Photograph by Ashley Gieseking
Saint Louis University is the only American Jesuit university with an accredited school of public health—and it’s growing. About 20 professors have joined the faculty in the past two years. Their new dean is Dr. Edwin Trevathan, a pediatric neurologist and epidemiologist who previously led the National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention.
When we reached him, he was en route to the Democratic Republic of the Congo, which is likely to become a strategic hub (along with Wuhan, China) for SLU’s global public-health efforts. He emailed from a café in Brussels, where, he pointed out, he “could be infected with a variety of diseases that only this morning were on another continent.”
All public health now requires a global perspective, he wrote, because the “factors that impact health do not respect borders. H1N1 influenza in 2009–10 spread into the U.S. from Mexico, and only a major international effort”—including collaboration with China, various European countries, and Australia—“prevented a much more severe flu pandemic.” And the deadly SARS virus was contained in Asia by a series of collaborative measures, including a ban on selling exotic animals from Madagascar. “The movie Contagion,” Trevathan added, “is a realistic picture of what would have happened if SARS had not been contained.”
Is public health in the U.S. far superior to other parts of the world?
We suffer virtually the worst basic health outcomes (infant mortality, life expectancy) of any developed country, in spite of the fact that we spend much more per capita than anywhere else in the world. The U.S. infant mortality (about seven infant deaths per 1,000 births) is over three times the rate of death among infants in Japan, and twice the rate of death of infants born in Spain or Italy. An infant has much higher odds of survival in Cuba than in the U.S., even though Cuba is a much poorer country overall. Yet we spend more than twice per capita what Japan, Spain, or Italy pay for healthcare.
So what’s killing our babies?
Inequity and poverty and the impact of low social standing on health—what we in public health refer to as “social determinants of health.” Poor housing, inadequate basic nutrition (e.g., access to fruits and vegetables), the biological impact of stress and a sense of “lack of control” over one’s life, and poor health literacy.
And in Africa, it’s even worse.
In DRC [the Democratic Republic of the Congo], infant mortality is among the highest in the world—about 80 deaths per 1,000 births, over 10 times the rate in the U.S. The highest infant mortality in the world (over 120 infant deaths per 1,000 births) and the highest maternal mortality in the world have occurred in the same country for many years: Afghanistan.
We’ve been hearing about these problems for decades. Why haven’t past efforts accomplished more?
North Americans have great hearts, [but] our interventions and efforts have often not been very effective. We have tended to think that we can bring U.S.–style healthcare to poor countries, and that simply doesn’t help. If we spend two to three times more on healthcare than most of the developed world, with worse outcomes, why would we try to take our methods to poor countries that cannot afford our system?
What are the most urgent public-health issues?
HIV/AIDS is no longer a death sentence, at least in developed countries, but continues to be a major problem worldwide. Emerging infectious diseases, made more dangerous by the lightning-like speed with which new deadly infections travel around the world, will be a major problem. Death from chronic diseases is driving up healthcare costs and threatens to make our children in the U.S. live shorter and more unhealthy lives than their parents. The obesity epidemic, with its epicenter in the U.S., is making its way around the globe. Obesity and diabetes threaten the health, the economy, and the status of the
United States.
How has new technology changed public health?
The Internet and global communications systems offer the greatest opportunities to solve many health problems. For example, integration of smartphone technology at low prices may be a good solution to establishing electronic health records in developing countries. Our biggest gains will come not from new biomedical science research (where we spend most of our money on research in the U.S.), but from learning how to better implement the interventions that we already know work.
What about medical breakthroughs—any hope there?
Medical breakthroughs are always nice, but will not bring us improved health on a large scale. We have seriously misplaced our development priorities in the U.S. We are suffering not because we don’t have enough fancy, expensive technology, but because we are at risk from preventable infections and from preventable chronic diseases.
Is St. Louis unusual in any way?
The Regional Health Commission has done a wonderful job over the last several years improving healthcare access, yet the major health indicators in St. Louis (life expectancy, infant mortality) have not significantly improved. Why? We have not seriously addressed the social determinants of health and our unhealthy environment (tobacco, alcohol, sedentary lives, unhealthy diets).
The good news for St. Louis is that we have discovered what the rest of the country will likely discover soon: Although healthcare access is critically important, solving the access problem alone will not make us a healthier country. We have to address the population-level determinants of health.
What’s been the history of public health within medicine? Has it been as sexy as, say, surgery? Or is there less money attached, and therefore less prestige?
Fads in medicine come and go. Our culture, curiously, will pay much more money to cut someone open to treat a disease that is totally preventable than to prevent the disease in the first place. I’d rather pay to not have cancer, diabetes, birth defects, or cardiovascular disease, because having seen those problems up close and personal, they are bad. Gradually, I think that our culture is beginning to come to this realization.
What motivates people to take good care of themselves?
It is complicated, or we would have all solved this problem. However, we know that the environment in which we live is important. Yesterday, I walked more than usual because I was in Brussels, and the Brussels “built environment” makes people walk more. In America, we have a strong belief in personal responsibility and personal decision-making, which has positive aspects. However, the bottom line is that when healthy options are more often the default decision, people are healthier. Smoke-free environments produce fewer smoking-related deaths. Banning added trans fat in restaurants results in less obesity and better health outcomes in communities. Policies that push fruits and vegetables into workplace cafeterias and into poor communities at low prices improve health. When people see their friends and colleagues choose healthy options, the peer pressure makes it easier for them to be healthy as well.
Why has it taken so long to eradicate diseases like hookworm, elephantiasis, and leprosy in other parts of the world?
Problems with logistics and political will. Specifically, the rich developed world was blind to the plight of these
people.
What concerns you most, globally, for the next decade?
The risk of poor, unstable countries with high death rates from malaria, malnutrition, diarrheal disease, and HIV/AIDS becoming more and more politically unstable. This will cause us more international diplomatic problems and will make us more prone to terrorist attacks (and war), and less able to address emerging infections that travel across borders with deadly consequences.
Is climate change affecting public health?
Yes. In Africa, for example, large populations escaped malaria because the big cities tended to be at high altitude, where it was cool at night. Climate change is causing the “malaria line” to rise to higher altitudes and is hitting big cities in Africa. The risk is enormous.
In some countries, like Nepal and India, huge populations are at risk of losing water supplies due to the melting of snow and ice in the mountains. We will have a major water shortage problem in some areas that will cause death, unrest, and war if not addressed quickly.
Unfortunately, the countries that have the ability to prevent these disasters are the U.S. and China, who seem to be blind to the impact their consumption has on other parts of the world.
