8
Potential Approaches for Research, Policy, and Practice in the Immediate Term
The first part of the fourth session of the workshop focused on potential approaches in research, policy, and practice to address the convergence between infectious diseases and noncommunicable diseases (NCDs) in the near term. The workshop participants first individually reflected on where they believe to have the ability to take or influence action to address the convergence and then shared their ideas in small groups. In the small groups, participants specifically focused on areas where they converged as well as diverged, areas that had not yet come up during the workshop, and areas where they thought broader research or policy efforts could be enacted to support actions in the immediate term. After the small group discussions, a participant from each group reported on their conversations, and then the workshop participants engaged in a larger group discussion, which was moderated by Bridget Kelly, principal consultant of Burke Kelly Consulting. The topics ranged from strengthening health systems and health care, communication approaches and information access, and data collection and methodologies.
POTENTIAL PRIORITY STRATEGIES AND ACTIONS FROM TABLE GROUP DISCUSSIONS
The session began with a discussion on the way many health systems, and much of health care itself, are structured in the world today. Emily Erbelding, director of the Division of Microbiology and Infectious Diseases at the National Institute of Allergy and Infectious Diseases, reported that her table discussed the challenge of overspecialization in the United States
as well as in low- and middle-income settings. For instance, she said that HIV has disease-specific community advocacy and disease-specific supply chain logistics, but other diseases and essential medicines do not. The number of specialists trained is often used as a country-level indicator of improved health care; this may have contributed to overspecialization and related problems in emerging health systems, she said. Some members of the group proposed identifying better quality metrics for evaluating health care systems, such as access to primary care, the number of health care providers, and availability of an essential medicines and primary care package at the community level. This package could potentially be designed by the ministry of health and include basic medicines, such as baby aspirin and hypertension treatments.
Mosa Moshabela, dean and head of the School of Nursing and Public Health at the University of KwaZulu-Natal, South Africa, reported that some participants at his table focused on the topic of understanding knowledge gaps and access to information. He said that it is often unclear which entities have which types of knowledge, or what knowledge is needed to influence the policy landscape and improve how work is carried out. Information access is a challenge, especially for entities that are not aware of what information they do not know; this problem is further compounded by siloing, he said. Some of the members of the group discussed developing strategies to access necessary information that already exists but is siloed, as well as developing research methodologies to generate new information when knowledge gaps are identified. In addition, a few participants suggested considering how to engage people with information at different stages in the life course. For example, information technology innovations could be leveraged to engage younger populations. Moshabela noted that efforts for innovation and invention should be directed toward evaluating what assets are already available and identifying how those assets can be maximally leveraged.
Furthermore, Moshabela said complexity can be embraced to achieve convergence. Some participants of the group discussed the use of dynamic approaches to plan services that are tailored to respond to a community’s needs more effectively than a standard package of care. This could be informed by creating a socioecological profile of a community to identify the right mix of services to integrate infectious diseases and NCDs in that particular profile. He suggested shifting toward more inclusive language to elicit community-level knowledge—a people-centered approach that takes into account diverse voices may reveal opportunities or information that would otherwise be missed.
Emily Mendenhall, Provost’s Distinguished Associate Professor at Georgetown University, noted that her table highlighted the importance of patient-centered, people-centered care, as well as issues on communication
and messaging approaches. She specified that some participants discussed how labels, such as researcher and policy maker, and categories, such as people who work on NCDs versus people who work on infectious diseases, can impede collaboration on complex problems. Some of the group members discussed the benefits of rethinking how messages are packaged and ensuring that health research is presented to people outside the health sector in productive ways. One strategy a few participants raised is to move upstream from individual-level interventions and frame health interventions as effective policy or social interventions.
Some of the members in Mendenhall’s group also highlighted the importance of catalyzing political interest, working as activists to publicly promote this work, and developing coalitions across sectors, as well as tackling the issue of corruption, as potential strategies. A few participants considered how the food and agricultural systems influence health and wider societal consequences, such as the overproduction of corn for high-fructose corn syrup that is put into high caloric foods, which are prevalent in low-income communities. Beyond corporate responsibility and targeting commercial determinants, she said it would also be helpful to consider historical subsidy programs fueling the overproduction of corn products and other systemic inequalities associated with these effects. Some of the participants indicated that a planetary perspective on health may be the most inclusive framework for understanding convergence, its drivers, and its outcomes at a macro level.
In a similar vein, Emma Mendelsohn, modeling and analytics research scientist at EcoHealth Alliance, added that a few members of her group also noted that in the infectious disease space there are incentives to cure disease while at the same time there are profit incentives that can contribute to NCD risk factors, such as unhealthy foods. In addition, some participants of her group discussed issues about communication, highlighting that communication with the public about specific issues can be part of a strategy to address a larger problem. For example, describing the mechanisms of the microbiome can apply more generally to communicating why convergence is important in tangible, mechanistic ways that can be accessible by a general audience. Finally, she noted that a few members discussed the need to improve the quality of data and facilitate data sharing to better inform models and make more accurate predictions. This includes the need to disseminate data within communities, she said.
As mentioned by some other groups, Matthew Coates, associate in global health and social medicine at Harvard Medical School, reported that many members of his group also raised the importance of person-centered care and community engagement to improve health care, as well as helping to prevent corruption. In terms of data, he said large data sources could be used to identify clustered comorbidities that can then be used to identify
endemics or underlying social factors that contribute to the clusters. He noted some of the participants of his group also discussed the need to improve the regulatory pathways for microbiome therapeutics and ensure they are accessible broadly and equitably. Forging personal connections across sectors, he said, could help mitigate silos and help prevent new ones from forming.
Finally, Paige Waterman, assistant director for Biological Threat Defense at the White House Office of Science and Technology Policy, reported that her table members touched on several issues. On the topic of strengthening health systems, she reported that a few members suggested a cluster analysis of the factors that make health systems efficient, which includes disease-specific inputs, social determinants of health indicators, or any other shared inputs. Economists could perform cost analyses to understand the required services and the relationships between individual-level needs in order to develop a strategy for allocating limited resources and shaping policy, she added. Some participants also noted the potential of leveraging the ubiquity of cell phones to empower, educate, and involve communities in health-related topics. The issues of siloed funding and disease-focused donor interests as challenges to integration were also raised by the group. Waterman noted that a few members of the group wondered if the messaging and framing of the national security dimension contributes to why NCDs receive less attention as a public health concern relative to infectious disease outbreaks.
DISCUSSION
Bridget Kelly, principal consultant of Burke Kelly Consulting, opened the discussion by asking participants to offer any further highlights or insights from their tables’ discussions. The discussion delved into issues related to trade-offs involved in the convergence, the role of industry and multisectoral collaboration, regulatory and funding considerations, and metrics.
First, Tolullah Oni, clinical senior research associate in the MRC Epidemiology Unit at the University of Cambridge, noted that convergence comes with trade-offs, because everything is interconnected. It is therefore helpful to understand how different components of the system interact, thus leveraging a systems approach. For example, there are interventions that could potentially improve an infectious disease but make an NCD worse (or vice versa), she stated. She also highlighted the benefits of broader multisectoral representation. Being more inclusive and seeking input from other sectors could help create a more holistic platform for leveraging a disaster as an opportunity to plan for and prevent infectious disease and NCD outcomes in future events. Kelly followed up, noting the need to think carefully about the assumptions being made regarding other sectors. Discussion often cen-
ters around what other sectors should do in terms of health interventions, but health may not be the priority of those sectors.
Cathryn Nagler, professor of pathology, medicine, and pediatrics at The University of Chicago, asserted that food allergies need to be recognized and advocated for as a global health problem. The food allergy community has received pushback because its prevalence has increased so rapidly in recent decades that relatively speaking, food allergies barely existed for an entire older generation, she explained. As a result, families in which a member has a food allergy often encounter problems accessing necessary accommodations, she noted. For example, peanuts on airplanes can be life threatening for a person with a peanut allergy, but there is still resistance from most airlines to allow families to preboard to wipe down seats and remove crumbs that could cause an anaphylactic response.
Moshabela suggested anticipating and preparing for pushback against the convergence agenda by proactively considering the potential unintended consequences of convergence as well as possible trade-offs that may arise. For instance, a focus on health promotion and upstream factors may be perceived as a threat by those who benefit from the current model. Kelly suggested working to mitigate the threat to people who may push back against the agenda. However, she noted that losses may be unavoidable for actors who benefit from profit incentives that are harmful to health.
Peter Daszak, president of EcoHealth Alliance, reflected on how various industries will be affected by convergence if the guidance being discussed at the workshop were to be actually implemented worldwide. For example, the livestock and vaccine industries would likely be less profitable, while the pharmaceutical industry might shift to developing microbiome-focused supplements and nutrients. Certain companies would likely exploit niches in this new market. Increasing obesity related to meat consumption in Asia could have significant implications in the future for companies supplying that meat, he added.
Following up on the role of industry, Oni noted that discussions about health and convergence of infectious diseases and NCDs often center on the private health industry. In countries in sub-Saharan Africa, for example, cities experiencing rapid urbanization are also subject to increasing environmental exposures related to infectious disease and NCDs. These exposures are being driven by private industries that are generally disengaged from public health policies and considerations, she said. To address this issue, Rachel Nugent, vice president of the Chronic Noncommunicable Diseases Global Initiative at RTI International, suggested that health impact assessments could be used to inform development decisions.
Regarding the U.S. Food and Drug Administration’s (FDA’s) regulation of the microbiome, the speed of the transition from knowledge to treatment is hugely influenced by the regulatory pathways, commented Jay Siegel,
retired chief biotechnology officer and head of scientific strategy and policy at Johnson & Johnson. For example, using fecal transplant to treat people with Clostridium difficile occurred before FDA decided that it was something to regulate. If such advances are relatively easy to do without regulation, it eliminates the incentive to invest in clinical trials. Regulation is at a critical juncture, said Siegel, because regulatory hurdles can have a major effect on the types of research that are carried out, the therapies that are developed, how much these therapies cost, and who has access to them. He highlighted that this has been illustrated in stem cell therapy, gene therapy, antibody therapy, and biosimilars.
The discussion transitioned to the implications of siloed funding, with Kelly remarking that siloed funding—such as earmarked government funding or disease-specific donor funding—is a cross-sectoral issue. She asked participants to comment on how efforts to reduce funding silos might affect the entities who hold the money. Siegel replied that while organizations may generally be interested in understanding the public health effect of their funding, they are often required to report back disease-specific metrics of effectiveness. It is more challenging to collect metrics to evaluate broader investments.
Along the topic of metrics, Patricia García, professor at the Cayetano Heredia University School of Public Health, Peru, noted the need for investments to strengthen the capacity to strategically collect information and analyze metrics on a systemwide level. She commented that sometimes funding agencies request too many metrics, which can often cause a burden for policy makers and other stakeholders when each funding agency is requesting different metrics. Being strategic about what metrics to collect and measure that would ultimately be reliable information is an important component of convergence, she asserted.
Mendenhall said that metric-driven interventions can be less effective and actually perpetuate inequalities and other problems, so making progress toward convergence will require moving beyond the current focus on individuated, disease-specific outcomes. She suggested that this message is not being heeded owing to the power of funders and their disease-specific motivations. It was noted that metrics that are not disease specific, such as health-related, quality-of-life indicators, are much more difficult to measure, and current information systems are not set up to capture those types of metrics. Oni added that even in projects that are explicitly designed to work intersectorally, the differentiation between infectious disease indicators and NCD indicators and outcome measures persists. Kelly pointed to the role of nonhealth sectors to inform new, integrated ways to measure health.
Finally, Siegel remarked that silos are also reinforced by the ways that health care providers are trained compared to the training received by public health professionals, particularly with respect to community health, epidemi-
ology, and a generally more holistic view of health. Kelly observed that it is easy to default to thinking about the convergence in terms of leveraging the successful practices of each side. In closing, as an alternative, she offered the framing that there is also space for both sides to recognize and collaborate to improve practices that are not working for either side to achieve mutually beneficial outcomes.
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