Global health in the 21st Century

What’s the challenge?

Can societies strike a balance between combating the dangers of viral outbreaks and pandemics, while maintaining the hopes of eradicating established diseases, such as malaria and HIV/AIDS, which continue to claim millions of lives each year?

Average global life expectancy has increased from 48 years to 68 years since 1950 but many diseases continue to remain a challenge; and in the UK, one in three baby girls born in 2012 will live to be 100 years old. Despite these changes we have seen diseases such malaria, tuberculosis and HIV reach pandemic levels. This 21CC event asks what are the challenges facing global health?

HIV/AIDS

The Human Immunodeficiency Virus (HIV) is a viral infection which targets and weakens the human immune system, allowing the body to be more susceptible to secondary infections and diseases which a healthy individual would be able to fight off. The most advanced stage of HIV is Acquired Immunodeficiency Syndrome (AIDS), which is characterised by the development of infections, certain cancers and other severe clinical manifestations.

There still remains no vaccine and no cure for HIV.

How is HIV transmitted?

HIV can be transmitted via body fluids from an infected person, primarily through unprotected sex with a HIV infected partner, mother to child transmission during pregnancy, childbirth and breast-feeding, the sharing of unsterile needles and transfusions with infected blood products.

Antiretroviral therapy

Standard antiretroviral therapy (ART) consists of the combination of at least three antiretroviral (ARV) drugs to maximally suppress the HIV virus and stop the progression of HIV disease. Huge reductions have been seen in rates of death and suffering when use is made of a potent antiretroviral regimen, particularly in early stages of the disease.

Sources: WHO, hivaware.org.uk

Malaria

Of all the infectious diseases that have plagued human history, Malaria has had the greatest toll on human life. Today it is estimated that over 1 million people die from the disease each year. Malaria, so named by the Romans because they believed it arose from bad (mala) air (aire) floating up from nearby swamps, is in fact caused by a single-celled parasite, Plasmodium, which is transmitted by the bite of the Anopheles mosquito.

Malaria infects people of all age groups; however, those who lack immunity – young children, pregnant women, and people living with HIV/AIDS – are more vulnerable to the disease.

It is believed that malaria existed prior to human life, as mosquitos preserved in Amber from the Pleistocene era (over 3 million years ago), have been found to contain the same parasite. This has allowed the disease to evolve alongside humankind, with the first record of humans being affected being over 3,000 years ago in preserved Egyptian mummies.

Who is at risk?

Prior to the 1930’s malaria was globally widespread, occurring across most of America and Europe. However with extensive eradication programmes, including spraying of DDT, Quinine tablets and land use change, malaria has declined or become locally eradicated in most of the ‘developed’ temperate regions. There still remains approximately half of the world’s population, 3.5 billion people, at risk from Malaria. Today 90% of Malaria cases occur within sub-Saharan Africa, further areas include parts of Asia, Latin America, and to a lesser extent the Middle East and Southern parts of Europe.

The economic cost of Malaria

Malaria causes significant economic impacts, with the gross domestic product (GDP) of some infected nations declining by as much as 1.3% per year. Over the long term, this can have a crippling effect to the economy, with the cumulative losses each year resulting in considerable difference in GDP between countries with, and without Malaria. This leaves little money for prevention and treatment to be provided to the population, creating a downward spiral of poverty and ill-health.

Working to eradicate Malaria

Under the umbrella of the Roll Back Malaria (RBM) Partnership, there has been increased coordination, political attention, and funding, resulting in an unprecedented scale-up of effective interventions, including widespread provisions of insecticide-treated bed nets, insecticides, and the creation of new drug treatments. This has resulted in a 25% decline in global mortality rates since 2000.

Global efforts over the last decades have contributed to dramatic declines in Malaria around the world. Progress is also being made on the scientific front; new tools for controlling the disease are now being tested. By investing in proven malaria-control programs and accelerating promising research, it may be possible to move closer to the long-term goal of eradicating the disease.

Resistance to antimalarial drugs

As both the parasites and mosquitos are able to evolve rapidly, resistance to current malarial drugs is a strong possibility. This has been the case with previous medicines, including chloroquine and sulfadoxine-pyrimethamine (SP) which are both now almost ineffective.

If this were to happen to the current artemisinins drug, the public health consequences could be severe, as no alternative is likely to be available for five years. This makes the provision of insecticides and insecticide-treated bed nets of particular importance, as they will continue to provide an effective response, and together have been shown to reduce the mortality from malaria by half in affected regions.

SARS

SARS stands for Severe Acute Respiratory Syndrome. It is a viral respiratory illness caused by a coronavirus. SARS was first reported in Asia in February 2003. Over the next few months, the illness spread to more than two dozen countries in North America, South America, Europe, and Asia before the SARS global outbreak of 2003 was contained. The disease is an especially challenging threat in a closely interconnected and highly mobile world.

SARS was the first severe and readily transmissible new disease to emerge in the 21st century. Thought many factors about the disease remains poorly understood, SARS has shown a capacity to spread along routes of international air travel.

How did the virus spread in 2003?

The first cases of Severe Acute Respiratory Syndrome (SARS) are now known to have emerged in mid November 2002 in Guangdong Province, in South Eastern China.

SARS was carried out of Guangdong Province on 21 February 2003 by an infected medical doctor who had treated patients in his home town. He brought the virus to the ninth floor of a four-star hotel in Hong Kong. Days later, guests and visitors to the hotel’s ninth floor had seeded outbreaks of cases in the hospital systems of Hong Kong, Vietnam, and Singapore.

At the same time, the disease began spreading around the world along international air travel routes as guests at the hotel flew home to Toronto and elsewhere, and as other medical doctors who had treated the earliest cases in Vietnam and Singapore travelled internationally for medical or other reasons.

How SARS is transmitted

The main way that SARS seems to spread is by close person-to-person contact.  The virus that causes SARS is thought to be transmitted most readily by respiratory droplets (droplet spread) produced when an infected person coughs or sneezes.

Droplet spread can happen when droplets from the cough or sneeze of an infected person are propelled a short distance (generally up to 3 feet) through the air and deposited on the mucous membranes of the mouth, nose, or eyes of persons who are nearby.

The virus also can spread when a person touches a surface or object contaminated with infectious droplets and then touches his or her mouth, nose, or eye(s).  In addition, it is possible that the SARS virus might spread more broadly through the air (airborne spread) or by other ways that are not now known.

The Royal Geographical Society (with IBG) held a panel discussion on 21 March 20123 to discuss this issue.

Hear about this challenge from:

Fergus Walsh, (Chair) BBC Medical Correspondent

Fergus Walsh is the BBC’s Medical Correspondent. He appears mainly for the BBC Six and Ten O’Clock News. He can also be heard on BBC Radio, on the Today programme and Radio 5-Live. He has a blog which aims to give greater detail about some of the news stories he covers and to feature some issues that don’t make it onto bulletins.

Fergus has reported for the BBC from around the world on topics such as stem cells, genetics, obesity, HIV/AIDS, malaria, TB, and swine flu. In 2007 he gave evidence to Parliament during the scrutiny of the Human Tissue and Embryos Bill. He is a firm supporter of the importance of medical volunteers and has taken part in several patient trials. He has had his genes sequenced, his brain, heart and other vital organs scanned for television reports, as well as being injected with a vaccine against avian flu.

In 2009 he appeared as himself in a BBC TV drama about assisted suicide for which Julie Walters won a coveted Emmy award. Fergus has won several awards for his journalism, but none for his acting.

Professor Peter Piot M.D, Director of the London School of Hygiene & Tropical Medicine and Professor of Global Health

Peter Piot MD PhD is the Director of the London School of Hygiene & Tropical Medicine, and Professor of Global Health. In 2009-2010 he was the Director of the Institute for Global Health at Imperial College, London. He was the founding Executive Director of UNAIDS and Under Secretary-General of the United Nations from 1995 until 2008, and was an Associate Director of the Global Programme on AIDS of WHO.
Dr. Piot co-discovered the Ebola virus in Zaire in 1976, and led research on AIDS, women’s health, and public health in Africa.

He was a professor of microbiology at the Institute of Tropical Medicine, Antwerp, the Free University of Brussels, and the University of Nairobi, was a Senior Fellow at the University of Washington, a Scholar in Residence at the Ford Foundation, and a Senior Fellow at the Bill and Melinda Gates Foundation. He held the 2009 chair “Knowledge against poverty” at the College de France in Paris.
He is a member of the Institute of Medicine of the US National Academy of Sciences, of the Académie Nationale de Médicine of France, and of the Royal Academy of Medicine of his native Belgium, and a fellow of the Royal College of Physicians. He is the President of the King Baudouin Foundation, was knighted as a baron in 1995, and published over 500 scientific articles and 16 books.

Professor W Ian Lipkin M.D, John Snow Professor of Epidemiology and Professor of Neurology and Pathology at Columbia University

W. Ian Lipkin, M.D., is the John Snow Professor of Epidemiology and Professor of Neurology and Pathology at Columbia University, Director of the Center for Infection and Immunity at the Northeast Biodefense Center, and member of the WHO Collaborating Centre on Diagnostics, Surveillance and Immunotherapeutics for Emerging Infectious and Zoonotic Diseases.
A graduate of the first class at Sarah Lawrence College that admitted men, he obtained his M.D. at Rush Medical College, did his Medicine Residency at the University of Washington, his Neurology Residency at UCSF, and a Fellowship in Neurovirology and Neuroscience at The Scripps Research Institute. From 1990 through 2001, he was on faculty at the University of California Irvine in the Department of Neurology, Anatomy and Neurobiology and the Department of Microbiology and Molecular Genetics, where he held the Louise Turner Arnold Chair of Neurosciences.

Lipkin’s work is focused on microbial pathogenesis and discovery. His contributions include the first use of purely molecular methods to identify an infectious agent; the implication of West Nile virus as the cause of the encephalitis in North America in 1999; the invention of MassTag PCR and the first panmicrobial microarray; the first use of deep sequencing in pathogen discovery; the discovery of more than 75 viruses including rhinovirus C, Dandenong, and LuJo; and the establishment of the largest prospective birth cohort devoted to investigating gene-environment-timing interactions and biomarker discovery in development and disease.

Dr. Lipkin is Special Advisor to the Minister of Science and Technology of China, and serves on the boards of the Guangzhou Institute for Biomedicine and Health, the Institut Pasteur de Shanghai, the Australian Biosecurity Cooperative Research Centre, and the 454 Life Sciences, Tetragenetics, Prosetta, and Akonni Corporations. His honors include NARSAD Young Investigator, NIH Clinical Investigator Development Award, Pew Scholar in the Biomedical Sciences, Japanese Human Science Foundation Visiting Professor, Columbia College of Physicians and Surgeons Visiting Bruenn Professor, American Society for Microbiology Foundation Lecturer, University of California Irvine Distinguished Lecturer, Ellison Medical Foundation Senior Scholar in Global Infectious Disease, Millennium Commencement Speaker Sarah Lawrence College, Dalldorf Research Physician NYS Department of Health, Fellow of the New York Academy of Sciences, Distinguished Lecturer of the National Center for Infectious Diseases, Honorary and Founding Director Beijing Center for Infectious Diseases, Fellow of the American Academy of Microbiology, John Courage Professor National University of Singapore, and Kinyoun Lecturer National Institutes of Health.

Dr Marie Charles M.D, Founder and CEO of Global Medic Force

Dr. Marie Charles is a medical doctor with a highly distinguished background in business and international relations, and is widely regarded as one of the key innovators in global healthcare. Initially groomed to run one of the world’s largest pharmaceutical companies in Europe; Dr. Charles chose instead to found a series of her own international healthcare enterprises, all of which have gone on to become global leaders in their respective fields, collectively active in over 42 countries. These include Tiger Healthcare Private Equity, which is currently ranked by leading banking institutions as one of the top performing closed private equity funds in the world, and her personal philanthropic organisation Global Medic Force, which as the global leader in clinical skills rapid transfer to emerging nations, transfers over $USD 6.5 billion in first world medical human capital expertise, from more than 1,700 volunteer doctors from 17 Western nations, directly into developing nations across four continents.

There is no government on earth that has such a resource, and as such, she is credited with having personally saved many millions of lives throughout the world through her international healthcare system optimisation programmes, which have also paved the way for developing nations to begin to free themselves from their perpetual dependence on Western charity and aid. Prior to this, Dr. Charles served as COO of IATEC (University of Amsterdam) and as an Adjunct Professor at Columbia University, School of International and Public Affairs. Dr. Charles is a frequent keynote speaker at international healthcare conferences including institutions as diverse as the World Health Organisation, the United Nations, Oxford University, Harvard University, Johns Hopkins Bloomberg School of Public Health, the Aspen Institute, the Geneva Health Forum, the Health Work Force Alliance, Duke University, Renaissance Weekends Group, Brown University, UCSF, UCLA, Columbia University, USAID, The Social Venture Network, Yale University, Brown University, the International AIDS Conference, the Global Health Council etc.

She is also regularly featured in international journals such as The Economist, and has been the subject of international television documentaries including for the PBS network and has extensive international professional medical publications to her name. In recognition of Dr. Charles’ personal achievements and contribution to global healthcare, she has been nominated for numerous international awards and honours, which include amongst others, the “National Medal of Honour” awarded by the President of Vietnam at the opening of the Vietnamese National Assembly in Hanoi and her appointment as a Henry Crown Fellow of the Aspen Institute. Dr. Charles received her MD degree from the Katholieke Universiteit Leuven (Belgium) and her Masters in International Relations (MIA) from Columbia University in New York City. She is fluent in 6 languages.

Further reading

Dealing with drugs: globalisation, funding and research, Geographical magazine, March 2015

Drug-resistant malaria hits Asia, Geographical magazine, February 2015

HIV and AIDS, Dr Ruth Evans for ‘Ask the experts’