Public Health Is The Broadest Bridge Between Science And Society


I’m Linda Fried I have the great honor
of serving as the introducer of today’s very important event which we’re very
excited about and also the honor of serving of course as the mammon school’s
Dean welcome of course to a very exciting next entry in this
year’s Grand Rounds on the future of public health at the mailman school this
series from our point of view is a critically important vehicle for
bringing faculty and students together from across every part of the school to
examine and debate and understand together critically important issues for
the public’s health that are relevant to all of us and we’re understanding them
together can accelerate significant progress and contributions the theme for
this year has been the theme of networks sometimes we focused on networks science
and data science but in this case today’s talk really is about networks
for building shared knowledge which is of course our aspiration in general I’m
particularly delighted to welcome you to this talk which is both our Grand Rounds
on the future of public health and the inaugural use of Hameed distinguished
lecture this lecture series is generously funded by the mammon school’s
board member and public health champion use of Hameed dr. Hameed is both a
world-renowned scientists as well as being the chair prior chairman of sip la
a global generic pharmaceuticals company dr. Hameed has worked with the school to
launch this series to foster the sharing of ideas in new ways across borders and
continents and of course we’re particularly pleased to welcome our
speaker who I’ll introduce in a moment but I want to mention that another part
of our partnership with dr. Hameed is his support for the development of the
use of Hameed fellowships and of course our inaugural class of fellow so you’ll
hear more about in a moment our here today which is one of the reasons for
the timing of dr. Reddy’s inviting dr. ready to launch this this program the
principal focus of the program under dr. he meets with dr. Mohammed’s vision and
guidance and support is to develop a robust research Network and stimulate
new collaborations especially in areas that have critical gaps in health
related research where partnerships between this school and leading scholars
in India might well help bilateral learning and substantive progress
dr. Hameed’s concern has been to particularly focus on issues of health
and the environment health care access and population of family health with a
particular focus on chronic disease prevention aging and reproductive health
so you’ll hear more about that but for the moment I particularly want to say
how honored I feel and the school feels to be able to welcome dr. Serena’s ready
president of the Public Health Foundation of India to our school and to
Columbia University and to be the first lecturer in this important series I’d
also like to thank the Mumbai office of the Columbia global centers who for
their collaboration on this series and to say how important that collaboration
has been according to our Grand Rounds tradition after dr. Worrell here for a
moment from Kavita Siva Rama Krishnan about the fellowship program and to
formally introduce dr. Reddy but after dr. Reddy’s remarks will
ample time for discussion with the audience your questions your comments
your thoughts and and then we’ll continue the conversation at our lunch
afterwards we’ll which will take place downstairs in the fourth floor
conference room and now I’m really pleased to turn this over to dr. Kavita
Siva Ramakrishnan co-director of the Columbia ageing Center and associate
professor sociomedical Sciences to introduce our esteemed guest today
Kavita so good good morning and I’m faculty director of this use of Hameed’s
fellowship program and it gives me really immense and huge pleasure today
and almost a sense of disbelief that we’ve reached a stage in this program
which which has been so productive that we reached this stage when we have this
inaugural use of Hameed lecture so a couple of brief comments about how we
started this journey we began to set up these fellowships when Dean freed Lynn
Friedman and I visited Mumbai we visited good Rath and a range of Indian public
health institutions to really try to understand what were the key challenges
on which the Mailman School of Public Health could partner with institutions
in India to be able to address some of these key questions and some of the
thematic areas as Dean freed mentioned turned out to be environmental health
access to health and medicines and chronic disease and aging but as we all
know we all draw a lot of programs but there are no programs without people and
I’d like to quickly therefore thank the people who’ve been absolutely vital in
setting up the use of Hameed program today the way you see it the first set
of people I’d like to thank is Gary Miller and Lynn Friedman who been part
of the selection committee of the Hameed fellowships Caitlyn hawk Vinita Gowda
Bethany a range of people who’ve supported us and we wouldn’t be having
the program as you see it today without them and I’d also like to thank dr.
Raveena a girl who’s been a vital member and collaborator and without this link
that we’ve had the cult with the Colombia global center it’s been a
critical link I don’t think we’d be able to do
is very vital and very innovative kind of partnership we’ve started globally
today and I’d also like to welcome the members from the Columbia global center
and now I’d like to really quickly turn for a quick round of introductions to a
first batch of use of Hameed fellows who are here today and I’d like I like them
to stand up as I read out their names so I’ll start with the the fellows who’ve
joined us here from India who’ve been here for three weeks and sadly enough
are now preparing to leave I’ll turn to Habib Hassan Farooqi Habib is an
associate professor at the Indian Institute of Public Health at the Public
Health Foundation of India the second fellow is Surinder KP justwell surinder
is deputy director research and professor at the Center for Health and
Mental Health at the Tata Institute of Social Sciences Mumbai and the third
fellow that we welcome from India is Aditi Roy she’s she’s research scientist
at the center for environmental health at the Public Health Foundation of India
welcome and thank you for being here and and I’d also like to especially thank
all the chairs of the various departments each of these fellows have
been embedded in a department in the in the school and both faculty and chairs
have been hugely welcoming so I’d like to expand extend a special note of
thanks to the chairs in the school and now I turn to introduce the mailman
school fellows the Hameed fellows from the mailman school who are now going to
be going to India the first is Alaina Ladas who is learner associate professor
for global integrative medicine in the department of pediatrics
the second fellow is Jasmine McDonald she is assistant professor Department of
Epidemiology and then having sampled who is associate professor department of
health policy and management and Mary Beth teri who is professor in the
Department of Epidemiology I’d also love to I’d like to do a quick plug for a
program if your faculty members here please do feel free to apply I’d invite
you cordially to apply for the next RFP for the homeys program and now to a very
distinguished guest here today prefer the kitchen already serves as the
president of the Public Health Foundation of India India’s first
public-private partnership in public health it was set up initially with a
range of partners the government of India the Gates Foundation a range of
philanthropies and corporate institutions in India and the pH fi of
which he is the president serves really as an administrative and scientific hub
that ties up with a range of Indian Institutes of Public Health where they
address questions relating to public health capacity building training
advocacy and researching public health needs in India and these Institute’s for
all of you who want to partner and I interested in research located all over
they rotated in Delhi in Canty Nagar in Hyderabad Bhuvaneshwari and Shalom
before founding the Public Health Foundation of India this is really when
I first met dr. Reddy when I was a graduate student when he was really at
the All India Institute of Medical Sciences and this is a word really for
some of the students in the audience apart from being an immensely well-known
global health leader dr. Reddy is really one of the most he’s one of the most
generous intellectual mentors one can actually find so I met him when I was
finishing up a PhD and when he was at the All India Institute of Medical
Sciences and he was at that point heading the department of cardiology at
Ames he secured a medical degree from the Oz mania Medical College in
Hyderabad and MD in medicine and a DM in cardiology
all from the All India Institute of Medical Sciences he was also the first
Indian to serve as the president of the World Heart Federation and he served as
a physician and held the pulse amass a of two prime ministers in India so I am
have no doubt he really knows how to answer questions that we pose to him
about translating public health evidence into policy advocacy it helps to hold
the pulse of Prime Minister as I’m sure dr. Railly
so before founding the so amongst his many current roles he also coaches the
thematic group on health of the UN sustainable development Solutions
Network he co-chaired the Health Ministry steering committee on health
related effects on air pollution and he was awarded the w-h-o Director General’s
Award in 2003 the Luther Terry medal of the American Cancer Society in 2009 for
leadership and global tobacco control is an elected member of the US National
Academy of Medicine you can see here a lifelong devotion to addressing
questions in public health public health questions both in India but also global
health challenges and I think that makes him absolutely the perfect and ideal
person here today to deliver this inaugural lecture welcome dr. Reddy namaste it’s indeed a great pleasure to
be here at the mailman school and certainly a great honor to have been
asked to deliver the first use of Hamid lecture the topic that I have chosen may
sound like a bit of a hyperbole when I say the public health is the broadest
bridge between science and society if I had just said a bridge it would have
been a self-evident truth and would not have required much elaboration but why
do I take the risk of sounding arrogant and say that it’s the broadest bridge I
suppose I’ll have to use my lecture time to justify that it was in 1896 that the
modern Olympics started in Athens with the motto faster higher and stronger
while they have been certainly very admirable accomplishments in the field
of athletics during successive Olympics it is indeed science that has adopted
and exemplified this motto with an amazing ability to generate knowledge
with great speed with ever-increasing speed with astounding leaps of
creativity and innovation and incredible strength of transforming human lives
sometimes terrifyingly so transforming human
on this planet and even beyond but whatever be the pace and promise of
scientific advances we must keep reminding ourselves that science has a
social mission science I believe is sterile if it lacks a social purpose it
must also for that reason connect with public policy which steers that social
purpose I believe again that public policy will crumble on clay feet if it
does not stand on the strong base of sound science and particularly in these
days when science is being denied or being substituted with fake science it
is worth reiterating this while this is certainly not an original idea but I’ve
spelt it out in my talks and my writings several times but then one has to define
what is science and try and understand where science actually links with public
policy in my view science is the structured systematic rigorous and
objective method of inquiry into natural or anthropogenic phenomena Lewis Wolpert
writing about the unnatural nature of science in his book says science is
different from technology though it’s frequently confused with technology
science yields an idea technology is a product and Patricia Farah a historian
of science says in a book a four thousand year history of science that
science is not just a final product such as a theorem chemical or an instrument
but is an integral component of society interval with industry business warfare
government and medicine she also goes on to say that taking
advantage of scientific discoveries entails making political decisions about
how to use them and it is here I believe that public health must serve as a very
valuable guide to making those political decisions in order that science serves
its social purpose with responsibility and impact so public health must be the
bridge between science and public policy for social good but then what is public
health that itself has so many interpretations and so many definitions
over the years John Coggan in his book what makes
health public says that there are about seven phases of public health in the way
it is interpreted or presented public health is a political tool public health
is government business public health as the social infrastructure public health
as a professional Enterprise of Public Health trained health professionals
public health as a blind benefit or harm for example controlling alcohol
consumption or drugs is beneficial to society public health where the
beneficiary is not identified but it extends to an undefined group of
population public health as conjoined beneficiaries where there is collective
good and public health as the populations health I would believe that
the last version that is public health as the populations health also
encompasses the preceding descriptors and therefore public health in the words
of the Institute of Medicine now called the US National Academy of Medicine is
what we as a society do collectively to assure the conditions in which people
can be healthy now this sounds a very satisfactory definition but is it
entirely true it suggests that we as a society all
arrived at a consensus which is not true it does not talk about the conflicts
between different sections of society what do we do with the tobacco industry
what do we do in the food industry which is not homogenous what do we do with the
polluting industries is there a consensus is the society functioning
collectively I do not believe so so I need to define
public health for myself in my view public health identifies and influences
the determinants of health at the population level to impact on health and
disease at the individual level it acts on risk factors and determinants in
terms of its elucidation but it acts in order to bring about change and impact
through policy through systems through services and community action indeed I
believe that health of the population is also shaped by science and society as
the Swedish Nobel laureate Kunal mirdle said he’ll sleep sort of science and
draws nourishment from the totality of society so while I do propose that
health should actually act as the pathway for connecting science to
society health itself is a product of science and society so it is this
integral relationship that we must actually identify and influence and the
cascade of determinants in public health previously focused on what acts on the
individual the classic epidemiology which investigated beliefs which were
acquired behaviors which were practiced and biology which was the gene
environment interactions but we then moved on to understand that there are
more upstream influences acting at the level of the family in the community
cultural perceptions socio-economic priorities whether you decide on having
better nutrition for the family or and tobacco for the father pathways of
availability and access of smoke-free public places of areas where you can
have safe and pleasurable physical activity and so on but even more
dominantly in in recent years we have seen influences acting even further
upstream at the national and global level in terms of the stage and speed of
development the distributional issues of equity and the demand and supply issues
of trade driving even the other determinants and ultimately impacting
upon individual health so public health must generate knowledge translate
knowledge apply knowledge and evaluate knowledge and the beginning point of
course is research which generates knowledge but then that knowledge must
lead to action quite often we say knowledge to action suffices but the
knowledge must also have impact and that impact will be seen as biological social
and economic changes but we cannot cease with impact that impact must also
translate into equity and we must maximize equity in all dimensions and
that ultimately is the difference that public health will make to society now
in terms of health equity as a philosophical construct we began of
course with the utilitarian philosophy of Jeremy Bentham which spoke of the
maximum good for the maximum people but that utilitarian philosophy actually
limited itself to proposing that society must advance the interests of those who
contribute maximum good to the society which suggested the productive workforce
but not necessarily the children or the elderly or the disabled and therefore
the idea of justice Kaman with John Rawls we talked about equality of
opportunity but that also had certain limitations which then sent try to
correct by bringing about the issue of capabilities so the concept
of capabilities which he held up as an important element of the right to health
I think this whole argument has been very well summarized by three the rank
atop a room in his book health justice he says quote a veil or dirt society
would ensure that all individuals have the capability to be healthy and at a
level that is commensurate with human dignity in the modern world which is
there right now we also know that health is one capability but is shaped by many
other capabilities education gender livelihoods physical environment
multiple other capabilities and those now have been reflected in the
sustainable development goals even avoidance of conflict all of those
matter when we see refugees are forced by climate or forced by conflict so
where their capabilities are diminished and their right to health is impeded so
I believe that the sustainable development goals actually represent
these multiple capabilities which interact with and influence health as
Martha Nussbaum says we are really talking about a cluster of capabilities
when we are talking of health or a meta capability and indeed when we think
about it despite the fact that we have 17 sustainable development goals and 167
indicators for those goals and multiple targets in between health is the best
summative indicator of success in sustainable development therefore the
global health must set itself some goals as we move towards 2030 which is the
year for attaining the SDGs and these are accelerating progress on the
Millennium Development Goals which is maternal and child health and infectious
diseases complemented now by concerted action to control non communicable
diseases and protect until health implementing universal
health coverage which provides the health system platform for action on all
of these but not forgetting that we must also promote the social determinants of
health so what we need are strong health systems and pro health policies policies
in all sectors or health health in all policies leading to better population
health outcomes and improved health equity indices so we again have to look
at health as something that is actually a combination of multiple elements
interacting with each other we traditionally look at the health system
in terms of what the WH word defines as the different elements that is workforce
infrastructure drugs vaccines and technologies health financing
information systems and governance we do not talk much about but nevertheless
need to pay a great deal of attention to factors that actually have a greater
impact on health than even the health system that is the social environmental
and commercial determinants of health and nutrition those that acted the
societal level like water sanitation food system environment social stability
and development but those which had seen as personal factors like income
education occupation social status gender and participation in social
networks which are nevertheless also driven substantially by social forces
but whether these are choices in the health system as to how the health
system is organized and what are its priorities or action in the area of
social determinants of health or commercial determinants of health or the
environmental determinants of health it ultimately depends upon the choices we
make in the nature of the political and economic system that we develop and that
drives all the other decisions and that is where public health now has to play a
greater role obviously I am NOT going to be disc
seeing each one of these but let me pick up a few to exemplify my arguments let
me pick up the area of drugs vaccines and technologies as well as food system
and environment and the interactions between those two we now live in an era
where technology is rapidly progressing at a dizzying speed and influencing many
elements of our life and we often believe that technology is science but I
believe that science discovers technology develops and public health
delivers if we only look at the vaccines that remains still undelivered to the
intended beneficiaries across the world we see where there is a secondary
translational barrier or a technology pileups if the health systems are weak
and incapable of delivering it that is such an obvious example of public health
being a very important necessary element in the delivery of the technologies that
have been developed but also Public Health must also guide the nature of
technologies that are needed for social good so that the technologies are
appropriately delivered and developed at an affordable cost now this is the
latest report from the w-h-o the guidelines which incorporate the
recommendations on digital interventions for health system strengthening released
just a week ago but here again we see that among the various technologies that
are available they have been prioritized for Public Health applications and that
is where I believe public health again has to play the role of showing the way
and we have an example from our own foundation where auxilary nurse midwives
with handheld tablets in which decision support systems have been incorporated
and point-of-care Diagnostics are available in the state of Himachal
Pradesh have successfully diagnosed and managed
hypertension and diabetes with excellent outcomes which have lasted for 18 months
and beyond again where the health system is not having sufficient number of
doctors for primary healthcare functions here we have demonstrated how an
appropriate technology can be truly transformational but again it is the
responsibility of public health show that this is the way technology should
be deployed then coming to drugs and again this is very consistent with the
person who is after whom this lecture is named dr. use of heme is the whole area
of drugs is around access whether it’s generates or price controls or pool
public procurement or trade agreements it is to ensure access to essential
drugs at an affordable cost whether it is insulin which is dominating your
congressional hearings now as to why people are dying because of a non
availability of insulin at affordable prices or anti-cancer drugs which have
agitated multinationals when India went in for a compulsory licensing or new
antimicrobials or biologicals the challenge is how do we ensure access and
here you can see for a drug which is now known to be curative for hepatitis C
treatment the prices vary markedly across the countries the fact that India
has pretty low well low price is because Gilead has in its wisdom franchised it
out to four and now I think 11 companies to produce it in India at a much cheaper
rate and distributed in India now if it can be done at a low cost in India why
not elsewhere why should other countries really have to spend so much of money
and make it so utterly unaffordable for the people who need it so these are
questions that do come up and of course dr. Hameed has been a pioneer in
breaking access barriers by taking on a major multinational
company and supplying antiretrovirals to South Africa at a very low cost by
producing them in the generic form and for that the multinational company sued
the Mandela government can you imagine a company swing Mandela government but it
did happen but ultimately thanks to public protest indignation including by
medical students in American universities the company had to beat a
retreat and used to permeate the imagine as a champion and India could actually
produce these generates because of a political choice made on public health
considerations India used to resort to product patenting earlier but in 1971
made a radical shift to process patenting that means you can produce the
same drug even if it is under patent by modifying the process a bit now this
generated a whole class of generic manufacturers who produced unbranded
generics and then went on to produce generic branded generics and India
became the pharmacy of much of the world supplying cheaper drugs in 2005 we had
to move to product patenting because we entered the World Trade Organization but
nevertheless we built up sufficient strength in the meanwhile to address the
essential needs of our people and of many other countries as well in terms of
life-saving medicines now that is a choice which was political but steered
on the grounds of public health now similar considerations led to the Doha
declaration where which provided trips flexibilities where on public health
considerations countries could employ compulsory licensing and other methods
in order to make sure that access to drugs remained protected
but many of the free trade agreements that have come up since bilateral or
multilateral have now gone in four trips plus provisions which undermined the
trips flexibilities prevent countries from undertaking compulsory licensing or
preventing export of generic drugs to third countries and so on that’s why the
United Nations Secretary General’s high-level panel on access to medicines
in September 2016 remarked that many governments have not used the
flexibility is available under the trips agreement for various reasons ranging
from capacity constraints to undue political and economic pressures from
the states and corporations both Express and implied political and economic
pressures placed on governments to forego the use of trips flexibilities
violates the integral integrity and legitimacy of the system of legal rights
and duties created by the trips agreement as reaffirmed by the Doha
declaration again this is an arena where trade politics economic interests and
public health collide and come into conflict but here is a ringing
affirmation of the primacy of the need to protect public health and that is
where public health must guide that entire debate moving to climate change
now all of you have to familiar with the consequences of climate change on health
but it bears reiteration to say that there are physical and mental effects of
heat vector borne diseases waterborne diseases extreme weather events playing
havoc excessive baited air pollution increase the risk of chronic diseases
climate refugees and an impact on agriculture and nutrition security but
whatever be the manifestation of this the poor are the worst victims and
therefore again that is damage to equity now obviously in each of these areas
whether its environmental degradation with forced migration civil conflict
mental health impacts loss of jobs and income
or degraded living conditions and social iniquities with exacerbation of existing
social and health inequities and vulnerabilities are changes in vector
ecology when because of the heat human beings like listless and wilting in the
heat the mosquitoes become athletic and
climbed to higher heights and therefore you see malaria spreading to areas which
were here that are protected then we have air pollution and increasing
Allegiance when the carbon dome descends the impact of air pollution and ozone
concentration at the ground level increase again causing a huge amount of
damage water quality impact as well as water and food supply and extreme
weather immense and extreme heat events as we have said but let’s look at only
one of the impact one of the manifestations which is on food and
agriculture we live in a world currently where food systems are threatening the
environment and environmental degradation from a variety of sources is
threatening the food systems and this will get worse if we don’t change now we
know in this relationship between agriculture food and nutrition
urbanization diminished arable land changing food prices water usage
increasing global population are all playing a role but climate change is
coming in as one of the biggest intervening factors the world would need
to produce 60 percent more food to feed a population of 9 billion in 2050 if we
look at climate change through the nutrition lens by year 2100 40% of the
world’s land surface will likely experience altered climates agricultural
output is projected to fall by 2 percent per decade due to impact of climate
change and crop and livestock production food demand is projected to rise by 14
percent per decade due to population growth urbanization and poverty
reduction also remember the age profile of the populations will be
changing the proportion of children will be decreasing the proportion of adults
would be increasing and adults consume more than children so this is the reason
why you’re going to see for multiple reasons the demand for food would
increase even as the supply of food would decrease higher production of
staple crops will not be enough to make agriculture more resilient to climate
change are better able to address the world’s need for improved diets nutrient
rich crops are more susceptible to draw its best diseases and temperature
fluctuations actually the production of staples is going to go around but what
is even more worrisome is the detriment to the non stables which are more
nutrient rich the higher carbon dioxide in atmosphere may reduce the nutrient
content of staple crops and soil degradation also reduces nutrient
quality sub-saharan Africa and South Asia which are actually going to be
seeing a population increase particularly prone to productivity
losses from climate change because major staples in these regions are often
already grown about their optimum temperature they are already operating
at a very high temperature level where the production is going to be limited
and the nutrient quality is going to be affected and with every 1 degree
additional rise in temperature that is likely to be a 10 percent yield loss and
that’s where we’ll be living on the razor’s edge of nutrition security
therefore agriculture and food systems will have to be reconfigured to assure
affordable access to diversify that that I calorie adequate but also
nutritionally appropriate to each person at every stage of his or her life in a
sustainable manner therefore we need climate resilient or climate smart
agriculture with crop diversity especially non staples and fruits and
vegetables with rising heat the fruits ripen early and rot early sustainable
fish production fiber preserving food grain processing
non-natural genic and non-diabetic genic processed food products food safety
against carcinogens well this is appears to be a very rational and reasonable
recipe but is it happening here is the so called Harvard footplate whether you
actually agree with it or not I do not know how Columbia reacts to Harvard but
nevertheless we generally agree that this is a reasonable philosophy that at
least half of the plate must be having fruit and vegetables and the remaining
of course should have other balance other nutrients in balance other food
items in balance but what we are actually producing according to FAO
is far different from what is ideally recommended by nutritionists as a
healthy diet and therefore our production forces are totally out of
sync with human nutrition needs and here political choices will have to be made
commercial choices will have to be made and it is public health raising the
banner of nutrition security alongside sustainable environment that has to lead
the way but of course we scientists are also great and confusing the matters you
only have to look at diet and in CDs and we find the controversies exist fats
nobody knows one day saturated fats are in one day fat relative heads are out
carbohydrates salt eggs one egg one egg in three days fish fowl flesh proteins
dairy fruits and vegetables antioxidants in
every one of this there is some controversy that we create but we must
also recognize in our humility that we have become a bit too reductionist in
our approach while we focused a lot on specific individual nutrients and then
moved with some reluctance to individual food items we have now recognized that
it is dietary patterns that matter whether it is Mediterranean diet or work
in our diet it’s a prudent balanced diet that matters is the dietary pattern that
matters so again we need to remind ourselves
even as we interpret science that science the spectrum of science is
reductionist in content but holistic in context the individual is like a
spectrum the individual colors of the rainbow are brilliant and wonderful in
terms of their attractive colors it is only when they fuse together that you
get the real white light which shows you the truth and that is what science has
to be holistic in context and in terms of the food environment we need to look
at the food transformation and consumer demand consumer purchasing power
agricultural production market and trade systems all of which actually influence
the food environment and diet quality so food supply food marketing food
transformation and retail and food demand and all of these will influence
food choices so the nutrition policy of the 20th century focused on technology
aided production the emphasis was an individual behavior change eat this
don’t eat this 21st century must focus on both production and consumption
patterns which are compatible with sustainable development and emphasis on
systems thinking for broader societal change rather than looking at individual
nutrients or individual crops but this is not easy as Hubbard namirov in his
letter to the Congress of the United States when it entered the third century
in 1989 wrote in a poetic form praised without end the go-ahead zeal of whoever
it was invented the wheel but never a word for the poor self sake
that thought had and invented the break so we need to put a few breaks on the
consumerism and for this we need to use the power of policy effectively in terms
of diet we have seen how preventive the impact of policy can be in terms of
Mauritius where the price of edible oils were switched in the public distribution
system from palm oil to soil and that
automatically changed the publish consumption patterns in Poland the
import of fruit and vegetables and healthy fats greatly changed the
trajectory of cardiovascular mortality and in Finland which has been the poster
child of prevention we have seen how changing and farming and marketing
practices from dairy farms to berry farms as they say and community
education transformed the situation and we are seeing new initiatives like tax
on sugar sweetened beverages in Mexico food labeling reduce salt and processed
foods ban on trans fats advertising restrictions and so on all coming into
play in terms of tobacco we have seen evidence from multiple countries
including low and middle income countries the taxation advertising bans
smoke-free policies and health warnings are all very effective indeed in the UK
between 1981 and 2000 what 48.1% of the mortality averted with attributable to
reduce smoking but then we are challenged we are said the state has no
business to intervene it’s a matter of free choice you cannot impose a nanny
state that’s a very typical British term you cannot impose a nanny state but then
we must recognize that the government has a responsibility to protect public
health and while the market does exist we should try and ensure that the market
aligns with the public health goals rather than conflicts with it Paul
Collier an economist at Oxford says in his book in his recent book on the
future of capitalism we need an active state but we need one that accepts a
more modest role we need the market but hardness by a sense of purpose securely
grounded in ethics wonderful formulation but when you talk about a sense of
purpose guiding the market does it currently exist can it be insured till
that purpose is clearly aligned to public interest and ethics are differ
in terms of protecting common good governments should not relax their
regulatory role we do need public-private partnerships as they say
pp peace but ppp’s have been often being defined by cynics as partnerships for
private profit we in public health Foundation of India redefine it as
partnership for public purpose define the public purpose define the
deliverables and define the accountability mechanisms then it will
work otherwise not so we are dealing with the market which now is the
reigning deity but markets cannot be autonomous entities totally impervious
to public interest therefore they will have to be sensitive and I align into
public interest particularly public health interest and for these we require
increasing consumer consciousness steering industry practices with
suitable regulation you need a carrot and stick approach with some incentives
and some disincentives or as I would like to call it a frozen carrot approach
because regulation can be both a carrot and a stick and a national policy
framework which provides also that kind of political economic and social
motivators but then we are told again it’s a matter of individual choice
you’re impeding individual choice but we from the public health community must
remove those layers and say that choice of an individual can be conscious which
can be well informed a real informed based on information that is available
or conditioned by aggressive marketing and promotion as in the case of tobacco
alcohol and so on or conditioned by cultural factors and peer influences or
compelled by or constrained by economic factors availability and affordability I
may be quite conscious of the fact that I may have a must have five helpings of
fruit and vegetables a day but if the prices are extremely costly then how did
I manage finally in terms of the economic growth and relationship to
public health we now recognize that there is a bi-directional relationship
between economic growth and population health but also that at any level of
economic growth equity matters because countries with a greater level of income
and other equity actually have better gains from economic growth than
countries with high levels of iniquity but at the same time we recognize at the
individual level poverty and individual health also have a bi-directional
relationship poverty creating greater susceptibility for allel and ill health
which for which working people into poverty so we come to universal health
coverage which tries to tackle some of these in terms of the individual
vulnerability and here we have to again define a balance between horizontal
equity and vertical equity horizontal equity is a universal access to a common
set of services an essential health package which is available to everybody
but recognizing that health inequalities already exist and some population groups
are more vulnerable than others we may need additional targeted services for
disadvantaged or vulnerable groups therefore they get services or resources
beyond the essential health package which is universal again here public
health must educate the policymakers how to bridge these equity gaps well William
Gibson says the future is already here it is just not very evenly distributed
universal health coverage is essential in terms of financial protection it is
necessary but not sufficient we also need multi sectoral action on social
determinants of health and empowered communities which can benefit from a
rights-based approach to health and even dazzling new scientific knowledge must
be examined through the equity lens like for example when we look at the
intergenerational impact of undernutrition we know that if a
pregnant mother has poor nutrition there are epigenetic changes
which influenced the girl fetus in utero and predisposed to adult cardiovascular
and chronic disease diabetes and chronic diseases but what we do not often
recognize is that if the girl if the fetus is a girl the developing news
sites in that fetus are also impacted by some of these changes so that it’s not
only the child that yet to be born but the child that yet to be conceived
who will suffer these consequences and that is during one pregnancy so
similarly we recognize that when there is inequality and that creates poverty
the maternal breast milk oligosaccharides are diminished they are
not useful for the fetus but they’re useful for the microbiome which in turn
provides nutrition and mineralogical protection to the growing child and this
can result in health disorders so inequality breeds inequality there
similarly when we talk about epigenetic changes due to different environmental
exposures where they say air pollution or tobacco or other kinds of
environmental exposures again the poor are much more exposed and they will
suffer the healthy disorders much more so again in equality baguettes
inequality so coming back to the concept of equality of opportunity of John Rawls
we have our H Tony a British economist of the 1920s and 30s who says that
merely talking about equality of opportunity is decorous drapery because
you may have created an open road but not an equal start so unless you act
upon the social determinants of health you are not providing that equal start
so again it becomes the responsibility of Public Health to go beyond equality
of opportunity through universal health coverage but really take into account
the need for action on social determinants of health so whether we are
talking about genes and epigenetics and are preoccupied with various omics
we must recognize the social determinants the alteration of the
microbiome in lifetime with changing environments and environment itself
influencing epigenetics are all interlinked and therefore it is these
linkages that we must identify and move from science into public policy so the
purpose of public health research is to provide evidence-based context specific
resource sensitive culturally compatible and equity promoting recommendations for
policy and practice I prefer to use the term evidence-informed rather than
evidence-based context relevant rather than context specific because there are
different areas which could actually have slightly similar specificity and
resource optimizing rather than resource sensitive and since culture is dynamic
it will be culturally adaptive rather than just culturally compatible while
context could be altered resources could be increased culture could be modified
evidence and equity remain non-negotiable
they have to be fundamental for policy and practice there for policy needs
interdisciplinary research this mark in the 19th century said that there are two
things that should not be watched while they’re being made sausages and public
policy rather sorry spectacle unedifying spectacles to watch but even an
enlightened policy will require scientific credibility evidence and
rationale which requires biomedical and epidemiological and clinical research
financial feasibility is it cost effective or affordable health economics
research operational stability is the sustainable or scalable which requires
health systems research political viability is the community ready and
receptive it requires social science research
therefore the compass of research must extend from molecules to markets
Arina of advocacy and action must extend from risk factors to rights now when
we’re talking about cell to society research now needs the joint efforts of
multiple disciplines ranging from molecular biologists to clinicians to
epidemiologists to social scientists to bioinformatics
you know informations are we ready so in public health foundation of India we
believe public health actually embraces multiple disciplines epidemiology and
allied sciences environmental and life sciences economics and management
humanities and Social Sciences all of them are relevant and provide the
platform for confluence of knowledge which is now going to guide Public
Health Action therefore the role of universities is to create t-shaped
individuals individuals who have a depth of expertise in a particular area but
have the breadth of orientation to understand the relevance of other
disciplines have the cultural adaptability to engage with others and
try and develop that kind of transdisciplinary research environment
which is problem-solving for society so in terms of understanding health it was
mentioned that I held the pulse of two prime ministers but I believe that the
lifeline of human health extends from pulse to planet persons who are
individuals people that is communities and populations that are Nations but
also the whole planetary health itself and unless we understand this
connectivity will be failing in our duty as public health professionals
connecting science to society rudolf virchow a famous pathologist founder of
the anthropological society of germany and considered the father of social
medicine in europe said in the 19th century that should medicine ever
fulfill it great ends it must enter into the larger
political and social life of our time it must indicate the barriers which
obstruct a normal completion of the life cycle and remove them should this ever
come to pass medicine whatever it may then be will become the common good of
all I believe ladies and gentlemen that medicine today is public health and it
must enter and influence the political and social life and thereby connect
science to social good and fulfill its mission as simone weil said attention is
the rarest and purest form of generosity thank you very much for your attention

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