To prepare for climate change, we must invest more in areas that impact health: John-Arne Røttingen

John-Arne Røttingen, the new CEO of the Wellcome Trust, has been at the forefront of global health science and advocacy for the past several decades. Røttingen began his career as a scientist – he completed a PhD focusing on cellular calcium signaling – and trained as a medical doctor before transitioning to infectious disease epidemiology and leading health organizations.

Røttingen, who was most recently Ambassador for Global Health at the Ministry of Foreign Affairs in his native Norway and a board member of Gavi, the Vaccine Alliance, was also intimately involved in the global response to COVID-19, mainly as part of the Access to COVID-19 Tools Accelerator’s various working groups and co-chairing the accelerator’s Facilitation Council on behalf of Norway.

He's now taken the helm at Wellcome, one of the largest charitable foundations in the world, which plans to spend £16 billion (about US$20 billion) by 2032 in four priority areas – discovery science, infectious diseases, climate and health, and mental health.

Exemplars News spoke with Røttingen about his plans for the organization, his lessons from the COVID pandemic, and the value of highlighting successes in global health.

First, congratulations on your appointment as CEO of Wellcome Trust. What are your plans for the organization?

Røttingen: What's nice is that Wellcome already has a new strategy with a 10-year outlook. We have a substantial capital base for investments and have committed to spend £16 billion [of funding] in the next 10 years. For me, it's not about thinking about the priorities – because the priorities are there and they're great – but it's really about how we can deliver the most impact within each of our four priority areas. So it's a question of how you invest. How do you identify the potentially most impactful projects? How do you help translate research findings into policy changes and practice changes? How do you potentially commercialize new solutions so they can go into the marketplace and be scaled up and be used worldwide? How do we create innovations that are adapted to, and in particular, usable in low-income country settings – and actually have that in mind from early on in the research process?

Wellcome now has four key priorities. One is the continued investment in discovery science, making sure that we can bring about new scientific discoveries that could be relevant across the board for medical sciences and health research. Then, in addition, we have three challenge-driven areas. One is infectious diseases, which is a longstanding priority of Wellcome, including substantial investments in infectious disease research centers in both Africa and Asia. We have two additional new challenge areas – climate and health and mental health.

The challenge areas are all connected. For example, in terms of climate and health, the impact of climate change on infectious disease is already substantial and will increase. We will have more vector-borne diseases in new areas. We're already seeing changes in climatic conditions that will increase the risks of general zoonotic diseases or spillover events, in particular transmission of viral diseases from animals to humans. An important part of any epidemic and pandemic preparedness system will be capturing these changes because the global community will need capacities in new geographic regions to identify infectious diseases that we're not necessarily seeing today.

On mental health – that is now a broader conversation given that the pandemic had a huge impact on mental health, in particular because of the closure of schools and the changes in social structures from shutdowns. I believe we now understand that we need to make sure those detrimental consequences of infection-control measures are as small as possible. Public health authorities and their governments need to try to understand the trade-offs when using public health and social measures to control infectious disease and make sure they don't undermine the social fabric or the mental health of people, in particular young adults and children. Mental health is an under-prioritized area and I'm very pleased that Wellcome has identified it as a key priority in its strategy, but we can only invest in parts of this important field of research. Others will also need to strengthen their support for mental health.

Climate and health initiatives notably cover a broad range of topics. What areas of research and impact are you most excited about in that area?

Røttingen: Wellcome has a great team and they're working across a broad range of areas. I'm not completely up to speed, but I would highlight two. One is getting even better data on the health consequences on climate change. This includes getting better data on climatic consequences, but also we need more detailed modeling-based and scenario-based understanding to communicate the need to act on climate. This includes reducing emissions, but also for the need to take action on adaptation.

We also need to develop a deeper understanding of the biological impacts of climate change on human health and its determinants and of how humans can adapt – from human physiology in hotter environments to changes in the microbial microenvironment.

More broadly, and outside Wellcome’s scope as health research funder, we also need to understand that the climate adaptation that can most impact health is not necessarily health sector investments. It's more about understanding how investments in other sectors can also have substantial health benefits. Policy makers need a strong evidence base for understanding the positive health impacts of climate adaptation measures in other sectors so that it becomes part of more holistic national climate adaptation strategies and plans.

Researchers need to help decision makers understand the broad impact of climate change and the most cost-effective adaptation strategies when it comes to mitigating the social and welfare impacts through broad-based adaptation strategies. That means turning away from the framing of “health sector investments” towards “investments for health impact.”

In terms of inspiring urgency and action, what lessons can organizations and researchers in climate and health take from those who worked on pandemic preparedness?

Røttingen: I might change that question to focus on those who worked on pandemic response because in some way the pandemic preparedness was insufficient. When the pandemic really hit us, there was an enormous collective effort in the research community to contribute with knowledge. There was international collaboration, in particular, on understanding the sequencing data of the viral genome, understanding the evolution of the virus, and understanding new strains. That generated new insights much more quickly than what we could normally expect from the scientific system. I don't see the same in the urgency around climate change. Many, of course, have used the metaphor of boiling a frog in gradually warming up water. We need to ask ourselves how we can document the direct health consequences earlier. How can we use data-based insights to explain how climate change already impacts health?

Looking back, how could the COVID response help us better prepare for future epidemics and pandemics? What were some of the lessons for you?

Røttingen: My involvement during the pandemic was first and foremost through the ACT-Accelerator – Access to COVID-19 Tools – partnership. I don't think we have ever seen such a collaborative environment of organizations working together to achieve impact in global health. The major global health agencies came together on three different pillars – developing and delivering diagnostics, new treatments, and vaccines. They also came together in terms of having a broader health systems approach to the crisis, but we struggled more in getting that part right.

Many would say, ‘No, that was not a success. It was a failure. It demonstrated that we couldn't deliver equitable access.’ I think we need to understand that given where we were, we achieved a lot during the pandemic. There were two issues in particular, I think, that we managed to substantially improve. The first was access to medical oxygen. That was really not understood internationally – there was a limited supply and during a situation like the pandemic the needs are tremendous. Systems were put in place for local production, for scaling up, and for building a supply system. A lot of that can now be maintained and used for everyday global health needs around the world. The other is really the vaccine collaboration, COVAX, which was, again, partly portrayed as a failure. But I would point out that we'd never been able to distribute more than two billion vaccines before, including to the most disadvantaged countries and settings. And this happened just a year after the vaccine had been approved and was starting to be used in the global North. But, no, it wasn't perfect and the world needs better approaches to ensuring timely and equitable access everywhere and for everyone.

What we learned is that we can build on the partnership model and the commitment to collaborate in order to be better prepared in the future. That's where I now see promise – that there is a commitment to build a more inclusive and long-term mechanism of coordination for medical countermeasures for the future. That would not only be useful for emergencies, it will also be a system that can provide value every day when it comes to access to medical technologies. On the health systems strengthening front, I have also had the opportunity to co-lead the Future of the Global Health Initiatives process this last year. Our Lusaka Agenda has just been published and is, likewise, calling for stronger collaboration across external multilateral and bilateral funders to better support country plans and priorities.

Exemplars in Global Health and Wellcome have partnered on a project called Advanced Warning and Response Exemplars (AWARE) looking at early warning systems for climate-sensitive infectious diseases. How do you think this work could inform epidemic preparedness and response?

Røttingen: My understanding is that this collaboration is exploring new ground and focuses on the opportunity to capture data and information from spaces other than the traditional public health surveillance systems. That will be important. Access to data from different sectors is expanding. Given the developments we're seeing in the world, we will have more opportunities [to gather data]. The main issue is how we identify signals in those multi-sectoral data sets that could be the first signals of a potential outbreak. Not just of potential outbreak of an existing disease, but also new diseases.

I don't see this as a substitute for the diagnostics and laboratory-based public health surveillance systems or sentinel node systems for identifying outbreaks, but it's an important complementary mechanism that will be important for the future. My understanding is that this investment can, by exploring new avenues and opportunities, perhaps identify very cost-effective ways for early warning and response.

Why do you think it’s important to learn from Exemplars, or bright spots, to inform global health priorities and investments?

Røttingen: In global health and many other sectors, we often focus on the problems. We tend to spend a lot of time identifying problems and the size of the problems and then talk about the need for solving them. I think it's important to focus rather on solutions, build their evidence base and try to sell them from a communications point of view. It's all about narratives. Good stories are also one way to motivate others to come into this field and have them understand you can have a big impact from your work. Identifying success stories and good examples is also a strong way to motivate a broader community. We are living in a world in dire straits, with ongoing conflicts, climate change, and a lot of economic challenges coming out of the pandemic. We need to turn that into understanding that we can actually make change. Global health is definitely a space where it's possible to improve the lives of individuals around the world, measure it, and tell good stories.