Global HealthWhat is it and why the fuss?

C. ‘Sola Olopade, MD, MPHProfessor, BSDClinical Director, Global Health Initiative

Presentation Outline• Define Global Health and importance• Discuss Global Burden of Disease• Discuss poverty and life expectancy• Describe Obama Global Health Initiative

and why US should invest in GH• Discuss work on energy poverty and

implication on health of women and children in Nigeria

Koplan et al: Lancet 2009: 373; 1993-5

What is Global Health ?

• “Area of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide”.

Koplan et al: Lancet 2009: 373; 1993-5

Global Health

• Emphasizes transnational health issues, determinants and solutions

• Involves many disciplines beyond health sciences

• Promotes interdisciplinary collaboration• Calls for actions to influence the

global forces that determine the health of people

Determinants of Global Health• Poverty• Weak governance• Weak infrastructure (education, water and health)• Urbanization• Globalization – int’l travel of people & goods; foods,

tobacco etc.• Cultural/societal norms• Environmental pollution- dumping, indoor pollution• Ecological and climate change

Health Risk Transition from Traditional to Modern Times

Global Health Risks | WHO 2009

Global Burden of DiseaseLeading Causes of Death

Global Burden of Disease 2004 |WHO 2008

Global Burden of DiseaseLeading Causes of Death

Global Burden of Disease 2004. WHO 2008

Distribution of Age of Death and Numbers of Deaths, World

Global Burden of Disease 2004 |WHO 2008

Gender Distribution of Deaths

Global Burden of Disease 2004 | WHO 2008

In Developing Countries, Death takes the Young and in Developed countries, the old

Global Burden of Disease 2004 | WHO 2008

Global Burden of Disease 2004 | WHO 2008

Distribution of Child Deaths for Selected Causes by Region

Leading Causes of Death in Adults

Global Burden of Disease 2004 | WHO 2008

Child Mortality Rate by Disease and Region

Global Health Risks | WHO 2009

Globalization and Health• Improved Global wealth and living standards• Widening gap between the rich and poor

– # of Billionaires owning 4% of world GDP 385– World population living on < $300/year 50%

• Exacerbation of extreme poverty (>25%)

– Condition of life so limited by malnutrition, illiteracy, disease, squalid living conditions, high infant mortality and low life expectancy

– Many in Africa live on $1 a day

Poverty and Life Expectancy

Institute of Medicine

Projected Deaths by Cause for High, Middle and Low Income Countries

Today’s Challenge

UNDP 2009

Global Disparities and Life Expectancy• Sub-Saharan Africa accounts for 25% of

Global burden of disease but has less than 3% of needed workforce

• 95% of global R&D directed at health problems of 5% of global population

• Marked disparity in life expectancy between developed and developing countries

– Canada: 80 years and rising– Sub-Saharan Africa: 49 years and falling– Angola: 38 years, Zimbabwe: 49 years

Brain Drain and Global Disparities in Health and Life

Expectancy

F Mullan: NEJM 2005; 353: 1810-8

Why The US Should Invest in Global Health?

• To protect Americans• Enhance economy• Advance USA international interests

Protection of US Citizens Across the Globe

• Infectious diseases• Biological and chemical terrorism• Unregulated pharmaceuticals• Contaminated foods• Natural disasters• Violence

Why Should We Care?U.S. Air-Travel Related Illnesses in

2009/11• Tuberculosis: 662 reports• Chicken pox and shingles: 518 reports• Measles: 78 reports• Mumps: 56 reports• Whooping cough: 41 reports• Typhoid fever: 19 reports• Lassa fever: 1 report• 15-70% of returning travelers to the USA have

a travel-related illness*

CDC 2009, CDC 2011*

Why The US Should Invest in Global Health?

• To protect Americans• Enhance economy• Advance USA international interests

Enhance U.S. Trade and Economy• Healthier populations abroad constitute

vibrant markets for U.S. goods• Provides employment for U.S. public

health professionals• Market for U.S. technology and industry• Training opportunities in the field for U.S.

health professionals• Benefit to U.S. local economies• Enhances U.S. Diplomacy – “soft power”

Why The US Should Invest in Global Health?

• To protect Americans• Enhance economy• Advance USA international

interests

Advance US Diplomatic, Military and other Interests

• US tradition of humanitarian interests• Integral component of US smart foreign

policy• Enhances US interests

– Global political, military and economic leadership

– Commitment to democratic principles– Foreign policy– Support for human rights– National security efforts

The Global Health Paradox

Targeted resources to disease and population specific programs

“PEPFER”

Inadequate effort made to strengthen health systems

Unintended Consequences

• Weakened health systems• Dysfunctional service delivery• Inequitable financing, especially for the

poor• Quality health care considered a luxury• Millions impoverished by out of pocket

expenses for catastrophic illness

Income Changes With Diagnosis

Antaracian C et al: CUGH 2011

Coping Strategy Utilization

Antaracian C et al: CUGH 2011

The Obama Global Health InitiativeCore Principles

• Health is at the heart of human progress• Focus on women, girls and gender equality• Encourage country ownership and invest in

country-led plans• Build sustainability through health systems

strengthening• Strengthen and leverage multilateral

engagement (Universities, Private sector, NGO)• Promote research and innovation• Engage academic institutions in global health

Gostin and Mok: JAMA2010:304

The Obama Global Health Initiative

• Pledged $63B in global health over 6 years ‘09-’15• Make global health an integral part of government’s

three pillars of foreign policy: Diplomacy, development and defense

• Develop whole-of-government approach• Promote strategic coordination in all departments• Ordered first Diplomacy and Development review by

USAID and Dept of State• Hilary Clinton: State Dept to use GH as “soft power”

Gostin and Mok: JAMA 2010:304

Funmi Olopade, MD Funmi Olopade, MD appointed BSD appointed BSD Associate Associate Dean/Director of GHIDean/Director of GHI

Faculty Steering Faculty Steering CommitteeCommittee

September September 2009 2009

Official Official Launch/GlobaLaunch/Global Health l Health Scholars Scholars TrackTrack

March 2010March 2010

Kenneth Polonsky, Kenneth Polonsky, MD appointed BSD MD appointed BSD Dean, and UC VPDean, and UC VP

September 2010September 2010

Strategic Strategic PlanningPlanning

July 2008July 2008

GHI Evolution at University of Chicago

Leveraging our Strengths

• Environment, Health and Vulnerable Populations

• Health Systems Development and Urban Health

• Genomics and Chronic Non-Communicable Diseases

• Maternal and Child Health• Global Health Ethics as a cross-cutting

theme

Energy PovertyImplications for the Lung Health of Women and Children

Energy Poverty in Developing Countries

UNDP/ WHO November 2009

Lack of Electricity in Developing Countries Lack of Electricity in LDC and SSA

UNDP/WHO November 2009

Distribution of People Relying on Solid Fuels for Cooking in Developing Regions

Commonly Used Traditional Biomass Fuel

Bangladesh 2008: Courtesy Faruque Pravez

Bangladesh 2009

Deaths and DALY’s Attributable to 5 Major Environmental Risks

Global Health Risks | WHO 2009

•Why is exposure to IAP so dangerous to women and young children?

Mother-Child Exposure to Biomass Smoke in Nigeria

Exposure to Biomass Smoke in Bangladesh

Scope of the Problem

• More than 3 billion people cook with biomass fuels– More than 75% of Asia – 50–75% in South America and Africa

• Cooking and heating with biomass fuel is the largest traditional source of indoor air pollution (IAP)

• 3 billion women and young children have the highest burden of exposure to IAP

• IAP accounts for 2.7% of the global burden of disease and is a major contributor to global health disparities

• IAP is major contributor to environmental degradation and climate change

Anderson et al., 2005; McCracken et al., 2007

Health Effects of IAP from Solid Fuels

• Causes 2.2–2.5 million deaths /year– 99% of deaths occur in developing countries– 19 – 21% of Acute respiratory infection (ARI) – 22% of Chronic Obstructive Pulmonary Disease– 1.5% of lung cancers

• Majority of deaths occur from pneumonia in children under five years of age

• Over 30% of IAP-related mortality burden is in Africa and South/Southeast Asia

Zhang and Smith, 2007

Specific Aims• Investigate levels of indoor air pollution

created by burning biomass fuels through monitoring CO and PM2.5

• Determine exposure-related symptoms in mother-child pairs in each household

• Determine effect of exposure on lung function• Investigate impact of distribution of low

emission stoves on indoor air quality, symptoms and lung function

The Rural Communities in Nigeria

Results

Characteristics of Participants

Age, years ±SD

Mothers 41 ±11.7

Children 13 ± 2.5

Education

No formal education 50 (43.7%)

Primary/Middle School 44 (37.3%)

Cooking fuel

Firewood 93 (78.8%)

Charcoal 34 (28.8%)

Kerosene 29 (24.5%)

Frequency of Reported Symptoms in Children exposed to IAP

Frequency of Reported Symptoms in Mothers exposed to IAP

Pre-intervention Indoor PM2.5 Concentration

Pre-intervention Indoor CO Concentration

Pulmonary Function in Mothers and Children Exposed to IAP

Pre-InterventionMother† (N=59)

Normal 35 (59.3%)

Mild Obstruction 5 (8.5%)

Moderate obstruction 18 (30.5%)

Restrictive pattern 1 ( 1.7%)

Child‡ (N=59)

Normal 29 (49.1%)

Mild Obstruction 12 (20.3%)

Moderate obstruction 14 (23.7%)

Restrictive pattern 4 (6.8%)

†ATS guidelines‡ATS/ERS guidelines

Humanitarian Award Chest Foundation

Efficient Stoves Distribution

Pre and Post Intervention PM2.5

Levels

Pre and Post Intervention CO Levels

Frequency of Reported Symptoms in Children 1 year Post Intervention

Frequency of Reported Symptoms in Mothers 1 year Post-Intervention

Conclusions• PM 2.5 and CO are major pollutants from firewood• Women and children are at greatest risk of IAP• IAP is associated with obstructive pulmonary disease• Distribution of efficient stoves is an important stop

gap measure in protecting the health of women and children

• Community engagement and partnership in research is essential for influencing research to policy translation and behavior change

• Preventing IAP related mortality has the potential to improve the likelihood of achievement of MDG 4 and 5 goals

Strategies for the Future

• Commitment to distribute 100 Million stoves to vulnerable populations

• Develop cleaner stoves and fuel• Create entrepreneurship around initiative to

empower women• Halt environmental degradation and

Climate change

Sunrise at Serengeti National Park, Tanzania, November 2009

Exposure To Biomass Fuel and Health Risks

Risks to Women•Chronic obstructive pulmonary disease (COPD)•Lung Cancer•Blindness•Emphysema•Adverse pregnancy outcomes

Risks to Children•Acute upper respiratory infection (ARI)•Asthma•Pneumonia•Early Infant Death

Nigeria 2008: Courtesy Femi Oluwole

Millennium Development Goals 2000

• Bolstering human capital– Nutrition– Healthcare– Education

• Improving infrastructure– Safe drinking water– Energy– Communication and preservation of the environment

• Increase social, economic and social rights– Empowering women– Reducing violence– Increasing security of property rights

Millennium Development Goals2000-2015

• 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 Tuberculosis• 7. Ensure environmental sustainability• 8. Develop a Global partnership for development

What’s Good about the MDG Goals?

• Unanimous acknowledgment of problem• Setting goals• Expanded donor base• Collaborative approach• Commitment to help developing countries

What Progress has been Made?

• Primary school enrolment has increased • Child health improved and mortality reduced• Access to clean water improved• Malaria control better with use of treated nets• Maternal to child HIV transmission reduced• Hunger and malnutrition rose from 2007-2009• Reduction in extreme poverty eradication mostly

driven by China with no change in SSA• New HIV cases outnumber those on treatment• Slow progress on gender equality, maternal

mortality reduction and reproductive health

United Nations General Assembly Document Sept 17, 2010

What Are the Challenges?

• No sustainability plans beyond 2015• Choice of goals? CNCD not a focus despite 2030

projections• Lack of measurement tools for some of the goals• Dependence on household surveys for outcome

monitoring• Lack of reliable records in countries with most

mortality in HIV/AIDS, Malaria and TB• Fragile or non-existent health care infrastructure• Limited research infrastructure to participate in

clinical trials

Globalization of Health Risks

• Unhealthy Dietary habits–fast foods• Reduced physical activity• Explosive growth of tobacco companies in

developing countries• Increased tobacco consumption• Ease of transcontinental travel• Globalization of food market

What Are the Challenges?

• No sustainability plans beyond 2015• Choice of goals? CNCD not a focus despite 2030

projections• Lack of measurement tools for some of the goals• Dependence on household surveys for outcome

monitoring• Lack of reliable records in countries with most

mortality in HIV/AIDS, Malaria and TB• Fragile or non-existent health care infrastructure• Limited research infrastructure to participate in

clinical trials

The Unavoidable

Haiti Earthquake 2010

http://www.flickr.com/photos/unitednationsdevelopmentprogramme/4275397038/

The Unavoidable

Tent City, Haiti 2010

The Unavoidable

Pakistan Flood 2010 http://stockmarkettoday.in/2010/07/31/pakistan-flood-400-dead-rescue-ops-on/

Beyond PEPFARWhere are the Opportunities?

• USAID strategic change to develop partnership with Universities

• Funding training programs (D43, R25, R01) in partnership with developing countries

• Medical Education Planning Initiative– $130 Million USA/Developing Country Medical School

• Grand challenges – Bill Gates– Canada-$300 Million

Brain Drain and Global Disparities in Health and Life

Expectancy

F Mullan: NEJM 2005; 353: 1810-8

Brain Drain and Global Disparities in Health and Life

Expectancy

F Mullan: NEJM 2005; 353: 1810-8

Global Lack of Access to Electricity 2008

UNDP/ WHO November 2009