Global health security: COVID19 and beyond

Dr Paul Vallet: Welcome to the Geneva Centre for Security Policy weekly podcast. I'm your host, Dr Paul Vallet, Associate Fellow in the Global Fellowship Initiative. For the past weeks this spring, I've been talking with subject matter experts to discuss issues of peace, security and international cooperation. Thanks for tuning in. In recent days, since this spring and the beginning of our weekly podcast, the rollout of vaccinations, however unequal in different parts of the world, has given us hope about the COVID 19 pandemic. It is also the time to reckon with other major public health questions that were side-lined by our preoccupations with the pandemic. As some of these concerns our everyday lives and can easily affect each of us and to remind us there are other ways to take care of ourselves, my guest today is Johanna Ralston, Johanna Ralston, who is currently the CEO of the World Obesity Foundation since 2017, has over 25 years’ experience in global health and development. She is a global leader in advocating for non-communicable diseases and a dual Swedish and US citizen. After training at the Harvard Business School and the Johns Hopkins Bloomberg School of Public Health. Her career took her  to the American Cancer Society, they were set up global programs on cancer and tobacco control projects in more than 30 countries. she proceeded on to the World Heart Foundation based in Geneva, which was appointed CEO in 2011. Working closely with the World Health Organization and other UN agencies tackling cardiovascular diseases. She was instrumental in implementing the Non-Communicable Diseases Declaration adopted that year and worked to place strong targets on cardiovascular disease mortality reduction in the WHO Global Action Plan, and the Sustainable Development Goals. She has worked and published with many institutions devoted to medicine and public health. And at least she's been a member of the GCSP Global Fellowship Initiative, for a few years now. So, it's nice to welcome you, Johanna, to the podcast. And thank you for speaking with us today.

Dr Johanna Ralston: Paul, it's wonderful to be here. Thank you so much. And it's a pleasure to see you again. As I have mentioned my time with GCSP as a fellow in 2017, was one of the best professional experiences of my life and has really broadened my thinking in ways that I hope are helpful for the work that I do. But even I can share how they've influenced my thinking on COVID and what has been going on recently.

Dr Paul Vallet: Glad to see you again. Johanna. My first question to you of courses as director of the World Obesity Foundation, what did you observe of the evolution and state of public health during these 16 months since the COVID pandemic was declared?

Dr Johanna Ralston: It's a great question. And it's certainly an understatement to say that the world was not prepared for a pandemic of COVID’s magnitude. And our public health systems were certainly not adequately prepared or resourced. I think one of the key points is that systems were not, for lack of a better term, talking to each other across borders, across countries or even within countries in ways that were helpful, not sharing data, often for political reasons, or having just different systems that were somehow incompatible. International Health Regulations IHR, as we know, is a tool that's meant to help sort of raise to the surface critical health security issues, but IHR itself could be best described as necessary, but not sufficient, in how information was shared. Helen Clark, who chaired the International Pandemic Preparedness Panel alongside Ellen Johnson Sirleaf to say, how do we avoid happening again, described IHR and the systems that were in places actually analogue systems in a digital world. So, we, on the one hand, we're getting information moving rapidly and a virus that was certainly moving even more rapidly. And yet on the other hand, having processes and systems in place for sharing information between and among countries that were just not somehow fit for purpose. And again, IHR, unfortunately seem to have slowed things down a bit, even the global health security agenda broadly, and I know that that's an area that GCSP has been involved with very much. And I've enjoyed being part of that as well, was overly focused on sort of this idea of securitisation as almost building up walls and not enough fun understanding, almost the opening side of it, of needing to share information across walls, across silos, across borders, not enough understanding perhaps, of the, how much politics culture, different forms of communication play a role. And even then, of course, the virus itself. It's a disease that had this very deadly combination of transmissibility, and an ability to be really asymptomatic for a long time. So, it's spread insidiously. But again, I think one of the key points there is also just the slowness of information, Dr Tedros had declared this, you know, of international concern, in late January, and yet the entire month of February was just a political period, where there were a lot of missed opportunities to close borders and to institute some global public health rules. I do want to though say, because I'm a profound believer in public health. And obviously, it's my work that this has also been a positive period, we're all thinking a lot more about public health now, which I think is great. It's much more in the common discourse. And then I think part of it is to understand too, that, health isn't just about a sort of a single infectious agent or pathogen transmitting from one place to another, one person to another, but it's showing how interrelated we are, how interrelated our systems are, an impact how vulnerable we are, but also how closing borders are engaging in the kind of vaccine nationalism, that unfortunately, we've seen quite a bit of, that's not going to help a world in which people and goods cross border with breath-taking speed and ease and indeed, in a world that is inherently has been more open than closed, with lots of good reason. I think the other piece, I just like to make this point, when you work in health, there's this temptation, there’s sometimes a tension between public health and the sort of medical treatment clinical side and I think the research innovations we see on the, on the sort of the clinical side, even things like surgical procedures, and even things like genome mapping, there's all these exciting, very high tech, expensive, extraordinary things happening. And public health is kind of like the plain sibling to a very exciting sibling, if you will, of the sort of the science and medical side. And so public health is a lot of, it's about things like wash your hands, wear a mask. In my world, it's also, getting exercise, eat nutritious diet, get screened regularly, etc. So public health doesn't sort of promise a perfect solution or to fix something, it's just tries to do the best for the most people. But if we can all commit to that, and understand it, and see that it needs to be resourced, and it's really important, which hopefully, this time has taught us, we could in fact, we could avoid in the future, lots of depth and pain, and suffering, and economic loss and all the other things that we've experienced, if we could just all get more comfortable with this following basic, very good sound, public health measures.

Dr Paul Vallet: Well, we'll certainly return, I think, to this important point you just made, I next wanted to ask you, in relation to your current occupations, in particular about the World Obesity Foundation, and if you could tell us how your activities as a Foundation, have they been much impaired by the sanitary protection regulations and by the public's general focus on COVID-19?

Dr Johanna Ralston: So I think so sort of for individual people with obesity or people in lockdown, and again, remember that there is actually almost 800 million people, children and adults living with obesity worldwide and 2 billion living, overweight. So, it's really extremely, extremely, broadly prevalent across all countries. At the individual level, people with obesity, in particular had a very difficult time and people in lockdown in general also had a difficult time. There was loss of access to medical care was difficult to get healthier foods. Certainly, opportunities for physical activity were severely limited, there was a transition inherently to unhealthy sedentary lives, we all have children who have been online doing online school for the past 16 months, which is, a huge loss, even socially, it has an impact on mental health. And then, of course, in many places, loss for children of school based food and physical activity opportunities

so there's been, we definitely know that there's been an increase in unhealthy weight gain among children and adults as a consequence of this and again, interrupted treatment for those who are fortunate enough to have that. But at the same time, the pandemic has also raised a great deal of awareness, I would say, genuinely people are much more aware of obesity, I think, than they have been, and indeed, of the fact that it's more complex than just eat too much, or too little that, that obesity is indeed a complex chronic disease, it's embedded in our genetic makeup, there's huge genetic drivers to it, it's very much accelerated by this the environments in which we live, which, in fact, encourage weight gain, through unhealthy foods making, healthier foods more costly, more difficult to transport. Definitely to get to people in cities. And then stigma and misunderstanding also making that worse. So, there's I think, a greater understanding of that, which is really helpful. I think what was fascinating for us and has meant that we've actually been extraordinarily busy, is that early in the pandemic, it became clear that people with obesity with a BMI of 30 or greater, so body mass index of 30 or greater, were especially vulnerable to the complications of COVID. And indeed, as it turned out to dying of COVID, it was so much so that, in fact, while age has been the biggest predictor of COVID, the older you are, the more likely you are to have a difficult complications and to die from it. Obesity could almost be considered the second biggest predictor and also that, because there's high rates of childhood obesity in many parts of the US where I'm currently based, in those States, in particular, like the state of Louisiana, for example. Obesity was driving down the age at which people were having complications from COVID if that makes sense. So, it was a very interesting, we've been kind of catching up with the unfolding science and the and the evidence is really clear, of the high association between the two. And so I guess looking ahead, if we were to want to prevent another pandemic like this, and I think we all do, it's not so much,  preventing the viruses which already exists, but the widespread infection that we saw, and in fact, the ways in which we had to have lockdown associated with the strains that our health systems, we need to do a better job of helping populations, including those with obesity, which very often is correlated high. There's a high comorbidity with heart disease, cancer, diabetes, other chronic non communicable diseases that we need to help our populations to become healthier.

Dr Paul Vallet: Well, my next question indeed ties into what you were just explaining about the, of course, the awareness, and that is, if we can consider that the pandemic has delivered to the global population, a wakeup call, and whether this is something that can be used to bolster other public health courses, such as the one your organization addresses, but perhaps some other correlated ones?

Dr Johanna Ralston: I absolutely think so. And I think many other health organizations in general, but chronic disease, non-communicable diseases, organisations in particular, feel that this this has been a time where there's much greater awareness of how important it is to address heart disease, how important it is to address stroke and diabetes. And then also some of the other risks that became sort of a bit exacerbated. So, there was wider availability of unhealthy foods and a wider availability of alcohol, which taken in great degree can be harmful as well. So, there's definitely I think, we hope a wakeup call because these are complex issues with a lot of drivers. And a lot of, financial interest in keeping in keeping unhealthy food out there, in keeping tobacco out there. It's not simple to just sort of, snap our fingers and say, let's fix this, but I think this greater awareness is really positive. It was interesting because early in the pandemic again, around last March, I sit on a World Health Organization Working Group on Civil Society and Non-Communicable Diseases and they shared with us this one of those word clouds, which just showed what are the kinds of requests for assistance and advice that they were getting from countries from member states from health ministries and others, and what were they feeling? And words like obesity, were coming up really prominently, and like heart disease and like cancer, and diabetes, and I think, again, it's because countries want it, we're saying, well, we are really discovering that, that those populations who are already dealing with those diseases are having the hardest time, how can you help us and certainly, WHO did great work in terms of introducing much more guidelines around this, trying to get common goals around this and has continued to be, attentive and really helpful in addressing those. So, it's partly because it's flipping this script a little bit, there's been a tendency to think of WHO is more focused on issues in low- and middle-income countries, with resources in a way and expertise coming from high income countries. But this was very much a kind of a flattening of the world, in terms of the countries that were the most challenged as, it turned out, were often higher income countries as well.

Dr Paul Vallet: Well, I also wanted to address the this this question to the experienced practitioner that you are, because you also, of course, have such an experience, especially of tackling public health issues within multilateral organisations, but the field of public health is being complex as it is, I was wondering whether you could explain to us are some issues actually best tackled at a local or at a multilateral level? And are some better suited to either local or multilateral solutions? I know, it's a lot to ask.

Dr Johanna Ralston: And I think what I would say the answer to that, in a way is yes, both are true. It's funny, because I was thinking about, this is a funny way of answering that which is in a way multi sectoral issues, which is what obesity is, which is, what chronic diseases are other things like climate change, things that really cut across sectors, they don't just sit inside health, they sit inside agriculture and sit inside education, they sit inside trade, those in a way are most successfully addressed at the local level. So, cities do a better job. And then even countries and certainly the multilateral systems in a way, because in cities, your constituency are right out your front door, if you're in City Hall, if you're the mayor of a city, you work alongside your head of health, and everybody kind of works together for the health of the population that's right in front of them. And that when it's a complex issue, in a way, it's best to do it that way. But you absolutely need the multilateral system for multiple reasons. And so, it was interesting. The former WHO Director General Bru Brundtland from Norway, she did many things during her tenure, but one of them was the first ever Public Health Treaty that WHO put together which was on tobacco, the Framework Convention on Tobacco Control. And, she was sort of, it was suggested, why don't you just let Member States solve their own tobacco challenge? At that point, there had been recognition that tobacco was, like, obesity is now 25 years ago, tobacco was driving many, many chronic diseases and quite a bit of avoidable death. She said you can't just leave this to Member States, tobacco can only be solved across borders, because of the nature of trade of how we move across borders of production. Like it's a cross border issue inherently, just of course, like viruses are, like pandemics are and so that was, that was a very important point. And so, the same is true, that pandemics are cross border issues, and non-communicable diseases like obesity are as well. The drivers include, again, changes in food systems, climate change, urbanisation, limited access to the ways we've changed our work. So, a country can't control all the variables itself, and you need those multilateral agreements in a way, and multilateral thinking and exchange of knowledge and best practice. Infectious diseases are simpler in that sense, there's usually a single vector like mosquitoes for malaria as an example. So, if you cut off the link to the vector, arguably, you put up the disease and it's harder. And I think, as we saw, even just with the ways that that COVID has felt so confounding, there are all these different. There's a simple transmission, but there's all these different drivers of it, including things like politics, which we certainly saw a lot of in the US. So, the multilateral system has been very challenged. And it's good to question governance and representation. One thing I was going to also mention is that for World Obesity Day this year, we did a study of the countries with the 10 highest and 10 lowest challenges in terms of COVID complications and COVID death, it turned out, they were also countries, almost to a one, I think there's one or two exceptions that have the 10 highest and 10 lowest rates of obesity. So, we saw it's not that obesity is causing this, but that underlying health is causing this. But the point is that the countries with the greatest complications, again, was were the countries in high income countries. So, this wasn't sort of a, the US and UK or Belgium or whoever has this all done figured out and, in other countries can use it as a model. It was not that model at all. Countries that did the best were those that had partnerships on multiple levels, including with community health workers and community leaders in the private sector. So, it is multilateral needs to happen and so does local, this is my answer to your question.

Dr Paul Vallet: Well, of course, the final one returns to multilateralism and asking for someone who knows the organization quite well, I wanted to figure whether you thought that in the wake of the pandemic, the World Health Organization will have been able to improve on its performance and footprint?

Dr Johanna Ralston: I deeply hope so. I deeply, deeply hope so. And I think there's good reasons to believe that will be the case. I think one thing that's been positive about this is there's no question that the world needs a good and effective WHO. People didn't understand that before. And certainly, there are still those who don't believe that, but I think far more people understand and recognise that WHO plays a really, really important role. As when I teach on WHO at the GCSP I always talk about finances and structure, and how challenging they can make it because in the past two decades, there's been this explosion of global health funding, as you probably know, but WHO has a budget that, just to put it really simply, it's about essentially 80% restricted or voluntary and 20% assessed or unrestricted. So, it means that it has a very narrow budget and scope where it can really react and respond to new challenges like, of course, COVID, and be adequately resourced to do those things. It means WHO has to deliver on its own programme of work, but it also has to sort of deliver to donors and in very little way of being able to respond to crises and its governance, while there's a lot of that's very positive about that, it can create constraints as well. But I think, WHO’s budget is somewhere is not too different from H.U.G. But it's different, like a mid-sized hospital in the US. So, and it's meant to be the World Health Organization. It's governed by Member States. But sometimes it seems as if when there's trouble to be chose treated as if it's some sort of rogue agency when it's very much again, governed by Member States. And it's carrying out preferences of member states and donors, and ideally, the people it's meant to help. So, we have to stop treating WHO like it doesn't belong to all of us. And I think that that's part of it. We all have a role in the International Pandemic Preparedness Council at a number of recommendations. But I thought a couple were interesting, having the Director General have a seven year term, and only one term is a great one, because that gets you out of the politics and running again, five years is not long enough, different things like a High Level Global Threats Council, which has power to and moves quickly and again, I think takes us from this analogue to this digital world, that COVID has made it really clear this is what we're living in.

Dr Paul Vallet: Well, that's already quite a lot. So, this will be all we have time for today. But thank you so much, Johanna Ralston for speaking with us on these many issues and imperatives of a global public health and I hope your advice will be vindicated.

Dr Johanna Ralston: Great, thank you. It's my great pleasure. Thank you very much for inviting me. Thank you, Paul.

Dr Paul Vallet: Well, thanks, Johanna. To our listeners, as I indicated, this is our final programme before the summer recess. And I want to thank you for joining us on this and on the past 19 programmes that we are displaying. I hope you will perhaps join us later this year to hear more about peace, security and international cooperation and a new series of the GCSP events and podcasts. Thank you again to my colleagues at the GCSP especially those at the DAT Ashley Müller and Christian Munoz, without whom these weekly podcasts would not have been possible. Thank you, listeners, for following us these past weeks on anchor FM on Apple, iTunes, and subscribing to us on Spotify and on SoundCloud. I'm Dr Paul Vallet with the Geneva Centre for Security Policy and wishing you a good safe, healthy summer. Until another time, bye for now.