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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 Countries—1990
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-
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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 needs—and 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 stocks—one in the United States and the
other in Russia—of 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.
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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 measures—to 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
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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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Representative terms from entire chapter:
developing world
