CFR Master Class Series With Thomas Bollyky

Tuesday, September 15, 2020
Alkis Konstantinidis/Reuters

Senior Fellow for Global Health, Economics, and Development and Director of the Global Health Program, Council on Foreign Relations; Codirector, CFR Independent Task Force on Preparing for the Next Pandemic; @TomBollyky


Vice President, Deputy Director of Studies, and Nelson and David Rockefeller Senior Fellow for Latin America Studies, Council on Foreign Relations; @shannonkoneil

For the first time in recorded history, bacteria, viruses, and other infectious agents do not cause the majority of deaths or disabilities in any region of the world. However, humankind's progress against infectious diseases has outstripped the pace of investment in good health-care systems, responsive governance, dependable infrastructure, and other more reliable guarantors of health. Thomas Bollyky will discuss how this unbalanced progress has made the world uniquely vulnerable to noncommunicable diseases and novel infections, even as humans grow healthier.

The CFR Master Class Series is a biweekly 45-minute session hosted by Vice President and Deputy Director for Studies Shannon O’Neil in which a CFR fellow will take a step back from the news and discuss the fundamentals essential to understanding a given country, region of the world, or issue pertaining to U.S. foreign policy or international relations.

O'NEIL: Thank you very much and welcome everyone back to CFR for the fall and welcome back to CFR's masterclass series. And this is, as those of you who have joined us before know, this is where one of our senior fellows joins us to do a deep dive into their particular area of expertise, be it a region or be it a particular topic.

So today we have with us Tom Bollyky. He is our senior fellow for global health economics and development. And he's also the director of our growing global health program. He was the founder and now the managing director of Think Global Health which is a CFR affiliated online magazine. If you guys haven't seen it, please check it out. It looks at all kinds of topics, how they relate to global health, economics, societal ones, political ones, as well. And he has become, as many of you well know, a trusted resource over these last six months, as we all deal with and try to understand better what is happening with global health and particularly given the COVID-19 crisis. So today, though, we're going to ask Tom to kick us off and to step back from all pandemic all the time, and look a little bit at the arc of global health and its history. So look at the rise and fall, and perhaps rise again, of infectious and non-infectious diseases, noncommunicable diseases, and where we are today, how we got here, and where we might be headed. So I'm going to turn over to Tom now for eight to ten minutes to kick it off with some opening remarks, and then we will go to our discussion. So go ahead, Tom.

BOLLYKY: Great, thank you so much for that kind introduction, I promise we will still have some pandemic. I will not move entirely off the topic of the year for everyone, but I'm grateful for this chance to interact with all of you and particularly, to take a step back and look at what's happening in global health more broadly. So this is a treat to be able to do that. So amid the coronavirus pandemic it may seem like a moment of evidence of microbe's triumph over humankind, but in fact the opposite is true at least from a health perspective. If this current pandemic...if this pandemic remains at its current pace, COVID-19 is unlikely to overtake cardiovascular disease, cancers or other major noncommunicable diseases as a leading cause of death globally. In fact, currently, it projects, and we have this analysis on Think Global Health just posted today. Currently, it projects to be the twelfth leading cause of death if it remains on its current pace. This situation is a relatively recent development in human history. That bacteria, viruses, and other infectious agents no longer cause the majority of death and disability in any region of the world. Since 2003, the number of people that die each year from HIV has fallen more than forty percent. Deaths from malaria, tuberculosis and diarrheal diseases have declined by more than a quarter over the same time period. Yet this dramatic progress that we have made against specific infectious diseases, endemic everyday infectious diseases, has far outstripped the pace of our investments in good public health, responsive governance, and dependable infrastructure--the very machinery that we need to deploy the non-pharmaceutical interventions that are the more reliable guarantors of health that we've heard so much about over the last few months. These basic systems are crucial not only to managing a novel infection for which we had no prior immunity, and there's no effective treatment, but also to preventing and managing chronic diseases, which have been on the rise worldwide. And today we are seeing the twin consequences of that dependency, where in many nations we are waiting for a vaccine to save us from this pandemic, which is not only wrong from a cross-country comparison, many countries have saved themselves without a vaccine. But it's also a historical...that historically it hasn't been vaccines that have saved us from infectious disease. It's been public health oversight and governance ourselves. So let's talk a little bit about that historical lens. Let's take the US as an example since we are, obviously most of us will be based here currently. Nearly sixty percent of the gains in life expectancy that have occurred in the United States since 1870, happened before the widespread availability of antibiotics, or the development of most vaccines. So what did drive progress over that time? It was public health and broader societal developments. It happened through changing social norms around the value of children, and childcare and hygiene. It happened with the advent of housing and labor laws, which relieved overcrowding, both in tenements and on factory floors and removed children from those factory floors. It happened through basic public health oversight and innovations like the pasteurization of milk. It happened especially through sanitation, chlorination and filtration of water which relieved the circular water systems that dumped residents' waste in the very same waterways from which they drew their drinking water. Many of the non-pharmaceutical interventions we're hearing so much about in the news today, mass contact tracing, quarantine, isolation, these are products of the fourteenth century with plague. These all emerged at that time for human societies to protect themselves against waves of infectious disease. Many of our public health institutions, particularly in cities evolved in response to cholera. Many...the argument is frequently made that government taking on its responsibility for broader societal oversight and its own people was a necessity to respond to infectious disease. Even when we had antibiotics become more publicly available after World War II, they're produced at much greater scale and the development of vaccines over the next couple of decades. The demographer Samuel Preston still attributes only half of the decline in death rates between World War II and 1970 were due to antibiotics and vaccines. Still, much of it depended on basic public health measures, vector control like mosquito control to reduce the spread of infectious diseases, oral rehydration to protect children from diarrheal diseases, simple salts and water in that instance. This shift started to occur towards medical interventions in the 1980s. Internationally, that's with the rise of the child survival revolution to vaccinate children worldwide, but also the shifts that occurred around HIV to expand access and development of treatment, and they save millions of lives, this is a good thing. Domestically in the United States, we saw more of our gains and life expectancy be attributable to improvements in cardiovascular treatment and cancers as opposed to primary healthcare and broad public health oversight. Unfortunately, as we have shifted to medical interventions to make progress, more progress against infectious diseases, we've woefully under invested in the health systems in governance and infrastructure that has gotten us here. That has been true for public health and primary health in the United States where we've had a sustained decline in public health spending for over two decades, particularly in respect to pandemic preparedness. And here I'll tease a taskforce report we have coming out at the Council in just a few weeks that will include that data. We've seen a corresponding under-investment in pandemic preparedness and our global health development assistance. You often hear about the boom and bust cycle of our investments in protecting ourselves from epidemic threats. The reality is it's persistently bust. We have never spent more than one percent of our development assistance for health on pandemic preparedness. Never. Not after ebola, not after H1N1. We have continued to under invest. The consequences of our becoming more dependent on medical interventions have been the rise of premature burden of NCDs, particularly in low and middle income countries which require more of a system to address rather than just aid funded medical interventions. More than eight million people die annually under the age of fifty-nine from noncommunicable diseases. There are twice as many deaths attributable to noncommunicable diseases in populations under the age of seventy, which is WHO's, World Health Organization's, threshold for premature deaths. Twice as many are due to NCDs than there are to infectious disease. In many low and middle income countries we're seeing a rate of increase of noncommunicable diseases that is three to four times as fast as we've ever seen in high income countries, countries like Myanmar, Ethiopia and Bangladesh. On the rise of the threat of emerging infectious diseases which is driven, I argue by the same factors, obviously, we're seeing this pandemic is an illustration of the threats there. I've gone on for a while. So let me stop and give a chance for a Q&A to dive into any of these topics. But hopefully it provides a bit of an overview for where we find ourselves today.

O'NEIL: Great. Thanks, Tom. That was great. I'm going to ask you the first question, but Teagan why don't you let people know how they can ask a question to follow up.

STAFF: (Gives queuing instructions.)

O'NEIL: All right, thanks. Now Tom, let's talk a little bit about when you make this very compelling case that especially with infectious diseases, these big general public health measures, right hygiene and labor and housing laws and sanitation really made all the difference, not antibiotics, or at least not until later. As you look at the noncommunicable diseases, or this next set of diseases that's growing so fast, what are the interventions public health people should make? I assume they may not be that list, or they may be a different list this time around. So talk a little bit about what, if we were going to spend the money that we decidedly do not spend the money on and haven't for many years, what should we be spending it on?

BOLLYKY: Yeah, so the major items, I would point to, of course, tobacco control was first and foremost on that list. Tobacco this century, tobacco use this century will kill a billion people. Those deaths that are almost entirely, or entirely preventable. Tobacco control works. We know how to do it. It works in low-income countries, it works in high-income countries. It's a matter of investment, internationally and domestically and accountability on both levels for implementing it. So that's high on the list. Hypertension management is another major item. All its treatments are off-patent but require a system to deliver. And we've really struggled in that regard. There are in some instances also vaccine-preventable cancers. Vaccines that have been around for some time that can be helpful as well. One thing I want to flag here is we did analysis in The Lancet on the role of governance and regime type. And historically, people have looked at the connection of democracy and health, really because we didn't have good international data just on life expectancy and infant and child mortality overwhelmingly. There hadn't been analysis on adult mortality and cause of death before. When we did that, in this 2019 study, what you found is that democracy is, and accountable governance is an incredible contributor and driving factor to noncommunicable diseases, but also to TB, and road traffic injuries. All things that require a system. So you really can see dramatic differences from the contribution of governance to those sets of diseases.

O'NEIL: So the accountability from democracy.

BOLLYKY: It matters. And I think where you know, whether it's democracy or other factors, and in this instance, where you really do have a cross country comparison on how countries are doing. Thomas Jefferson and Benjamin Rush say, Benjamin Rush, the famous physician from St. Mayer, and also as signatory of the Declaration of Independence argued that unhealthy political systems produce unhealthy populations. That despotism produces premature death and disease. And, you know, I think there's some argument for what we're seeing in this pandemic that accords along those lines.

O'NEIL: Right, let's take our first question from a member.

STAFF : Certainly, we will take our first question from Patricia Rosenfeld.

Q: Hello, thank you so much, Thomas. For this one. For an important presentation, I'm Patricia Rosenfield. And I'm, I was the first economist for the tropical disease research program at the World Health Organization and entered right as the Alma-Ata Conference had finished years ago, when the concept of primary health care was endorsed by member nations around the world. And of course that has gone by the wayside, as you so rightly pointed out, but it was so important for building from the grassroots up the efforts to achieve control first of all tropical disease, of infectious diseases, and could have been used as the as the way of bringing about the lifestyle and other public health interventions.

So, I wanted to just ask you to discuss a little bit more this perennial, continual, 100-year...200-year debate about prevention versus cure, and especially now and what are the factors that really undermine besides the lack of the more macro factors that underlie this lack of enthusiasm for preventive care and the preference for curative, I mean, the economic business rationale, for instance, and others that have really led to the kind of adverse situation that exists from the lack of preparedness around the world and the lack of investment in most countries around the world and public health.

BOLLYKY: Great, great question. And thank you for all the work that you did as part of that program. It's, for those of you that don't follow global health closely, it has quite a bit of renown around it. So it's a real contribution. You know, a lot of this falls in areas that you're quite expert in. So timing, consistency, of course, that investments need to be made today for benefits, long-term benefits that aren't received until later. You know, know the real value of public health is demonstrated by preventing an outbreak and it's hard, of course, sort of keeping an outbreak an outbreak, as opposed to an epidemic or pandemic. And it's hard to...for people to appreciate that value for all the threats that are prevented. So that has been a tremendous issue. And you know, of course, we invested in these things in the past, not because humankind was more virtuous than it was now, but because we had no alternative. There were no effective treatments. We tried everything else and it didn't work. So we finally set on a set of interventions, non-pharmaceutical interventions, that did seem to work. What we have not been able to internalize is that there are many things for which treatment is not a particularly good solution and I'm hopeful. But we'll see whether or not this pandemic has demonstrated that sufficiently to people. I think in the United States, we are clearly continuing to struggle, or there still seems to be underinvestment in the non-pharmaceutical interventions and programs that are working internationally, in favor for heavy investment in a vaccine. And I'm a supporter of vaccines as a tool like everyone else, but it will take quite some time to distribute effectively. And the early vaccines are likely to only be partially protective, so will still remain at risk. So this is a present concern, but thank you for the great question.

O'NEIL: Let's take another question.

STAFF: We will take the next question from Joseph Bower.

Q: Thank you, Thomas, I come across your books, and really enjoy and appreciate your work. My question has to really following up has to do with the role of doctors and medicine. And it seems in my work looking at the organization of health care delivery. A key is the role doctors play, and even ideologically the role of the doctor. And my sense is, and I wonder if you could answer this comparatively...France, UK, whatever versus US...where the role of the doctor is really very strong and a sense that they should be delivering individual care. It's very hard to organize a public health system.

BOLLYKY: I think that's true. You can think of lots of examples where it can be, it has been difficult to do public health protections due to some resistance from physicians associations. So that's been true on, of course, healthcare reform and how we pay for healthcare. It's true you think of fluoride in the classic example of dentists' opposition. You know, it's...again, doesn't make doctors or physicians worse people than everyone else. Other industries do this too, but it can be quite difficult. Where things really do rely on a system and public health to get physicians on board. You know, in terms of how the US has done from a medical--from the treatment--perspective, the US for particularly for the number of cases, if you look at age-standardized rates, is actually along lines of Europe. You know, certainly we're not doing as well as some countries in Asia have done and so forth. Where we've done very poorly, of course, is cases, and, you know, to some degree, our health system has been, treatment wise, has been making up for that. But that we can't keep up with that indefinitely, and it's come at a great cost. Your great question also reminded me when you mentioned the book that I am, once again allows the book salesman. Most of what I've discussed here, actually, the entirety of the argument I presented here is the argument of the book. So for those of you that haven't read it, you and would like to know more about this argument. You're certainly welcome to do so it's called Plagues and the Paradox of Progress--paperback came out in October. But that's really the argument I'm presenting here.

O'NEIL: Great, let's take another question.

STAFF: We will take the next question from Megan Carroll.

Q: Hi, can you hear me?

O'NEIL: We can.

Q: Thanks so much. We see how access to a universal health care system played a major role in the success of COVID containment in Japan, Thailand, and elsewhere around the world. Do you think the Coronavirus crisis will force the US to reconsider universal healthcare? If not what you think it will take to have more public and political support? Thanks.

BOLLYKY: So, universal healthcare has had a funny performance in this pandemic, to be fair. We did analysis also on Think Global Health where we looked at all the major indices or preparedness. We looked at the global health security index. We looked at, for those of you that are more involved in global health, some of these will be familiar. We looked at the joint external evaluations that are meant to track the international health regulations, the rules, international rules around pandemic response and preparedness. We looked at all these different measures. We also looked at universal health coverage. And interestingly enough, you don't see a correlation in performance. If anything, there's an inverse correlation, which isn't meant to be causal. It's just further indication. We did this comparison where we took account age structure. So the maternal mortality rates are each standardized. We looked at when we treated everybody equally in terms of the arrival of the case. So they're all indexed to their first death out 250 days. You still don't see anything. That isn't to say the US doesn't have significant work to do. But at least internationally and even with the US, I would be, I'd be thrilled to see universal health coverage. Our purpose of our healthcare system isn't just protecting against pandemics. And there's certainly a lot of benefits that comes from that. If the major motivating factor coming out of this is going to be pandemic response and preparedness, I would like to see more focus on primary health. Where we're hoping to do some analysis on that. I think you may see a very different result when you look at primary health and some other measures of government trust, but stay tuned for that.

O'NEIL: Let me follow up a little bit, especially in the US system, because the way our system is set up, lots of people lost their healthcare, particularly during the pandemic and with unemployment and, you know, before February, March in the US some of these health care debates were around these deaths of despair, right? Those are the things that we were worried about in the rising opioid use and other things. I guess, could you talk a little bit about, I mean, we've been absorbed with a pandemic and putting that aside for a minute. What about these underlying right? You're, as you were saying, COVID is only the twelfth deadliest thing that we have on our plate, right? If things continue, so what not what should we really be worried about? But what really should we be worried about and what should we be doing there? How is our health system dealing or not dealing with that?

BOLLYKY: Yeah, so to leverage the argument we talked about before and Thomas Jefferson and democracy and it's linked to health. The US has, for three years in a row, had its life expectancy decline. It was the only high income country where this was occurring. The UK has been stagnant, but not to the same extent. Over the same time period, interestingly enough, we have been the fastest dropping country on most democracy indices. And this predates (this not a political statement) it predates the current president. This has been happening really since 2009, 2010. And I think there is a connection between those two trends. Where we, what the biggest explainer of people that had voted in the past for Obama and shifted to the president in 2016. Wasn't education, wasn't wealth. It was health. It was a basket of these diseases of despair and performance. So county by county, this is an analysis, we did a piece in Foreign Affairs on this, if you want to look it up. And, you know, I think a less responsive government, a government to the needs of its people. And the consequences of that in health are both driving some of what we see in terms of our voting behavior in public, but also a consequence of that. These diseases of despair are not going away. There's some data to suggest that they've been increasing, not surprisingly, in the midst of this pandemic. So it's going to be a persistent problem. But I by outlining this argument, it suggests is that I think this these may be different symptoms of larger issue, not just an issue of these diseases themselves.

O'NEIL: Let's take another Question.

STAFF: We will take the next question from Charles Landow.

Q: Hi, thank you very much to Tom and Shannon for the discussion. Tom, I want to ask you, across the societies, you've looked at different parts of the world, different areas of history. Have health interventions such as vaccines and masks and so on, often been politicized and controversial in the way that we see in our time, or is that sort of a particular feature of American society today? Thank you.

BOLLYKY: So there is some history of this. You no vaccine hesitancy or opposition to vaccination is not a new phenomenon. It existed around smallpox. You know, particularly there were fights over compulsory immunization in the UK in particular, but some other European countries as well. There's, you've had some issues of this before, I don't know as much on the issues of masks, but inherently when you're talking about public health, and I teach a course at Georgetown Law School as well, public health law is about the actions of government taken on behalf of society and the tension that creates with individual rights. And you're going to see that in any instance where we are pushing the boundaries of public health that there will be some communities. In the past it's been particularly communities that feel more vulnerable to the government. Immigrant communities are the classic example around immunization that will have some opposition. What is quite unusual in this pandemic, is that you know, There have been pockets of this within our leadership in the federal government. And I can't think of an instance where public health measures taken by one part of the government or by some agencies have been politicized by other members of the government that I can't think of a precedent for.

O'NEIL: Thanks. Let's take another question.

STAFF: We will take our next question from Harold. Harold, if you could please introduce yourself.

Q: Hi, yeah, my name is Harold Schmitz. I'm with The March Fund and also UC Davis Graduate School of Management. Really appreciated this lecture I wanted to ask you about the role of food and nutrition in this rubric that you've been talking about and you know, any insights or future-looking thoughts you might have there.

BOLLYKY: So definitely in terms of the decline or improvements in human health, nutrition played some role in that. You know, there's been, for those of you that love public health literature, you can read the different people that have put forward arguments on either side. I think the current consensus is that certainly some role but perhaps not the dominant role that people thought. There are some places where health improved well ahead of economies and improvements in nutrition. So in terms of the overall argument, you know, a supporting role but not a major role. One big issue that of course, immediately comes to mind in the current pandemic is comorbidities. So, we are certainly seeing consequences in terms of our poor approach to nutrition oversight in in countries with high rates of obesity like the United States, but other countries as well, have played a big role as there are a number of chronic diseases that have significantly worsened mortality rates from this virus. So it's an important piece from that perspective too.

O'NEIL: Tom, let me take you back to your sort of bigger thesis, right? And I understand that we're all wrapped up in COVID, and rightly so. Right? But that is, again, an infectious disease. But when you look at your book, and a lot of the work you've been doing, you're really focused on these noncommunicable diseases, right? The other kinds of things that people are getting increasingly across society. So as you look at, one could you talk a little bit about the political optics of that? Because you know, does COVID, is it in some ways going to make us sicker not because of COVID but because it's going to take the eye off the ball from this noncommunicable disease. Is that true? Or how do you see that playing out in different countries? And then what would you, as a policy advisor, if you had someone's ear, what would you do about that?

BOLLYKY: Yeah, so I'm deeply worried about the future of global health and our investments. You know, this has been environment where a field that didn't get a lot of attention before, whether that be public health or global health more generally, is getting a ton of attention. So people would think this would be a good moment for the field and the fact that you know, you have a global health and public health issue being a primary subject of a presidential campaign is mind boggling. In terms of the level of attention it's getting from that perspective. What worries me is, I worry the outcome of this will be investments in global health security, to protect us against future pandemics at the expense of really most other things. Things in global health. So that shift or cannibalization of the architecture of global health, just to address pandemics, I think would be an overreaction. But it's also likely to come at a time where there's a significant economic hangover from this pandemic, which means countries will have less resources, so less appetite, perhaps, to invest in foreign assistance in general. And even some public health ministers domestically, at the same time, where they may have motivation to move some of those investments in the past and concentrate them all on this one issue. And I think it would be a grave mistake in part because I think, you know, the thesis is here, but I think has been proven out, systems really are what has enabled countries to succeed against this pandemic. So if we don't invest, if we just invest in the narrow programs around pandemic prevention and management, but not in the overall systems we will find ourselves with brittle systems that aren't adaptable to unforeseen challenges. And there always be unforeseen challenges. Nature guarantees it.

O'NEIL: Well, let me ask you about systems. So we have some systems and we have some international systems, right? We have the WHO we have a lot of other organizations. Where are they? Are they working? Are they not working? What would they need? How should it, what role should they play? And can they play it, given how they are today?

BOLLYKY: Yeah, there'll be many issues that are going to be relevant for how this election goes, but one of them will be the future of the US engagement in the World Health Organization where you have a pretty clear contrast between the two candidates. The US has filed a new notice of withdrawal with the Secretary General. So as of next June, maybe July, but I think it's June, we will officially be withdrawn from the World Health Organization whereas Vice President Biden has indicated that they will rescind that. So we'll see in terms of the US engagement on WHO. WHO has, in this pandemic, I think there are issues they can be faulted on, particularly in the early days, in terms of perhaps its interactions with China and perhaps not pressing quite hard enough. I think in terms of how they've done the core part of their mission, which is working with low and middle income countries in this pandemic, actually really done quite well, particularly on a shoestring budget. They're still doing their day job, so to speak consistently throughout this. I really it's remarkable. People need to know that the World Health Organization has a much smaller budget, of course, than the New York City Department of Health but also about a mid-size hospital. So to pull this off internationally is really something. So I hope irrespective that the outcome of the election cooler heads can prevail, and that we address the shortcomings and invest in this institution. Another key thing to watch in our last couple of minutes is around vaccines. We will in the next six to, I mean, weeks to months potentially start to see vaccines getting at least authorized for use, it is not clear how they will be distributed internationally. And that may have real consequences for the future of our cooperation on pandemics and on global health in general. That if wealthy nations including the United States fundamentally hoard early vaccine supplies, not just using them to address priority public health needs, but vaccinating even low-risk members of their own population before sharing, while other countries are forced to wait. If we can't manage to share those vaccines, at least again that we would otherwise use for low-risk members, with other nations...if we can't share a medical intervention that is in everyone's interest to share because it would end the pandemic sooner. What global health problem are we actually going to be able to cooperate on? What other challenge are we going to be able to cooperate on? So I worry a lot about what will come out of this fight. Because in the past, whether it's been the H1N1 pandemic, the early stages of this pandemic with personal protective equipment and ventilators and medical supplies, we have not shared. So we are we are swimming upstream here. There is a multilateral initiative, which again, WHO has played a large role in setting up we'll really know in the next couple of weeks whether or not other countries will join that initiative and contribute resources, real resources, to making it work. The US has already announced that we will not. But we'll see what other nations do.

O'NEIL: Well, on that sobering note, we are reaching the end of our time here. I know we have a few more questions, but I know you know, Tom is available and speaking of these issues, all of them in lots of places. So for those of you who are joining the masterclass series on a regular basis, in two weeks, we're going to have Alyssa Ayres talking about India and the US-India relationship. So please join us on September 29. But for right now, please join me virtually in thanking Tom for his time and for educating us all. So thank you very much.

BOLLYKY: My pleasure. Thanks so much for listening.


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