Hi class, I'm here today with Dr. Michael Merson. Thank you so much, Mike, for being here. >> Great to be here. >> And Dr. Merson's work 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 class. You also were the director of the WHO's program in AIDS. I know you spearheaded that program, that was literally working all over the world at a very tough time as we both remember those times very well. You have worked on health system strengthening and training scientists all over the world from Russia to South Africa. You have advised organizations ranging from UNAs to the WHO to The Global Fund. You'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, I'm commissioned for smart global health policy at CASIS, which is an organization we'd ask the students to look into as well, as you all try to find evidence-based, and upgrading the good policy in global health. So I think one of the reasons I wanted you to come today and talk a little bit is because I was thinking, 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 cannot 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 is that? >> How's that? [LAUGH] >> So, Mike, as I said earlier, you've been involved in global health for over three decades. 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. 30 years ago, we would have called this field probably international health which would have been meaning, the rich countries, the so-called countries of the north, helping poor countries that has unit flow. The idea being that their health problems were different and that poor countries still have mostly communicable diseases and needed the so-called foreign assistance. Today, we use the word global health because the problems are increasingly the same wherever you live in the world. >> Mm-hm. >> And the flow of information and experience is bidirectional, we learn from each other and we are innovation in one country in the world, and in Africa, it can be applicable in the US and vice versa. Along with that, of course, means that we're seeing more chronic diseases as the major cause of morbidity and mortality around the world. We still have an unfinished agenda. Probably what you've talked about in the class in terms of child mortality, maternal mortality, that agenda hopefully is becoming less and less of an agenda. And more today around the world, we're dealing disease, cancer, diabetes, mental health issues, wherever we are. Of course, we can't forget though that pandemics are still with us and we have now Ebola as our major pandemic we are facing. We have some big scares with Avian flu, with MERS, with SARS. 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. We've learned more about how to cope with them. The other change I would mention is the funding. Certainly, if you compare it to where we were 30, 20 years ago, we were lucky if there were hundreds of thousands of dollars involved in supporting global efforts in health. Today, that number is close to $30 billion. And we have totally new players. We have the global funds against HTP in Malaria. We have the World Bank. We have PEPFAR and, of course, we have some of the bi laterals. Particularly, the United Kingdom, still very active in health. And then, of course, the Gates Foundation which is a major funded 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. >> And the tremendous number of faculty who are pursuing careers in global health. So big changes, very exciting time, and it's been wonderful to be a 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, cultivates- >> So that's another change. >> Yeah. >> I would say that if you went back 30 years ago and you had a meeting of so called international health or global health, you would have mostly had doctors. >> Uh-huh. >> From medical schools and some public health schools. >> True. >> Today, I look at our institute, it's only about 40% physicians. >> Sure. >> And you have participation from every school on campus. And if you look at our students in our global health major, undergraduate major, all of them have a second major. 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 the value of looking at problems from the interdisciplinary or multi-disciplinary lens can be very, very helpful in addressing the major challenges we face today. >> Sure, especially if we're talking about bio-psycho-social determinents that solutions aren't just going to be biological. >> Correct. >> We have one major who is in theater studies. >> Wow. >> And she's in theater studies because she has realized that reading and studying health promotion that theater and getting kids involved in theater may actually be one of the important ways to change behavior and promote good health. >> I saw that a lot early in the 1990s with AIDS. There was so much stigma around AIDS, still is today, but in those days, there was a lot of stigma. Remember, we didn't have any retroviral drugs, so being HIV infected was presumed to be a death sentence. So, there was a lot of stigma and discrimination and very often inability to talk about HIV. And one way that was found you can do it was through theater. >> Really? >> And you could use the theater not only to talk about AIDS but also in how to prevent HIV infection, talk about sex, drugs, and issues that are were not easy to talk about in the average workplace or in a home. >> I see. So I saw a lot of the use of theater in those days. >> Sure as well. Those days remind me, I was thinking about the early 90s that during that time with AIDS. >> Right. >> And W were the program director, the WHO. And Zach, 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 walking scholarship. We didn't have the ART then. Do you think that HIV/AIDS changed the way that 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, right. >> And we didn't have a pandemic that touched every country. And I think it made us look at a disease problem globally. I think that's one thing that it brought us, the global dimension to global crisis. >> And interdependence. >> And the interdependence and, and the fact that the spread even was Quickly from country to country, through many different routes. >> Right. >> I think a second change that AIDS brought is a lot of resources. >> Mm-hm. >> The Global Fund, the involvement of the World Bank, PEPFAR, which was at the time by far the largest commitment of the US government and health globally, was an AIDS initiative. The fact that AIDS was talked about at the Security Council. 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 that was the first time. So certainly resources, political, the value of political commitment, that was certainly shown with AIDS. And that increase in resources helped to develop the larger field of global health, right? Another very important contribution from AIDS was the Holiary Health and Human Rights. >> Mm-hm. >> Many people don't know or don't remember when in the late 90's, 1990s, it cost as much as $15,000 a year to treat an AIDS patients with the new drugs. Today, it's less than $100 and Pharma is still making a profit. >> Yes. >> So you can see that that change was dramatic and it came about very much by activism, often by people with the disease. >> Yes. >> And invoking the issue of human rights. >> Sure. >> And access to care. And that would be another area where AIDS has really played a role. And that's in the access to care movement. We started with being concerned rightfully about access to care to anti-retroviral drugs. >> Mm-hm, sure. >> And now we are concerned about access to care for all drugs. >> Of course. >> And a lot of the drugs that treat chronic diseases are quite expensive. >> Sure, absolutely. >> 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, it was certainly a major stimulus to the global health field. And I think it's unfortunate that so many people died and still die from AIDS. And then I guess is the last point I would make and that is that AIDS has shown us the value of research. >> Yes indeed. >> In rapidly done targeted reserach against the disease. >> Absolutely. >> Look how fast the anti-retroviral drugs were developed. Now we know that even the drugs if given early can play a role in prevention. >> Sure. >> So that seemed at the time that it was taking forever, but if you take the view from 30,000 feet, these discoveries were pretty fast. >> Absolutely, and I know we all remember, once the ARVs became available, the rapid change in people who have been sick once they got on the- >> Right, dramatic change. >> It's dramatic. >> And the stigma decreased. >> Absolutely, yes. >> Discrimination decreased. >> Right. >> And I think the hope that someday there would be a cure is still there. >> Sure. >> And maybe a vaccine, tougher road ahead will come. >> Absolutely, and now I think those are great points and I also really interested in something that you said about research. I mean, because so many different actors are involved in global health. Now you have long involvement with positions of leadership in a variety of institutions, intergovernmental institutions in particular, education institutions, philanthropic institutions. It's really given you I think a unique insight into how global health actors look. And when I first teach global health courses, students always want to know how the global health system works. >> Mm-hm. >> And I see there's not really a system, there's a landscape of actors. >> Right. >> Sometimes collaborating, sometimes competing, sometimes working in silos. It's complex, that landscape. Now in your opinion, 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. First, who are the actors? Well, of course, governments. I mean, they are responsible for public policy around the world. The rich and poor. >> Of course. >> And we're seeing in the rate of wealth of the middle income countries, particularly the bricks countries, that middle income countries, the so called middle income countries, these Brazil, Russia, India, China, South Africa at different times, but all of them soon will become developed countries, right? And they are already becoming donors, they have their own World Bank. So we have the country actors and then we have the UN actors. And the last time I counted there were 16 UN agencies working in health. >> Yes. >> And people tell me, it's all WHO, not at all. I'll come back to that in a minute. But I think that you have a whole slew of UN actors with different mandates relating to different ministries in governments. >> Right, sure. >> And that would include the World Bank. And then you have other international institutions that have become about like Gabby, the vacciniary and the Global Fund. >> Right. >> UNAIDS, although that can also be seen, that's more of a UN agency. But I would say you have these other international institutions. The Gates Foundation. >> Of course. >> And that leads to the whole foundation world. The biggest one by far >> Giving over $3 billion a year is the Gates Foundation. >> Sure. >> And then of course you have more and more corporate, the global corporate sectors giving to AIDS. And now, giving to other diseases beyond AIDS. The global commodity market today, if you think vaccines, drugs, prosthetics, probably close to $4 trillion. So you have a lot of A lot of pharma in particular, but not only pharma, 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 a pandemic like Ebola. But I think we have to be realistic and appreciate their health today touches on so many other aspects of development that you can't expect it to be a siloed area. Many people see the value of health and want to be involved- >> Absolutely. >> The world has tried to mobilize around certain areas. 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 think the Ebola situation, again, points out a need to do something. 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. 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 in their current situation. And their current situation, in my opinion, is their own doing. And they have a structure and a bureaucracy which is archaic. >> Yes. >> And cannot work with all their regional offices, that it just isn't going to ever work. So what are you going to see in Ebola is what happened in AIDS, and that's having UN step in. >> Right. >> To try to coordinate all the major, at least UN and bilateral activism. There is been some thought, David, that maybe we need another Bretton Woods Conference. Some people have said that back in 1946, one of the few quick positive developments after the Second World War was the Bretton Woods Conference up in New Hampshire. Where it was decided to think about if we wanted to move forward in development, we ought to have a World Bank and an IMF. >> Exactly. >> And WHO more or less came out of that as sort of our lead in health. I think we need to bring 25, 30 people together. I don't know if they want to go up to New Hampshire, but they ought to go somewhere and think about this question. >> Sure. >> 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 graduate students. My answer is always the same. Wait untll you have a lot of gray hair or no hair, and that's when you should go to WHO, right? What you should do now is roll up your sleeves, go to the field, get experience in communities, get experience in urban areas. Work in whatever sector and whatever profession drives your passion and bring the health component to it. But don't think that by sitting in your steer holes of WHO in boring Geneva, that you're going to be able to make a difference in the world. >> Absolutely. >> So I think for the students that are hopefully hearing us now, WHO should be decades away in your thinking. Go out and make a difference in the world and finish your education. And then some day maybe when you're tired, go to work for WHO and write and some papers and go to some meetings. >> Policy papers, those, yes, yes, yes, yes, yeah. >> Policy papers, and that's important, that's important. >> Sure, yeah. >> But don't do that first.
