hlth2002: global health (wk1-wk5)

medical assassination

C → heart attacks, asthma/ respiratory B → vCJD, influenza R → leukaemia, lymphoma, other cancers - priming of the immune system - director of National Intelligence calls CRISPR "weapon of mass destruction"

surgery and anaesthesia: "implementation" approach of the integrated operating theatre

HORIZON 1 - does it work? - addressing unmet needs - feasible logistics - attracting patients - biggest pain points? - metrics: DALYs, patient throughput and survey data - approaches: pilot study and modelling HORIZON 2 - can it scale? - addressing differences in geography, procedures, governments and economics - metrics: per unit economics, inputs for broader business cases - approaches: multiple sites, financial modelling workshop, knowledge network HORIZON 3 - can it sustain? - ultimate business model? - profitability - metrics: impact on 2030 objectives, financials - approach: broad-scale roll-out

poverty-disease trap (poverty/ low SES VS TB)

ISSUES: - undernutrition - poor housing - HIV, diabetes, smoking, alcohol, etc. - poor healthcare access ↓ APPROACHES: - fight poverty - address risk factors - improve access - treat latent infection and vaccine - diagnose and treat active TB + ISSUES: - catastrophic health expenditure - worse health and stigma → loss of income ↓ APPROACH: social and financial protection

ACT-accelerator (response to COVID-19)

RAD ↓↑ manufacturing ↓↑ procurement ↓↑ deployment - Facilitation Council includes: > EU > Canada > France > Germany > Italy > Japan > Norway > Spain > UK > BMGF > WEF > Wellcome Trust - vaccine partnership: > research > foundations > international organisations > industry > funders > regulators > CEPI and GAVI are co-convenors > WHO leads product allocation > supported by WHO-led ACT-A hub - therapeutics partnership: > research > industry > regulators > funders > international organisations > Therapeutics Accelerator and UNITAID are co-convenors > WHO leads product allocation > supported by WHO-led ACT-A hub - diagnostics partnership: > research > industry > regulators > funders > international organisations > FIND and Global Fund are co-convenors > WHO leads product allocation > supported by WHO-led ACT-A hub

"Did PEPFAR investments result in health system strengthening? A retrospective longitudinal study measuring non-HIV health service utilization at the district level", Luboga, et al., 2016 (Health Policy and Planning)

THIS IS A CTRL+F PAPER

"From sovereignty to solidarity: a renewed concept of global health for an era of complex interdependence", Frenk, et al., 2014 (Lancet)

THIS IS A CTRL+F PAPER

"Global Epidemiology of Tuberculosis", Glaziou, et al., 2018

THIS IS A CTRL+F PAPER

"Governance Challenges in Global Health", Frenk & Moon, 2013 (New England Journal of Medicine)

THIS IS A CTRL+F PAPER

"Has donor prioritization of HIV/AIDS displaced aid for other health issues?", Shiffman, 2007 (The London School of Hygiene and Tropical Medicine)

THIS IS A CTRL+F PAPER

"Health and climate change: policy responses to protect public health", Watts, et al., 2015 (Lancet)

THIS IS A CTRL+F PAPER

"Health's role in achieving Australia's Sustainable Development Goal commitments", Brolan, et al., 2019

THIS IS A CTRL+F PAPER

"Primary health care and universal health coverage: competing discourses?", Hill, et al., 2018 (Lancet)

THIS IS A CTRL+F PAPER

"The World Health Organization and the Transition From 'International' to 'Global' Public Health", Brown, et al., 2006

THIS IS A CTRL+F PAPER

"Countdown on health and climate change: from 25 years of inaction to a global transformation for public health", Watts, et al., 2018 (Lancet)

THIS IS A CTRL+F PAPER ****WEEK 3 READING 3/4 IS NOT INCLUDING******

UHC-2030 framework

governance ↓↑ health financing ↓↑ service delivery ↓ - equity - quality - responsiveness - efficiency - resilience

"whole system" approach

governance, directive, oversight, coordination ↓ - service delivery: > public health functions > health service > procurement and distribution - health financing: > resource allocation and strategic purchasing > revenue collection > pooling ↓ - UHC is achieved - financial protection - equity - access to effective interventions ****************** throughout whole process, maintains quality, efficiency, equity, accountability, sustainability and resilience

"False dichotomies in global health: the need for integrative thinking", Frenk & Gomez-Dantes, 2016 (Lancet)

https://pubmed.ncbi.nlm.nih.gov/27771016/ (ENTER ON PROXY)

*WPRO's approach to UHC *Western Pacific Region

make all staff work on UHC Framework and make UHC Framework work for all ↓ - adopt quality improvement approach (TAG) which had successful experiences in implementing other priority programmes - incorporate UHC into broader WHO operational framework: CCS

The Triple Dividend

note: the early years matter!! early child development matters a lot! 1. during adolescence - health determinants - health risks - health problems - health services - structural actions - community actions - top causes of DALYs in adolescents: mental health, road injury, violence, communicable diseases, non-communicable diseases 2. later in life - obesity - cancer - smoking - intimate partner violence 3. intergenerational impacts - evidence linking maternal obesity during pregnancy to obesity in the children - maternal smoking linked to an increased risk of obesity in the children - child marriage

surveillance data flow

patient seeks medical advice ↓ focal point records syndrome (?) ↓ weekly tally sheet (of number of cases) ↓ surveillance reporting (EWARS) ↓ - weekly epidemiological bulletin → public health action - signal or alert for potential outbreak → verification and response (using surveillance officers, epidemiologists) → public health action

assessing food disease burden

policy objective ↓ - health: → incidence → hospitalisations → deaths - societal: → outbreaks → cost - summary metric: → DALYS → QALYs

SDGs, UHC and the health system

social, economic, environmental and political determinants ↓ - health system: > governance > financing > workforce > medicine and other health technologies > service delivery > responsiveness, efficiency, fairness, quality, resilience - other sectors: > education > energy > water > agriculture > transport > telecommunications > urban planning ↓ - achieve UHC (desired outcome) - all people and communities receive the quality health services they need, without financial hardship ↓ SDGS - SDG 3: health and wellbeing - SDG 1: no poverty - SDG 4: quality education - SDG 5: gender equality - SGD 8: inclusive economic growth and decent jobs - SDG 16: inclusive societies

WHO's TB strategy evolution: 1990-2005

"DOTS" strategy 1. sustained government commitment to TB 2. microscopy-based identification 3. standardised short course chemotherapy 4. secure supply of drugs 5. case registry, monitoring and evaluation

WHO's TB strategy evolution: 2016-2035

"End TB" strategy - 3 pillars - 10 components - Pillar 1: integrated patient-centred TB care and prevention → (A) early diagnosis of TB including universal drug susceptibility testing and systematic screening of contacts and high risk groups → (B) treatment of all people with TB including drug resistant TB and patient support → (C) collaborative TB-HIV activities and management of co-morbidities → (D) preventive treatment of persons at high risk, and vaccination against TB - Pillar 2: bold policies and supportive systems → (A) political commitment with adequate resources for TB care and prevention → (B) engagement of communities, civil society organizations, and public and private care providers → (C) universal health coverage policy and regulatory frameworks for case notification, vital registration, quality and rational use of medicines and infection control → (D) social protection, poverty alleviation and actions on other determinants of TB - Pillar 3: intensified research and innovation → (A) discovery, development and rapid uptake of new tools, interventions and strategies → (B) research to optimize implementation and impact, and promote innovations - foundations: > government stewardship and accountability, with monitoring and evaluation > building a strong coalition, with civil society and communities > protecting and promoting human rights, ethics and equity > adaptation of the strategy and targets at country level, with global collaboration

Declaration of Helsinki 1964

"It is the mission of the physician to safeguard the health of the people. His or her knowledge and conscience are dedicated to the fulfilment of this mission."

WHO's TB strategy evolution: 2006-2015

"Stop TB" strategy 1. pursue high-quality DOTS expansion and enhancement: - political commitment - quality bacteriology - guaranteed treatment - ensured drug supply - monitoring - evaluation 2. address TB-HIV, MDR-TB and other challenges: - vulnerable groups - e.g.- prisoners 3. contribute to health system strengthening 4. engage all care providers: - public and private - international standards 5. empower patients and communities: - ACSM - community participation - patients' charter 6. enable and promote research

MNCH: the SDGs

(#3: good health and well-being) 3.1. By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births. 3.2. By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-5 mortality to at least as low as 25 per 1000 live births. 3.7. By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.

climate change: converging issues

- "Climate change is the biggest global health threat of the 21st century" (Costello, et al., 2009) - climate change will disproportionately affect the most vulnerable people - indigenous people have a life expectancy at birth about 10 years shorter than other Australians - solutions include either adaptation or mitigation

climate change: is it an issue?

- "Climate change is the biggest global health threat of the 21st century" (Costello, et al., 2009, The Lancet) - "Tackling climate change could be the greatest global health opportunity of the 21st century" (Watts, et al., 2015, The Lancet)

ethics in medicine

- "The health of my patient shall be my first consideration." (World Medical Association, International Code of Medical Ethics) - "Many facets of medical ethics - clinical interventions, medical research, clinical governance and accountability, patient confidentiality, end of life decisions, complex technologies, etc." - the unequal power relationship between a doctor and a patient, and the vulnerability of the patient, is central to medical ethics - many examples of abuse of this power throughout history, on an individual level and in medicine as a collective profession → dual loyalty - disaster situation magnifies this inequality of power because of magnified vulnerability and reduced oversight - individual medical ethics applies to population health interventions on a larger scale

case study: HIV in Indonesia

- 1 of 29 priority nations that experienced an increased incidence - fastest HIV epidemic progression in Asia - contributing to 4% of newly infected cases and 2% of HIV-related death globally - contributing to 23% of total cases and 12% HIV-related death among the Asia and Pacific countries - second highest contributor after India - third highest prevalence rates in Indonesia (100.2 per 100,000 adult populations) - estimated PLWHA is 13,235, concentrating at Denpasar, Buleleng and Badung Districts - reported cases from 1987-2017 was mainly transmitted via heterosexual contact and IDUs, but new increasing trend was also evident from MSM and perinatal - high prevalence of HIV among FSWs and MSM subpopulations TIMELINE - sporadic action (1987-1990): > not enough information was available to formulate action rather than clinical care for patients with AIDS > more AIDS suspected cases were documented > focus action on clinical care of AIDS patients > hospital-based ↓ - emergency responses led by NGOs (1990-2008): > HIV and AIDS cases were found to be much common among IDUs and FSW (brothel-based) > HIV risk factors identified were needle sharing and 'risky' sexual behaviour > FSW and IDU were identified as HIV transmission epicentre > US-Based Collaboration Study 'Bali STIs and HIV Project' was established in 1990 to identify risk factors and key populations need to be targeted > after 2000, HIV prevalence among IDUs reduced > increasing role of transgender sex worker > HIV prevalence via heterosexual contact peaking up > increasing role of MSM population ↓ - health system response (2008-2014): > lack of coordinated actions among NGOs and government bodies to control HIV epidemic leads to establishment of institutionalised action via Bali AIDS Control Commission (2004) > ensuring sustainability > HIV prevalence among pregnant women and perinatal transmission increased > integration of HIV-related services to public healthcare > scaling up VCT, ART, T&T and TB-HIV LOCATION VS ISSUES - Buleleng: > northern part of Bali > high prevalence area > low fiscal capacity > historically sexual transmission nature > NGOs present - Karangasem: > eastern part of Bali > connecting Bali and Lombok Island > low prevalence area > low fiscal capacity > poorest in Bali > no HIV NGOs - Denpasar: > southern part of Bali > high prevalence area > high fiscal capacity > NGOs main working areas - Jembrana: > western part of Bali > connecting Bali and Java Island > low prevalence area > low fiscal capacity > no HIV NGOs

Operation Sea-spray

- 1950 U.S. Navy secret experiment - Serratia marcescens and Bacillus globigii bacteria were sprayed over the San Francisco Bay Area in California - eleven residents checked into Stanford Hospital for very rare, serious urinary tract infections - this happened a lot (especially between 1950s and 1960s)

WHO in the Western Pacific region

- 27 countries, 10 areas - 1.9 billion people - extreme diversity in social, economic, geographical, cultural characteristics - status of health and level of development also varies widely

foodborne disease in Australia

- 4.1 million cases - 5,100 non-gastro cases - 36,000 sequelae - 35,000 hospitalisations - 95 deaths - ~150 outbreaks

surgery and anaesthesia stats

- 5 billion people lack access to safe, affordable surgery and anaesthesia - 80 million people face catastrophic health expenditure on surgery and anaesthesia - between 20-40 surgeons, anaesthesiologists and obstetricians per 100,000 people seem to have the best health outcomes (based on maternal mortality) - countries should be doing at least 5,000 surgical procedures per 100,000 people per year - 143 million additional surgical procedures are needed to save lives and prevent disability - $350 billion needed to expand surgery (2015-2030) - total GDP losses from surgical expansion inaction: $12.3 trillion (2015-2030)

global epidemiology of TB: TB-HIV and drug-resistant TB

- 558,000 people with rifampicin-resistant TB - almost half were in three countries: > India (24%) > China (13%) > Russian Federation (10%) - among RR-TB cases, ~82% were multidrug-resistant TB - only 25% (1 in 4) started on treatment

the TB gap

- 6.4 million were detected and notified - 3.6 million global gap (i.e.- undiagnosed, undetected or not reported) - top 3 countries with the biggest gaps: > India > Indonesia > Nigeria - initiatives to close this gap: 1. TB REACH 2. Strategic Initiative

movement of people/ refugee crisis

- 79.5 million forcibly displaced people, globally (2019) - reasons include persecution, conflict, violence, human rights violations, events which seriously disturb public order - 26 million refugees: > 20.4 million under UNHCR's mandate > 5.6 million Palestinian refugees under UNRWA's mandate - 45.7 million internally displaced - 4.2 million asylum-seekers - 3.6 million Venezuelans displaced abroad

WGS international efforts (foodborne diseases)

- Australia: Genomics Network - USA: > PulseNet: * listeria prospective • * about to turn on other organisms > GenomeTrakr - European countries: > highly variable > most sequencing during outbreaks > COMPARE - United Kingdom: > completely turned over to WGS > dramatic change

TB: prevention

- Bacille Calmette-Guérin (BCG) vaccine: > developed almost 100 years ago > prevents severe forms of TB in children > dose is recommended in healthy babies as close to the time of birth as possible > no effective vaccine for adults - post-exposure prophylaxis ("preventive healthcare") is recommended by WHO

interim health system agenda for post-COVID-19 recovery

- COINS (2 SIDES): > health emergency plans taking account of health system capacity > health systems operationally ready for emergency and other health needs - CONTINUUM: > financing and reach of essential public health services and functions > financing and service models for continuity of care, with PHC as pivot - CONNECTEDNESS: > mainstreaming digital health > mainstreaming and scaling up mental health promotion and mental healthcare

novel antiviral approaches: gene therapy CRISPR Cas13

- CRISPR: clustered regularly interspaced short palindromic repeats - Cas9 → cuts DNA - Cas13 → cuts RNA

disability-adjusted life years (DALYs)

- DALY = YLD + YLL - YLD: > years lived with disability > = N x D x DW > N is number of incident cases > DW is the disability weight > D is the average duration of the case until death (in years) - YLL: > years of life lost > = M x RLE > M is the number of deaths > RLE is the standard life expectancy at the age of death (in years)

3 delays in the surgical system

- FIRST DELAY: delay in seeking care - SECOND DELAY: delay in reaching care - THIRD DELAY: > delay in receiving care (at hospital) > can be very long (e.g.- waiting times)

COVID-19 outcomes/ future scenarios

- GROWTH scenario: > vaccine allows prevention > recovery of patients > progress is continued - DISCIPLINE scenario: > living with partially-tamed COVID-19: > the "new normal" (as opposed to state-imposed order) - COLLAPSE scenario: > society falls apart > anarchy/ chaos > brutality > lawlessness - TRANSFORM scenario: > post-COVID-19 revolution and evolution > new methods emerge

H5N1

- H5N1 is a highly pathogenic avian influenza virus - emerged in 1997 and spread globally in birds - 386 human cases worldwide* (mostly in Indonesia (>40%)) - not transmissible from human to human - majority of human cases had close contact with sick or dead poultry/ birds - sparked pandemic fears and global - pandemic planning since 2005 - creation of transmissible H5N1: > pandemic may arise from random mutation > more research needed to anticipate and prepare for this > creation of engineered transmissible strains can occur

what does the data tell us?

- HIV and STIs health services are disproportionately distributed following the intensity of donor interventions in priority areas and fiscal capacity of different districts - i.e.- basically non-existing in non-priority areas - HIV and STIs service availability and readiness constitute the potential access

HIV persists as latent infection

- HIV becomes a part of the cell's DNA (retrovirus) - billions of copies every day - DNA-positive, RNA-positive - in latent infection, it is DNA-positive BUT RNA-negative - latency reversal: using an agent to kill latent-infected cells, which have been turned into a productive-infected cell - possible in vivo

what's special about HIV?

- HIV received more than 1/3 of all major donor funding for health, despite representing only around 5% of the mortality and morbidity in LMICs - other communicable diseases (e.g.- pneumonia, diarrhoeal diseases) kill millions of people each year - these diseases have cost-effective interventions but attract minimal donor resources - global policy communities (e.g.- researchers, advocates, NGOs, philanthropies, UN bodies and foundations) share a similar concern for HIV - arguments used by communities for support: morality, preventability, productivity - funding is dependent on: > strength of the actors involved in an issue > ideas used to understand and position the issue > nature of political contexts in which these actor operate > characteristics of the issue itself - global policies/ commitments such as MGDs, the US President (through PEPFAR initiatives), and bilateral donors health priority ⭐️ takeaway message: powerful global health actors engage in strategic social construction advancing claims concerning what does and does not deserve a public recognition ⭐️

Global Health Architecture (1995-2015)

- MDGs - health as key to social and economic development - increase in funding - proliferation of partners → GFATM, GAVI, BMGF, PPPs, development banks, regional political bodies, bilateral donors, UN agencies

importance of adolescent health

- MDGs (2000-2015) have no focus on adolescents (even in child mortality, maternal mortality and HIV/AIDS sub-sections) - first Lancet series on adolescent health was published in 2007 (then in 2012) - between then, three articles in 2009, and two in 2011 - four UN reports on global adolescent health (2011, 2012, 2013, 2014)

case study: New Zealand's investment in well-being

- New Zealand 'wellbeing' budget promises billions to care for most vulnerable - widespread praise for 'worldfirst' budget tackling mental illness, family violence and child poverty - forget GDP; New Zealand is prioritizing gross national well-being - the country's new 'well-being budget' emphasizes citizen happiness over capitalist gain

ethics of research

- Nuremberg code and Declaration of Helsinki are the foundation of modern HRECs - written, informed consent - risk VS benefit - avoidance of pain and suffering - privacy - samples cannot be used for any purpose other than what was approved by HREC - results must not be falsified - open disclosure of any breach of ethics

antimicrobial resistance (AMR)

- PNG has the most new multidrug-resistance TB cases in the Western Pacific region (10th highest globally) - malaria resistance to artemisinin in the Greater Mekong region is increasing - new strains of bacteria in community and hospitals resistant to all available antibiotics - AMR now → ~700,000 - AMR (2050) → 10 million

health system attributes that act as action domains for achieving UHC

- QUALITY: > regulations and regulatory environment > effective, responsive individual and population-based services > individual, family and community engagement - EFFICIENCY: > system design to meet population needs > incentive for appropriate provision and use of services > managerial efficiency and effectiveness - EQUITY: > financial protection > service coverage and access > non-discrimination - ACCOUNTABILITY: > government leadership and rule of law for health > partnerships for public policy > transparency, monitoring and evaluation (M&E) - SUSTAINABILITY AND RESILIENCE: > public health preparedness > community capacity > health system adaptability and sustainability

other health-related SDGs

- SDG1: > extreme poverty > vulnerability to economic, social, environmental shocks & disasters - SDG2: malnutrition - SDG5: > violence against women and girls > sexual, reproductive health & rights - SDG6: > safe and affordable drinking-water > sanitation and hygiene - SDG8: safe and secure working environments - SDG11: housing and basic services, air quality, waste management in cities - SDG13: climate-related hazards and natural disasters - SDG16: violence, legal identity

SDGs VS WHO

- SDGs are interrelated and divisible - SDGS reflect WHO's constitution - the WHO constitution defines health broadly as a state of complete physical, mental and social well-being - good population health improves productivity, sustainability and the economy, and vice versa. - the SDGs recognize the positive and negative links between health, its determinants and sustainable development

Sea-Orchid and Sea-Urchin

- South East Asia (SEA) Optimising Reproductive and Child Health in Developing Countries (ORCHID) - South East Asia (SEA) Using Research for Change in Hospital-acquired Infection in Neonates (URCHIN)

case study: Bristol's whistleblower

- Stephen Bolsin, 1988 - Bolsin noticed operations at BRI (hospital) took longer compared to Brompton, - patients seemed to be suffering more complications - Dr W took three times as long as average - records of cases and outcomes - 1990: Bolsin took tried to raise his concerns → "apathy" from colleagues - 1990: BRI became part of United Bristol Healthcare Trust. Bolsin wrote to the CEO of the trust about his concerns. No action resulted. - 1992: Bolsin left BRI. Began collecting data to compare with national register data. - 1993: Bolsin was unable to find a new job. Dr W became Medical Director of the Trust. Bolsin presented completed data to CEO. No change. - 1994 (June): Bolsin and 5 other anaesthetists requested a full review of AV switch procedure. Review did not take place for 7 more months. - 1994 (December): Dr D was going to do an AVS procedure on an 18 m child. Bolsin and the professor of cardiac surgery notified all clinical and non-clinical managers within hospital, but no-one was prepared to intervene. - 1995: Bristol problems on front page on Daily Telegraph and in BMJ. Bolsin's employment threatened. (incomplete)

climate change: impacts (general)

- Stern Review: > British > the benefits of strong, early action on climate change far outweigh the costs of not acting > impacts of climate change on water resources, food production, health, and the environment - Garnaut review: > Australian > impacts of climate change on the Australian economy > recommended medium to long-term policies and policy frameworks - e.g.- upon water erosion on coastal properties, is the solution to abandon the property, or rebuild it? (similarly for inland floodplains) - e.g.- droughts/ heat waves negatively affect the equilibrium of the human body, and homeostasis is not without limits

TB in men and women

- TB affects males more than females - children between 0 and 14 are similarly affected - men between 25 and 54 years are the most affected - women between 15 and 34 are the most affected, but not nearly as much as men - TB in children: >

declining TB

- TB is declining, but at different rates in different regions of the world - TB and TB-HIV declining the steepest in Africa - not declining very much in the Eastern Mediterranean region - low decline rate of both TB and TB-HIV in The Americas, Eastern Mediterranean regions, South East Asia and the Western Pacific

30 high burden TB countries

- TB: > Cambodia > Sierra Leone - MDR-TB: > Azerbaijan > Belarus > Kazakhstan > Peru > Republic of Moldova > Somalia > Tajikistan > Ukraine > Uzbekistan - TB-HIV: > Botswana > Cameroon > Chad > Eswatini > Ghana > Guinea-Bissau > Malawi > Uganda - TB & MDR-TB: > Bangladesh > DPR Korea > Pakistan > Philippines > Russian Federation > Vietnam - TB & TB-HIV: > Brazil > Central African Republic > Congo > Lesotho > Liberia > Namibia > UR Tanzania > Zambia - ALL: > Angola > China > DR Congo > Ethiopia > India > Indonesia > Kenya > Mozambique > Myanmar > Nigeria > Papua New Guinea > South Africa > Thailand > Zimbabwe

WHO country action framework

- UHC country support plan: > country offices → regional office → HQ > all collaborating via a joint working team > involves numerous human resources > aims to form a national UHC roadmap based on NHPSP (national health, policies, strategies and plans) - partners consortium: > WB > GF > GAVI > bilateral/ philanthropic organisations - actions of each: > joint working team: * coordination in CO, RO and HQ * monitoring progress * resource allocation > country office: * support for roadmap/ NHPSP development * environmental scan and situation analysis * coordination of partners & WHO programmes * technical support and capacity building > regional office: * Regional Action Framework & annual progress review mechanisms * knowledge synthesis, brokerage and capacity building across countries * policy briefs and dialogues * regional partners coordination * normative function: regional strategies > headquarter (HQ): * partner consortium * high- level meeting * resource mobilization * normative function: guidelines, data

universal health coverage (UHC)

- UHC means that all people and communities have access to quality health services without suffering the financial hardship associated with paying for car - UHC and SDGs: > without UHC, health gains will not be sustained and the SDGS cannot be reached > UHC brings different goals and efforts together - "To promote health for all, we must achieve universal health coverage and access to quality health care. No-one must be left behind." (SDG Declaration, para. 26) - "The Cube": > population: who is covered? > services: which services are covered? > financial protection: what do people have to pay out-of-pocket? > coverage mechanisms can: * extend to non-covered services * include other services * reduce cost-sharing and fees - "building blocks": > people (centre) > governance > finance > workforce > products, technology > service delivery > information

antimicrobial resistance (AMR) as a UHC/ SDG issue

- UHC: > over-prescribing antibiotics > poor infection control - 'One Health' > over-prescribing antibiotics > poor infection control > poor waste management > antibiotic overuse in cattle and fish farming - SDGs: > over-prescribing antibiotics > poor infection control > poor waste management > antibiotic overuse in cattle and fish farming > food security > no development of new antibiotics - need for governance of AMR as a development agenda: > national → national action plan on AMR > regional → harmonisation of surveillance and regulations > global → enhance R&D (new antibiotics and diagnostics)

HIV and global health

- UNAIDS 90-90-90: > 90% of all people living with HIV will: * know their HIV status * receive sustained antiretroviral therapy * have viral suppression > there is a global commitment to HIV - challenges: > resources for extraordinary access to HIV testing > resources to produce drugs and prevent stock-outs > resources to keep people on treatment for life > requires robust health systems to deliver these initiative > also requires a robust community health systems (community-based health programs, health cadres) > political will of the country leader to invest such money - to achieve the 90-90-90 targets, need to developing a list of priority districts/ cities for HIV interventions > e.g.- 137 or 31% of the total districts in Indonesia > e.g.- in Bali province, 3 out of 9 districts are priority areas - by focusing HIV interventions in these 137 districts, a total of 94% IDUs, 92% FSWs and 85% PLWHA would be reached by appropriate HIV-related services - there is a need to guide HIV-resource allocation to the severely-affected areas ⭐️ take-away message: global commitments endorsed by donors often dictate local actions and priorities at the cost of creating access inequities ⭐️

vaccine alliance partners

- UNICEF - Bill & Melinda Gates Foundation - the World Bank - WHO - donor country governments - research agencies - private sector partners - vaccine manufacturers - civil society organisations - implementing country governments

case study: Victoria's "whole of society" approach

- Victorian Health Promotion Foundation's work program on 'improving mental wellbeing' - strengthen social connections to improve health and wellbeing - young people and resilience - engage young people to utilize technologies for cybersafety, mental health and wellbeing - reducing race-based discrimination - preventing violence against women

Foodborne Disease Burden Epidemiology Reference Group (FERG)

- WHO expert group - established in 2009 - 5 working groups - estimates the foodborne disease global burden - aims: > estimate mortality, morbidity and disability > model disease burden where data lacking > develop source attribution models > tools to study foodborne burden in countries > reported in 2015...?? > circa 2010?? - methods: > global estimate incidence and mortality for 31 hazards: * 11 acute diarrheal diseases * 7 invasive infectious disease * 10 helminths * 3 chemicals > estimates for high-income countries for 4 hazards (4 bacterial toxins; 1 allergen) > imputation and expert knowledge to fill data gaps > expert elicitation: transmission mode

WHO system strengthening for foodborne diseases

- WHO self-assessment tool: 5 Key elements - countries nominate for a workshop → tailored to meet country needs - workshops conducted: → Federated States of Micronesia → Nepal, involving Thailand and Sri Lanka → Indonesia →Vietnam → Bhutan

global burden of foodborne disease

- all: > illness: 600 million > deaths: 420 thousand > DALYs: 33 million - diarrheal: > illness: 549 million > deaths: 230 thousand > DALYs: 18 million - invasive: > illness: 36 million > deaths: 117 thousand > DALYs: 8 million - helminths: > illness: 13 million > deaths: 45 thousand > DALYs: 6 million - chemicals: > illness: 0.2 million > deaths: 19 thousand > DALYs: 0.9 million

approaches to target HIV

- attacking the virus reservoir: > very early ART > latency reversal > pro-apoptotic drugs > immunotoxins > latency silencing > gene editing - using the immune system: > broadly neutralising antibodies (bNAbs) > T-cell vaccines > immunomodulation > CAR T-cells > gene editing

influencing policy-makers

- be strategic - be persistent - know their agenda - build alliances - have solutions - keep it simple - be lucky :( - bring credibility to your arguments by citing influential evidence or people

HIV and COVID-19's lessons for success

- behavioral change: community empowerment and engagement - public health system strengthening: test, trace (and isolate) - science matters: investment, collaboration and the private sector - multiple biomedical interventions needed: testing, treatments and vaccines - leave no one behind: health is a human right

importance of secondary education

- best investment in adolescent and youth health - lower secondary completion = 48 fewer births per 1000 - upper secondary completion = 68 fewer births per 1000 - Doctors in Secondary Schools (DiSS): > in 2015, the Victorian government committed $43.8 million to provide doctors in the 100 most disadvantaged schools > objectives: * make primary health care more accessible to students * provide assistance to young people to identify and address health problems early * reduce the pressure on working parents > huge success > clinical guidelines around confidentiality from esteemed professional associations

proving bioterrorism

- can only be done by law enforcement - public health experts can only point to unusual patterns... but usually don't - the greyness of an attack: > most BT agents also occur in nature > incitement of terror may not be a motive for a biological attack > attacks may or may not be severe > historically, most attacks have not been recognized at the time > identifying bio-attacks is not a standard public health competency

climate change: impacts (the challenge of shifting the scales)

- challenge of proxy measures: > proxy measures are basically underestimates of the independent variable at hand > climate change of the rate and magnitude predicted has not occurred in human history > changes that have already occurred are just the beginning > favoured proxy measures include renewable resource scarcity and its causes > e.g.- localised climate change, such as drought > however, these are not part of closed systems - challenge of independent samples: > studies usually look back no further than WWII > most studies divide the world into countries (though at least one divided it into geographic spaces) and years > i.e.- "what is the likelihood that there will be conflict in this country, in this year?", which is then related back to a selected climate change-related variable (e.g.- drought in that country) > country-years are not independent because: * violence breeds itself * violence spills over borders (i.e.- you are more likely to be involved in war if your neighbouring country is) * the Cold War and proxy wars - challenge of interpretation: > results across studies mixed > however, since proxy measures are basically underestimates of the independent variable at hand, it can be logically assumed that there is a connection > conflict has many risk factors of varying strength: * inclusion/ exclusion criteria * effect size frequently not measured, yet... * possible author bias?

combination antivirals for SARS-CoV-2

- clear reduction in viral load in throat swabs with combination treatment - median duration of symptoms 5 days (range 3-7 days)→ i.e.- early treatment - combination VS single therapy - quicker time to negative throat swab - shorter time to resolution of symptoms

climate change: impacts (migration)

- climate change "refugees" are likely to increase - in accompaniment to poverty and poor governance, climate change will negatively affect several countries (particularly around the equatorial band) - the estimate of how many people and within what time-scale is variant and unpredictable - may be a good way for the world to adapt to a changing environment - this hinges on cooperation and mutual understanding - it is expected that areas of crop production will shift to areas TOWARDS the poles (i.e.- "really really cold" places will become "really cold", whereas "really really hot" places will become "absolutely unbearable") - the optimism behind this internationally combined effort is slim - e.g.- "Turn back the boats" movement; "No way! You will not make Australia home" posters from the Australian government and the U.S. building a wall before Mexico (and other similar shifts towards xenophobia)

climate change: impacts ("threat multiplication")

- climate change can exacerbate a wide range of existing, interacting, non-climate threats to security - it may contribute to a conflict, rather than being the sole cause - i.e.- climate change = increased risk of conflict - "threat multiplication theory": climate change makes violent conflict more likely, which in turn is bad for health - this link is not exactly obvious - propositions: 1. link between climate change and conflict (requires evidence) 2. link between conflict and decreased health (requires exploration) - proposition 1: climate change makes violent conflict more likely: > contemporary qualitative explorations (i.e.- does climate change alter political balances in a way that promotes conflict?) > contemporary quantitative analyses (i.e.- statistical correlations) > need for proxy measures (see 'climate change: impacts (the challenge of shifting the scales)') > archaeological and deep historical methods - proposition 2: violent conflict leads to decreased health outcomes: > conflict hinders efforts to reduce infectious disease: * global disease eradication * regional disease and vector control * movement or motivated targeting of health care personnel (e.g.- Iraq) * reduced ability to monitor for new or re-emerging diseases * access to health care infrastructure is hindered * studies show that people are more likely to undertake risk during conflict (e.g.- have unprotected sex) which can spread disease * e.g.- polio is existent in countries in violent conflict, where health care workers are unable to distribute immunisation (i.e.- Pakistan, Afghanistan and Nigeria) * e.g.- theory that wartime conditions of WWI assisted the Spanish influenza to be an aggressive outbreak (due to mustard gas-weakened lungs and people living in close proximity)— people who were within the soldiers' age group were the most affected > possible consequences of war motivated partly by scarce resources: * food as a weapon → rising rates of under-nutrition and resulting disease outbreaks * genocide or other forms of resource distribution (due to population pressure) * e.g.- theory that the Rwandan genocide (1994), where almost 1 million people died, occurred due to the fight for arable land

integrated, people-centred health services (WHR, 2008)

- community: > primary healthcare, comprehensive, person-centred care > social services > self-help groups > community health workers - specialised care: > diabetes clinic > TB control centre > community (____?) health unit - hospital: > emergency department > maternity > surgery - training centres - NGOs: > women's shelters > alcoholics management - specialised prevention services: > environmental health > screening centres - diagnostic services: > CT scan > cytology labs

Global Surgery 2030 Movement

- consensus on safety and quality standards - consensus on critical role of district-level hospitals - modelling investments and impact - indicators (access, workforce, volume, safety, financial protection) - support of national surgical plans - global surgery education - global indicator initiative - single country studies - regional benchmarking - national surgical planning - infrastructure and supplies

prefabricated volumetric construction of integrated operating theatre

- contains: > reception > operating room > sterilisation > storage > utilities and recovery - advantages: > standardisation > quality control > time on site > cost-effective > less pollution > rapidly scaleable > future proof - sustainability: > stable energy > clean water and gas supply > reduction of energy consumption > reduction of costs > reduction of CO2 emission > climate-proof - smart and safe: > use ICT to improve patient management and referrals > electronic health records > remote diagnostics and consultation > remote patient monitoring > disease education and management - standardisation and optimisation: > supply chain management and usage > procedure-specific surgical instrument tray sets > data analytics for optimal consumables usage and minimal wastage > equipment maintenance feedback

early warning alert and response network

- critical for individual, regional and global health security - to support and strengthen implementation of the International Health Regulations in the context of a health emergency (e.g.- natural disaster) - sensitive and respond to signals that indicate outbreaks (uses range of information sources such as indicator-based and event-based surveillance)

big data, technology and health security

- data linkage, electronic medical records and connected medical devices are dual use technologies - advances in patient care, medical research, hospital management - potential for hacking of personal health data and targeted medical harm - zeal for e-health VS safeguards for health security

global epidemiology of TB: general

- deaths: > top infectious killer in the world > 1.6 million total deaths (2017) > 0.3 million deaths among people with HIV > leading killer of people with HIV - infection rates: > 10 million people infected (range: 9- 11.1 million) > 5.8 million men > 3.2 million women > 1 million children > 72% infections in Africa

benefits and risks of gene editing

- debate has been held in science and policy domain and focused on rights of scientists - curing genetic diseases - gene editing is not the only way forward - gene silencing - permanent and unintended consequences of gene editing

foodborne disease surveillance

- definition: > ongoing, systematic collection, analysis, and interpretation of data about foodborne diseases to inform implementation and evaluation of disease prevention > and; dissemination of data to those who need to know to prevent and control disease - aims: 1. to identify clusters and outbreaks of disease 2. to describe epidemiology of foodborne diseases 3. to monitor interventions through disease trends

adolescence

- definition: profound period of human growth and development in which the assets and capabilities that underpin future adult health and wellbeing, social relationships, parenting and employment are established - WHY DOES THIS DEFINITION MATTER? → how we conceptualise and define adolescence influences the scope and focus of laws, policies and programmes intended to protect and empower adolescents - we want to engage and empower adolescents - (currently) 19 and 364 days = adolescent - new biological insights: > different appreciation of biology, learning and behaviour > hormonal maturation → puberty > brain maturation: * region-specific, non-linear * cognition, emotions * limbic regions = emotion, reward * prefrontal cortex = planning, inhibition, future thinking - dynamic social context across adolescence: > family of origin (and family of one's own) > education > employment > peers > media > adolescents engage in more risk-taking behaviours when their peers are observing or present

major health issues affecting adolescents

- diseases of poverty: > infectious and vaccine-preventable diseases > undernutrition > HIV > sexual and reproductive health - injury: > unintentional injury > violence - non-communicable disease: > physical disorders > mental disorders > substance-use disorders ↓ - biggest disease burdens: > multi-burden countries: * e.g.- Africa * major infectious disease DALYs * includes violence-related injury * males are significantly more affected by violence * high chronic disease and mental health issues > injury excess countries: * e.g.- Latin America * males are significantly more affected by violence * includes violence-related injury * high chronic disease and mental health issues > NCD predominant countries : * e.g.- Australia * males are significantly more affected by violence * high chronic disease and mental health issues ↓ - 1990 VS 2016: > Australia NCD predominant → NCD predominant > North America: injury excess → NCD predominant > China: injury excess → NCD predominant > Africa: multi-burden → multi-burden > Indonesia/ PNG: multi-burden → multi-burden > southern South America: injury excess → NCD predominant

natural disasters are linked to infectious diseases

- displaced populations - access to clean drinking water - proximity to functioning latrines/ sanitation - nutritional status of the population - population immunity to vaccine-preventable diseases - access to healthcare services - damage to infrastructure: → directly affects public health → electricity

increasing adolescent visibility

- don't assume "child" refers to adolescents too (usually <5) - bring visibility with language → e.g.- "child and adolescent health" - ensure organisational policy documents refer to adolescents if they are inclusive of the age group - change the age of policies that should cover the span of childhood but don't - help build the field of adolescent health - join adolescent health associations (e.g.- Australian Association for Adolescent Health, International Association for Adolescent Health)

dual-use research of concern (DURC)

- dual-use applies to many technologies (e.g.- biology, AI, cyber, drones, robotics) - research or technology intended to benefit humanity which may also be used to cause harm - "Gain of Function" research (GOF) - harm can occur generally by two mechanisms: 1. laboratory accident 2. deliberate release. - in the case of biology, DURC can result in an epidemic or pandemic - types of DURC: 1. synthetic genomics: > first synthetic virus created in 2002 > no industry-wide regulation 2. genetic modification of pathogens: > documented since the Soviet bioweapons program > revolutionised by CRISPR Cas9 3. other: > 3D printing of biological materials > insect drones - where does DURC occur? > universities > scientific institutions > DIY labs > homes > anywhere!

TB: treatment

- effective drug treatments were first developed in the 1940s - treatment for drug susceptible TB is 6 months (4 antibiotics) - treatment for drug resistant TB is 9 months to 20 months (up to 5 antibiotics) - 20 TB drugs in clinical trials - the cost of treating drug-susceptible TB is $40/ person (with an 85% success rate) - the cost of treating drug-resistant TB is $1000/ person (with a 55% success rate)

precision medicine

- emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person - allow doctors and researchers to predict more accurately which treatment and prevention strategies for a particular disease will work in which groups of people - precision harm? > OPM hack and Anthem Health hack in US 2015 > Victorian Emergency Services data breach 2018 - devices connected to individuals > e.g.- insulin pumps, pacemakers > danger of hackers and devices connected to the internet

public health action

- enhanced health education activities (collaboratively between environmental health, primary health care and health promotion) - culture swab sticks and transport medium: > increase collection and testing of samples (e.g.- stool, blood, urine, hair) > regular transport service for shipment of samples - timely follow up of cases to prevent spread - recommendation for improvement of surveillance and outbreak response activities

MERS

- epidemiology: > low infectiousness > lound in camels, but >60% cases have no animal contact > discrepant outbreaks in several hospitals in KSA > different strains in single outbreaks, and at some transmissions cannot be explained by human to human transmission > unlike SARS, multiple independent introductions, combined with some person-to-person transmission within the hospital > Hajj pilgrimage - probability of international spread:

monkeypox

- epidemiology: > rare infection affecting monkeys, occasionally humans - cases: > Nigeria: * 1971 and 1978 (2 cases and 1 case respectively amongst individuals who were not vaccinated against smallpox) * other small outbreaks in Africa 1996, 2003, 2013 * 2017 largest outbreak ever reported in Nigeria (172 cases, 21 states, no epi-links between states) * 2018 outbreak (76 cases from 14 states in Nigeria) * population of Nigeria 190 million * N cases of monkeypox in Nigeria 2018 → <100, geographically limited area > UK: * first case in September 2018 → patient on naval base in Cornwall * second unrelated case diagnosed at Blackpool hospital within days → nurse caring for case 2 infected in late September * 8 airlines offering flights from Lagos to London

James Roswell Gallagher

- established the first Adolescent Medicine program in the USA (1951) → Children's Hospital Boston - invested in research and training - "It has been frequently said that adolescence is the neglected age group; perhaps it is more sound to say that it is physicians' training in the care of adolescents which has been given relatively little attention."

different surveillance types for foodborne diseases

- event-based: > outbreaks > epidemic-prone pathogens > e.g.- norovirus, chemical poisoning, ciguatera - indicator: > syndromic surveillance > case clusters > e.g. watery diarrhoea, dysentery OR > laboratory confirmed diseases > widely-distributed outbreaks > e.g.- salmonella, shigella, listeria

multiple meanings of sustainability

- financial - ecological - health outcomes - Sustainable Development Goals (SDGs)

key surveillance challenges in foodborne diseases

- financial costs - poor reporting of cases - rapid microbiological changes - practicalities of WGS: > data storage and management > analysis > visualisation - harmonising surveillance approach - sharing sensitive data

first generation of vaccines for SARS-CoV-2

- first generation vaccines: Moderna, Oxford/ Astra Zeneca, Pfizer - success defined as a reduction in disease by 50% (WHO and FDA) - protect against disease, not infection - need two doses - limited data in the elderly, children, pregnant - durability of immunity unknown - "unlikely to be the ultimate solution that many expect"

COVID-19-related discoveries at Doherty

- first to isolate and share the virus outside of China - developed mathematical models to inform Australian and Victorian Government response - characterised the immune response leading to viral clearance - leading the largest national trial of antivirals for hospitalised patients (ASCOT) - four vaccines candidates and COVID-specific antibodies in preclinical development

legal frameworks + professional education and training

- focus on the adolescent: > promote engagement of the adolescent > involve the adolescent in decision making > normalise confidentiality - policies and procedures: > support privacy and confidentiality > developmental, preventive orientation > match health actions to needs > link to community resources - family: > support parent involvement > build parent understanding of quality consultations > build parent understanding of adolescent development - delivery of quality healthcare: > build adolescent health literacy > routine assessment of emergent issues > minimum package of interventions

food and medication security

- food, drugs and vaccines can be used as weapons - 1982 Tylenol murders - 2014 Syrian measles vaccine "mix-up" - 2017 Sydney valium tampering - food security: > globalisation of trade and food supply > increase in large, multi-state outbreaks of salmonella, hepatitis A, listeria, E-coli, botulism other infections through imported foods > unusual vehicles for contamination becoming more common (e.g.- salmonella in vegetables) > toxins and poisons (e.g.- melamine in milk, rat poison in dog food, poison in infant teething remedy - 2018 needles in strawberries, Australia - digitised information on personal shopping habits

Global Fund Strategy

- founded in 2002 - public-private partnership - central theme: investing to end epidemics - four principles: 1. partnership 2. country ownership 3. performance-based funding 4. transparency and accountability

UHC challenges

- general challenges of UHC: > advanced economies (digital help, technologies, shared approaches) > transition economies (free, public, well-organised, etc.) > small Pacific island countries (submerged islands due to climate change, economic costs with farming and agriculture, importation, tourism) > highly-decentralised countries - common challenges: > quality: * infrastructure: facilities, supplies, equipment * regulation: standards * engagement: patient and community > efficiency: * system architecture: primary health care, public health * resource allocation: payment incentives * management: systems and capacities > equity: * financial burden: impoverishment Access - financial, geographical, disability * exclusion: discrimination > accountability: * leadership and coordination: within and outside health sector * implementation: rule of law, participation * information: access, reliability, currency > sustainability and resilience: * public health capacity: preparedness * community capacity * resource deployment flexibility: rigidities and fragmentation

"Global health is public health", Fried, et al., 2010 (Lancet)

- global health and public health are indistinguishable - world health needs are very complex - scientific opportunities for prevention and treatment have become more sophisticated - need for coordinated appropriated approaches are more urgent - similarities between global and public health: > both view health in terms of physical, mental and social wellbeing (rather than merely the absence of disease) > both emphasise poulation-level AND individual level approaches to health promotion > both address root causes of ill-health (via scientific, social, cultural and economic strategies) - key tenets of global public health: > global health is public health > dedication to better health for all (as a basic commitment to human rights) > belief in global perspective of scientific inquiry (and translation of knowledge into practice > scientific approach to health promotion and disease prevention > commitment to an interdisciplinary approach and collaborative team works to analyse population problems > multilevel systems-based interventions deployed to address the interactive contributions of societal and health-governance issues, corporate responsibility, etc. > comprehensive frameworks for financing and structuring health policies and services that support community-based and clinical prevention integrated with healthcare delivery - global health is (falsey) perceived international aid, technologies, interventions from wealthier countries, etc. - more contemporary perspective recognises contributions of resource-rich and resource-scarce nations - importance of global perspectives: > pandemic infectious diseases (e.g.- AIDS, influenza) are not confined by national resources > chronic disease will grow with the ageing population > cross-national comparisons of health systems can yield useful insights > health workforce is becoming globalised (current dominant model = migration of workforce from south to north) - public health schools remain at the forefront of efforts to educate global health experts - they bring systems approaches and focus on prevention science and evidence-based interventions with a multidisciplinary faculty - new university structures support synergies in global health education, research and service [IS THIS EVEN IMPORTANT?] - strokes account for 10% of worldwide deaths every year - incidence of stroke in high-income countries has reduced by 40% over 40 years - incidence of stroke in low-income countries has more than doubled (85%) over 40 years - gross underfunding of stroke research (compared to heart disease and cancer)

"Towards a common definition of global health", Koplan, et al., 2009 (Lancet)

- global health is derived from public health and international health (which evolved from hygiene and tropical medicine) - rarely defined (definition varies greatly) - can be considered a notion (current state of global health), an objective (world of healthy people, condition of global health) or a mix of scholarship, research and practice (questions, issues, skills and competencies) - without a definition: > obscures philosophy, physicians, researchers, funders, media and the general public > cannot reach agreement about what you are trying to achieve, approaches to take, skills needed and use of resources - Farr, Chadwick, Virchow, Koch, Pasteur and Shattuck's discipline on infectious disease (which are embedded in definitions of public health): 1. decision-making based on data and evidence 2. focus on populations (than individuals) 3. goal of social justice and equity 4. emphasis on prevention (than curative care) - Winslow's definition of 'public health': the science and art of preventing disease, prolonging life and promoting physical health and efficacy through organised community efforts for the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene, the organisation of medical and nursing services for the early diagnosis and preventative treatment of disease, and the development of social machinery, which will ensure every individual in the community a standard of living adequate for the maintenance of health; so organising these benefits in such a fashion as to enable every citizen to realise his birthright and longevity - US Institute of Medicine (IOM)'s definition of 'public health': > has a mission*, substance, organisational framework, which, in turn, addresses prevention, a community approach, health as a public good, and the contributions of various partners > *mission: fulfilling society's interest in assuring conditions in which people can be healthy - Dictionary of Epidemiology, 2001 (Last): > one of the efforts to protect, promote and restore the people's health > combination of sciences, skills and beliefs that is directed to maintenance and improvement of the health of all people through collective or social actions - 'international health' was previously related to health work abroad, with a geographic focus on developing countries and often with a content of infectious/ tropical diseases, water/ sanitation, malnutrition and maternal and child health - now includes chronic disease, injuries and health systems - Global Health Education Consortium's definition of 'international health': relates more to health practices, policies and systems... and stresses more the differences between countries than their commonalities" - Merson, Black and Mills' definition of 'international health': application of the principles of public health to problems and challenges that affect low and middle-income countries and to the complex array of global and local forces that influence them - commonalities ("entities") between global, public and international health: 1. priority on a population-based and preventative focus 2. concentration on poorer, vulnerable and undeserved population 3. multidisciplinary/ interdisciplinary approaches 4. emphasis on health as public good and the importance of systems/ structures 5. participation of several stakeholders - 'global' refers to any any issue that concerns many countries or is affected by transnational determinants - examples include climate change, urbanisation, polio eradication, epidemic infectious diseases (dengue, influenza A, HIV), maternal/ child health issues - should address tobacco control, micronutrient deficiencies, obesity, injury prevention, migrant-worker health, health-worker migration - unfortunate lesser focus on undernutrition, overnutrition, HIV/ AIDS, tobacco, malaria, mental health - 'global' refers to scale of issues (less so the location; global health can focus on domestic health disparities) - wealthier countries, organisations and foundations assisting health initiatives of countries is understandable but hinders distinguishing global health issues - steady evolution of philosophy, attitude and practice has led to the increased use of 'global health' - portions of western lifestyle are communicable (dietary changes, lack of physical activity, reliance on automobile transport, smoking, stress, urbanisation) - the spread of disease and health risks are often linked with trade, attempted conquest, improved communications, improved speed of travel, economic interdependency of multiple nations, globalisation, etc. - e.g.- plague spread across Europe → Asia in the Middle Ages - definition of 'interdisciplinary scope of global health': > professionals from many diverse disciplines contributing to the overall improvement > embraces curative, rehabilitative medicine > public health-based (rather than population and preventative-based)

climate change: indigenous connection to country

- globally, indigenous Australians are one of many minority groups with lower adaptive capacity than majority populations - when it comes to health equity, adaptation is a mirage - indigenous relationships with nature are seen as a problem as opposed to a solution - climate change and resultant ecological destruction destroys their personal and community health - the West needs to see their inextricable, respectful connection to the land as a valuable lesson

stakeholders in UHC-related decision-making in a post-COVID-19 world

- government - parliamentarians - health services and professionals - community members and social institutions - industry interests - WHO - bilateral and multilateral partners

surgery and anaesthesia: "partnership" approach of the integrated operating theatre

- governments: > Ministry of Health and Sports > Ministry of Finance > Ministry of Education - industry partners: > Bouygues Construction > Philips > Siemens > BBraun > Johnson & Johnson - international organisations: > Asian Development Bank > WHO > Lancet Commision (WHO) > SS2020/ Dalberg > GE Foundation > AO Foundation > SILENT Foundation > Temasek Foundation - academic and professional organisations: > Nanyang Technological University > National University of Singapore > University of Medicine 1 and 2 > Hong Kong University > Australian National University > Royal Australasian College of Surgeons > GlobalSurg

trend of Development Assistance for Health (DAH)

- grew significantly in 2001 to 2011 - highest total DAH reached in 2017 - need for continued progress in: > domestic financing > contribution from private sector (corporations, foundations, HNWIs) and innovative finance mechanisms > increased engagement of emerging economies > new narrative for advocating increased funding for global health > greater efficiency in allocation and spending

advancing UHC

- health system functions: > service delivery > health financing > governance ↓ - action domains for UHC: > quality > efficiency > equity > accountability > sustainability and resilience ↓ - outcomes and impacts: > reduced health risks and improved health > equitable health outcomes > improved financial protection

COVID-19-exposed fault lines and opportunities

- health system: > public health VS health care > disease control VS community engagement > hospitals VS primary health care > COVID-19 VS non-COVID-19 > mental VS physical health - population: > vulnerable population groups (frail, disabled, multi-morbidities, insecure employment, low income, carers, health care workers) > health literacy and infodemics > solidarity VS individual pursuits > trust VS suspicion

WHO 13th General Programme of Work (GPW 13)

- healthier populations (1 billion more people enjoying health and wellbeing) - health emergencies (1 billion more people protected from health emergencies - universal health coverage (1 billion more people benefitting from UHC) * the WHO is trying to ensure this happens, not that it has already occurred - general scope: > missions: 1. promote health 2. keep the world safe 3. serve the vulnerable > UHC: * financial risk protection * access to quality essential health care services * access to safe, effective, quality and affordable essential medicines and vaccines for all > health system strengthening: * achieve UHC and SDG * to contribute to health security and management of migration > outcomes: * step up global leadership (diplomacy, advocacy, gender/ equity rights, multisectoral action) * drive impact in every country (differentiated approach) * focus global, public good on impact (normative guidance and agreements, date, innovation)

people in poverty

- in 2025, almost 60% of vulnerable people will live in LMICs - 80% will live across middle-income countries - levels: 1. <$2/ day 2. >$2/ day - <$8/ day 3. >$8/ day - <$32/ day 4. >$32/ day

climate change: Puebloans/ the Anasazi

- in the capital of Chaco Canyon - had a population density that couldn't be locally supported - due to regional climate change, prolonged periods of drought, cyclical periods of topsoil erosion, environmental degradation and hostility from new arrivals - environmental stress is reflected by changes in the social structure - lead to conflict and warfare - distributed risk and resources to ensure against local drought - violent cannibalism and defensive architecture - ultimate cause is the increased population pressure - proximate cause is the drought

TB: basic facts

- infectious agent: > Mycobacterium tuberculosis complex > predominantly Mycobacterium tuberculosis > also Mycobacterium bovis, Mycobacterium africanum and Mycobacterium canettii - obligate human pathogen transmitted person to person via the airborne route, in the nuclei of respiratory droplets - bacteria are expelled when someone with untreated pulmonary or laryngeal TB coughs, laughs, sneezes or sings - typically affects the lungs (pulmonary-TB) - extrapulmonary-TB sites include the brain, heart, bone, kidneys, stomach and intestines

the Lancet Commission's national surgical plan

- infrastructure - workforce - service delivery - financing - information management - "the Cube" > 'cube' is surgical procedures, packages and platforms > areas to improve: * population covered * user fee (including prepay) * procedures, packages and platforms publicly financed > 100% enrichment = UHC

determinants of access to surgery

- infrastructure and referral pathways - human resources - facilities, protocols and training - financing - timeliness - capacity - safety - affordability

major shifts in global landscape

- institutional changes - global economy - demographic shift - movement of people/ refugee crisis - climate change - changing burden of disease ↓ SDGs (2030)

HIV funding

- international funding - bilateral assistance - multilateral assistance - private philanthropies (e.g.- The Bill and Melinda Gates Foundation, Gilead Sciences) - others (e.g.- ViiV, Healthcare, Aidsfonds, Elton John AIDS Foundation) *recently, domestic funding has been increasing (~57% in 2015)

improving foodborne disease control

- investigate outbreaks rapidly - characterise key outbreak agents - summarise outbreak investigations - outbreak surveillance - always think one level up! → communicate - improve collaboration across sectors - epidemiology, food safety and agriculture

MNCH: importance of maternal, newborn and child health

- is the greatest burden of mortality, illness and under-nutrition is in pregnant women, newborn and children under the age of two, globally - huge mortality - enormous morbidity - intergenerational impacts - neonatal mortality - huge majority of deaths are preventable - annual deaths: > women die during pregnancy and childbirth: N/A > babies <1 month: N/A > children <5 years: N/A

climate change: how much will it change?

- it is not exactly known how much it will change (because human activity damaging the Earth is fluctuating) - there are also temporal delays upon the release of greenhouse gases, meaning the Earth's temperature now may not reflect the reality of the damage - however, so far, the planet has been largely on a worst-case trajectory (based on future emission scenarios) - positive feedback loops - The Paris Agreement (2016) is an agreement within the United Nations Framework Convention on Climate Change - the Agreement aims for less than 2 degrees of increase (less than 1.5 degrees is preferrable)

international legislation

- legislations: > International Health Regulations > Biological Weapons Convention > Cartagena Protocol > terrorism laws > criminal laws - problems and gaps: > voluntary self-regulation of synthetic biology > no global oversight of dual-use research > DIY biology labs > insider threat > detecting planning for biowarfare > dark web > cryptocurrency

antiretroviral therapy (ART)

- lifelong HIV treatment regimen - does not 'cure' HIV - helps prolong life - tablet (consumed every day), injections (once every two months), antibodies (once every 6 months), implants (once a year) - $25,000/ year in Australia - more and more people are receiving treatment every year, but access is not universal

climate change: positive feedback loops

- loss of albedo: > a measure of how much light that hits a surface is reflected without being absorbed > ice in the poles reflects a majority of sunlight back into space as opposed to it being turned into heat energy > nonetheless, ice in the poles are being lost faster than prediction - destruction of forest carbon sinks: > carbon sink: any reservoir that absorbs more carbon than it releases, and thereby lowers the concentration of CO2 from the atmosphere > as the climate changes, fire regimes change also > fires are being apparent in extremely large carbon sinks such as the Amazon - methane release: > methane, a greenhouse gas, is a much more potent and shorter-acting gas than CO2 > East Siberian Arctic Shelf alone has 50 gigatonne reservoir > release could cause $60 trillion of damage (a similar scale to global economy in one year) > release appears to be underway > release could take 50 years or be "abrupt" (which is a vague word)

risk factors VS population attributable fractions for TB

- malnutrition: 27% - indoor air pollution: 26% - cigarette smoking: 23% - HIV infection: 16% - harmful alcohol use: 13% - diabetes: 6%

climate change: "it's not a thing"

- many people negate the reality of climate change, and reject scientific data - potential reasons include: > decreased trust in expert opinion/ data > the innate inability of human beings to handle bad news > people believe in 'climate change' but refuse to act on it > the concept of 'climate change' is perceived to be bleak and uninteresting

recommitting to UHC in a post-COVID-19 world

- means that all people and communities have access to quality health services without suffering the financial hardship associated with paying for care - UHC and post-COVID-19 world: > all people (especially vulnerable populations) > access and quality (full continuum of services, individuals and populations, good health outcomes) > financing (incentives for prevention and cost-effective care; efficient and accountable systems) > UHC and health security (two sides of same coin; all about preparedness) > without UHC, health gains will not be sustained

laws shaping adolescent culture and health

- minimum age of marriage - minimum age of consent for sexual intercourse - decriminalisation of homosexual behaviours - age of consent to medical treatment, including contraception - laws and sentencing for sexual assault - availability of legal abortion - legal working age - driving laws - discrimination laws - internet gambling laws - substance use laws

GAVI's "leaving no-one behind with immunisation"

- mission indicators: > child mortality reduction > lives saved > future DALYs averted > equity indicator - principles: > missed communities (migrants, displaced and vulnerable communities) > gender-focused > country-led, sustainable > community-owned > differentiated (targets national, sub-national needs and needs in fragile contexts) > integrated (primary healthcare in support of UHC) > adaptive, resilient (for global issues like AMR) > innovative (products, practices and services) > collaborative, accountable - goals: 1. introduce and scale-up vaccines 2. strengthen health systems to increase equity in immunisation 3. improve sustainability of immunisation programs 4. ensure health markets for vaccines and related products (see L8 36:56 for more info)

$ per DALY averted`

- more cost-effective to carry out some procedures (e.g.- adult male circumcision, cleft lip repair) than other public health interventions (e.g.- aspirin and beta-blockers for ischaemic heart disease and antiretroviral therapy for HIV) - note: adult male circumcision can reduce the risk of developing HIV (prevention before treatment)

growing health and economic toll of global health security threats

- new, emerging infectious diseases, AMR and drug/ insecticide resistance complicate healthcare - economic implications, global development impact, impact on productivity, national security and international cooperation - major epidemic threats: > SARS > H1N1 influenza > cholera > MERS-CoV > H7N9 influenza > Ebola > Zika > yellow fever > plague > COVID-19 - biggest causes of global death (epidemics): 1. cancer 2. diabetes 3. diarrhoeal diseases 4. TB 5. COVID-19 6. AMR 7. HIV/ AIDS 8. malaria 9. H1N1 influenza 10. Ebola 11. MERS 12. SARS

global emerging and re-emerging infectious diseases (2017)

- newly emerging: > Australia → Hendra virus > South America → Hantavirus pulmonary syndrome > Asia → E.coli, H10N8 influenza, H7N9 influenza, H5N1 influenza, SARS, Nipah virus > North America → H1N2v influenza, E.coli, Bourbon virus, 2009 H1N1 virus > Africa → HIV, Ebola virus, human monkeypox, Zika virus - re-emerging/ resurging: > South America → Zika virus, dengue, yellow fever > Asia → diphtheria, Rift Valley fever, typhoid fever > North America → measles, listeriosis, human monkeypox > Africa → Lassa fever, MDR/ XDR TB, cholera, yellow fever - "deliberately" emerging: North America → anthrax bioterrorism

climate change: other factors

- ocean acidification - stratospheric ozone depletion - nitrogen cycle !! - phosphorus cycle !! - global freshwater use - changes in land use/ land system change - biodiversity loss !! - atmospheric aerosol loading (NYQ) - chemical pollution (NYQ) - novel entities? - biosphere integrity (genetic VS functional diversity) NYQ: not yet quantified

critical issues for UHC in SDGs

- outcome: equitable and sustainable health outcomes - service delivery: > across the care continuum > individual and population level interventions > equity of access > people-centredness > co-production of health - financing: > from financial protection to removing financial barrier to access > from cost containment and technical efficiency to allocative efficiency > funding and payment incentives for prevention at scale and cost-effective care - governance: > macro-management through legal frameworks and policy coherence across sector > transparent information flow > citizen participation > path dependency and country-specific roadmaps

synthetic biology is not regulated

- over 140 private companies, self-regulated with voluntary codes of conduct - no enforceable global governance system in place - what are the potential negative consequences of self regulation for medicine VS synthetic biology?

epidemic-prone causes and diseases

- overcrowding of people: measles, meningitis, acute respiratory infections - waterborne diseases: diarrhoeal diseases, hepatitis A & E, leptospirosis - vector-borne diseases: dengue, malaria - other: injury, VPDs (e.g.- tetanus)

biosecurity: general

- pathogens, with or without a contagion can cause harm - designer pathogens can be made by genetic engineering - some pathogens have WMD potential and existential threat to humanity - capability is cheap, accessible and getting more so by the day - intent is clear; motives and perpetrators may be different to other terrorism - insider threat in laboratories is a major risk → may even be extra motives for scientists - an attack will usually pass as a natural event and no-one will know (stealth) - analogies to cybersecurity → technology has outpaced governance, legislation and preparedness, but you are 10 years behind in biosecurity - threat is occurring on domestic soil → your people will be exposed and need protection - prevention is better than cure → regulation, intelligence and law enforcement - natural pandemics occur every 10-40 years - engineered strains of avian influenza exist - methods for engineering avian influenza to make it transmissible in mammals are published and freely available - bioterrorism has been documented throughout history - lab accidents and mishaps are common! - there were at least 5 in the US alone in 2014, involving Ebola, avian influenza, anthrax and smallpox - the last case of smallpox in the world was from a lab accident

improving early detection of TB

- patient-initiated pathway: > patient recognising symptoms → improving knowledge and awareness > patient accessing healthcare → minimise barriers to healthcare access > identification of patient who requires TB test → strengthening identification of suspected TB > completing high-quality diagnosis + notification treatment → improve referral and notification practices - screening pathway: > contacts: * children * other risk groups * all household * workplace * wider society > clinical risk groups: * HIV * previous TB-affected patients * malnourished population * smokers * diabetics * drug abusers > risk populations: * prisoners * urban slums * poor area populations * migrants * workplace * elderly * infants

TB: risk groups for latent tuberculosis infection (LTBI) testing/ treatment

- people living with HIV - children <5 years old with contact to a bacteriologically confirmed pulmonary-TB - clinical indications: > silicosis > anti-TNF treatment > dialysis > transplantation - other groups exposed to TB: > factors related to exposure (e.g.- crowded living conditions) > biologic and genetic predisposition (e.g.- sex, age, genetic susceptibility) > factors related to health seeking (e.g.- sex) > factors related to disease progression (e.g.- HIV (16%), diabetes (6%), malnutrition (27%), smoking (23%), excessive alcohol use (13%), silicosis, end-stage renal failure, malignancy, corticosteroid use, tumour necrosis factor use) > other factors (e.g.- indoor air pollution (26%)) > there is also a strong association between TB and poverty *the %s are 'population attributable fractions'

routes of infection transmission

- person to person: > e.g.- smallpox, influenza > infection of one person can spark an epidemic - soil/ water/ food/ vehicle to person > e.g.- salmonella, anthrax > point source outbreaks - vector (animal or insect) to person > e.g.- plague, tularemia > continuing vector borne outbreaks (e.g.- tularemia in Kosovo) > insect to human → malaria, dengue, yellow fever > animal to human → typhus, bovine TB, plague > possibility of new vectors

climate change: multiple levels of health adaptations

- physiologic: > healthy people adapt to health stresses all the time > indigenous people have poorer baseline health: * high rates of CVD and diabetes * CVD and diabetes decrease ability to cope with heat - personal/ household: > often be expensive > households with higher levels of education will be best able to plan their adaptations > Australia's history of colonialism has led to indigenous people earning less and having reduced access to formal education - community: ? - state: > indigenous Australians do not have proportionate influence over government > more remote population means that indigenous people will probably disproportionately miss out on adaptive infrastructure and initiatives - 'high regret's adaptation (connection to country): > lack of good adaptive options will drive "high regrets" responses > some may contribute to further loss of cultural continuity, emotional and physical health > reliance on adaptation favors cultural assimilation, including through a different relationship with country > right to one's culture is enshrined in Article 27 of the UN's Universal Declaration of Human Rights

climate change: the next steps

- planetary boundary threats to health can usefully be conceptualised as a class, and several endanger humanity's continued health - planetary boundary threats to health are resistant to intervention even where technical solutions exist - many of the barriers to solutions are linked with the modern worldview of nature as commodity, and economic and political systems which support and rely on that view - given the diversity of planetary boundary threats to health, the most efficient way to avoid harms to health could hinge on altering the view of nature and making the necessary adjustments to our economic and political systems - the balance between mitigation and adaptation is critical - the balance is political - economics are rapidly turning in our favour, at least for climate change - current generation is mobilising - Public Health Association of Australia is the direct way to make change

lesson learned from HIV in Indonesia

- powerful global health actors engage in strategic social construction advancing claims concerning what does and does not deserve a public recognition - global commitments endorsed by donors often dictate local actions and priorities at the cost of creating access inequities at the local level - global health emphasis on the short-term measurable outcomes through implementation of global indicators, initiatives, and conditional health budgets put pressure on local health systems, distort local priorities, and exacerbate the existing access inequity to the most vulnerable groups

red flags for a planned BT attack

- precursor attacks of smaller scale may precede main attack - may see "testing" of naturally occurring agents on Category A list - if genetic engineering is involved, may see multiple outbreaks of related but different pathogens ("field testing") - may see multiple genetic variants detected at same or similar time, even in the same outbreak - may see multiple outbreaks of a desired syndrome (e.g.- pneumonia, encephalitis) caused by different pathogens, clustered in time - dead animals or birds - may see discrepant epidemiologic pattern

MNCH: world vision

- pregnant women (-9 months) 1. adequate diet 2. iron/ folate supplements and deworming 3. infectious diseases prevention (e.g.- tetanus toxoid (TT)), immunisation, PMTCT of HIV, STI, TB screening) 4. malaria prevention, treatment access and intermittent preventive treatment 5. healthy timing and spacing of pregnancy 6. birth preparedness 7. facilitate access to quality maternal health services - children (0-24 months) 1. appropriate breastfeeding 2. essential newborn care 3. adequate diet 4. adequate iron 5. full Immunization for age 6. hand washing with soap 7. oral rehydration therapy/ zinc 8. prevention and care seeking treatment for acute respiratory infection and malaria 9. prevention, care seeking and treatment for acute malnutrition 10. prevention and care seeking for paediatric HIV 11. deworming

climate change: how it affects health

- primary effects of climate change: > when altered climate has direct impact on the human populace > hospital admissions and fatalities increase > e.g.- floods, heatwaves, air pollution - secondary effects of climate change: > ecologically-mediated > climate change will have a great impact on vector-borne illnesses > e.g.- mosquitoes expanding their range of migration and coming south, spreading dengue to Australia (which is not endemic here) > e.g.- sickle cell anaemia is prevalent in malaria-immune populations— bringing malaria into non-physiologically immune populations will cause issues - tertiary effects of climate change: > mediated by social, political and economic systems > largest health effects > e.g.- the food price index experiences peaks upon events due to climate change, such as droughts in the US and Russia— this results in globally-diminished food production (and increases the price)

WHO reforms (2008-2017)

- programmatic reform: from 15 strategic objectives to 5 categories - management reform: Global Policy Group, Category Networks, Programme Networks - governance reform: financing dialogue, Framework for Engagement with Non-State Actors (FENSA) - World Health Emergency Programme (WHO): global programme embedded in regional structure

DIY biology

- proliferation of do-it-yourself (DIY) and biohacker laboratories - public labs worldwide (e.g.- Sydney, NY, London ) - Clandestine labs - technology is widely accessible: > lab equipment can be purchased on internet • > "lab in a box" (another example of DURC) > genetic code can be purchased > proliferation of illegal drug labs in the community > what about illegal bio labs? > what does this mean for police?

WHO's core functions (12th General Programme of Work (12GPW))

- providing leadership on global health matters - shaping the health research agenda - setting norms and standards - articulating evidence-based policy options - providing support to countries - monitoring and assessing health trends

TB: diagnosis

- rapid molecular tests: the only rapid test for diagnosis of TB currently recommended by WHO is the Xpert® MTB/RIF assay (Cepheid, USA) - sputum smear microscopy: developed more than 100 years ago - culture-based methods: current reference standard

Nuremberg code

- requirement of voluntary informed consent of the human subject - risk must be weighed against the expected benefit - unnecessary pain and suffering must be avoided - doctors should avoid actions that injure human patients

P1 and P2

- risk-benefit analysis is critical in order to compare the risks of a natural pandemic versus an unnatural one - P1, the probability of a natural pandemic - and; P2, the probability of an unnatural pandemic - we need to compare these estimates - if P2 is greater than P1, then risk outweighs potential benefit, as the benefits (such as drugs or vaccines) apply to an event of lower probability - learning exercise here is simply the principles of approaching a risk analysis and using probabilities as a starting point - estimates of P1 and P2 will vary depending on the data and assumptions used in the calculation - such an approach allows an early estimate of the relative difference in probabilities - early, rough estimates are important for prioritisation and action

Global Strategy for Women's, Children's and Adolescent's Health (2016-2030)

- roadmap to achieve right to the highest attainable standard of health for all women, children and adolescents - collaboration with stakeholders led by WHO - movement to accelerate the health-related Millennium Development Goals

diagnosing SARS-CoV-2

- saliva testing: planned in Victoria targeting high risk work places eg police, meat workers, Uber - rapid diagnostic tests: > antigen tests potentially suitable for widespread use in populations who have high exposure (e.g.- Uber/ taxi drivers) > point of care tests have transformed HIV testing

constituents of adolescent health

- sexual health - mental health - substance use - nutrition - injury - violence ↓ - every sector's responsibility - includes health and development - from prevent to clinical care

The Australasian COVID-19 Trial (ASCOT)

- sites in Australia, NZ and India - 2000 sample size - patients admitted are SARS-CoV-2 PCR +ve and not ventilated - randomise within multiple domains (e.g.- antivirals, antibodies, anticoagulants) - futile - effective (better than standard of care (SOC))

UHC in a post-COVID-19 world

- social: > engage with social institutions as public good: > impact for UHC: increased health literacy and more equitable uses of health services, including prevention and self-care - technology: > harness digital health > impact for UHC: improved access to quality services - health: > re-emphasize seamless care delivery, based on primary health care and prevention > impact for UHC: transforming service delivery, financing, and governance towards integrated people-centred health system - politics: > building bipartisan approach to intersectoral governance > impact for UHC: strengthened commitment to public policies to achieve health gain, including action on social determinants - economy: > consider innovative financing and operational efficiency > impact for UHC: move to more flexible and adaptable financing to create resilience and sustainable health systems - environment: > decrease carbon footprint of facilities and for seeking care > impact for UHC: plan for distributed network, based on PHC and telehealth

dimensions of the new future

- society: > health is redefining the way we live and behave > new social contract (individual health is a public good) > COVID is polarizing and fragmenting society → greater inequalities and new vulnerable groups > communities living with constant stress, uncertainty and pressure - technology: > COVID-19 has unleashed a flood of innovations that are penetrating society at record speed - health: > health sector (everyone has an interest in health) > years of health gains are undone > healthcare workforce pushed to limits - politics: > health hijacked by extreme politics > rise of the "failed states/ regions due to COVID-19" > new geopolitical alliances - economy: > increased household debt > less fiscal space for health

documented cases of scientific misconduct in medical research

- some mistakes are accidental and some deliberate - unapproved research (e.g.- Alder Hey, Thomas Butler) - falsification of results (e.g.- Haruko Obokata) - several senior scientists around the world have been caught out - Nobel laureates (e.g.-Alexis Carrel) - anonymous surveys show 2% of scientists admitted to falsifying results, and 14% saw others doing so - e.g.- 2001 anthrax attacks in the US and subsequent investigation of a US army-scientist as the main suspect led to National Research Council Committee deliberations and a report (The Fink Report, 2004) - insider threat: "Given the high level of knowhow needed ...(we) should be less concerned that terrorists will become biologists and far more concerned that biologists will become terrorists." (US Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism) - why would researchers create harmful pathogens? > pressure to publish > pressure to win grants and prizes > funding for research labs > desire for fame and recognition > financial gains > spectrum of human character present in all professions

need for an HIV cure

- stigma criminalisation - ART toxicity - ART access (fragile, not guarantee) - ART cost - treating everyone living with HIV by 2030 = $30 billion/ per - significant funding and access disruptions due to COVID-19 - cannot eradicate easily - next best option is "remission" → reduce cells by controlling with cytotoxic T-cells, NK cells and antibodies

benefit-cost ratio

- ten-fold return on every dollar invested on adolescents - improvements in health, education, road accidents and child marriage - highest in low-income countries and countries with highest adolescent mortality rates

non-pharmaceutical interventions for COVID-19

- test, trace and isolate - hand hygiene - masks - physical distancing - limit large gatherings - restaurant/ bar closures - "stay at home" orders - school closures

targetted attacks

- to disable or remove critical targets - likely done to appear "natural" (so homicide is not suspected) - if designed to appear "natural", such an attack would not involve agents such as anthrax or smallpox - DOSE-RESPONSE - one target may experience multiple (serial) attacks (abnormal frequency of infections, more severe infections) - potential locations: airplane, hospitals, workplace, suburban homes/ areas

SDG 3: good health and well-being

- to ensure healthy lives and promote wellbeing for all, at all ages - 9 targets: 1. maternal mortality 2. newborn and child mortality 3. communicable diseases (AIDS, TB, malaria, NTDs, hepatitis, waterborne diseases) 4. NCDs and mental health 5. substance abuse 6. road traffic accidents 7. reproductive health 8. universal health coverage 9. environmental health (chemicals, air, water and soil pollution) - 4 means of implementation: 1. tobacco control 2. vaccines and medicines 3. health financing and workforce 4. global health security

scientists' petition

- to publish or not to publish? > in December 2011, NSABB recommended censorship of publication of full research methods in Science and Nature > voluntary moratorium on engineered H5N1 research from December 2011 > scientific community divided (censorship of science vs risk of bioterrorism) > >1000 scientists (including Nobel laureates) signed petition supporting full publication - the petition: > "Only [by releasing the genetic sequences] can researchers establish and track the global pattern of the evolution of the bird-flu virus." > "And, hopefully, work quickly toward an effective vaccine should H5N1 develop into a pandemic." > "We, the undersigned, call on all governments, health authorities such as the World Health Organization (WHO), and other flu scientists who are researching H5N1 who have not yet released sequence data (such as the CDC, St. Jude's, Weybridge and Mt. Sinai), to deposit them immediately in GenBank. The future of humanity may very well be at stake here -- there is no longer any time to waste." - opposing view: > "... disseminating the entirety of the methods and results of the two H5N1 studies in the general scientific literature will not materially increase our ability to protect the public's health from a future H5N1 pandemic. Even targeting dissemination of the information to scientists who request it will likely not enhance the public's health." > "Rather, making every effort to ensure that this information does not easily fall into the hands of those who might use it for nefarious purposes or that a biosafety accident resulting in an unintended release does not occur should be our first and highest priority." - changing history: > NSABB voted in 2012 to allow publication > 2 papers published in 2012 in Nature and Science > other research has since been published > naturally occurring H5N1 is not readily transmitted between humans > methods for creating mutated H5N1 which can be transmitted readily through respiratory spread now published and available. > one genetic mutation can lead to transmissibility > other studies have followed, identifying genetic markers of transmissibility in mammals/ humans

TB: brief history

- tuberculosis (TB) is also known as: > consumption, > wasting disease > the white plague - affected humans for thousands of years - in 1865, a French surgeon (Jean-Antoine Villemin) showed that TB was contagious - in 1882, Robert Koch discovered the bacterium that causes TB - until the advent of antibiotics post WWII, a diagnosis of TB was a slow death sentence (although self cure is possible)

integrating surveillance data for foodborne diseases

- typing animal, food and human agents: > useful for source attribution > currently not done routinely - many isolates in sequence databases: ~4,500 Campylobacter strains in NCBI - benefits: > could allow intervention before problem > much more specific > minimise industry-wide impacts > capture additional information (e.g.- AMR)

WHO agile think-thanks (rationale)

- understanding how the future may play out and what this means for health and health systems - obligation: > identify actions to "future proof" health systems > reorient health systems to address current issues related to COVID-19 & future challenges - opportunity: > leverage change > lead and not be led

climate change: nature VS culture

- universal 'binary structure' - contrast is important cross-culturally, but differs in its specifics - modern culture is unique in the extent to which it commodifies nature, and its potential to inflict ecological damage

issues in medical research

- unsanctioned research - falsification of results - conflicts of interest - reviewing - plagiarism - self-plagiarism - duplicate publication - ghost-writing

climate change: David Zhang's research

- used historical written records of violent conflict - compared to records of weather, grain harvest and population size - found a strong link in China and Europe - "...long-term fluctuations of war frequency and population changes followed the cycles of temperature change. Further analyses show that cooling impeded agricultural production, which brought about a series of serious social problems, including price inflation, then... war outbreak, famine, and population decline successively. The findings suggest that worldwide and synchronistic war-peace, population, and price cycles in recent centuries have been driven mainly by long-term climate change." (Zhang, et al., 2007)

climate change: planetary boundary threats to health

- usefully considered as a class - characteristics (largely) in common: > mechanisms: * geographically dispersed * temporal lags * momentum from positive feedback (sometimes) > effects: * tertiary health effects are most critical/ important * adaptation comes with costs > barriers to solutions— what are the actions?: * diffuse responsibility: - multiple causes - multiple levels of intervention * over-determination * intergenerational conflict of interests * corruption (plausible deniability) * require international cooperation and mechanisms with teeth

climate change

- variations in the climate that last longer than individual weather events, which persist for a longer period of time, typically decades or more - current warming trend is of particular significance because most it is extremely likely to be the result of human activity - e.g.- global temperature rise, warming oceans, shrinking ice sheets, sea level rise, extreme events, ocean acidification

TB: vision, goal, targets, milestones

- vision: > NO TB > zero TB deaths > zero TB disease > zero TB suffering - goal: > end global TB epidemic > reduce incidence to <10 per 100,000 people - SDG targets (2030): > reduce TB deaths by 90% > reduce incidence by 80% > assist TB-affected families → N/A - "End TB" targets (2035): > reduce TB deaths by 95% > reduce incidence by 90% > assist TB-affected families → N/A - no milestones were reached in 2020 - no milestones are expected to be reached in 2025

public health surveillance in emergencies

- vulnerable surveillance systems: > damaged medical/ public health records etc. > breakdown in communication (e.g.- telephones/ mobile networks, roads) > medical care is priority > limited to negligible resources > staff fatigue - early detection of outbreaks - timely response and control of outbreak

TB: social and biological determinants of tuberculosis

- weak and inequitable economic, social and environment policy - globalisation, urbanisation, migration and demographic transition ↓ - weak health system, poor health access - poverty, low SES, low education - inappropriate health seeking - unhealthy behaviours ↓ - active TB cases in community - crowding, poor ventilation - tobacco smoke, air pollution - HIV, malnutrition, lung disease, diabetes, alcoholism, etc. - age, sex, genetic factors ↓ - high-level contact with infectious droplets - impaired host defence ↓ - exposure - infection - active disease - consequences

differences between terrorism and bioterrorism

- weapon: > terrorism: visible (macroscopic) > bioterrorism: * invisible (microscopic) * bioweapon against one person can spark an epidemic from a contagion * weapon is able to self-replicate - attack: > terrorism: recognisable as unnatural > bioterrorism: may appear natural - terror: > terrorism: present > bioterrorism: if not recognised as an attack, may be absent - target: > terrorism: often many people > bioterrorism: * many people OR one person * bioweapon against one person can spark an epidemic from a contagion

therapeutics for COVID-19

- what works now? > steroids > (Remdesivir) - what's coming? > antibodies > combination antivirals - what would be a game changer? → cheap, oral, non toxic antiviral to reduce chance of progression and reduce transmission - multiple companies developing antibodies to administer alone or in combination (Regeneron, Lily, VIR, GSK) - phase 3 clinical trials now enrolling patients who will receive standard of care or SOC+ LYCoV555 (Lily industries) or combination antibodies (Regeneron) in mild-moderate disease in hospital (ACTIV-3) or as an outpatient (ACTIV-2). Lily antibody paused for review of safety - exciting new approach potentially rapidly translatable to many infectious diseases

dual loyalty

- where a third party, usually a State, competes for the doctor's loyalty to their patient - numerous historical and contemporary examples - Geneva Convention: > states that medical personnel "shall not be compelled to perform or carry out work contrary to the rules of medical ethics." > central to ethics is the principle of "Do no harm" > "Who do I serve?" → the patient!! > what happens when doctors forget who they serve? - case study: Nazi Germany > "To serve this State must be the sole objective of the medical profession" (Executive Director, Hartmannbund, the largest German medical association) > fear of racial and genetic impurity dominated discourse to such an extent that doctors exceeded the demands of the State > Nazi doctors not victims of a "slippery slope" but enthusiastic participants > doctors took the initiative in designing innovations for mechanised mass killing (e.g.- Zyklon B) > Dutch doctors in Nazi-occupied Holland, in contrast to their German peers, refused enmasse to follow orders for forced euthanasia and sterilisation of "untermenschen" ("sub-human") > Nuremberg doctors trials → Nuremberg defense was "just following orders" → not deemed valid > experiments included: * freezing / hypothermia * genetics * infectious diseases * interrogation and torture * killing / genocide * high altitude * pharmacological * sterilization * surgery * traumatic injuries - contemporary examples: > South Africa: doctors under apartheid > Doctors in The War on terror > doctors participating in creation of interrogation plans for prisoners > participation in force feeding of prisoners > Manus Island and medical professionals > official statements negating medical ethics and limiting the role of doctors to obedience to the State

Alder Hey affair

- whole organs, tissues, etc. had been removed and stored without consent from the bodies of deceased children during necropsy at Alder Hey Hospital (a teaching hospital of Liverpool University, UK) by Prof Dick Van Velzen between 1988-1995 - organs were retained in more than 2,000 pots containing body parts from around 850 infants - Professor van Velzen found guilty over 7 years of malpractice in: > unethical and illegal retention of every organ in every case > falsifying records, research applications, and postmortem reports > ignoring written consents to limited postmortem examination > lying to parents about his postmortem findings

simulated smallpox epidemic

- worst case scenario - lasts 4.5 - >10 years - >520 million cases worldwide - 45% mortality - doses of vaccine required far exceed the WHO stockpile - impact greater than a nuclear attack - not Ebola or pandemic flu

surgery and anaesthesia: challenges in Asia and the Pacific

1. - dichotomy: urban growth VS rural poverty - challenges: > crowded facilities > underdeveloped facilities - demands: > average # hospital beds is ~33/ 10,000 people > OECD average: 47/ 10,000 people > need for quality AND access 2. - dichotomy: communicable diseases VS chronic disease/ injury - challenges: > emerging infectious diseases > increasing chronic diseases - demands: > 13 doctors and 32 nurses/ 10,000 people > OECD average: 33 and 91/ 10,000 people > need for acute care AND continuing care 3. - dichotomy: government spending VS out-of-pocket spending - challenges: > increased investment > risk pooling - demands: > public spending accounts for 50% of total health spending > OECD average: 72.7% of total health spending > need for resource mobilisation AND efficient usage

the Lancet Commission's indicators on global surgery

1. 2 hours access (to timely, essentials surgery) 2. surgical volume (procedures done in an operating room per 100,000 people) 3. impoverishing expenditure 4. SAO/ 100,000 (workforce density) 5. POMR ("problem-oriented medical record"; all-cause death prior to discharge patients) 6. catastrophic expenditure

TB: WHO's 5 facts on TB

1. TB kills over 4,000 people a day. It is the leading cause of death in HIV-positive people. 2. TB is airborne and can affect anyone, anywhere. When people with lung-TB bough, sneeze or spit, they propel germs into the air, spreading the disease. 3. Symptoms include coughing, chest pain, fever, night sweats and weight loss. Rapid diagnosis and treatment is important. 4. Drug resistant TB is a public health crisis. This strain can only be treated with a course of second-line drugs. 5. TB is treatable and curable. It takes 6 months and 4 different drugs, support and supervision for regular TB.

top 10 priority indicators (no rank) for monitoring the "End TB" strategy

1. TB treatment coverage: ≥90% 2. TB treatment success rate: ≥90% 3. percentage of TB-affected households that experience catastrophic costs due to TB: 0% 4. percentage of newly notified TB patients tested using WHO-recommended rapid tests: ≥90% 5. LTBI treatment coverage: ≥90% 6. contact investigation coverage: ≥90% 7. drug-susceptibility testing coverage for TB patients: 100% 8. treatment coverage, new TB drugs: ≥90% 9. documentation of HIV status among TB patients: 100% 10. case fatality ratio (CFR): ≤5%

WHO's priorities

1. communicable diseases: > EPI, NTDs, leprosy > HIV, TB, malaria 2. non-communicable diseases: > NCDs > risk factors > nutrition 3. health through the life course: > MCH > GER, SDH, ageing > environment 4. health systems: > health policy and financing > integrated service delivery > essential medicines and technologies > health intelligence and innovation 5. preparedness, surveillance and response: > outbreaks, surveillance > emergencies. disasters > food safety 6. corporate services and enabling functions: > leadership governance > enabilng and support

consequences of the vertical approach

1. creates parallel systems leading to inefficiency: > vertical approach relies heavily on simple and fast acting biomedical advances > bullet-proof methods to target HIV are not known > can also cause rifts in resources and knowledge > intervention and help is disproportionately distributed → basically non-existing in non-priority areas > e.g.- health information systems for HIV > rather than having one, integrated, unified health information system at the local level, there are two (or more) 2. promotes fragmentation of health systems and service delivery > minimises synergies between health systems and programmes > e.g.- in the vertical approach, the scale-up of antiretroviral treatment (ART) attracts staff away from general services and establishes parallel drug supply mechanisms that undermine national systems > in a horizontal approach, an ART scale-up would strengthens capacity of general services and existing health system drug-delivery systems 3. distorts recipient countries' national policies and priorities > because the perception of HIV is pushed by powerful global actors, local level approaches and strategies shift towards HIV instead of any other potential concerns > e.g.- HIV is the main cause of death in Indonesia, a country also suffering with mass pneumonia and diarrhoeal disease. Due to the global commitment to HIV, these diseases get ignored or neglected. > health resources can be wrongfully allocated towards HIV 4. "brain-drain" and local competitions: > "brain-drain": health worker migration from resource-poor countries to developed countries > significant barrier to achieving localised or regional health equity > resource-poor countries are unable to recruit and retain health workers for domestic health systems > this results in inadequate health infrastructure and healthcare investment losses > also creates access issues for communities already suffering from high infant mortality rates, low life expectancy, and the dual burden of non-communicable and infectious diseases > increased funding for vertical global health initiatives and their NGO partners has given rise to competition from NGOs in healthcare worker recruiting > this exacerbates internal migration away from local and public sectors to higher paying private sector NGO positions > financial incentive for working for HIV-specific programs **conditional funding (e.g.- by the Global Fund and AusAID) that may not align with the local/ regional needs, is also a downside to the vertical approach → very strictly controlled and distributed** ⭐️ take-away message: vertical approach is favoured by global partners because it offers measurable short-term outcomes, however, longer term bring harms to local health systems ⭐️

Fink report, 2004 (recommendations on biosecurity)

1. educating the scientific community 2. review of plans for experiments 3. review at the publication stage 4. creation of a National Science Advisory and Board for Biodefense (NSABB) 5. additional elements for protection against misuse 6. role for the life sciences in efforts to prevent bioterrorism and biowarfare 7. harmonized international oversight

improving diagnosis and treatment of drug-resistant TB

1. general improvements of TB detection and treatment → general health systems strengthening 2. specific MDR-interventions: - scale up rapid molecular testing with detection of rifampicin-resistance testing - scale up general drug-susceptibility testing - scale up shorter MDR-TB treatment regimens - provide optimal patient support: > counselling > psycho-social support > material support (e.g.- cash, food, housing, etc.)

prefabricated modular ORs for capacity building and system strengthening

1. health infrastructure 2. healthcare delivery capacity 3. education/ training AND facility and supply chain management 4. innovative financing AND health system strengthening

TB: tuberculosis spectrum

1. infection should be eliminated (with an immune response or with an acquired immune response) 2. latent TB infection 3. subclinical TB disease 4. active TB disease 5-15% of people exposed to TB develop the disease

the GAVI model at work

1. leveraging economies of scale 2. long-term funding 3. shaping markets 4. accelerating access to vaccines 5. strengthening vaccine delivery platforms 6. sustaining immunisation (see L8 39:21 for more info)

main 3 ways to end the TB epidemic

1. optimizing current strategies and interventions for TB care and prevention 2. achieving universal access to TB care and support within UHC and social protection and addressing social determinants of TB → part of the global development framework of eliminating poverty and addressing inequity 3. investing in research to develop new, better and rights-based tools and strategies for diagnosis, treatment and prevention of TB

lacking infrastructure in hospitals

1. post-operative care area (45%) 2. emergency care area (30%) 3. electricity source (30%) 4. oxygen source (25%) 5. running water (20%) - potential solutions: > rebuild in public sector > private hospital expansion > upgrade equipment and only necessary building repairs > supplement with mobile solutions > other innovations (e.g.- "technological leapfrogging")

context-catalyst-capacity wheel

1. prioritise: - stakeholder prioritisation processes - variation in practice 2. synthesise - research priorities - primary research - research syntheses - guidelines - policy briefs - evidence maps 3. translate: - knowledge translation strategies - implementation science 4. measure: - registries and audits - project evaluations - research use

four guiding questions and 12 action domains

1. what are countries aiming to achieve, and how will they know? - country-led selection of health goals, targets and indicators - robust monitoring and review process - adequate information capacity 2. what are the policy and programme priorities for leaving no-one behind? - equity in health services - realising win-wins through collaboration across sectors - financing strategies for promoting equity 3. how will countries put their priorities into effect? - collaboration across government - engagement of stakeholder beyond government - participation of affected communities 4. how can the health sector drive the agenda? - capabilities for knowledge exchange - leadership skills to navigate the policy system - institutional capacity for present and future challenges

regional action agenda on SDGs

1. what are countries aiming to achieve, and how will they know? 2. what are the policy and programme priorities for leaving no one behind? 3. how will countries put their priorities into effect? 4. how can the health sector drive the agenda? can leave nobody behind!