1 00:00:00,820 --> 00:00:09,130 Hello, everyone, and welcome to this evening's discussion discussion hosted by the Oxford Martin School. 2 00:00:09,130 --> 00:00:15,850 My name's Chris Dai and I work as an epidemiologist here in Oxford, based in the zoology department. 3 00:00:15,850 --> 00:00:20,800 And last year, I was visiting fellow at the Oxford Martin School. 4 00:00:20,800 --> 00:00:31,030 Our theme this evening is prevention in public health, and I'm absolutely delighted to say that I have with me to discuss this theme. 5 00:00:31,030 --> 00:00:37,630 Professor Salim Abdool Karim, who is joining us from Durban in South Africa. 6 00:00:37,630 --> 00:00:47,020 Slim has vast experience in epidemiology and an enormous amount of wisdom and wisdom on many aspects of public health. 7 00:00:47,020 --> 00:00:54,400 He's the director of Capricia, the Centre for the AIDS Programme of Research in South Africa. 8 00:00:54,400 --> 00:00:59,710 He's also a professor of global health at Columbia University in New York. 9 00:00:59,710 --> 00:01:11,260 He's been a key adviser to the South African government on the COVID pandemic, and he's recently been appointed a member of W.H.O. Science Council. 10 00:01:11,260 --> 00:01:21,730 And kudos to W.H.O. for making that appointment. W.H.O. being my former employer now, prevention is better than cure, 11 00:01:21,730 --> 00:01:29,770 as we all know and everybody repeatedly says, and yet we don't often behave as if we really believe it. 12 00:01:29,770 --> 00:01:35,500 And that's a fact that bothered me in the years that I worked at the World Health Organisation. 13 00:01:35,500 --> 00:01:43,930 And when I left W.H.O. three years ago, I decided to look into it a little bit more closely and ended up writing a book about it. 14 00:01:43,930 --> 00:01:47,950 And the book has just been published by Oxford University Press. 15 00:01:47,950 --> 00:01:56,050 And if you want to buy a copy, quick plug. There's a promotional cloud code at the bottom of the screen, which will get you a 30 percent discount. 16 00:01:56,050 --> 00:02:04,960 But here's what we proposed to do in this conversation. I'm going to take about 15 minutes to give you the gist of what's in the book. 17 00:02:04,960 --> 00:02:11,410 Then I'm going to ask Slim to give us his reflections on prevention in public health, 18 00:02:11,410 --> 00:02:18,370 based on his experiences with HIV aids, with COVID and many other aspects of public health. 19 00:02:18,370 --> 00:02:27,640 And once we've had a bit of a discussion amongst ourselves, we'll open it up to questions from those of you who are watching online now. 20 00:02:27,640 --> 00:02:36,280 Those of you who are following this on crowd cast will see a box bottom right hand screen which 21 00:02:36,280 --> 00:02:41,890 allows you to post some questions yourself or if you don't want to ask a question yourself. 22 00:02:41,890 --> 00:02:47,800 You can vote on the other questions and the questions that get the most votes tend to move towards 23 00:02:47,800 --> 00:02:53,680 the top of the screen so we can choose Samini when we get round to opening this for questions, 24 00:02:53,680 --> 00:02:58,640 we can choose which ones you collectively would like to have answered. 25 00:02:58,640 --> 00:03:06,400 I don't intend to answer all questions myself. I'm hoping that Slim will help me answer the ones that you want to pose. 26 00:03:06,400 --> 00:03:14,350 So let me begin then by sharing my screen and my slides, and I'll tell you a bit about what's in the book. 27 00:03:14,350 --> 00:03:22,660 The book, called The Great Health Dilemma and The Dilemma, is in the subtitle Is Prevention Better Than Cure? 28 00:03:22,660 --> 00:03:29,440 And Just a brief word about the cover a woman with a face mask, you should be able to see. 29 00:03:29,440 --> 00:03:41,200 Face masks, of course, have been highly controversial as methods of prevention during the COVID pandemic, but this painting was not made during COVID. 30 00:03:41,200 --> 00:03:45,850 It was made by Russian artist Paulina Senior Kina, 31 00:03:45,850 --> 00:03:50,890 who unfortunately a few years ago contracted tuberculosis and found herself in 32 00:03:50,890 --> 00:03:55,510 a Russian tuberculosis hospital being treated for an extended period of time. 33 00:03:55,510 --> 00:04:04,120 And this is one of a series of really nice paintings called Hold Your Breath series, which you can find on the website. 34 00:04:04,120 --> 00:04:10,150 I'm going to talk about COVID later in this presentation. I'm sure slim and I will talk about it together. 35 00:04:10,150 --> 00:04:20,200 I'm also going to talk a bit about tuberculosis as well. But first, my motivation for looking more closely into the question of prevention. 36 00:04:20,200 --> 00:04:25,090 This is one of the motivations, anyway. Take sanitation. 37 00:04:25,090 --> 00:04:33,610 We've known how to do safe sanitation to protect people's health and dignity for a long time, four thousand years at least. 38 00:04:33,610 --> 00:04:42,160 And yet, as I've travelled around the world in recent years, I frequently seen scenes like this one on the right hand side in part of India. 39 00:04:42,160 --> 00:04:48,850 But these scenes, which represent unsafe sanitation, are replicated across South Asia, 40 00:04:48,850 --> 00:04:53,950 through Africa, through parts of Africa, parts of the Americas as well. 41 00:04:53,950 --> 00:05:00,290 They represent a failure of safe sanitation and yet if we look at the left hand. 42 00:05:00,290 --> 00:05:08,540 All of this slide, this is an archaeological site in the Indus Valley, not far away from where the photo on the right hand side was taken. 43 00:05:08,540 --> 00:05:14,750 This is an excavation of a communal sanitation system that is personal toilets, 44 00:05:14,750 --> 00:05:22,670 a sewage system and the structure of that system indicates not just the technology that was used for sanitation, 45 00:05:22,670 --> 00:05:29,570 but it also points to the social organisation of societies that lived in the Indus Valley at the time. 46 00:05:29,570 --> 00:05:33,620 So we've been able to do this thing, this kind of thing, for about 4000 years. 47 00:05:33,620 --> 00:05:37,280 So why are we not doing it today? 48 00:05:37,280 --> 00:05:46,590 In fact, we might ask the question is that an isolated incident of the failure of prevention or are we failing on prevention more generally? 49 00:05:46,590 --> 00:05:51,770 And the answer is we're failing on prevention more generally. 50 00:05:51,770 --> 00:05:55,880 I'll tell you a couple of stories about the statistics that lie behind that failure. 51 00:05:55,880 --> 00:06:02,360 First of all, a standard set of statistics, which is useful but not quite true. 52 00:06:02,360 --> 00:06:13,040 As I explain in a moment, a headline on this slide seven trillion dollars spent on health around the world each year, that's about $1000 per person. 53 00:06:13,040 --> 00:06:23,150 Of course, that spending is heavily weighted towards the rich world and weighted away from the poorer world, but about $1000 on average per person. 54 00:06:23,150 --> 00:06:30,530 But only four percent of that is spent on prevention as distinct from curative treatment. 55 00:06:30,530 --> 00:06:37,910 And the paradox there, or the conundrum is illustrated by what you see on the left hand side of this slide. 56 00:06:37,910 --> 00:06:41,570 These are preventable causes of death, 57 00:06:41,570 --> 00:06:47,210 large preventable causes of death grouped into three different types environmental causes 58 00:06:47,210 --> 00:06:54,230 like the failure of sanitation causes associated with metabolic diseases like diabetes, 59 00:06:54,230 --> 00:07:00,110 causes associated with behavioural factors such as persistent tobacco smoking, 60 00:07:00,110 --> 00:07:06,680 which leads to lung cancer and many other cancers and other respiratory diseases. 61 00:07:06,680 --> 00:07:15,290 And the red numbers in the second column show you the proportion of deaths attributable to those different categories preventable deaths. 62 00:07:15,290 --> 00:07:21,950 And yet, as you see top right of this slide, only four percent is spent on prevention. 63 00:07:21,950 --> 00:07:31,430 How can that be? Well, one factor to bear in mind here is that that four percent is what's counted in the so-called system for health accounts, 64 00:07:31,430 --> 00:07:41,090 which is an excellent way of adding up money spent on health. But it has the caveat that this is money money only spent directly on health. 65 00:07:41,090 --> 00:07:46,580 It doesn't account for spending outside health, which has implications for health. 66 00:07:46,580 --> 00:07:51,860 So, for example, if you build a sanitation system which has many benefits, 67 00:07:51,860 --> 00:07:58,280 the component due to health allocated to health is a very tiny fraction of overall spending. 68 00:07:58,280 --> 00:08:08,780 So that four percent, we can expect to be an underestimate. And in doing research for the book, I ask the question how much of an underestimate it is. 69 00:08:08,780 --> 00:08:14,100 Ideally, what we'd like to do is to be able to add up all of the money that's spent on prevention versus treatment. 70 00:08:14,100 --> 00:08:18,380 But there isn't a system by which we can do that. We probably need one, but there isn't yet. 71 00:08:18,380 --> 00:08:28,550 So here's my proxy analysis. This picture shows you an analysis for more than 100 different health conditions 72 00:08:28,550 --> 00:08:36,480 of changes in mortality rate over the three decades from roughly 1990 to 2017. 73 00:08:36,480 --> 00:08:42,650 They asked the question Is that change in mortality largely a reduction in mortality? 74 00:08:42,650 --> 00:08:52,040 You can see that most points on this graph are to the left hand side of that vertical zero line sum, mostly for most of these conditions. 75 00:08:52,040 --> 00:09:02,540 Mortality is falling, but the graph asks the main question is that full in mortality, mainly due to a direct effect on mortality? 76 00:09:02,540 --> 00:09:10,250 In other words, due to treatment? Or is it due to a reduction in incidence of those conditions, in other words, due to prevention? 77 00:09:10,250 --> 00:09:19,130 So the two lines to look at are the horizontal line, which is pure cure and the the and the diagonal, 78 00:09:19,130 --> 00:09:26,090 the one to one diagonal that runs bottom left to top right on this slide, which is pure prevention. 79 00:09:26,090 --> 00:09:34,040 So you can see that, for example, for diarrhoeal diseases and what's labelled Eleri here, lower respiratory infections. 80 00:09:34,040 --> 00:09:38,210 These are major sources of mortality in young children. 81 00:09:38,210 --> 00:09:43,640 Most of the gains have been made by treatment, by curative treatment. 82 00:09:43,640 --> 00:09:52,910 But consider some of the conditions along the diagonal like yellow fever, measles, rabies, diphtheria. 83 00:09:52,910 --> 00:10:00,020 Most of the gains indeed, almost all of the gains have been made by reducing instance, so almost all of the reduction. 84 00:10:00,020 --> 00:10:06,860 The mortality is due to reduction in instance, in other words, a reduction in prevention, 85 00:10:06,860 --> 00:10:13,190 and if we take all of the results on this slide in aggregate, there are lots of individually interesting stories here. 86 00:10:13,190 --> 00:10:17,090 But if we take all of the results on this slide in aggregate, 87 00:10:17,090 --> 00:10:26,300 I calculate that about half of the reduction in mortality is due to prevention, and about half of it is due to cure. 88 00:10:26,300 --> 00:10:29,360 Now that's that's not a costing exercise, as I said, 89 00:10:29,360 --> 00:10:39,650 but it's pretty clear that much more is spent on prevention for the four percent that comes from the system of health accounts. 90 00:10:39,650 --> 00:10:46,070 Even if it's 50 percent spent on prevention, there's still plenty of scope to do better. 91 00:10:46,070 --> 00:10:53,030 And on this slide, I've identified different approaches to how we could do better. 92 00:10:53,030 --> 00:11:02,270 They are different, but they're complementary. At the top, I've put what I've called the aspirational approach based on ideology, 93 00:11:02,270 --> 00:11:13,130 and the quotation here comes from the opening paragraph of the of who's defining document. 94 00:11:13,130 --> 00:11:16,520 The highest attainable standard of health. 95 00:11:16,520 --> 00:11:24,530 That's what W.H.O. suggests that we all seek and and that's that's that's fine as a vision, as an aspiration. 96 00:11:24,530 --> 00:11:30,980 But when it comes down to what people really do in practise, I'd rather take an analytical approach. 97 00:11:30,980 --> 00:11:36,050 What I've called a conditional approach an approach based on economics, 98 00:11:36,050 --> 00:11:41,690 that the basic hypothesis is that what people essentially do is they consider the 99 00:11:41,690 --> 00:11:46,370 costs and they consider the benefits of their actions and they act accordingly. 100 00:11:46,370 --> 00:11:56,680 In other words, I've taken a rationalists approach to determining how much is invested in prevention and how much is invested in curative treatment. 101 00:11:56,680 --> 00:12:02,060 And this opens, explains the argument a little bit more detail here. 102 00:12:02,060 --> 00:12:07,580 Essentially, the argument is the proposition. It's a testable proposition. 103 00:12:07,580 --> 00:12:12,920 I'm not saying the argument on this slide is absolutely correct. It's a testable proposition. 104 00:12:12,920 --> 00:12:22,430 The argument is, if there's a great deal of benefit from prevention at very low cost, then we're going to tend to invest in prevention. 105 00:12:22,430 --> 00:12:30,020 If the cost is very high in relation to the benefit, then we'll postpone prevention and rely on cure. 106 00:12:30,020 --> 00:12:40,910 The argument with regard to benefit comes in three parts that you see in this simple former formula simple formula at the top of the slide. 107 00:12:40,910 --> 00:12:51,650 If there's a large, avoidable danger, a big hazard, if it's very likely to happen and if it's very likely to happen soon, 108 00:12:51,650 --> 00:12:55,640 then the benefit of removing that hazard is going to be large. 109 00:12:55,640 --> 00:13:00,260 And if we can do it at relatively low cost, then we will be inclined to do it. 110 00:13:00,260 --> 00:13:04,970 And when I refer to cost here, I don't just mean monetary cost. 111 00:13:04,970 --> 00:13:11,930 I mean effort information, the time that's taken to invest in it. 112 00:13:11,930 --> 00:13:21,290 I mean, willpower, for example, with regard to giving up cigarette smoking or changing one's diet or changing what Richard wants regiment activity. 113 00:13:21,290 --> 00:13:26,270 But if the cost is low in relation to the benefit, that will tend to favour prevention, 114 00:13:26,270 --> 00:13:33,410 and that's what we would expect to see more prevention and less reliance on curative treatment. 115 00:13:33,410 --> 00:13:42,350 So in the book, I have examined six different challenges for prevention, and you see the man pictured here. 116 00:13:42,350 --> 00:13:50,360 Health services in the context of health services, health services like the National Health Service in the UK, preventing epidemics, 117 00:13:50,360 --> 00:13:59,540 controlling endemic infectious diseases, chronic non-communicable diseases, sanitation that have already alluded to and climate. 118 00:13:59,540 --> 00:14:04,850 And in this brief presentation, I'm going to focus on three of these things. 119 00:14:04,850 --> 00:14:15,590 I'm going to focus on three and talk about them with respect to those three key components of identifying the threat, risk, hazard and time. 120 00:14:15,590 --> 00:14:20,920 Let's start with risk, and let's start with perhaps. 121 00:14:20,920 --> 00:14:24,340 The most important risk of the moment COVID 19, 122 00:14:24,340 --> 00:14:32,920 there's a great deal of effort now being devoted to considering not only how we control COVID the pandemic we have in front of us, 123 00:14:32,920 --> 00:14:44,110 but how we prevent pandemics in future. And there are a growing number of reports and proposals and opinions being suggested about how to do that. 124 00:14:44,110 --> 00:14:47,140 But published a couple of days ago, is one that's really worth reading, 125 00:14:47,140 --> 00:14:53,320 which comes from the show's independent panel for pandemic preparedness and Response. 126 00:14:53,320 --> 00:14:58,390 It's called COVID 19 make it the last pandemic, and there are many good things in this, 127 00:14:58,390 --> 00:15:02,260 and there are many good things in the background papers which are also worth reading. 128 00:15:02,260 --> 00:15:11,650 But let me just point to one of them. And that is their argument that this a strong case for applying what's called the precautionary principle. 129 00:15:11,650 --> 00:15:19,300 They say, for example, that there's a case for assuming without knowing if it's true that human to human transmission 130 00:15:19,300 --> 00:15:25,240 of an emerging pathogen will occur unless there's evidence that indicates otherwise. 131 00:15:25,240 --> 00:15:29,830 Well, the precautionary principle errs towards prevention. 132 00:15:29,830 --> 00:15:38,350 The difficulty with it is that it is not cost free, and if we go to prevention, we're going to have to consider how much that costs. 133 00:15:38,350 --> 00:15:44,260 It may well be worth it, and it may be worth it in the way that the independent panel has described. 134 00:15:44,260 --> 00:15:49,280 But there are alternatives, and let me point you to one of them. 135 00:15:49,280 --> 00:16:02,420 This is titled All the eggs in one basket. It's a pun on W.H. Ho's use of the idea, the very valuable idea far better than my pun of disease. 136 00:16:02,420 --> 00:16:12,050 X W.H.O. lists a set of pathogens which are likely to be threats in future caused major epidemics, even pandemics. 137 00:16:12,050 --> 00:16:17,900 They include diseases like Ebola virus, Zika virus, Lassa fever and so on. 138 00:16:17,900 --> 00:16:21,620 But at the bottom of that list is the unknown disease. 139 00:16:21,620 --> 00:16:27,320 The next potential big one, the one that we think will happen, but we don't know what it is at the moment. 140 00:16:27,320 --> 00:16:38,030 Zika virus was a disease X, so one approach to this is to consider each of these pathogens as they arise independently. 141 00:16:38,030 --> 00:16:43,430 We've often heard it said that COVID 19 is a once in a century pandemic. 142 00:16:43,430 --> 00:16:49,340 I think that's the wrong way to look at it. What we know from W.H.O. data and others. 143 00:16:49,340 --> 00:17:03,590 But let's use the W.H.O. data presented on this slide. W.H.O. reported 1483 epidemic events in the eight years 2011 to 18, coming from 172 countries. 144 00:17:03,590 --> 00:17:13,790 What this says is that outbreaks are not rare occurrences that are almost daily occurrences, or at least there are two or three each week. 145 00:17:13,790 --> 00:17:22,730 And one way forward, therefore, is to consider not each pathogen at a time, but to take them all together to pull the risk and share the costs. 146 00:17:22,730 --> 00:17:26,000 That's just what an insurance company would do. 147 00:17:26,000 --> 00:17:35,000 What's also interesting about the W.H.O. data is how little variation there is from year to year over those years. 148 00:17:35,000 --> 00:17:45,560 The variation in the number of events was only in the range 154 to 213, highly predictable, about 200 events each year. 149 00:17:45,560 --> 00:17:55,010 And that's a basis for establishing systems that will respond to not a single pathogen, 150 00:17:55,010 --> 00:18:01,790 but a whole variety of different pathogens corrected collectively. And there are no proposals in which we can. 151 00:18:01,790 --> 00:18:09,050 But ways in which we could do that. One of them is illustrated on the right hand side of this slide here. 152 00:18:09,050 --> 00:18:13,790 The the lines at the top right of the slide show an outbreak. 153 00:18:13,790 --> 00:18:17,510 Essentially, they're different colours, but let's just say that's an outbreak. 154 00:18:17,510 --> 00:18:27,500 What you see below that on the slide is the usual historical reactive approach where we consider how we're going to combat the epidemic, 155 00:18:27,500 --> 00:18:30,440 whether it's going to be a drug, whether it's going to be a vaccine. 156 00:18:30,440 --> 00:18:35,420 We do preclinical investigations, we test out a candidate, we do clinical investigations. 157 00:18:35,420 --> 00:18:39,260 Then we think about manufacturing what we need to do. 158 00:18:39,260 --> 00:18:48,830 In view of the fact that we can pool all of these risks is push that process early and make it proactive rather than reactive. 159 00:18:48,830 --> 00:18:57,200 Built on technology platforms built on generic regulatory processes that can be quickly scaled up for use, 160 00:18:57,200 --> 00:19:06,230 built on generic manufacturing processes, which can also be scaled up to use and fresh from the success with COVID vaccines, 161 00:19:06,230 --> 00:19:16,430 which have been created in a remarkable amount of time, there's now talk about in future making a vaccine and deploying a vaccine within 100 days, 162 00:19:16,430 --> 00:19:24,440 which of course, is far, far faster than has ever been achieved prior to prior to COVID. 163 00:19:24,440 --> 00:19:31,640 So that's that's an alternative idea for preventing risks, pool the risks and share the costs. 164 00:19:31,640 --> 00:19:37,490 Let's now move to Hassett, and this is the part where I talk about tuberculosis, 165 00:19:37,490 --> 00:19:42,140 the disease that I've probably spent more years working on than any other. 166 00:19:42,140 --> 00:19:49,220 The publicity around tuberculosis is rather consistent and rather unsuccessful. 167 00:19:49,220 --> 00:19:55,760 Here's a typical slogan at the top of this slide. Tuberculosis kills someone every 18 seconds. 168 00:19:55,760 --> 00:20:05,720 The problem with TB is that it's become so familiar it's considered to be a feature of everyday life. 169 00:20:05,720 --> 00:20:14,450 The argument has been amplified, or there have been attempts to amplify the argument by referring to the number of people who die each year. 170 00:20:14,450 --> 00:20:20,150 About 1.3 million more than that if we consider people who have HIV positive as well. 171 00:20:20,150 --> 00:20:25,760 About 1.3 million in terms of the number of jumbo jets that would need to crash. 172 00:20:25,760 --> 00:20:30,560 But this completely misses the point about the perception of Hassett. 173 00:20:30,560 --> 00:20:38,210 People are not frightened of tuberculosis because it is so familiar they are very frightened of dying in air crashes, 174 00:20:38,210 --> 00:20:43,970 and even one jumbo jet is enough to stimulate the world's media. 175 00:20:43,970 --> 00:20:48,340 Almost every plane crash is an item for. 176 00:20:48,340 --> 00:20:50,050 World news around the world, 177 00:20:50,050 --> 00:20:58,180 and that's because the hazards associated with flying are perceived to be totally different from the hazards associated with tuberculosis, 178 00:20:58,180 --> 00:21:03,760 even though far, far more people die each year of TB than they do from plane crashes. 179 00:21:03,760 --> 00:21:14,440 Indeed, that perception of Hazard with regard to flying is one of the reasons why international travel by air is so safe these days. 180 00:21:14,440 --> 00:21:21,280 Let me amplify this a little bit more with a table that I created after the West 181 00:21:21,280 --> 00:21:27,580 African Ebola epidemic that I was closely associated with in 2014 and 2015. 182 00:21:27,580 --> 00:21:38,500 I was struck coming from tuberculosis about the similarities and differences in spending and effects and deaths, and they're summarised in this table. 183 00:21:38,500 --> 00:21:45,490 So this is Ebola for West Africa. That's three countries, principally Guinea, Sierra Leone and Liberia. 184 00:21:45,490 --> 00:21:57,310 And it's compared with tuberculosis globally. So expenditure about $6 billion in each case, total economic costs about 40 or $50 billion, 185 00:21:57,310 --> 00:22:03,820 roughly the same total deaths in West Africa, about 10000 in each case. 186 00:22:03,820 --> 00:22:12,730 But the key difference here is that for tuberculosis, the expenditure and the economics refer to what's happening globally. 187 00:22:12,730 --> 00:22:19,990 The 1.3 million deaths. Whereas for Ebola, they refer only to the 10000 deaths in West Africa. 188 00:22:19,990 --> 00:22:27,010 In other words, in this sense, there's a completely different perception of hazard between Ebola and tuberculosis. 189 00:22:27,010 --> 00:22:35,050 And what I want to ask you is that tuberculosis becomes much more interesting when it starts looking like Ebola. 190 00:22:35,050 --> 00:22:40,330 And that's something for those who want to portray Hazard publicly to bear in mind. 191 00:22:40,330 --> 00:22:47,770 This was an incident that Slim will remember well, and he may want to comment on it when he makes his remarks in a few moments. 192 00:22:47,770 --> 00:22:53,440 This was an incident that took place at two Glenferrie in KwaZulu Natal. 193 00:22:53,440 --> 00:23:02,680 I since learnt that Tougaloo is actually a Zulu word that stands for or is translated roughly as something that startles. 194 00:23:02,680 --> 00:23:11,020 And the startling event that took place at the time was the emergence of a new strain of what was called XDR TB. 195 00:23:11,020 --> 00:23:19,330 This is not W.H.O. disease x here. This is X that stands for extensively drug resistant tuberculosis. 196 00:23:19,330 --> 00:23:25,780 This is TB disease that is resistant to both the first and second line drugs. 197 00:23:25,780 --> 00:23:32,470 And the really startling and tragic incident here took place in a hospital at Tougaloo Ferry, 198 00:23:32,470 --> 00:23:37,600 which was largely populated by HIV positive patients at the time. 199 00:23:37,600 --> 00:23:44,170 Once tuberculosis XDR tuberculosis got onto this ward, it spread quickly. 200 00:23:44,170 --> 00:23:51,010 52 or 53 patients on the ward died and half of them within 60 days. 201 00:23:51,010 --> 00:24:01,210 And as a consequence of that, that incident 53 deaths amongst the millions of deaths across the African continent from tuberculosis that got 202 00:24:01,210 --> 00:24:08,920 the world to sit up and take notice of drug resistant tuberculosis and indeed tuberculosis more generally. 203 00:24:08,920 --> 00:24:15,310 So part of the story for TB, TB, not all of it. There's much more to it as you read in the book. 204 00:24:15,310 --> 00:24:21,100 But part of the story about TB is the problem of how it is perceived as a hazard. 205 00:24:21,100 --> 00:24:28,690 The third thing that I'll comment on is the time factor, the discount time factor. 206 00:24:28,690 --> 00:24:35,560 The point about time is that we value events that take place now or very soon. 207 00:24:35,560 --> 00:24:42,580 We tend to devalue events that are likely to happen or might not even happen a long time in the future. 208 00:24:42,580 --> 00:24:46,960 And that's a major problem with regard to prevention. 209 00:24:46,960 --> 00:24:52,870 So let me just give you one example here with reference to climate change. 210 00:24:52,870 --> 00:24:58,720 The challenge for a challenge for climate change is that whilst more and more people are 211 00:24:58,720 --> 00:25:04,690 aware that climate change is real and more and more people are clearly seeing its effects, 212 00:25:04,690 --> 00:25:09,820 there is still the very strong view that climate change is something that's going to happen in the future. 213 00:25:09,820 --> 00:25:13,960 And for many people, it's not quite clear what will happen in the future. 214 00:25:13,960 --> 00:25:20,110 So this is a way to bring it into the present. The argument here is an argument about co-benefits. 215 00:25:20,110 --> 00:25:26,470 It makes the observation that air pollution is a combination of things. 216 00:25:26,470 --> 00:25:38,620 It's a mix of greenhouse gas release and a mix of particulates into the atmosphere and a mix of noxious substances like nitrogen dioxide, 217 00:25:38,620 --> 00:25:45,760 sulphur dioxide and so on. Air pollution has in its own right, never mind the greenhouse gases. 218 00:25:45,760 --> 00:25:47,930 Air pollution has an. 219 00:25:47,930 --> 00:25:56,510 Vanishingly large mortality associated with it each year, if we count deaths associated with indoor as well as outdoor air pollution, 220 00:25:56,510 --> 00:26:04,620 it comes to six to seven million deaths, and that's about 10 percent of all of the deaths that are counted each year worldwide. 221 00:26:04,620 --> 00:26:08,750 About half of that is due to external air pollution. 222 00:26:08,750 --> 00:26:17,540 The picture, incidentally, is actually from a Bryan Adams concert Typekit that took place outdoors in New Delhi in 2018. 223 00:26:17,540 --> 00:26:24,400 The air pollution was so intense that backlighting from his stage. 224 00:26:24,400 --> 00:26:29,050 Portrayed his shadow onto an air pollution crowd, 225 00:26:29,050 --> 00:26:36,730 and that's where you can see the shadow of Bryan Adams projected behind the crowd attending this concert. 226 00:26:36,730 --> 00:26:43,170 But the point about air pollution is that if we cut air pollution. 227 00:26:43,170 --> 00:26:48,120 The sources of air pollution, we can have an effect quickly, both in cleaning up the air, 228 00:26:48,120 --> 00:26:52,020 we've seen how clean the air has become during lockdown and the. 229 00:26:52,020 --> 00:26:57,690 We can have an effect on cleaning up the air and we can have an effect on health very rapidly. 230 00:26:57,690 --> 00:27:02,190 In other words, we can bring the health effects more or less into the present. 231 00:27:02,190 --> 00:27:12,640 And the consequence of that is a reduction also in greenhouse gases, which mitigates the effect of climate change. 232 00:27:12,640 --> 00:27:17,710 Will people buy the argument? Well, there are a number of different ways of looking at it. 233 00:27:17,710 --> 00:27:22,750 There are good news and bad news in this regard, but I sense that there's more good news, 234 00:27:22,750 --> 00:27:28,750 the bad news these days that the powerbrokers in the energy industry, 235 00:27:28,750 --> 00:27:38,680 those people who are very significantly responsible for greenhouse gas emissions are really and their pollution are really beginning to get it. 236 00:27:38,680 --> 00:27:42,250 This is an annual survey published by the World Economic Forum. 237 00:27:42,250 --> 00:27:44,230 It's a rather informal survey, 238 00:27:44,230 --> 00:27:54,670 but what I quite like about it is that uses two of the three dimensions of the threat with regard to prevention that I used in my slide earlier on, 239 00:27:54,670 --> 00:27:58,930 the had had an equation on it. 240 00:27:58,930 --> 00:28:08,620 This compares hazard and risk. And so what you need to do is to look at the top right hand slide, the perceived combination of hazard and risk. 241 00:28:08,620 --> 00:28:12,940 When both are high, the threat is high when the threat is high. 242 00:28:12,940 --> 00:28:17,620 There is a stimulus for action provided action can be taken at the right cost, 243 00:28:17,620 --> 00:28:26,890 so you can see the big items that have failed climate action, biodiversity loss, extreme weather conditions, natural disasters and so on. 244 00:28:26,890 --> 00:28:35,890 There is a growing sense amongst the powerbrokers in business and industry that these are existential threats. 245 00:28:35,890 --> 00:28:42,370 The challenge for the health community is to get health into the mix here, get health into those arguments. 246 00:28:42,370 --> 00:28:46,930 There are health consequences to all of the things at top right on this slide. 247 00:28:46,930 --> 00:28:55,840 And yet those health consequences are insufficiently mentioned. That's a that's a challenge that the health community faces now. 248 00:28:55,840 --> 00:29:06,160 And the last thing I'll say before handing over to Slim is that whilst this conversation has been what I've said has largely been about prevention, 249 00:29:06,160 --> 00:29:14,410 in other words, in voiding illness or death or causes of illness and death in future, we also need to be talking about promotion. 250 00:29:14,410 --> 00:29:22,120 This is also a way of being the future, bringing the future into the present, and we also need to be talking about health in context. 251 00:29:22,120 --> 00:29:25,900 We need to be talking, in short, about health promotion. 252 00:29:25,900 --> 00:29:32,440 In other words, promoting good health as well as avoiding illness that might happen in future. 253 00:29:32,440 --> 00:29:37,930 And this is one nice example that I've discussed at some length in the book. 254 00:29:37,930 --> 00:29:45,490 It really is a fine illustration of promotion, and it illustrates many of the features where health promotion works. 255 00:29:45,490 --> 00:29:53,380 This is the parkrun scheme that was started a few years ago and has spread rapidly around the world. 256 00:29:53,380 --> 00:30:02,530 It's a Saturday morning event. The reason people join in is not just for their health, and they probably wouldn't say primarily it's for the health. 257 00:30:02,530 --> 00:30:08,590 They do it because it's sociable, it's free, it's fun. 258 00:30:08,590 --> 00:30:13,750 It's great to be outdoors and everyone can be involved. 259 00:30:13,750 --> 00:30:20,020 Parkrun has taken a hit under COVID, of course, because congregations of large people have been disallowed. 260 00:30:20,020 --> 00:30:26,740 But I, for one, hope that parkrun gets back up on its feet again as we come to the end of this pandemic. 261 00:30:26,740 --> 00:30:34,120 But this is just to say, finally, that we need to be thinking about promoting good health as well as avoiding illness in future. 262 00:30:34,120 --> 00:30:44,710 So in summary, what I've said and essentially the argument in the book is that if we spend less on prevention and more on cure, 263 00:30:44,710 --> 00:30:52,510 the counter-argument is not simply to say that we should be more concerned about prevention or we should do more to promote good health. 264 00:30:52,510 --> 00:30:59,710 But we'd rather need to understand why it is that people fail on prevention or or prefer not 265 00:30:59,710 --> 00:31:06,550 to choose prevention and prefer to opt for waiting for illness and hoping for a cure instead. 266 00:31:06,550 --> 00:31:12,850 I've taken a rather rational approach to that, but I think a rational approach is the way forward. 267 00:31:12,850 --> 00:31:20,770 So with that, I'm going to stop here and I'm going to turn to stop sharing my screen, 268 00:31:20,770 --> 00:31:29,290 and I'm going to turn back to Slim because I'm really interested to hear slim your views about prevention 269 00:31:29,290 --> 00:31:34,880 and public health based on your experiences and actually whether you have any reflections on that incident. 270 00:31:34,880 --> 00:31:42,670 It took a ferry that took place a few years ago that I'm sure is still fairly fresh in your mind and the consequences of it. 271 00:31:42,670 --> 00:31:47,050 So over to you. Thanks very much, Chris. 272 00:31:47,050 --> 00:31:53,860 So let me just start by just making some general observations and that. 273 00:31:53,860 --> 00:32:02,120 Christmas decided in this book. You take on quite a difficult challenge. 274 00:32:02,120 --> 00:32:08,340 In that. We all essentially understand. 275 00:32:08,340 --> 00:32:20,390 That certain activity needs certain things carry this and that this translates into a certain portion. 276 00:32:20,390 --> 00:32:31,020 But we often don't choose to act on us. And so when Chris tries to give it some quantification. 277 00:32:31,020 --> 00:32:39,390 It tries to enable us to understand the underpinnings of prevention in that. 278 00:32:39,390 --> 00:32:53,370 And so I want to say that it's a brave attempt, and I think we've really captured it quite well in the way in which you vertically related. 279 00:32:53,370 --> 00:33:06,480 The nature and the dialectic between prevention and treatment and in cutting the costs and the costs and not just financial, 280 00:33:06,480 --> 00:33:17,790 but they are a whole range of costs associated with risks associated with hazard and associated with time. 281 00:33:17,790 --> 00:33:28,440 And you've shown us how closely intertwined gave us a better appreciation of what leads to prevention. 282 00:33:28,440 --> 00:33:42,060 So I would like to just commend you for taking on very bravely this this challenging topic and for sharing those insights with us. 283 00:33:42,060 --> 00:33:46,170 I can just tell you from my own experiences, 284 00:33:46,170 --> 00:33:56,570 I just touch on the XDR TB outbreak that I was involved in actually at the Church of Scotland hospital in together a very. 285 00:33:56,570 --> 00:33:59,900 Add together very well, 286 00:33:59,900 --> 00:34:18,650 we are a whole team led by Jerry Friedland have created a new way of trying to involve patients who had HIV and TB in engaging them in their disease. 287 00:34:18,650 --> 00:34:29,500 And so one of the things that we did and Gerry really initiated this was he got the HIV patients to sit together. 288 00:34:29,500 --> 00:34:38,080 And to pack the ponies into PO boxes so that they wouldn't forget to take the antiretrovirals. 289 00:34:38,080 --> 00:34:45,250 And so they he created a little car. They became good friends, they spoke and they interacted with a lot. 290 00:34:45,250 --> 00:34:54,100 And the next thing what started off was a really good idea led to an outbreak and that 291 00:34:54,100 --> 00:35:03,940 we saw fifty three of their patients or patients that were in the HIV clinic get XDR. 292 00:35:03,940 --> 00:35:16,090 Now, why did that lead to a global uproar, given you know, such a small event is not even the jumbo jet? 293 00:35:16,090 --> 00:35:23,740 It was for two reasons. The one, I think very cleverly. 294 00:35:23,740 --> 00:35:33,700 They didn't call the disease e the R T B, they didn't call it extensively, use the E, 295 00:35:33,700 --> 00:35:42,970 they use the X, and then that's the way in which it was phrased was it created an intrigue. 296 00:35:42,970 --> 00:35:48,520 It created a sense of fear, a little bit of fear. There's an x factor here. 297 00:35:48,520 --> 00:35:57,730 And the second was the high mortality that basically almost everybody died because this is a lethal condition. 298 00:35:57,730 --> 00:36:08,590 And even though the episode and the disease itself is not a very common condition compared to, say, drug sensitive TB, 299 00:36:08,590 --> 00:36:18,400 it was the benefits and the costs and the way in which the hazard was viewed, especially in the city in that time frame. 300 00:36:18,400 --> 00:36:24,310 As you pointed out, most of the people died in the first two to three weeks. 301 00:36:24,310 --> 00:36:39,670 And so the way in which we can better understand the role of prevention is to better understand how people at an individual level appreciate us, 302 00:36:39,670 --> 00:36:45,380 appreciate hazard and peace the two together within the common time. 303 00:36:45,380 --> 00:36:50,790 Mm hmm. Yeah. Well, I just making one point. 304 00:36:50,790 --> 00:36:57,430 And that is that. We are increasingly seeing. 305 00:36:57,430 --> 00:37:08,410 The the the distinction between prevention and cure becoming blurred now, 306 00:37:08,410 --> 00:37:16,360 the distinction between prevention and cure in in diseases like sexually transmitted infections. 307 00:37:16,360 --> 00:37:23,110 Pretty much treatment is prevention. You you'd the person who's got the disease and they don't transmit it. 308 00:37:23,110 --> 00:37:30,800 And that's been the basis of much of our prevention activities for sexually transmitted infections and HIV. 309 00:37:30,800 --> 00:37:35,710 We've gone the same route. We we don't draw that distinction anymore. 310 00:37:35,710 --> 00:37:40,060 In fact, the dichotomy is not particularly helpful. 311 00:37:40,060 --> 00:37:46,900 And you you've led us at a global level in our efforts to get global TB control. 312 00:37:46,900 --> 00:37:57,810 TB is yet another disease where identification and treatment is really a cornerstone of our prevention. 313 00:37:57,810 --> 00:38:08,520 And so I think that where you've got individual benefit, because that's the difference between prevention, treatment and prevention, 314 00:38:08,520 --> 00:38:14,370 we're really hoping to give a lot of people a certain intervention and hope that they will 315 00:38:14,370 --> 00:38:20,250 benefit from it because we're not sure if they actually want to get the harmful effects. 316 00:38:20,250 --> 00:38:29,190 Whereas in treatment, you've got the harmful effect, you know, you were the unlucky winner and that you will benefit from the cheap cure. 317 00:38:29,190 --> 00:38:39,600 So that distinction gets blurred when the two go together and the concepts of risk and has a change in that context. 318 00:38:39,600 --> 00:38:47,280 And I'd like you to just comment on that issue because I think it's going to become increasingly so. 319 00:38:47,280 --> 00:38:57,600 It's not the case now, for example, with COVID 19, but you know, we are moving in that direction towards antivirals. 320 00:38:57,600 --> 00:39:02,190 So I'll stop there. I'm just put up as one of the problems we might. 321 00:39:02,190 --> 00:39:06,030 Terrible. Yes, I think you're right. It doesn't. 322 00:39:06,030 --> 00:39:14,490 It doesn't apply to COVID because, well, first of all, the paucity of good treatments and the good treatments are the best. 323 00:39:14,490 --> 00:39:22,920 Treatments are essentially for people in hospital who are isolated from the chain of transmission and their treatments, 324 00:39:22,920 --> 00:39:34,110 which are not anti-infective in character, for example, that dexamethasone for for for COVID, but for for tuberculosis and for HIV. 325 00:39:34,110 --> 00:39:39,090 As you say, treatment as prevention has become a mainstay. 326 00:39:39,090 --> 00:39:46,110 Thankfully, because for those people who would look at what happened on Kofod and said, 327 00:39:46,110 --> 00:39:50,730 Well, why don't we just have vaccines for tuberculosis and HIV? 328 00:39:50,730 --> 00:40:01,500 Well, there is a perception of has it, as I discussed and you've reiterated, but it's actually just very difficult to make scientifically. 329 00:40:01,500 --> 00:40:07,320 Technically, it's very difficult to make vaccines against TB and HIV. 330 00:40:07,320 --> 00:40:14,940 And so we don't have that neat protective mechanism preventive mechanism that vaccines potentially offer. 331 00:40:14,940 --> 00:40:19,650 Although there are we are on the way to having partially effective vaccines, 332 00:40:19,650 --> 00:40:26,310 at least for TB, possibly not yet for HIV, but we vaccination is not really an option. 333 00:40:26,310 --> 00:40:34,200 And so far and what we're what we're talking about with regard to prevention going beyond treatment as prevention, 334 00:40:34,200 --> 00:40:38,160 so the treatments that kill the pathogens and stop transmission, 335 00:40:38,160 --> 00:40:46,230 what we're talking about are much more difficult interventions, social interventions, for example, for HIV. 336 00:40:46,230 --> 00:40:52,800 I'm sure you've had much experience of them. How do you prevent transmission in the first place? 337 00:40:52,800 --> 00:41:03,090 You know, the condom is actually the perfect method of prevention if it could be used if people used it properly. 338 00:41:03,090 --> 00:41:09,840 And yet it's essentially failed as a method of controlling HIV, a preventive method for HIV. 339 00:41:09,840 --> 00:41:15,580 Would you agree? Yeah, you touched on a key issue in that. 340 00:41:15,580 --> 00:41:22,360 We've spent many years start promoting condoms for HIV some 35 years ago, 341 00:41:22,360 --> 00:41:33,570 and I over the years began to understand that we actually did quite well in increasing condom use. 342 00:41:33,570 --> 00:41:41,670 The problem was condoms were used mainly by those who were at lower risk. 343 00:41:41,670 --> 00:41:47,610 Yeah, and those were at high risk of not using the condoms. 344 00:41:47,610 --> 00:41:58,830 So it's a mismatch between who we would like to use the intervention and who actually does it because it's come as is commonplace in public health. 345 00:41:58,830 --> 00:42:04,530 But let me ask you slimmer direct a more direct question, if I may. 346 00:42:04,530 --> 00:42:11,940 I mean, apart from treatment and prevention for HIV, the antiretrovirals are miraculous, frankly. 347 00:42:11,940 --> 00:42:16,050 They really are miraculous, and they should still be considered in that way. 348 00:42:16,050 --> 00:42:22,320 But what are the preventive mechanisms are really viable. Condoms don't really work. 349 00:42:22,320 --> 00:42:28,470 Educational mechanisms have limited value in my understanding. 350 00:42:28,470 --> 00:42:32,760 So social mechanisms don't really work either. 351 00:42:32,760 --> 00:42:41,430 We have circumcision as a potential, as a sort of rather dramatic intervention in my perception anyway, 352 00:42:41,430 --> 00:42:44,520 which has a degree of efficacy and that's been tried as well. 353 00:42:44,520 --> 00:42:53,550 But where where is the future of prevention in HIV, if not in vaccination, if not in condom use, if social interventions are difficult? 354 00:42:53,550 --> 00:43:01,290 Where do we now stand? Because although HIV actually the one thing I perhaps should have said is that TB 355 00:43:01,290 --> 00:43:07,710 is the the chapter heading in which I discuss TB is called normal ways to die, 356 00:43:07,710 --> 00:43:12,090 and TB has been different from HIV for a long time. 357 00:43:12,090 --> 00:43:20,520 In that the HIV was profiled as an emergency as indeed it was, but it no longer really is being considered as an emergency. 358 00:43:20,520 --> 00:43:30,720 It is also being considered as a way of life, which seems to me to be a risk in terms of the diminishing perception of HIV, as has it. 359 00:43:30,720 --> 00:43:36,390 But. So where do you think we're going on HIV prevention? 360 00:43:36,390 --> 00:43:47,010 Well, it's interesting you raise that point because actually we've been steadily lagging behind in HIV prevention over the last five years. 361 00:43:47,010 --> 00:43:57,450 We've made almost no impact. I would describe it as globally our efforts to prevent HIV stop. 362 00:43:57,450 --> 00:44:03,600 I mean, we saw five years ago about 1.8 million new infections. 363 00:44:03,600 --> 00:44:08,970 In the last year, we saw about 1.7 million new infections. 364 00:44:08,970 --> 00:44:14,610 So we're really not making headway. And I think fundamentally, 365 00:44:14,610 --> 00:44:29,490 it's because we don't really have a prevention technology or a prevention approach to get to the heart of where most new infections are occurring. 366 00:44:29,490 --> 00:44:32,490 The most new infections are coming into rooms. 367 00:44:32,490 --> 00:44:40,590 And I'll just focus on one of the two for that to save time, which is 70 per cent of all HIV is in Africa. 368 00:44:40,590 --> 00:44:53,430 In Africa, the primary driving force of new infections and HIV are older men having sex with average woman, and they're not that much different. 369 00:44:53,430 --> 00:45:03,750 They're about 10 years difference. So it's about men in their late 20s, early 30s, having sex with teenage girls and girls and their low 20s. 370 00:45:03,750 --> 00:45:12,300 And that is the main source of the infection because these men are having sex with women 371 00:45:12,300 --> 00:45:20,200 of their same age who have high prevalence and so they acquire HIV are asymptomatic. 372 00:45:20,200 --> 00:45:28,620 They've got high viral loads and in the heart on antiretroviral treatment because they haven't come in for a test yet. 373 00:45:28,620 --> 00:45:39,810 And many of them in that acute initial period are having sex with another partner and another young woman. 374 00:45:39,810 --> 00:45:49,050 And it's that situation, and it's about 40 percent of men in our context have a younger woman as the second partner. 375 00:45:49,050 --> 00:45:57,990 So that's the driving force that these young women acquire HIV from these men, they grow up, and when they get to their 30s, 376 00:45:57,990 --> 00:46:03,300 they in fact the next group of men in their 30s who infect the next group of teenage girls. 377 00:46:03,300 --> 00:46:09,960 And so the cycle continues. You have to break that cycle the way to break that cycle. 378 00:46:09,960 --> 00:46:17,880 I had to go to find the men who have acute infection challenge or you find the technology to give women, 379 00:46:17,880 --> 00:46:26,070 especially these young teenage girls, get them a technology that would protect now their prep. 380 00:46:26,070 --> 00:46:33,460 But each person in their right mind is going to take a daily tablet or disease they don't even think about. 381 00:46:33,460 --> 00:46:38,760 And if you're not thinking about it, then you'd have no motivation. It's very. 382 00:46:38,760 --> 00:46:47,880 And so we think that our current approach is to fail. And so we need to come up with new technologies just giving you this, taking you to your book. 383 00:46:47,880 --> 00:46:56,550 It's it's the way in which you look at the hazard, which is right and the way in which you look at the risk, which is not immediate. 384 00:46:56,550 --> 00:47:02,670 So all of those things come together in your analysis and the way you take us 385 00:47:02,670 --> 00:47:07,440 through this in your book enables us to analyse these kinds of situations. 386 00:47:07,440 --> 00:47:13,500 Yes, I feel I fear, however, that analysis is one thing. 387 00:47:13,500 --> 00:47:22,290 And of course, it's what I'm strongly promoting in the book that we need to take a rational approach to analysis along the lines that I've outlined. 388 00:47:22,290 --> 00:47:28,980 But of course, the analysis doesn't necessarily mean that we can come up with a conclusion without a better intervention. 389 00:47:28,980 --> 00:47:36,690 It will take us forward, I think, in having a better understanding of why we haven't succeeded so far. 390 00:47:36,690 --> 00:47:47,940 And what I'm suggesting to, well, several leaders in public health that I could think of is let's have less rhetoric, please. 391 00:47:47,940 --> 00:47:56,940 That's less aspirational stuff. And let's have more realistic analytical assessments of where we now stand with respect to prevention, 392 00:47:56,940 --> 00:48:01,110 because that's the way in which we're going to make progress if we can. 393 00:48:01,110 --> 00:48:11,010 But I think we're admitting here that TB and HIV is still different is still difficult, and we do have some tools, but they're quite hard to use. 394 00:48:11,010 --> 00:48:17,550 They're quite complicated, and the progress that we're making on both diseases is incremental. 395 00:48:17,550 --> 00:48:20,670 Perhaps we could put into the mix here. 396 00:48:20,670 --> 00:48:30,840 You know, the other member of the big three, which is malaria, and there have been exciting news recently that malaria vaccination is getting better. 397 00:48:30,840 --> 00:48:35,530 If malaria vaccines were like COVID vaccines, then that would be a. 398 00:48:35,530 --> 00:48:40,480 Game changer, as it would for HIV and TB as well. 399 00:48:40,480 --> 00:48:44,890 Slim, I'd like us to to try a couple of the questions that are being asked and pleased 400 00:48:44,890 --> 00:48:48,950 to see that the number of questions is increasing in the in the panel down here. 401 00:48:48,950 --> 00:48:56,290 So I'll start with number one and ask you to make a comment on it, and I will perhaps comment as well. 402 00:48:56,290 --> 00:49:02,020 And the question is Larry brilliant who you will perhaps then personally certainly be aware of, 403 00:49:02,020 --> 00:49:11,830 said that one of the obstacles to eradication of smallpox was the distrust of nurses administering the vaccine in certain countries. 404 00:49:11,830 --> 00:49:16,900 They were in fact not nurses, but they were spies or government officials, 405 00:49:16,900 --> 00:49:26,170 and a similar conspiracy was circulated that Microsoft had added a chip to the COVID 19 vaccine and and so on. 406 00:49:26,170 --> 00:49:30,100 This is, of course, a very good question, and it's very pertinent now. 407 00:49:30,100 --> 00:49:37,590 We already know with regard to COVID that there are conspiracy stories of that kind around the world. 408 00:49:37,590 --> 00:49:42,040 They're dominant in some countries. They probably exist in every country. 409 00:49:42,040 --> 00:49:50,260 Pakistan, in particular, is having a particular problem at the moment with the same kinds of stories, 410 00:49:50,260 --> 00:49:55,000 and I'm sure you've encountered it personally and what you've been doing with AIDS and other infections. 411 00:49:55,000 --> 00:50:11,910 What's your what's your response to that question? Yeah, the one thing is that, yeah, I have seen over the years the way in which misinformation. 412 00:50:11,910 --> 00:50:17,380 Can spiral out of control and in the COVID situation. 413 00:50:17,380 --> 00:50:21,250 The the perception of not Microsoft, 414 00:50:21,250 --> 00:50:31,840 but Bill Gates that is grand plan was to spread this virus so he can put in the vaccine a microchip 415 00:50:31,840 --> 00:50:38,920 because he's got nothing better to do than to follow all of us around it with microchips. 416 00:50:38,920 --> 00:50:48,100 So I think and and the more bizarre the story, the more traction it gets for some people. 417 00:50:48,100 --> 00:50:52,290 But what's what briefly do you think is the way to combat this? 418 00:50:52,290 --> 00:50:57,040 So the one thing is that the more I've been on television, 419 00:50:57,040 --> 00:51:09,820 radio and news trying to challenge it and trying to argue against it, the more people feel, it's rather the. 420 00:51:09,820 --> 00:51:17,200 So when you when you when you butt heads and you create attention. 421 00:51:17,200 --> 00:51:27,220 So I have generally gone the route of saying that it's not correct, but you can believe what you want to hear is where the facts are. 422 00:51:27,220 --> 00:51:33,370 So I don't yeah, I don't make it antagonistic. I just present an alternative. 423 00:51:33,370 --> 00:51:39,820 They don't have to agree to it. So that's what I mean. Yeah, that clearly is one way forward. 424 00:51:39,820 --> 00:51:50,860 Yeah. I mean, I would just relate some some of the actually many instances I had working on Ebola in West Africa where we would 425 00:51:50,860 --> 00:51:58,000 we would we would be confronted by a disbelieving population who wanted to carry out their own particular rituals, 426 00:51:58,000 --> 00:52:10,240 including exorcism, as a way of dealing with Ebola. And the I think the very sensible approach taken by W.H.O. was go go ahead and do an exorcism. 427 00:52:10,240 --> 00:52:14,230 We're not arguing you can believe in exorcism if you like. 428 00:52:14,230 --> 00:52:25,090 But what we want is that you don't handle bodies before you bury them because that is a major source of transmission of the way. 429 00:52:25,090 --> 00:52:34,360 The way into that is not through actually even local scientists explaining that fact, but rather community leaders, 430 00:52:34,360 --> 00:52:40,420 including religious leaders, explaining what needs to be done and making the associated changes. 431 00:52:40,420 --> 00:52:44,710 So it's trust. Trust is key to this and trust it to people. 432 00:52:44,710 --> 00:52:48,910 Conveying the message is clearly key to key as well. 433 00:52:48,910 --> 00:52:54,700 But of course, there are more dimensions to that question. I'm sure we'll see more examples on COVID. 434 00:52:54,700 --> 00:53:03,160 Let's turn to another question. This questions from Theresa Mahto. 435 00:53:03,160 --> 00:53:12,400 She says, I think it's moderate to me. Understanding the gap between the rhetoric of prevention and action is under theorised and understudied. 436 00:53:12,400 --> 00:53:18,520 Do you discuss in your book overcoming powerful commercial interests in making consumption of products that harm health, 437 00:53:18,520 --> 00:53:23,800 e.g. tobacco and alcohol and highly processed foods, and so on for fossil fuels? 438 00:53:23,800 --> 00:53:32,350 Well, the answer? The answer is yes in the sense that we have to confront the commercial interests because they 439 00:53:32,350 --> 00:53:39,280 are dominant partners in this and indeed a general point that wasn't made clear on the. 440 00:53:39,280 --> 00:53:45,820 The one analytical slide I showed is that we're not talking about decision making by one set of 441 00:53:45,820 --> 00:53:50,830 people or one individual person to the people whose health is at risk or even by governments. 442 00:53:50,830 --> 00:53:56,620 We're talking about a joint decision making by all of the people who have a stake in the outcome, 443 00:53:56,620 --> 00:54:05,380 including pharmaceutical industries, those people who manufacture tobacco, harmful foods and so on and so forth. 444 00:54:05,380 --> 00:54:17,500 And the discussion is the discussion is that we know many of the tools that are highly effective against commercial interests. 445 00:54:17,500 --> 00:54:25,660 And the number one is is taxation that influences people's behaviour enormously. 446 00:54:25,660 --> 00:54:33,430 It changes people's behaviour and it changes the perceptions also of manufacturers of harmful substances. 447 00:54:33,430 --> 00:54:43,960 The the issue is can you persuade governments to impose the necessary sanctions on those that are responsible when clearly they are powerful, 448 00:54:43,960 --> 00:54:47,530 influential, strong, strong lobbyists and so forth? 449 00:54:47,530 --> 00:54:53,740 So we're in a position with regard to those kinds of problems that we actually do have some good solutions. 450 00:54:53,740 --> 00:55:03,890 The problem is implementing those solutions and in the case of tobacco, even under an international convention in tobacco control. 451 00:55:03,890 --> 00:55:10,570 But let me try and find another one that might be suitable for you. 452 00:55:10,570 --> 00:55:23,430 Slim. OK, so before his one, how would you go about preventing a pandemic such as COVID 19? 453 00:55:23,430 --> 00:55:30,720 It seems quite uncontrollable since there have been so many variants, and this is a question from Sophia. 454 00:55:30,720 --> 00:55:36,810 So preventing pandemics like COVID highly topical, very much on people's minds, as I said. 455 00:55:36,810 --> 00:55:42,340 What's your view about preventing the next pandemic? 456 00:55:42,340 --> 00:55:52,330 So I won't go into too much detail on the variants, but I think it's just to be expected that a virus will mutate. 457 00:55:52,330 --> 00:55:56,770 And if you put pressure on the virus, it will try to escape that pressure. 458 00:55:56,770 --> 00:56:06,280 And as we vaccinate large numbers of individuals, we will find immunocompromised individuals who have been vaccinated, 459 00:56:06,280 --> 00:56:13,630 developing persistent infection and eventually leading to variants that can bypass vaccine immunity. 460 00:56:13,630 --> 00:56:19,780 I think that's something we have to be prepared for hoping that doesn't happen and we have to be prepared for it. 461 00:56:19,780 --> 00:56:25,540 So how do you prevent that? There's really a massive challenge in that. 462 00:56:25,540 --> 00:56:33,490 Yeah. And I would yeah, I would. You know, I would reinforce what you said is the issue is not so much around variants. 463 00:56:33,490 --> 00:56:38,140 I think those are those clearly are a difficulty with regard to COVID. 464 00:56:38,140 --> 00:56:42,160 And they will be and they are actually with regard to other viral diseases. 465 00:56:42,160 --> 00:56:45,640 We deal with that with influenza every transmission season. 466 00:56:45,640 --> 00:56:52,600 Of course, we're dealing with new variants and therefore we need new vaccines. And there's a pathway there forward for COVID as well. 467 00:56:52,600 --> 00:56:58,870 But I think one of the big debates about prevention that is still really unresolved 468 00:56:58,870 --> 00:57:03,220 we hear about a deep prevention is a term that's been used in the recent literature, 469 00:57:03,220 --> 00:57:11,560 where the argument is that if we want to prevent viral diseases from jumping out of animals and human populations, 470 00:57:11,560 --> 00:57:16,030 what we need to know is about viruses in animal populations. 471 00:57:16,030 --> 00:57:23,110 We need to know viruses in animal populations at source and assess the risks associated with those viruses. 472 00:57:23,110 --> 00:57:31,060 I think that's really a difficult call, actually, and very unlikely to be successful because we're really not good at all at 473 00:57:31,060 --> 00:57:37,840 predicting the risks or the reasons why pathogens jump out of animals into humans. 474 00:57:37,840 --> 00:57:49,960 I think what we need along those lines, the line of the slide that I showed all the eggs in one basket is that we need generic surveillance systems, 475 00:57:49,960 --> 00:57:59,350 for example, that can effectively spot at an early phase an outbreak of whatever pathogen it happens to be. 476 00:57:59,350 --> 00:58:05,560 And those need to be designed as rooted in public health services every day with 477 00:58:05,560 --> 00:58:11,890 surge capacity in countries when and where we see outbreaks of new infections. 478 00:58:11,890 --> 00:58:17,080 So I think that's the probably the way forward. Let's just we've got one minute left. 479 00:58:17,080 --> 00:58:25,450 I'm afraid we're running out of time. I'd really like to be able to answer all of these questions, but let's just take one. 480 00:58:25,450 --> 00:58:30,130 We could very quickly each have a go at in one sentence each, and it comes from Catarina. 481 00:58:30,130 --> 00:58:42,410 And she asks, how can the NHS or indeed any health service be persuaded to encourage people to have health checks before they fall ill? 482 00:58:42,410 --> 00:58:48,640 What's the situation, one sentence from South Africa is that the private sector in South Africa? 483 00:58:48,640 --> 00:58:57,920 Yeah, designing incentive schemes designed by Kevin Wolpe and others where you get points and you get benefits. 484 00:58:57,920 --> 00:59:05,490 If you do something by going to the gym, you swipe your card and gives you a certain number of points and you can use that to buy other things. 485 00:59:05,490 --> 00:59:10,460 So, yeah, incentive to create incentives. Yeah. 486 00:59:10,460 --> 00:59:15,050 And I think that part of the is not so much private sector in the in the UK. 487 00:59:15,050 --> 00:59:20,600 It's more public sector in NHS, of course, but incentives are clearly a part of that. 488 00:59:20,600 --> 00:59:26,630 Clearly, what's important is distinguishing between things that are worth screening for and are not worth screening for. 489 00:59:26,630 --> 00:59:30,050 And there's a big literature on that and some of it's discussed in the book, 490 00:59:30,050 --> 00:59:37,350 but there are strong recommendations that we want people to adhere to, such as screening for cervical cancer and so on. 491 00:59:37,350 --> 00:59:44,720 But we're out of time, I'm afraid, which is really a pity because there are lots more questions that have been posed them, 492 00:59:44,720 --> 00:59:53,000 which I would have liked to answer. But I just want to thank you in particular for joining me in this in this conversation. 493 00:59:53,000 --> 01:00:01,070 It's really been a pleasure to have you here and a real help. And thanks to everybody who's listened online and posed questions. 494 01:00:01,070 --> 01:00:04,910 And thanks, of course, to the Oxford Martin School for hosting this event. 495 01:00:04,910 --> 01:00:11,000 So thanks everybody and have a good evening, morning, afternoon wherever you are and take care. 496 01:00:11,000 --> 01:00:13,443 The COVID pandemic is not yet over.