Global Health: The Strength of Nations

Americans are fortunate to live in one of the most prosperous and scientifically advanced countries in the world. Organizations such as the Institute of Medicine (IOM) are able to be effective in large part due to the prevalence of scientific research and academic excellence in the United States.


However, neither the United States nor the IOM exists in a vacuum. Thanks to huge innovations in technology, the interactions between nations at a human level are greater than at any time in history. The development of this world community is one of the success stories of the last century. Yet globalization brings a shared responsibility to support countries with limited resources to tackle health problems within their own borders. In doing so, the United States has the opportunity to have a substantial, positive impact on the well-being of people around the globe. In this age of globalization, the actions of each nation globally will ultimately have an impact on its own welfare domestically.


The IOM is committed to act as an adviser not just to the nation but to the world. It sefis to advance the role of the United States as a force for improving global health and to explore international health issues that have implications for U.S. health policy.

BETTER SCIENCE = BETTER HEALTH

The American scientific community has a strong commitment to activities that will strengthen and support science in developing countries. The IOM’s African Science Academy Development Initiative directly supports eight African academies of science in building their capacity to provide independent, evidence-based advice to their governments and countries on health-related matters, much as the IOM does for the United States.


Supported by the Bill and Melinda Gates Foundation, this 10-year effort aims to strengthen each African academy’s capacity through better infrastructure, shared experience, and well-trained personnel. Each African academy is developing and sustaining a relationship with its government and nation to ensure, much like the IOM, that it will be recognized as a trusted source of excellent, actionable scientific advice.



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GloBal health: the strenGth of natIons Global Health: The Strength of Nations Americans are fortunate to live in one of the most prosperous and scien- tifically advanced countries in the world. Organizations such as the Institute of Medicine (IOM) are able to be effective in large part due to the prevalence of scientific research and academic excellence in the United States. However, neither the United States nor the IOM exists in a vacuum. Thanks to huge innovations in technology, the interactions between nations at a human level are greater than at any time in history. The development of this world com- munity is one of the success stories of the last century. Yet globalization brings a shared responsibility to support countries with limited resources to tackle health problems within their own borders. In doing so, the United States has the oppor- tunity to have a substantial, positive impact on the well-being of people around the globe. In this age of globalization, the actions of each nation globally will ultimately have an impact on its own welfare domestically. The IOM is committed to act as an adviser not just to the nation but to the world. It seeks to advance the role of the United States as a force for improving global health and to explore international health issues that have implications for U.S. health policy. BetteR Science = BetteR health The American scientific community has a strong commitment to activities that will strengthen and support science in developing countries. The IOM’s Af- rican Science Academy Development Initiative directly supports eight African academies of science in building their capacity to provide independent, evidence- based advice to their governments and countries on health-related matters, much as the IOM does for the United States. Supported by the Bill and Melinda Gates Foundation, this 10-year effort aims to strengthen each African academy’s capacity through better infrastructure, shared experience, and well-trained personnel. Each African academy is develop- ing and sustaining a relationship with its government and nation to ensure, much like the IOM, that it will be recognized as a trusted source of excellent, actionable scientific advice. 

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Informing the Future: Critical Issues in Health The activities of the African Science Acad- each african academy is deeloping emy Development Initiative are diverse and and sustaining a relationship with its take place both nationally and on a regional goernment and nation to ensure, basis. The science academies of Nigeria, South much like the iom, that it will be Africa, and Uganda—competitively chosen to recognized as a trusted source of participate in the program at the most inten- excellent, actionable scientific adice. sive level—are receiving support and collabora- tive counsel in their advisory activities. Additional funds have been set aside for the science academies of Cameroon, Ghana, Kenya, and Senegal, as well as the broader African Academy of Sciences, with the purpose of crafting specific acad- emy development strategies. More donors and scientific partners are needed for these programs to reach their full potential and be maximally successful. African nations face critical prob- lems and complex decisions, including HIV/AIDS; the acceptance of genetically modified crops; and the design of national systems for health, agriculture, and education. The IOM sets an example of how a respected, impartial, independent, and unified voice from the scientific and medical communities can force political and public attention to address objective evidence. This drives public policy debate and increases the probability that decisions will be made in the public interest. By creating similar scientific bodies, Africa can secure a healthy population that is critical to its future as well as the world’s. hiv/aidS: towaRd a SUStainaBle ReSPonSe In 2003, Congress passed the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act, establishing a five-year, $15 billion initiative to help countries around the world respond to their AIDS epidemics. The initia- tive is generally referred to by the title of the five-year strategy required by the act—PEPFAR, or the President’s Emergency Plan for AIDS Relief. Congress asked the IOM to evaluate PEPFAR’s progress in the three years af- ter the act was passed. The resulting IOM report, PEPFAR Implementation: Progress and Promise (2007), concluded that PEPFAR had made a promising start. However, continuing U.S. leadership is needed in the effort to respond to the HIV/AIDS pandemic. Since its release, legislators in Congress and journalists in the media have echoed this call. To that end, the report recommended that the U.S. Global AIDS Initiative shift from a focus on emergency relief to an emphasis on the long- term strategic planning and capacity building necessary to develop a sustainable 

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Global Health: The Strength of Nations response to the AIDS pandemic. Long-term factors that underlie the epidemics in each country should be addressed, including • emphasizing and enhancing prevention by accumu- lating better data to determine the most appropriate interventions needed in each country; • empowering women and girls by putting more focus on the factors that place them at greater risk of HIV/ AIDS and supporting improvements in their legal, economic, educational, and social status; • building workforce capacity both by increasing direct support and by focusing on the education of new health care workers in addition to training for exist- ing health care workers; and • expanding the knowledge base by emphasizing evidence-based approaches, learning from experi- ence, and adapting to new developments, as well as conducting operations research and robust program monitoring and evaluation. These strategies will help enable PEPFAR to have lasting impact on the focus countries’ AIDS epidemics. Making the transition to sustainability will require continuity with the established program but also improvement and greater flex- PEPFAR’s network model. SOURCE: PEPFAR Implementation: Progress and Promise, p. 57. 49 2-3

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Informing the Future: Critical Issues in Health ibility in implementation. In addition to addressing the long-term factors above, harmonization of efforts should occur through better coordination, the support of WHO prequalification, and the removal of budget allocations. Similarly, patient services should expand, improve, and integrate through data-driven prevention efforts, adequate provision of treatment medications, community- and family- centered care, performance targets for orphans and other vulnerable children, and greater attention to marginalized populations. eaSing the BURden of canceR Cancer is low on the health agenda of the world’s low- and middle-income countries (LMCs), even as it becomes an ever-increasing proportion of their over- all disease burden. Fully two-thirds of those dying from cancer globally live in LMCs—many times more than those dying from fully two-thirds of those dying from AIDS, tuberculosis, or malaria. Yet for an LMC cancer globally lie in lmcs—many battling problems on many fronts, cancer does times more than those dying from not command international headlines. In part, aidS, tuberculosis, or malaria. yet for the lack of focus on cancer is due to an impres- an lmc battling problems on many sion of intractability—people die and not much fronts, cancer does not command can be done. international headlines. In response to a request from the National Cancer Institute and the American Cancer Society, an IOM committee studied what efforts might be successful in easing the burden of cancer in LMCs. In Cancer Control Opportunities in Low- and Middle-Income Countries (2007), the committee described a series of appropriate, realistic actions that would help LMCs diminish the toll that cancer takes on their citizens. These opportunities include • signing and ratifying the Framework Convention on Tobacco Control to tackle the most significant cause of cancer and other noncommunicable diseases; • supporting measures to reduce the cancer burden related to infectious agents, responsible for one-quarter of all cancer deaths in LMCs; • developing resource-level-appropriate guidelines for the overall man- agement of cancers whose treatment can make a substantial difference to a large proportion of patients; • creating cancer centers of excellence in these regions, which can lever- age international partnerships; • treating highly curable childhood cancers; 0

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Global Health: The Strength of Nations TABLE 3-3 Deaths, Years of Life Lost (YLL), and Disability-Adjusted Life Years (DALYs), All Causes and Cancers by Country Income Level, 2002 (all figures in millions) All Causes of Death Cancer YLLa DALYsb YLLa DALYsb Deaths Deaths Population Country Income Level Low 28.5 606.4 877.7 1.8 20.8 21.4 2,560,762 Lower middle 17.2 221.0 402.6 2.7 29.4 30.3 2,214,697 Upper middle 3.4 42.2 90.4 0.6 5.9 6.3 513,406 High 7.9 52.4 118.7 2.1 15.4 17.4 933,917 All LMCs 49.1 869.6 1,370.7 5.1 56.1 58.0 5,288,865 World 57 922.5 1,490.1 7.1 71.6 75.5 6,224,985 LMC share of global 86% 94% 92% 72% 78% 77% 85% burden aThe component of the DALY that measures years of life lost by a population due to premature mortality. b A measure of the gap in healthy years of life lived by a population as compared with a normative standard. SOURCE: Data from World Health Organization (2006). Deaths, Years of Life Lost (YLL), and Disability-Adjusted Life Years (DALYs), All Causes and Cancers by Country Income Level, 2002 (all figures in millions). SOURCE: Cancer Control Opportunities in communicable diseases, maternal and perinatal conditions, and nutritional Low- and Middle-Income Countries, p. 74. • removing barriers to inexpensive and effective pain control medications and providing other types of palliative care for those suffering from can- cer; and • gathering better data on the burden of cancer and the results of control efforts. Progress on all of these fronts can be made with appropriate financial sup- port from the global community and the sharing of technical expertise around the world. childhood oBeSity: not JUSt a U.S. PRoBlem The United States shares a great deal with its neighbors, and the global com- munity is joined more tightly every day. As neighbors, Mexico and the United States are particularly united as they share residents, trade, and culture while at the same time maintaining their own cultural, social, and political uniqueness. Unfortunately, health issues are not immune to this relationship, and concerns 

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Informing the Future: Critical Issues in Health about public health often are common on both sides of the border. Among these problems is childhood obesity. The Joint U.S.-Mexico Workshop on Preventing Obesity in Children and Youth of Mexican Origin (2007) developed from a desire to share experiences regarding the problem of obesity in children and youth of Mexican origin on both sides of the border, with a particular focus on actionable solutions. U.S. and Mexican researchers, public health officials, industry lead- ers, and policy makers engaged in a valuable dialogue, sharing perspectives, challenges, and ideas for success. Commonali- ties and differences in the United States and Mexico regard- ing risk factors, potential interventions and programs, and the need for all sectors to collaborate and make progress toward reversing this serious public health problem were highlighted and characterized. This conversation served as the basis for a bilateral agenda dedicated to address- ing this epidemic. The situation is urgent. Despite the scarcity of data available to indisputably link risk factors to childhood obesity, all key players have a responsibility to de- velop and implement strategies to prevent childhood obesity based on the best available evidence. Participants suggested the creation of a Mexican National Obesity Task Force in order to • increase awareness of the problem; • conduct assessment of human resources; • develop and implement a national policy for obesity prevention; • increase community participation; • build trust among various sectors; • provide decision makers with recommendations based on science; and • develop prevention strategies. The workshop also identified areas in which the United States and Mexico could collaborate, including advocacy, funding, a trained labor force, collection of scientific evidence, program evaluation, and consistency in programs and messages. The workshop summary is being used in Mexico to support the formation of an interdisciplinary working group that would outline specific prevention initia- 

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Global Health: The Strength of Nations tives for Mexican children. It is being translated into Spanish with the expecta- tion that the translation will have an even greater impact among Mexican (and other Latin American) policy makers and government officials, school and indus- try leaders, and health providers. hiv/aidS: PReventing infectionS An estimated 13 million people worldwide inject drugs. Of those, 78 per- cent live in developing or transitional countries. The sharing of contaminated injecting equipment has become one of the driving forces behind the global AIDS epidemic and is the primary transmission vector in many countries, particularly throughout Eastern Europe, the Commonwealth of Independent States, and sig- nificant parts of Asia. In Asia, HIV infection rates have increased by as much as 20 times over the last two decades as a result of injection drug use. In some cases, HIV is spreading rapidly from drug users to their partners through sexual trans- mission and from drug users and their partners to newborns. Reversing the rise of HIV infection among injecting drug users is an urgent global problem—one that remains largely unaddressed. In response to this crisis, the IOM was asked to evaluate strategies for stop- ping HIV transmission among this vulnerable population. 50 BOX 1-3 Hierarchy of Steps IDUs Can Take to Reduce HIV Risk 1. Stop using drugs. 2. Stop injecting drugs. 3. Always use a new, sterile syringe to inject drugs, and use sterile equipment to prepare drugs. 4. Never reuse or share syringes, water, or drug-preparation equipment. 5. Use bleach to properly disinfect injecting equipment. 6. Share supplies with as few other people as possible (“partner restriction”). 7. Know your HIV status, and—if you are seropositive—do not pass on needles and syringes and use condoms during sex (“informed altruism”) and seek antiret- roviral therapy. 8. If you are an HIV-infected female who becomes pregnant, seek antiretroviral therapy to prevent perinatal transmission. SOURCE: Adapted (with modifications by the Committee) from NIDA (2002) and Des Jarlais (2005). Hierarchy of Steps IDUs Can Take to Reduce HIV Risk. SOURCE: Preventing HIV Infection Among Injecting Drug Users in High-Risk Countries: An Assessment of the Evidence, p. 50. 

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Informing the Future: Critical Issues in Health The resulting report, Preventing HIV Infection an estimated  million people worldwide inject drugs. of those, Among Injecting Drug Users in High Risk Countries:  percent lie in deeloping or An Assessment of the Evidence (2007), found that traditional countries. several key approaches can reduce the use and injection of illegal drugs and additionally curb other drug- and sex-related behaviors that increase the risk of HIV infection. There is strong evidence, for example, that two opioid agonist medications— methadone and buprenorphine—are effective in treating dependence on opioids such as heroin. This IOM report provided evidence-based recommendations regarding drug dependence treatment, sterile needle and syringe access, and outreach and educa- tion. Multicomponent HIV prevention programs that include better sterile needle and syringe access are effective in reducing drug-related HIV risks. High-risk countries are urged to take immediate steps to make these HIV prevention strategies widely available.