An introduction to key challenges and concepts important to understanding the current status and determinants of global health.
Interview with Dr. Michael Merson, Part 1
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The Challenges of Global Health
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Basic Concepts in Global Health
This module covers some of the most important basic concept that you need to know to understand global health. In particular we will focus on key terminology and the determinants underlying health and disease.
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Dr. David BoydHymowitz Family Professor of the Practice of Global Health
Duke Global Health Institute
Hi class, I'm here today with Dr. Michael Merson who is the director of
the Duke Global Health Institute and also a professor in the medical school here
at Duke and someone whom I am pleased to call my friend.
So.
Thank you so much, Mike, for being here.
>> Great to be here.
>> And you know, Dr. Merson's work is
spanned over three decades of being a leader in global health.
After medical school, I know you worked for the CDC, the center for
disease control, then moved on to the WHO.
You directed the diarrheal diseases program, then the acute
respiratory infections program, all things we've talked about in, in class.
You also were the director of the WHO's global program on AIDS.
I know you spearheaded that,
program that was literally working all over the world at a very tough time.
>> Right. >> As we both remember,
remember those times very well.
You have worked on health systems' strengthening and
training scientists, all over the world, from Russia to South Africa.
You have advised organizations ranging from U,
UNAs to the WHO to the Global Fund.
We've actually just finished lectures on all of these organizations so
the students are familiar with them.
And you're also, I'm happy to say, on the commission for
smart global health problems at CASIS, which is an organization we've
asked the students to look into as well as you all try to find
evidence based and pop, good pop, creating good, good policy for global health.
So I think the reason, one of the reasons I wanted you to, come today, and
we talked a little bit, is because I was thinking, you know,
I really want the students to understand something about challenges of
global health, how global health has changed, and.
Where we're going to see global health institutions moving or need to do in
the future, and I can not think of anyone who knows more about this than you.
So I'm going to ask you a few questions-
>> Sure. >> We'll have a conversation.
And if I say anything badly you can just slap me off camera at our meeting later,
how's that?
>> How's that?
>> [LAUGH] So you know, Mike, as I said earlier,
you've been involved in global health for over, three decades and
what are the most significant changes you've seen during that time?
>> Well, if you looked at global health 30 years ago, and
today, the most striking change is the word global health.
>> Uh-huh.
>> 30 years ago we would've called this field probably international health.
Which would have been, meaning the rich countries, the so
called countries of the North, helping poor countries, you know?
Union flow, the, the idea being that their health problems were different and
that the poorer countries still had mostly communicable diseases and
needed so called foreign assistance.
Today we use the word global health because the problems
are increasingly the same wherever you live in the world and
the flow of information and experience is by direction.
We learn from each other.
And our innovation in one country in the world, and
in Africa can be applicable in the US and vice versa.
>> Mm-hm.
>> Along with that, of course, means that we're seeing more chronic diseases.
>> Sure.
>> As the major causes of morbidity and mortality around the world.
We still have an unfinished agenda.
>> Sure.
>> Probably what you've talked about in the class in terms of child mortality,
paternal mortality.
That agenda hopefully is becoming less and less of an agenda.
And more today around the world we're dealing with heart disease, cancer-
>> Mm-hm.
>> Diabetes, mental health issues, wherever we are.
Of course, we can't forget though that pandemics are still with us.
>> Of course.
>> And we have now Ebola as our major, major pan, pandemic we're facing
we had some big scares with Avian Flu, with MERS, with SARS.
>> Yes.
>> But we now have a tough one with Ebola.
I think what's changed is we now have
many years of experience of dealing with these pandemics.
>> Mm-hm.
>> And we've learned more about how to cope with them.
The other change I would mention is the funding.
>> Uh-huh.
>> Certainly if you compare it to where we were 30, even 20 years ago.
>> Mm-hm.
>> We were lucky if there were hundreds of thousands of dollars
involved in supporting global efforts in health.
Today that number's close to 30 billion, and we have totally new, new players.
We have the Global Fund.
>> Sure.
>> Against HTP and malaria.
We have the World Bank, we have HEPFAR, and of course we have some of
the bilaterals, particularly the United Kingdom is still very active in health.
And then of course the Gates Foundation, which is a major funder,
primarily of global health research.
So it's a very exciting time, as exemplified by the growing
number of students going into global health, undergraduate, graduate, and-
>> That's you guys.
>> The tremendous number of faculty.
>> Sure. >> Who are pursuing careers in
global health.
So, big changes, very exciting time and,
it's, it's, it's been wonderful to be part of that.
>> Sure. No.
And even in our institute, we just had a faculty meeting this morning.
And to look around that our faculty from medicine to engineering,
cultural anthropology.
>> Right so that's, that's another change.
>> Yeah.
>> I would say that if you went back 30 years ago, you had a meeting of
so-called international health and global health, you would've mostly had doctors.
>> Uh-huh.
>> From medical schools and some public trust schools.
Today look at our institute and it's only about 40% physicians.
>> Sure.
>> And you have the participation from every school on campus.
And if you look at our students in our global health major undergraduate major,
and all of them have a second major.
>> Sure.
>> And sure, some are in the biological sciences, but
many of them are in the social sciences or even the humanities.
So I think what global health has really shown is how we value looking
at problems from an interdisciplinary or multi-disciplinary lens can be very,
very helpful in addressing the major challenges we face today.
>> Sure. Especially if we're, you know,
talking about bio-psycho social determinants,
than solutions aren't just going to be biological.
>> Correct.
>> I actually have we have one major who's in theatre studies.
>> Wow. >> And she's in theatre studies
because she's realized through reading and studying health promotion.
That theater, and getting kids involved in theater, may actually be one of,
one of the important ways to change behavior and promote good health.
>> I saw that, I saw that a lot in the, early in the 1990s with AIDS.
>> Uh-huh.
>> And there was so much stigma around AIDS.
It still is today, but in those days there was a lot of stigma.
Remember, we didn't have any retroviral drugs.
>> Sure. >> So
being HIV infected was presumed to be a death sentence.
>> Sure. >> So there was a lot of stigma and
discrimination and very often, inability to talk about HIV.
>> Sure.
And one way that was found you could do it was through theater.
>> Really. >> And you could use the theater not
only to talk about AIDS but also on how to prevent HIV infection.
Talk about sex, drugs-
>> Mm-hm. >> And iss, issues that are,
were not easy to talk about in, in the average workplace-
>> I see. >> Or in the home.
So I saw a lot of the use theater in those days.
>> Sure as well, you know,
those those days remind me, you know, I was thinking about the early 90s.
That during that time period with aids and you were the program director.
The WHO and you received a lot of acclaim for your leadership, and deservedly so,
during that difficult time where you and I both remember no doubt, friends who were-
>> Sure. >> Were like walking, walking skeletons.
>> Sure. >> We didn't have, you know,
we didn't have ART then.
Do you think that HIV AIDS changed the way we understand and
appreciate the importance of global health?
>> In many ways.
I think first, it was truly a global pandemic and besides maybe flu in 1917-
>> Sure. >> We hadn't had a global pandemic,.
>> Right. >> And we we didn't have a pandemic that.
>> Touch every country.
>> Of course.
>> And I think it, it made us look at a disease problem globally.
>> Uh-huh.
>> I think that's one thing that it brought us,
the global dimension to global.
>> Right.
And interdependence.
>> And the interdependence
>> Yes >> And, and
the fact that the spread even was quickly, from country to country.
>> Sure. >> Through, through many different routes.
>> Right.
>> I think a second change that AIDS brought is a lot of resources.
>> Mm-hm.
>> The Global Fund the-
>> Sure, right. >> Involvement of the World Bank.
PEPFAR, which was the largest, at the time, the lar, by far, the largest
commitment of the US government in, in health globally, was an AIDS issue.
The fact that AIDS was talked about at the security council.
>> right. >> The fact that there was a UN special,
UN general assembly special session on AIDS.
First time the security council,
first time the UN, General Assembly, talked about a health problem.
They're thinking of doing this now again for Ebola.
>> yes. >> But, but that was the first time.
So certainly, resources, political, the,
the value of political commitment, that will certainly show them the needs.
And that increase in resources helped to
develop the larger field of global >> Uh-huh.
Right.
>> And another very important contribution from AIDS was the whole area of health and
human rights.
>> Mm-hm.
>> Many people don't know, or don't remember when, in the late 90s,
1990s, it cost as much as $15,000 a year to treat an AIDS patient.
>> Yes.
>> With a new drugs.
Today it's less than $100.
>> RIght. >> And farmers still making a profit.
>> Yes. >> So you, you can see that,
that change was dramatic and it came about very much to activism.
>> Right, absolutely.
>> Or often by people with the disease.
>> Yes. >> And invoking the,
the issue of human rights.
>> Sure. >> And access to care.
And that would be another area where AIDS has really played a role.
>> Mm-hm. >> And that's in
the access to care movement.
>> Uh-huh. >> We started with being concerned,
rightfully, about access to care and antiretroviral drugs.
>> Mm-hm, sure.
>> And now we are concerned about access.
Supposed to care all drugs.
>> Of course.
>> and, you know,
a lot of the drugs that treat chronic diseases are quite expensive.
>> Sure, absolutely.
>> And the same issues are coming up about affordability and
access, to the most critical drugs for prevention and treatment.
>> Sure. >> So.
AIDS was certainly a lightning rod,
certainly a major stimulus to the global health field.
And I think it's unfortunate that so many people died,
still died from AIDS, but, and and that I guess is the last point I would make, and
that is that AIDS has shown us the value of research.
>> Yes, indeed.
>> and, and, rapidly done targeted research, against the disease.
>> Absolutely.
>> Look how fast the anti-retroviral drugs have been, were developed.
Now we now that even the drugs, if given early,
can be, to be, play a role in prevention.
>> Sure.
>> So that, it seemed at the time that it was taking forever, but if you
take on the you know, the view from 30,000 feet, these discoveries were pretty fast.
>> Absolutely.
And I think we all remember the, once,
once the ARVs became available, the rapid change in people who have been sick.
>> Right, they got a dramatic change.
>> Just dramatic change.
>> And, and the stigma decreased.
>> Absolutely.
>> Discrimination decreased.
>> Right.
>> And, I think the, hope that someday there would be a cure, still there.
>> Sure.
>> And maybe a vaccine, tougher, tougher road ahead.
>> Sure, yeah, yeah.
>> well, will come.
>> Absolutely.
And now with I, I think those are great points and I also am really
interested in something that you, you know, that you said about research.
Because so many different actors who are involved in global health.
Now you have, you,
you're long involved in the positions of leadership variety of institutions.
And new governmental institutions in particular, educational institutions,
philanthropic institutions.
It's really giving you,
I think, the unique insight into how global health factors work.
You know, when, when I first teach global health courses,
students always want to know how the global health system works.
>> Mm-hm. >> And I say there's not, really a system.
There's a landscape of actors.
>> Right. >> Sometimes collaborating,
sometimes competing, sometimes working in, in silos.
It's, it's complex, that landscape.
Now what are, in your opinion, you know, with all of your experience,
what do you think are the key challenges that global health
actors face today in improving global health [INAUDIBLE]?
It's an interesting question and not a simple answer.
>> No.
>> First who are the actors?
Well, of course governments.
I mean they are responsible for public policies-
>> Sure. >> Around the world.
The rich and poor.
>> Of course.
>> And we're seeing in the greater wealth of the middle income countries,
particularly the BRICS countries-
>> Mm-hm.
That middle income countries, we so called middle income countries.
>> Right. >> These Brazil, Russia, India, China,
South Africa.
At different times, but all of them soon will become developed countries.
>> Sure, right.
>> And they're already becoming donors.
>> Yes. >> They have their own world bank.
>> Sure.
>> So the acts that we have the country at, there is, and
then we have the UN actors.
And there, last time I counted, there were 16 UN agencies working in health.
>> Yes. >> And people tell me, oh, it's all WHO.
>> No. >> Not at all.
I'll come back to that in a minute.
But, but I think that you have a whole slue of UN
actors with different mandates relating to different ministries in governments.
>> Right, sure.
>> And that would include the world bank.
Then you have other international institutions that have come about,
like like Gaby, the Vexsharie, the Global Fund, UNAs,
although that can be seen, that's more a UN agency.
But, I would say you have these other international institutions like the Gates
foundation, and that leads to the whole foundation world, the biggest one by far,
giving more than three billion dollars a year is the Gates Foundation.
And then of course, you have more and
more corporate the global corporate sectors who are giving to AIDS.
>> Right. >> And now giving to
other diseases beyond [CROSSTALK].
the, the global commodity market today, you can take vaccines, drugs.
>> Mm-hm. >> Prosthetics,
probably close to $4 trillion.
>> That high. Wow. >> So you have a lot of,
a lot of farmer particular, but not only farmer, biotech.
Becoming major actors as well.
>> Sure.
>> So when you have so many actors the obvious question that I get asked.
Who's in charge?
[LAUGH] And the truth is no one's in charge.
>> No one's in charge, right.
>> And that at times is frustrating.
Particularly when you have an epidemic, coming like, you know,
pandemic like Ebola.
>> Sure.
>> But I think we have to be realistic and, and appreciate the health today
touches on so many other aspects of development.
And that you can't expect it to be a silo area.
Many. >> Of course.
>> People see the value of health.
>> Right.
>> And want to be involved in health.
>> Absolutely.
>> The the world has tried to mobilize around certain areas.
The, the best example was the effort in AIDS.
>> Sure. >> But
even in AIDS, you have the global fund, you have UNAIDS,
you have, you have UN agencies on their own, there's no single leader.
>> Of course.
>> So what do we do?
And I, and I think the Ebola situation, again, points out a need to do something.
>> Yes.
>> Here we have a situation with Ebola right now where
people are saying WHO is failing.
WHO should have done this, should have done that.
>> Right. >> Well, the truth is WHO hasn't had
the ability to lead Ebola or anything else for almost 20 years.
>> Sure.
And to suddenly think they're going to rise up.
>> Right. >> With, with, in their current situation,
and their current situation, in my opinion, is their own doing.
>> Mm-hm. >> They have a structure and
a bureaucracy which is archaic.
>> Yes.
>> And, and cannot work with all their regional offices that, that it,
it just, it just isn't going to ever work.
Okay. >> So what are you going to see in
Ebola is what happened in AIDs, and that's having the U.N. step in.
>> Right.
>> To try to coordinate all the major, least U.N. and bilateral acts.
>> Mm-hm.
>> There is been some thought, David-
>> Mm-hm. >> That maybe we need another Breckenwoods
incomes.
Some people.
>> Sure. >> Had said that, you know,
back in 1946 one of the few positive quick positive developments after
the second world war, r was the Bread Woods Conference up in New Hampshire.
>> Sure. >> So where it was decided to think about
did we wanted to move forward in,
in development we ought to have a world bank in IMF.
>> Exactly.
>> And WHO was more or less came out of that as sort of our lead in health.
>> Mm-hm.
>> I think we need to bring 25,
30 people together, I don't know if they want to go up, up,
up to New Hampshire, but they want to go somewhere and think about this question.
>> Sure.
>> I, I must say that it's a common, the students.
So many students come to me and say can you help me get a job at WHO?
Sometimes undergrads or or graduate students.
My answer is always the same, wait until you have a lot of gray hair or
no hair and that's when you should go to WHO.
What you should do now is roll up your sleeves, go to the field, get experience.
Get experience in urban areas.
Work in whatever sector, and whatever profession drives your, your passion.
And bring the health component to it, but
don't think that by sitting in the austere halls of WHO in, in boring Geneva.
>> Right. >> That you're going to be able to
[LAUGH] to, to make a difference in the world.
>> Absolutely, you got it.
>> So I think for the students that are, that we're, we're hopefully.
Hearing us now WHO should be decades away in your thinking.
>> Sure.
>> Go out and make a difference in the world and finish your education and
then some day maybe when you're tired.
>> [LAUGH].
>> Go work with WHO and write, write some papers and go to some meetings.
>> Policy papers.
>> Policy papers.
>> Yes, yes, yes, yes.
>> and, and, and that's important.
That's important.
>> Sure. Yeah.
>> But, don't do that first.
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