Open Mike: Future Perfect

We are heirs to a great legacy. The last century brought vaccines, antibiotics, safe drinking water and many other innovations that led to quantum improvements in health. At the Bloomberg School, where we’re celebrating our Centennial year, it’s especially tempting to gaze back at past accomplishments. Instead we want to focus on future challenges and opportunities for public health. 

In retrospect, the big public health victories since 1916 can seem easy. Applying the germ theory to prevent infectious diseases now seems like picking low-hanging fruit. The monumental decline in mortality from infectious diseases in the U.S. and other high-income countries is a good example. Tuberculosis mortality fell by 10-fold before the discovery of the first anti-tuberculosis therapy because of improved living conditions (better nutrition, less crowding, etc.) and behavior change (Cover your mouth when you cough! No spitting!)—saving millions of lives. But we humans often remember only the exhilaration of victory and selectively filter out the blood, sweat and tears that it takes to reach the finish line. Viewed prospectively, the infectious disease challenges that had to be solved seem monumental. Take the effort to eradicate smallpox led by my predecessor D.A. Henderson. It was accomplished without cell phones, the Internet or even fax machines.

Make no mistake—infectious diseases are still with us. An estimated 1.5 million people died in 2013 from TB alone. But more people now die from noncommunicable diseases—cardiovascular disease, cancer, injuries—than infectious diseases. And, unlike many infectious diseases, there are no vaccines to impart lifelong immunity against noncommunicable diseases. Combatting chronic diseases requires changing lifestyles and building health systems that can detect risk factors to prevent disease and can deliver effective treatment to reduce mortality.

The list of current and future public health challenges is daunting: humanitarian crises that have led to record numbers of refugees; natural disasters and climate change; emerging pathogens; inequitable distribution of resources and access to health care; food and water insecurity; disempowerment of women and lack of access to reproductive health services, among numerous others.

Many of these problems are exacerbated by or directly due to population growth. We are stressing our planet like never before. Our population is now over 7 billion and is projected to be over 10 billion by 2100. A Malthusian, dystopic future predicted in the 1970s didn’t happen. Massive famines and hundreds of millions of deaths were averted in large part because new technologies—like synthetic fertilizers and pesticides, and new hybrid varieties of rice and wheat—led to remarkable increases in agricultural productivity. But the so-called “Green Revolution” is not sustainable.

We will have new and bigger problems in the next 100 years, but we also have more and better tools that a century ago would have seemed like science fiction. We can now sequence the genome of emerging viruses in days and edit the genomes of organisms with speed and precision that were impossible just a year or two ago. Instead of performing national demographic surveys in Africa on a 5-year cycle, our faculty get real-time data in two weeks using mobile phones. Researchers can use computers to assign characteristics to millions of individuals and then create models to predict the spread of disease or the impact of a community-based intervention. Our ability to collect, analyze and display massive amounts of data grows day by day. If there is continued funding for basic and public health research—a huge IF given the unwillingness of the U.S. Congress to fund innovation—our tools will continue to improve. 

Yet technology creates risk. Modern jet travel, for example, means that a person with an emerging infection can move from West Africa to Texas within 24 hours of being infected. Big data raises the specter of “Big Brother,” with the loss of confidentiality and potential loss of personal liberties. Monocultural food crops, whether GMO or not, reduce biological diversity and risk the failure of entire harvests.

It’s clear that we can’t rely on technology alone. We have to change the way we think about problems. Dr. Paul Batalden is credited with observing, “Every system is perfectly designed to get the results it gets.” Unfortunately our current systems give us unchecked climate change, mass extinction of species, epidemic gun violence in the U.S. and rampant health and economic inequities.

In addition to reducing problems to the simplest causes and effects, we need to think more broadly and engage in systems thinking about our most pressing challenges, discerning the connections between seemingly separate problems. We need to see the whole picture, to consider not just the cost of action but of inaction, and to assess not only short-term costs but long-term ones.

We have inherited great foundational knowledge from previous generations. We have new and amazing tools. It’s our responsibility to draw on these and apply our own insights, creativity and determination to solving the public health problems of the next century.

October 2015