Public health

Global Rx

Randall M. Packard tells this story: In a small village in southeast Guinea in late 2013, a 2-year-old boy died. He died from Ebola, and the disease that killed him quickly spread to neighboring Sierra Leone and Liberia. In the end, 11,315 people succumbed to Ebola, their deaths the result of a confluence of factors that included extreme poverty, a dysfunctional and threadbare health care system, unsafe burial practices, a mistrust of government officials, and a months-long delay in properly responding to the outbreak. Ultimately, the widespread transmission of Ebola in West Africa was controlled with the assistance of U.S. government agencies, the World Health Organization, and other partners that deployed teams of public health experts, doctors, and nurses. It's a familiar tale. Outbreak occurs. Medical SWAT team swoops in with Western-world pharma and tech to shut down the epidemic. Victory. Yet, it's only a matter of time until the cycle repeats because the underlying disease ecology has not been addressed.

Packard, director of the Institute of the History of Medicine at Johns Hopkins, tells this story in his book A History of Global Health: Interventions Into the Lives of Other Peoples (Johns Hopkins University Press, 2016). The book is a 400-page big-picture history of medicine's long struggle to improve the health of all the world's peoples. But Packard wants to make a point, forcefully. "I thought the Ebola outbreak set the stage for the central argument of the book, which is that this epidemic was allowed to spread in local communities because there were not adequate health services at the time, meaning not enough people adequately trained and supplied to actually deal with it," he says. "That is part of a broader problem that affects populations across the globe: the absence of basic health services. Despite the fact that we've invested hundreds of billions of dollars over the past century to improve health care, we're still addressing this fundamental problem that is driving these diseases."

Though global health initiatives have indeed saved millions of lives, Packard argues, they have had limited impact on the overall health of people living in underdeveloped areas because little effort has been made to address the underlying social and economic determinants of ill health. Global health campaigns rely on the application of biomedical technologies to attack specific problems—the bifurcated needle, which became the primary field instrument for the World Health Organization's Smallpox Eradication Programme, or vitamin A capsules to reduce child mortality. "Most of the lives we save are children, by reducing child and infant mortality, as these are the most vulnerable populations," Packard says. "And that is good, but these people grow up with health needs and no place, or limited places, to go to seek care for their needs. What if someone gets cancer and there's literally only one oncologist in the country? It's a conundrum because you don't not want to do the things that we in public health do. They are really important. They save lives. But we can't say that's all we can do. We don't do enough to address the things that make people sick and create the conditions [for disease]."

Though global health initiatives have indeed saved millions of lives, Packard argues, they have had limited impact on the overall health of people living in underdeveloped areas because little effort has been made to address the underlying social and economic determinants of ill health.

Packard says that while the term global health was popularized in the 1990s, many of its principles and practices date back to the early 20th century and have persisted through the years, often reinforced by the need to address epidemic diseases exacerbated by international wars and conflicts.

His book chronicles the successes of global health, like the smallpox eradication campaign, and some of its failures. In the 1940s, when millions of people were dying from malaria, the World Health Organization launched a campaign to defeat the disease with the introduction of the insecticide DDT. While it eliminated malaria from Europe and North America, and reduced it in parts of Asia and southern Central America, the disease returned in many areas of the globe and increased in sub-Saharan Africa.

In addressing today's global health issues, Packard says those in public health will likely end up dealing with the Zika and dengue viruses with a vaccine, as was the case with yellow fever. But Zika and dengue are also both mosquito-borne diseases driven by the same environmental conditions: poor sanitation, poor sewage systems, and the failure to eliminate breeding sites. "So what comes after Zika in these areas?" he says. "Probably something even worse, as has always been the case."

In a show of optimism, Packard does point to some examples of initiatives that global health might want to emulate in the future. He mentions the work of Paul Farmer, who founded Partners in Health, a global organization that has built health systems in Haiti and Rwanda from scratch. And there's the Comprehensive Rural Health Project, a community-based health care model founded in 1970 in Jamkhed, India, by Johns Hopkins alumni Raj and Mabelle Arole. 

"Partners in Health is perhaps not a model that is applicable everywhere because it requires a lot of resources, but this is a permanent solution where other efforts have been temporary," Packard says. "Now, how do you do this across the globe? It will be hard-going, but it's a vision worth having. There are signs that there is finally recognition that this is important." The Gates Foundation is starting to take on primary health care, and providing basic health care for all is one of the United Nations' Sustainable Development Goals to address by 2030. "Whether we do this or find another vaccine, it's hard to know. We need to rethink our priorities and not keep doing what we're doing."