Hello, everyone, and welcome to this evening's discussion discussion hosted by the Oxford Martin School.
My name's Chris Dai and I work as an epidemiologist here in Oxford, based in the zoology department.
And last year, I was visiting fellow at the Oxford Martin School.
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.
Professor Salim Abdool Karim, who is joining us from Durban in South Africa.
Slim has vast experience in epidemiology and an enormous amount of wisdom and wisdom on many aspects of public health.
He's the director of Capricia, the Centre for the AIDS Programme of Research in South Africa.
He's also a professor of global health at Columbia University in New York.
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.
And kudos to W.H.O. for making that appointment. W.H.O. being my former employer now, prevention is better than cure,
as we all know and everybody repeatedly says, and yet we don't often behave as if we really believe it.
And that's a fact that bothered me in the years that I worked at the World Health Organisation.
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.
And the book has just been published by Oxford University Press.
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.
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.
Then I'm going to ask Slim to give us his reflections on prevention in public health,
based on his experiences with HIV aids, with COVID and many other aspects of public health.
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.
Those of you who are following this on crowd cast will see a box bottom right hand screen which
allows you to post some questions yourself or if you don't want to ask a question yourself.
You can vote on the other questions and the questions that get the most votes tend to move towards
the top of the screen so we can choose Samini when we get round to opening this for questions,
we can choose which ones you collectively would like to have answered.
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.
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.
The book, called The Great Health Dilemma and The Dilemma, is in the subtitle Is Prevention Better Than Cure?
And Just a brief word about the cover a woman with a face mask, you should be able to see.
Face masks, of course, have been highly controversial as methods of prevention during the COVID pandemic, but this painting was not made during COVID.
It was made by Russian artist Paulina Senior Kina,
who unfortunately a few years ago contracted tuberculosis and found herself in
a Russian tuberculosis hospital being treated for an extended period of time.
And this is one of a series of really nice paintings called Hold Your Breath series, which you can find on the website.
I'm going to talk about COVID later in this presentation. I'm sure slim and I will talk about it together.
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.
This is one of the motivations, anyway. Take sanitation.
We've known how to do safe sanitation to protect people's health and dignity for a long time, four thousand years at least.
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.
But these scenes, which represent unsafe sanitation, are replicated across South Asia,
through Africa, through parts of Africa, parts of the Americas as well.
They represent a failure of safe sanitation and yet if we look at the left hand.
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.
This is an excavation of a communal sanitation system that is personal toilets,
a sewage system and the structure of that system indicates not just the technology that was used for sanitation,
but it also points to the social organisation of societies that lived in the Indus Valley at the time.
So we've been able to do this thing, this kind of thing, for about 4000 years.
So why are we not doing it today?
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?
And the answer is we're failing on prevention more generally.
I'll tell you a couple of stories about the statistics that lie behind that failure.
First of all, a standard set of statistics, which is useful but not quite true.
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.
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.
But only four percent of that is spent on prevention as distinct from curative treatment.
And the paradox there, or the conundrum is illustrated by what you see on the left hand side of this slide.
These are preventable causes of death,
large preventable causes of death grouped into three different types environmental causes
like the failure of sanitation causes associated with metabolic diseases like diabetes,
causes associated with behavioural factors such as persistent tobacco smoking,
which leads to lung cancer and many other cancers and other respiratory diseases.
And the red numbers in the second column show you the proportion of deaths attributable to those different categories preventable deaths.
And yet, as you see top right of this slide, only four percent is spent on prevention.
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,
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.
It doesn't account for spending outside health, which has implications for health.
So, for example, if you build a sanitation system which has many benefits,
the component due to health allocated to health is a very tiny fraction of overall spending.
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.
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.
But there isn't a system by which we can do that. We probably need one, but there isn't yet.
So here's my proxy analysis. This picture shows you an analysis for more than 100 different health conditions
of changes in mortality rate over the three decades from roughly 1990 to 2017.
They asked the question Is that change in mortality largely a reduction in mortality?
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.
Mortality is falling, but the graph asks the main question is that full in mortality, mainly due to a direct effect on mortality?
In other words, due to treatment? Or is it due to a reduction in incidence of those conditions, in other words, due to prevention?
So the two lines to look at are the horizontal line, which is pure cure and the the and the diagonal,
the one to one diagonal that runs bottom left to top right on this slide, which is pure prevention.
So you can see that, for example, for diarrhoeal diseases and what's labelled Eleri here, lower respiratory infections.
These are major sources of mortality in young children.
Most of the gains have been made by treatment, by curative treatment.
But consider some of the conditions along the diagonal like yellow fever, measles, rabies, diphtheria.
Most of the gains indeed, almost all of the gains have been made by reducing instance, so almost all of the reduction.
The mortality is due to reduction in instance, in other words, a reduction in prevention,
and if we take all of the results on this slide in aggregate, there are lots of individually interesting stories here.
But if we take all of the results on this slide in aggregate,
I calculate that about half of the reduction in mortality is due to prevention, and about half of it is due to cure.
Now that's that's not a costing exercise, as I said,
but it's pretty clear that much more is spent on prevention for the four percent that comes from the system of health accounts.
Even if it's 50 percent spent on prevention, there's still plenty of scope to do better.
And on this slide, I've identified different approaches to how we could do better.
They are different, but they're complementary. At the top, I've put what I've called the aspirational approach based on ideology,
and the quotation here comes from the opening paragraph of the of who's defining document.
The highest attainable standard of health.
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.
But when it comes down to what people really do in practise, I'd rather take an analytical approach.
What I've called a conditional approach an approach based on economics,
that the basic hypothesis is that what people essentially do is they consider the
costs and they consider the benefits of their actions and they act accordingly.
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.
And this opens, explains the argument a little bit more detail here.
Essentially, the argument is the proposition. It's a testable proposition.
I'm not saying the argument on this slide is absolutely correct. It's a testable proposition.
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.
If the cost is very high in relation to the benefit, then we'll postpone prevention and rely on cure.
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.
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,
then the benefit of removing that hazard is going to be large.
And if we can do it at relatively low cost, then we will be inclined to do it.
And when I refer to cost here, I don't just mean monetary cost.
I mean effort information, the time that's taken to invest in it.
I mean, willpower, for example, with regard to giving up cigarette smoking or changing one's diet or changing what Richard wants regiment activity.
But if the cost is low in relation to the benefit, that will tend to favour prevention,
and that's what we would expect to see more prevention and less reliance on curative treatment.
So in the book, I have examined six different challenges for prevention, and you see the man pictured here.
Health services in the context of health services, health services like the National Health Service in the UK, preventing epidemics,
controlling endemic infectious diseases, chronic non-communicable diseases, sanitation that have already alluded to and climate.
And in this brief presentation, I'm going to focus on three of these things.
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.
Let's start with risk, and let's start with perhaps.
The most important risk of the moment COVID 19,
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,
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.
But published a couple of days ago, is one that's really worth reading,
which comes from the show's independent panel for pandemic preparedness and Response.
It's called COVID 19 make it the last pandemic, and there are many good things in this,
and there are many good things in the background papers which are also worth reading.
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.
They say, for example, that there's a case for assuming without knowing if it's true that human to human transmission
of an emerging pathogen will occur unless there's evidence that indicates otherwise.
Well, the precautionary principle errs towards prevention.
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.
It may well be worth it, and it may be worth it in the way that the independent panel has described.
But there are alternatives, and let me point you to one of them.
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.
X W.H.O. lists a set of pathogens which are likely to be threats in future caused major epidemics, even pandemics.
They include diseases like Ebola virus, Zika virus, Lassa fever and so on.
But at the bottom of that list is the unknown disease.
The next potential big one, the one that we think will happen, but we don't know what it is at the moment.
Zika virus was a disease X, so one approach to this is to consider each of these pathogens as they arise independently.
We've often heard it said that COVID 19 is a once in a century pandemic.
I think that's the wrong way to look at it. What we know from W.H.O. data and others.
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.
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.
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.
That's just what an insurance company would do.
What's also interesting about the W.H.O. data is how little variation there is from year to year over those years.
The variation in the number of events was only in the range 154 to 213, highly predictable, about 200 events each year.
And that's a basis for establishing systems that will respond to not a single pathogen,
but a whole variety of different pathogens corrected collectively. And there are no proposals in which we can.
But ways in which we could do that. One of them is illustrated on the right hand side of this slide here.
The the lines at the top right of the slide show an outbreak.
Essentially, they're different colours, but let's just say that's an outbreak.
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,
whether it's going to be a drug, whether it's going to be a vaccine.
We do preclinical investigations, we test out a candidate, we do clinical investigations.
Then we think about manufacturing what we need to do.
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.
Built on technology platforms built on generic regulatory processes that can be quickly scaled up for use,
built on generic manufacturing processes, which can also be scaled up to use and fresh from the success with COVID vaccines,
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,
which of course, is far, far faster than has ever been achieved prior to prior to COVID.
So that's that's an alternative idea for preventing risks, pool the risks and share the costs.
Let's now move to Hassett, and this is the part where I talk about tuberculosis,
the disease that I've probably spent more years working on than any other.
The publicity around tuberculosis is rather consistent and rather unsuccessful.
Here's a typical slogan at the top of this slide. Tuberculosis kills someone every 18 seconds.
The problem with TB is that it's become so familiar it's considered to be a feature of everyday life.
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.
About 1.3 million more than that if we consider people who have HIV positive as well.
About 1.3 million in terms of the number of jumbo jets that would need to crash.
But this completely misses the point about the perception of Hassett.
People are not frightened of tuberculosis because it is so familiar they are very frightened of dying in air crashes,
and even one jumbo jet is enough to stimulate the world's media.
Almost every plane crash is an item for.
World news around the world,
and that's because the hazards associated with flying are perceived to be totally different from the hazards associated with tuberculosis,
even though far, far more people die each year of TB than they do from plane crashes.
Indeed, that perception of Hazard with regard to flying is one of the reasons why international travel by air is so safe these days.
Let me amplify this a little bit more with a table that I created after the West
African Ebola epidemic that I was closely associated with in 2014 and 2015.
I was struck coming from tuberculosis about the similarities and differences in spending and effects and deaths, and they're summarised in this table.
So this is Ebola for West Africa. That's three countries, principally Guinea, Sierra Leone and Liberia.
And it's compared with tuberculosis globally. So expenditure about $6 billion in each case, total economic costs about 40 or $50 billion,
roughly the same total deaths in West Africa, about 10000 in each case.
But the key difference here is that for tuberculosis, the expenditure and the economics refer to what's happening globally.
The 1.3 million deaths. Whereas for Ebola, they refer only to the 10000 deaths in West Africa.
In other words, in this sense, there's a completely different perception of hazard between Ebola and tuberculosis.
And what I want to ask you is that tuberculosis becomes much more interesting when it starts looking like Ebola.
And that's something for those who want to portray Hazard publicly to bear in mind.
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.
This was an incident that took place at two Glenferrie in KwaZulu Natal.
I since learnt that Tougaloo is actually a Zulu word that stands for or is translated roughly as something that startles.
And the startling event that took place at the time was the emergence of a new strain of what was called XDR TB.
This is not W.H.O. disease x here. This is X that stands for extensively drug resistant tuberculosis.
This is TB disease that is resistant to both the first and second line drugs.
And the really startling and tragic incident here took place in a hospital at Tougaloo Ferry,
which was largely populated by HIV positive patients at the time.
Once tuberculosis XDR tuberculosis got onto this ward, it spread quickly.
52 or 53 patients on the ward died and half of them within 60 days.
And as a consequence of that, that incident 53 deaths amongst the millions of deaths across the African continent from tuberculosis that got
the world to sit up and take notice of drug resistant tuberculosis and indeed tuberculosis more generally.
So part of the story for TB, TB, not all of it. There's much more to it as you read in the book.
But part of the story about TB is the problem of how it is perceived as a hazard.
The third thing that I'll comment on is the time factor, the discount time factor.
The point about time is that we value events that take place now or very soon.
We tend to devalue events that are likely to happen or might not even happen a long time in the future.
And that's a major problem with regard to prevention.
So let me just give you one example here with reference to climate change.
The challenge for a challenge for climate change is that whilst more and more people are
aware that climate change is real and more and more people are clearly seeing its effects,
there is still the very strong view that climate change is something that's going to happen in the future.
And for many people, it's not quite clear what will happen in the future.
So this is a way to bring it into the present. The argument here is an argument about co-benefits.
It makes the observation that air pollution is a combination of things.
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,
sulphur dioxide and so on. Air pollution has in its own right, never mind the greenhouse gases.
Air pollution has an.
Vanishingly large mortality associated with it each year, if we count deaths associated with indoor as well as outdoor air pollution,
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.
About half of that is due to external air pollution.
The picture, incidentally, is actually from a Bryan Adams concert Typekit that took place outdoors in New Delhi in 2018.
The air pollution was so intense that backlighting from his stage.
Portrayed his shadow onto an air pollution crowd,
and that's where you can see the shadow of Bryan Adams projected behind the crowd attending this concert.
But the point about air pollution is that if we cut air pollution.
The sources of air pollution, we can have an effect quickly, both in cleaning up the air,
we've seen how clean the air has become during lockdown and the.
We can have an effect on cleaning up the air and we can have an effect on health very rapidly.
In other words, we can bring the health effects more or less into the present.
And the consequence of that is a reduction also in greenhouse gases, which mitigates the effect of climate change.
Will people buy the argument? Well, there are a number of different ways of looking at it.
There are good news and bad news in this regard, but I sense that there's more good news,
the bad news these days that the powerbrokers in the energy industry,
those people who are very significantly responsible for greenhouse gas emissions are really and their pollution are really beginning to get it.
This is an annual survey published by the World Economic Forum.
It's a rather informal survey,
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,
the had had an equation on it.
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.
When both are high, the threat is high when the threat is high.
There is a stimulus for action provided action can be taken at the right cost,
so you can see the big items that have failed climate action, biodiversity loss, extreme weather conditions, natural disasters and so on.
There is a growing sense amongst the powerbrokers in business and industry that these are existential threats.
The challenge for the health community is to get health into the mix here, get health into those arguments.
There are health consequences to all of the things at top right on this slide.
And yet those health consequences are insufficiently mentioned. That's a that's a challenge that the health community faces now.
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,
in other words, in voiding illness or death or causes of illness and death in future, we also need to be talking about promotion.
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.
We need to be talking, in short, about health promotion.
In other words, promoting good health as well as avoiding illness that might happen in future.
And this is one nice example that I've discussed at some length in the book.
It really is a fine illustration of promotion, and it illustrates many of the features where health promotion works.
This is the parkrun scheme that was started a few years ago and has spread rapidly around the world.
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.
They do it because it's sociable, it's free, it's fun.
It's great to be outdoors and everyone can be involved.
Parkrun has taken a hit under COVID, of course, because congregations of large people have been disallowed.
But I, for one, hope that parkrun gets back up on its feet again as we come to the end of this pandemic.
But this is just to say, finally, that we need to be thinking about promoting good health as well as avoiding illness in future.
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,
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.
But we'd rather need to understand why it is that people fail on prevention or or prefer not
to choose prevention and prefer to opt for waiting for illness and hoping for a cure instead.
I've taken a rather rational approach to that, but I think a rational approach is the way forward.
So with that, I'm going to stop here and I'm going to turn to stop sharing my screen,
and I'm going to turn back to Slim because I'm really interested to hear slim your views about prevention
and public health based on your experiences and actually whether you have any reflections on that incident.
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.
So over to you. Thanks very much, Chris.
So let me just start by just making some general observations and that.
Christmas decided in this book. You take on quite a difficult challenge.
In that. We all essentially understand.
That certain activity needs certain things carry this and that this translates into a certain portion.
But we often don't choose to act on us. And so when Chris tries to give it some quantification.
It tries to enable us to understand the underpinnings of prevention in that.
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.
The nature and the dialectic between prevention and treatment and in cutting the costs and the costs and not just financial,
but they are a whole range of costs associated with risks associated with hazard and associated with time.
And you've shown us how closely intertwined gave us a better appreciation of what leads to prevention.
So I would like to just commend you for taking on very bravely this this challenging topic and for sharing those insights with us.
I can just tell you from my own experiences,
I just touch on the XDR TB outbreak that I was involved in actually at the Church of Scotland hospital in together a very.
Add together very well,
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.
And so one of the things that we did and Gerry really initiated this was he got the HIV patients to sit together.
And to pack the ponies into PO boxes so that they wouldn't forget to take the antiretrovirals.
And so they he created a little car. They became good friends, they spoke and they interacted with a lot.
And the next thing what started off was a really good idea led to an outbreak and that
we saw fifty three of their patients or patients that were in the HIV clinic get XDR.
Now, why did that lead to a global uproar, given you know, such a small event is not even the jumbo jet?
It was for two reasons. The one, I think very cleverly.
They didn't call the disease e the R T B, they didn't call it extensively, use the E,
they use the X, and then that's the way in which it was phrased was it created an intrigue.
It created a sense of fear, a little bit of fear. There's an x factor here.
And the second was the high mortality that basically almost everybody died because this is a lethal condition.
And even though the episode and the disease itself is not a very common condition compared to, say, drug sensitive TB,
it was the benefits and the costs and the way in which the hazard was viewed, especially in the city in that time frame.
As you pointed out, most of the people died in the first two to three weeks.
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,
appreciate hazard and peace the two together within the common time.
Mm hmm. Yeah. Well, I just making one point.
And that is that. We are increasingly seeing.
The the the distinction between prevention and cure becoming blurred now,
the distinction between prevention and cure in in diseases like sexually transmitted infections.
Pretty much treatment is prevention. You you'd the person who's got the disease and they don't transmit it.
And that's been the basis of much of our prevention activities for sexually transmitted infections and HIV.
We've gone the same route. We we don't draw that distinction anymore.
In fact, the dichotomy is not particularly helpful.
And you you've led us at a global level in our efforts to get global TB control.
TB is yet another disease where identification and treatment is really a cornerstone of our prevention.
And so I think that where you've got individual benefit, because that's the difference between prevention, treatment and prevention,
we're really hoping to give a lot of people a certain intervention and hope that they will
benefit from it because we're not sure if they actually want to get the harmful effects.
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.
So that distinction gets blurred when the two go together and the concepts of risk and has a change in that context.
And I'd like you to just comment on that issue because I think it's going to become increasingly so.
It's not the case now, for example, with COVID 19, but you know, we are moving in that direction towards antivirals.
So I'll stop there. I'm just put up as one of the problems we might.
Terrible. Yes, I think you're right. It doesn't.
It doesn't apply to COVID because, well, first of all, the paucity of good treatments and the good treatments are the best.
Treatments are essentially for people in hospital who are isolated from the chain of transmission and their treatments,
which are not anti-infective in character, for example, that dexamethasone for for for COVID, but for for tuberculosis and for HIV.
As you say, treatment as prevention has become a mainstay.
Thankfully, because for those people who would look at what happened on Kofod and said,
Well, why don't we just have vaccines for tuberculosis and HIV?
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.
Technically, it's very difficult to make vaccines against TB and HIV.
And so we don't have that neat protective mechanism preventive mechanism that vaccines potentially offer.
Although there are we are on the way to having partially effective vaccines,
at least for TB, possibly not yet for HIV, but we vaccination is not really an option.
And so far and what we're what we're talking about with regard to prevention going beyond treatment as prevention,
so the treatments that kill the pathogens and stop transmission,
what we're talking about are much more difficult interventions, social interventions, for example, for HIV.
I'm sure you've had much experience of them. How do you prevent transmission in the first place?
You know, the condom is actually the perfect method of prevention if it could be used if people used it properly.
And yet it's essentially failed as a method of controlling HIV, a preventive method for HIV.
Would you agree? Yeah, you touched on a key issue in that.
We've spent many years start promoting condoms for HIV some 35 years ago,
and I over the years began to understand that we actually did quite well in increasing condom use.
The problem was condoms were used mainly by those who were at lower risk.
Yeah, and those were at high risk of not using the condoms.
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.
But let me ask you slimmer direct a more direct question, if I may.
I mean, apart from treatment and prevention for HIV, the antiretrovirals are miraculous, frankly.
They really are miraculous, and they should still be considered in that way.
But what are the preventive mechanisms are really viable. Condoms don't really work.
Educational mechanisms have limited value in my understanding.
So social mechanisms don't really work either.
We have circumcision as a potential, as a sort of rather dramatic intervention in my perception anyway,
which has a degree of efficacy and that's been tried as well.
But where where is the future of prevention in HIV, if not in vaccination, if not in condom use, if social interventions are difficult?
Where do we now stand? Because although HIV actually the one thing I perhaps should have said is that TB
is the the chapter heading in which I discuss TB is called normal ways to die,
and TB has been different from HIV for a long time.
In that the HIV was profiled as an emergency as indeed it was, but it no longer really is being considered as an emergency.
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.
But. So where do you think we're going on HIV prevention?
Well, it's interesting you raise that point because actually we've been steadily lagging behind in HIV prevention over the last five years.
We've made almost no impact. I would describe it as globally our efforts to prevent HIV stop.
I mean, we saw five years ago about 1.8 million new infections.
In the last year, we saw about 1.7 million new infections.
So we're really not making headway. And I think fundamentally,
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.
The most new infections are coming into rooms.
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.
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.
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.
And that is the main source of the infection because these men are having sex with women
of their same age who have high prevalence and so they acquire HIV are asymptomatic.
They've got high viral loads and in the heart on antiretroviral treatment because they haven't come in for a test yet.
And many of them in that acute initial period are having sex with another partner and another young woman.
And it's that situation, and it's about 40 percent of men in our context have a younger woman as the second partner.
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,
they in fact the next group of men in their 30s who infect the next group of teenage girls.
And so the cycle continues. You have to break that cycle the way to break that cycle.
I had to go to find the men who have acute infection challenge or you find the technology to give women,
especially these young teenage girls, get them a technology that would protect now their prep.
But each person in their right mind is going to take a daily tablet or disease they don't even think about.
And if you're not thinking about it, then you'd have no motivation. It's very.
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.
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.
So all of those things come together in your analysis and the way you take us
through this in your book enables us to analyse these kinds of situations.
Yes, I feel I fear, however, that analysis is one thing.
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.
But of course, the analysis doesn't necessarily mean that we can come up with a conclusion without a better intervention.
It will take us forward, I think, in having a better understanding of why we haven't succeeded so far.
And what I'm suggesting to, well, several leaders in public health that I could think of is let's have less rhetoric, please.
That's less aspirational stuff. And let's have more realistic analytical assessments of where we now stand with respect to prevention,
because that's the way in which we're going to make progress if we can.
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.
They're quite complicated, and the progress that we're making on both diseases is incremental.
Perhaps we could put into the mix here.
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.
If malaria vaccines were like COVID vaccines, then that would be a.
Game changer, as it would for HIV and TB as well.
Slim, I'd like us to to try a couple of the questions that are being asked and pleased
to see that the number of questions is increasing in the in the panel down here.
So I'll start with number one and ask you to make a comment on it, and I will perhaps comment as well.
And the question is Larry brilliant who you will perhaps then personally certainly be aware of,
said that one of the obstacles to eradication of smallpox was the distrust of nurses administering the vaccine in certain countries.
They were in fact not nurses, but they were spies or government officials,
and a similar conspiracy was circulated that Microsoft had added a chip to the COVID 19 vaccine and and so on.
This is, of course, a very good question, and it's very pertinent now.
We already know with regard to COVID that there are conspiracy stories of that kind around the world.
They're dominant in some countries. They probably exist in every country.
Pakistan, in particular, is having a particular problem at the moment with the same kinds of stories,
and I'm sure you've encountered it personally and what you've been doing with AIDS and other infections.
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.
Can spiral out of control and in the COVID situation.
The the perception of not Microsoft,
but Bill Gates that is grand plan was to spread this virus so he can put in the vaccine a microchip
because he's got nothing better to do than to follow all of us around it with microchips.
So I think and and the more bizarre the story, the more traction it gets for some people.
But what's what briefly do you think is the way to combat this?
So the one thing is that the more I've been on television,
radio and news trying to challenge it and trying to argue against it, the more people feel, it's rather the.
So when you when you when you butt heads and you create attention.
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.
So I don't yeah, I don't make it antagonistic. I just present an alternative.
They don't have to agree to it. So that's what I mean. Yeah, that clearly is one way forward.
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
we would we would be confronted by a disbelieving population who wanted to carry out their own particular rituals,
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.
We're not arguing you can believe in exorcism if you like.
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.
The way into that is not through actually even local scientists explaining that fact, but rather community leaders,
including religious leaders, explaining what needs to be done and making the associated changes.
So it's trust. Trust is key to this and trust it to people.
Conveying the message is clearly key to key as well.
But of course, there are more dimensions to that question. I'm sure we'll see more examples on COVID.
Let's turn to another question. This questions from Theresa Mahto.
She says, I think it's moderate to me. Understanding the gap between the rhetoric of prevention and action is under theorised and understudied.
Do you discuss in your book overcoming powerful commercial interests in making consumption of products that harm health,
e.g. tobacco and alcohol and highly processed foods, and so on for fossil fuels?
Well, the answer? The answer is yes in the sense that we have to confront the commercial interests because they
are dominant partners in this and indeed a general point that wasn't made clear on the.
The one analytical slide I showed is that we're not talking about decision making by one set of
people or one individual person to the people whose health is at risk or even by governments.
We're talking about a joint decision making by all of the people who have a stake in the outcome,
including pharmaceutical industries, those people who manufacture tobacco, harmful foods and so on and so forth.
And the discussion is the discussion is that we know many of the tools that are highly effective against commercial interests.
And the number one is is taxation that influences people's behaviour enormously.
It changes people's behaviour and it changes the perceptions also of manufacturers of harmful substances.
The the issue is can you persuade governments to impose the necessary sanctions on those that are responsible when clearly they are powerful,
influential, strong, strong lobbyists and so forth?
So we're in a position with regard to those kinds of problems that we actually do have some good solutions.
The problem is implementing those solutions and in the case of tobacco, even under an international convention in tobacco control.
But let me try and find another one that might be suitable for you.
Slim. OK, so before his one, how would you go about preventing a pandemic such as COVID 19?
It seems quite uncontrollable since there have been so many variants, and this is a question from Sophia.
So preventing pandemics like COVID highly topical, very much on people's minds, as I said.
What's your view about preventing the next pandemic?
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.
And if you put pressure on the virus, it will try to escape that pressure.
And as we vaccinate large numbers of individuals, we will find immunocompromised individuals who have been vaccinated,
developing persistent infection and eventually leading to variants that can bypass vaccine immunity.
I think that's something we have to be prepared for hoping that doesn't happen and we have to be prepared for it.
So how do you prevent that? There's really a massive challenge in that.
Yeah. And I would yeah, I would. You know, I would reinforce what you said is the issue is not so much around variants.
I think those are those clearly are a difficulty with regard to COVID.
And they will be and they are actually with regard to other viral diseases.
We deal with that with influenza every transmission season.
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.
But I think one of the big debates about prevention that is still really unresolved
we hear about a deep prevention is a term that's been used in the recent literature,
where the argument is that if we want to prevent viral diseases from jumping out of animals and human populations,
what we need to know is about viruses in animal populations.
We need to know viruses in animal populations at source and assess the risks associated with those viruses.
I think that's really a difficult call, actually, and very unlikely to be successful because we're really not good at all at
predicting the risks or the reasons why pathogens jump out of animals into humans.
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,
for example, that can effectively spot at an early phase an outbreak of whatever pathogen it happens to be.
And those need to be designed as rooted in public health services every day with
surge capacity in countries when and where we see outbreaks of new infections.
So I think that's the probably the way forward. Let's just we've got one minute left.
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.
We could very quickly each have a go at in one sentence each, and it comes from Catarina.
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?
What's the situation, one sentence from South Africa is that the private sector in South Africa?
Yeah, designing incentive schemes designed by Kevin Wolpe and others where you get points and you get benefits.
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.
So, yeah, incentive to create incentives. Yeah.
And I think that part of the is not so much private sector in the in the UK.
It's more public sector in NHS, of course, but incentives are clearly a part of that.
Clearly, what's important is distinguishing between things that are worth screening for and are not worth screening for.
And there's a big literature on that and some of it's discussed in the book,
but there are strong recommendations that we want people to adhere to, such as screening for cervical cancer and so on.
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,
which I would have liked to answer. But I just want to thank you in particular for joining me in this in this conversation.
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.
And thanks, of course, to the Oxford Martin School for hosting this event.
So thanks everybody and have a good evening, morning, afternoon wherever you are and take care.
The COVID pandemic is not yet over.