Question: What would be your vision for good public health in 10 years’ time and what actions or steps do we need to take to realize this vision?

Joan Kaufman

The Covid 19 pandemic has made public health a topic on everyone’s screen. It has highlighted the global inequities in access to lifesaving vaccines and medicines described by the WHO in 2008 as the social determinants of health. It has demonstrated that one country’s infectious disease outbreak can easily spread globally but that national policies and responses and geopolitics are outside the control of global health bodies tasked with managing the world’s health. While public health problems are partly driven by microbes, they are increasingly driven by other forces. These include unchecked pollution, global warming, unhealthy diets, etc. Poor diets driven by profit driven food production and trade practices and from repurposing agricultural land to grow corn and other commercially profitable grains have led to a global obesity and diabetes epidemic. Industrial livestock raising practices have contributed to antibiotic resistance and global warming has fueled endless flooding, forest fires, drought, hurricanes and devastating impacts on human health. These are outside the purview and control of health agencies and unless we find a way to regulate those global processes with a greater lens for their health impacts, we won’t be able to fully control the factors that lead to better health for the world, especially the poorest.

The stark inability of the WHO, the new COVAX Initiative or any other global body to enforce scientific best practices in pursuit of the goal of management of the world’s health has highlighted the need for more effective global governance mechanisms for health. I would like to see a world in 10 years’ time with an effective global institution, with the teeth to enforce its decisions, and tasked with governing with a health lens the many drivers outside of health systems that increasingly determine good health. Such an agency would have the ability to coordinate climate policy, trade policy including food and pharmaceutical production, the export of polluting industries like mining, land use policy including habitat destruction, intellectual property protection for life saving drugs and medical technologies, and other policies that have profound impacts on health. Doctors globally are faced with the frustrating and devastating consequences of factors outside their and their patients’ control. It is high time to recognize and marshal our efforts to create policies that will contribute to better global health.

Joan Kaufman is Senior Director for Academic Programs for the Schwarzman Scholars Program at Tsinghua University and Lecturer in Global Health and Social Medicine at Harvard Medical School. She was previously the Director of Columbia University’s Global Center for East Asia, Distinguished Scientist at Brandeis University, founder and Director of the AIDS Public Policy Program at the Harvard Kennedy School, and the China team leader for the International AIDS Vaccine Initiative, a public-private partnership based in New York.

William L. Jaffe

Is good health care a right or a privilege? Probably both. In advanced, capitalistic countries, modern health care is available to the affluent and the indigent with the middle class often struggling to obtain the best care. In advanced societies with socialized, government sponsored medicine, availability is improved but quality and accessibility are limited by necessary cost containment. Quality is further limited by disincentivizing physicians to endure decades long, competitive and costly education with limited expectation of appropriate income received in the nationalized scheme. Additionally, treating physicians like civil servants will further destroy the deteriorating “doctor patient relationship” changing it to the increasingly common description as a “health care provider”. Cost containment will be critical to providing health care in the future. Excessive profits in the pharmaceutical, implant, and insurance industries have diverted enormous funds from patient care. Control of these profits either by taxation or regulatory mandates will be required to keep medical funding at a reasonable percentage of GDP.

What actions can improve the public health prospects for the next decade? Universal health coverage should be mandated for all populations, either government based, private industry supported or a combination of both as is most appropriate to each nation’s tradition and political philosophy. Reimbursement based upon quality metrics including mortality, morbidity, infection and readmission rates, preventive medicine, women’s health, pediatric and geriatric care should be instituted. Create centers of excellence in advanced medical and surgical subspecialty fields that require highly skilled physicians and institutions with increased technology and reimbursement available. Encourage increased accessibility to medical education for talented students with limited resources. NYU Langone Grossman School of Medicine has recently become tuition free allowing our medical students to no longer accumulate hundreds of thousands of US dollars of debt before beginning their careers. This lack of financial stress allows the students to choose less lucrative but critical fields such as pediatrics and primary care medicine, which are currently underrepresented by quality students. Good public health will always be a right and a privilege but adherence to the Hippocratic Oath of “First Do No Harm” and a quality-based reimbursement schedule would appear to offer the most hope worldwide for the next decade.

Dr. William L. Jaffe is a Clinical Professor and Vice-Chair, Department of Orthopaedic Surgery at NYU Grossman School of Medicine. He is a fellow of the American Academy of Orthopaedic Surgeons. Following his training in orthopaedic surgery, he took additional fellowship training in hip replacement surgery in England and biomaterial training at MIT.

Christine Loh

Experts measure health of a society by life expectancy, child and maternal mortality, and burden of disease. On this basis, things have improved over the years in world population terms, currently standing at 7.7 billion. On a day-to-day basis, the notion of good health depends on whether you are rich or poor. If you are among the 860 million people in the world who suffer extreme poverty living on less than US$2 per day, health is tied to your next meal. The poorest can’t access enough clean water, never mind about sanitation and medicine. If you are “rich” – defined as those who are able to live on $50 per day – you have the luxury of thinking about “wellness” as the state of being in good health that encompasses not only physical but also emotional, social, financial, environmental and even spiritual dimensions. Between the poorest and the richest are the majority in the middle – health depends on whether they live in places where the authorities have prioritised public health. The COVID-19 pandemic is telling. Death rates in some of the rich countries, such as the US and UK, were much higher than lower income countries, such as Vietnam and Thailand, whose political leadership took early decisive action to contain outbreaks. For example, COVID deaths were tied to a significant life expectancy drop in the US – the richest country in the world.

Looking out 10 years, what might the global health picture look like? Medicine and healthcare will continue to make incredible advances among the rich. The middle-income folks will also benefit. Yet, a major part of their health condition arises from excesses in consumption of foods tied to unhealthy lifestyles resulting in the rise of non-communicable diseases, such as heart diseases, cancers, diabetes, etc. The primary responsibility of “health” lies with the individual who has consumption choices in diet and recognises that their well-being includes social and emotional dimensions that relate to interactions with others. Governments get bigger bang for their bucks by focusing on public and environmental health and promoting healthier lifestyles. The tobacco industry is a “big bad”, and there are others in the food and beverage industry too, which is why the World Health Organization campaigns against foods with high saturated fats, trans fats, sugar and salt.

Christine Loh is Chief Development Strategist, Institute for the Environment at the Hong Kong University of Science and Technology. She was previously a Hong Kong legislator and Undersecretary for the Environment.

Viroj Tangcharoensathien

To prepare for the next pandemic or public health emergency, Thailand’s public health system should improve national management capabilities for preparedness, prevention, and response. Thai Universal Health Coverage has been the cornerstone for the effective response to the COVID-19 pandemic, where all populations, including migrant workers, had full access to pandemic related services, including vaccines. We should maximize use of the current nation-wide online case-based surveillance systems for not only the detection and control of infectious disease outbreaks that are mandated to be notified according to the Ministry of Public Health, but also for risk assessment and prevention.

Zoonotic disease outbreaks in different parts of the world over the past two decades have been caused by various viruses. Current global sentinel sites should be expanded to provide coverage in wider geographic areas for the detection of corona virus and other high impact viral families in bats and other wildlife, as well as domesticated animals such as poultry and swine. One Health integrated surveillance of zoonotic diseases is critical for preparedness capacity in detecting and containing the spread of novel viruses. Surveillance relies on laboratory capacity for detection and genome sequencing, monitoring of variants of concerns and sharing to the WHO as a global public good. Competent health workforce, public health officers and epidemiologists are the backbone of surveillance, prevention and response. Capacity building for conducting outbreak investigations and controlling disease transmission can be mobilized to support public health during emergencies, and Surveillance and Rapid Response Teams should be strengthened. Public health measures (test, treat and quarantine) and social measures (face mask, social distancing, large gathering restrictions) can contain the initial spread of infection. However, vaccines are one of the sustainable solutions to end pandemics. The National Vaccine Institute’s measures to increase national capacity for vaccine R&D and manufacturing through provision of funds and facilitation of international collaborations for the transfer of technology and know-how on various vaccine platforms is promising. Manufacturing capacity of pandemic response products such as diagnostic and personal protective devices must also be bolstered. Thailand is one of the six Bureau members of the Inter-governmental Negotiating Body for the WHO for pandemic preparedness, prevention, and response to be adopted in 2024 and will look to play a role in addressing these important global issues in the future.

Viroj Tangcharoensathien, MD PhD is a senior advisor to the International Health Policy Programme of the Ministry of Public Health, Thailand. He designed strategic purchasing of Universal Health Coverage in Thailand and has published over 300 articles on healthcare financing, health systems and policies.

Jeremy Lim

Good public health is by definition predictive, preventive, participatory and personalized. These have just been lofty words but for the first time, true public health can be realized. Imagine yourself in 2032 – an unobtrusive sensor (choose from a watch, ring, necklace or even a patch) collects in real-time your vital signs. Environmental scanners measure temperature, humidity, pollutants in the air and pollen-inducing allergens. The toilet analyzes the microbiome profile of your poop. You chat online about your health goals with your physician, Dr. Richards, who is trained in medical informatics and behavioral sciences as part of medical school. She notes that your microbiome profile has worsened and gently chides you for the ultra-processed foods you are so fond of, which devastate the microbes in your gut, so essential for overall human health. You know she has been at the forefront of a global campaign to ban additives and artificial flavoring in food, comparing these to tobacco in the 1960’s. Interestingly, she also shares some insight about her father who is working in a traditional healthcare center. She comments that she had never seen her father so happy. He used to whiz through 30 patients in one morning but with the new technology-enabled care models for most of the population, he can spend the same time focused on just 6 patients, and give them the attention they need. She rounds off the session with prescribing a personalized formulation of probiotics, vitamins and minerals, telling you also that she’s greenlighted you taking an extended lunch hour three times a week to walk in the local park.

The individual pieces of the vignette above already exist but integrating them for public health remains in its infancy. Technology is ironically the easier part. Societal norms are embryonic, regulations around responsible data collection, use and sharing are only just being developed and despite the lofty rhetoric around health, today’s governments and insurers largely pay for sick care rather than health care. Too many today do not even have digital access. But we can act now to address these roadblocks. This is just too important for us to do nothing and squander the opportunity to see in our lifetimes “a world where all peoples attain the highest possible level of health”.

Dr. Jeremy Lim is Associate Professor and director of the global health leadership program in the National University of Singapore Saw Swee Hock School of Public Health. He is also founding president of the Precision Public Health Society (Asia) and co-founder and CEO of Asian Microbiome Library (AMILI).

If you or your company has a due diligence requirement or needs assistance on a fraud issue, corporate investigation, risk advisory, or other related matters, please contact us at info@kalavinkaadvisors.com or +852 2196 2727