Lancet editorial on Global health, 2012, and Rio+20

Integrating health into a sustainable development framework and agenda

The Lancet, Volume 379, Issue 9812, Page 193, 21 January 2012

doi:10.1016/S0140-6736(12)60081-6

Global health in 2012: development to sustainability

The Lancet

In 2012 there will be a major strategic shift in global health, away from development and towards sustainability. Since 2000, the Millennium Development Goals (MDGs), driven by a macroeconomic diagnosis of global poverty, have focused on investment in a small number of diseases as the most effective approach to decrease poverty. Institutions such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, Roll Back Malaria, and GAVI have been created to respond to that diagnosis.

But this approach is now delivering diminishing returns. The AIDS epidemic has peaked, both in terms of deaths and new infections, non-communicable diseases (NCDs) are increasing, and the climate change crisis is an ever present threat. India is a good example of a country facing these new challenges. It has an NCD epidemic and yet still endures the highest number of maternal and child deaths in the world. The old macroeconomic approach to solving poverty-related disease is simply insufficient to meet the demand of countries. At the same time, institutional tensions are growing—the Global Fund is in difficulty and WHO is facing a financial emergency. And there are new concepts forcing their way into global health agendas—such as integration and accountability. There is a view among some development experts that health has had its decade. It is time now for other sectors to take centre stage, such as agriculture or energy.

All these issues will come into sharp focus later this year at Rio+20, the UN Conference on Sustainable Development in Rio de Janeiro, Brazil (June 20—22). The summit marks the 20th anniversary of the 1992 UN Conference on Environment and Development and the tenth anniversary of the 2002 World Summit on Sustainable Development. World leaders, stakeholders from the public and private sectors, as well as representatives from environment and development communities will convene to define a new roadmap towards economic growth, social equity, and environmental protection. The objectives of Rio+20 will be to review progress on sustainable development from previous summits, identify gaps in implementation, renew political commitment on past action plans, and find ways to safeguard the planet from future destruction from emerging threats. The two core themes will be a move towards a green economy (in the context of sustainable development and poverty eradication) and strengthening the institutional framework for sustainable development, which to date has not fulfilled its potential because of a lack of coordination and coherence. The zero draft outcome document published last week lists seven priority areas for Rio+20. They are: job creation, food security, water, energy, sustainable cities, oceans, and disasters. There will be ten new sustainable development goals to be decided by governments just before the meeting—and introduced in 2015 as part of the post-2015 UN development agenda. There will be no legally binding agreements and countries will set their own targets, working voluntarily towards them. Disappointingly, health is hardly mentioned in this draft.

It is vital that this major shift from development to sustainability is governed by a clear set of principles and values. One report to draw from is The Lancet's 2010 Commission titled: The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015. The authors of this multidisciplinary analysis represent many different sectors, and explain that much more could have been achieved if the MDGs were better integrated. They conclude that future goals should be built on a shared vision of development across the lifecourse, and suggest five principles: holism, equity, sustainability, ownership, and global obligation. Their report exemplifies the positive contribution the health community can make to sustainability after 2015.

The health sector has a vital part to play during the next 12 months. We need to make a strong case for health as part of sustainable development and future sustainable development goals—to protect the gains of the past decade and ensure that the unfinished agenda of the past decade is continued. However, we also need to embrace a new and emerging health agenda—one that includes NCDs and climate change. And we must sharpen our advocacy for health as we rightly integrate other sectors into this broader vision. We have an extraordinary opportunity to re-vivify global health. But we are unprepared to do so. We must identify the lessons learned from the MDGs, as well as bringing to the fore evidence for new threats and emerging challenges. The Lancet plans to be a strong partner in shaping this future health and sustainability agenda—towards finding equitable solutions to improve the health and lives of people worldwide.

What is the future of epidemiology?

The Lancet 6 August 2011

Raj Bhopal a, Gary J Macfarlane b, William Cairns Smith c, Robert West d, on behalf of the Management Executive Committee for the XIX World Congress of Epidemiology

Epidemiology is thriving. The striking features of contemporary epidemiology are diversity, change, and global reach: from society to the molecule, responding to technical advances and changing patterns of disease. The two main challenges are: translating epidemiology into evidence, practice, and ultimately better health; and strengthening epidemiology research capacity, particularly in low-income and middle-income countries.

Epidemiology is confronting old and new threats to human health and wellbeing. Established threats, such as tobacco, alcohol, and tuberculosis, that are controlled in some places are affecting new populations, particularly in low-income and middle-income countries. Further evidence on alcohol consumption and related harms is informing the development of public health policy on alcohol. New threats, such as volcanic ash and Shiga toxin-producing Escherichia coli, are posing new challenges. Re-emerging threats of poliovirus and measles along with neglected tropical diseases1 that affect about a billion people all need to be tackled with epidemiological concepts and methods used in tobacco control. Furthermore, understanding of population change through urbanisation, migration, and ageing, and inequalities arising in modern societies, is critical to epidemiology as a population-based discipline.

Epidemiological methods are evolving through multidisciplinary collaboration with other areas of expertise, including basic sciences, computing, and social sciences. New and improved methods of assessment of exposures, analysis of gene—environment interactions, informatics, biobanking, spatial analysis and graphic presentation, and approaches to mixed qualitative—quantitative methods are emerging from cross-disciplinary working.

Epidemiology is a discipline with a broad international reach where robust evidence can be generated by the application of sound epidemiological methods in a range of different settings using modest resources. Increasing global connectivity has facilitated the development of epidemiology through open access to electronic publication databases, sharing of research tools, and knowledge exchange through interactive websites and discussion lists. Supercourse,2 a dynamic repository of lectures on epidemiology and global health, is an excellent example of this global connectivity.

The International Epidemiology Association's XIX World Congress of Epidemiology3 to be held in Edinburgh on Aug 7—11, hosted by the academic departments of public health in Scotland, has adopted five overarching strategic themes: global problems; chronic diseases; cutting edge methodology; epidemiology and policy; and neglected conditions. Epidemiology and policy is the one theme generating most interest among those attending.

The generation of increasing volumes of evidence by epidemiology is of little consequence unless that knowledge influences policy and practice, in addition to improving our understanding of aetiology and causal pathways. Given that epidemiology needs to be relevant for policy, it needs to be presented in a meaningful way for policy makers. This requires recognition of the different language used by epidemiologists and policy makers, as well as their very different timescales—epidemiologists operate over years if not decades, whereas policy makers make shorter term decisions. Policy makers need to learn more about epidemiological strengths and limitations while epidemiologists need to understand the timescales and cycles in policy making and political processes. Epidemiology also needs to be applied to individual patient care in the assessment of risk at an individual level, tailoring preventive and therapeutic interventions as is increasingly the case in cardiovascular disease.

The second challenge for the future is capacity strengthening. Masters level courses in epidemiology are widely available in all regions through medical schools and universities, often with North—South collaboration. These courses provide an understanding and an appreciation of epidemiological research methods, but it requires doctoral and post-doctoral level programmes to develop advanced and practical research skills in epidemiology. An important challenge for the International Epidemiology Association at both regional and international level is the facilitation of advanced epidemiology training to develop research capacity, particularly in low-income and middle-income countries. The forthcoming XIX World Congress of Epidemiology will be preceded by an advanced course in epidemiological methods. The 1500 Congress delegates will debate the challenges of relevance to policy and practice, and capacity building at a global level.

References

1 WHO. First WHO report on neglected tropical diseases 2010: working to overcome the global impact of neglected tropical diseases. Geneva: WHO, 2010.

2 WHO Collaborating Center University of Pittsburgh. Supercourse: epidemiology, the internet, and global health.http://www.pitt.edu/∼super1. (accessed July 18, 2011).

3 International Epidemiology Association XIX World Congress of Epidemiology. http://www.epidemiology2011.com. (accessed July 18, 2011).