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1· ~ ~ ~ ~SummaryDistinctions between domestic and international healthproblems are losing their usefulness and often aremisleading.Health and disease are universal human concerns. The health of all people isprofoundly affected by economic, social, behavioral, political, scientific, andtechnological factors, many of which are changing at an unprecedented pace bothin the United States and abroad. Since the end of the Cold War, the world economyhas become increasingly interconnected and globalized; increased competition,trade, and communication have brought benefits to people in virtually everycountry and have created a remarkable degree of mutual interdependence. Yetthese changes have also brought risks that frequently cannot be addressedadequately within traditional national borders and have created problems that havespread among nations at an accelerating pace. The movement of 2 million peopleeach day across national borders and the growth of international commerce areinevitably associated with transfers of health risks, some obvious examples beinginfectious diseases, contaminated foodstuffs, terrorism, and legal or banned toxicsubstances.Burdens of illness vary among countries according to their economic, social,and climatic conditions; these circumstances and disease patterns vary markedlyamong different populations within a country as well. Poverty and violenceimpose major burdens on health, burdens that are shared by people in developingand developed countries alike. Due to the ease of rapid international travel,emerging and drug-resistant infectious diseases in one country represent a threatto the health and economies of all countries. Changes in demography,particularly increased life expectancy, are dramatically altering patterns ofdisease epidemiology (see Table 1-1~.Health problems, issues, and concerns that transcendnational boundaries, and may best be addressed bycooperative actions, represent what is encompassed, inthis report, by the term "global health."The aging of populations also entails major increases in chronic cardiovascularand neuropsychiatric diseases in all populations around the world and expands theneed for adequate care. With ever-growing public demands for health, the need tobalance private and public-sector responsibilities in health, assess and improve the
2AMENCA 'S VITAL INTE~STIN GLOBAL HEALTHquality of health care, control costs, and establish rational and humane priorities forhealth resource allocations are problems with which the United States and everyother government in the world are currently struggling.In this report, the term "global health" refers to health problems, issues, andconcerns that transcend national boundaries, may be influenced by circumstancesor experiences in other countries, and are best addressed by cooperative actionsand solutions. The report argues that the direct interests of the American people arebest served when the United States acts decisively to promote health around theworld. This country has a strong humanitarian tradition, and the American peoplehave long supported efforts to improve the health of people around the world. Yetthe United States now contributes a lower percentage of its gross domestic product(GDP) to foreign assistance than any of the other top 20 industrial nations.Foreign assistance, in any case, can be only one small component of America'scontribution to improving global health. In a context of rapid worldwide change,other activities, such as research into major global health problems, are equallyimportant. Many players contribute, including numerous governmental agencies,nongovernmental agencies, and international organizations, yet coherent andeffective leadership is lacking. The report recommends that the United States exertgreater leadership in global health by taking full advantage of its strength in scienceand technology. In so doing, the United States will fulfill its national responsibilityto protect Americans' health, enhance U.S. economic interests, and project U.S.influence internationally.The direct interests of the American people are bestserved when the United States acts decisively to promotehealth around the world.PROTECTING OUR PEOPLEThe U.S. government has a vital responsibility to protect all its citizens itsresident population, its soldiers, and its travelers. It must be aware of threats posedby emerging infectious diseases and the potential for biological and chemicalterrorism, and must be prepared to respond. Food safety and security, violence,poverty, and natural disasters can all threaten the health and well-being ofAmericans at home and abroad and represent common problems to be solved.Some of the medical and scientific knowledge needed to protect the health of ourpeople is uniquely available or acquired most cost-effectively through the study ofpopulations abroad. In addition, knowledge of differing national experiences withhealth care systems and financing, and the analysis of novel approaches to solvingproblems of health care delivery, access, cost-containment, and quality are criticalfor infonning health policies within the United States.
SUMMARYTABLE 1-1 Projected Change in the Rank Order of Disease Burden for15 Leading Causes, Worldwide 1990-20201990 RankDisease or InjuryOrder2020Disease or InjuryLower respiratory infectionsDia~Theal diseasesConditions arising during perinatalperiodUnipolar major depressionIschemic heart diseaseCerebrovascular diseaseTuberculosisMeaslesRoad traffic accidentsCongenital anomaliesMalariaChronic obstructive pulmonarydiseaseFallsIron-deficiency anemiaProtein-energy malnutrition24s67Ischemic heart diseaseUnipolar major depressionRoad traffic accidentsCerebrovascular diseaseChronic obstructive pulmonarydiseaseLower respiratory infectionsTuberculosis8War9Diarrheal diseases1 0HIV11Conditions arising during perinatalperiodViolence12Congenital anomaliesSelf-inflicted injuriesCancers of trachea, lung, aridbronchus-NOTE: Disease burden is measured in disability-adjusted life years (DALYs), a measurethat combines the impact on health of years lost due to premature death arid years lived witha disability. One DALY is equivalent to one lost year of healthy life.SOURCE: Murray and Lopez, 1996.ENHANCING OUR ECONOMYClearly, it is desirable in itself that all populations achieve better health. Buthealthier populations abroad would also constitute more vibrant markets for U.S.goods and services. Health, like education, is an investment in human capital, andtargeted health investments can help to break cycles of poverty and politicalinstability around the world and contribute to national and global economicdevelopment. U.S. businesses are adapting to meet the rapid globalization of theworld economy, and demands for health and medical services are growing in themany countries with a rising standard of living. Political and regulatory barriers,however, deter the United States and other industrial countries from developingdrugs, vaccines, and medical devices for these markets. These distortions need tobe overcome if U.S. markets are to expand effectively overseas and compete in thearea of health goods and services. Examples of current constraints include failure to
4AMERICA 'S VITAL INTERESTIN GLOBAL HEALTHrespect and enforce intellectual property rights, pricing restrictions, patentinfringements, and lack of harmonization in regulatory and enforcement standards.ADVANCING OUR INTERNATIONAL INTERESTSGovernments are no longer the sole agents acting in He global health arena.Beyond national programs, the global health system now includes (1) the private orcommercial sector, including multinational corporations; (2) the independent sectorand nongovernmental organizations (NGOs), such as universities, privatefoundations, and relief and advocacy organizations; (3) the multilateral sector,including multinationally funded organizations such as the World HealthOrganization, the United Nations development agencies and regional healthorganizations, and the regional development banks and the World Bank; and (4)the bilateral sector, involving entities such as the U.S. Agency for InternationalDevelopment that are funded by single governments or regional partners. With thispluralism comes a strong need and opportunity- for active U.S. engagement inglobal health issues. Despite popular misconceptions about the size of U.S. foreignaid, the importance and value of improving the health of people around the world issupported by a majority of the American public (see Chapter 3), spanning broadlydiffering political, social, and cultural perceptions. U.S. commitment to democraticprinciples, our active foreign policy, and our continued support for human rightsform the historical basis for U.S. leadership in this effort, and our scientific andeconomic capabilities provide the practical basis for concerted, productiveengagement. The failure to engage in the fight to anticipate, prevent, and ameliorateglobal health problems would diminish America's stature in the realm of health andjeopardize our own health, economy, and national security.The failure to engage in the fight to anticipate, prevent,and ameliorate global health problems would diminishAmerica's stature in the realm of health and jeopardize ourown health, economy, and national security.LEADING FROM STRENGTHThe scientific and technical expertise of the United States is unsurpassed in thehealth sector. The capabilities of science to enhance both life expectancy and thequality of life are unprecedented. As Figure 1-1 shows, over the decades ofthe pastcentury, an income of any given amount has steadily bought more years of life.This suggests that, while income growth is important for enhancing people'schances of survival and health, the explosion of lalowledge about health and itsdeterminants and the application of public health measures have also played asignificant role in increasing life expectancy.
SUMMARY8070-a)>, 60Lax 50 _a_4030-.i :930/ · · About 1900199005,00010,000 15,000 20,00025,000Income per Capita(1991 international dollars)FIGURE 1-1 Knowledge pays: A given income buys a longer life in 1990chart in 1910, thanks to research and public health measures. NOTE:International dollars are derived from national currencies, not by use ofexchange rates, but by assessment of purchasing power. The effect is to raisethe relative incomes of poorer countries, often substantially. SOURCE: WorldBark, 1993. Reproduced with permission.The United States in partnership with other nations and internationalorganizations should lead from its strengths in medical science and technology toplay a central role in global health. The basic medical knowledge being accrued bythe National Institutes of Health and the expertise in disease surveillance andprevention of Be U.S. Centers for Disease Control and Prevention are uniquenational resources that help to create and sustain the international public good. Inaddition, the U.S. pharmaceutical, medical device, and vaccine industries andacademic sector are among the most innovative and productive in the world. TheU.S. government should engage these institutions to provide leadership in globalhealth in at least five areas, as follows.The United States should lead from its strengths inmedical science and technology.Research and Development. The United States must continue to invest inglobal health research in order to maximize the many opportunities to understand,prevent, or control diseases that threaten the American people. The United Statesshould also broaden the scope of its research and development activities to includehealth problems that impose the greatest burden of disease around the world,toward whose alleviation we can make important contributions. These problemsinclude those infectious diseases that remain a major health burden in the
6AMERICA 'S VITAL INTERESTIN GLOBAL HEALTHdeveloping world, particularly for children; noncommunicable diseases such asheart disease, cancer, and depression; substance abuse; injuries; and the effects ofviolence. Expanded research and development in these and related areas wouldprovide means for disease prevention and control that could also be directlyapplied to improving the health of the U.S. population.Surveillance. The United States should contribute to the creation of a globalsurveillance network for emerging and resurgent infectious diseases and drug-resistant pathogens. Efforts should build on the 1996 Presidential Directive thatinstituted a new national public health policy on infectious disease prevention andcontrol (see Chapter 4~. The successes of global surveillance networks forinfluenza and polio indicate that such networks are feasible and of criticalimportance to our nation's health. These same systems should be adapted toinclude early warning systems for lapses in the safety of the global food supply, forthe possible release and spread of chemical and biologic agents, for environmentalstresses, and for other global health threats.Education and Training. Long-term investments made by the United Statesin the education and training of physicians and other health care providers,scientists, and policymakers around the world have contributed substantially tohealth and biomedical science. America's commitment to health education andtraining both of its own scientists, researchers, clinicians, and public healthprofessionals at home and abroad and of those from overseas studying in theUnited States must be maintained to ensure the development of a competentglobal health infrastructure. Well-trained health professionals and leaders with anunderstanding of global health issues working in the United States and abroad canimprove the identification and monitoring of diseases threatening the U.S. andother populations and can enhance opportunities for shared learning about the bestmeans for preventing, detecting, and treating disease.Global Partnerships. To deal adequately and efficiently with the complexityof changing health problems and policies, new partnerships will have to be forgedbetween the U.S. government and multinational and multilateral public and privateagencies. Creative, mutually beneficial partnerships can leverage expertise andincreasingly scarce resources for global disease surveillance; prevention, control,and elimination of specific diseases; and health care policy analysis. Effectivepartnerships can also enhance research and development of new generations ofvaccines, drugs, and diagnostics for preventing and treating major diseases in theUnited States and abroad.Coordination and Leadership. These opportunities for advancing U.S.leadership in global health should take advantage of America's strengths inscience and technology to achieve our health goals in a constructive andhumanitarian way. Many TJ.S. government agencies have statutoryresponsibilities for, and could make major contributions to, global health
SUMMARY7activities particularly the Department of Health and Human Services,Department of State, U.S. Agency for International Development, Food andDrug Administration, and the Departments of Defense, Commerce, andAgriculture-and the U.S. role is clearly too complex to be fulfilled by anysingle agency. However, as noted previously, serious legal and organizationalobstacles-fragmentation of governmental responsibilities, divisions of authoritybetween domestic and international health activities, and lack of coordinationamong U.S. governmental agencies and with the nongovernmental sectorimpede progress toward global health. Enhanced coordination of the activities ofthe many U.S. federal agencies with responsibility for global health; clearermandates, lines of authority, and responsibility among agencies; and strongercollaboration with the nongovernmental and corporate sectors would enablemore cost-effective, productive policies and programs. In addition, there is afundamental need for strong leadership to coordinate the missions of theagencies within the U.S. government and to integrate this work with the activitiesof NGOs and international organizations to ensure that the limited resourcesavailable to improve global health including the health of Americans areused more effectively and efficiently.The Board on International Health, therefore, recommends establishing anInteragency Task Force on Global Health within the U.S. government to anticipateand address global health needs and to maximize global health opportunities forthe United States and the world in a coordinated and strategic fashion. Becausesolutions to global health problems increasingly demand new and expandedscientific and technical approaches, the board further recommends that additionalresources and specific authority be allocated to the U.S. Department of Health andHuman Services because of its unique scientific and technical expertise-exemplified by the National Institutes of Health, Centers for Disease Control andPrevention, and the Food and Drug Administration. This would enable thedepartment to coordinate global health strategy and priority setting across the U.S.federal agencies represented in the Interagency Task Force and to act as leadagency in establishing liaison with academia, NGOs, industry, and internationalagencies. The globalization of health problems, needs, and risks represents anurgent international challenge and an extraordinary opportunity for the UnitedStates, given its scientific and technical expertise, to benefit the American peopleand global humanity. Our nation's vital interests are clearly best served by anactive, sustained, and strengthened engagement in global health.