TED 2016: A smarter, more precise way to think about public health
Vancouver, British Columbia
February 19, 2016
OK, first, some introductions. My mom, Jennie, took this picture. That's my dad, Frank, in the middle. And on his left, my sisters: Mary Catherine, Judith Ann, Theresa Marie. John Patrick's sitting on his lap and Kevin Michael's on his right. And in the pale-blue windbreaker, Susan Diane. Me.
I loved growing up in a big family. And one of my favorite things was picking names. But by the time child number seven came along, we had nearly run out of middle names. It was a long deliberation before we finally settled on Jennifer Bridget. Every parent in this audience knows the joy and excitement of picking a new baby's name. And I was excited and thrilled to help my mom in that special ceremonial moment.
But it's not like that everywhere. I travel a lot and I see a lot. But it took me by surprise to learn in an area of Ethiopia, parents delay picking the names for their new babies by a month or more. Why delay? Why not take advantage of this special ceremonial time? Well, they delay because they're afraid. They're afraid their baby will die. And this loss might be a little more bearable without a name. A face without a name might help them feel just a little less attached.
So here we are in one part of the world -- a time of joy, excitement, dreaming of the future of that child --while in another world, parents are filled with dread, not daring to dream of a future for their child beyond a few precious weeks. How can that be? How can it be that 2.6 million babies die around the world before they're even one month old? 2.6 million. That's the population of Vancouver. And the shocking thing is: Why? In too many cases, we simply don't know.
Now, I remember recently seeing an updated pie chart. And the pie chart was labeled, "Causes of death in children under five worldwide." And there was a pretty big section of that pie chart, about 40 percent --40 percent was labeled "neonatal." Now, "neonatal" is not a cause of death. Neonatal is simply an adjective, an adjective that means that the child is less than one month old. For me, "neonatal" said: "We have no idea."
Now, I'm a scientist. I'm a doctor. I want to fix things. But you can't fix what you can't define. So our first step in restoring the dreams of those parents is to answer the question: Why are babies dying?
So today, I want to talk about a new approach, an approach that I feel will not only help us know why babies are dying, but is beginning to completely transform the whole field of global health. It's called "Precision Public Health."
For me, precision medicine comes from a very special place. I trained as a cancer doctor, an oncologist. I got into it because I wanted to help people feel better. But too often my treatments made them feel worse. I still remember young women being driven to my clinic by their moms -- adults, who had to be helped into my exam room by their mothers. They were so weak from the treatment I had given them. But at the time, in those front lines in the war on cancer, we had few tools. And the tools we did have couldn't differentiate between the cancer cells that we wanted to hit hard and those healthy cells that we wanted to preserve. And so the side effects that you're all very familiar with -- hair loss, being sick to your stomach, having a suppressed immune system, so infection was a constant threat -- were always surrounding us.
And then I moved to the biotechnology industry. And I got to work on a new approach for breast cancer patients that could do a better job of telling the healthy cells from the unhealthy or cancer cells. It's a drug called Herceptin. And what Herceptin allowed us to do is to precisely target HER2-positive breast cancer, at the time, the scariest form of breast cancer. And that precision let us hit hard the cancer cells, while sparing and being more gentle on the normal cells. A huge breakthrough. It felt like a miracle, so much so that today, we're harnessing all those tools -- big data, consumer monitoring, gene sequencing and more -- to tackle a broad variety of diseases. That's allowing us to target individuals with the right remedies at the right time.
Precision medicine revolutionized cancer therapy. Everything changed. And I want everything to change again. So I've been asking myself: Why should we limit this smarter, more precise, better way to tackle diseases to the rich world? Now, don't misunderstand me -- I'm not talking about bringing expensive medicines like Herceptin to the developing world, although I'd actually kind of like that. What I am talking about is moving from this precise targeting for individuals to tackle public health problems in populations.
Now, OK, I know probably you're thinking, "She's crazy. You can't do that. That's too ambitious." But here's the thing: we're already doing this in a limited way, and it's already starting to make a big difference.
So here's what's happening. Now, I told you I trained as a cancer doctor. But like many, many doctors who trained in San Francisco in the '80s, I also trained as an AIDS doctor. It was a terrible time. AIDS was a death sentence. All my patients died. Now, things are better, but HIV/AIDS remains a terrible global challenge. Worldwide, about 17 million women are living with HIV. We know that when these women become pregnant, they can transfer the virus to their baby. We also know in the absence of therapy; half those babies will not survive until the age of two. But we know that antiretroviral therapy can virtually guarantee that she will not transmit the virus to the baby. So what do we do?
Well, a one-size-fits-all approach, kind of like that blast of chemo, would mean we test and treat every pregnant woman in the world. That would do the job. But it's just not practical. So instead, we target those areas where HIV rates are the highest. We know in certain countries in sub-Saharan Africa we can test and treat pregnant women where rates are highest. This precision approach to a public health problem has cut by nearly half HIV transmission from mothers to baby in the last five years.
Screening pregnant women in certain areas in the developing world is a powerful example of how precision public health can change things on a big scale. We can do that because we know. We know who to target, what to target, where to target and how to target. And that, for me, are the important elements of precision public health: who, what, where and how.
Let's go back to the 2.6 million babies who die before they're one month old. Here's the problem: we just don't know. It may seem unbelievable, but the way we figure out the causes of infant mortality in those countries with the highest infant mortality is a conversation with mom. A health worker asks a mom who has just lost her child, "Was the baby vomiting? Did they have a fever?" And that conversation may take place as long as three months after the baby has died.
Put yourself in the shoes of that mom. It's a heartbreaking, excruciating conversation. And even worse -- it's not that helpful, because we might know there was a fever or vomiting, but we don't know why. So in the absence of knowing that knowledge, we cannot prevent that mom, that family, or other families in that community from suffering the same tragedy.
But what if we applied a precision public health approach? Let's say, for example, we find out in certain areas of Africa that babies are dying because of a bacterial infection transferred from the mother to the baby, known as Group B streptococcus. In the absence of treatment, mom has a seven times higher chance that her next baby will die. Once we define the problem, we can prevent that death with something as cheap and safe as penicillin. We can do that because then we'll know. And that's the point: once we know, we can bring the right interventions to the right population in the right places to save lives.
With this approach, and with these interventions and others like them, I have no doubt that a precision public health approach can help our world achieve our 15-year goal. And that would translate into a million babies' lives saved every single year. One million babies every single year.
And why would we stop there? A much more powerful approach to public health -- imagine what might be possible. Why couldn't we more effectively tackle malnutrition? Why wouldn't we prevent cervical cancer in women? And why not eradicate malaria?
I live in two different worlds, one world populated by scientists, and another world populated by public health professionals. The promise of precision public health is to bring these two worlds together. But you know, we all live in two worlds: the rich world and the poor world. And what I'm most excited about precision public health is bridging these two worlds.
Every day in the rich world, we're bringing incredible talent and tools -- everything at our disposal -- to precisely target diseases in ways I never imagined would be possible. Surely, we can tap into that kind of talent and tools to stop babies dying in the poor world. If we did, then every parent would have the confidence to name their child the moment that child is born, daring to dream that that child's life will be measured in decades, not days.