Plagues and the Paradox of Progress: Why the World Is Getting Healthier in Worrisome Ways

CFR Senior Fellow Thomas J. Bollyky discusses his new book, Plagues and the Paradox of Progress: Why the World Is Getting Healthier in Worrisome Ways.

HAASS: Well, good evening. I’m Richard Haass, and I want to welcome you to the Council on Foreign Relations. Tonight is—as you’ve guessed, is an event in our Book Launch Series.

And the book we are launching is written by the gentleman next to me, Tom Bollyky, who’s a senior fellow here at the Council for global health, economics, and development. And at the risk of getting ahead of myself, he is actually well-titled given the book he has written because he combines global health, economics, and development in this book. He also directs the Global Health Program here. When he’s—in his spare time, when he’s not playing third base for the Yankees, he’s also an adjunct professor of law at Georgetown University.

What we are going to do is talk for a few minutes. And what I hope you will do is not just listen raptly to what Tom has to say; then you will hopefully ask some penetrating questions, unlike me. Afterwards there’s drink and food but, more important, there are advance copies of Plagues and the Paradox of Progress: Why the World Is Getting Healthier in Worrisome Ways for sale. The actual pub date is about a week from now, the 27^th, but in ways I will not describe we got advance copies. (Laughter.) You don’t need to know. As we used to say in the intelligence business, you have no need to know. But the good news is they are here.

The even better news: it’s an extraordinary book. And it’s rare that one reads a book that so challenges the way one thinks about a subject or a set of subjects, and this book does it. And it will challenge you and will educate you at one and the same time.

So, Tom, congratulations.

BOLLYKY: Thank you so much.

HAASS: So let’s start with the basics here. As I said, the title of the book is Plagues and the Paradox of Progress—say that fast three times, I dare you—Why the World Is Getting Healthier in Worrisome Ways. So let’s deal first with the—why don’t we put the two together? What is the paradox of progress? And how can getting healthier be worrisome?

BOLLYKY: Great. Well, thank you so much.

Let’s start with the good news, which is the progress part. In 1950 in more than a hundred countries, one out of five children died before their fifth birthday. Today that happens nowhere. For the first time in recorded human history viruses, bacteria, and other infectious diseases do not cause the majority and death—of death and disability in any region of the world, including sub-Saharan Africa. In the past these types of health gains have been—have been the path to great prosperity and inclusion. So, between 1890 and 1950, the decline of infectious diseases in the United States has been cited as one of the single most important facts in the history of American economic growth. China was poorer than Chad and Benin in the 1950s when it began a campaign against infectious diseases that helped lift that country into the great global economic power it is today.

But we’re not seeing those kinds of economic gains being paired or broader gains being paired with better health today. And that leads us to the paradox part, which is the bad news. We’ve become very good at reducing—the good news is we’ve become very good at reducing infectious diseases and child mortality in deeply poor countries with dysfunctional governments and limited infrastructure. The problem is that they have largely remained deeply poor countries with dysfunctional governments and limited infrastructure. And that has meant many of the things that go along with better health—a rising young adult population, less deadly cities, a shift in health needs to adults—are now sources of potential poverty and instability rather than the opportunity for prosperity that they used to be. This, if it persists and we do not act, is a risk of instability and to the future of those countries. But given the size of these trends and their effects, it really should concern all of us.

HAASS: So what you’re basically saying, for those people like me, the laymen here, is the good news is we’ve figured out ways to keep a lot of people alive who in previous centuries or decades would have died. And the challenge is now we’ve got to deal with the fact that we have these large populations, and we’re not dealing with them well.

BOLLYKY: That’s exactly right. And let me be clear, it is really good news that we’ve made this progress against infectious diseases. There’s no worthier goal, no more noble accomplishment of humanity than reducing unnecessary suffering and death in children. The problem is we haven’t made the same investments in what happens to them when they reach adulthood.

So let me give an example of that: Niger. Let’s take Niger for an example. Niger, since 1990, has extended its life expectancy by sixteen years. It has reduced its infant mortality by sixty percent. Infectious diseases have declined by twenty percent over that time. Over the same time period, Niger has gotten poorer than it was in 1990. The government spends $17 per person per year on health. It ranks or it’s tied for last in the amount of education a child can expect to receive. And in the U.N.’s Human Development Index rankings, out of 187 countries, Niger ranks eighty-six. So, faced with that situation, young adults in Niger are doing what you or I might do when faced with that situation: they’re moving. And we’ve seen a tremendous increase in migration from sub-Saharan Africa out of the region, and that’s spurred by trends like this.

HAASS: OK, so—again, so you’re not—you don’t have issues with what we’ve done. You’re not against—I just want to get for the record here—you’re not against—(laughter)—curing infectious diseases or preventing that? Could we get that on the record there, Mr. Bollyky?

BOLLYKY: Yes.

HAASS: (Laughs.)

BOLLYKY: I’m not only not against having done it; I am—I’m for continuing it. I really—we’ve done remarkable—

HAASS: OK, that’s a more serious point. So you’re not arguing that we’ve reached a point where we can safely afford to let up.

BOLLYKY: No, not at all. The war between man and microbe is not over. Enormous threats still loom in global health. The threat of avian influenza is quite real. The threat of anti-microbial resistance, antibiotics—becoming resistant to antibiotics is quite real and can do an enormous amount of damage. This is not a time to stop being vigilant. The problem is, though, we need to pair our global health investments in investments with what happens to these people as they reach adulthood, into human capital really.

HAASS: So, again, your problem tonight in one area is you’ve got a moderator who’s not an expert here. What I hear you saying is that we’ve done fine in one narrow area, but now we’ve got to embed this, essentially, in a development strategy, and flesh it out, and complement it with all sorts of other things that the narrow intervention that we’ve carried out has been narrowly successful, but if anything it’s actually by keeping so many more people alive and the rest, bizarrely enough, it’s actually added to the challenge.

BOLLYKY: Yeah, no, it has. That’s exactly right. It’s a great summary.

HAASS: OK.

BOLLYKY: It has added to the challenge. I mean, we’re at an inflection point. We have made this tremendous progress, but the—but the trends are some—are worrisome. So allow me to throw a few more—few more stats at you.

So, between now and 2050, we will add 2.1 billion people to the working-age population. At current employment rates in the regions where this growth will occur, that means nine hundred (million) unemployed people.

The growth of cities has become so unprecedentedly rapid in lower-income countries that you see now close to a billion people living in slums. There are countries like Central African Republic where ninety-six percent of its urban population resides in slums.

You see an incredible surge in noncommunicable diseases. So, in countries like Myanmar or Ethiopia and Bangladesh, that will—in 1990 had roughly twenty-five percent of their overall health burden be related to NCDs, by 2040 that will reach eighty percent, which is the same as it is in the U.S., except in those countries it will be happening in much younger people and in a country with many fewer resources to deal with it.

So we should continue to invest in what we’re doing. But by not having invested to date, we have put ourselves in a situation where there is enormous pressure to act.

HAASS: I don’t know if he was invited tonight, but it’s clear from looking at who’s here tonight Bill Gates couldn’t make it. (Laughter.) But if he and his colleagues from their foundation were here and they heard what you just said—better yet, if they read your book—would they be—would they take offense? Would they say you’ve got it wrong? Would they say you’ve got it right? I mean, ideally, what would be their response? Would they essentially continue doing everything they’re doing but double their funding and now start funding other things?

BOLLYKY: So let me be clear. The world—Bill Gates has done an enormous amount of good. The world needs more Bill Gateses, frankly. What they have done in terms of investing and reenergizing global health is remarkable. The problem is that we do need more Bill Gateses in these other areas in terms of investing in educational quality, in health systems, in livable cities.

So, you know, my sense of how the foundation would react actually changed just this week. They released a report—

HAASS: Did you get a big grant from them or something, or no? (Laughter.)

BOLLYKY: Maybe, maybe. They released a—they released a big report, their second Goalskeeper (sic; Goalkeepers) report, and really it is actually about the precarious circumstance we’re in in terms of unprecedented population growth in sub-Saharan Africa threatening our global health gains and the gains that we’ve made against poverty. That’s really, effectively, the message of the book. So I think they actually might be more onboard with what this book says than even I had realized a week ago.

HAASS: Up to now I’ve mainly associated you with being one of the few people, along with Mike Bloomberg and others, who has really popularized or evangelized on the subject of noncommunicable diseases; saying it’s good that we’re doing all this work on infectious diseases, you’re not against it, but we have—to the—the fact that a lot more people are living longer lives, a lot of them are succumbing to noncommunicable diseases.

BOLLYKY: Yeah.

HAASS: And that seems to me also it’s not just a question of jobs and infrastructure and all that. So why don’t you say a little bit about the unintended consequences of saving people from infectious diseases? What’s happening to them in the global health space? Talk about the trajectory of many people’s lives now and where it now intersects with noncommunicable diseases.

BOLLYKY: Yeah. So we did a task force here at the Council on Foreign Relations, our first Task Force on Global Health, that looked at noncommunicable diseases in 2014, and we pulled together really an all-star group to look at this. It was co-chaired by Tom Donilon and Mitch Daniels, and really just had a great group. But they were people that largely hadn’t spoken out on NCDs, or noncommunicable diseases—cancer, heart disease, diabetes, for those of you that don’t know the term. And when we first went into it, they were unconvinced this was a real problem. So we showed the data that it’s increasing faster than the rate of population growth, three times as fast as the decline of infectious disease in poor countries and is rising overwhelmingly in people that are fifty-nine and younger. And that helped convince the group that it was a problem.

But then the question is, is this kind of good news? Is it good news that people aren’t dying as children from malaria or of some exotic parasite and, you know, at least are having this opportunity? And there’s nothing sustainable about saving people as children and infants to see them perish in their thirties and forties, when they’re heads of households and members of the workforce, from diseases that are largely equally preventable.

The good news is that there are things that have made a tremendous amount of difference. Tobacco control works in poor countries and wealth countries—wealthy countries alike. We have really evidence-based strategies for doing that. And Mike Bloomberg, as you mentioned, and others, really have done unbelievable work in promoting that.

But it’s also true that we can do more to provide care to people that are having these needs as well. You know, roughly, the largest source of it is hypertensive heart disease. A lot of the medications for those are cheap, but people don’t get diagnosed. And there’s a big effort afoot—I saw Tom Frieden in the audience, and this is something he’s doing as well. And I think, really, there are some targeted approaches that can make a big difference in this area. So I am not without hope.

We do have a big U.N. high-level meeting next week on noncommunicable diseases. If you miss this one you will be forgiven. It is not expected to really generate the kinds of results people like to see. That said, it is good that within seven years this is the third high-level meeting before the U.N. and it’s pulling together world leaders. And the takeaway, at least, that should be drawn from that is that this is a serious global problem. We, just like lots of other areas in global governance, now need more work to do something about it.

HAASS: So imagine you are given the opportunity to testify before Congress on this or meet with people at OMB and talk about U.S. aid or spending in this realm. What would be your—what would be your prescription?

BOLLYKY: So the good news—well, we have two bits of good news. We did testify before Congress on this based on that task force report in 2004—2015, right after that task force report. So we have good recommendations, so I have an answer to your question. The bad news is they still haven’t done them.

So what I—what I can say is at the end of the day noncommunicable diseases seems like it’s a different problem from the other ones we’ve dealt with in global health, but it’s largely arising in poor people that can’t afford preventative care and aren’t getting access to the same kind of prevention strategies that are in wide use here. And the governments aren’t providing them with the chronic care to get the treatment they need, so they die early. In short, it’s a result of poverty and inequity, just like all our other global health problems.

So a lot of the other strategies that we’ve used to address global health are equally applicable here. We have—we have this wonderful infrastructure. We’ve had a ramp-up in global health aid programs since the last 15 years. There are pooled procurement mechanisms that might be able to extend access to medications. The same kinds of strategies that Mike Bloomberg and his wonderful team are pursuing on tobacco control in terms of generating evidence-based strategies, building civil society support for them, monitoring their implementation, and having governments be accountable will work with a lot of other global health programs that we see in the NCD space.

We’re not talking about a lot of money here. This is—this is not—this is not the—even the kind of lift that you saw around HIV in the early 2000s.

HAASS: Just to be clear, we are talking—since you’re—well, I’ll ask the question this way: Are you suggesting that we shift money from fighting infectious disease to what you’re talking about here or are you suggesting additive?

BOLLYKY: So I am—I am suggesting additive, but I do think in terms of the money that we’re spending on infectious disease it does need to be spent differently. This is one of the takeaways of the book. And it’s not just in infectious disease; it’s true in education and in other areas.

So much of what we do in aid is we pay for inputs. We pay for the—in the health area, the drugs we want to supply to the diseases we want to address instead of responding to the health needs of that population and monitoring the overall health of that population. We have no idea what the broader health of people are that go through the PEPFAR program, not a clue. It is—we monitor the specific targets and programs we implement, and that needs to shift.

And it needs to shift for two reasons. One, I think you’ll end up with healthier populations, so you don’t have people showing up at PEPFAR-funded clinics obviously hypertensive and have nothing you can do for them. So it’ll solve that potential problem. But, in the long run, the U.S. does not want to be in the business of running health systems in poor countries forever.

The challenge with that is if we have funded health systems that only respond to the very narrow needs that we want to fund and provide the very narrow interventions we want to provide, what reason is there for the governments to assume these? If it is not addressing their changing health needs, the prospect for government ownership, which is a big push in development, it just seems very unlikely.

HAASS: So, again, this seems, as I listen to you, this is a—is this a different paradigm? You used the word “paradox.” Let me use the word “paradigm.” And, by the way, I want the record to show I have not made a joke about two doctors. I just want everybody to understand that. (Laughter.) Those are called dad jokes, by the way.

But this—rather than having a drug- or disease-focused strategy, you’re talking much more either about a health-oriented strategy or a development strategy, or both. So it’s almost opening up the lens and taking something much broader. Is that fair?

BOLLYKY: Yes, but let me—let me tell an anecdote that’s in the book. It’s about the early days of the international health program at the Rockefeller Foundation. Rockefeller Foundation is still a foundation that does an enormous amount of good, but in its day was really the equivalent to what the Gates Foundation is now. It was the big actor on international health. And their first international health director was a gentleman named Wickliffe Rose. What Wickliffe Rose said is that what we should be using these health programs for, the health—the health—what we achieve in these specific programs should be secondary to running a demonstration project that shows to those countries the benefits of long-term investment in health and having them assume those investments. And he was told—he was forced out upon taking this position and told that that will never happen in a thousand years. And that is a debate we are still having in global health today. But I think there’s a good case to be made that we need to return to the recommendation that Wickliffe Rose made then.

HAASS: You used Niger before as a case study of, how would I put it, a success that in many ways wasn’t. I mean, it was a narrow success, but not a large success. Are there some places or countries where you’d say they’re kind of getting it right, that you would point to and say this is an example of steps in the right direction, of what I’d like to see, what I’m advocating? Are there any places that you would point to?

BOLLYKY: Great. So here’s the good news. What’s happening now is the outlier. The norm is that improvements in global health do lead to prosperity. They do lead to broader societal benefits. What’s been happening now is what’s unusual. And what I take from that is that there’s—there is hope for that to still be the case with investments. And there are some great examples out there of countries that have intervened on some of these problems and made a big difference.

So voluntary family planning programs, investment in girls’ education in Senegal, and in Kenya is spurring lower fertility rates and more economic growth.

Vietnam, in 2010, was a low-income country. They now rank among the leaders in global education performance under quality standards—not just how many people go to school, but what they learn while they are there.

Brazil has a family health program that costs $50 per person per year. It covers half of the population. And they have reduced not just infectious diseases; it’s also reducing heart disease, diabetes, and so forth.

Mexico, which has invested not only in its ability to analyze its own problems but in its implementation of those, is achieving remarkable health results and is actually one of the—has done the best, really, on tobacco control and other measures.

So there are some really good examples out there.

HAASS: How does what you’re writing here apply—I know that you’re talking about global health. How does this apply to our own country? Could the United States absorb some of the lessons of your—of your thinking and writing?

BOLLYKY: Great. So part of it is, of course, by helping, we—this is primarily an agenda for the low- and middle-income countries themselves. Nobody can build a health system for them at the end of the day, nobody can enforce smoking laws, no one—no one can maintain a quality education system but those—but those governments themselves. But there’s lots we can do to help them.

Some of it is by funding some of those programs I referred to, like the Senegal and Kenya program. But some of it is by doing no harm. We’re at a moment right now in this country where we are—we are pursuing a policy that is both anti-trade and anti-immigration. And the problem with that in the context that we’re currently in, those policies run cross-purposes. If we are opposed to the kind of trade that allows people to build low-wage employment in poor countries, you’re going to see more migration from those countries. So you can choose. You can be anti-trade or you can be anti-immigration; you can’t be both. So that is one.

The second is that we have, as a policy—as a former trade negotiator, I’m sorry to say—in some areas have taken as a policy to bully countries that are really adopting the same types of approaches to tobacco and health that we’ve adopted in our own country. I understand the need and I applaud the need—I don’t think there’s any problem with international trade law and no conflict in vigorous health regulation under that. But we have used those standards to allow companies to use those standards in a way that has kept countries from acting for their own benefit, and that’s something we can stop doing too.

HAASS: OK. I’m going to turn to the members and audience here in about one or two minutes. But before that, I want to do something that every author always wants to do, which is acknowledge one or two people who suffered with you or suffered you as you wrote this book. So who would you like to give a shout-out to here?

BOLLYKY: Thank you. I appreciate that. Sadly, it is more than two people who suffered through this book.

I, in the book, describe what writing a book was like, at least for me, and it’s quite frankly like swimming an ocean. It is—it’s long. It’s hard. Nobody can do it for you, but you’d be an idiot to try to do it without the support of others.

And I will start by saying thank you to you, Richard, and to Jim Lindsay, and to other CFR staff members, Trish Dorff in particular, who have been really enormous supporters of this book, sometimes bigger fans of this book than I was. And as a(n) author and an employee that’s a great way to feel, so thank you for that.

I also want to thank Kelly Henning and Betsy Fuller, I think are both here, from Bloomberg Philanthropies, who funded a great deal of the research that’s in the book, and for years have been wonderful colleagues and steadfast supporters and collaborators. And I’m really grateful for that.

I also want to thank Bob Prior, the editor of this book from MIT Press, who’s here, who did a remarkable job with it. I’m grateful for that.

Matthew Cohen, who was my RA through this process and really deserves a co-author title. He worked two years on this book and deserves a lot of credit for how well it turned out.

And then just a little bit of family—two members, that’s it. I want to thank my sister Andrea, who has—who’s there in the front row, who has always been my biggest fan and is responsible for at least a third of this audience. (Laughter.) So thank you for that. Go sell some books, Andrea. (Laughter.) And—

HAASS: Does she get a cut?

BOLLYKY: She should. (Laughter.)

And then, lastly, I want to thank my father, who’s here, who sacrificed a lot to come to this country as a refugee and to give us these opportunities, including writing this book. So thank you for that.

HAASS: Well, good. Well, thank you and—(applause).

OK. We got about twenty minutes for you members in our audience to ask questions of Tom Bollyky. And again, what you’ve got here in this book I think is a—something that’s somewhat rare, which is actually an integrated intellectual approach. So it’s much more than about how to deal with this or that disease; it’s really a health strategy and it’s a development strategy, as you’ve heard. So it brings together things that are often not brought together, which I think is part of the real contribution of this—of this piece of work.

I should also say that in the next issue of our magazine, in Foreign Affairs, there’s a chunk of this, of Tom’s argument, in it, and it’s a good piece as well. But I don’t want—I say that with some hesitation because as much as I love people to read our magazine, I don’t want to discourage anybody from purchasing and reading the book itself.

So, again, let me open it up for any questions. Just raise your hand and we’ll get a microphone to you, identify yourselves, and we’ll take it from there. Yes, sir?

Q: Hi. Chris Stocco (ph) with FedEx. Tom, thanks for everything.

Where would you say we should invest some development dollars to get the biggest bang for the buck to mitigate human suffering?

BOLLYKY: So I think in the near term, actually, family planning and girls’ education can make an enormous amount of difference, particularly in sub-Saharan Africa, given some of the population trends that we are seeing. Sub-Saharan Africa will add eleven million people to its workforce each year for the next ten years, so it is—it’s important to address that. So that’s one area.

Again, as I mentioned before, you know, noncommunicable diseases in low- and middle-income countries represent now the majority of death and disability. We invest nothing in these. So if you’re looking for areas where we could make great progress and isn’t already being taken by aid dollars, that’s an area where we could really—we could do some good.

HAASS: Take a second—just explain for one second why NCDs would be a good use of marginal dollars. Why would it make sense to put some more monies into dealing with it? Just explain the—we’re so aware of the reality or threat of infectious disease, but say something about NCDs, why that’s a good place to devote some resources.

BOLLYKY: So the thing about it is, is, you know, NCDs affect, particularly in lower-income countries, working-age adults. So you can imagine the knock-on effects—the knock-on effects and the size. I mean, you’re talking about eight million deaths in 2015 alone under the age of fifty-nine from NCDs just in low- and middle-income countries. So—

HAASS: This is—this is heart disease or diabetes or cancers or—

BOLLYKY: This is overwhelmingly heart disease by a long way, followed by cancer, chronic respiratory illnesses, and diabetes is rising fast but is relatively small compared to the other three.

HAASS: And the prevention, just to be clear, again, are not expensive drugs in many cases. In many cases, it’s lifestyle.

BOLLYKY: No, I mean—well, first of all, a lot of the prevention is just policy. So tobacco control is policy. And, you know, we do tobacco taxes here. We do it in Republican states. We do it in Democratic states. It is something that lots of low- and middle-income—lots of low-income countries can do, and we should be doing more. We don’t support it as the U.S. government. We have never supported it. That’s not something unique to this administration. And we can certainly do a lot more in that regard.

Part of the challenge we have had on—well, let me finish the point about why it matters. So not only do you have the health care costs which are extreme—because NCDs, once you have them, are chronic, and of course that leads to more health care costs—it keeps you from working, and if you perish in middle age of course that has knock-on effects through your whole household. And when you’re talking about eight million people, the effects are just enormous.

So you don’t have to take my word from it—for it. If you believe—if you believe that little-known university, Harvard University, and the World Economic Forum, they did an economic analysis of this. And between 2011 and 2030, they estimated just in low- and middle-income countries NCDs would extract $21 trillion in economic costs. That’s the entire economic output of low- and middle-income countries in a year. So that’s enormous, and it really—it really does matter a great deal.

HAASS: Gentleman standing in the back. I think those who don’t get chairs ought to have a little bit of, you know—(laughter).

Q: My name’s Andy Gersh (ph). I’m a friend of your sister’s. (Laughter.)

HAASS: Thank you for acknowledging that, the—(laughter).

Q: Exactly.

My question is food policy, and where does food enter into this from a policy standpoint? Because it seems to me that, you know, as much as we talk about family planning and tobacco, and we talk about diabetes and sugar in food, and what goes on just not only here but in the developing countries, how that can play a role.

BOLLYKY: Great. Well, really in two ways. So the interesting thing about nutrition as a health risk in low- and middle-income countries is to date a lot of it has been the absence of healthy foods rather than the presence of unhealthy foods. So the disappearance of fruits and vegetables in a lot of low- and middle-income countries, and a lot of that comes from the consolidation of food chains and food production that has made those more expensive. And that has—that has real health consequences, but that’s not going to remain the case for long. So we—you do have a shift to more unhealthy foods and—foods and beverages.

There are lots of cities and countries now experimenting with different regimes from, you know, voluntary programs to cut salt on one end of the spectrum to taxes to reduce consumption. And, you know, we’re starting to see really positive results from, actually, really the range of those. So the U.K. has done good things, relatively speaking, with voluntary programs. Hard to enforce because, you know, the companies that comply get undercut by the companies that don’t. But where you can really build that consensus it’s—you know, it’s something that might work in—or has worked in a place like the U.K. Mexico, on sugar-sweetened beverages, has generated great results so far. So there’s a lot—a lot to be done on both those areas, both increasing access to healthy foods but also making sure we’re not seeing the kinds of shift of consumption.

The thing I always hesitate, though, is I don’t want people to get the impression that that is—there have been a suite of New York Times articles about the KFC in Accra. People are really excited that Accra has a KFC. I don’t want people to believe that what has happened is that low- and middle-income countries have decided to become slothful or indulgent or lazy all of a sudden. You know, again, there are—primarily what we’re seeing now is a shift in demography and poverty, and the consequences of lack of access to both the regulatory oversight and treatments we have here. And that’s really what’s driving.

HAASS: Let me just make sure I understand one other point, which is, you know, we’re the Council on Foreign Relations, so you’ve mentioned Africa several times.

BOLLYKY: Yeah.

HAASS: Latin America you’ve actually mentioned several times, but more positively. Just very quickly say something about the other parts of the world like South Asia, the other demographic boom that’s coming; East Asia and the Pacific; Europe. Like, just give us a little sense of the—to what extent does this—does this vary by region?

BOLLYKY: Great. So you’ll be pleased to know that the book actually does have chapters on different—each chapter is built around a case study. So the chapter on cities is about Dhaka and Bangladesh and what has happened there, and the remarkable growth of that city, which now is has sixteen million inhabitants, until last year didn’t have a freeway. It has grown pretty rapidly. That’s, you know, sixteen million inhabitants in a city the size of Greensboro, North Carolina. So people are pretty packed in there, and it talks about some of the challenges that have resulted there from that kind of uninhibited growth.

And, again, I don’t want people to get me wrong. Urbanization is a good thing. In fact, there is no country in the world that has become wealthy without urbanizing; none. Cities are a(n) engine of growth. And we can get into the economics of that, but for lots of reasons—trading ideas, sharing infrastructure—they’re an engine of growth.

The problem is, is if your rate of natural increase is so high that you’re outstripping the infrastructure to that extent, what you end up with is people not being able to make productive use of shared resources. You end up with congestion. And Dhaka is a good example of that in the sense that it—you know, the—it consumes 3.2 million working hours per day to traffic of its people. The average driving speed has dropped to four miles an hour. That’s little faster than walking.

HAASS: That’s going to be pretty good next week in New York, by the way. (Laughter.) You’re going to—you’re going to wish you were moving four miles an hour. (Laughter.)

BOLLYKY: That’s right. That’ll be—that’ll be pretty good.

So, I mean, the circumstance we find ourselves in is that under these trends, these may be the first cities in history to make their people poorer instead of richer. And that’s a concern.

HAASS: Good reason. Yes, sir.

Q: Tom, I’d like to go back—

HAASS: Introduce yourself.

Q: Oh, sorry. Henry Greenberg from Mailman at Columbia.

Go back to this policy issue, and take diabetes and obesity and food. What has to change are trade agreements, subsidies, corporate policy. Do you see any likelihood that the public health community/population health community is willing/able to take on that debate and confront those agencies?

BOLLYKY: I do see some willingness that the public health community is willing to take on some of those interests. I mean, there has been a push city after city for taxes on sugar-sweetened beverages. So they have. In the past, advocates took on tobacco and achieved enormous, really remarkable progress in many countries. So it’s certainly possible.

But it is an area which distinguishes noncommunicable diseases from other areas of global health. There is no lobby for mosquitoes. There are lots of lobbies for the various—the various products or industries affected or that are implicated in NCDs. So that is a challenge to come into.

On the treat side, the thing to get across—and again, I say this as both a lawyer and a former trade negotiator—the sad—it’s actually—global trade law, international trade law, is perfectly consistent with public health. The problem is the way that people have used it to threaten and bully people. So we’re not talking something that’s baked into the system. This is user error. This is—this is not a systemic problem. And that’s something that can change, too.

HAASS: OK. Yes, ma’am, in the front row. Wait for a—just wait for a microphone, please. It’s coming your way. Not by drone, but here we go.

Q: Have you—I’m sure you’ve thought about the—

HAASS: And introduce yourself first.

Q: Oh. Mary Mittelman, NYU School of Medicine.

Do you—do you discuss in your book the consequence—the ultimate consequence of living longer, which is the diseases of old age, not trivially dementia and other disease that occur in old age, which is growing faster in these same countries with less infrastructure to take care of the people who are suffering?

BOLLYKY: It’s a real—it is a—it’s another problem, and there are a variety of them. So there’s the problem of growing rates of Alzheimer’s and dementia in older populations. There is a problem we haven’t talked about; mental health is a huge issue in low- and middle-income countries. So there’s a—there is a great list of them.

I will say on the dementia and Alzheimer(’s) it is still that’s a wave behind where we are now on heart disease or some of these other things that are really hitting now with great numbers. But it is coming and something that needs to be grappled with, too. So thank you for the question.

HAASS: Dr. Knapp.

Q: Thank you. Albert Knapp, NYU School of Medicine.

My question regards the ideal health care system for these countries in the sense if you’re looking at hypertension and diabetes, are you talking about small outreach clinics and small hospitals or larger hospitals? Or what is your ideal, the bang for the buck?

BOLLYKY: So I had to—I wrote a review or—that should be coming out in Health Affairs of the three global health quality reports that just came out: one by The Lancet, one by—one by the National Academy of Medicine, and one before by the World Bank and the OCED and WHO. And I actually like The Lancet’s prescription about restructuring health systems around having—there’s been a great focus in low- and middle-income countries on trying to extend reach into rural areas, so lots of clinics that do lots of things in rural areas. And for a more complicated—what it has resulted in is for more complicated health needs go undiagnosed and unaddressed or misaddressed. Their big example is maternal health and the consequences you see from that, but the argument that they make is that you would see—you would see clinics—or a restructuring of the system to move the more complicated health tasks that require more engagement to more centralized facilities and try to keep the outreach really more on to the—to the simpler tasks in doing intake, in directing and funneling into that system.

HAASS: Here. Allen, it’s coming to you.

Q: I’m Allen Hyman, Columbia Presbyterian. Thank you very much for your talk.

You didn’t mention very much about China. China is a country that’s taken five hundred or six hundred million people out of—out of extreme poverty. How has that changed their issues about noncommunicable diseases?

HAASS: If I can just interrupt for a second, today’s Wall Street Journal had a frontpage story that the percentage of people in the world in extreme poverty has reached a modern low. Numbers are still high, but the percentage has reached a low. So just—

BOLLYKY: It has. And China is a lot—most of that story, frankly. No, there’s—one of the other chapters that focuses on economies and youth populations is all about China. So there’s a lot in this book, I’m pleased to tell you, about China.

On noncommunicable disease, China’s actually doing better. Historically, their big problem has been tobacco. There are lots of people in this audience who will know this statistic better than I do, but something like thirty or forty percent of the men who smoke worldwide are Chinese. It has a state-owned tobacco industry. It has been very difficult to make progress. Even many of the physicians smoke. It’s been very difficult to make progress.

That has really started to slowly turn around, or there are signs of it slowly turning around in the last couple of years. And that’s through the—through the great effort not of only Chinese health advocates, but of course people working with them.

China—we did a piece in Health Affairs last year that ranked all countries on their expected NCD growth and their preparedness for it, and then we also looked at spending. And the interesting thing is, sadly, most of those charts look like this, which is basically all the wealthy countries are going to have very minimal growth in NCDs and lots of increase in health spending, and all the poor countries or poorer countries will have an enormous increase in NCDs and are not projected to have much of an increase in health spending.

China is the one country that’s sort of in the middle on a per capita basis. So it actually really is increasing its health spending. So it is—it’s building a better health system, and it’s starting to slowly take on some of these health risks. People make a big deal about pollution in China, and it’s terrible. But they have taken some steps to improve that and they are—certainly pale in comparison to Delhi in India, where if you really want to see some brown, brown skies that’s sort of the place to go. It’s—

HAASS: So you mentioned in the—that’s the other—you know it’s probably, what, in twenty years India will overtake China as the world’s most populous country. What would you say about India in the context of what you’re writing about?

BOLLYKY: So, I mean, India is—India is a—is a funny country in a lot of ways in the sense that it is a fast-growing economy, but it has a significant share of the world’s poorest people. India has a space program. It also has incredibly high rates of child undernutrition. And you see a lot of that same dynamic play out on its health characteristics in the sense that—the one unique and positive thing I will say about India is that they really have revolutionized some health delivery models in terms of providing low—decent-quality care at high volume and low cost to great swaths of the population. And, honestly, it’s something—they have pioneered some programs we should look at. So they’re doing some things right, but by and large they have had a historical issue in terms of addressing the needs of their own poorer population.

HAASS: Alas, we’re going to have to cut it off there. One of the very few principles that I have is that we try to begin and end meetings on time. Again, I want to remind you that the book is available for sale. Tom is not available for sale, but he is available to sign your book and he’s available to answer any questions that we haven’t had time for.

BOLLYKY: I’m available to rent. (Laughter.)

HAASS: And I’d just ask you one more thing, which is let’s show some appreciation for Mr. Bollyky here. (Applause.)

(END)