The Road to Universal Health Coverage
Table of Contents
- - Thank you everyone for coming again for our conversations in global health.
- Intending to become an academic chemist to ending up working in global health.
- That George Elaine really got started when he was, when he was head of PAHO.
- And and the local ministries do.
- For the outcomes of the industry would like to have.
- - Yeah, it's an interesting question. I think that, you know one of the things.
00:18
- Thank you everyone for coming again
for our conversations in global health.
John, Professor Monaghan
is not here tonight.
He is traveling overseas,
but excited to welcome our guest tonight.
Yes, Jeff Sturchio.
And I'm going to sort of you
know continue our classes
where we asked global health professionals
about their life, how they got here
and that turn to you for questions.
And I'm really excited
Jeff and I met many years ago,
which you probably
actually don't remember,
when I was just out of graduate school
and working at the Center
for Health and Gender Equity.
(laughs)
Back in the day,
and you've had a wonderful,
an interesting career
working you know at the head
of the Global Health Council
and going into private sector,
but I want to as we
like to do in this class
sort of start at the beginning
when you were here.
01:19
So could you talk a little bit,
and we're gonna, Jeff in
a very interesting day
on Capitol Hill,
so we're gonna wind to that.
But can you talk a little
bit about where you were
in high school
and what were the things
that you, excuse me, college,
and the issues you were thinking about
and what you were studying as you
were thinking of what to do afterwards.
- Well, first thanks for inviting me.
It's good to be here with all of you.
And you know one of the things I noticed
just as I look around the room
is, and you know we could talk about this,
or you may have a different point of view,
but I find that these days recruitment
into global health is
leading to a workforce
that tends to be skewed towards
females for some reason,
you know, which is good,
and what I was just going to observe
is that sitting here it reminds me
of being back at Rabin Martin,
the little global health
consulting firm I run
because we have about 40
people in New York and London
and close to 90 percent of them are women,
02:21
and so I'm one of the few
men and the entire firm.
So it's been an interesting
experience for me, you know,
I've been there for this
will be my ninth year
and that gender balance
has been pretty constant
through the whole period but...
- [Maeve] Why do you think that is?
- Well, yeah it's a good question.
I mean maybe we can save
a little time at the end
and you can tell me why you think that is
because you know I think certainly on...
I think that there's
an age differential too
that the gender balance in global health
skews female, the younger you,
the younger the cohort is,
because you know people my
age in global health they're,
I mean there certainly are women in it,
but there are more men
than people in their 30s
or in their their 20s,
so at least that's
based on my observation.
I saw that when I was at the
Global Health Council too,
but that I digress because the question
that Maeve asked me is
how did I get into this.
Well one I mean it will,
I'd ask you to guess what
my undergraduate major was,
03:27
but some of you may have
looked me up on the internet,
so there won't be a lot
of suspense around that,
but I started off actually before
I decided to study history of science,
which is the degree that I got
when I was an undergraduate.
I wanted to be a chemist,
so I was interested in science.
My father had been a chemist
so I grew up around laboratories
and was interested in science.
My mother was a math teacher
so it was natural to
gravitate to her the sciences,
so I went to to college
and I discovered that
there were two reasons
why I went into history.
One was that I was
terrible in the laboratory,
so I had an experience,
I'm sure some of you have
taken organic chemistry
or will take organic chemistry.
Well I had an experience.
In those days, I'm old enough that we,
it was before the days
when you had cell phones
and calculators so you know
to do a quick calculation
you had to take out a slide rule.
Some of you may know
what it's slide rule is,
and actually do this calculation manually,
and so when I did I was
trying to figure out
04:31
how much of a reagent to put
into the reaction mixture
and so I quickly did this
calculation on my slide rule,
measured out the stuff and
then put it into the mixture,
and the moment it hit the mixture
it sort of, it was a
hundred times too much,
that's the point of the
story, I had miscalculated.
And all of a sudden I heard this whoosh
and the stuff went up the reaction column,
came down the sides, hit the flame
and sort of blew into this
remarkable ball of fire.
The TA then put out,
but then I just thought to myself
you know maybe this is
God's way of telling me
that I don't want to be
an experimental scientist,
but I was always interested in the theory
and also I happen to be
you know relatively good
at expressing myself and writing.
You know most, in my day,
this is back in the late 60s and 70s,
there tended to be a
dichotomy between people
who are interested in the sciences
and people were interested
in the humanities,
and I don't know if that's
still as sharp a division
as it was,
but I was actually interested in both
and I was pretty good at both,
05:34
so anyhow I was lucky
enough that Princeton
where I went to college
had a history of science program,
was one of the best in
the world at that time.
And so I was still
interested in the sciences,
but I gravitated into history
and got my degree in history of science,
and eventually got a PhD
in history of science
and then went to be a professor
in history of science.
So the beginning of my career
was oriented toward the life of the mind
in the academic world.
And then after I had
been teaching for a while
I had an opportunity to go back
to the University of
Pennsylvania where I got my PhD
and helped to run a research center
that worked on the history of chemistry
and chemical technology,
so that gave me an opportunity
to get more engaged
with with the chemical
industry at that time,
and some of the pharmaceutical
companies as well,
and then from that I ended
up I had an opportunity
to go to AT and T where I
worked for a little while
and then I had an
opportunity to go to Merck
where I actually still
used my history training
because I set up, I was
hired to set up an archive
and do a Centennial history
from Merck and Company in 1989.
06:38
But one of the things that's interesting
about working in a big
multinational like Merck
is there are literally thousands of jobs
that you can move into,
because it's not, you know,
if you go to a university
to become a professor
that's what you do, you know,
and it's very rare that
people change fields
and people will come to a university
and stay for 50 years
teaching the same courses
and doing research
on the same thing,
but in a big multinational like Merck,
you know by the time I had finished
the Centennial history
which was the job I was hired for,
my bosses had already identified
some other opportunities
for me to move into,
and a couple of years
later I moved into a job
as director of science
and technology policy
for the US,
and that got me involved in
coming to NIH and the FDA
and it was a time when this,
by then it was the early 90s
and there was some early
research on HIV and AIDS
that I had some connection with
because at the time we were
engaging with HIV activists
to help provide information
about the new treatments
07:39
that were being developed,
and eventually in 1996
the first antiretroviral,
combination antiretroviral treatments
were approved by the FDA,
so I'd been become involved in that
as part of this role of doing
science and technology policy.
And that's ultimately what
got me into global health
after that so, you know, now it's been
you know close to 30 years
that I've been working in the field
in one way or another,
but one of the interesting things
about the development my career
is I've never taken an academic
course in global health.
All right, so you know that might strike
some of you as odd in that you know
now there are hundreds
of programs in the US
and it's you know it's one
of the most popular majors
on many campuses,
but all of everything I know about it
has been through on-the-job training.
You know having started
by working intensely
on HIV AIDS in the mid 90s,
and on until I left Merck
and I've retired from Merck in 2008,
but then I failed
retirement the first time
by going to the Global Health Council
and then I failed retirement again
by going to Rabin Martin in in 2011,
08:41
but it was you know what was interesting
in the last 15 years that I was at Merck,
I was there for almost 20 years,
but I had the opportunity
to spend most of my time
working around the world
with external audiences,
so AIDS activists for a number of years
with the WHO and UN AIDS with UNICEF
and other multilateral organizations,
and then at the country
level to work with, you know,
implementing organizations on the NGO side
and with you know indigenous hospitals
and clinics and companies in other areas
who were also implementing HIV policies,
and then I got to work with the Global
Business Coalition on HIV/AIDS
which is now GPC health,
so I ended up spending a
large part of that time
as kind of an external ambassador
for Merck's global health policy,
and you know that was the role
that I spent a lot of time on.
Although my formal role by that time,
I'd become the head of External Affairs
09:43
which was largely health
policy and communications
and media relations and
alliance development
and stakeholder engagement
and a bunch of other things
that I was responsible for in a territory
that included Europe, Middle East, Africa,
Latin American and Canada,
so you know that's
another aspect of working
for a large multinational.
You end up working on
you know a vast territory
and of course I had lots of help in doing.
You know my team was about by
that time was about 36 people
but we worked with about a 150
people throughout that region
which is another aspect of
working in large multinationals.
First of all there are
plenty of opportunities,
so you know people end up having very rich
and varied careers by staying
with the same company,
but moving around the world
into different functions
over the course of a career,
and also everything is
done in teams, you know,
that your task is to learn how to work
with a broad team that
has all kinds of skills
because you can accomplish
much more together
than you can alone.
That's one thing that's different
than the life of a professor
because most professors just
spend endless amounts of time
10:46
alone at their desk,
writing things and thinking,
and it's you know it's
different in a medical school
or in a business school
because that takes on the nature
of the kind of professional lives
the people who are trained
there end up having,
but you know that was one
thing I learned very early on
when I went into the private sector
was that you know you learn
to participate in teams,
you learn to take advantage of the skills
that your colleagues have,
and you also, you know,
there's a division of labor
that enables you to focus on
the things that you have to do,
and you know and that was very different
than my experience in the academic world.
So in any case as I said I retired in 2008
after doing a lot of work on HIV/AIDS
and I was involved in the
the first big collaboration
between UN agencies in the private sector
to ensure that people in Africa
would get access to HIV drugs
at prices that were more affordable
than they were in the north
and the West at that time,
11:46
and then when I went to
the Global Health Council
I was I continued to work on building
the kinds of partnerships
that I'd learned to do
when I was at Merck,
and you know GHC then, was you know,
now it's...
Let me just finish two to final thoughts
then we'll move onto the next one.
- [Woman] Can you define GHC for us?
- Oh sure.
It's the Global Health Council
which you know still exists,
Loyce Pace is the executive director,
it's based here in Washington,
but it's an organization
that focuses on advocacy
for global health issues
for people living on less
than two dollars a day,
so it really focuses largely on
lower and middle-income countries,
and the key challenges
that are on the agenda,
whether it's maternal mortality
or non communicable disease
or HIV/AIDS and other infectious diseases,
and they're based in Washington.
When I was chair or excuse me CEO
of the Global Health Council
there were about 500 or 550 organizations
in over a hundred countries,
and so it was something like
5000 individual members.
12:48
They've gone through
a transformation since
where I don't think they have
as many international organizations
who are members,
but they still have a focus on advocacy
for global health issues,
and so they do a lot
of work on Capitol Hill
and working with other NGOs in town
to really advocate for more
US investment in those issues,
and you know it's a good organization
and you know I think you'll find,
you know in December they
always do a big meeting
on the state of global health.
That's something you
might be interested in
if you haven't gone.
And you know I think they still have,
you know memberships,
relatively inexpensive,
and it gives you access to
a whole network of people
and information around global health.
So all I was going to say is that
and then went from basically doing
what I had been doing in
terms of creating partnerships
and working on these issues
to bring the public and
private sectors together.
When I was at the Global Health Council,
I was still working on
the same sets of issues,
but from the perspective of being
one of the largest and most
effective advocacy organizations
13:49
from civil society working
on on global health,
so that was an interesting
change of perspective.
That I went, in 2011 I joined Rabin Martin
where we're a consulting firm
that focuses on strategy,
but we focus entirely
on global health issues,
so we've, as I said we're
in New York and London,
and we work on you know
probably half the people
who work at Rabin Martin have MPH degrees,
so there's a lot of
public health expertise,
and then we, our client base is largely
large healthcare companies
and we work with the Gates Foundation
and the Rockefeller Foundation
and other foundations,
and a lot of our work is
devoted to creating partnerships
to bring our clients together
with people on the ground
in African and India,
in particular,
to really help improve population
health in dramatic ways.
So you know a big program that we work on
is Merck for mothers,
which is a program that Merck and company,
the company I used to
work with set up in 2011
14:51
to eliminate preventable
maternal mortality
around the world,
and in the in the past
eight and a half years
they've helped more than
twelve million women,
and have done a lot of
work both outside the US,
but also in the U.S. in
inner cities, for instance,
to address the the disparity
between pregnancy outcomes
for women of color and and Caucasian women
because it's, I think the number is,
my colleagues always correct me
because I never get the
facts completely straight,
but I think it's true that
there's something like
a six-fold difference in the likelihood
that a young woman of
color in certain US cities
will die in pregnancy, or die
in childbirth I should say,
than it is for Caucasian
women are the same age,
so that's one of the things
that Merck's been working on
and they've had some real success
in helping to iron out
some of those inequalities.
So that's sort of a meandering account
in a big nutshell
of how I ended up going
from where I was, you know,
15:51
intending to become an academic chemist
to ending up working in global health.
- I'm glad you didn't
become an academic chemist
because we need you in the field.
There were sort of two teams
that I was thinking of
as you are sort of telling your story.
One is just the theme of advocacy,
where we've had other people come
and sort of talk about how
they push forward issues
of importance to them,
but for you it was sort of
working through partnership.
Seems that this
public-private partnerships
and the importance of
bringing people together
in order to achieve those goals,
and that's really in some ways
a skill that you've honed
(chuckles) throughout the years.
So can you talk a little bit more about
because I think that idea of
public-private partnership
now is, you know, there's
public-pirate partnership,
part of the Department of State
that didn't exist before,
so you sort of created that field as well
16:54
or one of the creators of the the field
through your career.
- Well, it's certainly true
that a lot of the work I did
was based on trying to
create certain partnerships.
The idea behind it
is just that you know no matter...
You know so I worked for Merck,
one of the largest pharmaceutical
companies in the world,
has a gazillion dollars in assets
and you know something like
40-plus billion dollars in sales.
They have an R and D budget
that's measured in the billions,
but even that company is
only a small fraction.
For instance if you look at R and D,
they only have a small fraction of the
total investment in R
and D around the world.
So if you're at Merck and
you want to accomplish
something useful in the world,
if you want to work on your own
you have to make a bet that
you're smarter and luckier
than everybody else working in that area,
and that, you know,
that's something I learned
from the scientists when I was there,
you know and when I did
this work on science policy.
I mean Merck at one point in the early 90s
created something called
the Merck gene index
which was, you know, at an early stage
of the development of genomics,
which you know now has
progressed way beyond that.
17:55
But at the time they decided
that they gonna create a public database
of what were called
expressed sequence tags,
you know which were short lengths of DNA,
and if you catalog those you could begin
to correlate them with you know
with interesting structures
that could be used in drug development.
You could you know use them as probes
to deal with certain druggable targets
and then that could lead
to potential new therapies.
And you know what Merck decided to do
was invest in a project
with Washington University
to just generate these
Express sequence tags,
hundreds of thousands of them,
and then put them into
the public databases
in you know what's now a database of ESTs
and other genomic data that's kept
by the National Library of Medicine.
But you know when people
thought that was odd
because most companies would
generate that information
and keep it closely held,
and try to use it to compete
with others in the field,
but the guys who were running this,
the geneticists and you
know bioinformatics guys
19:04
who were creating this database together
with Robert Waterston and his team
at Washington University.
You know, the comment that I made
about you had to be smarter and luckier
than everybody else
is something that they told me
because that's why they
made this investment
because it was a way of
leveraging the 95 percent
of the other R and D
laboratories around the world
to work on issues that
they were also working on,
and then you know what they realized is
that if somebody came
up with a bright idea
that could lead to a new drug
there's still, there's a long path
between getting a basic
science breakthrough
and having a product that
makes it through FDA approval
or EMA approval.
You know the European
Medicines Agency approval
to actually be in a position
where you can now introduce
it to the marketplace
and get it to patients so you can use it.
And what they realized is
that if they have everybody
in the world who's
interested in basic science
working on those problems,
because it's a probabilistic process
the likelihood that somebody
would get a breakthrough
was higher,
and then Merck could work with them
to do the development and
actually bring it to market.
20:05
And that's basically how
the entire relationship
between the biotech industry
and the large pharmaceutical
industry has developed
over the past 30 or 40 years,
because you know people
have made an analogy
between the way that biotech operates
in relationship to Pharma
and the way that producers
create blockbuster movies.
You know, most of the
time when you go see,
I mean what's a new movie, 1917,
let's say you know that World War I.
That movie is made not by a team
that's all owned by one studio, right,
they don't own the director,
the actors, the producers,
the people who run the cameras,
they don't own the cameras,
they don't own the the prop people,
they don't own the catering service
that provides catering for the crew,
they don't own the distribution network.
You know they don't own the Netflix
and they don't own all the the ways
that films get to you now.
But what they do is just
bring that together,
21:06
you know it's sort of they create,
they bring together the
resources that are needed
to create a blockbuster movie,
and that's the same way
that large pharma companies
have started to act toward
the biotech industry,
because, you know, often again you know
there are hundreds of biotech companies.
Let's say you're trying to
come up with a new medicine
for asthma,
there are hundreds of companies out there
trying different targets
to see if they can come up
with a new asthma medicine,
and it makes more sense
for a large pharma company
to simply do a deal with a company
that looks like it has
an interesting prospect
for a product,
and then they can use the
assets they have in place
for a development engine
to actually do the further
research and the clinical trials
that will make that be
able to pass the hurdles
that a regulatory agency
that that medicine
is safe and effective
and can be introduced
in the marketplace.
So anyhow it's you know that was
coming back to partnerships,
public-private partnerships
in global health,
it's the same concept.
That you know if Merck was
interested in, you know,
22:09
figuring out a way
to get differentially
priced AIDS medicines
to people who needed them in Africa,
we could try to do
everything along the step
the way ourselves,
but it was much more
efficient to find people
who actually had access to patients,
who ran clinics in developing countries,
who you know were able to
distribute the medicines
in different ways,
and so what you end up doing
is bringing together a group of partners
who have complementary
skills and expertise
that enable you to do more together
than any single partner can do alone.
So that was sort of the philosophy
behind the kind of
partnerships that I worked on,
and you know and we,
you know as I mentioned,
I mentioned one that was,
you know it's probably
one of the best-known
of the ones I worked on,
which was the accelerating
access initiative
that was begun in 2000
which was a partnership
of UN AIDS, WHO, UNICEF,
UNFPA and the World Bank
and five pharmaceutical companies
that had new antiretrovirals,
and together we negotiated an arrangement
23:09
where the companies made
their medicines available
at significant discounts,
and all the UN agencies
helped work with the countries
to make sure that they
would implement plans
to provide antiretroviral therapy
to the people living with
HIV in their countries,
and it began with Uganda and Rwanda.
Those were the first two countries,
and then Senegal decided that
they were going to treat.
And you know in retrospect,
I mean if you look at a
number of the the stories
that have been written about those days,
you know one, usually the
form of argument you'll find
is that AIDS activists and patients
brought the pharmaceutical
industry to their knees
over patent protection
and the industry for defensive reasons
had to eventually license its products
and lower its prices.
But the reality is that the first time
that patients in Africa
had improved access
to antiretroviral
was through this partnership
between five UN agencies
24:11
and five companies
which realized that they needed, you know,
it was great that when you
looked at the introduction
of anti retrovirals in 1996 in the north,
in the global north,
you know death rates plummeted.
There's a famous paper by Pantaleo
that looked at this in the US,
and what you have are you know AIDS,
the number of AIDS deaths
climbs through the 80s
and into the 90s,
and then all of a sudden the graph,
you know in one year
just drops off a cliff
because antiretrovirals became available.
So you know everybody
in the industry realized
that the same thing would happen in Africa
or other parts of the lower
middle-income countries,
so the challenge was how to
get those medicines to people
who needed them,
you know but at the same time
there were all kinds of
challenges with you know,
with health system readiness
and you know whether you know,
whether you have the right
kind of system in place
to diagnose and treat
and keep people on therapy,
but you know I remember,
you know just to stay with
this story for a while
25:11
because it's a very
complex story that unfolded
over about 15 years,
but I used to, one of
the things I used to do
was talk to reporters about
what Merck was trying to do
in those days,
and in those days Mike Waldholtz
was the leading healthcare reporter
for The Wall Street Journal,
and I remember in 1998 he was
having a conversation with me
in Geneva at one of the
global AIDS conferences,
and he just kept hammering me
because this was two
years before Merck decided
to lower the prices of
its anti retrovirals,
and so I'm actually on record
if you look it up on the Internet
of telling him in 1998
that even if we gave our products away,
the health systems in
Africa weren't ready,
and therefore would be difficult to ensure
that these medicines were used
effectively, and you know.
I mean it wasn't as bad
as when James Natsios
who was the head of a USAID at the time,
said that you couldn't use
anti retrovirals in Africa
because Africans can't tell time,
and you had to take medicines
at certain hours of the day.
So I wasn't quite that egregious,
but what's interesting
is when he interviewed me
26:12
two years later,
and you can look this up as well,
I completely changed my tune
because by then we realized
that we could get the medicines,
we could provide them at lower prices
and the sky wouldn't fall in,
and we could work in partnership
with people at the country level
and with international
agencies and international NGOs
to make sure that the
infrastructure was there
to make sure that medicines
got to people effectively
and they would stay on
therapy once they started,
and that happened all
around the same time.
I mean within a couple of years
the Bush administration
started the PEPFAR program
which I'm sure Mark Dybul
talked about when...
- [Woman] That was last semester.
- Oh, that was last semester, sorry.
But you know Mark's a
professor now at Georgetown,
but he was involved in
creating the PEPFAR program
which you know has now helped
tens of millions of people
get access to therapy.
But you know this was
all before that happened
and it was really the
first major initiative
that helped more, you know,
by the end of the first few years
almost a million Africans
have gotten access
as a result of this program,
27:14
but it took, you know,
from the outside you know just
to come back to what I said
about activists.
You know obviously that
helped with public opinion,
and it helped move the
interests of big donor agencies
and you know it helped make it possible
for the US government to think
when George W. Bush
decided to set up PEPFAR
that it made sense to do this.
But the other thing that Mark and others
who were involved will tell you
is they didn't, they
realized it was possible
because of the efforts of things
like the accelerating access initiative
a few years earlier,
and a program that Merck
got involved in in Botswana
where we worked with the government,
the Gates Foundation and Merck
to help Botswana completely transform
its approach to the AIDS epidemic,
and they became the
first country in Africa
to actually achieve universal coverage
for AIDS treatment for
their their patients,
so it required those
kinds of collaborations
to really move the needle on these things,
and that's what people
who haven't worked in
28:17
in the industry don't realize
is that you know people who
decide to spend their career
as a researcher in a
pharmaceutical company
are just as committed
to finding the solutions
as people in the academic world,
or you know people who work for,
you know say Act Up New York
or the treatment action group
which has been really active
on treatment information
over the last 20 or 30 years.
You know they just work
in in different context
and they have different
constraints on their work,
but at the same time you
know they get up every day
hoping they're gonna find a solution,
and you know they don't
want to find a solution
to a problem like HIV/AIDS
and then not be able to get it to people
who are gonna need it
when they're you know something
like 40 million people
around the world who are infected.
So, the challenge is to find ways to
bridge the gap between you
know company that obviously
is a profit-making institution
and has to continue to have
a viable business model
and the tens of millions of
people who can benefit from that
29:17
who don't necessarily have the resources,
but you know the other thing
and if some of you read
that little article of mine
on global disrupt disruptors,
you know it's not that there
isn't enough money in the world
to solve these problems,
there's a huge amount
of money in the world.
It's just misallocated.
So the trick is figuring out ways
to allocate it in different ways
to actually achieve different goals,
and that's in a way
that's what I spent
most of my career doing
either when I worked for
a company like Merck,
where I was able to effect this directly
or when I was at the global health council
when I was advocating for
those kinds of changes,
where now as I work with clients
who have the kind of resources
that actually Merck is one of our clients
and we worked for a number
of other companies like that,
where we can persuade them
that if they work in this way
they can actually try different models
that will be sustainable,
and will have a much broader impact,
so you'll improve population health
at the same time that you're able
to bring these new innovations
to many more people.
So that's what's cool about what I do now
because you know we can actually,
if we persuade clients to
try something differently
30:19
it can actually end up
helping millions of people,
and it's you know it's just
this little group of us
in New York and London
who are trying to make
those things happen.
- I imagine you as the little group,
but very powerful.
One of the things that you said
is the Health System readiness,
and just one of the things
that we've talked about
in preparing for this,
talked about your work on
universal health coverage,
and if we're thinking about
how to actually make sure
that the medicines that have been created
by the scientists actually get to people.
We need those strong health systems,
and they benefit you know everyone.
So can you talk a little bit about,
you know again another
pivot in your career
is really, you know,
as the world and the SDGs focus on UHC,
so goes Rabin Martin.
- Yeah, well, we did spend
a fair amount of time
on non communicable disease,
because that was you know back in,
you know around the
beginning of the last decade,
that was really the focus of a lot of work
31:25
that George Elaine really got started
when he was, when he was head of PAHO,
and that continues to be
a challenge, obviously,
because more people die of
chronic disease around the world
then of infectious diseases.
You know the last time I looked
it's like 70 percent of
the deaths every year
are from NCDs, you know,
largely the big four of them, you know,
asthma and other respiratory diseases.
Diabetes, cardiovascular
disease and cancers,
and there are huge gaps in
capacity of health systems
to deal with that.
Everything from right place,
are they the right diagnostics,
are their primary health care systems
that can actually, you know,
see whether people have
some of these conditions
then refer them for specialized treatment.
Are the treatments available,
do people actually stay on the treatments
because you have to take them every day
for the rest of your life?
And and as a result can you
actually get the outcomes
that you would predict in a you know,
in a population that takes
the treatments systematically
32:28
and follows all of their
doctor's instructions,
and you know things that just don't happen
in the real world,
which is why there are so many problems.
And that was in the context
of the Millennium
Development Goals, initially,
which were introduced in 2000,
and then the switch to the SDGs in 2015
and you know in both
the MDGs and the SDGs,
you know one of the things that people
tend not to focus on like, you know,
the Millennium Development Goals
had a specific goal for HIV/AIDS,
had a specific goal for child,
under five child mortality,
had specific goals for maternal mortality,
and then the SDGs were much broader
and included not just those
specific health goals,
but also no environmental goals
and poverty reduction and
education and women's rights,
but what people didn't notice as much
is that the last goal,
goal eight in the MDGs
and goal 17 in SDGs
was about partnerships,
because you know the conviction
was and if you read the preamble
33:29
and you know all the rest of it,
the conviction was that
health ministries alone
aren't going to be able
to achieve these goals
unless they have sort
of an all, both an all
of government approach
and an all of society approach.
You know one of the reasons is,
and this comes out more in the
SDGs than it did in the MDGs,
is that you know some large
percentage of health outcomes
really depends on things
that have nothing to do
with the health system.
You know and that's something
that we've come to see
much more in the last 10 years.
There was a major report in 2008
that was led by Sir Michael Marmot.
It was called the WHO Commission
on social determinants of health
and that took a you know a
systematic look at those issues,
but you know if you
just think for a minute
about the intersection
of an aging society.
So you know most,
I think the only the only natural resource
that's clearly growing
is the number of people over
the age of 65 around the world,
and that's a different conversation,
34:32
but this relates to end NCDs
and social determinants.
And then you know when you think about
the incidence of chronic
diseases like diabetes
and heart disease and
asthma and mental health,
you know mental health
conditions and cancers.
You know more and more
people over the age of 65
are going to be affected
by those conditions,
and then when you think
about social determinants.
So let's say you're over the age of 65
and you have a number of
these chronic conditions,
and that's actually a growing problem.
You know if you look at
Medicare in the U.S.,
it cost something like,
if somebody has one chronic condition,
say they have diabetes,
you know costs a certain amount of money
in Medicare reimbursements
to keep them on therapy and healthy,
but if if they have three
or four chronic conditions
which is more and more common, you know,
it's called well very imaginatively,
multiple chronic conditions or MCCs.
Medicare pays more than 12
times as much on average
in annual costs
35:33
for somebody who has a
number of chronic conditions
than just one,
and part of that also has to
do with the social determinants
where let's say they live
in a high-rise apartment
and you know their doctor
is in a clinic that's miles away
and they have to take public
transportation to get there,
you know some people who have,
let's say they have you know
heart failure or emphysema
from smoking for decades,
they don't want to walk up and down
their high-rise apartment
to get to the bus stop
you know to wait hours to
take the bus to the clinic,
and so most of the time they'll just say,
well I'm not gonna go today,
I just don't feel up to it
and that just exacerbates
their conditions,
and then it gets to the point
where it spirals downward
and they can't leave their apartment
and then somebody has to
send an ambulance to get them
and bring them to the clinic
and all of that adds money,
and so when you multiply
that times tens of millions
of elderly people living
alone in apartments
times the amount of money it takes
36:33
to deal with chronic conditions
or to you know send ambulances
to get them, it all adds up,
and so you know where they live,
what they eat, whether they have friends
and a social life because
interdependence is,
there's a really strong correlation
between the degree of
interdependence of elderly people
who are living with chronic conditions
and what their health outcomes are.
So the more they're isolated,
the more likely they are to be ill,
so anyhow the point is that you you know,
to deal with these things
requires partnerships
and that was the point that I was making,
and so that's why it's
in the MDGs and the SDGs
and that's why to deal with just a almost
any of the major health threats we take
is going to require a wide range
of multi sectoral partnerships
and that's really what we try to,
you know work on in specific
instances with our clients
and I think that it's
also part of, you know,
where the global health
community stands right now,
and one last thing I'll say about this
is that you know Tedros who's the new,
relatively new head of the
WHO understands this well
37:36
and you know one of the
comments he keeps making
when you follow his speeches
is that that that health
is a political choice,
so you know we tend to think that
or there is a general feeling that health
is about what health ministers do
and you know it's about what
doctors do and nurses do
on behalf of people who
are living with various conditions,
but actually he's right,
because you know in every country,
just about every country,
the U.S is slightly anomalous in this way,
but just about every country
manages its health system
through tax dollars
and tax resources,
and so the decision on
how much to allocate
out of the general budget
is a political decision,
the decision on how to allocate
what's in the health budget,
whether it's going to be in surgery,
building new hospitals,
dealing with primary care,
paying for drugs, paying
for medical devices,
paying for mental health,
all of those are political decisions.
They have technical elements,
but ultimately they're technical decision,
excuse me, political decisions,
and you know and health ministers
38:38
end up spending most of their time
negotiating with finance ministers
on what envelope of resources
they're going to get,
and again those are all political.
And you know in other
speeches Tedros has said
health is too important to
leave to the health ministers,
you know for for all those reasons,
and then and of course
you know politicians
who make the decisions
about resource allocation
are also you know paying careful attention
to what voters want
because that's how they
maintain job security,
so if people start agitating
for different decisions about health
then you can actually move the needle,
but to do that you need coalition's,
you need partnerships, you need people
to start agreeing on common ground
on how to improve health outcomes
so that we can keep
population health improving,
and it you know it either becomes,
you either get together the
right coalition of partners
to work on things like that
or you're constantly fighting
for what little you can get
from a declining amount of money
that goes into health care.
39:38
- Just a couple of things,
but the the idea, the political
nature of global health
is also something that's
come up in this class
a few times,
and so just turning to what you are doing
on Capitol Hill today.
One of the more political
global health crises
that is occurring currently
is the coronavirus,
and that is not just about data,
and it's not just about
global health security,
but it's about the politicians
and how people are acting.
So can you just sort of redescribe
as we talked before
about what you were doing
on the hill today,
and what the discussion is going on.
- Yeah, no, I was this afternoon
there was a launch of a new report
by the Center for Strategic
and International Studies,
a think-tank downtown.
You know you've probably come across it
from time to time in your studies,
but they created a commission
on America's health security
about two years ago,
and today they launched the report
after two years of work,
and so you know this,
looking at Global Health security broadly,
40:40
the idea is just how can
we be better prepared
to deal with health emergencies
and emerging diseases,
and coronavirus is a perfect example.
I mean you know if the timing
couldn't have been better
given that that epidemic
is just developing now,
but it also has to do
with things like Ebola
or before that the SARS epidemic
or the H1N1 epidemic before that,
but the problem is and the
the theme of this report
is that we have to get away
from the cycle of crisis
and complacency
that has affected most
global health emergencies
and global health security.
You know the other aspect
of global health security
is not only preparedness
for new epidemics,
you know either of existing agents
like annual, the seasonal flu,
you know that that's something
we have to be prepared for,
because vaccines have to be reformulated
given what the genetic complexion
of the flu virus is every year.
But also it involves
things like bio terrorism
41:41
or you know the interaction of,
you know, for instance in
parts of the Middle East
hospitals are being bombed,
health workers who are there
to try to eliminate polio
are being shot and killed,
so there's just this whole complex mix
of really bad and scary things
around global health
emergencies and pandemics
that require attention,
and it's also, I mean the old cliche
that a pound of, excuse
me an ounce of prevention
is worth a pound of cure applies
because if you plan ahead of time
for what to do if a new virus
emerges like coronavirus,
then it costs less,
the interventions are more effective,
you can manage the the fear and concerns
that sort of ripple through society.
You know often,
I mean I first saw this back in the 80s
when I was living in
Philadelphia in graduate school,
and Three Mile Island
almost blew up, right,
and it was interesting I just,
42:43
this is a variant on the
same kinds of conversations
that I'm sure are happening
all over the country
with respect to coronavirus,
but I was at a dinner party
one night with some friends
and one of them was a physicist
and the other was a musician,
you know there's a young
woman friend of ours
who was a musician,
and she was like in tears
because she was afraid
that her life was in danger
because of what happened
at Three Mile Island,
even you know we lived
probably a hundred miles away
in Philadelphia and this was
out in central Pennsylvania,
and my physicist friend
tried to explain to her,
you know, rationally, well look, you know,
he drew, he sort of
wrote out the equations
and showed that you know by
the time any radionuclides,
you know had dispersed
through the atmosphere
over a 100 years, excuse me 100 miles,
the dosage that you would be exposed to
is less than you know you would see
if you know if you went to the dentist
and got one tooth x-rayed,
you know would be nothing,
nothing to care about,
43:45
but she was, she couldn't be persuaded
that she wasn't in danger that moment
sitting in Philadelphia.
And you know with coronavirus
we're seeing the same sorts of things.
The stock market went down
dramatically on Friday,
just on the fear that
something would happen,
you know there have only been
a handful of cases in the US,
but I'm you know people are anxious,
you know and most of the cases
of people who were in Wuhan and flew back,
and you know I just read like
over the first five cases,
four had been in Wuhan
and one was married to one of the four
who came back from Wuhan,
so we don't actually have a
full-blown epidemic in the US,
but think back to Ebola in 2014-2015,
you know there was one guy
who came back from Liberia I think it was,
who rocked up in in Austin or Dallas
and the whole country
went crazy, you know,
because of this one person
who had been exposed,
but you know I don't mean to,
I'm not trying to downplay
the seriousness of this
or try to deprecate the emotion
that many people have in response,
44:46
but the whole point of
global health security
is that you have you can
prepare for these things.
You know there need to be
mechanisms for communicating
and you know the CDC
should have regular
bulletins out to people
and they should canvass what
people are worried about
and make sure that there are responses
that are calibrated to the level
of anxiety that people have
that aren't just, you know,
you know it's not just Tony Fauci
and some technical explanation on TV
but there are actually
people who they trust
who can tell them well here's how it works
and here's what makes you at risk,
and you know because most of
the people have this disease
are halfway around the world,
you're not gonna get it randomly,
but you know on the other hand
don't go to you know live animal markets
where you know you could be at risk
much greater risk of catching
this new coronavirus,
but anyhow today's meeting
we were talking about those issues,
but what's interesting about,
you know come back to this
point about how health
is a political choice,
you know what's interesting
if you've been following this
45:47
is that the Chinese knew that
there was something going on
in Wuhan in October or November,
you know and here it is February
and we're only really now hearing about
what actions they've taken,
and you know and they've actually made
this dramatic decision to to quarantine
about 57 million people, you know,
and after a third of
the population of Wuhan
had already left town,
so you know like the you
know it's a classic case
of the horse being out before
the barn door is closed,
and also we know from a hundred years
of pandemic control
that quarantine is ineffective,
but what was interesting
is one of the reasons there was this gap
between when people knew
something was going on
and when the Chinese
government began to take action
in a public way,
is because these decisions
went all the way up to Xi Jinping
and because the Chinese
Communist Party controls,
you know they have sort
of political control
over everything of the Health Ministry
46:47
and and the local ministries do,
the doctors who knew something was up
were prohibited from
sharing that information
with the public,
much less publicizing it more broadly
until the politicians had decided
that it was okay to share the information.
So that kind of secrecy
and lack of transparency
is a big reason why the SARS epidemic
had the impact that it had,
and now again with the
coronavirus epidemic,
you know that's one of the reasons
there are more than
15,000 infections already,
and why they feel that
they have to now, you know,
quarantine this large population,
but what's interesting,
the other thing that was
coming up now, flipping around,
so there were political
considerations in China
on how they were going to address this,
and even now that they've
decided to go public with it,
just think about what's been happening
between the US and China recently.
So when SARS came out,
the US and China were actually
getting along much better,
and so there was more
cooperation on a technical
47:47
and on a material level
between the US and China to help spread,
help limit the spread of SARS.
Now, I think it's fair to
say that the US and China
aren't getting along that well,
I mean think of the tariff war,
think of you know a number of other things
like fights over technology transfer
and all the other things
that the Trump administration
has been doing to harass China.
So you know just it's an open question,
but you know do you think that
they're that well disposed
to cooperating now with the U.S.
in addressing this epidemic particularly
since the U.S. and and the
British Airlines and others
have now said they're
gonna stop flying to China.
So that has a dramatic
impact on the Chinese economy
and it will you know because
of global supply chains,
and so you know that's a diplomatic mess
that's you know going to
continue to have an effect
on the global economy,
and then come back to the U.S.,
the U.S. now has decided
through secretary Azar
that they're going to quarantine people
coming into the country
and they're going to put
48:48
all these restrictions in,
and we know that as I said before,
and this is what came up today
in this discussion on Capitol Hill,
which included senators
and some of the members of
the House of Representatives
and a whole range of experts
from different aspects
of thinking about global health security,
they they found out that,
or I mean they know that
from decades of public health practice
that eventually a
quarantine's not gonna work
because people are ingenious
about getting around a quarantine,
so you know there will
ultimately be more infections
in the US,
and then politics will
come into play again
because that will be weaponized
given our current political climate
of you know complete inability to disagree
on what time of day it is,
much less anything substantive,
so what will happen inevitably
is that there will be people on one side
claiming the government failed
to contain the epidemic,
you know as if it were a
failure of government policy
when it's simply a fact
that you know viruses
are wily adversaries and you know
the coronavirus really doesn't care
49:49
if you have people quarantined
because any chink in that armor
will be exploited by the virus,
just because you know
that's what viruses do.
So it's just a completely,
it's it's a hugely
complicated set of issues,
but the technical issues
about how does the coronavirus
actually infect people,
you know how lethal is it,
you know what what's the percentage
of you're infected you'll die,
and then what's the probability
that you'll transmit it to others.
You know those are the
two critical factors
in any kind of epidemic,
and as scientists are
trying to figure that out,
this whole thing will play
out in the public sphere
in ways that have much
more to do with politics
and with public perceptions,
and and the level of
knowledge than anything else.
I mean one of the things that
came up at this meeting today
was there's a person who
works on national security
who said that, you know,
already there have been rumors around
that you know this was being done
50:50
to really affect, to
cripple the Chinese economy,
you know so the US would get an advantage
in the global, in global competition,
but what they've already learned
is that the people
who've been spreading those
rumors on the internet,
through social media,
are the same people who
interfered in the 2016 election,
the Russians not the Ukrainians,
and you know and this is tied into people
who are known adversaries of the U.S.
in terms of national security,
because what they're trying
to do is weaken institutions
through cyber methods,
and if they can spread
craziness about the coronavirus
and get people all worked up and fearful
then it again weakens trust in-
- [Woman] Probably doesn't
help that Wilbur Ross
actually said it's actually
good for the US economy.
- Yeah, yeah, well,
no that doesn't help either, right.
Anyhow that's what we
were discussing today,
and it comes back to,
I mean that discussion
shows that you know Tedros
is onto something
when he says health is a political choice
because you know the way
that all these issues will,
51:52
you know one other thing that was noticed
is when Tedros declared coronavirus
a national health emergency,
he went out of his way to praise China
for what they'd been doing to stop it,
but of course that just
aggravates the U.S.,
you know the State
Department and administration
because you know they're in the midst
of this big trade war with China,
and that didn't help Tedros' case,
so you know and the U.S.
provides most of the WHO budget
or the largest share of the WHO budget
of any of the Member States,
so that wasn't a particularly
astute comment by Tedros
in that statement.
But those are part of,
or those angles are part of
how to make sense of what's
happening in global health
around the world.
- Thank you so much, Jeff,
and I think we're just reminding us all
what you said which is biomatically,
we actually know what to do with a virus,
and it's the political and the human,
and you know and how do we address those
52:54
which are complicated
and everyone's,
there is sort of an interest,
there is definitely an
interest in partnership,
but what does that mean.
I want to make sure that we
have time for our students
to ask questions for you.
So I'm gonna turn it to...
And can you,
before I ask a question will you just
remind, or you know say your
name in your program please.
- Hi, I'm Joey, I'm a sophomore
I'm studying international economics
at the School of Foreign Service,
and my question is is
that the private sector
can be good for like investing
and funding different programs,
and then research of course,
but there's a lot of negative consequences
such as like inflated
pharmaceutical prices,
so what are the cautions
of the private sector
getting involved in
the health care system,
and how can these issues be mitigated.
- Oh, later tonight,
you know when the president
does his State of the Union address,
everybody's predicting
that he's gonna hammer the
pharmaceutical industry,
just because it's an
easy political target,
but on the other hand
you could ask the question, well,
what does his administration actually done
53:58
about pharmaceutical prices,
and the answer is not much.
So, you know, and that's
a perennial challenge,
but but look at this question more broadly
because you know and if you look at
some of the the articles
that Maeve was good enough to send around
on some of the things I've written,
you know there, you know,
a lot of folks think
that you know that public health
should be just that, public,
and the private sector should
have nothing to do with it,
and I think even if you believe that,
there's a problem with that conviction
because if you just think
about how health commodities
get to the people who need them,
it's through the private
sector in the marketplace,
so you can't avoid
private sector engagement
in implementation of either, you know,
like doctors or corporations, right,
so they're there in the private sector.
You know you think Georgetown probably
has a billion dollar hospital, you know,
which is a privately owned hospital.
So just wherever you go in the U.S.,
55:01
you know health insurers are
all private corporations.
Most most of the trillion dollars
that the U.S., trillion
plus that the U.S. spends
on health care every year,
a lot of it is funded by the government,
whether it's Medicaid or Medicare,
but it's delivered through
the private sector,
and so that leads to all kinds of curious
and interesting anomalies for instance.
You know we spend more money
on administrative costs
in the U.S. healthcare system
than we spend on cancer care.
So you know it's, so those
are some of the pathologies
of having a system
that's a mix of public and private,
but they're not you know
those aren't necessarily,
they don't necessarily have to be,
those pathologies don't
necessarily have to occur
because you can redesign the system,
and that's what the
debates over the, you know,
but at first when you know when I was
a young public policy guy at Merck,
or a younger public policy guy at Merck,
we dealt, you know we
spent hours and hours
56:02
pouring over the Clinton Health Care Act
to see if there were ways
that we could figure out
how to use the provisions
that they were making
that would make it possible
for us to do more to
actually improve health
in a way that was consistent
with our business.
You know now there's been
this debate for years
about Obamacare and whether
it should be repealed or
replaced or changed or whatever,
but that's all based on
these these basic tensions
about you know people demand
health care reasonably enough,
but how are you going to
provide it efficiently
and effectively given the
resources that are available.
The other thing, if
you look at health care
outside the U.S.,
again you know many countries,
for instance people in
the UK will tell you
that they have complete faith
in the national health care service,
which is government-run
and government-funded,
but most of them at least,
if they're middle class or you know
in the professional classes,
also have private top-up insurance,
because they don't want to
go to their local clinic
because it's mandated by the NHS,
or they don't want to
wait for a specialist
and you know and wait for an operation,
57:03
so they just opt out and
use private resources.
If the UK didn't have that kind
of private health care
system on top of the NHS
it would fall.
I mean the NHS would fall apart,
there would just be too
much demand for the system,
and as it is they've had challenges
with waiting lists and
an allocation of resources for decades.
In other countries, you
know let's take a look
at places like India or a
lot of African countries,
again the assumption is
that it's all public sector,
it's all run through tax funded resources,
but India provides something
like 80 percent of its care
through the private sector.
You know because the government
simply doesn't allocate enough resources
to treat the health needs
of over a billion people,
and so you have a very
complex and robust system
of private providers
and private, you know, hospital networks
and managed care organizations
and doctors groups
and everything who actually
provide most of the care
58:06
that India has.
So partly, you know just I
wanted to just sort of turn
your question around a little.
It's not you know that there are problems
and you have to worry about pathologies
that the private sector might bring
to the healthcare system,
health care systems around
the world would fall apart
unless there was private
sector engagement,
that's the reality,
so the question is what
are the outcomes you want
and how can you redesign the system
to make sure you get those outcomes.
So you know so in the U.S., for instance,
let's just stay with that example.
You know there are pharmaceutical
companies, for instance,
can't promote medicines off-label,
you know and that's
part of the whole system
that the FDA administers,
and that's there to ensure
the safety of people
who are taking those medicines,
so that's one kind of check.
So you have regulatory interventions
that you can use to
make sure that companies
don't do things that are against the law
or skirting ethical guidelines.
You know when companies act in ways
that are non anti-competitive,
59:07
they get huge fines,
you know so there are other
kinds of legal remedies
and guardrails that are put in place,
and you know are in place,
but it's not just
pharmaceutical companies.
You know I haven't looked
at the most recent data,
but it's usually the amount of money
that the U.S. health budget
in the U.S. health budget
that's allocated to pharmaceuticals
is less than 15 percent,
and it's actually been going down
over the last several years.
So despite the fact that you have,
you know for every medicine like Zolgensma
which is a new medicine
for spinal muscular atrophy
that Novartis sells
which is now the most
expensive medicine in history
at 2.1 million dollars per treatment,
but they argue that it's cost-effective,
but you know that's a different,
we can go into that in great detail.
But for every 2.1 million
dollar medicine you have,
you know a hundred that cost
a couple of pennies a day,
so you know there's a huge distribution,
so just to say drug prices are too high
is actually a little bit simplistic.
01:00:08
But the other point is that
if you look at it in the context of
all the money that's spent
on health care in the U.S.
and this is true for most
developed country economies,
the percentage that's spent on on drugs
is relatively small
compared to the amount of
money that's spent on doctors
and other health care professional fees
and hospital care.
So the U.S. could actually say,
and remember I said that we spend more
on administrative costs in the U.S.
than we do on cancer care,
and it's a paper by David Cleary
and some of his colleagues at Harvard
that came in a couple of years ago
in the New England
Journal that spells it out
in great detail.
So you know if you really
want to reform the U.S.
healthcare system,
and you just focus on pharmaceuticals,
you still have an enormous problem
of inequalities and
disparities and access to care
that are actually much more complicated
for people to solve
than just bringing down
the price of drugs.
You know I'm not arguing
that we shouldn't.
I mean personally I think that
you know the U.S. industry
has tried for decades to keep
from having government control of prices,
01:01:11
but they make very robust
prices in every other country
in the world where
prices are administered,
so I think the the argument
that you can't control our prices,
there'll be no new medicines
is just belied by the facts
which is everywhere else in the world
there are price controls
and they're still robust
pharmaceutical innovation
in those countries,
so I think inevitably
just given the pressures
on our system now,
there will be some form
of a price control,
you know I predict that in
within the next 10 years
Medicare will negotiate
the price of new medicines,
you know which is the hill
that the pharmaceutical industry has said
that, you know, they're
just never going to
agree to that.
I think it's inevitable that
they're going to agree to that,
particularly now you know
when when the Clinton
health care plan came in
in the early 90s,
that was a democratic plan
the Republicans were dead set against it.
Now you have both
Republicans and Democrats
arguing that the pharmaceutical industry
has to, we have to do something
about the pharmaceutical industry.
You know that's, that doesn't bode well
01:02:12
for the outcomes of the industry
would like to have,
so that's one point I
was just trying to make
is that at least when you
look at pharmaceuticals,
you know it's a complex situation,
but the industry actually,
if you think that prices are too high,
the other thing that people miss
is that there are thousands
of different purchasers
in the U.S.,
and the US already has a
highly competitive market
for pharmaceutical,
in pharmaceutical prices
and that most of those purchasers,
most of those buyers all
have different prices,
and it's worked out so that the,
because the price negotiations are secret,
Richard Cave is an economist
who you may have come across
who's actually written about this.
If each of those
purchasers and and sellers
negotiates a price
that both of them are happy with,
and doesn't signal what
that price is to the rest,
you know to all the other
purchasers and sellers,
the prices on average are
lower them that would be
if you actually had the
kind of transparency
01:03:13
that HHS has been calling for,
and because the other thing
that we miss about this
is that you know if you have
heart disease, for instance,
there are literally hundreds of drugs
you can take for hypertension,
so there is actually a
perfectly competitive market
for hypertension drugs.
You know I mean I actually
have hypertension,
that may be more
information than you need,
but you know my main hypertension medicine
costs a couple of dollars a month, right,
it's not thousands of dollars a month
because there are probably
50 other medicines
that my doctor could prescribe for me,
most of them are generic,
and you know and actually 90 percent
of U.S. medicines are
prescribed generically
and those have very low prices,
so it's just a very complicated picture,
but I want to just spend one minute
on on other kinds of challenges
in you know in the role
of the private sector.
You know for instance there are
some who argue that there are companies
in the private sector that
actually cause chronic disease
rather than fight chronic disease,
so think of food companies
and beverage companies
01:04:17
and alcoholic beverage companies,
and so yes if people over
drink too much sugared coke
they're going to have a problem,
you know could have a
problem with diabetes
or heart disease or other things,
and you know similarly for other products,
and then think of tobacco companies
and you know there a range of products
that are marketed by companies
that actually can have
deleterious health implications,
but they're the the solution again
is regulation,
and it's both self regulation
and government regulation.
I mean if you look at
the International Food
and Beverage Alliance,
which is you know a lot of big companies
like Coca-Cola and Pepsi
and and food companies
like Mandela's and Nestle
and Danone and others,
they've actually agreed
to a set of requirements
that were agreed with
the WHO some years ago,
and they've taken
trillions of ounces of fat,
salt and sugar out of the
food that they formulate,
so that actually has a positive
impact on health outcomes,
01:05:19
but you know it's not,
you know companies like Pepsi colas
is well known for this,
that when Indra Nooyi was CEO of Pepsi,
she spent billions of
dollars designing new foods
that were good for you in addition,
they still sold at that
time they made Fritos,
they sold it off later,
but you know they still sold
foods that were fun for you
as she said,
but they were also just
because the marketplace
required them to,
because people stopped buying high-fat,
high-salt sugared products,
so it really was in their
interests as a company
to make foods that people wanted to buy
that were healthier.
So the point I'm just making
is that you know yes you can point to,
you know we haven't even
talked about climate change
and you know carbon emissions
and practices that companies have
that are deleterious to the environment,
but what's interesting
is that the combination
of economic self-interest,
public pressure and government regulation
01:06:20
actually moves things
ultimately in the direction
of products that people are willing to buy
and if everybody wakes up one morning
and decides, you know,
we want to eat kale instead of Big Macs
then the marketplace
moves in that direction,
and if you just think of
like the biggest product,
I mean the the product that's had
the most deleterious effect on more people
than anything is tobacco,
and so now you know just in my lifetime
there's been a tremendous
social transformation
in people's attitudes towards smoking.
You know when I was a kid,
you know my mother smoked
a couple of packs a day,
you know my father smoked cigars,
you know every adult I knew smoked,
and now you walk down the street
and you barely run across anybody smoking.
You know this transform,
and it happened quickly too,
I used to go to Norway all the time
among other things when
I was working at Merck,
and Ireland, I went to Ireland a lot,
so it was in the space
of a couple of months
01:07:24
it used to be if you
went to a pub in Ireland
and you sat there for an hour,
when you came out you just
smelled like an ashtray.
It was just inevitable and unavoidable.
The same thing was true in Norway.
In fact Norwegians smoked more
than any other European
country on a per capita basis,
and in the space of a couple of months
that completely changed
because enough people
advocated for changing the laws
that you could no longer smoke in pubs,
and eventually you could no
longer smoke in public places,
so it's possible to change these things
because you know for one
thing tobacco, I think,
and personally I think it's
right that it should be,
you know a product that actually
if you use it properly will kill you,
doesn't seem to me to be a
product that really needs
to be available to people,
but you know those kinds
of changes will happen
as a result of those three factors
and what we've been seeing
over the last 10 or 20 years
is just an acceleration
in the way in which people
are more aware of this
and are asking companies
to change their practices,
and because companies you
know want to have customers
who want to buy their products are going
01:08:25
to move in that direction,
so it's really, from that point of view
it's relatively easy to
get companies to change
what they want to do,
you just have to make it clear to them
either by voting with your feet
or getting others to raise their voices
that you know their current practices
just aren't going to lead
to the kind of outcomes
they would like to have,
and you've seen that in industry
after industry, I think.
So my point is that companies respond
to economic incentives,
so you know you're beginning
to see more and more use
of those kinds of economic incentives
to change their behaviors.
- Thank you so much,
and I also just that,
I think you made such a good point
about the ease of advocating
about high drug prices,
which is not that we're
not in disagreement
about the drug prices too high,
but we look at how
complicated the issues are.
It's much easier to, you know,
the low-hanging fruits are those things
that we can define in one sentence
and it is much more complicated than that.
01:09:28
- Yeah, just one final point about that.
It's not that drug price,
what I would do is say some
drug prices are too high,
and so the question is that if
there's more public education
about the nature of the drugs
that they use.
So for instance you know you can go,
you know if you get
prescribed a brand-name drug
that you have to pay four
times as much in a copay
and it also costs your insurers
a lot more,
you just ask your doctor
for a generic version,
you know because most drugs
do have a generic version.
So that kind of consumer awareness
can actually, you know,
and you multiply that by 300
million people in the U.S.,
that will shift the marketplace,
and actually that's largely why we have
90 percent generic prescribing now,
because that's, you know in 1980,
I remember the statistic that there was
hardly any managed care in the U.S.
and now it's virtually all managed care,
and a concomitant of that
has been managed drug administration too,
so now you have these
pharmacy benefits managers
in this really complex system,
01:10:29
you know it's so rare that,
like you never just
walk into your pharmacy
and ask them for a particular product
because you know there's a
whole network of pharmacy
and therapeutics committee,
formulary committees
for your drug company
that have negotiations
with pharmacy benefits managers
and then they have negotiations
with drug store chains,
you know and all of that leads to
why you get the product you get
when your doctor prescribes X,
you get something else at the pharmacy,
but that's happened over
the course of 40 years
because of economic forces
and economic incentives,
so you know so it's possible
to change these things.
- I'm Paula, I'm a sophomore
studying global health
in the School of Nursing.
So you mentioned how the
current head of the WHO
really emphasizes health
is a political choice,
and I'm just wondering how you think
that this concept has changed,
decades or what has it
always been seen as a
like health and politics...
Okay, so yeah, so how do you think
01:11:36
that at least in your career
you've seen this concept either be changed
because I think at least that
nowadays it's more so seen
as health is a political concept.
- Well, I think actually this reality
has been around for a long time.
If you go back to the mid 19th century,
Rudolf Virchow was a German physician
who created a discipline
called social medicine,
you know which had to do
with with the kinds of things
I was talking about earlier
on social determinants,
but you know but he's the first person
who's well known to have made this comment
about, well for one thing,
he said medicines are diseases of society,
so that you know that had
to do with his interest
in social determinants,
but he also made this linkage
between health and politics
and you know that's sort of been a thread
through public health ever
since the mid 19th century,
and then you know if you fast-forward
from Virchow to Bismarck in the 1880s,
01:12:40
you know Bismarck was
the the first politician
who put in place you know
universal health coverage,
and that he did that for political reasons
because he knew that
voters would be interested
in keeping his government in place
if he was able to give
them you know insurance
that would keep them out of the hospital,
keep them from going bankrupt
if they had a big illness,
you know and so you can
actually trace this back,
and Jesse Bump who used
to be at Georgetown,
I think he's now at the Harvard
School of Public Health,
but you know he's written
a really interesting paper
about the historical roots
of universal health coverage
going back to the
Germans and to the French
in the 19th Century,
and you know and pointed out
that actually although Bismarck
put social health insurance in place
in the 1880s,
it took Germany almost a hundred years
to get to true universal health coverage.
And if you just you
know think about the way
that I mean you can't look
at what's happened in the US
over the last last 10
01:13:41
years with Obamacare
and not think that health is political.
And the reason,
you know and all of this has to do with,
I mean it's not surprising
that it becomes political
because you're talking about
a trillion dollar industry
and you know in a large chunk
of the entitlements budget
of the US government,
you know which translates into taxes
which translates into voter interests
and who's doing better for them and stuff,
so it's all about power and money,
and you know those issues always lead
to political discussions
and political decisions,
so and it's true not just in the U.S.,
but in every other country in the world.
You know I mentioned before Xi Jinping
doesn't want his officials
to tell the world that
they have this new epidemic
until he's sure that he can control it,
so they keep a lid on
it for political reasons
and it's administered,
that control is administered
through the Communist Party
which is in control.
If you look at,
you know you think of the
debates between Sanders
and the other Democratic candidates
01:14:47
about Medicare for all,
and then you know that in
the election in the fall
whoever the candidate is,
the Republican opponent
is going to talk about it
as democratic socialism,
because they're trying
to do something different
with healthcare.
In every European country,
because the system of,
you know the health care system is run by
and paid by the government,
the you know the core health care system,
all of the decisions that they make
about whether they're going to
reimburse for new medicines,
whether you're gonna be able to get
access to you know a new hearing aid
that's digitally enabled,
whether you can get glasses
or go to the dentist,
all of those decisions
are the result of what
allocations they make
to different aspects of the
healthcare system service,
and you know so it just it's inevitable
that these are political decisions,
so I think the answer,
the short answer is,
as far back as you can trace,
health has been a political
choice as Tedros says.
01:15:48
What's interesting is the reason
that he's so,
I mean he's really an interesting guy
because he was the,
he was actually trained at Hopkins,
at the Hopkins School of Public Health,
and his first big job in
government was Health Minister,
so you know he,
you know some of you may
have studied the system
of community health workers,
that he implemented it when
he was Health Minister.
So they have something like 36,000
government paid community
health workers in Ethiopia.
It's had a dramatic
impact on health outcomes
because of the transformation
in primary care,
but after he was Health Minister
he became foreign minister,
so you know you you couldn't imagine
something more different
than being Health Minister
than being foreign minister,
but that's what gave him this insight,
that ultimately if you
want to change these things
and certainly if you want to
change them on a global level
you have to bring diplomacy and politics
into the end of the conversation
where you really can't get access
to you know most of the resources
that governments have
because they're always going
to be allocated to other things.
So it's just, and also when he became head
01:16:50
of the WHO a couple of years ago,
you know normally what
the new head of WHO does
is go around the world and
meet all the health ministers.
He started with foreign
ministers and finance ministers,
not health ministers,
because he knew that
ultimately his success
was going to depend on
having political support
and having financial
support from member states
for what WHO wanted to do.
So I think it was really astute,
but it comes back to health
as a political choice.
- Thank you.
I'm Sodia, I am a senior...
Politics.
My question is more about research...
Helping countries.
So since it plays a crucial
role in the development...
That in turn shape...
That health care practitioners
pay attention to.
In some countries health research
is more to the educators, defined
by international standards
rather than local contacts
and like (audio cuts out) of health,
and so I was wondering what do you think
the private sector should do to support...
01:18:08
- Yeah, it's an interesting question.
I think that, you know one of the things,
and again you know my experience
has been largely in the
pharmaceutical industry,
so I'll use that as an example,
but you know the industry
actually supports
a tremendous amount of research
in lower in and middle-income countries
through the clinical trials
it conducts around the world,
and you know the,
and actually what they try to do
is build capacity in local,
you know in various countries
to do that that research.
So I'll give you two examples.
One is countries like Spain for many years
used to actually
because remember in European countries
the government decides how much
they'll reimburse for medicines.
So Spain was actually pretty smart,
they had a system, excuse me,
where they would rate the companies
on how what kind of a contribution
are they making the
Spanish health care system
and the Spanish economy,
and then let's say they ranked
them on a scale of 1 to 100,
and companies that ranked high
01:19:11
actually got credit for that contribution,
were able to get a higher
reimbursement price
for their new medicines.
So that provided an incentive
to fund research in Spain
because that's what it was called,
the Planes de Fomento
or the plan for growth,
and that was a way the Spanish government
provided incentives for companies
to invest in research in Spain,
so you know they would
invest in clinical research
in various universities,
they would invest in basic research,
and that all gave them
credits for this system
that decided how to
allocate the drug budget.
You know other countries
like South Africa,
you know companies over decades
have made real you know
substantial investments
in helping you know major
South African universities
like the University of Witwatersrand
or the University of Cape Town
to build clinical capacity
to do clinical trials in South Africa,
and that's been important
because a lot of countries
would like their,
you know Japan used to require this
and a number of EU countries did as well,
01:20:13
as well as African countries.
India is also you know
well known for this.
Before they'll give you
approval for a new medicine
they want to know that
you've done clinical trials
in their populations,
so that's another incentive
for investing in healthcare infrastructure
and research interest infrastructure
in those countries.
So you know and some companies like,
for instance the company
I used to work for, Merck,
for 25 years had a fellowship
in clinical pharmacology
where they would give that fellowship
to someone from South Africa
or from you know Latin American countries
and what's interesting is that,
you know and then that would enable them
to do research in clinical pharmacology
which is a discipline
that's absolutely critical
for drug development,
and many of those scholars
then became leading professors
in South Africa.
One became the head of the FDA in Japan
because that, you know,
those investments early in their career
gave them the opportunity
to become part of the
international research community
01:21:14
and then, you know,
that then led them to these successful
and important positions
later in their careers,
so you know those are
just a couple of examples,
but I think that there are,
you know it's actually,
and think about it it's actually
in the company's interest to
make those kinds of investments
because then it makes it easier
to find laboratories and clinics
where they can actually do the research
they need to get approvals
or regulatory approvals,
and so it works both for the country
that's their partner and for the company,
so you know and and that's why you see
more and more of that.
You know I think more generally
what's interesting is
there's more and more
of a global economy in, you know,
I'm just using that term
in the most general sense,
of where people make decisions
about where to invest in doing research
and also where to train people
and you know how to ensure
that you know it's actually,
we just think about
if you're in research administration,
if you're trying you know let's say that
you know you work in a company
that's based in Germany,
01:22:18
but you're a global company
and you want to make sure
that you have the,
you maximize your chances for success
in developing a new product.
You actually want there to be
as many countries as possible
where you can get people
with the requisite skills
and experience to do
the kind of clinical research you need,
so that's really what
people have begun to do
over the last 20 or 30 years
is make those broadly based investments,
so there are more and more
countries where you can do
that kind of research,
and then the the folks
who've been supported
in those countries then become part
of a global research community,
so you find that for instance
the NIH has the smallest
Institute at the NIH
is called the Fogarty
International Center,
and their mission in life
is to create research partnerships
between lower and middle-income countries
and U.S. institutions
so that people come and train in the U.S.
and go back to their
country and train others,
and that sets up
these kinds of you know
twinning arrangements
that actually lead to better
research on both sides
01:23:20
because it enriches the U.S. community
as well as you know
whether it's South Africa
or Nigeria or another country,
and so you know,
even though it's the
smallest NIH Institute,
the money they have has had
a disproportionate impact
on improving the quality of
research around the world,
so I think you know there are
lots of examples like that.
- [Victoria] Hi, my name is Victoria.
I'm a junior studying global business,
and I was interested particularly
when you were talking about NCDs
and particularly their rise in developing,
emerging countries,
and I was wondering what
private sector initiatives
or partnerships you've seen implemented
in these countries
to effectively combat these diseases,
and what are some of the
challenges that you're seeing.
- Well, I think one,
well it's a big subject,
and I think they, you know one of the ways
the private sector has
been engaged in this,
just to change direction for a moment,
is you know when you just think about it,
70 percent of deaths around the world
01:24:25
are caused from chronic conditions,
and that affects people in lower
and middle-income countries
as well as in the global north
and highly developed economies,
and in fact something like
if the statistics are available
on the WHO website,
but I think that 70 percent of deaths
and then of those deaths
something like 80 percent of them
are in lower in middle-income country,
so it actually
disproportionately affects people
in in those countries
even though these diseases
used to be called lifestyle diseases,
and with the implication
that they only affected wealthy
people around the world,
but that simply isn't true,
and so one of the,
but then so that's one point,
but then if you think about the role
that the private sector you can play,
you know most people work
and most of us who work
spend a lot of time in our workplace.
So since, you know,
one of the things
that the Robert Wood
Johnson Foundation says
getting back to social determinants
is most health occurs
where people live, learn,
work and play.
01:25:27
So if you just think that
all of the interventions
that are gonna help people
live healthier lives
are gonna take place in
a clinic or a hospital,
you're missing a huge opportunity
to help, have an impact on people's lives
and health outcomes.
So one of the ways that the private sector
has begun to have an impact
on NCDs around the world
is through programs that
focus on the workplace,
so you know and they do that
in a number of ways.
You know when, this isn't an NCD example,
but one of the things I
worked on 20 years ago
through the GBC on HIV/AIDS and malaria
was to encourage
companies to have policies
on what to do about HIV,
people who are HIV positive,
and you know to make testing available
to make sure people had access to therapy,
to make sure that there were
education programs available
to people in the work place
about how to ensure that you weren't
putting yourself at risk
through different sexual behaviors,
and so there was a huge
movement about 20 years ago
for large multinational
companies to do that
particularly in countries that had
01:26:30
generalized epidemics,
and the same things true for NCDs.
So you know the company
I used to work for,
you actually got lower healthcare,
you paid lower healthcare premiums
if you could demonstrate
that you didn't smoke, for instance,
you know because that's what led
to most of the health care expenses
for that company's covered population,
and that's a common
thing that companies do
is just make it, provide
incentives to people
to have healthier behaviors.
You know and then companies
are also doing things
like you know building fitness centers
and letting them, giving
employees the opportunity
to get more physical activity.
You know having a non-smoking workplace.
You know those are all things
that are sort of structural changes
that can be made that help nudge people
in the direction of healthier behaviors
which leads to an impact on on NCDs.
Then there are other ways
that companies do this,
they, you know,
in addition to focusing on the workplace,
you know they can work
together with others,
this gets back to what we're
talking about with partnerships
01:27:30
on things.
Everything from training
health care workers,
so that, you know and again
this is in the company's interest.
If you're, let's say
you've got your big company
that has operations in Brazil,
if you, well Brazil is
probably a bad example
because they have a good
primary health care system
and lots of primary health care workers,
but you know let's say that you know
in particular parts of Brazil
where the company has an operation,
they can help the local government
train more health care workers.
That helps the general population,
but it also helps the
population of their workers
and their workers families
because they have access
to better primary care,
and then that leads to
higher productivity,
so it's actually in the company's interest
to make those kinds of investments,
and there are plenty of examples of that.
And then the other thing they can do
is actually just you know
and this is much more directly related
to the kinds of products
that they make available,
and so this applies to
other companies as well
as pharmaceutical companies,
but one project I worked in
with a pharmaceutical company
01:28:31
called AstraZeneca a couple of years ago
it's called healthy heart Africa,
and to make a long story short
they realized that not many people
were using their antihypertensive
medicines in Kenya,
and it turned out that Kenya has something
like eight million people
living with hypertension,
but hardly any of them were on treatment.
So we worked on a project with AstraZeneca
to number one,
one reason that not many
people are using their products
was that they were 10 times as expensive
as other antihypertensive medicines,
so we got them to change
their entire supply chain
so they could lower the price
by a factor of 10.
So now instead of a dollar a day,
they were 10 cents a day,
and so they were now the same price
as other antihypertensives,
but then they had to figure
out a way to reach the people
who didn't know they had hypertension
and make sure that they
began to get on treatment,
so we we worked on a big project
that number one we worked
with a number of NGOs
that were being supported in
Kenya by the PEPFAR program
01:29:33
to ensure that the well run clinics
that treated people for HIV
and maternal and child
health were available
to something like two million people a day
through this network of 2000 clinics,
so that was a much more effective way
of reaching a large population
at the primary care level
then detailing cardiologists
which is what they'd been doing before,
and there were so few
cardiologists in Kenya
that even if every single cardiologist
prescribed AstraZeneca products
for every time they found
somebody with hypertension
it still was only gonna
reach a few thousand patients
which is exactly what what was happening,
but by implementing this program
of routine blood pressure screening
for everybody who came to the clinic
in this network of US
government supported clinics
they were actually over
the first few years
able to screen more than 11 million people
and they found more than a million
who had hypertension
who weren't on treatment
and then were able to
get them on treatment.
So that was a way of you know instead of
01:30:33
taking a traditional kind of
approach to to this problem,
by taking a public health approach
you could actually have
a much greater impact
and it was also sensible for AstraZeneca
because they ended up selling
more of their products.
Well you know even though
it was at 1/10 the price,
they were selling it you know
ultimately to millions of people
and millions of patients
not just a few thousand,
so it worked out to make sense
both for them as a sustainable business,
and also for the Kenyan government
and you know and all
these communities in Kenya
who were now getting better
treatment for hypertension,
which was the, you know at
the time they started this,
the leading stroke from
uncontrolled hypertension
was the leading cause of
death among adults in Kenya,
and so they're actually
able to have an impact
on a really big public health problem.
So that's another way
in which the you know
the kinds of partnerships
we've been talking about
actually do have a major
public health impact,
that they're designed in the right way,
but that was done through you
know there were five big NGOs
that were involved in this,
the Kenyan government,
you know thousands of
communities around Kenya,
01:31:36
the PEPFAR program,
so you know it was a
really complex partnership,
but it ended up with a very
simple and powerful result.
- I didn't know that story,
that's a really impressive story,
and there are so many examples
of how the companies,
you know there really are
part of these communities,
and the incredible work that they do,
and I think you specifically mentioned
working with families
it's not just the people
who are walking in the door,
you know, the good ones,
recognition that a healthy family makes
a productive worker.
- Another thing just to reflect on
is that you know in Kenya,
most of the people who
work for AstraZeneca,
which is a UK based company are Kenyans,
so you know this is personal to them,
it's really helping their communities,
helping their country do a better job
of dealing with NCDs,
and so it really,
you know they what's great about
putting these kinds of
partnerships together
is you can see the motivation
from the company side
because it has that kind of direct impact
on you know in the lives of people
they care about,
and so you know it's
just another incentive
01:32:42
for them to do this kind of work.
- I want to thank you so much, Jeff,
for coming here tonight.
- Sure.
- It's been wonderful
hearing your stories,
it's really really
exciting work that you do,
and the partnerships you're
able to build, you know,
here on Capitol Hill and across the world
it's just really impressive
and I know there's a lot of people
who are eager to follow in your footsteps.
(laughs)
So thank you very much.
We can all sort of...
- Thank you.