Jaime Sepulveda: Stand Up for Global Health

Jaime Sepulveda lives global health. A veteran of senior health posts in Mexico’s government and a leadership position at the Gates Foundation, Sepulveda designed Mexico’s universal vaccination program and founded the country’s National AIDS Council. (An HIV/AIDS clinic in Mexico City is named in his honor.)

And now as executive director of the Institute for Global Health Sciences at the University of California, San Francisco, Sepulveda, MD, DSc, MPH, oversees the work of more than 300 faculty and staff. In an exclusive interview with Global Health NOW, the fierce global health advocate discusses this week’s health forum in Mexico City, the results of Mexico’s soda tax, the diagonal approach to health systems and advice for global health students.

This week you’re convening a forum in Mexico City. What will you be doing there and what do you hope the result will be?

This second meeting of the Binational Health Forum—under the auspices of the National Autonomous University of Mexico and the University of California—will focus mainly on disseminating the recommendations of the World Bank publication “Priorities for Disease Control, 3rd edition.” The translation into Spanish in a compendium of the main chapters of this publication will allow a more rapid spread and impact in the countries of Latin America.

In times of exacerbated nationalism in the United States and other nations, the construction of bridges—and not walls—among the countries of the hemisphere is important. Health is a natural bridge, and its crossing is the main intention of this forum. The findings and recommendations included in this compendium—the product of a 7-year effort by more than 300 international experts—provide a roadmap that could help improve health and reduce inequities in countries in this region, and thus aim towards meeting the Sustainable Millennium Goals in health.

In the last couple decades, global health as a field has really surged and attracted a lot of support. Where do you see the next 10 years going?

That's a very interesting and important question. You're right, I think the year 2000 marked the birth of global health in a major way with new political will—the Millennium Development Goals—, with new institutions being created—like the Global Fund and Gavi—and with big money coming in—the Bill and Melinda Gates Foundation. It was kind of a magical moment.

I'm seeing now a plateau in funding and also a decline in political will, unfortunately led by the current [US] administration. I see that global health will have less support from the US, clearly, with our introspection and America First doctrine.

What’s the one global health issue that keeps you up at night?

Personally, I think the obesity pandemic is the one that keeps me awake because it has so many consequences on the rest of the body. This is preventable, and this is something that is costing people, in terms of suffering, and costing society in terms of the financial burden, so it looks like an uncontrollable epidemic. I think we have to work on prevention much more forcefully. At the policy level, I have been personally involved in studying the sugar tax law that was effectively passed in Mexico. My colleagues succeeded in making exactly the case from evidence to policymaking, persuading the legislators that something needed to be done based on the data and results.

—Is it too soon to get any results on terms of the effects of the soda tax there?

Soda consumption decreased significantly, particularly among the lowest income sector, which is exactly what they wanted to achieve because those are the most affected by cheap calories coming from soda. The consequences in diabetes reduction, of course, will take much longer to be measured because there's an incubation period, if you will. I think it will take at least 5 years, if not 10, to see the result of the sugar tax law in obesity and diabetes decrease.

The soda industry is fighting so hard! It's similar to the tobacco industry in many ways. They are using every single marketing tool to bring back consumption to the levels they had, so hopefully diabetes obesity will decrease measurably, but success will depend on having the consumption kept low, or lower.

In 1990, you designed Mexico’s successful universal vaccination program in just 2 years. It relied on the “diagonal” approach. Can you tell us about that?

The “Diagonal Approach” is a system, a new model with which we no longer went by the vertical approaches such as [focusing on a single disease like] polio or HIV, nor to the European horizontal model of health systems strengthening alone, in abstract. Instead, specific health priorities became the drivers of changes in the health system. We called this the diagonal approach. It's a package of health services, of highly cost-effective interventions, delivered [to] communities. And that's a model that [former UNICEF executive director] Jim Grant wanted. He had been advocating children's health, oral rehydration, vaccines, so this in Mexico for him was like, “Wow.” He actually brought 3 batches, if you will, of health ministers from Africa and Asia to Mexico to learn about the diagonal approach.

I think vertical programs can only work for so long and I am a strong advocate that we need integrated health solutions. When I was at the Gates Foundation, my title as director was exactly that, Integrated Health Solutions. In Afghanistan and Pakistan now, the only region with remaining cases of a wild polio virus circulation, they incorporate that approach, integrating it, not only vaccinating for polio. People were fed up with polio drops, didn't make much of a visible difference for families. A package of other goodies, along with polio vaccination, was effectively done in a clinical trial comparing polio alone or integrated solutions and measurably, in that complicated area of the world, integrated solutions work much better for polio vaccination than polio vaccination alone. I think that's a lesson that has been probably inadvertently copied in many other regions of the world.

Let's talk about the Institute for Global Health Sciences here at UCSF. What makes it unique?

Historically, Richard Feachem created the Institute of Global Health in 1999 here at UCSF. To my knowledge, that was the first institute of global health created anywhere. The first Master's in global health in the country was started right here. We have now 10 generations, 10 cohorts of Master students in global health. When I say we, I'm taking credit, but I was not even here; I came to UCSF in 2011.

I think that also linking the basic and the clinical and the population health sciences is what makes us distinct. UCSF is better known for its basic and clinical sciences research, less well known—that's a best kept secret—for its population health. The ability to harness all of the wealth of basic and clinical sciences into population health interventions, I think makes also a difference.

Where do you see the institute heading in the next five years?

I think we are moving to make our STEPS to impact strategy more visible. STEPS is an acronym I coined to link science, technology, economics, policy and society. I'm deeply convinced that unless you bring the best of science and technology, but also of economics and policy and the social sciences, you won't be able to reach impact in the future. So, STEPS to impact is our strategy.

As a university, this is not only about knowledge creation through research or knowledge transmission through education. It's about knowledge implementation in the field, in countries, in communities, in families. I see that as part of our public mission. I think the focus has been more on knowledge creation and transmission, not so much on the implementation part.

You think that's a weakness in the wider global health community?

Yes, and I think universities have a role to play. I remember being a member of the board of overseers at Harvard, and the corporation and the overseers were reluctant to have Harvard involved in any health delivery services at all. I think they were worried about liability, and I made a strong case that universities have a role in knowledge implementation, not only knowledge creation. If Harvard had a way to deliver HIV treatment in some communities, so be it. Why not? It was a long battle, but I strongly believe universities have a role to play. We have opened offices, NGO-affiliated offices to UCSF in 6 African countries, so we're very actively involved as part of research and delivery programs in those 6 countries in Africa.

As hard as knowledge creation is, implementation seems to be even more difficult.

There's a new field of implementation sciences, as you know. And yes, it's hard. You have to have “boots on the ground” experience. [There’s] no way to do the implementation component theoretically.

What would your advice be to students who are interested in getting into global health?

Of course, they should work hard. That would be my first piece of advice, and to understand the notions and concepts. They have to walk the talk. Global health is not a financially rewarding field, so it does take a real wish to serve—and personal sacrifice. My advice would be, of course, work hard, learn the trade or learn the skills and competencies that you need to do your work, and be serious about it. Check whether this is what you want to do for the rest of your life because it's hard work.

Do you have advice for students who are in global health and think, “Oh, I want to go and work in Africa.”? Should they be working in health in their own communities first?

My advice would be work within a secure environment as much as you can with a program or a project that will offer safety, first of all, and also a true learning experience along with service.

I don't think you necessarily want to work first in your community. Now, I just want to emphasize that when I say global health, I am referring both to local and global. We do about half of our work and almost half of our staff is working here in California in poor communities, in the Central Valley with Mexican migrants or Central American migrants. That is also global health. As long as you work in vulnerable populations on issues that affect the bottom of the pyramid, in preventing disease and reducing health inequities anywhere, you're doing global health.

One last question. Bill Gates is famously optimistic about global health and where we've come in the last 20 years or so. Do you share that optimism?

Totally. First, I deeply admire Bill Gates. I've worked with him closely and I think he's a true champion. He's putting his money where his mouth is. He's walking the talk. Polio will be eradicated, and that is only in large part thanks to the persistence of many groups and people, but I think Bill was a key factor in finishing the last mile.

I share his optimism among other things because the alternative is defeat, and I don't admit defeat. You have to be persistent. If you fall once, you get up again.

Any last thoughts?

I think we all have to have moral courage and stand up and defend our values, particularly in a time when the current administration is fighting against all of the things that we value. I hope we see that more moral courage. I think it's a fundamental part of good leadership and universities need to have a larger role. I hope that message gets transmitted.

This article has been edited for length and clarity.

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