by 2015. I saw the UN, international and national Government agencies, NGOs, wealthy donors, and rock stars like Bono and Bob Geldof stepping up to raise the funds to achieve the MDGs, in service of the world’s poorest citizens.
Post 9/11 young Americans were hungry to know more about global health, and many global health education programs were set up around the country.
Four of the MDGs directly impacted health. Considerable success was achieved. Here I quote from the Millennium Development Goals Report 2015:
Goal 1: Globally, the number of people living in extreme poverty has declined by more than half, falling from 1.9 billion in 1990 to 836 million in 2015. The proportion of undernourished people in the developing regions has fallen by almost half since 1990, from 23.3 per cent in 1990–1992 to 12.9 per cent in 2014–2016.
Goal 4: The global under-five mortality rate has declined by more than half, dropping from 90 to 43 deaths per 1,000 live births between 1990 and 2015.
Goal 5: Since 1990, the maternal mortality ratio has declined by 45 per cent worldwide, and most of the reduction has occurred since 2000. In Southern Asia, the maternal mortality ratio declined by 64 per cent between 1990 and 2013, and in sub-Saharan Africa it fell by 49 per cent.
Goal 6: By June 2014, 13.6 million people living with HIV were receiving antiretroviral therapy (ART) globally, an immense increase from just 800,000 in 2003. ART averted 7.6 million deaths from AIDS between 1995 and 2013.
Over 6.2 million malaria deaths have been averted between 2000 and 2015, primarily of children under five years of age in sub-Saharan Africa. The global malaria incidence rate has fallen by an estimated 37 per cent and the mortality rate by 58 per cent.
Between 2000 and 2013, tuberculosis prevention, diagnosis and treatment interventions saved an estimated 37 million lives. The tuberculosis mortality rate fell by 45 per cent and the prevalence rate by 41 per cent between 1990 and 2013.
Case Study – Malaria
I will now talk specifically on malaria, a disease that has been the focus of much of my research. By the 1980s we were looking at rising death rates due to malaria, with 2 million children dying each year, mainly in Africa. There was increasing prevalence in areas where malaria was previously under control, due to the failure of the only cheap, safe antimalarial drug, chloroquine. The global spread of antimalarial drug resistance was left unchecked and mosquito control had failed because of insecticide resistance.
The absence of any effective tools to control malaria led to a lack of interest on the part of donors to tackle malaria.
Funding was desperately needed to discover new drugs, diagnostics, vaccines and methods of vector control. This funding came from a variety of sources but particularly the Rockefeller Foundation and the Wellcome Trust as well as national research funding, particularly in the USA and UK.
Over the past 20 years, global efforts against malaria have been greatly strengthened and guided by three significant events. First was the discovery and availability of new technologies and interventions. Prominent among these were Artemisinin Combination Therapy (ACTs), Rapid Diagnostic Tests (RDTs), and Insecticide-Treated Nets (ITNs).
A second watershed event was increased funding, initially through the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) in 2002, which rapidly raised international investments in malaria control from fewer than US$100 million per year in 2000 to just under US$2 billion per year in 2012, with major contributions from the US government’s President’s Malaria Initiative (PMI) established by President George W. Bush, and the World Bank’s Malaria Control Booster Programme, as well as other important donors.
Many consider a third strategic tipping point to be the call by Bill and Melinda Gates in October 2007 for a major global malaria eradication program. This combination of new tools, new financing mechanisms, and renewed commitment to the ambitious vision of malaria eradication has enabled comprehensive roll-out of these tools.
Overall, considerable success has been achieved, but let’s look to the future.
Good news – the Sustainable Development Goals
The Sustainable Development Goals build on the successes of the Millennium Development Goals. The Global Goals are supported by the United Nations Development Programme, who describe it thus:
The Sustainable Development Goals (SDGs), otherwise known as the Global Goals, are a universal call to action to end poverty, protect the planet and ensure that all people enjoy peace and prosperity.
These 17 Goals build on the successes of the Millennium Development Goals, while including new areas such as climate change, economic inequality, innovation, sustainable consumption, peace and justice, among other priorities. The goals are interconnected – often the key to success on one will involve tackling issues more commonly associated with another.
The SDGs work in the spirit of partnership and pragmatism to make the right choices now to improve life, in a sustainable way, for future generations. They provide clear guidelines and targets for all countries to adopt in accordance with their own priorities and the environmental challenges of the world at large. The SDGs are an inclusive agenda. They tackle the root causes of poverty and unite us together to make a positive change for both people and planet … The SDGs provide us with a common plan and agenda to tackle some of the pressing challenges facing our world such as poverty, climate change and conflict.
Bad news – the rise in anti-globalisation
Countering the optimism of the SGD’s, current political events speak to a rise in anti-globalisation. Brexit, closing borders in Europe and Trump’s America are all examples of rising nationalism. We see the same trends here in Australia.
A recent report from National Public Radio (NPR) in the US dissected President Trump’s proposed federal budget, highlighting his plans to spend far less on global health and development than previous presidents. The article states:
One of the five bullet points in the introduction to the document "America First: A Budget Blueprint to Make America Great Again" states that the fiscal plan "puts America first by keeping more of America's hard-earned tax dollars here at home."
To accomplish that goal, the administration proposes slashing the appropriation for the State Department and USAID by $10 billion or roughly 28 percent and cutting Treasury International Programs by nearly a billion dollars, almost a 35 percent drop from last year.
The budget proposal states that the cuts to foreign aid "free up funding for critical priorities here at home."
NPR identified proposed cuts to many organisations and programs that are crucial to improving global health and development opportunities, including:
- United Nations and UN affiliates
- Banks that finance global development, including the World Bank, which would lose $650 million over the next 3 years
- The Global Climate Change Initiative (GCCI), which funds climate change initiatives in developing countries
- Many agencies that specifically address global issues will receive no federal funding in President Trump’s budget, including:
- The Woodrow Wilson Center for International Scholars
- The African Development Foundation
- The Fogarty International Center at the National Institutes of Health (devoted to global health research and training)
- The Inter-American Foundation
- The U.S. Trade and Development Agency
- The U.S. Institute of Peace
- The East-West Center
Fortunately, several key initiatives in global health have been spared by the budget cuts, including a program – Gavi, the Vaccine Alliance – that supports vaccination programs in the developing world, and the hugely successful anti-AIDS program, PEPFAR.
Extraordinary gains have been made in global health since the 1990s, as a result of good policies, technical solutions developed by the scientific community and engagement with donors, as well as public/private partnerships. The success of the Millennium Development Goals policy speaks to the need for good governance as it is the countries with effective governments and democracy who made the greatest gains by 2015. However, we are at risk of going backwards in the current climate of anti-globalisation and the rise of nationalism.
Speaking now to those of you about to embark on your careers: My mentor says that we decide early on in life if we want to do well or do good. Bill Gates and Warren Buffet have shown that you can do both.
If you think of a career in global health it is never an easy road – there is never enough funding to do all that is necessary. You need to be a glass is half full person and to be resilient. It is like climbing a mountain – with rocks falling and setting you back. You have to be determined to achieve your goal and get to the top.
You face a choice as I did; to “treat the individual”, and become a nurse, doctor or other health care worker, or to work in public health and preventative medicine, and to “treat the population”.
To conclude, as global citizens I call on you all to support the Sustainable Development Goals.