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7
Call to Action
A PROMINENT ROLE FOR HEALTH IN U.S. FOREIGN POLICY
At this historic moment, the United States has the opportunity to advance
the welfare and prosperity of people around the globe through intensified and
sustained attention to better health. Especially during this time when the global
economy is under pressure, attention to global health is essential. Working with
partners in other countries and building on previous commitments, the United
States has the opportunity to demonstrate global leadership by fulfilling its
responsibility to save lives and improve the quality of life for millions around the
world, and there are a variety of reasons to do so. U.S. leadership in global health
reflects many motives: the national interest of protecting U.S. residents from
threats to their health; the humanitarian obligation to enable healthy individuals,
families, and communities everywhere to live more productive and fulfilling
lives; and the broader mission of U.S. foreign policy to reduce poverty, build
stronger economies, promote peace, and enhance the U.S. image in the world.
Protecting Health at Home Requires Transnational Attention
The 1997 Institute of Medicine (IOM) report America’s Vital Interest in
Global Health emphasized America’s self-interest in solving global health prob -
lems (IOM, 1997). The report suggested that the United States could reap eco -
nomic benefits and provide security to its citizens through increased attention to
global health. The messages of that report still hold true and perhaps are even
more pressing. The 2009 H1N1 (swine) influenza illustrates that Americans do
have a stake in the health and healthcare systems of low- and middle-income
countries.
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0 THE U.S. COMMITMENT TO GLOBAL HEALTH
Twelve years after the initial IOM global health report, globalization has
increased the urgency and changed the way in which nations must protect and pro-
mote health, in part due to the growing number of health hazards that increasingly
cross national boundaries (Dodgson et al., 2002; Lee, 2002, 2003). These threats
include infectious diseases, such as avian flu, swine flu, and severe acute respi-
ratory syndrome (SARS), as well as unhealthy imports, such as tobacco, which
heighten the risk of many noncommunicable and chronic diseases (Dodgson et al.,
2002; Lee, 2003; Lee et al., 2002). Common, modifiable risk factors—unhealthy
diet, physical inactivity, and tobacco use—underlie the major chronic diseases
and explain the vast majority of premature deaths from chronic diseases, among
men and women, in all parts of the world (Donaldson and Banatvala, 2007).
No country, acting alone, can adequately protect the health of its citizens or
significantly ameliorate the deep problems of poor health in low- and middle-
income countries. Mitigating the spread of disease and the import of unhealthy
consumer goods into already burdened, low-resource societies depends on inter-
national cooperation and assistance. Globalization also demands creative solu -
tions to complex problems in areas such as trade and the environment that affect
the determinants of health (Dodgson et al., 2002).
Leveraging solutions to address our “shared” global disease burden is essen -
tial. In low- and middle-income countries, the purchasing power of investments
in health is amplified by local ingenuity, as well as lower labor costs and over-
head. (Goldman Sachs estimates that research and development in India costs
12.5 percent of R&D in wealthy countries [Gardner et al., 2007].) The emerging
markets increasingly function as big global “labs;” for example, countries such
as China, India, and Mexico are experiencing huge variations of diseases like
diabetes and obesity within their populations and provide ideal conditions for
large-scale drug trials.
Investments in Global Health Reflect American Values
Despite the economic downturn, a large majority of Americans support U.S.
efforts to improve health in low- and middle-income countries. This support is
grounded in both an altruistic concern for the poor and an understanding that
in today’s interconnected, globalized world, a health crisis in any country can
impact Americans. In fact, a greater share of Americans support global health
spending because it is “the right thing to do” than because it will advance U.S.
national objectives (KFF, 2009; WorldPublicOpinion.org, 2009).
In today’s market crisis, the financial policies and practices of high-income
nations, including the United States, are seen as the cause of painful economic
spillovers in low- and middle-income countries. During economic downturns, the
health of a country’s population worsens due to lowered household income and
reduced access to health care (Hopkins, 2006; Pongou et al., 2006; Waters et al.,
2003). The poor in low-income countries are most affected because they pay a
large portion of their healthcare costs out-of-pocket, without the benefit of social
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CALL TO ACTION
safety nets (Gottret and Schieber, 2006; Hopkins, 2006). It is therefore crucial
for the reputation of the United States that the nation live up to its humanitarian
responsibilities, despite current pressures on the U.S. economy, and assist low-
income countries in safeguarding the health of their poorest members.
Good health is a necessary condition for economic development and global
prosperity (Bloom and Canning, 2000; Feachem, 2002). Numerous studies have
demonstrated that as people benefit from the positive economic aspects of global-
ization, good health is important in keeping them from falling back into poverty.
Ill health has been shown to be one of the leading reasons that individuals and
families descend into poverty in countries such as Argentina, Chile, Ecuador,
Honduras, India, Kenya, Peru, Uganda, and Vietnam (Baeza and Packard, 2006;
Eggleston et al., 2006; Krishna, 2007a, 2007b). Poor health not only reduces
economic productivity and earning potential, it also reduces personal resources
by imposing higher healthcare costs and diminishing savings (WHO, 2005; World
Bank, 2007). Without investments in health, prosperity from economic growth
will be tenuous, especially among the poor.
Improvements in health are thus a core investment in stable and vibrant econ-
omies around the world. One study shows that more than half of Africa’s growth
shortfall, relative to the high-growth countries of East Asia, can be explained by
disease burden, demography, and geography, rather than by the more traditional
variables of macroeconomic policy and political governance (Bloom and Sachs,
1998; WHO, 2001). The Commission on Macroeconomics and Health of the
World Health Organization (WHO) estimated that 8 million lives saved from
infectious diseases and nutritional deficiencies would save approximately $186
billion per year (WHO, 2001). China, India, and the Russian Federation could
each forgo between $200 billion and $550 billion in national income over the
next 10 years as a result of heart disease, stroke, and diabetes (WHO, 2005).
Investments in health can also demonstrate a U.S. commitment to avert conflict
and promote a more peaceful world (Hotez, 2001). Many of the world’s poorest
societies either are currently engaged in a civil war or have recently been through
one (Collier, 2007). Indeed, countries with the highest infant and child mortality
rates are those most likely to be engaged in war (Hotez, 2001); in both 1990 and
2005, Afghanistan, Angola, and Sierra Leone—three war-torn countries—had the
highest mortality rates in the world for children under 5, even during times of
relative peace (UNICEF, 2008). Implementing disease control and public health
activities—which help break the cycle of poor health, poverty, and conflict—is
particularly challenging in these fragile states, especially under conditions of
conflict (Hotez et al., 2007). However, by improving health and restoring human
dignity, the United States can help avoid or reverse the social fragmentation,
economic decay, and political instability that often cause, prolong, or result from
devastating conflict.
The expansion of U.S. government investments in global health has the
potential to change perceptions that the United States is indifferent to the plight
of the global poor. Health is a highly valued, visible, and concrete investment.
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THE U.S. COMMITMENT TO GLOBAL HEALTH
Public opinion polls following U.S. aid efforts in the aftermath of the Pakistan
earthquake and the South Asian tsunami showed an improvement in how America
is viewed (Terror Free Tomorrow, 2005, 2006). In fact, while the recent opinion
of the United States has been negative in most regions of the world, the U.S.
image has remained consistently positive in Africa (Ray, 2008), the region that
has received the most U.S. foreign aid for health (U.S. Department of State,
2007). Saving and improving lives worldwide will help to rebuild global trust in
U.S. leadership and make possible the global cooperation required for the critical
challenges of the twenty-first century, such as nuclear disarmament and climate
change.
Global Health Is a Responsibility and an Opportunity to Be Seized
Given the importance of health in building stable and prosperous communi -
ties, the committee encourages the new President to make a bold public statement
that global health not only is important for protecting the health of Americans, but
is an essential component of U.S. foreign policy. This could be confirmed by a
major speech early in his tenure to pledge support to successful U.S. investments
in this arena and propose new means for pursuing global health objectives in a
committed, cooperative, and nonpartisan manner. In this address, the President
should declare that the dominant rationale for U.S. government investments in
global health is that the United States has both the responsibility as a global
citizen and the opportunity as a global leader to contribute to improved health
around the world.
The U.S. government should act in the global interest, recognizing that long-
term diplomatic, economic, and security benefits for the United States will follow.
Priorities should be established on the basis of achieving sustained health gains
most effectively, rather than on short-term strategic or tactical U.S. interests.
Government efforts should focus on reducing deaths and disabilities among the
most vulnerable and marginalized populations in regions with the greatest need,
in countries that possess the capacity to effectively use financial and technical
resources.
Equally important, health resources should not be withheld from people in
countries where the United States takes an unfavorable view of the governing
regime. The U.S. offer of cyclone assistance to Myanmar in February 2008 was
a good example of prioritizing humanitarian needs over politics. In developing
sanctions at the United Nations (UN) and elsewhere, food, medicine, and other
health necessities should not be included among the areas of denied trade or
assistance.
Recommendation 7-1. The President should highlight health as a pillar of
U.S. foreign policy. The U.S. government should act in the global interest,
recognizing that long-term diplomatic, economic, and security benefits for
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CALL TO ACTION
the United States will follow. Priorities should be established on the basis of
achieving sustained health gains most effectively, rather than on short-term
strategic or tactical U.S. interests.
INCREASE COORDINATION AND COHERENCE
WITHIN THE U.S. GOVERNMENT
If health is to hold a more prominent position in U.S. foreign policy, the U.S.
government will have to increase coordination among the multiple agencies and
departments engaged in global health promotion. Through greater coordination,
the U.S. government can vastly enhance its own effectiveness, mobilize a criti -
cal mass of the nongovernmental sector, and also be an example for the global
health community. The administration should take this opportunity to examine
whether the existing architecture, investments, and activities of the U.S. global
health enterprise are best geared to achieving sustainable and measurable global
health gains.
To this end, the committee examined two aspects of the U.S. enterprise: (1)
the governance structures across U.S. government agencies and departments that
engage in global health, either by providing financial and technical resources to
countries to expand public health infrastructure or through research focusing on
health problems endemic to poor countries, and (2) the relationship of the United
States to nonstate actors within and beyond U.S. borders.
Need for Coherent Strategy for U.S. Government
Involvement in Global Health
More than 20 U.S. government agencies work internationally, with many of
them contributing to some aspect of human development. Seven executive branch
departments, four independent federal agencies, and numerous departmental
agencies and operating units contribute to single- and multiagency initiatives
that operate in more than 100 countries. More than 15 congressional committees
have jurisdiction or oversight over global health programs (see Figure 7-1) (Kates
et al., 2009).
Despite the involvement of multiple government agencies and the growth
in the global health budget, to date, the committee is not aware of any efforts to
broadly coordinate U.S. actions in global health across even the major govern-
ment agencies, let alone the smaller agencies less directly involved in health. A
governing body to help guide U.S. investments in global health across the U.S.
government does not exist.
Not only are health programs not well coordinated within the U.S. govern -
ment, but “at times their efforts appear to be at odds, competing for resources
and attention on the ground” (Garrett, 2009). Agencies are often working in the
same country on the same agenda and contracting out to the same organization
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THE U.S. COMMITMENT TO GLOBAL HEALTH
C
The White House
O
N
State HHS
OGHA
OGAC
G
MCC OPHS
OES
Ambassador s
R
Missions
CDC
E
USAID
NIH
Bureaus for: Global Health ;
Defense
Economic Grow th, Agriculture S
and Trade; Democracy,
FDA
Conflict and Humanitarian
S
Assistance USDA
HRSA
Homeland
Security
PMI PEPFAR EPA
KEY
NTD Labor
Water for Department
Peace Corps
Poor Ac t
Independent Agency
Commerce
Avian Influenza Dept. O peratin g Unit
Ac tion Group
Multi-Agency Initiative
FIGURE 7-1 U.S. government global health architecture.
5xb.eps
SOURCE: Kates et al., 2009.
without any coordination, either among themselves or with U.S.-based private
sector health actors. Such duplication is both inefficient and wasteful and should
be prevented, especially in an increasingly competitive environment for limited
resources.
To ensure that the U.S. government is working in a strategic fashion and
having the greatest possible impact to improve health globally, the government
should inventory current U.S. efforts as a baseline and should track, measure, and
coordinate future investment across different federal agencies and departments
both at home and on the ground within countries. This strategy should consult
the increasingly important nongovernmental sector. It is within this context that
the committee suggests governance reforms to the U.S. government global health
enterprise.
Appoint a Senior White House Official and an Interagency Committee on
Global Health
The 1997 IOM global health committee called for the establishment of an
Interagency Task Force on Global Health within the U.S. government to antici -
pate and address global health needs and to maximize global health opportuni -
ties—for both the United States and the world—in a coordinated and strategic
fashion (IOM, 1997). The 1997 committee further recommended that the U.S.
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CALL TO ACTION
Department of Health and Human Services (HHS) coordinate global health
strategy and priority setting across the federal agencies represented in the Inter-
agency Task Force and act as the lead agency in establishing liaison with the
private sector and international agencies. While this recommendation has yet to
be implemented, the potential benefits of formalizing cooperation and coordina -
tion across government agencies and departments engaged in the important task
of achieving global health can be realized. This IOM committee supports the
concept of the 1997 IOM recommendation, but finds that the interagency group
should be located more centrally, in the White House. Locating the effort in the
White House, potentially within the National Security Council (NSC), and report -
ing to the President through the NSC adviser would give it convening authority
among agencies and the ability to make policy recommendations directly to the
President. Any other reporting line would not have the coordinating power that
comes with the direct presidential chain of authority. Moreover, housing the
interagency group in one of the major departments or agencies, such as the State
Department, the U.S. Agency for International Development (USAID), or HHS,
might imply that one group is more relevant than others, when several have an
important and unique role in global health improvements; for example, while
the State Department may be the development and diplomacy arm of the U.S.
government, health expertise rests with HHS.
The committee recommends that the President create a White House Inter-
agency Committee on Global Health to lead, plan, prioritize, and coordinate
the budgeting for U.S. government global health programs and activities. The
interagency committee, which would consist of heads of major U.S. departments
and agencies involved in global health activities, would play the crucial role of
ensuring that the U.S. government has a coherent strategy for ongoing invest -
ments in global health, including the means to achieve measurable, significant,
and sustained health gains. This interagency committee would be the primary
structure for bringing together the diverse and widespread global health efforts
cutting across multiple government operations. While some agencies, such as
HHS, the Office of Management and Budget (OMB), the State Department, and
USAID, would be ongoing participants, other agencies such as the Department
of Defense, the Department of Homeland Security, the Environmental Protection
Agency (EPA), and the Food and Drug Administration (FDA) could participate
as appropriate.
The interagency committee should work with OMB to create a review mech-
anism for global health funding across the major contributing agencies. The inter-
agency committee and the OMB could review agency proposals to ensure that the
U.S. government is meeting its overarching policy goals, to reduce duplication
of efforts, and to fill gaps.
The committee also recommends that the President designate a senior offi -
cial at the White House (Executive Office of the President, potentially within the
NSC) at the level of deputy assistant to the President to chair the interagency
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THE U.S. COMMITMENT TO GLOBAL HEALTH
committee. The deputy assistant to the President for global health should serve as
the primary adviser at the White House on global health, attend all NSC meetings
that deal in any way with global health issues, and work with the national secu-
rity adviser, the director of management and budget, and the President’s science
adviser in carrying out his or her responsibilities.
The deputy for global health should be an individual of recognized accom -
plishment, with a significant background in health issues and programs, and
should have the stature to play a leading role in formulating U.S. global health
policy. A staff of three to five officers should support his or her work at the White
House.
Finally, if the deputy for global health and the interagency committee are to
be effective, individuals who directly oversee global health activities within the
various government agencies should be strong and effectual leaders with signifi-
cant experience and success in global health programming.
Designate Nongovernmental Advisory Committee on Global Health
As previously mentioned, the nongovernmental sector is playing an increas -
ingly significant role in global health financing and programming. To acknowl -
edge its role and create a formal feedback mechanism, the deputy for global
health should create a small committee of nongovernmental advisers to oversee
the work of the interagency committee.
The nongovernmental advisory committee would be a first step to formally
involve civil society, academia, and private industry in discussions regarding
global health activities and programs across the U.S. government. By engaging
this sector, the U.S. government would help to resolve the deficit of its represen -
tation on intergovernmental bodies such as the UN and WHO, which are driven
by the interests of their member countries. The U.S. government could further
involve nonstate actors by consulting with the nongovernmental sector in forming
the U.S. platform on global health policies at UN agencies, such as WHO.
Coordinate U.S. Government Response to Global Health Research
Federal agencies in the United States have played a critical role in global
health research; their work has helped to transform the understanding, prevention,
and treatment of diseases that disproportionately affect populations in low- and
middle-income countries. The National Institutes of Health (NIH) has been a
world leader in studying the basic biology of infectious diseases and developing
strategies for vaccines and drug treatments. For example, work by intramural and
extramural NIH-funded scientists is responsible for the sequencing of genomes
of many pathogens responsible for infectious diseases prevalent in the developing
world and for much of the progress that has been made against HIV and AIDS.
DOD, spurred by the exposure of field personnel in tropical countries, has con -
tributed to the development of biomedical technologies that also benefit the global
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CALL TO ACTION
poor, such as its trailblazing work in malaria. The Centers for Disease Control
and Prevention—the world’s premier public health agency—has developed suc-
cessful programs and partnerships in many countries over many years, especially
epidemiological research to improve the surveillance and control of diseases and
conditions from avian influenza to road traffic safety. With decades of field expe -
rience and a presence in more than 70 countries, USAID is uniquely positioned to
integrate health research into foreign assistance programs, help strengthen health
systems, collaborate with partner agencies, and provide leadership for programs
in the field (USAID, 2006).
Government agencies such as the EPA and the FDA may be poised to
play a more prominent role in global health. For example, the FDA recently
launched guidelines to clarify its role in the development of vaccines to protect
against global infectious diseases (FDA, 2008). Given that regulatory authori-
ties in many low- and middle-income countries lack the capacity to review new
biomedical interventions, the FDA can play a major role in the registration of
safe and effective interventions for diseases with direct impact on global health,
through its “guidances,” expertise, and experience. This is particularly important
in light of the maturing pipeline of drugs from global health product development
partnerships.
The committee recognizes that the full potential for contributions of the U.S.
agencies to research on global health has yet to be tapped and will require addi -
tional financial support and coordinated efforts. Given the importance of the U.S.
government contribution to health research, increased coordination between and
among the various U.S. government agencies involved in global health research
is critical to create the desired synergies.
The Interagency Committee on Global Health can be an important forum for
coordinating global health research across these agencies and others. Such coor-
dination may avoid wasteful duplication of efforts, identify promising research
opportunities that are not being effectively pursued, and create a global health
enterprise in which the advantages and skills of each agency are appropriately
tapped and supported. Such an interagency committee, under the leadership of
the deputy for global health, can recommend a coherent plan for advancing and
financing global health research, and this plan can be reflected in the President’s
budget.
Address Overlap Between Health Sector and Other Fields
The interagency committee would also play the critical role of making sure
health is taken into account when setting U.S. foreign policy in others areas, such
as trade, environment, and security. Public health is currently underrepresented
in many key areas of international economic and trade policy (Friel et al., 2008).
The growing overlap between the health sector and other fields presents a number
of tensions that could impede global health objectives, as well as synergies that
could be utilized to improve health.
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THE U.S. COMMITMENT TO GLOBAL HEALTH
For example, increased trade liberalization, one of the driving forces behind
globalization, may well improve economic prosperity generally, while the
increased trade in health-related goods, services, and people offers numerous
opportunities to economies around the world (Blouin et al., 2009). Yet trade can
also bring challenges by spreading disease across borders, advertising unhealthy
lifestyles, and potentially limiting access to medicines under restrictive trade
rules.
The health sector itself also has a significant impact on the trade sector. Dis -
eases such as SARS and avian flu can have a powerful economic impact on travel,
tourism, and commerce (Drager and Sunderland, 2007; Gostin and Mok, 2008;
Helble et al., 2009). The interlinkages between trade and health are complex and
require debate and new rules. Because the two sectors bring entirely different
philosophies, institutions, and laws, their intersection can raise larger questions.
For example, In the event of tension or a conflict, which philosophy, institution,
or legal system should prevail, and why (Gostin and Mok, 2008)? Support for the
International Health Regulations to protect the health of Americans and commu -
nities abroad is an important step in mitigating the negative health consequences
associated with increased systems of trade.
Environment and health are clearly linked, with environmental deterioration
leading to insufficient potable water, indoor smoke, road traffic, urban air pollu -
tion, unintentional poisonings, and lead exposure (Smith et al., 1999). Climate
variability causes disease and death through natural disasters such as droughts
and tsunamis, as well as longer-term problems such as food security (Confalonieri
et al., 2007). These environmental factors especially affect the most vulnerable
populations, placing most of the burden on children under the age of 5 and those
living in low- and middle-income countries (Smith et al., 1999). U.S. govern -
ment efforts to participate in global agreements to curtail climate change have
important consequences for human health.
In the past, health was thought to be of “little importance in the hierarchy
of foreign policy objectives” (Fidler, 2007). However, recent pandemics such as
H1N1 (swine) flu and national security threats from bioterrorism have dramati -
cally elevated the status of health on foreign policy agendas. The international
community now links health and foreign policy in relation to three key areas:
(1) national security (i.e., the need to protect from external threats); (2) trade,
economic prosperity, and political stability; and (3) globalization and develop -
ment (Owen and Roberts, 2005). As previously discussed, global health—when
done well and in the global interest—can bring long-term diplomatic, economic,
and security wins to the United States.
Recommendation 7-2. Within the first year of his administration, the Presi-
dent should create a White House Interagency Committee on Global Health
to lead, plan, prioritize, and coordinate the budgeting for major U.S. govern -
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CALL TO ACTION
ment global health programs and activities. The President should also desig -
nate a senior official at the White House (Executive Office of the President,
potentially within the National Security Council) at the level of deputy assis-
tant to the President for global health to chair the interagency committee.
CALL FOR SUMMIT TO HIGHLIGHT U.S.
COMMITMENT TO GLOBAL HEALTH
In recognition of the partnership needed to achieve the health-related Millen-
nium Development Goals and meet the global burden of disease for the twenty-
first century, the President should call together world leaders for a summit at the
UN General Assembly in the fall of 2009 to announce the U.S. commitment to
work with the global community to support global health and other major devel -
opment initiatives, such as food and water security. The President should take this
opportunity to highlight the importance of health in building stable and prosper-
ous communities and should pledge to assist low- and middle-income countries
in safeguarding the health of their poorest members.
The President should announce the U.S. commitment to the overall fund -
ing levels recommended in this report ($15 billion spent annually by 2012)
and ask heads of state of other wealthy countries to recommit to their financial
promises on global health. In the interest of sovereignty and sustainability, the
President should also ask low- and middle-income countries to commit publicly
to providing additional resources by 2012 to finance their own health initia -
tives. Despite temporary setbacks to the growth of their gross domestic product,
the commitment by low- and middle-income countries to leverage additional
resources for health is particularly important given the emerging data on health
financing showing that with external assistance, the financing pie often does
not get bigger; countries merely shift expenditures out of government spending
onto donors, defeating the goal of increasing overall health spending to ensure
long-term sustainability.
Undertaking investments and activities in global health is not only a matter
of protecting Americans’ health from overseas threats or leveraging global know-
how to solve our shared disease burden. Today, U.S. leadership in global health
reflects the values of many Americans—generosity, compassion, optimism, and
a wish to share the fruits of U.S. technological advances with others around the
world who can benefit from them. Resources dedicated to improving health also
play a crucial role in the broader mission of U.S. foreign policy to reduce poverty,
build stronger economies, promote peace, and enhance the U.S. image in the
world today. Working with partners around the world and building on previous
commitments, the United States has the responsibility and chance to save and
improve the lives of millions; this is an opportunity that the committee hopes the
United States will seize.
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0 THE U.S. COMMITMENT TO GLOBAL HEALTH
Recommendation 7-3. In recognition of the partnership needed to achieve
global health, the President should call together world leaders for a summit
meeting at the UN General Assembly General Debate and the meeting of the
G20 in September 2009 to announce a commitment to the overall funding
levels recommended in this report ($15 billion spent annually by 2012) and
to emphasize the importance of the closely related issues of food and water
security. In the interest of sovereignty and sustainability, the President should
also ask low- and middle-income countries to commit publicly to providing
additional resources by 2012 to finance their own health initiatives.
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