What is the relationship between science, politics and practice in global health?
The practice of global health is both science and politics: science because research produces evidence that we use to identify and address global health problems; politics because questions of power and political will are fundamental, to putting in place and addressing global health issues. Global health is done in an international space and as a result, ever since colonial times, diplomacy has been crucial to determining what matters and what gets addressed in global health. I would add a final thing, which is that science is not, in a sense, objective, because politics determine which questions are seen as relevant and amenable to scientific research. It is impossible to separate science and politics in global health. Everything we do, everything we talk about in global health is infused with both scientific and political concerns.
How is the changing face of war changing the infectious disease threats we face?
War is changing and what we have found is that conflict, which involves non-state actors and armed groups of various kinds, has transformed the infectious disease threats that we face. Classically, war leads to epidemics because of poor sanitation – most importantly no access to clean water, which leads to epidemics of cholera or tuberculosis. We have a very clear idea that the consequence of war on both the material environment and on people produces epidemics. What we are finding now is that these conflicts are changing the ecosphere and in the process, changing microorganisms and breeding antibiotic resistance. How do they do this: through a convergence of three different phenomena.
The first is we have large numbers of people wounded by improvised explosive devices, which produce easily infected wounds because the explosives are dirty and have shrapnel. The second is that these conflicts are occurring in an era where antibiotics are readily available but inconsistently, which is a recipe for allowing bacteria to develop resistance. The third is the congregation of large amounts of wounded in poorly equipped healthcare facilities, which allows infections to spread, including drug-resistant infections.
Putting those elements together creates a kind of “antibiotic anarchy”, where you have a lot of people with wounds, infections, antibiotics available over-the-counter of variable quality, no stewardship of their use and a population that is eager to use antibiotics because, understandably, they are worried about infections. This is what is leading to the global epidemic of antibiotic resistance, or AMR, anti-microbial resistance.
Another worrisome dimension of conflicts it that they increasingly involve deliberate targeting and attacks on healthcare, in effect weaponising it, which also contributes to antibiotic resistance.
How could world funds be best channelled, in your opinion, to eradicate disease?
There has been a lot of talk about eradicating infectious diseases, and this is, I think, perhaps a problematic way of framing the issue of epidemics today. We are drawn to the idea of eradication, it promises a kind of definitive solution to what seem to be attractable problems, and we have had, certainly, one remarkable success, which is the eradication of small pox, so why not do it for other diseases? And certainly, there are other diseases that are candidates, which are similar to small pox, in that there is a vaccine and they are diseases caused by organisms that don’t have an animal reservoir: measles and polio are two examples.
The challenge is that eradication efforts require more than technical solutions, they require social traction, or broad acceptance, to enable the technical measures to be adopted. This is increasingly difficult because of the wide global mistrust in authority and in public health. This suggests that trust is an issue to be addressed and worked on but there is no easy answer, no one-size-fits-all approach and a social approach requires significant and sustained political will and mobilisation; people have to really adhere and stay motivated.
Ironically, the closer we come to eradication, the lower the number of cases, the more that will and that energy dissipates. An alternative would be to no longer talk about eradication as a goal but to figure out how to best live with the infectious disease risks that we face. The antibiotic resistance story shows us that our technical biomedical attempts to address infectious diseases often result in unexpected and undesirable consequences. So, perhaps it’s time to think of a more planetary and ecological approach to figure out how to best live with the pathogens that make up our environment.
Watch Professor Ngyuen's Lunch Briefing on 28 May on "New Wars and New Epidemics":