In a new feature for Now@NEJM, we ask the authors of the new Global Health review article series — all with different backgrounds, experiences, and perspectives — the same set of questions.
Answers from Anthony J. McMichael, M.B., B.S., Ph.D., of the National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia.
Dr. McMichael is author of the April 4 article, “Globalization, Climate Change, and Human Health“
What do you regard as the most significant success in global health within the past decade?
On a mission-accomplished basis, polio eradication almost wins the accolade. However, on the basis of long-term health-related investments, there has been an important increase in the recognition and development of much better and wider-spread population health infrastructure and integrative public health thinking. The limits of enhanced clinical biotechnology and specialised medical/hospital treatments and salvage, provided in settings of poverty, under-education, and fundamental deficiencies in nutrition, water quality and general hygiene, have become increasingly acknowledged (often despite commercial interests).
The difficulties in achieving the UN Millennium Development Goals in many regions have underscored the need to integrate environmental quality and sustainability into the programs to reduce poverty, hunger, maternal and child mortality, and major infections — and to not treat “the environment” as an add-on task. Meanwhile, the work of WHO’s Commission on the Social Determinants of Health has underscored the need to think and act in relation to the pervasive underlying social, cultural, and economic forces and influences that impede good health and its equal sharing.
The determinants of social and environmental conditions lie predominantly outside the health sector. This is now being recognised in policies of the World Bank and the Asian Development Bank; both are looking beyond the constricting walls of neoclassical economics and seeing that population wellbeing, health, and survival are at risk from unbalanced GDP-enhancing development strategies. These broadened and ecologically-framed concepts have enriched primary health care and the general upgrading of health services in many lower-income countries. At last we are starting to think and act holistically. That should yield a triumph of enlightenment.
In the coming decade, which arena of global health do you feel warrants increased attention and awareness?
As my recent article in the NEJM (April 4) argues, we now face a new and unfamiliar generation of large-scale environmental risks, of our own making. These are fundamentally different in nature from the conventional environmental concerns over local chemical, physical, and radiation hazards, including urban air pollution. The new risks arise from systemic disruptions to the planet’s biophysical operating system — its climate, elemental cycles, soil replenishment, ocean chemistry, stock of biodiversity, and others. These are a consequence of excessive and energy-intensive economic activity in combination with a growing world population. Both components make governments uneasy (and the clearly unsustainable continuing growth of human numbers has, as a topic, been shamefully off-limits for political, religious and moral reasons for the past two decades).
These new human-induced global environmental changes are disrupting the foundations of population health and survival – food supplies, water flows, soil quality, the resilience that biodiversity affords us, and a liveable climate. The consequences for population health are much more serious and widespread than any other foreseeable global threat to health (except perhaps for an unprecedentedly catastrophic pandemic).
If we could bring this topic onto the international political radar screen, and raise awareness of the risks to population health and survival, this could achieve considerable and much-needed acceleration and strengthening of national and international policies to act — to slow and arrest climate change and its syndromic bed-fellows and commit seriously to transforming our ways of living that are healthy, equitable, rich in opportunities, and sustainable.
We now face a new and unfamiliar generation of large-scale environmental risks, of our own making.
This is a key, urgent, health-securing task for the coming decade.
How can we best harness the revolution in IT to improve health outcomes in the developing world?
In public health and preventive medicine, information and public understanding is vital. (This applies too to networking between medical practitioner networks and information sources.) In semi-literate (e.g. poor rural) populations in lower-income countries, village radios and TVs are a precious source of otherwise unavailable information. The dissemination of mobile phone facilities and internet connectivity will greatly enhance this resource.
The IT revolution also enables quick access to open access publishing. Hopefully this facility will also increase and become more user-friendly (and without the infernal need to store/remember too many passwords!).
When American physicians think of global health, many are dissuaded from a global health career because they cannot spend a majority of their time abroad. What are other ways for physicians to contribute to this discipline?
Many useful contributions can be made without relocating abroad. Traditional “international health,” often conducted on a bilateral basis, has typically required travelling to the partner country and spending time specialising in that particular research topic or implementation program.
“Global health” is broader in scope and more systemic, and needs diverse inputs from interested and capable persons able to participate in developing new understanding, drafting strategy documents for international agencies and NGOs, and reviewing draft reports. (For example, working from my home base in Canberra, Australia, I have recently reviewed drafts of two new World Bank reports on the risks posed by a possible Plus 4C World by 2100. I have also just completed chairing a 4-year project for the Tropical Diseases Research Program (WHO) resulting in the recently-published report [WHO Technical Report Series, No. 976, 2013] on the need for and methods of integrating understanding and activity in the environmental, agricultural, and social sectors in relation to the emergence and spread of infectious diseases. That latter task has involved four one-week overseas meetings with the drafting team in four years.)
Otherwise, American physicians, as for all other physicians, can engage in good progressive citizenry that supports pre-existing international campaigns — for example, campaigns to constrain the marginalisation of health considerations by the World Trade Organization, to rein in population growth and to support family planning facilities, to curb the emissions of greenhouse gases, and to ensure that important medications are affordably available to low-income populations.