Ruth Bishop Lecture 2021

This lecture was held virtually on Wednesday 24 November 2021.

The Indo-Pacific Centre for Health Security was honoured be joined by Dr Sarthak Das, the Chief Executive Officer of the Asia Pacific Leaders Malaria Alliance.

Sarthak joined APLMA from the Harvard T.H. Chan School of Public Health, and continues to hold a position as Senior Advisor for research translation and Global Health Policy at the Harvard Global Health Institute. However, it's his 25 years of experience as a public health scientist, development practitioner, and global health policy advisor that inspired his lecture.

You can listen to the address using the player below or via your regular podcast app through the Contain This website. A written transcript with selected slides appears below.

 

Dr Sarthak Das 

It is indeed such an honour to be delivering this lecture in honour of Professor Ruth Bishop, such a venerable scientist. By some accounts, in the pre vaccine era, rotavirus was responsible for up to half a million deaths a year. Today by one estimate from IHME, that's the Institute for Health Metrics and Evaluation, that number is down to 128,500. And while there is still a long way to go, I wanted to remark on this because in researching more about Professor Bishop, I am understood that this was someone who is exemplary, not only in their pursuit of science, but also in terms of how to take that science and translate it into action. So much of her pioneering work was not only about the science, but also ensuring \ that the challenging work of delivery would happen. If we look at these data in terms of global decline, in rotavirus deaths, in terms of rotavirus as a proportion of diarrheal diseases, and the declines over the last several decades, it is formidable. And a legacy that inspired me in terms of thinking about how to make this a meaningful presentation, which I hope it is.

So the first thing I wanted to touch on before going into anything else, is really to understand why don't we talk about diseases like malaria, HIV, TB, in the common discourse, as pandemics anymore, we hear about COVID, certainly all the time. But when we look at these other three big diseases, there are no less in terms of the toll that of suffering that they are inflicting on the world. And the answer to that is pretty straightforward to me. And this echoes a sentiment that was shared by Executive Director of the Global Fund, Peter Sands in a piece that he authored over this past July. And that is that people aren't dying from those diseases in most of the wealthy nations in the world, however, COVID hit everybody. And I think it's very important just to start with that as a framing, because epidemiology is always about reinforcing, or should be, equity. Understanding what a pandemic is, and how we use that word is a subject of debate, even among public health scholars and scientists.

But clearly, these are pandemics, and malaria is the oldest pandemic that we have. So, before diving into the substance of this talk, I'd like to visit some of the recommendations that have recently been made by the G20 Panel in regards to pandemic preparedness. And the reason why I'd like to keep these at the front of this talk is because my hope is that over the next 20 to 22 minutes, we can spend some time thinking about and reflecting upon: What do such recommendations mean, in terms of how we put them into practice? In particular, what do they mean, in geographies that are most removed from where service delivery is the strongest? Because at the end of the day, when we think about pandemic preparedness, or the next pathogen that may emerge, it is quite likely that it will emerge from a place where systems may not be as strong. So the essence of this talk is really around capacity building and sub national delivery for pandemic preparedness, and to interrogate that subject.

So what can we learn from the oldest pandemic, that is malaria, that may help us understand how we begin to address some of the factors that we may wish to consider. One of the first things that we need to think about is where,\ and who? One of the things that malaria teaches us is that when we look at malaria in Asia Pacific, and I'll spend most of my time focused on global health in the Indo-Pacific, and a fair amount of time talking about Papua New Guinea as well, given its proximity to the hosts of this lecture, in the Indo-Pacific centre, and also given that a fair bit of my career and learning has occurred in Melanesia. So when we look at malaria in Asia Pacific, we find that in according to 2019 data, 86% of malaria is concentrated in a handful of places Papua New Guinea, Indonesia, India, Pakistan, and Afghanistan. And the region has made remarkable progress to be certain, particularly in the Greater Mekong sub-region. And, of course, most recently with the certification of China as malaria free, and in the past, we have Sri Lanka’s certification, and other countries such as Bhutan, and Timor-Leste staying on the cusp of elimination.

Globally, the Greater Mekong sub region, and rightfully so, because of the concern over the emergence of drug resistance has received a fair amount of attention, resources and focus. And that has produced results leading to dramatic reductions in terms of the elimination of Plasmodium falciparum. And another hopeful note, while this data is still subject to the fluctuations, given the fact that we remain in the midst of the COVID pandemic, there has not been the appreciable impact on the elimination trajectory within the Greater Mekong sub region that one may have expected.

And that is hopeful news, but when we look at malaria, across this region, what we increasingly find that is that it is an invisible disease, but not invisible to those who live where it is endemic. If we look at Indonesia, the eastern half, or the western half of the island, or across the border from Papua New Guinea, in Papua which remains an area that struggles to attain modest levels of control. In India, there has been tremendous progress as well. And at the same time, we find pockets of endemicity in mostly rural and tribal areas in states such as Orissa and Madhya Pradesh.

And when we look at COVID, and we begin to see where the bulk of vaccination has occurred, we also begin to see not so much in the case of Indonesia or India, but certainly in the case of PNG, and a very diminished ability and I'll say more about that later.

The first point that I'd like to make in regards to lessons around the wisdom of local knowledge is from experience that I had during the 2014 Ebola crisis in Sierra Leone. One of the critical things that we know in public health is that we must understand the perception of disease at the local level. How do people decide whether a given treatment is efficacious? What is the treatment seeking pattern of a community? And how involved are those communities in the planning and evaluation of programs?

In October of 2014, I was in Port Loko district, Sierra Leone. This was during the height of the Ebola crisis in Sierra Leone. And amidst all of the tragedy that was unfolding around us, among many other things, one thing became eminently clear. And that is that there were real issues in terms of communication, obviously, major issues in terms of trust in the health system. And one central component of the Ebola crisis was the inability of Sierra Leoneans, many of them in these remote and rural communities to understand fully the messages that were being shared.

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So as a concrete example, individuals were being told to not touch a dead body. But of course, as the crisis got worse, that became very difficult when multiple family members in one household were dying, and people wanted to administer the last rites and rituals, another message was being given to wash hands. And so what was happening was, people were in many communities, putting aside water to dip their hands in while they also conducted the ritual dressing of a body. And that's just one very potent example of an inability to understand how and which messages needed to be delivered. How do they need to be delivered? And how would they be received.

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A second important lesson that I'd like to share is really around co-creation. And with this, I'd like to turn back to my time, which continues in Papua New Guinea, albeit around HIV. And this bears some relevance potentially, to what's currently being faced in terms of challenges, not just around vaccine supplies, but around vaccine uptake.

As many of you may be familiar, voluntary counselling and testing centres were established across much of the world, and certainly in PNG, that was no exception. And within this model of VCT, among rural communities, you often would have freestanding structures that were of course for confidentiality purposes, made to be separate from communities. One of the things that we learned in working with communities, particularly those in the highlands, was that there was a real reticence to engage with any form of testing within the confines of a standalone voluntary counselling and testing centre. But upon discussing further with provincial  leadership, and others leaders within the community, it became abundantly clear and, stated emphatically that what would be preferred would be for certain communities to receive counselling as a group similar to antenatal counselling in the way that is done, and then to test together as a group. And over time, what began to happen was a radical transformation and adoption of the model of testing to use or repurpose buildings that were already within the communities, such as this church.

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We would conduct group counselling outside and then begin a process of individual testing inside. And this became a very powerful way to reach many who had previously been reticent. Often, these events would be accompanied by other routine health screening. It also became an opportunity for food to be prepared or other ways in which people could gather on the periphery of this. And all of this was happening within the context of a project, which was really meant to seek to decentralise services to rural communities within the highlands.

And the reason why I'd like to share this is because if you think about building a system of complex chronic care, such as HIV, and you think about the lack of availability of primary health services, it's not going to be something that one would think would result in high levels of patient retention. But in fact, the levels of patient retention, over 24 months were significant, as highlighted in excess of 80%, in some cases, and this being able to deliver on this level of quality became a vehicle for community trust. Often when I think about what's happening with malaria in Papua New Guinea, and when I think about health and infectious diseases and approaches to intractable public health issues, I think it's very important to reflect on the country and its ability to not only develop systems for HIV. But similarly, the way in which the country has been able in the past, to battle back malaria, to less than 1% of prevalence. And while there has been a backsliding, we've seen some significant progress in the latest report that was issued by the indicator survey done by the PNG Institute of Medical Research.

Another critical lesson is around cultivation. And when I say cultivation, what I really mean is the cultivation of networks, the cultivation of local leadership, the cultivation of the ground, if you will, in a way that fosters exchange between those who are there with the presence of those who may provide support externally, but doing so in a manner that really is both flexible, as well as looking towards the long view of fostering local leadership. And so when we think about the cultivation of leadership, really what we're thinking about in this context that I'm speaking of, is how do we improve the capacities of district level management? If we look to the example for example of Sri Lanka, and the malaria elimination successes there, these are really due to the district level management and the exemplary network of regional malaria officers and the leadership at the provincial level. And one of the things that we can also see before turning to these data is part of the successes in HIV and so many parts of the world has seen similar ability to create networks of providers, networks of people who work with data so that they can work with one another and work within the context of supportive supervision. And so when we think about these types of efforts to cultivate, it's very important also to reflect on the fact that while we may be describing vertical diseases, what we're also talking about are effects that have impact on broader strengthening of health systems. Malaria elimination is but one example of documented strengthening of health systems. We've seen this with HIV as well, in terms of improved antenatal care, and a variety of other primary health outcomes.

Finally, in terms of commitment. I think some of the most interesting lessons across many of these domains that I mentioned, also emerge from smallpox and the eradication effort. When we think about commitment, commitment needs to come from several levels, obviously, there needs to be a level of broad-based political commitment. But at the same time, one of the things that's very important is that there is a commitment. And that commitment is to be at risk of using a very overused term, a commitment to the empowerment of those working at a provincial state, or district level, to be able to approach intractable or difficult public health issues within a parameters that are allow for some flexibility. In other words, a top-down approach will never work, particularly in these communities, and in these regions that I'm describing where systems may be the weakest, and what smallpox eradication efforts taught us. And this holds true for as well for successful efforts in combating drug resistant tuberculosis, HIV, malaria, is that solutions that emerge from public health systems, which are able to try different approaches, and quickly change direction, in course, with the support from donors, partners, and national normative bodies, is tremendously helpful. What we see is that these things that we all know and hear about, which are critical leadership, the ability to use local data, effectively, strong management. These first three are truly up deployed at their best when they're happening within the context of a national effort, or an international or multilateral or bilateral lateral funding environment that allows for flexibility that allows for a longer-term investment, and one that also, you know, really allows for thinking about how funding flows can be more effectively channelled to those geographies themselves.

So a very specific example, not from smallpox but thinking about Papua New Guinea again, would be something like the Provincial Health Authority Act, which is quite precious in its own way to bring together curative health services, along with preventative health services under one overarching authority, and the degree to which aid can help support provincial health authorities in collaboration with the National Department of Health in a place like Papua New Guinea, generate greater control and autonomy to improve efficiencies with particular funding that may be present will yield better results. And this was actually also true when it came to the global effort around smallpox eradication.

Finally, I think that embracing remote digital tools and telehealth, obviously, will be critical when that is feasible and should be a longer-term goal. But just thinking again, about the statistics that were showed very quickly, earlier on, in terms of right now what we're witnessing in terms of the ability not just to deliver a vaccine in terms of doses, but vaccine uptake is something that is of increasing concern. In PNG specifically, and I wanted to raise this at this time, given the recent report that some of you may have seen, issued by the Lowy Institute, and I also received correspondence from colleagues, who are CEOs of provincial health authorities in Papua New Guinea describing to me as well, the challenges in being able to deliver the COVID vaccine effectively. And I think this speaks to the earlier points around Ebola, the earlier points around models of testing for HIV, we need to allow for funding paradigms, programmatic frameworks that really take an approach, which can in real time, look at and understand and listen to, why there may be resistance and then be able to, through trial and error, see what different approaches may work. So it could be that an outreach model for vaccination that includes other ancillary services will yield better results, it could be that we need to be deploying radio in a way or drama in a way that we are not. There are a variety of things that could be contributing to that. And I think that's really critical for us to think about.

Another point, which I was asked to make was around the malaria vaccine. The malaria vaccine, it gives tremendous hope, in terms of the future of the effort to eliminate malaria from Asia Pacific and indeed the world. At the same time, it's important to remember that one, this is a vaccine, which has not been trialled in Asia Pacific. And two, perhaps more importantly, we have tried and true tools that have yielded strong results by eliminating malaria in over 40 countries in the world.

As my dear friend and colleague, Professor Kamini Mendes, likes to remind me malaria was eliminated from Sri Lanka with pen and paper. So it's very important for us to pay attention to what is already there, what is available. To understand that there are no silver bullets.

In the end, it is going to require a longer investment. And it's one, a longer investment in terms of longer investments not only in terms of capital necessarily, but in terms of longer investments in listening, longer investments in being able to learn through experimentation.

And I wanted to close with one other set of questions or comments here. And that is that in our effort around global health, security, and meeting this pandemic, whether it's malaria, HIV, TB, or COVID, and really challenge ourselves to think about when we establish programs, who are those programs accountable to, because the accountability for the programs certainly needs to be first and foremost to the government's and to the people that they seek to serve, balanced with those who are providing those resources. And, ostensibly, those who provide the resources seek the same as the governments that they are supporting. And so it's very important then to continually remind ourselves of that. And to remind ourselves as we do that, that successful civil society entities and NGOs are ones that are truly supporting the public sector.

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So many of you, some of you may be familiar with the concept of root bridges, and those who have heard me speak before, or I've talked to me know about my affinity for them. Root bridges, for those who don't know, are trees that are trained from the time that they are saplings to grow in a certain way, so that they can ultimately become bridges. And over time, decades, of course, these trees can become stronger than concrete and steel. This is an image from Meghalaya in northeastern South Asia. But I think this is a very apt metaphor for where we are today, because all of us who have been working in global health, for the last several decades, have been truly forced to think about our own paradigm, whether it's personal, or whether it's collective, around how we build capacity, and how much of what we have done, truly reflected what needed to be done based on an ability to hear what those solutions need to be. And I think that if there is, and there are many, I do think, but if there is yet another silver lining that COVID has given us in terms of an emphasis on global health, it is that we can rethink our paradigm around capacity building to more actively reflect that intuitive sense that one would hope every global health practitioner has that the solutions that we need to bring to bear need to emerge from the place for them to endure.

With that, thank you so much for your time, and for listening, and I look forward to the discussion.

Dr Stephanie Williams  

Thank you, Sarthak, that was terrific. You've really laid down the current challenge for all of us in going beyond global and reminding us that, in fact, all health is local. I was struck by the fact that we seem to continue to need to learn the lessons of past pandemics about putting people at the centre, you gave examples from Ebola, from PNG and the HIV testing. And reminded us as well, that when a local health service delivers something perceived to be worthwhile and useful to the individual, they will continue to come back as your study showed in PNG.

I have a couple of questions to begin with. And I know in these lectures, one can never do justice to the many ideas you've put on the table by getting a question for each of them, but they're there. I wanted to come back to your idea of the Sri Lanka example, and the cultivation of networks and what it meant to have a functional public health district and national system working in concert. And I wonder if you could talk more about what if anything, our current global health funding models and interventions, and not doing or doing or could do better to enable what effectively clinical and public health governance models versus some of the more technical interventions of service delivery? So could you talk a little bit more about the kind of training that you think is necessary and the end where interventions can better support those network based solutions?

Dr Sarthak Das  

Thank you for that great question. I'll try to respond in two parts. So the first is thinking about networks. I really I don't think we can talk about it enough in terms of management, and public health management and what that means. And I think you were perhaps alluding to this in terms of that this isn't only a question about the clinical or the science, but this is a question about being able to operationalize, and in the upper and so that's one level I want to talk about is management in operationalizing, public health programs at country level, or in sub national level. And then the second level at which I wanted to address this is, I don't know if you're asking this, but I'm going to go ahead and take the opportunity to talk about the kind of training also that we need to be thinking about in terms of those who are in the positions of influence, as we are to determine how funding might get shaped how programs might be designed.

So to the first point, I think, you know, in the end, I think we can see many, many examples of this, but I think the smallpox one is actually a good one. Because Smallpox is, maybe it's partially luck, but it's this singular example of eradication that we have. And if you really read and go into the history, so much of what was written about also talked about the fact that part of what that did was say that some of the things that needed to get done were, they were managerial, they were operational, and you needed people who were passionate about it, who were very much willing to think outside the box, who knew what their remit was in wasn't in terms of the science, but that fundamentally getting to the eradication was something that was operational, we see that again.

And again, we think about it in terms of malaria, if we think about supply chain issues, in terms of drugs for drug resistant TB, if we think about it in terms of bed nets, if we think about it in terms of a variety, a plethora of diagnostics and commodities. And also data, we talk about a pandemic preparedness facility being something that we need to really think about having, you know, an army of firefighters to detect the next outbreaks and be able to share that information. But the ability to be able to actually use data act on that data is also fundamentally linked to management, public health management. And because if you can't do that, you're not going to be able to then take that data and translate it into something meaningful, because you may know there's a reservoir in a particular place of infection. But how do you know how much diagnostics, how much drugs you know, how many people and how much fuel you need to allocate to that, and what kind of a team needs to be in place to do that.

So management is critical. And the ability to build those effective networks, I think it the successful ones are around this model of supportive supervision, encouraging and modelling good leadership, good management through real examples, live examples that people can see. And some of those examples may be people who just are intuitively good, who have not, in my experience, that's what it is. It's people who have never had the benefit of management training, but are just good managers.

But I think that there's space there to bring more people into the fold of that kind of work at a country level, at a state level, at a provincial level. And I think there's a really interesting phenomenon if we look at it. On the flip side, when we think about internationally, I think there's wonderful things that have happened in global health over the last 20 years where there has been this explosion in terms of global health as a field where there have been so many people coming from disciplines, like management, like engineering, into global health, who don't come from scientific or clinical backgrounds, and then are part of a no these massive efforts to address some of the most critical challenges in global health of our time.

At the same time, I think it's really critical that we continue to push what kinds of training experience is necessary for our institutions. Whether they're in Australia, whether they're in Europe or the United States, akin to residency programs in medicine, where you say, here's the practicum that you need to do to understand public health management, if you're going to be making decisions on resource allocation for systems building. I don't know if I took that too far afield. But I was excited about your question.

Dr Stephanie Williams  

And I think that is an excellent point around public health, and you call it global health. One is that it is multidisciplinary by nature. And two, it is a management task first and foremost.

Can we come back to your comments around PNG and your discussion about some of the approaches to addressing the hesitancy challenge which you talked about? Real time listening and empowering local decision makers. Through Australia's bilateral health program and vaccine initiative, we’re funding and enabling a range of activities to connect our understanding of hesitancy by province by community, to respond likely supporting provincial health authorities to do so, as well as our bilateral program has, really, for a long time, tried to do empower the core functions of provincial health authorities to sit above and manage the resources. There's been two questions in the chat, asking you to expand a bit further, around overcoming some of the barriers in delivery. You talked about civil society and NGOs being accountable, but can talk a bit more about overcoming the barriers to very crowded health spaces in local areas, between different partners? It has been two questions that have asked you to expand a bit on that in a PNG context.

Dr Sarthak Das 

Well, another great question, I think. Fundamentally, it comes down to, I don't think we can overstate, particularly within the context of Papua New Guinea, and I think this is also holds true for many other cultures in Melanesia, how we understand what it means to make decisions. how we understand what it means to listen, because very often, when you're in a room with your counterparts, it's what's not being said in a group of people. That is the subtext, so I bring up listening first, because I do think it's important to recognise that what if the breathing space isn't allowed to, for people to feel comfortable enough to speak up. Decades of ideas being thrust upon people. And so a reticence to really offer up anything. I mean, I think that's very true, where there's almost a fatigue about wanting to say something when there are if what you were referring to was a crowded field of civil society actors, and a kind of lone few people from the public sector, who are, especially if they've been there a long time, they're at this point used to either being talked over or not asked. Or maybe they are asked, but their way may not be to come forward with the idea as quickly. And so I think that breathing space on the front end, sounds fairly obvious, but it's important to restate that giving the space for the trust and that can happen even in a short span of time. I think that putting people at ease – that’s truly not a lip service. It's okay to be actually sitting in a circle in silence, because eventually someone will say something but you don't necessarily have to be the one to say, hey, here's what I think we should do, or here are the five things that worked and A, B, or C. I think listening and giving space for people to speak, or even holding a space for people to talk to each other. Listening and giving space for people to speak, or even holding a space for people to talk to each other. Because I've seen that through and through, where the idea was already there but nobody gave the time to end the space for those discussions to happen. So that's one piece. What was the other in that question?

Dr Stephanie Williams 

I think you addressed it really in a way, I think it was written from the perspective of one of several actors in decentralised systems, external actors, and I think you've hit the nail on the head, you know, about how swamped, a very small number of public sector leaders in a certain country can become with a plethora of effort, despite the best of intentions, and empowering both the coordination capacity and the ownership at that level. It's something that we say that we really want to do, but in practice, it looks like from your experience, in our shared experience, that we have some way to go to be actually doing that.

Dr Sarthak Das 

That's right. And I do think, though, that an element of it is being really attuned to who the leaders are, right? Because there's so much we don't know or understand about what's happening. But if you, again, give it the space, eventually, there are people there. There's some very effective leaders within the public sector. But often in my own experiences, some of the most effective leaders are the most quiet ones in the beginning.