Professor Graham Brown, Director of the Nossal Institute for Global Health, identifies and discusses key issues for the coming decade, for Australia and the world
1 Avian influenza, SARS and Australia’s vulnerability
Health specialists are mindful that new strains of influenza arise nearly every year and although ‘bird flu’ is currently out of the headlines, it is just a matter of time until a new epidemic strain arises. Since the beginning of this year, patients have contracted the ‘danger’ strain in China, Egypt and Vietnam, and if this strain develops the capacity to spread easily from human to human, a major epidemic is likely to occur, leading to massive health and economic problems, with trade, travel and tourism all disrupted.
It is impossible to predict the probability of such an occurrence, but it would certainly take time to develop vaccines of uncertain efficacy against the variant, and anti-viral drugs may not be very helpful in controlling a bird flu epidemic.
Australia’s geography and climate make it vulnerable to emerging disease threats like SARS or the Nipah virus (a newly recognised zoonotic virus, a form of henipavirus, the other form of which, Hendra virus, caused the deaths of horses and a horse trainer in Hendra, a suburb of Brisbane), emphasising the importance of effective surveillance mechanisms to identify such diseases at their first appearance. Chikungunya virus (transmitted to humans by virus-carrying Aedes mosquitoes) is causing problems in many places, and rabies has reappeared in Bali.
Further research is critical to understanding the ebb and flow of epidemic diseases of animals and humans.
2 The rise and rise of antibiotic resistance
A creeping and worrying epidemic is the global rise in antibiotic resistance. Multi-drug-resistant tuberculosis has emerged in South Africa, with rapid fulminant disease leading to death in weeks in individuals also infected with HIV. Multi-drug-resistant disease is also increasing in prevalence in China, which is already second only to India in terms of burden of disease.
Suboptimal or abbreviated courses of treatment with standard drugs provide an ideal environment for selection of these highly resistant bacteria, resulting in devastating consequences for patients for whom proven effective therapy is simply not available.
Antibiotic resistance has also emerged in bacteria responsible for travellers’ diarrhoea, and anecdotal reports from experienced practitioners suggest that resistant bacteria are now more likely to occur in patients acquiring urinary tract infections during travel. Such reports of rising resistance are not surprising, given the widespread and uncontrolled promotion and overuse of antibiotics in uncontrolled settings in many countries, particularly where there are financial incentives for prescribing.
Commenting in The Lancet on the problem in China, Andreas Heddini and colleagues have claimed that ‘the faceless threat of antibiotic resistance is likely to be one of the greatest challenges to global health in the 21st century, with a direct effect on health indicators in low-income, middle-income and high-income countries’.
In Australia, we have seen multi-resistant organisms in hospitals, and multi-resistant ‘golden staph’ (Staphylococcus aureus) has also made an appearance in the community. For some infections, we now have no proven antibiotics – just as in the pre-antibiotic era – and, worryingly, there are few fully efficacious products in the pipeline.
3 ‘New’ malaria
Malaria has become resistant to many agents and combination therapy is now advised for treatment of acute illness. The burden of disease in the region is higher than previously estimated, with characteristics that are different to those in Africa, where most research has been focused.
Malaysian scientists using the latest gene amplification techniques have identified a number of people in Malaysia who have been infected with a species of malaria that is normally confined to monkeys (P. knowlesi). Whether this relates to increased recognition or a true change in distribution of this species, or closer contact between humans and animals due to shrinking forest habitats, is yet to be demonstrated. Fortunately, current therapy is effective.
4 Climate change
Climate change will alter habitats for carriers of disease like mosquitoes and bats, which could lead to altered geographic distribution. Dengue fever already causes epidemic disease in Australia and countries to our north, with no prospect of vaccines or drugs in the near future.
Human behaviour can exacerbate the problems as populations move to susceptible areas or create conditions for enhancing the spread of disease. The mosquitoes responsible for carrying the dengue virus breed easily in water tanks, meaning strict adherence to public health guidelines and extra vigilance will be required to ensure homeowners do not inadvertently increase transmission by installing rainwater tanks to combat growing drought conditions.
Greater extremes of climatic conditions, leading to increasing numbers of humanitarian disasters following floods, heatwaves and tropical storms, have been predicted. Associated crop failures and economic suffering add to the likelihood of a failing state being unable to care for the basic needs of its people.
Some would therefore argue that the greatest requirement for the future health of the world is a sustainable replacement for fossil fuels. Development agencies are already stressing the need for international action on global warming, which will have the greatest effect on those with the least ability to pay.
5 Changes to tackling international health issues
Major donors such as the Bill and Melinda Gates Foundation have contributed funds for ‘vertical programmes’ for the control of AIDS, TB and malaria. These are making a difference in the areas where delivery systems are in place.
There is belatedly, however, more widespread recognition that money cannot be used efficiently in the absence of functioning systems, hence donor agencies are redirecting some of their efforts and resources to capacity development and systems.
Recognition of the requirement for a holistic approach to health leads to better engagement with responsible local authorities and the co-creation of knowledge to solve logistical and human resource impediments that impair successful outcomes. Inevitably, this requires stronger interaction with the United Nations agencies such as the World Health Organization, whose convening power and in-country respect need strengthening and international support.
6 Australia’s future role
AusAID has implemented a number of new programmes to improve the quality of Australia’s aid as we move towards the promised doubling of budget in the next few years. To address gaps in evidence and engage Australian academic institutions, novel partnerships have been established to create ‘knowledge hubs’ of expertise in critical aspects of Public Health.
The Nossal Institute for Global Health at the University of Melbourne will focus on health policy and health financing. The University of New South Wales will focus on human resources for health. The University of Queensland School of Population Health will focus on information systems and burden of disease. The Melbourne-based Burnet Institute, along with the Centre for International Child Health (University of Melbourne) and the Darwin-based Menzies School of Health Research, will focus on women’s and children’s health.