How Does the World See U.S. Public Health?

Ashish Jha: 00:00:06

Hey everybody. Ashish Jha here from a cloudy, rainy afternoon in Providence, Rhode Island, where I'm coming back to you with another moment in health, the episode the podcast, where we cover one data point, we talk about one study and then we answer one question. Okay, so let's jump right into it. Our data point. It's a big data point for the week. It's 1288 that's the number of people who have a confirmed case of measles through January 3. Now why is that number important? You may have heard about this in the news. That number is important, because it is now the biggest outbreak that we've had of measles in the United States in the last 25 years, since measles was declared eliminated inside the US, more people have gotten measles, and so obviously we're on track to have a pretty horrible year. Three people have died so far. That's pretty terrible, and a large number of people, about 155 have been hospitalized. Last point I will make about this is that that 92% of people were either unvaccinated, these are mostly kids, or whose vaccination status was unknown. The final point I want to make is that people look at measles and measles outbreaks and say, Well, you know, obviously it's among unvaccinated people. Maybe it's parents making bad decisions. It's not going to affect me if I'm a parent who's committed to getting my kids vaccinated. Turns out it's more complicated than that, and there are people who are a lot more people are going to be vulnerable than I think we often think about, remember, most kids don't get their first measles vaccine till they're 1215 months of age. They have some protection from maternal antibodies in the first few months of life, but there is still a large chunk of time where kids are vulnerable to measles, even if you're planning on getting your kid vaccinated, and a lot of measles around means that those kids are going to get infected. There are kids who are immunocompromised who can't get the measles vaccine,

Ashish Jha: 00:02:03

and for them, they rely on a high degree of population immunity, and when that doesn't exist, those kids are vulnerable. And last but certainly not least, you have immunocompromised adults who might also be vulnerable if their immune system is really not up to task of dealing with measles, even if they got vaccinated earlier. So there's a whole group of people who are vulnerable, and when vaccination rates fall, when measles outbreaks get big, it puts a lot of people at risk. And one more thing I wanted to add in about measles is a piece that I've written with my colleague, Stephanie Psaki, who was a guest early on in the in the podcast in a recent issue of BMJ, where we talk about measles outbreaks as a canary in the coal mine of a failing health system, that often it's because of the inability of a health system to deliver vaccines, that's true in many low income countries, or it's because there is so much distrust in the health system that people are not willing to get even the most basic of services, and like the measles vaccine, and obviously, measles vaccination numbers falling across the globe, particularly here in the US, is a combination of both a demand problem and a supply problem. We kind of laid this all out in a recent issue of the BMJ, so if you have a minute, take a look at that with my colleague, Stephanie Saki. All right, so that's your data point of the week. Let's talk about a study, a really important study, called trends in us, children's mortality, chronic conditions, obesity, functional status and symptoms. It's in the Journal of the American Medical Association from the July 7 issue of the journal, and it's a really well done study that basically looks across what has been happening with kids health over the last essentially 20 years, and looks at everything from mortality rates to chronic conditions. And there are two or three findings that I want to lay out at a high level, mortality rate among kids, and they break it

Ashish Jha: 00:04:01

down into two groups, which is I think, worth doing, infants, kids under one mortality rates fell pretty precipitously from 2007 all the way to about 2020, and then you see a bump up in mortality during the pandemic. So it was at a little over 700 per 100,000 dropping down to almost 500 and then again, a little bump up during the pandemic. Then the second group that they look at is one to 19 year olds. And obviously these are kids who are dying of different reasons. And here the trend is a little different. Again, going back to 2007 there was a very nice decline till about 2014 2015 and then rates of kids, young kids, one to 19, again, a lot of them, you know, obviously, across that whole age range, that mortality rate starts increasing around 2014, and then bumps up substantially during the pandemic, really suggesting that there has been something going on with. Children that we need to understand better. And then when you dig more deeply into the data and say, Well, what's driving this? What is driving kids dying at higher numbers over the last 10 years, really, from 2014 2015 onwards, it's three things, firearms, substance abuse and suicide. Guns, drugs drugs and mental health, other things have largely been flat or coming down. Motor vehicle accidents have come way down. The little bump up in the last couple of years, but in general, they've come way down. Asthma is way down. But the three things that are really driving increases in childhood mortality over the last decade are firearms, substance use and suicide. So when you hear policy makers talking about the crisis that is children's health, those are the three things we should be focused on if we're going to be based on data. One last, final point I want to make is that the study also looked at underlying chronic diseases. Looked at a whole range of different diseases, lots of things, increasing, decreasing. Two things I want to point out, as you know, because it's been in the news, autism

Ashish Jha: 00:05:59

rates have gone up quite substantially over the last 20 years. Think most of the evidence suggests we've gotten much better at diagnosing autism. That's probably the major determining factor, though there may be other issues as well. And the other interesting finding from this study that I thought was interesting is childhood diabetes rates essentially flat over the last 20 years. We know childhood obesity peaked around 2004 2005 and has been steady to slightly declining, again, too high, but childhood obesity has been flat to slightly down over the last 20 years, and diabetes rates are actually pretty flat over the last 20 years as well. So lots of interesting data, if you have a chance pull up the study trends in us, children's mortality, chronic conditions, obesity, functional status and symptoms in the July 7 issue of the Journal of the American Medical Association.

Ashish Jha: 00:06:57

All right. And now to our one question of the week, and to answer our one question of the week, I'm very excited to have my friend and colleague, Wilmot James, here. Let me tell you a little bit about Wilmot, in case you don't know much about him, he's a professor of the practice here at the Brown School of Public Health, formerly a Member of Parliament and shadow health minister in South Africa, and really one of the leading thinkers about global public health, I would say pretty broadly, certainly on issues around biosecurity, pandemics, but I would say his expertise goes well beyond that. And Wilmot has been here at Brown for the last year and a half or two years. Wilmot, thank you so much for coming in and willing, your willingness to chat with

Wilmot James: 00:07:39

me. Happy to be here and looking forward to our discussions.

Ashish Jha: 00:07:43

Great. So Wilmot , I have a question, as I always have just one question, and I'm going to frame the question in the following way. Over the last six months, we have seen America radically disengage with the Global Health architecture. USAID, who Gavi, I can keep going. We're also going. We're also making very substantial changes in the public health infrastructure inside the United States. Now, I understand you live in America, you see the day to day, but I'm wondering if you could take yourself, take one step back and think from a global perspective. What is your sense of how the world is looking at what's happening with public health in America, what are the reflections of global public health leaders, but just the broader global community, when it looks at both how America is engaging with the world, but also what America is doing internally.

Wilmot James: 00:08:37

So thank you for that fundamentally important question. I mean, my first comment is about the United States role in terms of the global health architecture, and what the consequences for both interpreting the actions taken in terms of the global health framework and also looking at why, how that's tied in with international affairs, the use of power and understanding of power in the world. And the first observation would be that when it comes to the US and global health, is that that's usually defined as soft power. And soft power, clearly is an important ingredient in what has now been 100 years, of the way in which the US exercises its its its role in the world, globally, which is a mix of hard and soft power. And now it's pulling back on the soft power and not replacing it with anything but a more dominant role, a more you know, emphasis on strength, exacerbating current tensions by launching a trade war, and through that prism, that's how health is seen. And so the consequences of those actions are quite extraordinary in terms of the effects of what's happening with the who and the global infrastructure. And then, very specifically, with regards to my own country, with the withdrawal of PEPFAR, and what that means. And the two things about this, the one is the kind of slash and burn approach to health, because any thinking, rational, concerned person would say that it's your right to not fund the health of others. Every county should, in fact, have funded health Amazon citizens. And if you could withdraw, please do it very carefully, because there are human consequences. So the one perception is, is kind of recklessness around what happens with human beings. Any considered person would would have a very careful, managed approach of pulling out so, so that's the one. The second observation is that people do not understand why there is an effort to undermine what has been an enormous success in domestic science, technology and healthcare. The

Wilmot James: 00:10:57

infrastructure has been built up through a well tested and tried system of having a particular portion of what are considered to be high overheads put back into the research and development infrastructure of the country. So that model, that biomedical model, has put the US in the forefront of innovation, of global expertise in a whole variety of areas, and why would anybody undermine that within their own country? So that's perplexing, yeah, and it's so can I ask you a

Ashish Jha: 00:11:31

question about that? It is perplexing to us living here as well, why are we undermining this? What's your sense of people's best guess of why America is doing this? Well, how do outsiders? They're perplexed by it. They're surprised by it. Do you have an explanation of what is happening?

Wilmot James: 00:11:55

My suspicion is that the current leadership SEC that they get what they need from universities that are not traditionally, Ivy League, for example. They can get it from other universities, and they can get it the cheaper price with less investment. And that's enough that this is, this is a kind of a overblown Rolls Royce that we have, and what we actually need is a Toyota to do it so and it's, it's partly a misunderstanding of the both the function of universities and a kind of freedom we require in order to have robust inquiry. Partly that, and partly the fact that universities are often seen as places where there's just a lot of trouble that's created. Yeah. So this is kind of notion that universities are a bit of a nuisance, yeah, and what we need are more compliant ones. Final

Ashish Jha: 00:12:50

question in all of this, which is going back to both your point on recklessness and this sort of pulling back of biomedical infrastructure is one of the things I would like America to be seen as, as a is as a reliable partner that we stick to our word that when we say we're going to do something, we do it. I think that is now at substantial risk. And you could argue it is actually in some ways gone in terms of that perception. First of all, do you agree that in some ways that is gone in terms of a perception of America as a reliable partner. And if you do, how does America get it back?

Wilmot James: 00:13:28

So I pointed point to disaggregate here, yeah, so that it's trust in the American government that has been compromised very severely and in a more nuanced way with the federal government, not with the individual states over the individual cities. Firstly, it's not a loss of trust in the science community at universities. There's not a lot of trust in the world of entertainment, the world of sports, and certainly in my own country, for example, South Africa, has long standing ties to the churches and the religious communities and go back 200 years. Yeah, so there's a lot of loss of trust there. Now there's a loss of loss of trust in government in terms of its foreign policy and and its relationship with with other countries. And the fact is that if you can't keep a promise, if you deal with your allies in the way that presently is happening, and you lose trust. That's really, really difficult, because you cannot govern through a military sense alone. It doesn't last. Joe Stalin once made this interesting. He asked this interesting question. He asked he was annoyed by the Pope, and he said, How many divisions as a pope, the Soviet Union no longer exists. Yeah, the papacy stat does Yes. And so so long term survival and long term sustainability does require good balance between hard and soft power, and what the US is trading is a loss of soft. Power and a loss of trust in its federal government. That's, that's what's happening presently.

Ashish Jha: 00:15:05

Yeah, without a clear necessarily gain in hard power, just a one sided loss. Wilma, I've already I try to ask one question. I never can keep it to one question. I'm really grateful for your taking time to talk this through with me. So thank you for coming by and helping all of us better understand how the world sees what the US is doing at this moment. Thanks so much.

Wilmot James: 00:15:27

Wilmot. Great pleasure. Thanks.

Ashish Jha: 00:15:35

And there you have it. Another episode of a moment in health where we talked about one data point, 1288 the number of people who have been confirmed to have measles so far in 2025 making this the worst year of a measles outbreak in this century, in the 21st Century. And we're only halfway through the year, folks. So we still have some ways to go. Where we talk about one study the trends in us, children's mortality, chronic conditions and so forth, and where the bottom line answer was, in general, childhood mortality was falling. In the last 10 years, we've seen an increase, particularly among among younger kids, and the major drivers of that are firearms, substance use and suicide. And then we talked to my friend and colleague, Wilmot James, former member of parliament and shadow health minister of South Africa, and now a professor here at Brown and I asked him, How is the world looking at all of the things that we are doing in global health? What is their perception? I mean, no one person can speak for the world, but I thought Wilmot did about as good of a job as anybody could possibly do in synthesizing what I think is broadly perceived as recklessness. Look, it's fine for a country to say we're not going to support Global Health anymore, but the speed, the recklessness with which we pulled back is absolutely awful devastating, and it's going to lead to a lot of people's deaths, and then a real sense that America, which had enormous amount of soft power and generated so much goodwill around the world with our global health engagement, we were the indispensable country in global health that we have just decided to close up shop and leave. And I think people are just perplexed by why you would give up all of that soft power and goodwill that you've been generating. And finally, the thing that gave me maybe a little bit of hope from Wilmot comments was he said, you know, while there is clearly a sense of

Ashish Jha: 00:17:26

unreliability among for when people look at the US government, that people still understand that American universities, American scientists, are not representative of our government, and that while our government has acted wildly irresponsible, irresponsibly in the way that is dealt with global health, that there are still really excellent people here who are committed to these issues. So that was, I think, a little bit of of a ray of sunshine and what has otherwise been a pretty dark moment in global public health. Thanks so much for joining us once again. Great music by Katherine Beggs. I'm always grateful that Katherine put this together for us, and I look forward to being back next week to talk about another data point, another study and another question in the podcast, a moment at health you