Public Health: A Global Challenge

Fast food, lack of physical activity, stress - more and more people around the world suffer from diabetes, obesity, cardiovascular disease and cancer. Treatment is expensive and many countries lack the necessary health care systems to deal with these problems. And the situation is likely to get worse. Climate change poses new threats to health. Global health problems require global solutions. We spoke with Prof. Rainer Sauerborn about the most pressing problems and about possible ways to solve or prevent them. He is the director of the Institute of Public Health in Heidelberg and a lead author for the IPCC.

What do you consider to be the greatest challenge faced by medical research in the future?

I believe that climate change poses the biggest challenge to health in the 21st century. Now I know that some of my colleagues will say we can't put that in numbers, but that is not the point. The point is that we may be facing irreversible changes. And even though they lie in the future and are not so easy to grasp, we can't ignore them. We need a paradigm change. We have to change our viewpoint. We have to agree to make decisions - even on an uncertain basis - decisions about the connection between climate change, changes in temperature and precipitation, extreme weather events and health - and we have to get prepared.

What does that mean concretely? What is the connection between climate change and health?

Once the CO2 is in the air we can't get it out again - it stays there for a thousand years. If we - the generation that caused this problem - wait until the health problems are so obvious that even the last scientist who claimed it's not true can see it, then it will be too late to turn back. These are irreversible effects. If you stop smoking after a certain time your risk goes back to being as great as that of a non-smoker. If you shed your excess weight, go to the gym, then things can improve again. But that is not true of climate change: we can't go back. Climate changes are a one-way street - and so are the consequences of global warming.

"Climate change acts like an amplifier"

So the health effects can't be foreseen yet?

Yes, but at the moment they are not so much at the center of attention as diseases like AIDS. There are unmistakable links between climate change and malnutrition, malaria, dengue fever or diarrhea. Insects react to the temperature of the surroundings and a warmer temperature changes their biting and stinging behavior. It accelerates their breeding cycle. And even mental illnesses increase because when the environment gets destroyed people have to leave their land. That leads to greater streams of migration - that is something we can foresee. It's already predicted that sea levels will rise by 80 centimeters. Countries like Bangladesh, Indonesia or the Netherlands lie below today's sea level and you don't have to be a pessimist to see that there's a lot in store for us.

It's already clear that the number of extreme weather conditions, like flooding and heat waves will increase [...] Climate change acts as an amplifier that intensifies the connection between weather, insects and disease [...] We have to understand that it is a disturbance and that it affects most diseases in a negative way - in some cases considerably. We believe that heat waves, malnutrition and infectious disease will cause the greatest mortality and that this is rising exponentially. We have to realize that we must look to the future.

"We are exporting our hamburgers, our lifestyles, our cars."

So in public health you are not so much involved in treating disease as in preventing it?

Medicine is the art of healing the sick. That is a radically different thing from keeping healthy people healthy. Such questions as 'do we need to improve cancer treatment?' 'Do we need better medications for heart attacks?' 'Do we need better hospitals?' represent a different approach. Medicine is the glitzy thing we see in hospitals with all the fancy equipment - and here in Germany we are at the top in that regard. And then we have the question: what are the health problems that are going to affect the population? [...] When we consider whether there are going to be heat waves we assume they will affect healthy people, or that malnutrition will affect people who are not ill. Global Health is a special aspect of public health, one which not only ignores national borders, but actually undermines them. Let's take the examples of an epidemic, or climate change or smoking. The Americans are now exporting their Marlboros to China because they can't sell them at home so well because of the strict restrictions on smoking. So now the problem is not longer an American public health problem, but a global one. We are exporting our hamburgers, our lifestyles, our cars. That means much of public health can no longer be addressed - or even measured - on a national level, quite apart from solving the problem.

Global health is the aspect of the population's health that depends on global factors like climate change or lifestyles. I'm not talking about specifically medical research like new medicines, new vaccines or new methods for curing the sick.

"This is not just a matter of medications; it's not about dropping CARE packages."

Which themes apart from climate change call for the most research in your opinion?

Non-infectious chronic diseases like diabetes or high blood pressure [...] The population in China, India and Indonesia is growing older and people's lifestyles are becoming more and more westernized - that is, more unhealthy. Today there are more fat people than undernourished people in the world, including in China and other countries. So this is an international issue, one which the UN has recognized. We have to build up a new kind of cooperation to combat this problem. Unfortunately, chronic diseases are often much more expensive to treat. They are often life-long diseases. Diabetes or cancer require months of intense, costly therapies. Diabetes is life-long, controlling blood pressure is life-long, and so are other chronic diseases. This is not just a matter of medications, it's not about dropping CARE packages with a parachute. Diabetics require continual management. They need to see a doctor every couple of weeks or months. And treatment has to be adjusted if they do sports or eat more. It's incredibly elaborate. With malaria patients you give them 10 pills and it's taken care of. But the chronic diseases require life-long care. It's a completely different kind of challenge. Health care systems - especially in poor and middle-income countries are absolutely not prepared for this. The next wave that is coming will be terribly difficult to handle. There is an uncovered demand for health care that can only be solved on the basis of global solidarity. Burkina Faso and Bangladesh cannot manage that on their own.

"How can we manage - especially with chronic diseases - first of all to reach everyone, and secondly to always reach them when it's needed?"

How can life-long treatment of diseases and access to health care be guaranteed in developing countries?

That is point number three. Only 20 percent of sick people in Africa go to a doctor. That means that all the things we're putting concocting in health services doesn't reach these people. How can we manage to ensure that all people can make use of their right to medical care? It is also a question of financing. Health insurance is a great thing all over the world. But even assuming a sick person consults a doctor, say, in Calcutta, he may not get the necessary follow-up afterwards because he doesn't have an address. That is an incredible challenge and a lot more research is needed. How can we manage, especially with chronic diseases, first of all to reach everyone, and secondly to always reach them when it's needed?

"It's a kind of colonial research. You send in the blood, the saliva and the stool samples and we'll tell you what you have. Of course that is awful."

So are you saying that German scientists are just a part of a global whole?

Yes, that's right, and that is how research should be organized. We can't always be saying that the problems are global, but the research is national. Germany's research funding organizations do quite a lot, but they will have to support even more research networks - North-South networks. You can't do malaria research here in Germany; you can't study the problems of diabetes in Bangladesh here in Germany unless you have partners in countries that are not as financially well-off as we are. That means we also have to help boost their research capacity until they are equal partners. They shouldn't have to send their blood samples here and we look in our lab to see what's in them. That is a kind of colonial research: you send the blood, the saliva and the stool samples and we'll tell you what you have. Of course that is awful. So we have to create research networks for the long term. The BMBF [the Federal Ministry of Education and Research] put out a tender for Africa that was quite exemplary. We also took part in it. The idea is 10 years of funding of research centers and research networks in Africa with German partners. What they said is that are not trying to support the research itself, but to fund the building up of research capacity. That was very forward-looking.

"The culture of sugar has to stop."

You have said that people have to be persuaded to get regular medical care. Tell us about some innovative approaches or projects that are already out there, trying to keep people healthy.

Public health is not just something done by health services. Public Health is also about regulation - for example the salt content of bread or sugar levels in drinks. We have to work on regulation and health education. Look at how we've reduced the numbers of smokers. Doctors had almost nothing to do with that. Public health has more controlling elements than doctors or nurses. It involves parliamentarians, and marketing people. It requires ad campaigns, followed by legislation. And a lot more has to be done. For instance with diabetes: if someone eats sugar like people in Bangladesh do and you just chase after them with insulin - it's a lost cause. We have to ensure that this culture of sugar stops. And it has to be replaced somehow. Whether it's done with artificial sweeteners so things continue to taste sweet, or if you say, 'Stop drinking sweet beverages' - that is another issue. The focus of public and global health is not on sick people and on the health care systems, but on the healthy population.

Staying healthy, not getting diabetes, not getting cancer, not taking up smoking. Lung cancer in a poor country can't be treated. Even we can hardly do it here. If you have lung cancer it's practically a death sentence and over there it's out of the question to provide the operations and post-treatments - with radiation etc. The only chance is to start at the roots and get people to stop smoking and stop getting obese. You have to offer community walks or bicycle trips. That is a much better approach than just waiting until people get sick and show up in my practice.

"We have to address the psychology; we have to start with the role models. It is a completely different issue than developing new medications."

Let's just stay on the example of Bangladesh and sugar consumption: how can the culture of sugar be changed there?

Just like the culture of smoking has been changed here. It's a slow process, it proceeds from down up, for example at the community level. Imams can explain it in services. Above all women are the ones who are affected and are becoming overweight in these countries. Once they're married they start to gain a lot of weight. In part it is culturally acceptable or desirable for a woman to be a bit plump. But in some places it's going far beyond that. It's also a question of self-image - in the same way that it is cool to smoke. We have to address the psychology; we have to start with the role models. It is a completely different issue than developing new medications. We also have to deal with organizing health care - and how that should be accomplished. Should we have 20 new glistening hospitals and nothing else, or do we need many small ones? What can be covered by municipal health care, what has to be done by the district, or in large hospitals? That is also a part of public health - the organization of healing.

“Germany has massively supported research on aging, because we have recognized that it is a problem.”

At what point has public health arrived at the moment? You’ve mentioned plans, dreams and summits where the players meet and discuss. But what is actually happening already?

If nothing happens then everybody is on their own. Let's say I have a couple of ideas and a colleague in Australia has some ideas, so we apply for a grant from a research organization and if they are far-seeing they will fund it. Or we have a global cooperation that says: these are our three or four main focuses and we support them via development cooperation, via direct financing of the countries. For example: AIDS. It is also a chronic disease that requires an expensive, life-long cocktail of treatments. The patients have to keep having lab tests because of the thousands of side-effects. And something has actually happened in this area. Because Bill Gates and the summits – the G8 and the G20 and all that – because they said, OK we’ll put 10 billion on the table, and so that is a success. I don’t want to complain all the time – this is really a great example of how international determination can massively reduce three diseases: AIDS, tuberculosis and malaria. Today nearly everyone in Africa sleeps under a mosquito net and that is the result of a global volition.

There has to be global volition, a consensus to say: our rich countries will come together and fund research and treatment for chronic illness, for example. It’s not necessary to give anti-diabetic injections. There are also pills. If they’re too expensive they have to be subsidized. If blood pressure medication is too expensive we should subsidize it. If research is needed – as in keeping diabetes under control in Bangladesh, we will do it. There has to be a will to solve global problems in a global way.

Researchers are proud of the fact that they don’t need to be spoon-fed, but can see for themselves what is needed. But that is not enough – we need large-scale research programs. Here in Germany massive resources have been put into research on aging because it’s been recognized as a problem. It isn’t just being left up to some initiative of Sauerborn or other scientists to study this area. It gets put out for tender and it has to be combined with efforts to boost capacity in countries in the global south. Because, ultimately, they are the ones who have to investigate their problems. We can really only participate in an advisory role. The problems have to be solved globally, but the solutions have to be implemented locally.