Why Global Health Research Matters for U.S. Health

Transcript

[Sandro Galea]
Welcome to Ideas Matter, a podcast hosted by WashU. I’m Sandro Galea. Global health is by definition about supporting the health of people everywhere, including right here in the United States. Yet the link between health abroad and home can sometimes be unclear, leaving global health vulnerable to political headwinds. Recent disinvestment in global health research and institutions reflect this.

Why does global health matter for health in this country? What kind of return should we expect on our global health investment? And what kind of return are we getting? How can we reimagine global health to meet the challenges and opportunities of this moment? I look forward to discussing these questions with today’s guest. Joshua Ehrlich is the Paul Lichter Research Professor of Ophthalmology and Research Associate Professor in the Institute for Social Research at the University of Michigan. He’s also an associate director of the UM Center for Global Health Equity. I’m pleased to be having him with us today. Josh, welcome.

[Josh Ehrlich]
Thanks, Sandro. It’s really such a pleasure to be having this conversation with you today, particularly on a topic that I know is near and dear to your heart and that you’ve done so much important work on.

[Sandro Galea]
Thank you. So let’s start by talking about you. So how did you, what was your path? How did you become involved in global health?

[Josh Ehrlich]
Yeah, I would say my path to global health really goes all the way back to my time at your current institution, at WashU, when I when I was studying anthropology. And anthropology sort of introduced me to issues of health across cultures, conceptions of illness and well-being across culture. And it was through a circuitous route from anthropology that I ultimately wound up going to medical school and then to public health school. But I think one of the things that I always took with me from WashU and from anthropology was this grounding in the social sciences, a proclivity to bring the social sciences with me to bear on issues of health.

And it was really through anthropology that my eyes were open to many of these issues that continue to drive me. On the one hand, these issues of vast global inequities and problems that can tangibly be solved to make the world a better place, and on the other hand, a deep appreciation for just how diverse the world is, which personally, I find to be stimulating and find that it makes life sort of a richer, more interesting experience.
I wound up specializing, coming out of medical school, in ophthalmology, which to some seems sort of a peculiar choice for a global health person. But it turns out that blindness and vision impairment are these enormous issues that are largely addressable through public health interventions and that tend to affect older adults in low and middle income countries and that’s precisely where much of my research has gravitated to is global aging.

[Sandro Galea]
Let me broaden the lens. Let’s talk about global health broadly. I’m gonna ask a very big question. We are in a moment of some turmoil, but tell us from your perspective, what’s the state of global health at the moment? What are the big challenges and opportunities you’re seeing?

[Josh Ehrlich]
Yeah, it’s I think it’s an understatement to say that global health is being stressed at the current moment. Certainly that’s the case. And I think this is the result of quite a number of simultaneous stressors, including decreasing financial resources, but also a leadership void, and also a retreat from global cooperation and from multilateralism. But this moment, even if we didn’t ask for it and would prefer to wish it away, I think also does have to be seen as an opportunity.

You know, if we look historically kind of outside of global health, there are many stressors that we can look to; war, political upheaval, economic downturns, that have acted for catalysts for positive transformation. World War II, a prime example. You look at the GI Bill or the Marshall Plan, and we saw an economic boom, women entering the workplace en masse, ensuing civil rights movements. My hope is that we emerged from the very challenging time we’re facing in global health through some hard work, but more resilient than we have ever been, hopefully not taking the path of least resistance, which would be superficial and rhetorical reform, but taking the path that requires a bit more hard work to really reform institutions in meaningful ways.

[Sandro Galea]
You know, I appreciate that you’re taking the moment to say it’s gonna lead to hard work to be done. So perhaps it ties into what I want to ask you next. So to what extent do you think that some of these challenges reflect a sense that the global health enterprise, be it research, be it practice, would benefit if we understood that this actually benefits the U.S. as well as the rest of the world? Or to what extent has the challenges come from a sense that the world is benefiting at the expense of this country?

[Josh Ehrlich]
It’s a great question. You know, I think that the way you just articulated has certainly been a dominant thread in the discourse, right? That the global investment is at the expense of investment in the U.S. I don’t believe there’s actually a lot of truth to that critique. There may be idiosyncratic examples that support that posture, but I would argue that those exceptions don’t prove any rule. And that unfortunately those arguments tend to be rooted more in ideology than in empirical data or true experience.

First and foremost, most global health funding from high-income countries, the U.S. included, actually stays in high-income countries. By some estimates, as much as 90%, and we could discuss whether that’s appropriate or not. But under this system, it’s certainly creating jobs, it’s driving further private sector investment in those same high-income countries. There’s also a lot of innovation that we’re all benefiting from that’s created in low and middle-income countries through high-income country investment in global health. Vaccines that were developed for malaria and Ebola provided the same platforms that have been used to develop COVID and RSV and shingles vaccines that we benefit from here in the United States.

A tuberculosis vaccine is now the basis for bladder cancer treatment. And we have parasitic drugs to treat parasitic infections like river blindness that are now used to treat rosacea. So I strongly support open dialogue and including contrarian viewpoints in that dialogue, but I think it’s critical that we also cut through ideology and actually look at facts. And the economic and health benefits of these investments is actually quite vast for the United States. It’s, I think if we care to look, it’s actually money well spent.

[Sandro Galea]
Those are some really excellent, concrete examples. Thank you. You know, before the pandemic, I used to in my talks give the example of infectious disease outbreaks as a case where we can all recognize that our health is interconnected. Now the pandemic happened, COVID happened, and what emerged from COVID is not that lesson at all. I was just wrong. We did not learn from the pandemic that our health isn’t interconnected.

In some respects, the backlash to COVID seems to have led us to a place of renewed support for disinvesting from each other. So what happened? Why did this obvious example that should have taught us that health for you is better for my health seems to have led us down this path where we are trying to separate ourselves on the wrong assumption that we can partition off somehow your health from my health?

[Josh Ehrlich]
Yeah, you know, it’s interesting. I would push back on one little part of what you just said. I do think we learned that we’re very interconnected. I just think that we are implementing those lessons in foolhardy ways. You know, we can we can look at the current response to the Ebola epidemic in Central Africa, and certainly there’s a sense that we’re interconnected, and that’s why we’re closing down borders, for example.
So I think that interconnectedness is understood. I think it’s operationalized in maladaptive ways, perhaps. I think we can’t ignore the fact that concurrent with the pandemic, but also preceding and succeeding the pandemic, politics obviously entered the picture in a very big way, and a distrust of institutions and nationalism certainly acted as strong counter forces.

Some of that though, I think, we have to be self reflective. We have to look as a scientific community. I think during the pandemic, our community, the scientific community, was sometimes a bit dogmatic and not open to kind of honest, and I’ve heard you speak about this, honest discourse about autonomy and trade-offs. And I think in some ways this created a bit of a void that somebody was bound to fill, right? A void in sort of that discourse. And in this instance it was filled by sort of an anti-science, anti-intellectual rhetoric that has unfortunately stayed with us.

You know, I hold hope that as a community we’ll coalesce around some of the important lessons that the pandemic, you know, taught us and and may still teach us. I think if you look at history, we could look, say, to the HIV and AIDS epidemic of the 1980s and early 1990s, and there was an enormous amount of politicization and stigmatization at that time. But public health and society more broadly, I think over time has learned lessons from some of the mistakes of that era. Whether we’ll get there in this sort of post-COVID era, I think really remains to be seen, I suppose in a more precarious position than we perhaps were at that point.

[Sandro Galea]
Yeah. Tell us about, let’s talk about health inequities. You’re at the UM Center for Global Health Inequity. So how does global health research help us understand and even perhaps address health inequities in the U.S.? For example, interventions that could be adapted for underserved communities here?

[Josh Ehrlich]
Yeah, yeah, I’m glad you asked that question. There’s so much innovation going on all over the world. And unfortunately, I think we tend to sort of reflexively think about innovation as diffusing from higher income to lower income settings. And this has probably stymied a lot of opportunity for us to learn and adapt highly effective low-cost interventions for underserved populations in the United States and for disrupting inequities.

The reality, of course, is that innovation should be reciprocal. And broadly speaking, I think disease screening is one of these areas where we’ve seen a lot of innovation in lower income, middle income settings that could really make a difference in thinking about how to address health equity here at home. I’ll give you a couple examples. One example of screening is using low-cost models for detecting diabetic retinopathy that have been pioneered in India.

Some of these approaches even use artificial intelligence-based image analysis and point of care to determine who has disease and who doesn’t. We’re now actually seeing these same models pioneered in India implemented in some parts of the United States, particularly for rural populations, including in the Veterans Administration, Veterans Affairs hospital system. It’s not screening, but we’re also seeing randomized trials coming out of India also that are showing that investments in simple health interventions like vision correction have an enormous return on investment.
While we’ve not done similar work here in the U.S. yet, this kind of work could be framed as valuable health intervention work and smart investments for underserved communities. I’ll give you a third example: community health workers are an innovation that was born in low and middle income countries to extend the reach of primary care, as well as for specific purposes like implementation of directly observed therapy for tuberculosis.

And now we’re seeing actually implementation of community health worker models in places like right here in Michigan. We have a community health worker alliance. And this is extending the reach of practitioners and people, particularly for rural communities. So I think there’s a lot of this concept of looking beyond our borders and even beyond high-income countries for innovation, has and will continue to pay huge dividends so long as we don’t restrict our worldview. I think there’s real opportunities to really learn and to address inequities in that fashion.

[Sandro Galea]
You make a really compelling case for, with specific examples, about how global health lens, the global health research, global health perspectives can really inform what we do in the US, which is commendable. Talk us through similar examples around health systems. What can global health research and work teach us about building stronger primary care systems and what can it teach us about what kind of care models we can adopt?

[Josh Ehrlich]
Yeah, yeah. You know it’s an interesting question. And I think when we look at primary health care, it’s not traditionally been the area where I would say the U.S. is known for excelling. Although there are some exceptions there. The U.S. actually is a high performer when it comes to certain cancer screenings and vaccinations, and some of that may be related to pay-for-performance incentives. But there are other areas of primary health care where clearly the United States is at a disadvantage relative to other high income country systems.

When we think about this, the idea of this global mirror… The Commonwealth Fund does a great series of reports called Mirror Mirror, where they leverage this idea of the global mirror and compare the United States and a whole slew of other high-income healthcare systems. And what we see is that compared to other high-income countries, in the U.S., it’s much more common to not have a regular doctor, primary care doctor, to have relatively limited options for getting treatment after office hours. We see high cost-sharing requirements that can make it difficult for Americans to visit a doctor when they have a health issue.

Americans are more likely to skip medical tests, treatments, refill their prescriptions. Of course, the Affordable Care Act is a major step towards improving some of these issues of equity in primary health care. But I think we can look to global research to show us where there are different elements of primary care that are delivered especially well and that we can, in theory, learn from. For example, countries like the United Kingdom and Germany have very high levels of equity in primary care.

They’re kind of rated towards the top of the list on those dimensions. And these settings have little or no cost sharing and have very, very strict limits on out-of-pocket expenses. In terms of issues like access, the Netherlands does extremely well on that issue, in particular, with access. They’ve implemented specific policies in Germany as well to expand primary care hours outside of what we would consider regular 8 to 5 or 9 to 5 office hours. And the offshoot of this has been that it’s also brought down emergency room visits.

So there are really concrete ways that we can look to chip away at some of the issues in equity and in access that we see in the U.S. system by looking at some sort of peer nations that are performing well in these dimensions.

[Sandro Galea]
So when I’m listening to you, I think you’re making you make a such a compelling case for what we’re learning from global systems that we can apply here. I feel like we should all be rushing to global health to learn ways in which we can actually improve U.S. systems. So why don’t we do that? What are the barriers that’s keeping us from more effectively learning from global health research, more effectively leaning into global health research?

[Josh Ehrlich]
Yeah, I mean, you know, I think there are a couple systems barriers or institutional barriers that really get in the way. And we could probably do a full podcast just on this one question, but I’ll mention two barriers that I think are particularly germane from a systems perspective. The first is this idea of American exceptionalism, and this idea that the world should be learning from the United States rather than the other way around. And this can be a rather limiting and constraining posture, I think, for any country to adopt. It takes more humility to look outward, and I think not doing so, we do at our own peril.

Not doing so gets in the way of us benefiting from the kinds of reciprocal innovation that we were talking about. The second sort of structural barrier that I would mention is special interests. We see that implementing new care models often means being very disruptive, and disrupting what already exists is challenging when there are strong invested interests in maintaining current models of care and current payer-provider relationships.

[Sandro Galea]
You know, these barriers are barriers. There’s no question about it. And they’ve been with us for a long time. But if you were to say we can make a convincing argument to move beyond them, you’re gonna prioritize one global health research agenda, what would it be?

[Josh Ehrlich]
Yeah, I think if there’s one, I don’t know if it moves beyond these institutional barriers, these systemic barriers, but if we were to prioritize one item for the global health agenda, and it’s very pertinent right now, I think it would have to be pandemic preparedness.

Pandemics are by definition global phenomena. And they are by definition, as you said before, they’re phenomena that really show us how interconnected we are as a world. So if we’re going to invest globally in research in just one area, I think pandemic preparedness very quickly has to rise to the top. There are other areas that are massively important that I think warrant investment and are timely as well at this point in time. Things like climate and health is becoming ever more relevant and ever more important, and also a hugely global issue. Obviously the climate pays no attention to political borders.

And the other area that I do a lot of my work in, so maybe I’m a bit biased in that sense, is population aging. I mean this is a phenomenon that’s happening in essentially every country of the world, every region of the world for sure, and is differentially affecting different places, but lots of lessons to be learned and shared between countries as different countries are at different points in their demographic and epidemiological transitions. So I think, you know, you asked for one, I gave you three, but I would put pandemic preparedness way up at the top.

[Sandro Galea]
Yeah, I think those three I align with. So how do we reimagine global health in the moment to improve its standing in the context of the political headwinds we’re facing?

[Josh Ehrlich]
Yeah, it’s a big question. I think a huge part of reimagining global health today has to be — it comes back to interconnectedness again. I think we have to emphasize this trait, this feature. When we speak about global health broadly as a sector, beyond just global health research, this this populism has been a huge and very challenging force that I mentioned before, and it certainly continues to weaken global cooperation and understanding and of course multilateral institutions as well.

I think conversations have to become more transformative. We have to shift the dialogue, and it has to move beyond dialogue, from simply fine-tuning frameworks and fine-tuning governance, which I think is a lot of the dialogue that I’ve been hearing, to much more difficult questions about things like ownership, on-the-ground operations, and elevating important voices that have been left out of these conversations at the multinational level for years or decades.

But as I just alluded to, global health is multifaceted, and if we’re gonna focus on research, I would say my response is a little bit more nuanced. I think there has to be an understanding that global health research is not development aid. Development aid is important, and that’s a whole other conversation, but global health research serves a scientific purpose, and science serves humanity regardless of political borders.
Now, it would be naive to not mention that in addition to this populism and retreat from multilateralism, that we’re also weathering attacks on science itself as an institution. We know that. And this certainly complicates the picture. But I think one of the keys here is openness. On the one hand, we need to create very open spaces, like you’re doing, for genuine intellectual discourse and a willingness to engage with diverse, and sometimes even heterodox viewpoints and in well-meaning dialogue.

And this includes, it should be said, airing our mistakes, you know, the earnest learnings that come with trying difficult things and failing. And then I think on the other hand is discourse with society. And this is something that doesn’t come naturally, that is difficult for many scientists.

But evermore knowledge translation has to become a bigger and more central part of what we do in global health if we are to be the ones to shape the conversation. And I say we very broadly, rather than leaving the same kind of void that we spoke about before, which will inevitably get filled by some actor if it’s left, if a vacuum is left in place.

[Sandro Galea]
So in this moment of challenge for global health, what gives you hope?

[Josh Ehrlich]
Yeah, so you know, I’m extremely hopeful when I look at the large number of people and grassroots institutions and partnerships who remain so dedicated to making the world a better and healthier place for everyone, even in spite of the working conditions that have gotten so tough.

You know, the reciprocal, the meaningful partnerships that I share and I maintain with colleagues all around the world are — I can’t overstate what a source of energy and motivation they are. You know, here at University of Michigan, our Center for Global Health Equity has really become an inspiring hub for debate and research, training, knowledge translation. And it’s doing really meaningful and transformative work, just like I know you’re doing at WashU. So I would say it’s the people, it’s the genuinely good community of global health scholars and practitioners who, even when they find themselves in a hugely difficult situation and environment today, are still dedicated to making the world a fairer and healthier place for everyone. That gives me hope.

[Sandro Galea]
Hmm. It’s a great way to end. I’m Sandro Galea. I have been talking with Josh Ehrlich about why global health research matters for U.S. health. Thank you, Josh, for this conversation. Thank you everybody who’s joined us for Ideas Matter. I look forward to continuing the conversation.

[Josh Ehrlich]
Thank you very much for having me