Guru promotes global health

As the United States faces increasing public health problems, David McQueen, associate director for global health promotion at the Centers for Disease Control and Prevention, tells Abi Berger that doctors are beginning to look at inequalities in health

When Dr David McQueen returned to the United States after 10 years in Scotland he gained a stone in weight. "I started eating just a bit more than I needed to, and I found I needed a car to get around," he said. He wasn't alone in this behaviour: overeating and lack of daily exercise are creating major public health problems in the United States.

David McQueen thinks that the time is ripe to look at health inequalities (CENTERS FOR DISEASE CONTROL AND PREVENTION, ATLANTA)

In Edinburgh, a carless McQueen (a medical sociologist who had trained at Johns Hopkins University School of Public Health) had been the director of a stand alone research unit in health and behavioural change. From there, in 1992, he was recruited to join the Centers for Disease Control and Prevention (CDC), a federal government run agency in Atlanta.

He is now associate director for global health promotion at the agency, a programme that includes a wide variety of tasks, from advising countries on vaccination schemes to helping countries tackle problems such as cancer and cardiovascular disease. These last problems have become more critical in recent years as people have started living longer and fewer now die of infectious diseases.

"In Europe the emphasis in health promotion was on a more macro or economic approach," says Dr McQueen. "We were generally more interested in the social determinants of health." Back in the United States he found a greater emphasis was placed on the individual. McQueen says that he has, by nature, a more European bent with respect to public health and has brought his European experience back to his work at the CDC.

"We're beginning to develop more of an interest in ethnic disparities and looking at ways to reduce inequalities in health--by improving access to health care, as well as reducing social inequalities. The document Healthy People 2010, published in January this year reflects this" (25 March, p 818-9).

Despite the CDC's efforts, Dr McQueen thinks the "magic bullet" concept is very much alive and kicking in America. "The hope has always been that a new drug or particular approach will win out," he says. "Americans would like to think that the world is not as complex as it is."

At the National Center for Chronic Disease Prevention and Health Promotion, Dr McQueen pursues the CDC's role in global health, while also concentrating on national healthcare issues related to public health. "We're pushing the role of prevention in healthcare organisations," he says "and they're beginning to take it seriously."

Dr McQueen is interested in working with agencies with worldwide infrastructures, such as the World Health Organization, especially when it comes to chronic disease surveillance. But he doesn't like the word "surveillance." He thinks it has a negative connotation, reminiscent of old-style eastern European politics. Monitoring is too passive, however, because it implies watching, without doing anything.

"We're lucky, because through the CDC, I think the United States has a sound infrastructure for collecting data, and also acting on it," he says. Britain and Europe do not fare so well in his view. Communicable disease surveillance is better than chronic disease surveillance, but generally Europeans could be doing much better. "There's a tendency to produce perfect data but to do little with it," he says.

The CDC can provide technical assistance to other countries to help them to develop such infrastructure if they want it. Some poorer countries have better systems than the wealthier ones, as a result of colonial legacies; others, such as China, have already got systems in place that are working reasonably well because many of their epidemiologists and statisticians have been partly educated in the United States and Europe. China is also willing to spend money on maintaining its systems.

By taking a global approach, CDC thinks that it can avoid many of the political and historical barriers that tend to appear when an international approach is taken. "Globalisation has helped us to reach new places over the past 20 years," says Dr McQueen.

At the end of the day, how-ever, the CDC is still a domestic agency, and local health promotion is arguably more important to his work than global health care. "To be effective in promotional work you have to collect smaller and smaller units of data," says Dr McQueen. "People want it by the street, rather than the state, before they'll engage in health promotion programmes that seek to change behaviour." They also have to buy into the notion of self care, rather than trust in magic bullets.

It can be a long lag time before you see any results, he says, and there is little opportunity for instant gratification in this line of work. "I have pessimistic days, like watching the two tribes of Northern Ireland trying to live together, and more optimistic days, when I find myself thinking that taking a global perspective might actually be a way to avoid war," he says.

He says that he has a sense of urgency--that the time is ripe to get things done--tempered by a belief that solutions take time. "The quick fix approach is a bit suspect," he says. "We've got to accept that we may not see the fruits of our labour in our lifetime, and we have to be happy with small incremental changes, and acknowledge that some of our successes are left unseen, such as successful immunisation programmes."

But, he says, "It's frustrating that we can buy Coca-Cola and McDonald's hamburgers anywhere in the world, but not get fresh drinking water." These companies have clearly established a more successful cold chain than anyone has so far managed for getting vaccines around the world.

Abi Berger, BMJ


studentBMJ 2000;08:175-216 June ISSN 0966-6494