Public Health is Diplomacy.
There is a joke in China that the North Korean’s have two weapons of mass destruction: nukes and tuberculosis (TB). And not just TB, but multidrug resistant TB – which knows no boundaries or borders, and is spread person-to-person through the air. The country is also experiencing exceptionally high rates of malaria and hepatitis B.
While diplomatic efforts with the country focus on denuclearization, the country poses much more of a global deadly force and significant security concern than just nuclear weapons. Despite claims from North Korean media that the country developed a cure-all drug that has eradicated HIV/Aids, cancer and Ebola from the entire country, the truth is that there are millions of lives hanging in the balance, needing access to basic necessities like clean water, food and vaccinations.
Immune To Drugs: How Antimicrobial Resistance Could Kill 10 Million A Year Globally If Nothing Is Done
The Centers for Disease Control and Prevention (CDC) contends that, “Antibiotic resistance is one of the greatest public health challenges of our time.” And it’s true. Bacteria, viruses and parasites are growing evermore resistant to the drugs that have been developed to combat them. In fact, this resistance – antimicrobial resistance – has surged into a public health nightmare around the world.
Annually, at least 700,000 people die from drug-resistant diseases, and that number is expected to increase to 10 million deaths per year by 2050 if nothing is done. And at present, the incentives to get something done are so misaligned it’s a frightening possibility.
Because of this growing emergency, the United Nations created the Interagency Coordinating Group on Antimicrobial Resistance, and published a report with international agencies and experts noting that without immediate global action, the crisis of drug resistance bacteria and viruses could lead to an economic catastrophe as bad as the 2008-2009 global financial crisis, and by 2030 could force as many as 24 million people into poverty.
And it hits home more often than we know. In the U.S., antimicrobial resistance causes more than 2 million infections and 23,000 deaths per year – the equivalent of a Boeing 747 crashing each week. Financially, it is projected that due to lost wages, hospital stays and premature death, the U.S. lost about $35 billion in 2008 to antibiotic-resistant infections, and this number continues to rise.
And sadly, there is no slowdown in sight, as more and more antibiotics lose their effectiveness each year. And there are many reasons for this crisis including overprescribing, hospital breeding grounds, plant and water supply contamination, and lack of new research.
When thinking about traumatic brain injuries (TBI), most people immediately conjure images of NFL players, car accidents or nasty falls. But there is a global public health epidemic going completely unrecognized – and untreated: intimate partner violence (IPV). In fact, IPV is the most common form of violence against women in the world, with nearly 1 in 3 women age 15 or older experiencing physical or sexual IPV. And it occurs in all settings, amongst all socioeconomic, religious and cultural groups.
Shockingly, up to 90% of injuries sustained in IPV are to the head, face, and neck. And research has shown that 75% of women with a history of IPV sustained at least one partner-related TBI and nearly 50% sustained repetitive TBIs. Thus, it is sadly not surprising that the women who experience IPV report symptoms consistent with those who have sustained TBIs, such as problems with, “concentration, memory, headaches, depression, anxiety, fatigue, and sleep.”
According to Eve Valera, Ph.D., “The number of women sustaining IPV-related TBIs dwarf the combined number of military and NFL TBIs or concussions reported. Using annual estimates of severe physical violence (totaling 3,200,000 women), about 1,600,000 women are estimated to sustain repetitive IPV-related TBIs in comparison to the total annual numbers of TBIs reported for the military and NFL (18,000 and 281, respectively).” While she suggests that we need to learn more about all of these cohorts, she points out that there are only two IPV/TBI imaging studies published, compared to the growing body of literature on TBI in athletes and military populations. And she should know, because both of those studies are hers.
But what makes this epidemic so difficult to understand, is much greater than just a lack of research on brain injuries. The truth is, there are a number of confounding factors at play including a general lack of research on women, and thus extreme underrepresentation of sex and gender differences that exist in brain injury. Add in that women who suffer from IPV are often unable to join research studies either due to fear of their partner, societal stigma associated with domestic violence, or simply a lack of resources in their daily lives.
While IPV affects all socioeconomic strata, according to the Prevention Institute there is a multifaceted set of risk factors including, poverty, social marginalization, weak social support networks, gender and cultural norms that promote harming others that frequently accompany IPV – making resources and access to care and research extremely limited. Additionally, because domestic violence happens behind closed doors, many individuals are unwilling to get involved in what happens in other people’s homes.
"If brain injury is the “invisible illness” of our time, then within this invisible injury, women have been the invisible patients,” says Katherine Snedaker, Founder and Executive Director of PINK Concussions. And the data support Snedaker’s statement. Even if some estimates were overstated, and as few as half (50%) of women who are exposed to IPV suffer TBIs, that would still be one in every eight women – the same statistic as breast cancer. Yet we have very little existing knowledge and research exploring this intersection.
Although very little research has been done on the repetitive damage of IPV and TBI, the number of research faculty around the world is growing. And like Lin Haag and Dr. Valera, their voices are gaining volume and their body of work is growing. There is also a growing awareness amongst the general population that invisible injuries – whether sustained on the battlefield or the sport field – are real and dangerous. And they can be life changing due to the cognitive, emotional and physical challenges associated with a TBI. The next step is making this same realization for women survivors of IPV-related TBI.
Improvements in combating stigma and shame associated with IPV are also making small strides in communities of every religion, race and socioeconomic strata, as mental health efforts grow in number. This also includes training community workers, shelter employees and medical staff to recognize the signs of TBI earlier – and be looking for it in women who present with complaints about cognitive troubles or behavior associated with trauma. Attempting to do just that, Lin Haag, Dr. Colantonio and their team, are just completing a web-based toolkit educating frontline workers about TBI in women exposed to IPV. And, as Dr. Valera hopes, that the education of police forces and judges will make a significant difference in the lives of women and their children. “As first responders and judicial personnel learn to ask about and recognize IPV-related TBI, women’s behaviors may be interpreted in the context of a TBI that occurred behind closed doors rather than simply ‘strange’ or ‘uncooperative’. This interpretation will ultimately help women receive appropriate care and legal decisions.”
All the women in this article are open to being contacted by those with questions about IPV, TBI or how to get involved in their research. If you’re a survivor of intimate partner violence, there is a 24/7 hotline and online resource where you can get help here.
As we become more comfortable with at-home DNA testing kits and allowing companies to assess our biological makeup, the market continues to shift in a variety of ways including the types of diseases and disorders that can be tested, how accurate the tests are, and the amount of information shared – which can include selling your data to third parties. And this should concern us for a number of reasons ranging from blatant privacy concerns to subtle discrimination by insurance companies to emotional distress caused by unexpected results and misunderstood results.
Thus, before you mail in that DNA sample, here are some very important things for you (and your family) to consider.
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In recent weeks suicide has been written about extensively in the United States, with high profile individuals giving a renewed focus to the tragic loss of life, taken by one’s own hands. And while advocates and educators of mental health care are doing their best to use these tragedies to save countless other lives, the conversation appears to get continually lost in the sordid details of celebrity and scandal.
But with new data just released in the U.K. and global efforts garnering traction in the most wide-ranging geographies in the world, it is time to take a step back and refocus on the global epidemicthat is suicide. Especially among the world’s young people.
Here are some key takeaways for better understanding how large of a global health problem suicide really is:
- According to the CDC, the link between suicide and mental disorders - in particular, depression and alcohol use disorders - is well established in high-income countries like the U.S. However, “many suicides happen impulsively in moments of crisis with a breakdown in the ability to deal with life stresses, such as financial problems, relationship break-up or chronic pain and illness,” in all countries in the world, and are on the rise.
- Suicide is the 2nd leading cause of death globally for 15-29 year-olds, and at record breaking levels for students in high income countries, especially among students. Researchers concluded that the suicide rate among U.K. students has risen by 56% between 2007 and 2016. Although it is important to remember that the number of students has also changed in that period, making it difficult to accurately know the increase.
- An alarming 78% of suicides occur in low-and middle-income countries. Moreover, it is estimated that around 30% of suicides in low- and middle-income countries are via self-poisoning with pesticides. Most of which occur in rural, agricultural areas.
- The Japanese, despite being a very high income country and having a population less than half the size of the United States (126 million compared to the United States' 275 million), has the same number of suicides annually.
- In 2017, former Surgeon General Vivek Murthy asserted that loneliness was a growing health epidemic related to loss of life. He cited a study that contends social isolation is associated with a “reduction in lifespan similar to that caused by smoking 15 cigarettes a day,” or long-term illness.
- The U.K. has just appointed the world’s 1st Minister for Loneliness. The country leadership was stunned when reports came out last year from the Jo Cox Commission on Loneliness, more than 9 million people in Britain alone (about 14% of the population) admitted they often or always feel lonely. And, that the impact costs U.K. employers up to $3.5 billion (USD) annually, in addition to high levels of suicide across age groups.
Although any and all efforts to curb mental and physical health problems associated with suicide are important, it is clear that around the world, efforts are collectively falling short. The taking of one’s life is not a rich or poor problem, nor is it a cultural phenomenon. It is pervasive across every society and region of the world, and only getting worse. It’s time we stop thinking about suicide as individual acts, and begin thinking about the health of the human race.
In recent months, small amounts of information about the state of the North Korea's health system have made their way out of the country. And the data points have gone from bad to worse to revisiting accusations of massive human rights violations. While there is no more vital diplomatic effort in the world today than the denuclearization of North Korea, there is a second deadly force at play for the country’s more than 25 million citizens: health. And that means health security concerns for the rest of the world.
North Korea, officially the Democratic People's Republic of Korea, has undoubtedly faced many natural and man-made disasters in recent decades, but the greatest of which appear to stem from the economic collapse in the 1990s and subsequent deterioration of the citizens in the country. Since that time there has been a sharp decline in life expectancy – 12 years less than their genetic peers in South Korea. The North Koreans are also estimated to be 1-3 inches shorter than South Koreans, primarily due to chronic malnutrition and extreme poverty. At The Center for Strategic & International Studies (CSIS), experts contend that health decline is a direct result of choices and priorities made distinctly by the Kim family to create politically defined castes and introduce famine to the masses so that military efforts could be funded.
So, despite claims from North Korean media that the country developed a cure-all drug that had eradicated HIV/Aids, Cancer and Ebola from the entire country, the truth is that there are millions of lives hanging in the balance, needing access to basic necessities like clean water, food and vaccinations. And without those, an estimated 60,000 children will starve, millions of adults will live with communicable diseases other regions of the world have eradicated, and the world will continue to fight weapons that are only a part of the larger problem.
But why is global health so important for national security?
To understand a culture and a people, you must understand more than the military – which is what most of the world seeks to understand about North Korea. Nuclear and biological weapons are of global security priority. But the focus cannot be limited to those weapons alone. It must also be on the status of the citizens, culture, economy, and most importantly, what happens during and after the Kim dynasty? What happens to North Koreans now, could have global implications when they leave their country’s boarders in the near future.
There is a joke in China that the North Korean’s have two weapons of mass destruction, nukes and tuberculosis (TB). And not just TB, but multidrug resistant TB, which knows no boundaries or borders, and is spread person to person through the air. The country is also experiencing exceptionally high rates of malaria and hepatitis B. While many health-related organizations have been able to skirt restrictions about entering the country for the purposes of health care, all signs point to a growing number of destructive diseases and shrinking number of professionals that can help. Which in turn means a growing body of diseases and human destruction just waiting to spill over the North Korean borders.
In fact, multiple sources have confirmed over the years that the political regime had strategically used food and starvation as tactics to control the people and get the United Nations and other visiting personnel to see whatever the North Korean elite wanted them to see. However, an early 2018 defector gave the world some insights into the status of the people, including the military, as it stands today. The soldier in question was cared for after crossing into South Korea with multiple bullet wounds. But what doctors found inside the man shocked even the most experienced doctors: dozens of parasites in his intestines and roundworms up to a foot long. It is believed that because North Korea does not have chemical fertilizer, farmers use human excrement – infamous for spreading parasites like the ones in the defectors stomach.
Can diplomacy make a difference?
Though humanitarian exemptions are written into all sanctions against North Korea, recent years have seen mass exodus (ie: voluntary departures and expulsion) of nonprofit, nongovernmental and aid organizations because basic principles of humanitarian action were forbidden. Even banking transfer systems have collapsed. And it’s been consistently reported by organizations like Medecins Sans Frontieres/Doctors Without Borders that for decades medical supplies and food aid were not delivered to those who needed it. As recently as last month (April 2018) commodities funneled through China have been met with resistance, and the Global Fund reached a breaking point, declaring that it will be pulling out of the country within weeks.
When more than 40% of citizens (10.5 million people) are considered undernourished, and millions more have little food, humanitarian aid could go a long way in fighting the health decay of North Koreans. Further, it could foster a cultural revolution – and build trust - within the common people, as well as lead to health, education and job opportunities to help increase the average yearly income is North Korea – currently just over $1,000 a year. But as it stands, neither South Korea or China are really prepared for the health insecurity, ramifications of North Koreans crossing their borders. That said, so long as North Korea focuses
However, as President Trump and Kim Jong-Un prepare for a potential meeting to discuss nuclear disarmament, the implications for global health hang in the balance. Without a meeting, and without compromise, the situation is North Korea will likely grow worse. UN and humanitarian efforts will continue to be scaled back (meaning even less food, clean water and medical aid), and multidrug resistant TB and malaria stand to spread rapidly across the nation. Conversely, if diplomacy prevails – or talks are even allowed to advance – sanctions against North Korea could be decreased, and a flood of humanitarian aid and health care could enter the country.
Although North Korea’s health decay appears to be truly horrific and dangerous to the outside world, the truth is that for most of the country, health data is not available. Hopes are that in the coming months, real change is possible, and the world gets a better understanding of life, death and disease in North Korea.
The introduction of smart devices and connectivity has made many of life’s activities easier. However, sharing ones information – even through one device or app – means that many third-party organizations and potential threats have access to information they previously did not. Digital medicine has grown leaps and bounds in the last five years, and the next five are unpredictable. Yet, the one thing we can count on is that as technology moves into the body and brain, the data we collect and share will become more and more valuable, as well as more and more accessible.
This will introduce a whole new assessment of what privacy means, and how to secure the information collected.
The Risks Are High
Security and privacy are a foundational component of digital medicine’s future, and we must begin looking at the wide-range of implications that data and technology will have in the health arena. When telecommunications and remote monitoring are pillars of digital medicine’s ease of use and improved patient adherence, we know the trends are here to stay. And, as new technologies emerge, they will certainly be faster, cheaper and better for patients. But they will also be ripe for hacking and disruption as communication channels increase exponentially and storage moves to the cloud.
In addition to individual data collection, we cannot forget that hospitals, clinics, communities and governments collect data about our day-to-day activities through the same devices. Recently, several hospitals across the U.S. were hacked using RansomWare – leading those hospital systems to pay large ransoms to get their own patient data beck.
With sensors, ingestibles, remote monitoring and cell-based data looking like leaders of the pack in the near future, consumers (patients, providers and payers) must be concerned about the amount of information that is at risk. And those recent attacks have proven that our care providers are not prepared.
Partnerships Are Key
Health providers must make data security a top priority, but so too must entrepreneurs in the health space. Digital medicine companies need a business strategy to ensure their innovative ideas will get to market while protecting their users. Because of the ever-changing nature of health technology, working with other industry stakeholders to protect information will have the biggest impact.
Connections and collaboration with various decision makers and investors from the life sciences sector can make all the difference. In January those attending the Digital Medicine Showcase in San Francisco and CES in Las Vegas will get a taste of what those best alliances could look like.
One of those forward-thinking partnerships was announced this week. Qualcomm has linked the American Heart Association (AHA), the American Medical Association (AMA), DHX Group, and the Healthcare Information and Management Systems Society (HIMSS) to revamp a multi-stakeholder collaborative nonprofit – Xcertia - dedicated to improving the quality, safety, and effectiveness of mobile health apps. Xcertia's membership and governing board will be open to broad representation from consumers, developers, payers, clinicians, academia and others with an interest in the development of guidelines, best practices and security of mobile health tech.
Solutions Are Limited
At present, health technology is evolving so fast that regulating bodies and practitioners cannot keep up. Further, closed systems means that pharma, med device and research organizations do not share their information in ways that lead to collaborative data protection.
However, as open source technology increases, government agencies require shared information, and new partnership models emerge, the ability for new problems to appear also mean new solutions will arise. One way for protecting telecommunications and data is the emerging 5G – a network system that is much faster, has a higher capacity and much lower latency than existing systems. But again, this is not currently available to all.
Although data glitches, breaches, hacks and loss are nothing new, the potential threats of the coming five years are unparalleled. Greater amounts of information – no matter how convenient - mean that consumers must be acutely aware of the impact that violations could have. As 2017 begins, thought leaders and innovators need to turn their attention to security and privacy in all new ways. And patients need to hold their providers accountable, while simultaneously being proactive I protecting their own information and health.
The health care sector does not behave like other industries when it comes to money. First, attracting investors – especially in the early stages - is minimal, and the odds of capitalizing on a blockbuster drug or device is becoming ever slimmer. Second, because the U.S. health system does not incentivize it, payers do not rush to financially support or reimburse the waves of new technologies flooding the market. Third, companies entering the market often fail to stand out from the noise of competitors, meaning that getting noticed by investors or being able to commercialize well is near impossible.
In fact, according to Asher Rubin, Global Head of the Life Sciences and Healthcare Industry Team of Hogan Lovells, when separating the tools from the toys in digital medicine, some of the first questions asked by potential investors are, “How will it be approved, or not? How will it be reimbursed? And will the industry even care enough to pay?” Therefore, health investors remain risk averse - and if the recent past has taught us anything, it’s that there are far too many options and an ever-changing industry that will ensure this trend continues.
Because landscape transformations due to technological advancements and policy shifts have made health care financing a Wild West compared to other industries, products and devices of real value have a hard time communicating their importance above the noise. The upside is that the products, devices and apps of impact have led to digital health and medicine progress in the last five years, attracting potential investors and payers. But the downside is that there are so many new items making similar claims, even the experts can’t determine the difference.
At the recent Digital Medicine Connect conference in Boston, VC’s claimed they see the value in getting ahead of growing trends like digital health and mobile medicine. But, they are taking cues from third-party payers like insurance companies (particularly in states with one primary insurer like Blue Cross Blue Shield or Kaiser) to see where the returns might come from.
They are also searching for products that are ready to be commercialized to the public, and past the R&D trials, as they are more likely to succeed. This means being funded early is very difficult for startups. That is, unless they embrace the new world where M&A is replacing R&D, and the startup is willing to go in as a partner with the investor for commercialization. And we’ve been seeing this more frequently as larger company’s like J&J and Google are willing to put money into supporting health startups, but also partnering with them to roll out packages of products.
While VCs have never played in the health sector the way they traditionally do, the importance, interest and potential gain in the emergent health tech space is proving that they make good partners. And for startups, partnering with investors in novel ways can create all kinds of new opportunities to learn from their expertize. Not only from financial investment, but also mentorship, network, intellectual property and contributions to help make commercialization successful in today’s market. Which in turn decrease the risk for third-party payers and those who reimburse for new technologies.
With the Midwest relying increasingly on foreign-born healthcare professionals to fill critical labor gaps, a new study by the Chicago Council on Global Affairs finds that urgent immigration reforms are needed to ensure the future vitality of the healthcare sector. Updating visa allocations for foreign-born graduates from US medical schools, removing H-1B visa quotas and caps for healthcare professionals, and streamlining credentialing processes for foreign-born professionals would help the United States, and the Midwest in particular, mitigate acute shortages of healthcare workers just as the aging baby boomer population is expected to demand increasing resources.
The healthcare sector, which is fundamental to the U.S. economy and livability, is under strain:
A continued political stalemate on immigration reform means these issues will only grow in urgency. The report argues that Congress should work urgently with the next Administration to update policies to: