 Salvatore Bobonis, and today's lecture is public health as a global social problem. Medicine may be a biological science, but public health is mostly a social science, and threats to public health are almost always, in the end, social problems, not scientific ones. The larger the scale, the clearer it becomes that health problems are primarily social problems. Both infectious diseases and lifestyle diseases closely follow socially determined patterns of incidents and prevalence. And of course, the ultimate health issue, the existence of human life itself, is closely tied to societal levels of development and governance. It's pretty obvious, even from a quick glance at worldwide life expectancy, that people's health possibilities are strongly patterned by geography. People in Western Europe, North America, Australia and New Zealand live longest. People in Eastern Europe and Latin America fall somewhere in between. East Asia has some serious health problems, but by far the worst continent for life expectancy is Africa, and in particular, Sub-Saharan Africa. Only a few places in the world outside Sub-Saharan Africa have levels of life expectancy below about 65 or 70 years. On this map you can see Afghanistan is a notable exception, Laos has particularly low life expectancy, but for the most part the place is in the world where people statistically have the shortest lives is Sub-Saharan Africa. Much of this geographical distribution of good health or at least of life expectancy, which is not always the same thing, much of it is clearly related to countries' levels of income per capita. Now among poor countries or middle income countries, countries below $10,000 per year GDP per capita, the overwhelming determinant of life expectancy is income. As incomes rise from the very poor countries to the middle income countries, life expectancy rises extremely rapidly from 40 to 50 years of life expectancy rapidly up to 70 to 80 years of life expectancy. And then there's very little additional increase at incomes above $10,000 per year. There is a slight increase and there does tend to be a tiny additional benefit of living in rich countries, but most of that additional benefit seems to come from the extension of life when people are close to death. So in a very rich country, someone who is 75 or 80 or 85 years old who might not make it through one more winter or might not make it through one more operation, instead in a developed country is able to get first-class hospital care and survive. There are also people with chronic illnesses who only survive because they're in rich countries with very high levels of medical support, so people who require regular kidney dialysis to stay alive, people with Alzheimer's disease who stay alive, albeit at a very degraded quality of life in the very richest countries. But for most part, the big gains in life expectancy come between very, very poor countries and middle income countries. Now, there are a few exceptions to this general rule. You can see them on this chart. Russia has relatively low life expectancy for its income level, and that can entirely be traced to the 1991 transition from communism to capitalism, which had a dramatic wrenching downward impact on life expectancy as health systems deteriorated, as people's lives returned upside down, and as levels of alcohol and drug abuse skyrocketed as a result of that transition. We would probably expect Russian life expectancy to rise up more to typical middle income levels as the decades pass. Also, there's a group of Sub-Saharan African countries that have been very extensively impacted by the AIDS crisis, and as those countries get AIDS under control, and most of them have already made big strides toward getting AIDS under control, again, their levels of life expectancy would be expected to rise to a level commensurate with their income levels. But as that kind of tour of the world shows, raising life expectancy is not all about income. I mean, obviously, among very poor countries, more income is necessary just to give people the nutrition they need to survive, to help them get appropriate medical care, to have proper water and sanitation. But once those basic needs are met, and in most middle income countries, those basic needs have been met, then the question becomes the strength of society in general. There's a big difference, well, not a big difference, but there is a difference of four or five, six years in the levels of life expectancies among rich countries, among countries that can afford to have a full and healthy life for everybody. And a great example of a country that is not an especially rich country, but nonetheless has raised its levels of life expectancy to rich country levels, is Cuba. Cuba's life expectancy is about half a year or a year lower than that of the United States, despite the fact that the United States is something like eight, seven or eight times as rich as Cuba. Nonetheless, Cuba has done very well on health, and comparing it to other countries in its vicinity, the Bahamas are much richer, but have a lower level of life expectancy. Belize, Dominican Republic are a little poorer than Cuba, but have lower levels of life expectancy. Jamaica, again, a little bit poorer than Cuba with much lower levels of life expectancy. And even Mexico doesn't do nearly as well as Cuba in terms of overall population health. And the big reason for that is that Cuba has made a country-wide commitment to providing basic public health and disaster preparedness. So all over the countries, you would find clinics like this small roadside clinic in a rural area in Cuba. The provision of basic public health, what some people used to call both admiringly and also derisively barefoot doctors, can do a lot to really raise people's quality of life and standard of health. Now, these doctors in Cuba are not barefoot at all. In fact, Cuba has made a massive commitment to democratizing medical education, for making it possible for anybody with the requisite ability to go on to medical school and to go on to serious medical school. And in fact, many Americans attempt to get into medical school in Cuba, partly as a political statement, but partly also because medical school in Cuba is absolutely free. Cuban medicine is well regarded throughout the world. It is probably not at the level of the most advanced care available in countries like the United States and France and Germany. But nonetheless, it's at an extremely high level of general practice. I would suspect that if you went to your general practitioner, you wouldn't see that much of a difference between Cuba and a country like Australia or the United States. You would see a different if you went to the top hospitals in Havana versus the top hospitals in Baltimore and Boston. But most people don't need that kind of care. So at a relatively low income level, Cuba is able to provide a really relatively decent standard of health care for its entire population. And importantly, again, as the Cuban example shows, it's not just health care. It's also the whole infrastructure around it. So having an infrastructure of civil preparedness for disasters, having an infectious disease reporting network so that when an outbreak occurs, it's quickly discovered and the central government can react in an appropriate way. These are the sort of systems that developed countries have and Cuba has, but very few other middle income or poor countries have the kind of public health infrastructure that Cuba has developed for itself. Now, we don't really have an indicator of who it does a good job at providing an overall societal infrastructure, but we do have an indicator that's often used for the robustness of society as a whole. And that's the level of inequality. We usually think that countries that have relatively low inequality have low inequality because they have government institutions that help provide support for poorer people and government institutions that help provide a leveling out of opportunities among the entire population. And countries that have high inequality tend not to do that kind of public leveling and public support for the entire population. Well, here we have graphed the Gini coefficient, which is an indicator of inequality. It runs from a low of zero perfect equality to a high of 100 total inequality. One person has all the income. And as you can see here, there is a modest correlation between income inequality and life expectancy. That is to say, on average, more unequal countries tend to have lower life expectancy. It's not a strong relationship, but it is a statistically detectable and statistically significant relationship. This correlation of negative 0.33 indicates that, well, something around 10% or so, or maybe 9% of differences in life expectancy across countries, can be explained by looking at their levels of inequality. Now, 9% may not sound like a lot, but when you consider that income inequality is not really measuring what we want to measure, it stands in for the level of social support in a country, but it's really only a very error-prone indicator of level of social support. When you consider that, then this correlation becomes much more remarkable. But of course, neither income nor inequality actually causes good health or bad health. Nobody is dropping dead because somebody else nearby has a higher income. And in general, people are unable to buy good health for themselves. I mean, sure, people can buy access to the best medicine, but usually that only serves to extend their life for a very short period at the end of life. For a very small number of people, access to the best medicine prevents death from diseases like cancer younger in life. And while that may be very important at the individual level, from the perspective of explaining health levels in an entire society, it's just not that important. Income and inequality in income don't really measure, don't really buy us good or bad health. On the other hand, they do serve as indicators of how strong a society is. I mean, rich countries don't have good health because they're rich. Rich countries have good health because, well, they have hospitals, they have ambulance services, they have roads for the ambulances to drive on, they have a proper refrigerated food chain so that food doesn't spoil and people don't have all sorts of foodborne illnesses all the time. They have clean water supplies. So countries that have high income tend to have all these things, all these that go along with high income that help produce good health. Also countries that have low inequality tend to have more of these things and it tends to, they tend to extend them to the whole population. So while every rich country may have hospitals, a low inequality country may also have health insurance for everybody, not just for, not just for the rich and so health becomes something democratized, not just for people who can afford it. And as we move from, you know, kind of like the most immediate aspects of society that influence health to the broader, we can see the very many ways in which both, in which the strength of society, no matter how you measure it, leads to better health outcomes. I mean, first of all, hospitals, medical facilities having public health systems so that if a disease is detected, the news is spread to other hospitals and they can be prepared for the flu emergency or whatever emergency arises. But then kind of moving away from immediate health care, richer, less, richer, more equal countries, countries that have strong social institutions tend to have health insurance and free vaccination and things like paid sick leave. I mean, you may think of paid sick leave as an individual benefit, but it came about as a social benefit. People have paid sick leave so that they don't come to work sick and make everyone else sick. Again, moving even further away from the immediate determinants of life or death, having good health education and availability of information, societies that have, countries that have strong societies have things like billboards giving advice on good health, have advertising on television about improving health, have, if they have cigarette sales at all, increasingly in the future, hopefully they won't, but if they do, they have health warnings right on the packets of cigarette to try to convince people not to smoke. Again, it further removed from health itself, nutritious food. I mean, in 1917 to 1919, a flu epidemic spread around the world that killed more people than were killed in World War I. Why have there been no flu pandemics since then? Well, you know, a lot of epidemiologists who want funding will tell you that there have been no flu epidemics since then just because we've been lucky and the magic virus has not appeared. I think it has much more to do with the fact that we're all much better fed than we were in 1918. In 1918, much of the world was teetering on the edge of starvation. Well, today people have so much food, most people have so much food that the big threat is obesity, not malnutrition. So people are just much healthier and much less susceptible to the flu than they used to be. The avoidance of dangerous work, you know, those of us like me giving this lecture and like you listening to it, tend to have office jobs and we tend to think that the real health problem at work is sitting too much all day long. Well, in fact, the real health challenges from manual labor, people doing serious manual labor, you know, digging in the ground, you know, farmers, people who work on construction sites, they suffer serious degradation of health. They're literally giving their bodies for their job. So the less of that kind of work, the more that work is automated, the more that it's made safe, you know, the more we use machines for heavy lifting instead of our bodies, the longer people live. Of course, at an even broader level, support of family policies and good employment opportunities improve health by improving psychological health. And that improvement in psychological health doesn't just make people happier, it makes people physically healthier, it makes them live longer. And there's a lot of strong research about that that people who are able to spend more time with families live longer. People who have good employment opportunities who don't feel trapped in a job or who have regular employment rather than irregular employment gain a boost to their health as well. And I stress they gain a boost to their physical health, they're less likely to have heart disease, they're less likely to have diabetes. It's just a massive improvement in health that can result from having a decent home and work environment. And finally at the broadest level, living in a more democratic, more open, less hierarchical society is good for overall health both in the direct sense, people are able to engage in, people are able to engage in life in ways that are healthier all around, but also in the sense that having that kind of society reinforces all these other determinants of good health. So when you put it all together, there's no magic bullet, there's no one reform that if you do it will improve health. Rather there's everything about a modern, democratic, developed, welfare society that improves the health of everybody in it. Now the spread of neoliberalism, which if you're a social science student you've heard a lot about, tends to degrade health at all levels and I think it's no coincidence that among developed countries the United States has the worst health indicators of any of them, being the most liberal of the developed countries, liberal in the sense of minimum government regulation and most reliance on private initiative. So what happens at each of these same levels, this slide eight corresponds to slide seven, level by level, is that in neoliberalized countries public hospitals and health systems are defunded. People are forced to rely on private hospitals and private health systems, which means that the rich remain healthy, but the poor have more challenges and not just the poor, the poor, the working class, and even the middle class have more challenges getting health care. They also suffer more iniquity in health care because health insurance tends to be degraded and differentiated. Those who have the best jobs have the best health insurance. Those who have the worst jobs or no job at all have the worst health insurance. Making work contingent so that people only get paid for the days they work or maybe a peace rate, only get paid for the literal work they do. Think of a taxi driver or an Uber driver who only gets paid when she or he works. Well, that encourages people to work when sick, which is not just bad for them. It's bad for their co-workers or if they're drivers, it's bad for their passengers. There's a defunding of the public bodies that spread public health information. So one of the favorite targets of neoliberal governments is to target the public health establishment. Corporations are very much in favor of getting rid of public health that may be a nuisance. For example, tobacco companies are very happy to remove restrictions on the marketing of tobacco products. So again, if complete neoliberal freedoms are accepted as a governing political philosophy, then often that results in the dismantling of public health information systems. Of course, the deregulation of food also leads to greater threats to food systems. In a highly regulated country, all restaurants are inspected regularly and not just regularly, but at unannounced intervals because regulators want to make sure that restaurants are always healthy. So at any moment, a health inspector may drop in on the restaurant. In a neoliberalized society, restaurants are responsible for ensuring their own food safety, which of course leads to much less safe food. The same thing for workplaces. In a highly socialized society, employers are forced to hire employees as regular employees who have employee protections. In a more neoliberalized society, many workers are independent contractors and thus responsible for their own safety. So imagine a construction site where everyone on the construction site works for a construction company that is responsible for making sure they work safely. Contrast that with a neoliberalized construction site where every worker is an independent contractor being paid to do a particular job. And as an independent contractor, that worker is legally her or his own company responsible for his or her own safe working practices. Well, obviously the second situation results in a lot of cutting of corners and unsafe work. Broadly speaking, policies that increase stress on families and on workers are of dubious economic benefit. I mean, we can debate the economic benefits of making it easier to hire and fire workers and the economic benefits of getting rid of welfare support so that people are forced into the labor market. We can debate the economic benefits. We can't debate the health benefits. We are absolutely certain that policies that are more stressful for families and more stressful for workers reduce the overall health of the workforce. And of course, neoliberalism tends to promote less democratic, more hierarchical societies. A particularly favorite neoliberal reform is to make it possible for people to donate unlimited amounts in elections, complete freedom to try to persuade the public of their point of view. Now, that may be right or wrong. We can debate whether that's moral or immoral for democracy, but certainly it results in a more hierarchical society in which a smaller number of people have a greater voice. That is, the society itself becomes less democratic. And as it becomes less democratic, it tends to erode all of these other factors that taken together tend to support good health. In fact, neoliberal health sector reforms haven't just threatened society's health. It also has threatened global health. In the 1990s, the World Health Organization was severely embarrassed by its poor performance in addressing the AIDS crisis, particularly in Africa. As a result, there was a lot of pressure to reform the World Health Organization and to take its laboratory functions away. The argument was that the World Health Organization had not successfully identified the AIDS virus. In fact, that was French researchers at the Pasteur Institute who identified the virus. As a result, and that the World Health Organization had not done very well in preventing the spread of AIDS. As a result of this failure, the organization itself was attacked. Instead, funding for health initiatives was moved out of the World Health Organization and into individual silos of organizations fighting particular diseases. The most famous being the Global Fund to Fight AIDS, Tuberculosis and Malaria, but with other diseases having their own advocacy organizations and NGOs attached to them as well. Now, the problem with that is that it hollows out the center. If you have AIDS, Tuberculosis or Malaria, and particularly if you have AIDS, there is some international organization monitoring the problem and trying to solve it. But what if you have the Zika virus or some new threat that's not been covered by these previously existing siloed, dedicated organizations? Well, there's nobody watching out in a systematic way for these new threats. By the way, this reform logo at the bottom is the World Health Organization's most recent reform program. They are promising managerial reform in pursuit of organizational excellence. And I think this kind of captures the zeitgeist of it. They're not promising better scientific research. They're not promising better lab work. They're promising better management. These new special purpose health organizations that are siloed disease by disease often miss new infections because they're not looking for them. It's not their business. So we've had a series of epidemics that have been not part of the global or not covered by the global public health establishment. The SARS epidemic, the H1N1 flu epidemic in 2009, MERS in 2012 and most recently the Ebola virus or you could say now the Zika virus. These are all disease threats that require a standing bureaucratic organization whose job it is to continually scan the horizon for new threats. Before 2002, there was no SARS NGO dedicated to eradicating SARS because there was no SARS. Even Ebola, which existed before 2014, didn't have much of a dedicated international response because it was a very limited disease. It was a terrible, horrific disease, but one limited to a few rural districts and a few poor countries. And so there was no global initiative to fight Ebola. We'll see how that came back and bit us as a result. The result of World Health Organization in capacity is that two organizations have become indirectly but nonetheless responsible for monitoring global health problems, the Centers for Disease Control in the United States and the Institute Pasteur in France. Now, they're both doing fantastic work. The problem obviously is that it's not their job, day-to-day frontline main responsibility to monitor global health. They do monitor global health because nobody else is and they have the resources to do so, but it's not their dedicated bureaucratic mission to do so. When we take a look at the sorts of criteria I talked about for a strong social society, a society that collectively engages with health problems to improve all people's levels of health, when we take those same criteria and apply them at the global level, we see enormous gaps at every level running from the most specific, right down to organizations that are providing healthcare up to the most general, the character of world society. For all that's been written about globalization creating a new world society in which the whole world acts together to solve global problems, there's very little evidence that that is actually happening. So take the immediate sense of delivering healthcare. The World Health Organization used to be involved, still is nominally, but used to be deeply involved in working with healthcare delivery in poor countries to help countries improve their hospital systems and medical systems to actually deliver care. The World Health Organization didn't deliver care but it provided a lot of technical assistance to countries in attempting to deliver care. These sort of efforts have been almost completely defunded in favor of siloed efforts like the Global Fund for AIDS, tuberculosis and malaria. The problem with the Global Fund is that it sucks doctors away. I mean, a doctor in a poor developing country can either work for an underfunded national health service or can go work for the big famous NGO, the Global Fund. There are obvious incentives for them to do the latter. And in fact, in Liberia and the other countries affected by Ebola, the best doctors were not available to the public system because they had all been hired up by NGOs fighting specific causes. Healthcare for the poor is primarily provided by the charity sector. So the model of how you get healthcare is that some caring movie star or some very caring Westerner gives money or gives her or his time to go provide healthcare for free in poor places. The most famous example of this is Medesansans Frontiers MSF or Doctors Without Borders. Don't get me wrong, they do fantastic work. They're probably one of the most successful non-governmental organizations in the world and we should all, I think, admire the very real sacrifices and the real commitment that these doctors are making to improving healthcare. Nonetheless, should healthcare be provided as a charity or should healthcare be something that governments deliver for their citizens? I don't want to blame MSF and MSF is doing a fantastic job picking up the pieces of the health systems that have collapsed. But instead of pouring money into NGOs, we should be really pouring money into the health systems to prevent them from collapsing. And to be very fair to MSF, that is MSF's official position. That is MSF itself lobbies for improved strengthening of local healthcare systems and MSF to its credit seems to genuinely want to put itself out of business. That is they'd rather see healthcare being delivered through official bureaucratic government channels and they're simply filling the holes where these do not exist. Health education, of course, has become highly politicized. So whereas in rich countries there may be a strong enough society to insist, for example, on basic sex education for children and teenagers and free provision of condoms and needle exchanges for drug users, people in rich countries then go to developing countries and spend a lot of money to prevent these very things from being delivered there. So while free condoms may be pretty easy to come by for teenagers in a developed country, there is huge political debate over whether they should be provided in poor countries. It's highly politicized. And not just politicized by religious groups and moral pressure groups in rich countries, it's also politicized within poor countries themselves. There is the globalization of dangerous working conditions. So as the world has integrated, dangerous working conditions have shifted from being a local problem to being a global problem. Obviously those 2,000 people killed in the Rania Plaza collapse in Bangladesh weren't sowing clothes for Bangladesh. They were sowing clothes for the Western market. And so dangerous working conditions, instead of being a small local problem, like they might be on a construction site in Sydney, become a massive global problem as they are in the garment industry in Bangladesh. Policies that foster family and societal disintegration are being spread through world society mechanisms. Policies that prevent countries from providing social safety net for their citizens. The privatization of health care and medicines is being spread via world society mechanisms. Again, just making it all that bit more difficult for countries, poor countries, to provide a real social underpinning for people's health. And of course, the integration of the world is creating a much more hierarchical, less democratic world. Even as Western countries attempt to promote democracy in developing countries, there is an increasing democratic deficit in the world as a whole. And think of it this way, in a typical corrupt, poor country, it may once have been that if you wanted health care, you had to go to some local corrupt official or some local organized crime, organized criminal in your area and pay a bribe or do a favor or somehow do something extra legal in order to get health care. Well, that was hard enough. That's not ideal. That's certainly not desirable. But imagine how that changes when instead, in order to get health care, you have to get a favor from an international NGO that is based in the United States, but doing, giving health service in your country. Well, the first situation may not be ideal, but at least people know who their, who the enemy is or who the authorities are. In this globalizing world, the people responsible for your health care may not be, forget about your elected leaders or your local corrupt officials, it may be people sitting in Washington, New York, London, or Sydney. It's the move towards the privatization of the provision of health inevitably de-democratizes it, not just within a country, but de-democratizes it by moving decision-making power away from the local level and towards the global level. Now, that may be good or bad politics. I mean, in many ways, I would rather see health care delivered by medicines on frontiers than see health care delivered by a corrupt and inefficient local system. I'm not saying it's necessarily a bad thing, but it's certainly a less democratic way of providing health care. And in the end, ultimately, it undermines health itself, which is not to say that health is not improving. Health is improving and it's improving not just for the rich, it's improving for the poor as well. You can find graphs like this all over the internet showing life expectancy in developed countries rising from 65 years up to 82 or 83 years and life expectancy in less developed countries rising from little over 40 years at the end of World War II up to something approaching 75 years. So there have been massive increases in human health and, in fact, the improvements in health have been bigger in poor countries than in rich countries, but that shouldn't be so much of a mystery. After all, life expectancy doesn't increase forever. I mean, the oldest people, we have reliable records that the oldest people in ancient China and ancient Greece lived to be 105 or at most 110, and today the oldest people live to be 105 or 110. Now, if you go back to the Bible, of course, maybe people live to be 900, but reliable sources from classical history, both east and west, suggest that the human lifespan has remained about 110 years at the absolute maximum for the last 3,000 years. So since the lifespan is relatively fixed, people are going to die younger than 105 or 110, the most we can do, you know, there's a ceiling above which life expectancy just can't rise, and most we can do is make sure that people don't die in infancy, that they don't die from accidents, that we're able to treat heart disease, we're able to treat cancer, but at some point people are just going to die of old age. So in rich countries, the available ceiling, the amount by which life expectancy could possibly grow, is starting to reach its limits. It can still grow, but it's mainly growing by preventing people from dying young rather than growing from expanding the actual lifespan of human beings. Well, poor countries are catching up on that slowly but surely, and they're converging slowly, but definitely converging in life expectancy. But is that something to be proud of? I mean, that's something to applaud, it's not a bad thing, but does it represent any kind of actual accomplishment? I suspect not. Poor countries are closing in on rich countries simply as a result of the technological frontier moving forward. I mean, even if a poor country invents no technology of its own whatsoever, kinds of technology that are now 10, 20, 30 years old in rich countries inevitably will trickle down to poor countries. Now, careful of the words trickle down, the income doesn't trickle down. There's no evidence for trickle down economics, but there's a lot of evidence for trickle down technology. People in India, I mean, this is a woman who works on a garbage heap in India, but nonetheless has a cell phone. She doesn't have the most modern, you know, contemporary smartphone, but nonetheless she has a phone that will make phone calls and take pictures and send SMSs and emails. Well, that's a remarkable technological gain over what her life would have been like 20 years ago. And that's only made possible by the fact that such technologies are now so cheap, you know, they're 20 years back before the technological frontier that even in India they've trickled down. There's a controversial plan now to sell secondhand refurbished iPhones in India. I say now as of 2016, the time of recording this lecture. It's, you know, inevitably technology trickles down. Now, same thing with immunization in Africa. This is an MMR, I'm sorry, no, this is a DPT immunization, diphtheria, pertussis and the DPT. The DPT immunization was developed in the west, but, you know, it became cheap enough to be mass produced and extended to the entire world, right? So the technological frontier is advancing, bringing with it improvements in health almost automatically. I don't think that the rich world is demonstrably doing anything, to improve health in the poor world. And to be clear, I don't think the poor world is doing anything demonstrably to improve health in the poor world. There's been a miserable record from both rich and poor countries on improving health. There was a big jump after World War II in constructing national health systems. Since then, it's simply been technology trickling down from rich to poor. And as a result, poor people have access to kinds of technology that improve health, whether directly like immunization or indirectly, like having a mobile phone and being able to call in an emergency or being able to access health information or, you know, being able to make micro payments for drugs, simply being connected to people on a cell phone, literally having people to call improves people's health. So I don't think we can really applaud ourselves for the improvement in health, even if we should be happy that it's occurring. In fact, you know, we collectively don't show much commitment at all to world society principles. Now, the whole idea of world society was that humanity is becoming a single society and that people throughout the world feel the same sense of commitment to everybody regardless of where they live. And that's a beautiful idea, but it doesn't seem to be happening. We don't embrace world society principles, even though we do in fact live in a single global society. That was made very clear with the Ebola outbreak in West Africa, which while it was a localized outbreak in West Africa, attracted very little international attention despite the thousands of people who were dying. Mostly it was viewed as a kind of curiosity. You know, those look at all those poor people dying in Liberia and Sierra Leone. It quickly caught the rich world's attention when there was a transmission from person to person in the United States and when there was a transmission from person to person in Spain. Then Europe and North America woke up to the Ebola crisis. United States sent in the army to help solve the Ebola crisis. There was a vast mobilization of resources to help with Ebola and actually the rapid development of a vaccine that had been on the back burner for a decade. But all of this happened only once, a few. And I stress a very small number of people were infected and a couple died in rich countries. Then there was a massive mobilization. Until then, there was virtually nothing at all. We're seeing this pattern repeated with the Zika virus. The Zika virus seems to cause microencephaly, a small brain or a small head among babies of women who have the virus during pregnancy. The virus itself has a very minor impact, a light fever, and in the past does not seem to have been associated with microencephaly. But for whatever reason, maybe a mutation. I don't link anyone at this point. Mid-2016 knows exactly why. The Zika virus has come to be associated with microencephaly in the babies of pregnant women who get it. Well, the Zika virus was a localized, has been a localized problem in Brazil. But it's rapidly spreading throughout Latin America, threatening the southern border of the United States with Mexico. But it's mostly gotten attention because of the Rio Olympics. There's been a lot of debate over whether the summer 2016 Olympics should be held in Rio. Now, of course, Rio's summer Olympics are actually the winter Olympics because they occur during the southern hemisphere winter. So they'll be held in August, which is actually the coolest month of the year in Rio de Janeiro where the Olympics will be held. And the Olympics will be held in urban areas. So there's a consensus view that the Zika virus does not pose an enormous threat to Olympic athletes and spectators. Nonetheless, many Western academics have called for the Olympics to be called off at enormous expense to minimize the threat that people will come back from Brazil carrying the Zika virus in their blood, which then will be transmitted by mosquitoes in their own country. This Zika Olympics connection simply dramatizes the fact that we live in a single global society. It's pretty obvious that we do. But it takes an event like this to bring it home to people that it really is one world that needs a worldwide public health response. Now, there is a disease threat lurking out there that is much more serious than the Zika virus. Now, I don't want to minimize the seriousness of the Zika virus. It's very serious for those who get it. But there's a much more widespread health risk, and that's the risk of tuberculosis. About one third, it's amazing, some two billion people in the world have the tuberculosis bacterium in their bodies. Tuberculosis, for those of you too young to remember, is a bacterial lung infection that was once the single largest cause of death in the 1800s and early 1900s. In the United States, tuberculosis killed far more people than wars in the country ever had. It was that big a killer. There were signs everywhere to promote public health. So for example, this tuberculosis, don't kiss me, because your kiss of affection becomes the germ of infection. And there are all sorts. If you go online and look for old tuberculosis signs, you'll see lots of them. Some of them just say to leave your windows open at night, because one of the things facilitating the spread of tuberculosis was people living in very close quarters. So people living five people to a room with closed windows and no fresh air, were much more likely to spread this airborne pathogen than people who lived one person to a room with lots of fresh air. So by the early 1900s, rates of tuberculosis infection had been brought down dramatically in western countries, in developed countries, by public health precautions. Not just public health precautions like sanitization, covering your mouth when you cough, no spitting. People wonder why Singapore has such aggressive no spitting rules. Originally the no spitting on the sidewalk rule was to prevent the spread of tuberculosis, because people with tuberculosis have, generate large amounts of sputum through which the infection can be spread. And so the no spitting rules in Singapore originally were don't spread tuberculosis by spitting. So no spitting in public, using a tissue when you blow your nose, providing fresh air, but also crucially having fewer people per room. I mean just having more space to live in breaks the chain of the spread of tuberculosis. And then after World War II, antibiotics became widely available. And once they did, that killed the remainder of the tuberculosis problem in developed countries. The few remaining cases were simply treated with antibiotics. Tuberculosis is bacterium and the antibiotics killed them. But the overuse and incomplete use of antibiotics has resulted in the emergence of new strains of tuberculosis that are resistant to all known treatments. These are known by the name multi-drug resistant tuberculosis, or MDR-TB. And about 10% of MDR-TB is so drug-resistant that it's resistant to all known drugs. These are extensively drug-resistant tuberculosis, XDR-TB. MDR, including XDR, are spreading like wildfire. No one knows the exact numbers, but estimates are that they're spreading 20% per year, now reaching half a million new cases per year around the world. But that's up from something like 100,000 not long ago. This epidemic is worst in South Asia, in India and Bangladesh, and in Latin America, particularly in the Andean region, Peru, Bolivia, Ecuador. But cases can be found everywhere in the world, not just in Latin America and in South Asia. And they're mainly caused by inadequate health systems. When you are given a course of antibiotics and your doctor tells you, make sure you take them all, even if you start to feel better. The reason for that is that if you only take part of the course of antibiotics until you feel better, you're encouraging the development of strains of a bacteria that are antibiotic resistant. Because you don't kill all the bacteria off, you only kill off the weakest bacteria and the strongest may survive in your system. So you might take enough antibiotics to cure your own personal infection while still leaving a bunch of toughened, strengthened bacteria in your system to spread to somebody else. Well, in developed countries, this is mainly a problem of convincing people to take their antibiotics, even though they might cause a little upset stomach. In developing countries, it's a severe financial burden on people. I mean, antibiotics are expensive and they're usually bought one by one. You buy today's antibiotic pill with your earnings today and if you don't earn money tomorrow or if you're feeling better tomorrow, you don't buy antibiotics tomorrow. People live on incredibly tight budgets in poor countries and as a result, they routinely take insufficient courses of antibiotics. So multi-drug resistant tuberculosis has arisen because of poor health systems. These very society-wide systemic problems that I mentioned early in this lecture are creating this problem of multi-drug resistant tuberculosis. If everyone in the world lived in a system where tuberculosis treatment was complete and free, we would have much less MDR TB. It may not have it at all. Now, with AIDS, there's very strong public support in developed countries for curing AIDS globally. And so much of the treatment of AIDS that's going on in Africa right now is funded by Americans and Europeans who care deeply about beating this disease. Well, there's no lobby full of people with tuberculosis in rich countries who are willing to pay lots of money to see tuberculosis addressed in poor countries. It's simply faded from our memories in rich countries. As a result, we have this problem that nobody is solving tuberculosis in poor countries. From a financial standpoint, it's becoming almost impossible to solve it. I mean, this graph shows the cost of treating tuberculosis. Standard tuberculosis is essentially free to treat. These numbers, $17,000, is numbers due to lost productivity. But the $17,000 is a combination of lost productivity and treatment costs. But the numbers for the treatment costs for MDR TB and for XDR TB are exponentially greater. So as the problem becomes more and more difficult to treat, it becomes more and more expensive to treat. So we have the double problem that MDR tuberculosis is spreading rapidly. And also it's more expensive to treat than ordinary tuberculosis. So you kind of have to multiply those two impacts together. That tuberculosis is rapidly getting more expensive to treat at the same time that it is rapidly becoming more widespread. It's reaching the point where it's hard to see that it will be possible to fight this disease back. Now, this is not just a theoretical concern. It's happening all over the world, all over the non-rich world. And the main response from the rich world has been the fortress mentality. Let's keep people out who have tuberculosis. So there was a story recently in April 2016 of a woman from Papua New Guinea who arrived in Australia with multi-drug resistant tuberculosis. Instead of attempting to treat it in an Australian hospital, she was rapidly deported. Her tuberculosis problem is Papua New Guinea's problem, not Australia's problem. In general, rich countries won't let you in if they can find out you have tuberculosis. And the immigration card for Australia, this is the Australia incoming passenger card, explicitly asks, if you are not an Australian citizen, do you have tuberculosis? And you can see that there are only two questions here that have this kind of, you know, yes and red. It's do you have tuberculosis and do you have a criminal record? They're considered at the same level. And if you have tuberculosis or criminal record, you are very likely simply to be excluded from the country. That it's a scent right back on a plane. You have tuberculosis, let's get rid of you. That's the general response to tuberculosis. Now, that may work in a short term, but in the long term, I mean people travel, people go to other countries. You know, are we going to completely eliminate connections between the rich and poor world? If not, we're going to see tuberculosis come back. Now, we've already seen tuberculosis come back. Many people from countries like Australia and United States go to poor countries, contract tuberculosis, come back and then get cured, have to go through a treatment regimen of antibiotics to get cured. But right now, there are 2 billion people in the world with tuberculosis, and there are only a half million new cases a year of multi-drug resistant tuberculosis. So most of the people who travel to India or Latin America and get tuberculosis and come back, most of them are treatable. Well, that's going to change as it gets as multi-drug resistant tuberculosis spreads and spreads in developing countries. More and more of the people who go to developing countries and come back to rich countries are going to be coming back with multi-drug resistant varieties, not with the ordinary old fashioned varieties. On tuberculosis is just a test case for public health. If you look at the timeline, antibiotics were discovered in 1928. They were industrialized by 1932. Less than 100 years later, 70, 80 years later, we've already run through them. The first line antibiotics that were first discovered in 1928 are no longer effective against anything. We're now into second and third line antibiotics, and there are no new antibiotics in the pipeline. I mean, there's no promise that there will always be some magic drug that will kill whatever bacteria come into contact with it. So in 100 years, less than 100 years, we have virtually exhausted the utility of antibiotics to fight bacterial infection. What about another 100 years? I mean, you might say that we'll always discover a new drug. Well, for another 100 years? What about another 500 years? You know, I mean, institutions where I have visited or worked or, you know, like the park I like to walk through on my way to work, that's been there for a couple hundred years. Some universities have been around for 800 years. Thinking in terms of humanity, we'd certainly like to think that humanity will still be on the planet in a thousand or 10,000 years. Well, if humanity's on the planet, so will the bacteria. And if bacteria are there, we're going to have to either fight them or live with them. And living with them means living with tuberculosis. I mean, many people used to, they're on the edges and the outskirts of towns all over the developed world. You can find, I don't have it in the lecture, you can find tuberculosis hospitals, places where sanatoriums were people with tuberculosis simply went to live because they were too much of a threat to have in the rest of society. So they lived out their years in these sanatoriums. But do we really want the return of that kind of society? And who wants to end up living out life with tuberculosis? Now, we have been irresponsible in managing our ability to fight bacteria with antibiotics. What about the next health threat? I mean, surely in the next 100 or 200 years, some unanticipated health threat will arise. What will we do about that? You know, we've been lucky with AIDS perhaps that with extreme difficulty and after tens of millions of deaths, we are now able to manage AIDS as a disease. What about the next AIDS? What about the next tuberculosis? We're running out of tools with which to fight those illnesses. I should say we are not doing a good job of managing the tools we have. Global disease management in general is plagued by a silo approach that focuses on addressing the disease rather than strengthening the system. Now, two great examples of that success stories are smallpox and polio. Smallpox had a global campaign to eradicate smallpox. The only purpose of this health establishment was destroying smallpox and in fact, smallpox was eradicated from the face of the earth. It only exists in samples in a few government laboratories, but it's been eradicated from the population due to the development of vaccines and the widespread application of vaccines. Polio is on the verge of eradication. It exists in just two countries, Pakistan and Nigeria and in Pakistan it's almost been solved even despite the very significant political hurdles to immunizing people in Pakistan. It's only in northern Nigeria where there's a large reservoir of polio still in the areas infected by insurgencies like Boko Haram, which is vehemently against vaccination. These are two great success stories and I certainly endorse the eradication of polio. It's something we should do. But these two success stories show the difficulty of public health in general. While it's great that we've eradicated smallpox and maybe polio, what about the thousands of other diseases? We can't solve global public health on a disease by disease basis. Choose one disease at a time and eradicate it. That will get us nowhere in the long run. In the long run we have to manage the health of all people. If you look at the health of a country like the United States or Germany or France or the UK or Australia, we manage health reasonably well despite the fact that there are diseases running around in all these countries. When diseases arise they're quickly addressed. When an outbreak occurs there's a quick government response. There's a quick medical establishment response. We try to keep people as healthy as possible so that when they do get diseases they're likely to survive them. We have adequate space so that when people get a disease they don't immediately spread it to dozens of other people who are sharing the same room with them. There are lots of ways at which we're able to manage the disease burden in developed countries and that model of disease management really can be spread out from countries that do it well like Australia to having a global perspective of managing disease at a global level rather than at a national level. It seems pretty obvious that the global continuous management of infectious diseases is just as necessary as the global management of greenhouse gas emissions but there's much less attention to it. Diseases only get attention when they're new or epidemic. Had anyone heard about Zika virus before this year, tuberculosis has been around for all of human history. There are mummies that have signs of having had tuberculosis in ancient Egypt but because it's been with us forever it doesn't get in the news. What's more, even if it does get in the news people want to treat tuberculosis rather than actually creating health systems that would prevent all disease. The global warming analogy would be to just have electric cars without solving all the other problems of emissions from animals and emissions from power plants and emissions from cement factories. If all you do is solve one part of the problem, the problem is not going to go away, it's just going to shift somewhere else. What we need, just as with global warming, we need a global response to it. With public health we need global public health institutions starting with a reformed and revitalized and much better funded world health organization but also more broadly supporting national health systems. One of the real strengths of the old World Health Organization approach was that the World Health Organization primarily worked through and supported national health organizations in countries around the world. Well that's the sort of approach we really need, not a bunch of well paid who bureaucrats in Geneva but we need the World Health Organization having robust field operations and responsibility for helping every country in the world raise its overall level of health management. What we really need is an institutionalized long term commitment to public health infrastructure not just solving not just curing a case but providing the infrastructure that supports good health. Unfortunately there doesn't seem to be any movement whatsoever in that direction. Key takeaways, life expectancy is rising throughout the world but this really reflects general technological progress more than any real achievement at addressing public health. Second, MDRTB, multi-drug resistant tuberculosis is a major threat to global public health that is simply not being addressed. And finally, silo approaches that attack one disease at a time even if that disease is superculosis are no substitute for institutionalized ongoing public health infrastructure. Thank you for listening. You can find out more about me at SalvaturbaBonus.com or you can also sign up for my monthly newsletter on global affairs.