The Globalization of Health
Remarks to the Conference on World Affairs
HHS Secretary Kathleen Sebelius
University of Colorado at Boulder
April 7, 2014
Thank you all very much. I’m delighted to have the opportunity to join you this morning.
It’s truly an honor to follow in the footsteps of some of the past speakers at this conference. And frankly, it’s a little intimidating as I read through the roster of people who have been part of this event -- luminaries like Annie Liebowitz, Molly Ivins, Henry Kissinger, David Crosby, Yitzhak Rabin, Arianna Huffington, Samuel Huntington, Studs Terkel, Ted Turner, and Roger Ebert, to name a few. (In fact, that group would make for some pretty interesting dinner table discussion.)
To borrow a phrase from former President John Fitzgerald Kennedy... this conference may well be the most extraordinary collection of talent and human knowledge since Eleanor Roosevelt dined alone. And in fact, I’m told that Eleanor Roosevelt herself was a speaker at this conference.
I know Roger Ebert named this conference “the Conference on Everything Conceivable.” I hope you’ll forgive me if I narrow down the topic of my remarks – at least just a little bit – to just focus on the world.
Today, I want to talk just a little bit about a topic that is near and dear to my heart, “the globalization of health.”
Some people in the United States would call it “soft diplomacy;” I like to call it “smart diplomacy.”
Tom Friedman speaks about globalization as having come in three stages. Globalization 1.0 began around 1492, when the world went from large to medium. Then, Globalization 2.0, came when the world went from medium to small. At the turn of the millennium, Globalization 3.0 came about, and the world went from small to tiny.
And I would suggest it’s growing tinier still.
All of this was illustrated to me very vividly in April of 2009 when I came to Washington to be sworn in as Secretary of Health and Human Services.
We had a well-planned out succession event in Kansas. The Senate was going to take up my nomination early the morning of the 28th, and assuming that they would confirm me, my plan was to resign as Governor of Kansas, swear-in the Lieutenant Governor, come with my husband and family to Washington, get sworn in and start my new job.
Unfortunately, that’s not quite what happened.
I got a call early in the morning saying the Senate debate had, begun but there was a plane in the air and President Obama needed me on that plane at noon. And when I reminded the caller that I was not sworn in yet and confirmed yet, he said “I understand but the President wants you on the plane.”
Needless to say that disrupted a few plans at home, and it also made me file a contingency plan, which was to leave a note literally on my desk in the Governor’s office in Kansas saying “in the event I am confirmed, I hereby resign.” I didn’t want to give up one gig before I really knew I had the next one.
We were in the sky –somewhere over Ohio or Pennsylvania (I was solo at the time because I had scrambled and had no idea actually what was going to happen) – when a call came through saying Madame Secretary you have been confirmed.
When we landed, there was a car waiting for me and I said, “where are we going?”
“Well,” they said, “you’re going to the Oval Office, you’re going to be sworn in.”
At this point, it was about 4 o’clock in the afternoon. A little trivia note: It turns out that the President can’t swear anybody in. He didn’t know that at the time. I didn’t know that. He can hold the Bible, but the Secretary of the Cabinet could swear you in.
I got sworn in and immediately got whisked off to the Situation Room: We were in the midst of an outbreak of what was known at that point as the flu virus strain H1N1, which became commonly known as the swine flu.
It was already becoming a worldwide crisis because it was the first flu virus in a very long time which was killing people, killing particularly young people fairly rapidly and there was no vaccine and there was no identification.
Nobody knew how fast it would spread. But it was very clear from the outset that the United States could not tackle the situation alone.
The virus at that point was thought to have started in Mexico and was now presenting across the country.
So the Situation Briefing Room that night included officials from both countries trying to share ideas and figure out what was going on.
And after that briefing broke up and I went to the Department for the first time the next day, my first call in the office was not from a colleague, a former Governor, saying congratulations or from a member of the House or Senate, it was from Dr. Margaret Chan, who is the head of the World Health Organization. She was welcoming me to the job but also saying “we have a crisis on our hand,” in what became the first identified pandemic in 40 years.
So the dual reality of a “tiny” planet became very clear to me very quickly. Crises, outbreaks, emergencies – these those situations do not recognize or stop at national boundaries. And yet, neither does our capacity to counter them.
Leading & Learning
There is a story about Neil Armstrong, who one day was having lunch with the photographer, Yousef Karsh, after a photo session. Armstrong was fascinated by Karsh’s global travels and peppered him with questions about the places he had seen. Finally, the photographer turned to the astronaut and said “Now wait a minute, you’ve walked on the moon, I want to hear about your travels” – to which Armstrong replied “But that’s the only place I’ve ever been.”
I think in some ways that’s a metaphor for our country. Especially when it comes to public health. In some areas there’s no question the United States has reached the moon. But still there is a lot of territory left to explore and to visit. There’s still a lot to learn.
American research and resources have literally changed the face of humanity, by tackling deadly and once-deadly diseases. From eradicating small pox, to fighting polio, to focusing the eyes of the world on the vision of an AIDS-free generation, we have worked to save lives on every corner of our planet.
And yet, in the United States, we still have one of the highest rates of infant mortality in the industrialized world.
Americans scientists are busily unraveling the mysteries of the human genome. Yet, expensive medical bills have put too many American parents at risk of losing their family’ home.
Americans researchers are advancing the promise of individualized medicine. But there continue to be vast – and unacceptable – disparities in health outcomes between white and minority populations throughout our country.
Therefore, I believe that when it comes to globalization, we have two imperatives in this country. The first is to lead in the community of nations. The second is we have to learn from the community of nations: To expand our understanding of how best to improve health outcomes for our own people.
We do that against the backdrop of three realities of globalization:
- Reality #1 is that actions and outbreaks anywhere, impact countries and people everywhere. Because we live in a world where microbes and diseases are moving faster and farther than ever – and we have to work together as a global community in order to counter them.
- Reality #2 is that advancements by any of us, are advancements for all of us. Every country on earth has an interest in preventing the spread of HIV/AIDS or curing diabetes or reducing heart disease – and this has major implications for our health, for our economy, and for humanity.
- Reality #3 is that healthier people mean more prosperous economies, anywhere in the world. If we in the United States continue to spend more money, live sicker and die younger than our global competitors, as we do today, we as a country are at a disadvantage. At the same time, we know that developing countries, whose leaders invest in the health of their people, see results quickly in the wealth of their economies.
I want to spend a few minutes talking about each of those realities with you.
Let’s start with Reality #1: Outbreaks and actions anywhere, impact people everywhere.
I want to share with you a few words from one of our great health leaders, Dr. Tom Frieden, who heads the Centers for Disease Control and Prevention. He said, “The health security of the United States is only as strong as the health security of all nations around the world. We are all connected by the food we eat, the water we drink, and air we breathe.”
I wholeheartedly agree with Dr. Frieden, and I would argue that these connections extend beyond just our security. Our economy is impacted every day by the health of our trade partners, and the ingenuity of American companies. Our diplomacy is impacted as our allies and adversaries address major health crises. Our hearts break, when we learn about the loss of life of global neighbors. And our souls lift up when American inventions, discoveries, and innovations heal people across our shrinking planet.
In this 21st century world, we are no longer insulated by our two oceans or the border crossings to our north and south.
Every time a traveler boards a plane in Manchester, England, and finds his or her journey ending in Manchester, New Hampshire, our world gets a little smaller – and our vulnerability a little larger.
Every time a Kansan or Californian unpeels a banana that was grown thousands of miles away, our world gets a little smaller – and our vulnerability a little larger.
Every time a ship sets sail from the Port of Baltimore and docks in Europe, South America, or Asia, our world gets a little smaller – and the vulnerability of citizens in all countries grows larger.
These are our new global realities.
I want you think how our world has changed.
On a typical day, a million people enter the United States by land, sea and air. A million people
In 1963--not so long ago for old people like me -- 26,000 international passengers a year flew through Dulles Airport in Northern Virginia. Last year, 7 million international passengers flew through this same airport. And that’s just one of three major airports that service the Greater Washington D.C. area.
Looking beyond Washington, 826 million passengers fly on airlines that serve our country. That’s more than two passengers, almost three, for every U.S. citizen. It’s also 826 million opportunities to spread flu viruses, avian flu, or TB, in addition to the common cold.
And that’s just air passengers. Ten million commercial trucks drive across our Canadian and Mexican borders on an annual basis. They carry not only people but livestock, food products, hazardous chemicals, and countless other goods and products that impact our nation’s health every day.
The next time you go to your local supermarket or grocery story, think of this, 80 percent of the seafood aisle has been imported from waters beyond our shores. 50 percent of fresh fruit and nuts that are for sale in this country come from outside our borders and one fifth of the fresh vegetables you see are likely to have been imported.
So when you take a bite out of an apple, it’s just about as likely to have been shipped in from a place like New Zealand, as it is to have been grown domestically in a place like Washington State.
Therefore, our health is also the health of the people who might have picked that apple in New Zealand – and the decisions of the public health and food safety officials in countries around the world.
It’s all connected.
And there some situations where threats to our health are actually more overt and more dangerous. We know, for example, that terrorists are out there who have designs on bringing biological warfare to our shores.
And we know that there are counterfeiters all over the world who are peddling fake medications. Tragically, it’s been estimated that more than 1 in 3 of the anti-malaria medications being taken right now by patients in Southeast Asia and Sub-Saharan Africa, are counterfeited: They’re either useless, dangerous or watered down.
As we think about the best ways to address these challenges, ask yourself this question: Should we invest our resources in responding to a global pandemic after it’s already swept across the globe? Or is it better to stop an outbreak at its source, before it becomes a pandemic?
Now, I think we’d all agree that important that we have prevention strategies, so that we have the necessary vaccines stockpiled in case of an emergency situation. At the same time, we can surely all agree that we invest in these things in hopes that we’ll never have to use them.
To make that so, we have to go after outbreaks before they become pandemics.
By the same logic, in order to prevent humanitarian crises, we have to offer humanitarian assistance.
And if we want to be a leader, we have to be a willing partner.
I want to give you a couple examples of how we’re trying to advance that notion.
Last year, Northern Uganda was one of just a handful of places on our shrinking planet, where citizens were able to look up at the sky one day and see one of the rarest of rare occasions: a full solar eclipse. The moon was able, just for a moment, to completely shut out the sun.
Earlier in the year, Uganda had experienced an outbreak of cholera. People lost their lives, and hundreds of thousands more were considered highly at risk. But through the darkness of this tragedy, helping hands from both Uganda and the United States worked to prevent the further loss of life—one might say it was like they were shedding a few rays of light through the darkness of an eclipse.
The American help had come from the CDC. They were able to help Ugandan officials pre-position rapid diagnostic tests, in the most rural communities, and they mobilized local health and security staff.
CDC also sent teams to Vietnam when they saw the first outbreak of the Middle East respiratory syndrome, another very dangerous viral infection that started in Asia. Our efforts in both Vietnam and Uganda showed us a very simple thing – that with a fairly limited investment of resources it was possible to build in-country capacity, diagnostic capacity, surveillance capacity, and really identify these emerging diseases as they started. So the efforts in Uganda and Vietnam were focused around three primary strategies –prevention, detection, and response, the backbone of what has been announced our Global Health Security Agenda.
In the midst of one of our all-too-frequent Washington snow storms this year, we announced this global initiative with partner countries.
With President Obama’s proposed investment, and joint efforts from the Departments of State, Defense and Agriculture, we’ll be able to expand our efforts beyond Uganda and Vietnam to another 10 countries. And other developed nations plan to use the U.S. model to expand capacity in other parts of the world.
Working together across the first 30 countries, we can protect at least 4 billion global citizens within the next five years. That’s a pretty good investment, and it’s an important start. But our vision is eventually for all people in all countries to be effectively protected against the threats posed by infectious disease.
So at the end of the day, this is more than just a security agenda. It’s an economic agenda. It’s a humanitarian agenda. And it’s a diplomatic agenda.
In 1984, French and American researchers first discovered HIV and identified it as the cause of AIDS. Fast forward to 2014: Scientists and researchers everywhere from Finland to France to Frederick, Maryland, are working in common cause toward the dream of an AIDS-free generation.
Reality #2 is that on our shrinking planet, advancements by any of us, are advancements for all of us. A discovery in a lab in India can cure Americans; a protocol tested in Atlanta can be used in Africa, Asia, Australia, South America, and Europe.
What country isn’t currently impacted by cancer, by Parkinson’s, or diabetes?
Because of these common health challenges, there are some real economic implications as well. It’s been suggested that in the new, knowledge-based global economy, it will be those countries and companies, which lead in life-saving and planet-saving innovation that ultimately emerge as economic winners as well.
Bill Gates has said that “never before in history has innovation offered promise of so much, to so many, in so short a time.”
In this 21st century world, some of our country’s most significant exports and imports extend beyond goods and services: They also include innovation, knowledge, discovery, and healing.
It’s happening in laboratories, incubators, classrooms, and classrooms, and boardrooms throughout our country. It’s happening right here at the University of Colorado. It’s happening in North Carolina’s Research Triangle, and across the “Route one twenty eight” corridor in Massachusetts, and the “I-two-seventy” corridor in Maryland. It’s happening in California’s Silicon Valley.
And it’s happening in concert with scientists and researchers across our planet.
The National Institutes of Health is the world’s gold standard for biomedical research. And today they have thousands of global collaborations with researchers in countries like Mexico, Cambodia and Tanzania.
We’re not only exporting ideas to them, we’re importing ideas from them. And we’re also importing some of our world’s greatest minds.
Today right now, there are more than 3,000 foreign researchers working at NIH’s Bethesda, Maryland, campus. And that’s in addition to millions of people from all over the world who come to our universities both to teach and to learn, and who come to work in companies and laboratories across our country.
When scientists working in India, Israel, or Ireland develop new devices, drugs, technologies, therapies, or cures, we import those to America.
But just as we import innovations and innovators, I’d also argue we should also aspire to import some of the successes our global neighbors are having in achieving outcomes that have so far eluded our country.
Nowhere is this more apparent than in women’s health and maternity.
We in the United States are doing important work around the globe to help other countries obtain the very same services and innovations that we often take for granted in this country: OB/GYN access, a sterile place to give birth, pregnancy tests, the latest medications and treatments. We still have about 500,000 women dying in this world every year because of preventable birth-related illnesses. The United States is the largest single donor to family planning efforts across the globe – which is one of the simplest interventions to save lives and keep women healthy.
And yet we still trail behind much of the world in some important measures of women’s health. And frankly, it’s inexcusable.
We have not done our job well, when our country’s mortality rates among women have increased dramatically at the same time mortality rates among men have either decreased or held steady.
And when you consider that healthy mothers mean healthy babies – we’re not only doing women a disservice. For generations we’ve been letting down entire families, and the communities who depend on them.
And this has both human and economic implications for our country.
Reality #3: Healthier People mean More Prosperous Economies
Reality #3 means healthier people mean more prosperous economies.
Throughout our country’s history, American ingenuity has been matched only by American generosity.
In the 20th century, we opened our hearts to the world through the Marshall Plan, Food for Peace, the Peace Corps, and so many other endeavors. In the 21st century, we’re helping to save lives through initiatives like PEPFAR, the President’s Emergency Plan for AIDS relief. PEPFAR has already prevented HIV infections for at least 1 million babies across the globe.
At the same time, we’ve spread some of our bad habits too – things like tobacco-use, and overconsumption of unhealthy processed foods. And congratulations to the Boulder community for being No. 1 in obesity prevention. But something is out of balance when some of the very same unhealthy foods that Americans are eating less of, are actually getting more popular in other countries.
Of course, these things are more than just habits, they’re life-threatening medical conditions – and there is a term for them: “Non-Communicable Diseases” or “NCDs.” At one point they were thought of just as afflictions of the affluent. But the new global reality is that NCDs are killing people in every country, on every continent, in every part of our world.
Take for example the issue of obesity. I want to read you a brief quote from researchers at the Harvard School of Public Health: “For many low and middle income countries already struggling in the world economy, obesity takes a particularly high toll--sapping productivity, increasing illness in sole wage earners, and further stretching health systems already burdened with persistent problems of infectious disease and even starvation and under nutrition."
The new reality of globalization is that it’s in all of our interest to care what’s going on in other countries. You see, we know NCDs are one of the biggest drivers of health care costs around the world. In the United States alone, the total economic costs of smoking now top $289 billion every year – that’s billion with a “b.” And that’s being seen in countries around the world.
In 2014, a drag on one economy pulls down other economies. We no longer have the luxury of not caring as much about what happens to peoples in other parts of the world.
When it comes to NCDs, our country has been both a part of the problem and a part of the solution.
On the one hand, we are some of the world’s leading exporters of unhealthy foods.
On the other, initiatives like First Lady Michelle Obama’s Let’s Move! is already inspiring the other countries who are working toward similar goals.
And if I were to tell you that there is a disease that takes the lives of 6 million people across the world, every year: More lives than are taken by AIDS, malaria and cholera combined. We’d all agree it was a crisis.
Now, what if I were to tell you that for generations our country actively worked to help spread this disease, I think you would probably be disappointed and shocked.
This Sunday will mark the return to the airwaves of AMC’s Mad Men, which is set in the 1960s. If you watch an episode you will notice tobacco use – in the workplace, in public places like restaurants – even in the doctor’s office. In fact, during the 1960s, cigarette companies actually ran ads featuring doctors and promising better health.
So over the past 50 years, there’s no question that the United States has made big strides. U.S. tobacco production has fallen. Our tobacco control efforts have prevented – by some estimates – as many as 8 million deaths in this country alone.
In fact, our nation’s smoking rate is half today, what it was during the Mad Men era.
But the fact of the matter is that tobacco-use is still the world’s leading cause of preventable death.
And here is the snapshot of today in the United States: If we don’t change the current trend line, we will have 5.6 million American children who are alive today who will die prematurely due to smoking. 5.6 million of the kids born today. And tobacco-related deaths across the globe could reach 10 million a year.
But we are actively working to reverse these trends. In the international arena, we’ve been working with the World Health Organization and partnering with foreign governments on new data-driven cessation strategies.
The CDC is assisting other countries with developing laboratory capacity. One of the first bills that President Obama signed in 2009 was a new tobacco regulatory act, finally passed after decades of work in this country that gives the FDA the first time ever to the capacity to regulate nicotine.
And at the NIH, the Fogarty Center is conducting cutting-edge research into how low and middle-income nations can reduce tobacco consumption.
On the home front, we have set the goal of making the next generation a tobacco-free generation. Since the very first days of this Administration, we have taken a coordinated approach to help tobacco users stop smoking… to keep others from starting … and to leverage our regulatory authority to protect more consumers, and save more lives.
The Affordable Care Act allows Americans to access tobacco cessation services at no out-of-pocket cost before they get sick, rather than having to wait until after they are diagnosed with an illness. And it invests to support innovative and effective community-based projects across our country.
In fact, I think one of the most underreported and un-touted benefits of the Affordable Care Act, is the real investments we are finally making in this country in prevention.
The world we inherited from our parents and grandparents was a very different place than the world we will leave to our children and grandchildren. The question I think we all have to grapple with is: How will we shape it?
For in many ways, human health is the great, global connector.
It aligns our interests and impacts our economies.
It compels us to work together, and actually punishes us if we drift apart.
It calls upon our greatest human impulses for compassion, healing, and for love.
And it motivates our greatest human capacities for discovery, innovation, and invention.
It asks us to open our hearts and challenges us to open our minds.
It inspires us to lead, and it invites us to learn from one another.
And global health issues remind us – perhaps more than any other issue – that we are all children of the same extended family; rays of light seeping through the darkness of a solar eclipse.
Thank you for inviting me to keynote this wonderful conference and thank you for having me here today.