How can we
think differently about health?
To help end preventable illnesses?
And improve the lives of millions of people worldwide?
Ideas into impact
At The George Institute for Global Health we are focused on tackling the world’s biggest killers: non-communicable diseases (NCDs) and injury. We’re a 600+ person, world-class medical research organisation, operating in 50 countries with four major centres in Australia, China, India and the UK.
Our mission is to improve the lives of millions of people around the world. We believe that practical, cost effective approaches to managing non-communicable disease offer unparalleled opportunities to help people live longer, healthier lives.
We conduct high quality research, develop answers and solutions, and drive impact.
To complement our world class research, The George Institute’s unique global health policy thought leadership effort focuses on non-communicable diseases and injury, and improved systems for prevention and treatment. We share our insights, challenge the status quo and foster the kind of debates and discussions that lead to improvements in health outcomes. The think tank program involves current researchers at The George Institute as well as non-resident Distinguished Fellows – external experts who are leaders in their respective fields.
Our priority areas
The George Institute’s think tank program priority areas of focus are:
Our think tank advocacy work follows these guiding principles:
- Challenge the status quo;
- Drive critical analysis and reflective thinking;
- Develop networks and collaborations to enact real change;
- Target global epidemics, particularly of non-communicable diseases and injury; and
- Focus on vulnerable populations in both rich and poor countries.
Do you want to be part of this? Are you a leading health researcher, health policy expert, policy maker or health advocate?
Through The George Institute’s Distinguished Fellows program, you can contribute to the global debate. As a George Institute Distinguished Fellow, you’ll stay right where you are at your own organisation. We’ll support your thought leadership work, helping to amplify your insights to key stakeholders around the world.
Our Fellows will be driving the conversations around non-communicable diseases and injury, and improved systems for prevention and treatments. You will do this through blogs, public talks, videos, social media and discussion papers. We’ll even support you leading an event that will highlight specific challenges and solutions or sponsor your conference presentation or similar announcements related to your research. Our Fellows can also seek the opportunity to engage directly with stakeholders through our offices in Beijing, Delhi, Oxford or Sydney. Our social media, design, events and media teams will help you throughout.
The George Institute Distinguished Fellows Program: Ideas and solutions to reduce the burden of NCDs and injury and improve people’s health.
Who we are: Professor Corinna Hawkes
Distinguished Fellow, The George Institute for Global Health, focusing on Promoting Healthy Environments.
Corinna is also Director of the Centre for Food Policy at City University of London, Vice Chair of the London Child Obesity Taskforce established by the Mayor of London, and serves on a variety of international initiatives. Between 2015-18 she was Co-Chair of the Independent Expert Group of the Global Nutrition Report, which tracks progress on addressing malnutrition in all its forms.
You wanted to be a politician when you were younger and your PhD in geography focused on environmental change, so how did you end up working in food policy research?
After my PhD, I wanted to do something more people-focused. I went to Los Angeles for a few months after I got married, and I discovered the wonderful local farmers’ markets. Not only that, but I found there was a movement of people actively engaged in trying to improve the food on their plates. I’d grown up with a progressive mother passionate about good food, a love of cooking myself and a long-standing interest in the science of food (I idolised my great-grandfather, who had won a Nobel Prize for his contribution to the discovery of vitamins). All of this came together in my mind, and I realised I had found my passion and resolved to do something about it.
What keeps you motivated?
For me, food is something to be relished and enjoyed; it’s part of our social fabric. However, millions of children around the world live in poverty and consume dull, monotonous diets. Others enjoy eating (too many) sugary, fatty and salty foods – but then they get sick. I believe the world would be a better place if everyone gained health and happiness from eating well. It’s a tough nut to crack, though, and I often contemplate how little we have moved in that direction. I am driven by wanting to find out how to design actions that will really make a difference to people’s lives and change how they eat for the better. If we fail, we learn, and then we try again.
On a personal note another intrinsic motivation was my mother, who died when I was 18. When I was discovering food, I realised how deeply I was affected by the fact her beliefs about the importance of good food were never listened to. She cut an isolated figure, for example, when she complained about the food in my schools. As a result, I am constantly motivated by wanting to give her the voice she never had. That’s pretty motivating.
What does the latest Global Nutrition Report tell us?
The Global Nutrition Report 2018 focuses a lot on diets. It’s a pretty dismal picture. Globally, the proportion of babies who are exclusively breastfed up to 6 months of age is 41%, and sales of infant formula are growing rapidly. Regardless of wealth, school-aged children, adolescents and adults are eating too many refined grains and sugary foods and drinks, and not enough foods that promote health, such as fruits, vegetables, legumes and whole grains. For example, 30.3% of school-aged children do not eat any fruit daily, yet 43.7% consume soda every day. Meanwhile, analysis of over 23,000 packaged food products shows that 69% are of relatively poor nutrient quality, with the proportion higher in lower income than high-income countries.
These are diabolical findings and show that food policies need to do so much more. They must be effectively designed to ensure the system that produces our food is incentivised in the right way and that people have support to eat well.
That said, there is some good news; more and more countries are requiring front-of-pack nutrition labelling, legislating on sugary drink taxes, and taking actions to reduce trans fats and salt. And, crucially, these actions are proving effective.
You advise a range of policymakers on diet-related ill health, at city, national and international levels. Which level do you feel is most important in terms of impact?
To be honest, all of them; they’re all interconnected. At the city level, I’m really enjoying my work as Vice Chair of the Mayor of London’s Child Obesity Taskforce, which brings me closer to the people affected by the problem, as well as to those decision-makers who can make a difference. The work I do with policymakers at the national level feels more top down, but is fundamentally important because it’s where the national direction is set, as well as decisions about population-wide policy applicable to all citizens.
Then the international – and global – level is important for two main reasons. First, we need frameworks, political statements and technical guidance at a global level where there are issues relevant to the whole world. This was one of my objectives in establishing the NOURISHING Framework for policies for healthy diets, when I was working at World Cancer Research Fund International. Second, engaging at the international level is a means of inspiring and sharing lessons. For example, I am excited by the various city networks that have been established around food and health.
What do you think are the biggest challenges policymakers face in addressing rising levels of obesity?
The biggest challenge is that the policies designed to address obesity come up against two pretty major conflicts: our current economic model, and the reality of people’s lives.
Our prevailing economic model creates incentives that contribute to obesity. All food companies, no matter their size, compete with each other to attract custom. These competitive dynamics are at the heart of the problem and create a lock-in, preventing crucial change.
These dynamics would not be so powerful if it weren’t for the reality of so many people’s lives. What’s the use of supplying delicious, nutritious foods if people cannot afford them? Or if they lack the spaces to cook, or the skills to do so? People then develop unhealthy habits and preferences that keep them locked in.
What food policy research or data is most urgently needed?
If we are going to shift the needle on diets, there are four areas we really need more work on. First, we need to identify policies that can help create healthier food economies and healthier business models. Second, we need to understand people’s lived experience of food in a way that can help us design people-centred solutions that work. Third, we need to test these solutions in cities, to see if they are effective and equitable. And finally, we need to ensure policies are consistent and coherent throughout the food system in supporting these changes.
For me, all this comes together in urban food environments. When I started working very proactively in food systems, I realised that changing how people encounter the food system – which is where we shop and acquire food in stores, restaurants, schools, urban gardens etc. - is potentially a very powerful lever for change.
Taking a people-centred approach to urban food provisioning (where people acquire food in an urban setting) means understanding how people live their lives and their feelings around food, identifying the viable business models that cater to this and then figuring out if we have policy frameworks that incentivise change in a consistent way. I am interested in exploring this much more proactively, from the local to the global.
What would you be doing if you hadn’t moved into food policy?
If I were to be doing something other than food policy, I’d have set up a bookshop with my husband, with a little café attached where I’d take on the role of cook and business partner. I know what a tough job that would have been, though!
Who we are: Dr Rajani Ved
Dr Rajani Ved is a medical doctor with public health training and is also the Executive Director, National Health Systems Resource Centre in New Delhi, India.
Your career spans more than three decades. Can you give us a snapshot?
The early part of my career was spent providing community-level clinical care both to Self Help Groups of women and providing services to the general community. I worked with NGOs, international agencies, including donor agencies, and government. For nearly a decade now, I have been working with the National Health Systems Resource Centre (NHSRC), established by the Ministry of Health and Family Welfare, where my role has been to work with state- and district-level health systems and strengthen implementation through program reviews, capacity building, and mentoring and enabling responsive policy adaptation and formulation.
I’ve been fortunate that for quite a lot of my career, I have worked extensively with NGOs and therefore directly with communities. This, I believe, has stood me in good stead in what I do now, because I try to bring a people-centred approach to what I do. The last few years have been much more at a policy level, but there are enough opportunities here that enable me to link ground reality with policy change.
You have worked in many areas of primary healthcare. Are there any projects that stand out to you?
Around 15 years ago, through a MacArthur Fellowship, I received a grant to test delivering a package of reproductive health-related knowledge and skills to women organised in groups as part of micro-credit programs. The women were more interested in micro-credit and employment generation than hearing about messages/content around reproductive health. So I had to design an intervention that was acceptable to the women and the very limited time that they had for themselves. In the span of a year, from spending an hour a week with them, I managed to get about 15 women’s Self Help Group leaders to spend two days every month with my team and I in a residential camp, talking about their day to day lives and how health impacted themselves, their families, and livelihoods. I understood that unless we were able to deliver health messages to them in ways that enabled action in their lived reality, most of this knowledge was superfluous.
It was also here that I understood how information was enabling – particularly how information on health entitlements, based on a good understanding of services and rights, could be effectively converted into demanding accountability from the health system. This was the case for the women who were already empowered as a result of being part of the Self Help Groups. I think my best moment was when one of the women who I had worked with demanded that a gynecologist in a district hospital actually examine her more thoroughly in a way that used some of the technical language we’d covered.
You know, when we talk so much about health promotion and putting health in people's hands, we don't really look at their everyday lives. I think these women gave me the grounding to understand how health systems should approach women’s health and this laid the foundation for my work with community health workers, which is the other thing I’m really passionate about. My time in NHSRC has taught me much about how to grow such programs through capacity building, onsite mentoring and just, and rightful payment mechanisms. I like to think these two experiences would rank as my most valuable learning and perhaps my most significant contributions.
How transferable are community health worker programs, known as ASHAs, to other low- and middle-income countries?
I certainly think they are transferable because almost all the situations in India would be applicable to other low- and middle-income countries. In India, we have implemented ASHA training at scale, systematically developed guidelines and standards, devised certification programs, created incentive systems, supportive and supervisory mechanisms, and enabled integration into health systems, creating the institutional mechanisms to run community health worker program at scale, and I think those are very relevant to other countries.
What are some of the challenges in scaling up community programs?
I will give you an example of an NGO pilot in Western India for a home-based newborn care intervention involving community health workers who were trained in home-based newborns, including asphyxia management, sepsis management, provision of injectable antibiotics, and of course a host of other home care behaviours. This was approved by the Government for inclusion into ASHA training, given our high newborn mortality rate in 2011.
It was a fairly intensive program and we realised it required a lot of hand-holding support of the workers and supervision. Some of our ASHAs were low-literate or non-literate so we needed to make sure that their training was of very high quality and focused more on skill than on didactic knowledge. We also had to provide a regular medicine kit, as well as ensuring their credibility, both in terms of knowledge and skills and also in terms of connection with the larger system and structures. I think that was essential for the community to be accepting of them in taking care of their newborn babies.
I can by no means say that we achieved the results of the small-scale project because in large-scale implementation, particularly of models that are process-intensive and complex, quality and supervision tend to be compromised. To overcome some of these challenges we made several adaptations - splitting training into modules so that trainers met more often with ASHAs, providing them with some handholding, reducing the components of the intervention, building a supervisory cadre, linking newborn care to a monetary incentive, etc. I would say that just under half the ASHAs are now contributing to newborn care, but this needs to be viewed from the perspective of scale.
What role does digital technology play in improving primary healthcare in India?
There is a lot of emphasis on the use of digital technology from policy makers as in India we are moving from selective healthcare to comprehensive care. There are several potential uses. The first and most basic is population numeration, and empanelment – or understanding where people live in proximity to Health and Wellness Centers, which provide the first level of care. Other uses of digital applications include recording patient data, use in population analytics, reporting on prevalence and control, especially for chronic diseases, use in decision support systems, telemedicine/teleconsultation, etc.
Of course, part of this is providing ASHAs with smartphones so that they have the population data in their phones linked to the facility level, and then to primary health centre records. We are moving in that direction but internet connectivity is a problem in about 20 to 25 percent of the country. Also, ASHA workers are dealing with complex chronic diseases now and they need to be much more highly skilled, have much more hands-on training and have higher literacy levels. In areas where they have been trained to use smartphones, they have adapted remarkably but here one is talking about ASHAs who already have higher literacy levels.
In this fellowship you want to focus on women’s health, can you tell us more about the focus of your work?
For my fellowship I’d like to focus on non-communicable diseases among women, particularly related to their understanding of and access to care, and increasing provider sensitivity to women’s health issues.
Most of my work has been in an environment where we have implemented selective primary healthcare, especially for women, limited to pregnancy and delivery. Access to care for NCDs amongst poor women is a challenge, because women from lower-ranked socioeconomic classes in India have much less access to healthcare than their counterparts who are richer, belong to the upper class and who live in urban areas. Poverty and lack of access affects every part of their life, not just maternal health. My concern is that we don’t have much experience dealing with women with chronic diseases, much less among poor women in rural and urban areas. We hardly know anything about their risk of stroke, cardiovascular disease, kidney disease etc. There is a real lack of information and research in this area.
We need to use some of those lessons that we have already learned about accessing marginalised and vulnerable women and transfer the learning to implementing a chronic disease program. Finally, I have a new found interest in the challenge of mulitsectorality. Care for chronic diseases will have to involve all sectors, it's not just the health system alone. It’s about improving sanitation, nutrition, livelihoods, and other areas that pose challenges to the health of women. It’s far more complex than anything that we have dealt with in the past and we don't have either the institutional structure or the program experience. These are the areas I am interested in working on during the fellowship.
Who we are: Professor Trish Greenhalgh
Professor Trish Greenhalgh is our inaugural Distinguished Fellow and has a focus on Transforming Health Systems.
Trish is also Professor of Primary Care Health Sciences at Nuffield Department of Primary Care Health Sciences at the University of Oxford.
What inspired you to work in health research, and what keeps you motivated?
I think I’ve always had a ‘research brain’. Even at my university interview back at age 17, I was asking the interviewers more questions about their research than they asked me! Research is the systematic search for new knowledge. Whether qualitative or quantitative, research is characterised by careful selection of the appropriate methods to answer the question posed, rigorous application of those methods to the highest standard achievable, reflexive awareness of the possibility of error, and measures taken to minimise and take account of error. I guess what keeps me motivated is the excitement of discovery. And by that, I don’t mean dramatic Eureka moments but the more incremental enlightenment we get as we deepen our understanding of complex phenomena.
If you hadn’t gone into health, what would you have done instead?
If I hadn’t been accepted for medicine, I would have kept applying until I got in. I wanted to be a doctor from age three. I never had a Plan B.
What do you see as the most pressing goals for public health?
The 17 Sustainable Development Goals announced last year by the United Nations are pretty good. One, “good health and well-being”, is explicitly about health; the other 16 e.g. “end poverty”, “reduce inequalities”, “reduce climate change” are all health-related in some way. I think those of us who are interested in the strategic direction of public health are shifting from single-issue approaches to a more ‘health in all policies’ mindset. I once heard Sir Andy Haines give a brilliant lecture on planetary health; he talked about how he’s working increasingly with zoologists, soil scientists and other experts outside health to try to address global challenges.
When do you think health initiatives work best and can you give an example?
Health initiatives tend to flop when they’re too narrowly conceived, e.g. not sufficiently interdisciplinary, and when they fail to take account of context and practicalities. Indeed, I worry about the medical mind-set whose basic script is the ‘drug for a disease’ model. Physician researchers over-use randomised controlled trials – which focus the analysis on demonstrating internal validity (‘can it work’) at the expense of external validity (‘is it going to work here?’). Yes you’re right that research, advocacy and policy need to come together, but I would also say that these streams of activity need to co-evolve from the outset so that – for example – the researcher is writing the grant application with a clear and respectful idea of where the policymakers and advocates are coming from, and that research as it unfolds takes continual account of its intended end-users, ideally through ongoing, cross-sector dialogue.
Here’s an example. My team have been doing a series of studies, mostly secondary research and modelling, on how best to prevent type-2 diabetes through both individual and population measures. We worked from the outset with local policymakers, and also from an early stage, national policymakers to shape the questions we were asking. They told us that they found existing systematic reviews unhelpful because the questions posed were of academic interest but did not tell them for example which options were likely to be affordable, given local contingencies. Our recent publications, and more in the pipeline, have been tightly focused on providing the kind of answers that policymakers will find useful. See for example:
- Efficacy and effectiveness of screen and treat policies in prevention of type-2 diabetes: systematic review and meta-analysis of screening tests and interventions.
- Preventing type-2 diabetes: systematic review of studies of cost-effectiveness of lifestyle programs and metformin, with and without screening, for pre-diabetes.
- Economic evaluation of type-2 diabetes prevention programs: Markov model of low- and high-intensity lifestyle programs and metformin in participants with different categories of intermediate hyperglycaemia.
What recent research excites you and why?
I love Richard Osborne’s work on health literacy. He’s extended the term ‘health literacy’ from the narrow meaning of 'can the person understand medical terms', to a much broader meaning that embraces capacity to access care - including such things as ability to navigate the system, social support, digital access/literacy and what I’d call self-advocacy - and various additional dimensions of being unmotivated, downhearted and downtrodden. These of course relate to the traditional social determinants of health such as poverty and social exclusion. In the OPHELIA project, Osborne’s team have developed high-quality survey instruments to assess these wider aspects of health literacy in a particular community and use those to target different aspects of service development and community support. See for example:
- Systematic development and implementation of interventions to OPtimise Health Literacy and Access (Ophelia)
- Optimising health literacy and access of service provision to community dwelling older people with diabetes receiving home nursing support
- Measuring health literacy in community agencies: a Bayesian study of the factor structure and measurement invariance of the health literacy questionnaire (HLQ)
- Distribution of health literacy strengths and weaknesses across socio-demographic groups: a cross-sectional survey using the Health Literacy Questionnaire (HLQ)
What would you like to see come out of your work with the think tank?
I’m keen to develop some ideas on system-level change and what we might do to complement and/or replace the dominant randomised trial approach. Don’t get me wrong – I owe my life to randomised trial research and I believe these designs have a crucial place in healthcare. But I think The George Institute for Global Health is now at the stage where it’s asking what other methodologies might be helpful in addressing global grand challenges, and how can we apply these appropriately. One of my specific interests is large-scale IT projects and why they so often fail or, if they don’t fail completely, why they so often don’t achieve the benefits anticipated. Whilst I’d be happier studying successful IT projects, I think we’ll have plenty of material to chew on as we consider why some of the tech initiatives funded by The George Institute in recent years have been partial rather than unqualified successes.
Who we are: Michael Moore AM
Distinguished Fellow, The George Institute for Global Health, focusing on Promoting Healthy Environments.
Michael is also Adjunct Professor at the University of Canberra , Visiting Professor at the University of Technology Sydney, is the former CEO of the Public Health Association of Australia and the Immediate-Past President of the World Federation of Public Health Associations.
You started out as teacher, what prompted your move to politics, and then onto public health?
I fell into politics really, trying to attempt to keep the major parties under control with regard to planning issues, like many of us do. Not realising even at the time that planning issues were really also public health issues. And when I got elected, I thought what am I going to do? I'm only here for one term. Who is it that the major parties are not looking after? And I decided to focus on the most vulnerable in society.
What achievements are you most proud of during your career in politics in the ACT with the Public Health Association of Australia, and the World Federation Public Health Associations?
During my early days in the ACT Legislative Assembly we achieved the decriminalisation of cannabis and the legalisation of prostitution. On the prostitution issue, the thing that was different about our approach was that we decided that we were going to empower the sex workers – and this was unusual thinking in the early nineties. Others working on the issue were trying to put controls in place. At the same time I was suggesting that we needed to provide heroin to dependent users and worked with the National Centre for Epidemiology and Population Health to get that proposal up in a sound academic way as a medical and scientific research project. It was very important in terms of changing discourse.
The other thing that I'm particularly proud of nationally is turning the Public Health Association of Australia (PHAA) around to an organisation that really has impact. I had previously left the Public Health Association because I thought it had lost its ability to work across governments, and therefore was not having much influence at all. Of course, it was a huge advantage to understanding how politics works. As President of the World Federation of Public Health Associations (WFPHA) and of the PHAA, I was able to facilitate the building of support groups for young professionals. I've also been a catalyst for the implementation and establishment of the Indigenous Working Group of the WFPHA.
What do you think can be done to improve the Australian healthcare system?
Globally, we're doing quite well and the best indicator, or the easiest indicator of it, is longevity. We're amongst the highest in the world. But when you look at the socioeconomics and the distribution of wealth as a determinant of health it is clear that the distribution is anything but even. The most obvious weakness is in the health outcomes of Aboriginal and Torres Straight Islander people, who have around a 10-year gap in life expectancy. However, Australia’s lack of expenditure on prevention, health promotion and protection has been reduced while there is a focus on hospital and treatment. The most important element, or the first thing we should be doing here is taking prevention, protection and health promotion away from the tight control within the political system. This could be achieved with an Australian Centre for Disease Control, which would help set out what are the highest priorities for prevention.
As a Distinguished Fellow, you will be focusing on the food policy aspect of Promoting Healthy Environments. What do you see as the most important measure that can be implemented to help tackle the obesity crisis?
Sometimes it is really obvious what people should be doing and they're not doing it. I'll use a specific example, the sugar tax. It's really obvious that we should be implementing this policy like many other countries in the world. We know what the evidence is - it's really clear. But on the other hand, we also know that we've got a government that's has just lost its one-seat majority. So you have to understand that getting a sugar tax might take some more time as some sugar seats are marginal seats. But, you never let anything go. Rob Moody, professor of Public Health at Melbourne University, says there are three P's in advocacy - persistence, persistence, and persistence. I think that's the issue. I don't think it's a question of whether or not we have a sugar tax - it's just a question of when.
What do you think you can bring to The George Institute that will benefit people not only here but globally?
I am doing a PhD on advocacy right now which I'm hoping to finish in the next three or four months. I think that's something that I can add to the area of knowledge. It's not just the experience that I've had inside government and outside government, but also because I'm interested in understanding how advocacy works. I've made considerable effort to keep up with the reading to understand what other people are doing and how to carry out advocacy most effectively locally, nationally, and internationally. We need organisations like The George Institute, and the people that work within it, to take leadership and persist until we are able to make things happen.
Who we are: Jacqui Webster
Head, Public Health Advocacy and Policy Impact Centre, The George Institute for Global Health
Director, WHO CC Salt Reduction
Associate Professor, Faculty of Medicine, UNSW Sydney Honorary Associate Professor, University of Sydney
You are a passionate healthy eating advocate. What inspired you to work in health research?
I have always been interested in food. I grew up on a farm in North Yorkshire in England. Everything was home cooked or from the farm or garden. Mum thought that buying anything like jam or packet gravy from the shop was cheating.
I studied Sociology and then International Development which was when I first became aware of the massive inequalities in relation to food security globally. My first job was advocating for food policies to improve health for people on low incomes in the UK. Later I worked for the UK Food Standards Agency where I helped establish the UK government’s successful salt reduction strategy.
The George Institute’s researchers are leading thinkers on global health. What do you see as the most pressing goals for public health?
A lot of my research to date has been on reducing population salt intake by supporting companies to take salt out of foods and meals. But increasing the focus and spending of governments on prevention policies more broadly is urgently needed. This includes improving environments to support healthier living through better food and nutrition, improved mental health and reduced injuries.
What would you like to see come out of your work with the new think tank?
The George Institute’s research focuses on low cost solutions that have the potential to improve the health of millions of people globally. Our new think tank initiative is about ensuring our research influences policy and practice and ultimately affects people’s health. We will tackle this through cross-cutting issues including healthy living environments, improved health systems, women’s health inequalities and social enterprises. We will engage a suite of different channels including digital media and events to share insights, challenge the status quo and foster the kinds of debates that can deliver real impact in relation to health, both in Australia and globally.
What do you find most intriguing about healthy eating research?
Every individual is different and the factors that influence food choices are complex and changing. The move towards personalised nutrition is fascinating but probably only relevant to a small minority of self-motivated people – for the vast majority of people the food environment, including price, availability, culture, knowledge, and skills, is what influences their daily food choices. Telling people what to eat won’t have much of an impact unless we can change the food environment.
What kind of diets would you like us all to be eating in the near future?
There’s no one size fits all when it comes to diets but in general it would be good to see a shift towards increased consumption of fresh foods and less processed foods. The VicHealth Salt Reduction Partnership tagline, “If it’s packed, chances are it’s packed with salt,” says it all. We need to enable people to eat more fresh foods, including fruits and vegetables, and less processed foods. Obviously, not everyone is going to be able to cook from fresh at home every day so we need to be ensuring that manufacturers increase the healthiness of processed packaged foods and that restaurants and food outlets sell healthier meals.
How have you changed your lifestyle as you learn more about diet through your work?
There isn’t really much I won’t eat occasionally. I love food and enjoy eating out and entertaining. So I try to balance this out by bringing healthy lunches to work and making sure we only have healthy meals and snacks at home most of the time.
When do you think health initiatives work best? Can you give an example of how our research has made a big impact on people's lives, such as with regards to better dietary choices?
Certainly, one of the reasons for the success of the UK salt reduction strategy (that has already reduced salt by 15% and estimated to be saving around 9000 lives a year) was the fact that research, advocacy, government and industry were all brought together on the same page. Plus, the main focus was changing the food environment – in this case reducing salt levels in foods and meals – which was key to success.
Salt reduction programs also have great potential in developing countries and sometimes changes can be made quite quickly. As part of a visit to Mongolia I visited a bread factory and discussed the importance of reducing salt with the manager who immediately reduced the amount of salt added to the bread in the factory – which was producing 50% of the bread in Mongolia. This would have had an immediate and significant impact on people’s health in Mongolia.
But not all changes are that easy. Processed foods are increasingly available in many countries, and I’m concerned about the rising consumption of products like instant noodles, which may be cheap and convenient, but contain huge amounts of salt.
What keeps you motivated to keep helping people eat better?
Initially my interest was in tackling malnutrition in the form of people not having enough to eat. But over the last 10-15 years my priority has shifted to the growing problem of people eating too much, or the wrong kinds of foods, leading to non-communicable diseases such as diabetes or cardiovascular disease. It’s not difficult to stay motivated. Food systems are complex and there is always something new to learn. Plus, everyone loves to talk about food and health.
The George Institute researchers mainly focus on prevention and low-cost solutions, which ones are you most excited about?
One example is the new affordable dialysis machine that has the potential to massively increase access to this life-saving treatment for people with kidney disease globally.
Meanwhile, SMARThealth provides an exciting opportunity to improve efficiency of patient healthcare in many countries and our trials of a new combination pill (that combines treatments for multiple risk factors) will help to increase adherence and has the potential to dramatically cut costs to health budgets around the world.
These are just some of the examples of low-cost solutions that can deliver impact in relation to healthcare choices, treatment and improving efficiencies of healthcare systems. Our challenge now is to make sure the right people know about them so that they are integrated into policy and practice and ultimately impact people’s health and save lives.
Who we are: Kelly Thompson
Program Manager, Women’s Health, The George Institute for Global Health
What inspired you to work in health research, and what keeps you motivated?
I obtained a great deal of satisfaction from being a bedside nurse but it was really tough work in a challenging system and towards the end I often felt like I wasn’t doing “enough”. I’ve always had an intrinsic knowledge that my purpose in life is to be of service to others and in research I can do this on a large scale and without the burnout that often happens when working on the frontline. Knowing my purpose is what keeps me motivated.
If you hadn’t gone into health, what would you have done instead?
As soon as I stepped foot into my first job after school as a medical receptionist, I knew I would always work in health so I can’t imagine myself working anywhere else.
What do you see as the most pressing goals for women’s health?
It’s such a vast area with so much work to be done but the bottom line is about making real, measurable progress towards achieving gender equality in every possible context worldwide. In some contexts it’s about ensuring women are given the same opportunities and in others it’s about women being given the same basic human rights as men.
What would you like to see come out of your work with the think tank?
I’d love to see a really strong advocacy program to support the dissemination of women’s health research outside of traditional models so we can have the biggest possible impact.
When do you think health initiatives work best? Can you give an example of how our research has made a big impact on people's lives?
I think public health initiatives work best when they are designed (from the outset) in consultation with the communities they serve, like all of the Aboriginal and Torres Strait Islander Health research done at The George Institute– that really inspires me.
The George Institute researchers mainly focus on prevention and low cost solutions, which ones are you most excited about?
Obviously – the low cost dialysis project is a mind-blower. It is such an innovative model and will drastically improve the lives of people not previously able to access or afford dialysis. This is particularly important for women who are less likely to access and receive life-saving treatments like dialysis due to gender inequality.
Who we are: David Peiris
Director, Health Systems Science, Office of the Chief Scientist,
The George Institute for Global Health
Professor Faculty of Medicine, UNSW Sydney
What inspired you to work in health research, and what's your background?
I came to research fairly late in my career. I'd been a practicing GP for about maybe 12 years and I was always very much more clinically focused. But in my clinical work, my passion was always around delivering good primary health care to underserved populations.
I worked in a remote Aboriginal community for a number of years and did my junior medical years in the Northern Territory. So I’d been working in Indigenous health as a clinician for quite a long time already when I came back to Sydney. Then I did a Master's of International Public Health at Sydney University, and doing that started to open up my horizons towards public health research.
I then had a year in New Zealand working as the clinical director for a Maori primary health organization. That was a non-clinical role, but it was where I started to look at designing and implementing programs to improve quality of care for Indigenous populations- in this instance Maori and Pacific populations in Auckland.
I moved back to Australia when a job at the George came up to do work on a new Indigenous health services research program. The program was then led by Alan Cass (now at Menzies School of Health Research), Alex Brown (now at SAHMRI) and Anushka Patel. The role seemed right up my alley because it was starting to bring that very practical, clinical focus, and the new work I was doing around quality improvement, into a research lens. That was 12 years ago and for the first few years I focused exclusively on that program of work, and did a PhD on it.
What keeps you motivated?
I think throughout all of my career, the focus hasn't really changed. It's still primary health care and strengthening systems for populations that miss out on access to good care. In the post-PhD era for me at the Institute, this focus was really important as the Institute was also growing regionally in India and China. I was able to take the learnings from the work I'd done in Indigenous health services and see its application in other settings.
This year it's the 40th anniversary of a landmark declaration on primary healthcare which was made in Alma-Ata in 1978 [Declaration of Alma-Ata]. The Declaration really sets up a charter for how to use primary healthcare as, essentially, a kind of restorative justice mechanism for community control of health services and framing access to quality health care as a right.
Way back when I was a medical student, I saw the Declaration as being an absolutely inspirational document. It's interesting that it's being revisited this year, and a new declaration is about to be announced at Astana, Kazakhstan at the end of October.
I think all of the things in there were inspiring for me as a med student. They were inspiring for me when I worked in Indigenous health. And, they still remain very inspiring now as a more established researcher.
What's your role now?
My role now is as Director of Health System Science, which may be difficult to understand. Health systems really encompasses a whole range of things in terms of how healthcare is organized, financed, the workforce that underpins it, and how systems are structured in terms of things like information systems. Then, even more broadly, not just in healthcare, but also how you might influence governments and industry to play an active role in the health of whole populations. So, it's a very broad area.
I come from the more grassroots primary care angle on health systems. At the Institute we've got activities on all ends of the spectrum, from more micro-level clinical interventions to try and improve care, right through to big policy changes. For example, the work in food policy and in injury prevention, which is trying to improve public health through government regulation.
A key part of my role is to harness our strengths across the Institute; provide support to all four regional offices; build networks through multi-lateral, government, industry and academic partnerships; and look at how we can use our expertise and experience to contribute to furthering our mission through stronger health systems.
What's an example of one of the micro activities?
We do a lot of work using point of care decision support systems. One of the things that came out of my PhD work was that it's very hard for clinical people to consistently apply guideline recommendations into practice, and to make those recommendations practical when there is a patient in front of you. This work has grown through our Smarthealth program and our staff lead projects in many countries, particularly in the Asia – Pacific region.
These are simple, low cost tools that can essentially bring guidelines into the consultation, alert a provider to where best practice recommendations might be, and then using communication tools to be able to bring that into discussions with patients.
We've done a lot of trials to assess its effectiveness and learnt greatly how local contexts drive adoption of these types of strategies. For us, the next stage with that body of work is to test if it can be scaled to reach a larger group outside of just research project settings.
That's where the health systems part becomes more important. Asking questions such as ‘how do you pay for these things?’ ‘How do you build a workforce that can sustain it?’ And, in information system management, ‘how can it actually be embedded into existing systems?’
Whereabouts are you thinking implementation of guideline tools into the existing systems?
We've got programs actively in Australia, China, Indonesia, India and the UK as well as other regions. We're at this interesting point where we're looking at how we can improve the process. We clearly can't do all this ourselves. It's about partnerships-
So it’s important to have both private and public partnerships. Particularly, partnerships where people have access to large networks.
In Australia, for example, we're exploring partnerships with industry providers of digital health products. In Indonesia, we're working with one of the district governments to embed the tools into the current information systems that are used there. In China, we're collaborating with China CDC on a project to strengthen their existing health information systems. So, not using our tools, but actually just incorporating our knowledge expertise into those existing systems.
In a number of areas we're now at this interesting point where we can see even bigger possibilities that could become quite big scale national projects.
Is there a particular area that you're most excited about? A particular thing that you're working on, or a challenge that you can see?
To be honest, I find doing the mundane things, like supporting a clinic to function more efficiently, the most exciting stuff. Because, I just see the opportunity being so huge. And, this is always hard to communicate because my work isn't about a fantastic new pill, and, it isn't about a great piece of technology that's going to suddenly transform the world. It's about those slow plod things that might shift a service to a better quality and standard. This may, in itself, only be a little nudge, but if it can be done on a big scale, it actually has a huge reach and implication in terms of improving health.
I get excited about solutions to questions like, ‘how can you make a clinic workflow better?’ ‘How can workers become less busy but at the same time improve the quality of care they provide?’ And, ‘how can you make sure no one in the community gets left behind when delivering a better service?’ Or, ‘where can you find a bit of waste that could be removed out of the system to free up resources that are really scarce?’
Tackling these sorts of challenges is a very granular process, but also exciting in terms of the implications.
Who we are: Bruce Neal
Deputy Executive Director, George Institute Australia
Professor of Medicine, UNSW Sydney
Honorary Professor, Sydney Medical School, University of Sydney
Professor of Clinical Epidemiology, Imperial College London
What inspired you to work in health research?
Probably not the right way to start, but I ended up in health research by chance. I thought I wanted to be a vet and I left school with a place to do veterinary medicine in the UK. Fortunately, I decided to take a year out beforehand and after 6 months on sheep farms in New Zealand it was pretty clear to me that veterinary medicine was the wrong choice. Travelling through Asia on the way home, I decided I needed to save the world(!), and that medicine was what I wanted to do.
I turned up to vet science on the first day and let them know that I’d changed my mind. And then went to the medical school and told them I’d just relinquished that spot and asked if I could be a medical student. Probably because I had been rash enough to quit the vet course before asking to do medicine, they agreed to interview me the next day. The day after I became the shortest application to admission in the history of the Bristol medical school. You don’t need to plan everything months ahead!
After qualifying I worked hospital jobs in the UK National Health Service for about four years completing initial postgraduate training in general medicine. While trying to pick a speciality to further train in, Anthony Rodgers who I went through medical school with, called me from the other side of the world and said, “What about research?” Long story short, I got on a plane to New Zealand for a three month trial and ending up there for five years. I found the work really interesting, got a PhD with Stephen MacMahon as my supervisor ,and decamped to Sydney for the establishment of the George, then called the ‘Institute for International Health’.
How long have you been at The George Institute for Global Health? What’s your role?
I joined the George at the beginning, so it’s been 19 years. I'm now the Deputy Executive Director for Australia. I split my time about equally between clinical and food policy research. My focus at the moment is the latter, as we try to build the program in scale and scope. But the clinical work, where I've done most of my research over the last 20 years, remains extremely rewarding.
How did you come to focus on Food Policy?
The work in food policy grew directly from my clinical research interests. Even as a first year junior doctor, it was clear to me that poor diet, alcohol and smoking underpinned the great majority of clinical presentations. After a decade in clinical research assessing new interventions for the consequences of these issues, I decided we should also work on some of the upstream determinants. Food seemed like the area most aligned to my prior work, as well as being an area in which few people were doing global research and an area where there was an enormous amount to be gained from new discoveries.
I had done a fair bit of research on blood pressure lowering drugs so my interest in sodium (salt) followed from there. The vision was for a new program that spanned the globe – there were some amazing people doing food research, but most of them were working in just one area, or just one institution, and few were taking a global perspective. I also wanted to bring the sorts of methods that we use to such good effect in the clinical space to public health nutrition: research that is highly quantitative, massively collaborative, drives policy change, involves lots of countries and employs standardized methods and protocols. This seemed like something novel that we could bring to the space.
How many countries are you doing that sort of work in now?
We’re working in about 15 countries now. Most recently we launched the FoodSwitch program in the US. We use a franchise-type model with FoodSwitch identifying partners to work with in each country. We have developed technology, tools, and expertise but are not in a position to do it ourselves in all the places we want to operate. Therefore, we find an interested collaborator, typically an academic institution, and then support them to implement the project. We help them raise money, collect the data and use the outputs with government, industry, and their academic colleagues.
What are some of the most pressing goals in food policy?
We’re interested in the issues that cause the most disease burden. Ultimately that comes back to sodium and high blood pressure, fats and high cholesterol as well as sugars and obesity. We're mostly focused on the over consumption part of the malnutrition problem but in many low-income countries there is now a dual burden of malnutrition. With under consumption, mostly during pregnancy and early childhood, accompanying overweight and obesity throughout older life. These problems can now co-exist in communities, families and even an individual.
A big part of the next few years will be figuring out how to link up the research and response agenda to these joint nutrition problems. Bridging that gap between under consumption and over consumption offers a real opportunity, because there is great infrastructure in many low-middle income countries for the under consumption piece. But almost nothing able to address the other over-consumption side of the problem. This is a huge issue, because in many poor countries economic development and greater access to food means that the disease burden caused by over consumption has now overtaken that caused by deficiency disorders.
In terms of the prevention and low cost solutions we're working on at the moment, which ones are you most excited about?
Our philosophy is to focus on the environment, not the individual. Trying to get individuals to do the right thing has been the priority of most initiatives for the last few decades but has been almost entirely ineffective. This is because diet related ill health is caused first and foremost by changes to our food environment – not because everyone has decided to become a sloth or a glutton. They're essentially the same people as they were 30 years ago, they just now live in a food swamp - high calorie, high salt, high fat food in big portion sizes provided at low cost is available everywhere, all the time. In that situation, it is difficult to do anything but get fat and get diet related diseases.
Instead of trying to persuade individuals to do the right thing, we have to change the underlying food system, and that is our focus - generating data that can be used to push governments and industry towards a model that is sustainable from not just the economic perspective, but also for health and the environment.
The potential impact of our food policy work is enormous because everyone eats and almost everyone eats a diet that is sub-optimal for health. The way forward is to change the food environment so that individuals don’t have to make any active change themselves. For example, if industry reduced the salt in every food by 10 per cent almost no one would notice and we would prevent thousands of strokes and heart attacks every year in Australia. And millions more worldwide. If we can figure out how to get the system to make this sort of intervention, it's potentially really low cost and highly cost effective and that's where we’re heading with our research.
We have a long-term plan but it’s happening too slowly. Fifteen countries are contributing toward our program and the transparency and accountability agenda we are pursuing is getting real traction. We believe we can change the food supply in 50 countries, affect what a billion people eat and avert a million deaths each year by 2025. We need a few million dollars investment each year to make that happen and achieve this impact – and getting that is mostly what occupies me right now.
Who we are: Lisa Keay
Acting Program Director, Injury Program
Program Head, Eye Health Program, The George Institute for Global Health
Associate Professor, Faculty of Medicine, UNSW Sydney
What inspired you to work in health research, and what's your background?
I was always interested in working in health. I worked as an optometrist in regional New South Wales which I enjoyed and I certainly have a passion for eye health, but it wasn't until I moved into research that I think I became fully immersed in my work.
I like the variety of medical research; to be able work with other people to find out what the challenges are in health and think of solutions and then to evaluate those.
I really haven't missed a beat since I changed to research. I do appreciate that I have a health background because I have some good insights that guide my research.
What's your role at The George Institute?
I am Acting Director of the Injury Division at The George Institute. I've been at The George Institute in Sydney full-time since January 2009, working in the Injury Division. Coming into injury was a new area for me. Injury is a really interesting field because it's very broad and multi-disciplinary. It's also a major public health concern. One in 10 deaths are due to injuries and the burden of disability is much larger again. Injuries can occur at a young age and have life-long implications.
Those statistics are world-wide. It’s an interesting area to work in, given where I started, however there is a strong link between vision and injury risk. How well you see does dictate injury risk, particularly in later years of life when you're much more at risk of injuring yourself through falls.
A lot of my work is at the intersection of eye sight and injury. For example, we’re working with Guide Dogs Australia, a large community organization that provides solutions for preventing falls in people with low vision or blindness. That's going really well.
I've also done some work with ageing and road traffic injuries, looking at the challenge of keeping people safe on the road but also maintaining their mobility.
What keeps you motivated?
I think a lot of people are motivated about injury because it is something they can identify with. Injuries are not just bad luck. There are reasons and practical ways we can take action to prevent them.
As well as this, it’s often personal. When talking to my peers in road safety research, you realise that everyone can name an event which makes them feel like this is important.
My mother had a very severe car crash when I was a teenager. I think almost everyone has a story like that because it's common enough actually. I don't think that my story's that unique, but it certainly had a pretty big impact on the way I thought about what can happen to people on the road.
What are some of the key challenges in Injury research?
One challenge is engaging people in the philosophy of injury prevention; we need to change the way people think about injuries. Like I said, it's not just back luck that people get injured. If we can prevent injuries, we're preventing a lot of suffering and loss.
It's a different way of thinking; system-level changes to prevent injuries. Because as a society our tendency is to allocate blame for something happening, and it shifts the focus from where it should be. That tendency is detrimental to making gains, and it’s a position we should be challenging.
In road safety as an example there are certainly things you can do behind the wheel that change your risk, but we need to develop systems where it's difficult for people to act in ways that increases risk. When human error does come into the equation we've got to have slow enough speeds and good enough road networks that they don't end up with really severe consequences.
It’s an ongoing challenge to advocate for evidence based prevention strategies and policies. In Australia and in Europe there is a lot of good regulation, and good preventive strategies, but even in these regions there is a constant need for improvements to road safety policy. You have to advocate and challenge politicians to continue to make decisions that can prevent road crashes and save lives.
What are some research areas coming up in the near future that you're excited about?
There are a few areas. Populations across the world are ageing, and different regions have different challenges.
I’m interested in practical solutions such as proactive initiatives in the area of preventing injuries in older people. Lifetime activity fits in well with lots of other healthy ageing programs. There's some challenges with inactivity and having good physical fitness on older age. This is becoming a priority in low and middle income countries with the epidemiologic transition and population ageing in these countries. Falls prevention is gaining importance. We're trying to keep people on their feet and not falling.
For Australia, we've got a really rapidly changing landscape with what we can do with technology in vehicles. I have worked in the space of ageing and driving, and it's a really challenging area. In Australia these days it’s completely common for people to be participating in driving into their 80's.
Keeping people on the road is a good thing for socialization and mobility, but it can be difficult to maintaining safety. There's a lot of capacity to promote safety with just semi-autonomous features that vehicles have now.
That's an area that I'm really interested in. However, I think it can be difficult to get the human technology interface right because you can't have too many bells and whistles and distractions. You need to make use of technology in appropriate ways for the different groups.
We've done studies where we've had devices in cars. We're measuring exactly what's going on in vehicles. That's changed the face of doing research because you can get very large, fairly low-cost systems that can collect a lot of objective information.
I think technology in vehicles will revolutionize road safety. It's an area for debate about how it actually can be implemented but there are real possibilities. That's exciting.