CRICOS #00212K

Poverty, demography and infectious disease: three warnings

Prof Colin Butler

CRICOS #00212K

Outline

Systems thinking – and the “milieu” for epidemics

“Neoliberalism”, inequality, demography and the rise of magical thinking

3 case studies as warnings

1. Ebola in West Africa 2. Sanitation in India 3. The future

What we might do

CRICOS #00212KRefugees en route from Africa to Italy, 2014

CRICOS #00212K

Damascus, 2014. Line for food aid from UN Relief and Works Agency in a great city - large parts of which have been destroyed by civil war, along with basic food supply infrastructure

CRICOS #00212K

Who am I to be giving you this talk?

CRICOS #00212K

CRICOS #00212K

CRICOS #00212K

CRICOS #00212K

CRICOS #00212K

CRICOS #00212K

CRICOS #00212K

CRICOS #00212K

integrative

interactive, feedbacks, thresholds

(emergence, phase changes, shocks )

context – milieu – “terrain”

Systems thinking

1313

CRICOS #00212K14

Claude Bernard (1813-1878)vs

Louis Pasteur (1822-1895)

milieu and microbe

CRICOS #00212K

15

Milieu and the

Adapted from Oxford et al Lancet Inf Diseases 2002; 2:111-4

2.5% global mortality (with bacterial co-infections)

CRICOS #00212K

“Neoliberalism”

inequality

the “cornucopian enchantment”

CRICOS #00212K

“Washington Consensus”(neo-liberalism, Reaganomics, etc)

Reduce subsidies

Broaden tax base – cut marginal tax rates

Deregulation – reduce protection

Reduced role for the state

http://www.who.int/trade/glossary/story094/en/

CRICOS #00212K

CRICOS #00212K

CRICOS #00212K

CRICOS #00212K

CRICOS #00212K

Share of income received by top 1% (UNCTAD, 2012)

Keynesianism – dominant, Primary Health Care – health systems approach

“Health for all by 2000”

CRICOS #00212K

Ascendancy of neoliberalism

Share of income received by top 1% (UNCTAD, 2012)

CRICOS #00212K

CRICOS #00212K

Inequality – essential – but thresholds exist

Envy, risk of “blowback” not main problem

-matters even if living standards of poor rise slightly

matters if/when elites lose touch with the poor and rig (shape) society so that “public goods” erode

(eg public health, development, climate system, biodiversity, eventually global law and order)

CRICOS #00212K

Some ways the powerful “rig” the system, harming public goods*

1. Own, control, influence media*2. Excessive influence on policy*3. Ignore big tax evaders4. Encourage social norms blaming poor5. Cut foreign aid *6. Promote loyal academics *7. Ignore, imprison, or murder dissidents** (not just neoliberalism)

CRICOS #00212K

Demography, inequality, magical thinking

1. Reliance on market will provide public goods (including public health)

2. Ridicule “Limits to Growth”

3. Fallacious doctrine (conceit) of capital substitutability

CRICOS #00212K

Demography, inequality, magical thinking

Inequality, in one boatDanger of sinkingHypocrisy, loss of connection with poor

CRICOS #00212K

Demography and politics

1. Deny role of slowing population growth rate in development process

2. Conceit that ingenuity more important than resources

CRICOS #00212K

Orthodoxy: 1950s-early 1980s

High population growth impedes economic takeoff

30

US President Lyndon Johnson

“… less than five dollars invested in population control (sic) is worth a hundred dollars invested in economic growth”

CRICOS #00212K

World Population: 0-2012

31

31

infection (plague),

undernutrition, unfavourable

climate

Borlaug’s warning

Le Bras: “problem a bit passé”

Reagan: problem “vastly exagerated”

CRICOS #00212K

3 case studies as warnings

1. Ebola in West Africa

2. Sanitation in India

3. The future

CRICOS #00212K

Eric Gweah, 25, grieves as he watches a Red Cross burial team remove the body of his father, Ofori Gweah, 62, a suspected

Ebola victim (photograph Daniel Berehulak) http://news.nationalgeographic.com/news/2014/10/141005-ebola-quammen-west-

africa-dallas-gates-foundation/

CRICOS #00212K

EBOLA “recipe” (milieu) West Africa – 3 stages

Social, economic, demographic and ecological factors (determinants) for all three

stages

1: increased viral load in the reservoir?

2: increased human – virus contact

3. viral “takeoff” in human population

CRICOS #00212K

Does adverse ecological change (forest clearing, climate change, cave mining?) stress bats – hence higher bat viral load – more spillover?

Hansen et al, 2013

CRICOS #00212K

Does adverse ecological change (forest clearing, climate change, cave mining?) stress bats – hence higher bat viral load – more spillover?

CRICOS #00212K

More poverty, people, protein demand

more roads, forest clearing, mining

Palm oil?

more human-bushmeat contact including hunting (whether bats or primates)

? Intermediary factor, eg pigs?

EBOLA human-virus contact(West Africa) (stage 2)

CRICOS #00212K

More poverty, people, protein demand

more roads, forest clearing, mining

Palm oil?

more human-bushmeat contact including hunting (whether bats or primates)

? Intermediary factor, eg pigs?

EBOLA human-virus contact(West Africa) (stage 2)

CRICOS #00212K

EBOLA human-virus contact(West Africa) (stage 2)

kimberlite diamond pit mine, Sierra Leone, Photo: David Levene

CRICOS #00212K

EBOLA human spread factors (West Africa) (stage 3)

1. Cultural unfamiliarity, though virus apparently long present

2. Relatively high population density and mobility

3. Poor health system

4. Poverty, history of conflict

5. Slow international response

factors 3-5: related to neoliberalism

CRICOS #00212K

Case study 2:

Sanitation in India

CRICOS #00212K

Poor Sanitation in India May Afflict Well-Fed Children With MalnutritionBy GARDINER HARRISJULY 13, 2014 (New York Times)

Image: Daniel Berehulak, NYT

Stunting affects 1/3 of the children of wealthy Indian families?

CRICOS #00212K

“cause of many of our diseases is condition of our lavatories and our bad habit of disposing of excreta anywhere and everywhere,” Gandhi 1925.

Number who defaecate outside per sq km (H Fairfield; NYT)

50 100 150 200

% stunted childen

60

50

40

30

20

10

India

Nepal

CRICOS #00212K

CRICOS #00212K

.. Not happened in India .. It cannot happen just by constructing latrines ..you really need a large social campaign..

.. Indian Hindu culture: latrines supposed to cleaned by people regarded as unclean caste .. The stigma remains .. Who will clean the pits of cheap latrines?

CRICOS #00212K

The Pedagogy of the Oppressed

CRICOS #00212K

Case study 3:

The future

CRICOS #00212K

“Planetary Boundaries”

A safe operating space for humanity

Steffen et al, 2015

What does this mean for society? And for health?

CRICOS #00212K

CRICOS #00212KPNAS - 2015

CRICOS #00212KPNAS - 2015

2007−10 drought .. worst recorded .. widespread crop failure, mass urban migration.

human forcing .. increased probability severe, persistent droughts in this region

We conclude human influences on climate system implicated in the current

Syrian conflict.

CRICOS #00212K52

rapid public health response*limited antimicrobial resistance, but increasing nutrition ok

public health breakdownnutrition worseliving conditions worseconflict increasing?

Could civilisation failure “breed” a megapandemic?

* At least for diseases perceived threats to high income populations

CRICOS #00212K

What we can do

1. Form coalitions – among colleagues, with other disciplines and with other groups

2. Strive to challenge neoliberalism and magical thinking

3. Keep optimistic but not complacent

CRICOS #00212K

He Had a dream

5454Health for all on a single planet