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~ ~ ~ Hi ~ ~ ~ Global Health Health, like education, is an investment in human capital, and targeted health investments can help to break cycles of poverty and political instability around the world and contribute to national and global economic development. America's Vital Interest in Global Health (1997) Hearth and disease are universal human concerns. The health of all people is profoundly affected by scientific, technical, eco- nomic, social, educational, and behavioral factors that are changing at an unprecedented rate as the world economy becomes increasingly interconnected. GIobal- ization has brought benefits to people . . . the direct interests of the in many countries, but it has also ore- American people are best served ated risks that cannot be addressed when the nation acts decisively to within traditional national borders. promote health around the world. More than 2 million people each day move across national borders, and the growth of international com- merce inevitably leads to an increased transfer of health risks. Obvi- ous examples of these risks include infectious diseases, contaminated foodstuffs, pollutants and toxic wastes, and used! but potentially dangerous commercial products such as pesticides. For the United States, distinctions between domestic and interna- tional health problems are losing their usefillness and cart be mislead- 85

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Informing the Future: Critical Issues in Health ing. Indeed, the direct interests of the AmencaI1 people are best served when the nation acts decisively to promote health around the world. The Institute of Medicine produces reports that provide a scien- tific basis for improving health glob ally as well as nationally. To en- sure that our reports reflect the requisite international perspective and expertise, scientists, policymakers, and other distinguished individu- als from foreign countries both developed and developing fre- quently serve on our study committees. AMERICA'S INTEREST IN GLOBAL HEALTH Worldwide, there is a growing demand for access to new interventions to diagnose and treat disease, as well as for access to effective ways to prevent disease and promote good health. The knowledge base required to meet these needs is not only technical, derived Dom experiments of researchers, but also draws Tom the experiences of gov- elements In allocating resources effectively and efficiently to Prove human health. America's Vital Interest ire Global Health: Protecting Our People, Er~har~cing Our Economy, and Advancing Our International Interests (1997) was ~nst~ental in demonstrating that the nation wall best Fife its responsibility for protecting Americans' health, enhancing U.S. economic interests, and projecting U.S. influence internationally by ex- WorIc~wide, there is a growing demand for access to new erting leadership in global health. Of cntical importance, the United States interventions to diagnose and treat should lead Tom its strengths in medi- disease, as well as for access to cat science and technology. The report effective ways to prevent disease calls on the federal government to es- and promote good health. tablish an Interagency Task Force on Global Health to address heath needs and opportunities. The various U.S. agencies win statutory responsi- bilities in this area will need to act in a coordinated fashion, and the federal government will need to fonn partnerships with the nation's 86

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Global Health The 10 Major Causes of Death in Developed and Developing Countries1990 Deaths (thousands) Cause of Death Developed Developing World Cardiovascular disorders 5,245 9,082 14,327 Infectious and parasitic 163 9,166 9,329 diseases Malignant neoplasms 2,413 3,611 6,024 Respiratory infections 389 3,992 4,380 Unintentional injuries 552 2,682 3,233 Respiratory disorders 500 2,435 2,935 Perinatal disorders 82 2,361 2,443 Digestive disorders 424 1,426 1,851 Intentional injuries 282 1,569 1,851 Genitourinary disorders 167 568 735 SOURCE: Control of Cardiovascular Diseases in Developing Coun- tries: Research, Development, and Institutional Strengthening, 1998; page 18. academic community, industrial sectors, arid nongoverrunental orgaru- zations, as well as with other nations and international organizations, to most effectively advance human health around the world. THREATS FROM EMERGING INFECTIONS The spread of HIV, the emergence of new diseases, arid the resurgence of diseases once thought to be under control are together causing al- most half of all deaths worldwide among people under the age of 45. The spread of HIV, the emergence The result is a humamtanan crisis of new diseases, and the resur- with broad social arid economic An- gence of diseases once thought to plications. Emerging Infections: Mi- be under control are together crobial Threats to Health in the causing almost half ofall deaths United States (1992) points to major worIdwicle among people under the challenges for the public health and age of 45. 87

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Informing the Future: Critical Issues in Health 45 35 a' `~ 30 c: O 25 a) `~ 20 Q 25 10 .- 40 _ Number of Cases _ Pefcentageof Cases / o 1 986 1 987 1 988 1 989 1 990 1 991 1 992 1 993 1 994 1 995 1 996 1 997 1 998 Year 1 6,000 1 4,000 1 2,000 Ad 1 0,000 ~ Or ID 8.000 O - c) ID 4,000 2,000 Trends in tuberculosis cases among foreign-born people in the United States (the 50 states, the District of Columbia, and New York City), 1986-1998. SOURCE: Ending Neglect: The Elimination of Tuberculosis in the United States, 2000; page 36. medical care communities in detecting arid managing infectious dis- ease outbreaks and monitoring the prevalence of endemic diseases. The report promotes early prevention as a cost-effective and crucial strategy for maintaining public health in the United States arid worldwide, arid it presents an action plan for enhancing surveillance systems, fostering vaccine and drug development, improving methods for controlling the organisms that spread disease, promoting public education aimed at behavioral change, expanding research alla training, and strengthening the U.S. public health system. We have a new study under way to review these issues and pres- ent a comprehensive 10-year plan for addressing the continued threat of emerging infections. Our Forum on Emerging Infections also pro- vides an ongoing venue, in a neutral setting, for discussion among scientists arid policymakers in government, industry, and academia on problems in prevention, detection, management, and research on in- fectious diseases. Forum workshops focus on such issues as direc- tions for research to better understand and prevent emerging infec- 88

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Global Health lions, education and training needs for the medical and public health communities, and opportunities for strengthening partnerships be- tween the public and private sectors. Tuberculosis (TB) is the leading infectious cause of death worId- wide even though the disease is both preventable and, in most cases, treatable. In the United States, recent years have seen a resur- gence in TB, which in the mid-1960s had been under fairly tight con- trol. Particularly troubling has been the appearance of cases of multi- drug-resistant tuberculosis, which is difficult and costly to treat, at best, and often proves fatal. Ending Neglect: The Elimination of Tu- berculosis in the United States (2000) demonstrates that promoting global tuberculosis control not only will help improve the well-being of millions Tuberculosis is the leading of people around the world, but also is infectious cause of death worIcl- strongly in the U.S. national interest. wide even though the disease is The proportion of foreign-born patients both preventable and, in most with tuberculosis in the United States cases, treatable. has been steadily increasing in 198S, 41 percent of all TB patients were foreign-born. As a blueprint for eliminating TB in the United States, the report details a number of intertwined steps that involve all levels of government, international agencies, as well as the private sector. Underlying these steps, there must be a concerted effort to build and sustain the public and political support necessary to ensure that sufficient resources are made avail- able for what must be a long-lasting effort. As the number of TB cases declines, such "social mobilization" by countless groups and individuals may be all that prevents a shift of attention and resources to other perceived needsand thus all that prevents the onset of yet another period of neglect. Smallpox was one of the most deadly diseases the world has ever known, and its elimination in the late 20th century represents a public health triumph. Its elimination also left a question: What should be done with the two known stocksone in the United States and the other in Russiaof vanola virus, which causes the disease? ~ 1986, the World Health Organization (WHO) proposed that the two re- maining stocks of variola be destroyed in June ~ 999. In Assessment of 89

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Informing the Future: Critical Issues in Health the Future Scientific Needs for Live Variola Virus (1999), art TOM committee concludes that there are important scientific reasons such as aiding In vaccine development and studies of the human immune system for maintaining small quantities of the virus arid that the most compelling need for long-term retention is to protect against a reemergence of smallpox due to accidental or intentional release of the virus. HEALTH IN DEVELOPING COUNTRIES Cardiovascular diseases (CVDs) have reached epidemic proportions in developing countries. Of the 52 million deaths reported worldwide in 1990, IS million were Mom CVDs. Moreover, their incidence is in- creasing CVDs are projected to be- come the developing worId's leading cause of death over the next decade. Contnbuting to the problem is the fact Cardiovascular diseases have reached epidemic proportions in developing countries. 90

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Global Health that some of the interventions that have reduced CVD mortality in de- veloped countries are not practical or available in the developing world. Control of Cardiovascular Diseases in Developing Countries: Research, Development, and Institutional Strengthening (1998) rec- ommends strategies to reduce the CVD burden in these locations, along with research to monitor these efforts and develop new strate- gies as needed. Of key importance, U.S. government agencies and other organizations, both public and private, need to work with their counterparts in developing countries in implementing programs to re- duce the prevalence of CVD risk factors, such as tobacco use, high blood pressure, and dietary intakes high in fat, salt, and sugar. Micronutnent maInutntion affects approximately 2 billion people worldwide. People who consume too little iron, vitamin A, iodine, and other micronutnents cart suffer a variety of profound effects, in- cluding premature death, blindness, stunted growth, mental retardation, Micronutrient malnutrition affects learning disabilities, generally poor approximately2 billion people health, and low work capacity. Preven- worldwide . . . [~t can cause] a tion of Micronutrient Deficiencies: variety of profound effects, Tools for Policymakers and Public including premature death, blind- Health Workers (1998) provides a con- ness, stunted growth, mental retardation, learning disabilities, public health workers to improve pre- generally poor health, and low vention programs globally. The report work capacity. serves as a guide for international and national funding in the tailoring of programs that use multiple strate- gies such as nutrient supplementation and fortification, food-based approaches, and public health measuresto ensure that people in all countries consume healthful diets. ~ - , ~ ceptual framework for policymakers and Brain disorders affect at least 250 million people in the developing world, and this number is expected to increase as more people live to old age. These disorders affect the highest human faculties and, led unheated, can destroy a person's dignity, productivity, arid autonomy. Yet, public and private health systems in developing counties have paid scant attention to brain disorders, concentrating instead on the major connnnunicable diseases. Neurological, Psychiatric, and De- 91

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Informing the Future: Critical Issues in Health velopmental Disorders: Meeting the Challenge in the De- veloping World (2001) presents a comprehensive plan for reducing the toll exacted by these disorders. The report focuses on six representative disorders that are prevalent in developing countries: developmental disabilities, epilepsy, schizophrenia, bipolar disorder, depression, arid stroke. The good news is that there are effective and affordable ways to treat or even prevent many forms of these brain disorders approaches that have proved their value in the industrialized world. The report highlights strategies and interventions to be considered by local, national, and inter- national policymakers In bringing these successes to more arid more people in the developing world. INTERNATIONAL ASSISTANCE The United States has close ties with six island junsdictions in the Pa- cific Basm, and the health and well-being of their citizens is of consid- erable Amencan interest. The U.S.-Associated Pacific Basin consists of three U.S. flag territories (American Samoa, Commonwealth of the Northern Manana Islands, and Guam) and three independent countries that are freely associated with the The United States has close ties United States (Federated States of Mi- with six island jurisdictions in the cronesia, Republic of the Marshall Is- Pacific Basin, anc! the health and welI-being of their citizens is of consicIerable American interest. Most health indicators for the islanders are worse than those for mainland Americans. lands, and Republic of Palau). Most health indicators for the islanders are worse than those for mainland Amen- cans. The jurisdictions' health systems must deal with conditions nonnally seen in both developing courses (maInutrition, tuberculosis, dengue fe- ver, and cholera) and developed countnes (diabetes, heart disease, arid cancers. Each year, the United States provides approximately $70 mil- lion In funding for health care in the region. Several U.S. health agen- cies, wanting to improve health conditions in the islands, asked for our help in assessing the health needs of the region. Pacific Partnerships for Health: Charting a New Course (1998) examines the strengths arid J 92

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Global Health weaknesses of the reglows health-related systems and details a strate- g~c plan for improving the islanders' health. The plan has four compo- nents: adopting and supporting a system of community-based primary care and preventive services, improving coordination within and be- tween the jurisdictions and the United States, increasing community involvement and investment in health care, and promoting the educa- tion and training of the local health care workforces. 93

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