An introduction to key challenges and concepts important to understanding the current status and determinants of global health.
Interview with Dr William Pan, Part 1
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From the course by Duke University
The Challenges of Global Health
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From the lesson
Basic Concepts in Global Health
This module covers some of the most important basic concept that you need to know to understand global health. In particular we will focus on key terminology and the determinants underlying health and disease.
Meet the Instructors
Dr. David BoydHymowitz Family Professor of the Practice of Global Health
Duke Global Health Institute
[SOUND].
Hi, class.
I hope you are doing well today.
I am in Kunshan, China, with my friend and colleague, Dr. Bill Pan.
Dr. Pan is a professor as the Duke Global Health Institute, and
he is also a professor in the Nicholas School of the Environment at Duke.
Dr. Pen's done work all over the world.
Everywhere from Asia to South America and he specializes and
works in the relationship between health, population change and the environment.
So I thought it would be a beautiful place to sit down and
have a little discussion about these topics and why they are important.
Okay with you?
>> Great, looking forward to it.
>> All right, so first I just gotta, can I just, like, push you in?
[LAUGH] Now, how are we going to get over here.
All right.
>> Big step, big step.
>> Excellent, all right.
Kids, don't try this at home.
[LAUGH] All right.
You know Bill,
a lot of times when people think about global health they think about humans.
Right? Humans.
Biological, biological issues.
They don't necessarily think that there could be a relationship between human
health and various other factors which is population change in the world around us.
Now, I know that you were one of the people working to dispel this notion.
So, I'd love it if you would just take a few minutes and talk to the students about
why this interaction is so important and what impact it has on human health.
>> Yeah. Sure. So it's very common for
people to have a very anthropocen, anthropocentric view of the world.
>> Mm-hm.
>> Because we're people.
>> Right. >> So anything that we
are doing will ultimately effect ourselves.
>> Right. >> And so when you
think about global health, everyone always thinks about people first.
>> Right. >> The problem is that whenever you change
a landscape, you drive your car, you plug, you know your computer in to the wall or
you fly in an airplane, you're affecting something in the environment.
>> huh.
>> And so, you have to always think about those changes in the environment,
you have to adjust to as well.
>> Mm-hm. >> But not only yourself, but
the plants, the animals, the insects, all of those,
all the creatures on Earth are adjusting to the changes that we make.'
because we, we as humans produce the biggest changes to the enviornment.
>> huh.
>> Through mostly through agriculture urbanization other kind of things about
economic development and these changes really effect the way other species live.
And there is a very close relationship between how the health of
other species is related to the health of humans.
>> huh. >> So, we always have to think about it,
and it's, it's not just in tropical environments when you think
about varying infectious diseases, like Ebola, which is a big one.
>> Of course, yes.
>> But it can be very simple, like having a dog at your house.
Mm-hm.
>> Your dog interacts with the environment much differently in the way we
interact with the environment.
>> Huh. I hadn't thought about that.
>> So, that, you know?
They can in some ways introduce different diseases to
your home that you wouldn't normally think about.
>> Right, right, right.
And yeah.
I remember reading somewhere that actually dogs can get strep throat, and
it can be constantly passed between children and and dogs.
What are some, could you give us a couple of examples, of this issue,
perhaps using some of the research that you're doing in, in South America?
>> Sure.
well, let me give you one example that's,
just to connect to home a little bit more easily first.
>> good, okay. >> So, there are lots of studies on,
on pet ownership.
>> uh-huh.
>> And how there's this relationships of how pets often get ill before humans.
>> Really. >> So there's lots of case studies, for
example, in Connecticut, where dogs would have an unknown illness,
they have a rash, they start getting lethargic, and a pet owner,
and I, and I forget the name of the woman, but she brought the pet to the vet,
the vet did various tests on the animal trying to figure out what was going on,
they couldn't quite figure it out.
The pet kept on getting on getting and
ill, wasn't eating, was getting emaciated, and eventually the dog died.
And about four or five days later the, the woman started getting the same symptoms.
She was getting fever, lethargic she couldn't eat as well,
and the vet just by chance, did an autopsy on the dog and
found out that the dog had Rocky Mountain spotted fever.
They had tested it for lots of things.
>> Really?
huh. >> So the vet, by chance, and it was only
because the vet knew the MD that the woman was going to, called her physician,.
>> huh. >> and said,
We tested the dog positive for Rocky Mountain spotted fever, they did the tests
on the woman right away, that's what it was, she was treated and she was fine.
>> No kidding, so-
>> so, there's this, this relationship between humans and
animals that we can't forget.
In the Amazon, you know, my research deals with vector borne diseases.
We look at how toxicology things like
gold mining can affect mercury in the environment.
>> Mm-hm. >> And increases the amount of
mercury you can be exposed to, through bio accumulation of mercury in fish.
So, the mercury is,
is, is a very broad example because it can have a lot of impact on,
on ourselves, not just having toxicity, but it effects immune response.
>> Hm. >> It effects our heart functioning and,
and it, and it can effect the absorption of nutrition.
So, specifically iron, vitamin A,
folate, Vitamin B, all these things are affected by, by mercury so-
>> And these are all examples of micro,
common micronutrient deficiencies that have-
>> Exactly. Exactly. >> Physical and cognitive impact on children.
Uh-huh. >> So one of the things we see in our
studies is, we have one of the highest anemia rates in the Amazon.
>> And the area's not poor, but about 48 to 55% of,
of children under ten are severely anemic.
>> That high.
>> But, but these are not kids that are malnourished.
They're not stunted, they're not wasted.
There's actually about 15% are obese.
But they're anemic.
>> And anemic as well.
>> So then the question is, why are they not getting iron?
They have a fish diet, they eat meat,
they have a lot of peanuts in their like a peanut type of foods in their diet.
And so our our kind of hypothesis is that they are getting very low
chronic exposure to mercury because they eat fish but
it is not at a high level that would, set off alarms.
>> Right.
>> But it is a high enough level that it prevents absorption of iron.
>> Of iron.
>> And that very simple low exposure can cause massive effects as they grow older.
>> Mm-hm. >> So,
if they're anemic they eventually, they will have cognitive impairments.
>> Sure.
>> They will probably eventually become stunted as they hit their teen years.
>> Of course, right.
>> When they reach their full potential.
And it just, it, it puts a handicap on a population.
>> Sure, sure, sure.
And I would say also, especially with girls as well.
As they grow up, there are so, so
many issues with anemia among women, in many parts of the world, as well.
I wonder if some of the implications of your work would be to
look in other parts of the world for their, a lot of issues with, you know,
industry, manufacturing, or other things where there might be a lot of mercury and
see if they have women and children, in particular women were anemic at,
where there's more anemic, in those in those areas surrounding as well.
So it's interesting how this could translate.
>> Yeah. Yeah. >> Eventually from one area to, to, to, to the other as well.
>> I mean the, the gold mining example and the merc, merc gold mining to mercury is,
is probably isolated to areas that there is a lot of natural resource extraction.
>> Mm-hm huh.
>> I would say a more general example especially in
developing countries is agricultural production.
>> huh. >> So a lot of,
the theory of population environment deals with this idea that
you start out as a subsistence farmer.
>> Mm-hm. >> And
this is a household that is a nuclear household, husband, wife.
>> Right.
>> They might have a child.
>> Mm-hm.
>> In almost all situations the man is the one that is the head of household.
>> Right. >> The woman more than
likely does not have more than a primary education.
>> Mm-hm.
>> And because they are subsistence farmers usually what
happens is they don't have access to a large labor pool.
>> Right.
>> To help survive on the farm.
>> Sure. >> So
the only way to get labor is to have more children.
>> Ah-ha.
>> And if the woman is put pressure to have more
children that means she will have less opportunity to get education.
>> Right. >> Less opportunity to get other kinds of
technical skills that might also contribute to families.
>> Sure.
>> [CROSSTALK] This vicious cycle where she's reproducing and
having lots of children and she never quite gets herself out of
poverty because most of the evidence suggests that once families make this
decision of having more children, they, they don't break out of poverty.
>> Right.
>> It actually puts them into deeper poverty and so
we really need to work on this idea that or, or
kind of erase this idea that more children are better for someone.
>> Right. >> you, you really need to just invest in
the children that you have, invest in female education and, and
make sure that you know, the other sex in humans.
>> Right. >> Is actually as empowered as males are.
>> Sure, sure, sure and I guess that, that is going to be an increasing issue.
>> Huge issue. >> In the world yes, absolutely.
Absolutely.
And it's interesting that, you know, in class we talk a lot about,
determines health proximal and we talked about the web of causation and
how all, so many determinates, interact in multiple ways.
It seems to me that, your work which ranges from,
looking at toxicological, right, all the way to issues of,
of education and gender inequity, or a really good, good, good example of that.
Now do you see that is I mean as we know is with the issues of climate change.
We're going to see not only humans having an impact on, on the, the world but
the world's going to start looking different as well.
And what role do you think that climate change is
going to have on health and just on movement and how populations work?
>> So that's a very tough question.
[LAUGH] >> Guess I'm good at that.
Yes.
So no one really honestly knows how climate change is going to affect health.
>> huh. >> Most of
the impact from climate change is based on scenarios and models that,
you know, we know how to link climate variability with vector borne diseases.
>> Right.
>> So a lot of the evidence suggests that things like malaria, dengue, and
now Checkengunya.
>> Right. >> And other not just vector borne but
zoonotic diseases-
>> Right. >> that are spread by
animals will likely increase.
>> ha. >> Because you're going to
have a bigger interface between people and those environments.
>> Sure right.
>> The one thing that I think that is likely not well understood
not for the future and not for our history.
>> Mm-hm. >. Is how people will move.
>> hah. >> And migration.
I think, is something that is a response to climate change.
But it's also something that is not well understood at all.
So demographers.
I'm trained also in demography.
Demographers generally study international migration.
>> Mm-hm.
>> The problem with climate change-
>> Mm-hm.
>> Is that you will likely not only have international migration, but
you going to have a lot of internal migration.
>> Sure.
>> Internal migration is something that can be temporary, can be permanent,
either way, we don't know where people move in countries very often,
that data doesn't exist.
Determinates of international migration, yes, we,
we know that as a science pretty well.
But when we talk about how movement affects health,
international migration is kind of like,
I'm getting out of this situation, I'm moving to an entirely new country-
>> Right. >> With a different set of
social standards.
>> Right. Right.
>> Different type of infrastructure can give me support.
So that's different.
But if you're moving within country, you're,
you're staying within the same support mechanisms.
>> Right. >> You're likely still exposed to
the same environment, and you're still trying to keep your tie to your home.
>> Right. >> So, we're, in that sense,
your risks for poor health outcomes, I think, is higher.
>> Sure. >> Because you're trying to hold on to
what you had as well as adjust to the new
within your same country which is easier in some ways.
So I kind of feel like in our, in our data that we look at, internal migration and
specifically, malaria and dengue, we actually see the people who are temporary
labor migrants or people who are migrating because of the flood in their home,
they are at greatest risk for disease.
>> Uh-hm. >> It's not just malaria it's diarrhea,
malnutrition.
>> Right. >> And you name it.
>> Right. >> They're at greater risk for it.
People who have more resilience to changes, are obviously better off.
>> Sure. Right, right, right.
And I was thinking you know when you were talking about that what country.
Trees like, I don't know, Bangladesh, where so many people live on the coast.
Right? You have to,
if people end up migrating and have to migrate in, there can also
be as a population moves to a smaller space or changes,
changes to exactly where they are, there can be other things, increased competition
for food, water, maybe even more change in how the, how the land looks.
>> Yeah. >> Again, those are all,
I, I said we have known unknowns and unknown unknowns, right?
And that would be an unknown unknown.
You'd be busy.
Yeah. >> Well, it's funny.
I was teaching a course this summer, on sea level rise,
the impact on human health.
One of the things we looked at were a number of
people who lived five meters above sea level and ten meters above sea level, and
I can't remember the exact number but it was something like,
I want to say 150,000,000 people globally live five meters or less above sea level.
>> Really. >> More than likely all those people will
be displaced.
>> Yes.
>> And Bangladesh is one of the main countries.
There's a lot of areas around Egypt.
Surprisingly, Germany is going to be badly hit.
>> Germany?
>> You look at one of the main, I think it's the road that come out of Germany.
>> Yes.
>> The road is very well-leveled.
>> I did not know that, actually.
>> So if they, if you get a five, if you get a four meter rise in sea level,
the flooding goes all the way to Hamburg, which is 100 kilometers inland.
>> Absolutely.
Absolutely.
>> And it's amazing actually.
>> Yeah. >> So
when you talk about climate change and movement, it's not just the,
the poor countries that are going to get bacteria, it's, it's an everybody issue.
>> Great, great example of sort of intentional independence.
And really what global, global means, right?
Global is not just the global self and I assume even the the East Coast of
the United States, they'll be an impact as well.
>> Right. >> I don't know, we live in.
Door and maybe we'll have beachfront property one day.
>> Yeah.
>> Probably not.
>> Although North Carolina's got its own problems.
I mean, they, the legislature, I don't know if you want to talk politics but-
>> Please. Talk away.
>> Legislature, you know, they actually got rid of all the scenarios for
future climate change.
And they're requiring the predictions of climate change for North Carolina and
for planning, only to go out, I think it's a ten-year scenario.
So, they only want to plan out 10, or maybe it's 15 years.
I forget the cutoff.
>> Uh-huh. >> But, it's
a ridiculously short amount of time.
But the, the belief is that, I think the belief among the Republican
legislature is that we don't have have to plan out 50 years in advance.
>> Uh-huh. >> We can plan as we go.
>> I see.
>> I don't know if it does.
By my opinion is that's not a smart thing to do,
but different states are taking different strategies.
>> Sure. >> New York and
New Jersey are much more progressive-
>> I see. Mm hm. >> In their planning than, than we are,
from [INAUDIBLE] as well.
>> Mm hm. Yeah. Well, you know that, that's actually a good example that I
talk, I, I talk with the students a lot about Data, and the uses of data.
How data can be used, how it can be misused, how data can be aggregated
to the extent that it, obfuscates lots of issues it might affect,
say vulnerable populations or particular groups, but it's another point is that
intentionally, not collecting data, right, not making predictions,
can also help you escape and
not have to deal with things.
I don't know if you remember the the the cholera outbreak in South America,
right, in the early 1990s.
Well, in Venezuela of course, I was very worried about tourism at the time.
So, one of the things that happened was that they were there was one point in
the the crisis was really hitting me in the indigenous population that you
could not, nothing counted as cholera unless there was a confirming test,
laboratory test.
But the Ministry reviews the say, any equipment, to do the test.
So, cholera rates dropped.
Right? I mean this is,
these are the stories I just go again, and again, and
again, global north, global south, you know, exactly.
I, also, I know, just from, you know, talking with you,
hanging out with you drinking with you that you are also very interested.
>> Don't drink.
>> Don't drink.
Don't drink, kids.
>> [LAUGH] >> Save it for us.
That you're very interested and actively involved in, in the issue of
translational or translation medicine translation to science.
This is a term that students hear a lot.
I wonder if you would explain exactly what that is, why that's important?
And give us some examples.
I know I ask translational [INAUDIBLE], or translational research.
>> [INAUDIBLE].
>> And I think everyone has their own definition of
what translational research means.
>> I see. >> I mean, to me,
I kind of feel like translational research just means something that
you can directly apply to policy.
>> ha, okay.
>> and, I, I, I feel like, kind of like the word global health,
which is public health, translational research and translational medicine is
a way to get more money for things that we've already been doing.
>> Aha! Right.
>> Which is trying to evoke policy to promote public health.
>> huh. >> And to promote human-
>> Right. >> Welfare and environmental welfare.
so, you know, in my own examples, for example you know,
we produce we are trying to produce very simple tools for
people in the improving Amazon to choose fish that they can consume that are safe.
>> Aha.
>> And so very simple codes on vectors of carnivorous,
first non-carnivorous fish which we clearly show in some of our papers that
the carnivorous fish are extremely toxic in terms of, being exposed to mercury.
>> I see. >> Whereas, the non-carnivorous ones have
a much lower probability of exposing you to mercury.
>> Right. >> So, in a way,
I view that as translational research.
>> Right. Yeah, right.
>> We work with. The history of health.
We help produce some of the posters that they're using to advertise and
help post and give out to families.
So that, that's kind of how I do it.
>> Sure, yeah.
>> That's how I think of translation.
>> Right, well, that, that makes a lot of-
Right? Because it's,
it's right to move from one place to the other.
It, it's like the shift that we talk, you just talk about a lot in, in,
in in public health and instead of you know, health research, right?
We do reasearch for health, like we really want to take what we learn,
take the research, get it on the ground, see if we can work, get it to work, and
then scale it out.
But I like the example that you just gave about.
Out, something as how effective something as
simple as having photographs in codes, you know, can, can be.
Because also when we think about doing things on
the ground we think about improving global health, think a lot about technology and
innovation, but you know, not all innovation, is high-tech.
>> Right? >> I tell the students we
need to absolutely innovate, but
also you have, have better utilization of things that we already know.
And you just gave a really, really.
>> Yeah. >> Effective example.
>> Innovation doesn't have to require a new technology.
>> Right. >> Yeah.
>> Right, right, right, right.
[INAUDIBLE]. >> And especially, I mean,
you need to come up with innovations that are technology-free.
Right.
>> Because most of the people that we work with overseas in
poor countries don't have it.
>> Exactly.
>> And they can't get access to that, so.
>> Right. >> We need to make simple, I guess,
old-school solutions from when you were young.
>> [LAUGH] >> On communicating ideas.
[LAUGH] >> Just rub it in.
You're older than I.
No, I'm older than you are.
Rub it in.
Okay.
After the video I'm drowning him in the lake.
Just letting you know that.
>> [LAUGH].
>> No, it's, it's, it's, it's, it's true. Right?
So, yeah, so those old floppy discs and
eight tracks I used to use probably won't have any-
>> No, no. >> Any role in the, in the future.
>> No. >> [LAUGH].
Yeah, it's really interesting.
Now, you, you mentioned a couple of other things.
You mentioned, chikun, chikungunya, which now, of course, is in the Caribbean.
>> Right.
>> you, I remember we talked about malaria.
I don't know
if you mentioned dengue or not >> Right.
>> But you know I remember, in the early 80s, there, had,
there was not a dengue problem in Latin America.
There was a lot of chagas.
>> Yeah. >> But not so much dengue.
Pretty much been brought, brought under control and
now it seems that it spread almost everywhere.
>> Everywhere.
>> As well.
>> Yeah.
>> How did that come about?
And is that, is the story of that-
>> So- >> Related to your work in any-
>> It is.
>> Way? >> It is.
So one of the things that has happened.
Over the past, I'd say 20 years in Latin America especially,
is the rapid rate of organization.
>> Mm-hm.
>> So prior to 1990,
there was only I think two cities in the Amazon that had over a million people.
>> Uh-huh.
>> By 1995, I think there were four.
By 2000, I think there were seven.
And, and now the Brazilian Amazon is I think it's 70% urbanized.
>> I actually did not realize that.
>> I can say it's that's a wrong statement.
I should say 70% of the population live in urban areas.
>> In an urban area.
>> That's another way to say it.
But, whereas in Peru you still have.
Maybe it's closer to 40% urbanization in Ecuador also maybe it's closer to 39%.
>> Mm-hm. >> But that rates are going up.
>> Dengue is is spread by Aedes aegypti.
Aedes aegypti is a urban mosquito.
>> Uh-huh.
>> It exists in the back yard, tires, flower pots,
you know, it's associated with human construction.
>> Right.
>> And you can actually see as, as for example, sitting in or
in You can actually see the clear trend of increasing human population density or
size, with the number of, with the incidents that they gave.
It's, with more people obviously you have more cases.
But, now that you have even more people living in Iquitos,
you have these cycles that occur every couple of years where you
have these enormous outbreaks where 60,000 people will be-
>> Hm. >> Diagnosed with dengue.
>> Right.
>> And then it kind of goes away.
>> Interesting. >> Where it fluctuates between-
>> Hm. >> Ten and twenty thousand per year.
>> I see. >> And then you get this jump again.
>> Aha.
>> In Puerto Maldonado where, where we work and
we're based now, before 2004, there was zero cases.
Then the mosquito didn't exist.
>> Zero. >> Zero, zero cases.
2005, they had about 15 cases.
Most of them were imported, probably from Brazil.
But the thing that happened was in 2005, they began construction of
the inter-ocean highway and so you had more migrant workers coming in-
>> Right. >> To help build the roads.
That construction went on from 2005 to 2011.
>> Mm-hm. >> And the case rates for dengue went from
20 people in 2005 to 100 people by 2007 to 500 people by 2010.
>> Mm-hm. >> And now it's over 5,000 people.
>> Big num. That's, that are getting.
>> Wow. >> diagnosed ju and
gideon in the past year.
And so the rains that they're going up exponentially and you know
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