Shaping the world we want to live in


Shaping the world we want to live in

Photo Credit: Jessica Scranton/FHI 360

As FHI 360 marks its 50th anniversary, explore our history of solutions and future of possibilities. 

Dr. Timothy Mastro, FHI 360’s Chief Science Officer, offers his perspective on where we’ve been, where we’re going and what’s at stake in human development.

FHI 360 turns 50 this year. Looking at the next 50 years, what do you see as the biggest challenges in human development?

Inequity continues to be one of the world’s most gnawing problems. I’ve seen it my entire career, from public hospitals in New York City and refugee settlements on the Thailand-Cambodia border in the 1980s to the COVID-19 pandemic today. There are inequities in access to lifesaving commodities, including personal protective equipment, treatments and especially vaccines. I hope that the world will use the pandemic as an opportunity to redress the inequities in our systems.

We must learn from the lessons of COVID-19 and work to avert the next pandemic, so that we can contain an infectious disease outbreak at the beginning. Finally, we must address changes to our climate. It’s impossible not to address this existential threat.

How is climate change tied to inequity?

Wealthy people can sequester themselves from challenges. They can live behind walls to remain separate from people fleeing unproductive land. They can live at higher elevations to avoid flooding. They have air conditioning. They can buy high-quality, nutritious food.

But we will get to a point where air and water quality are so compromised that there are challenges to social stability, like wars fought over water. The wildfires we are seeing in the western U.S. states should serve as an alarm. Currently, there are more people in the world displaced from their homes than at any time since World War II. Humanitarian crises are a symptom of inequity and climate change.

Since you began working in global health in the 1980s, what has changed?

Awareness of the world’s interconnectedness has grown — when I joined the U.S. Centers for Disease Control and Prevention in 1988, the global health office was very small. Over the years, the office has become a much larger Center for Global Health, and there is greater awareness of the need to address health globally.

There have been major investments in global health over the last two decades, largely driven by the need to provide HIV and AIDS treatment. For the first 15 years of the AIDS pandemic, there was no effective treatment for HIV. Highly active antiretroviral treatment became available by the late 1990s, but it was expensive and there was profound inequity in access. People in rich countries received treatment and lived, while people in resource-limited settings did not and continued to die. This unacceptable moral tragedy resulted in major investments in the 2000s by The Global Fund to Fight AIDS, Tuberculosis and Malaria and the creation of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Those investments in HIV were, in many ways, the tide that lifted many boats in global public health.

And what has stayed the same?

There is still a power imbalance between wealthy and poor countries. In 1999, I traveled to Lusaka, Zambia, to attend the AIDS in Africa conference. UNAIDS had started an early HIV drug access initiative the year before, and a few African cities were beginning to use antiretrovirals. At this conference, there was a debate on whether it was appropriate to spend limited resources on expensive treatment for the few rather than broader HIV prevention for all.

A man walked up to the microphone and said, “I’m from Uganda and I started antiretrovirals six months ago. It sounds like you’re debating whether people like me should live or die.” He was alive because he could access treatment. We had an effective, lifesaving intervention. And yet, for the vast majority of people in Africa, it wasn’t available.

Fast forward to 2021 — there have been more than three billion doses of COVID-19 vaccines administered globally, but a large proportion of them has been in wealthy countries. In Africa, fewer than two percent of the population has received a vaccine because of limited access. Morally unacceptable power imbalances and distorted access to health services remain.

You’ve been at FHI 360 since 2008. Would you share a moment that has stuck with you?

As FHI 360’s Chief Science Officer, I’m thrilled that our tagline is “The Science of Improving Lives.” I’ve seen how the power of science and evidence can make a difference in the lives of people.

For example, FHI 360 is part of the HIV Prevention Trials Network. We contributed to the study (HPTN 052) that showed treating people living with HIV prevents them from transmitting the virus to others. Treatment is prevention! It was no longer treatment or prevention. This study formed the cornerstone of the global strategy to control HIV.

FHI 360 has been working in reproductive health since its beginning. For decades, there was a question of whether Depo-Provera, the most-used contraceptive product in many resource-limited settings, especially in Africa, might increase women’s risk of HIV infection. We played a key role in the ECHO study, which yielded high-quality evidence that hormonal contraceptives like Depo-Provera do not increase HIV risk among women in Africa. These data led to expanded access to family planning for women in Africa. The two studies show how good science and producing evidence can improve lives.

How does a multidisciplinary approach help FHI 360 meet evolving human development challenges?

Our humanitarian work shows how an integrated development approach is effective. FHI 360 has contributed to crisis response in northeastern Nigeria, in Yemen and now in Tigray, in northern Ethiopia.

What I learned, working in refugee camps many years ago, is that you need to create a comprehensive system providing health care and other essential services in a microcosm. When people stay in one place for more than a short time, you recognize the need for a holistic approach. Children need education. People need the opportunity to earn a living and support themselves and their families.

FHI 360 brings a broad perspective — in gender inequities; security; reproductive health; water, sanitation and hygiene; primary health care services; maternal and child health; education; and economic opportunity. To shape the world we want to live in, we must simultaneously address all of these dynamics.

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