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AMERICA'S VITAL INTEREST IN GLOBAL HEALTH Protecting Our People, Enhancing Our Economy, and Advancing Our International Interests Board on International Health INSTITUTE OF MEDICINE IOM glib NATIONAL ACADEMY PRESS Washington, D.C. 1997

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NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. This study was supported in part by the Carnegie Corporation of New York, the National Institute for Environmental Health Sciences, Rockefeller Foundation, and the Institute of Medicine of the National Academy of Sciences. The views presented in this report are those of the Institute of Medicine Board on International Health and are not necessarily those of the funding organizations. Additional copies of this report are available for sale from the National Academy Press, Box 285, 2101 Constitution Avenue, N.W., Washington, D.C. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP's on-line bookstore at http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at http://www2.nas.edu/iom. Copyright 1997 by the National Academy of Sciences. All rights reserved. International Standard Book No. 0-309-05834-1 Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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BOARD ON INTERNATIONAL HEALTH BARRY R. BLOOM* (Cochair), Howard Hughes Medical Institute, Albert Einstein College of Medicine HARVEY V. FINEBERG* (Cochair), Harvard School of Public Health JACQUELYN CAMPBELL, The Johns Hopkins University School of Nursing RICHARD G. A. FEACHEM, The World Bank, Washington, D.C. JULIO FRENK,* Fundacion Mexicana pare la Salud, San Jeronimo Lice, Mexico DEAN JAMISON,* University of California, Los Angeles EILEEN T. KENNEDY, Center for Nutrition Policy and Promotion, Washing- ton, D.C. ARTHUR KLEINMAN,* Harvard Medical School WILLIAM E. PAUL,* National Institute of Allergy and Infectious Diseases and Office of AIDS Research, National Institutes of Health, Bethesda, Md. ALLAN ROSENFIELD,* Columbia University School of Public Health PATRICIA L. ROSENFIELD, The Carnegie Corporation of New York, New York City THOMAS J. RYAN, Boston University School of Medicine and Boston University Medical Center SUSAN C. M. SCRIMSHAW,* University of Illinois School of Public Health JUNE E. OSBORN (~Institute of Medicine Liaison),* Josiah Macy, Jr., Foun- dation, New York City JOHN H. BRYANT* (Ex Officio), Moscow, Vermont WILLIAM H. FOEGE* (Ex Officio), Carter Center, Emory University DAVID P. RALL* (Institute of Medicine Foreign Secretary), Director Emeritus, National Institute of Environmental Health Sciences, Washing- ton, D.C. Stay CHRISTOPHER P. HOWSON, Director, Board on International Health KIMBERLY A. BREWER, Research Assistant STEPHANIE Y. SMITH, Administrative/Research Assistant MONA BRINEGAR, Financial Associate (from 3/95 to 9/96) SHARON GALLOWAY, Financial Associate (from 9/96 to present) ~ Member, Institute of Medicine. . . .

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~ ~ ~ ~ Preface The health of individuals is shaped by many factors: biological, economic, social, educational, and environmental. The health of populations is still more complex, and the forces that affect it are no less varied. The burdens of premature death and disability do not fall equally across populations within countries, nor between countries. The major factor that reduces years of healthy life in the world is poverty and its consequences, including poor nutrition and sanitation: many people are sick because they are poor, and poor because they are sick. Yet, as a recent World Health Organization report (WHO, 1996a) points out, "half of all gains in human life expectancy of the past several thousand years have occulted In this century." Some of this improvement can be attributed to gains in income and education, others to extraordinary advances In medical knowledge and public health. Social policies are as relevant to health as health policies. As populations throughout the world live longer, there is an increasing trend toward global commonality of health concerns. This trend mirrors a growing demand for health and access to new interventions to prevent, diagnose, and treat disease. The knowledge base required to meet these needs is not only of a technical kind, deriving Dom experiments of researchers, but must also draw Tom the experiences of governments in allocating resources effectively and efficiently to improve human health. This report Tom the Board on International Health of the Institute of Medicine focuses on the interest of the United States in these global health transitions. The report argues that America has a vital and direct stake in the health of people around the globe, and that this interest derives Tom both America's long and enduring tradition of humanitarian concern and compelling reasons of enlightened self-interest. Our considered involvement can serve to protect our citizens, enhance our economy, and advance U.S. interests abroad.* *There is effective historical precedence for such U.S. engagement. In 1881, Washington, D.C., hosted the Fifth International Sanitary Conference after a major outbreak of yellow fever spread through maritime contacts in the Mississippi River Valley in 1878, causing an estimated 100,000 cases and 20,000 deaths in the United States. A regional sanitary conference in the Western Hemisphere, which later became the Pan American Health Organization, began in 1902 to organize an effective united front against diseases that were engulfing the region (PAHO, 1992, p. 19~. v

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V1 PREFACE For the United States to engage successfully in global health, coordination among the multiple U.S. agencies with statutory responsibilities in the area will be needed, as well as the formation of partnerships with the U.S. industrial and academic sectors and nongovernmental organizations, other nations, and international organizations. This report stresses the areas of U.S. global health engagement that are most likely to benefit the health of the U.S. population and recommends changes in policy and implementation that can enhance the health of Americans and other peoples of the world, provide economic benefit, and advance U.S. global leadership. America must engage in the fight for global health from its strongest basis: its preeminence in science and technology. U.S. expertise in science and technology and its strength in biomedical, clinical, and health services research and development are the engine that has helped power many of the advances in human health and well-being of this century. Our leading research institutions, the National Institutes of Health and universities-together with the Centers for Disease Control and Prevention, private-sector health industries, and many U.S. foundations and nongovernmental organizations-have been major contributors to this process. The U.S. Agency for International Development, in turn, has been the principal supportive institution for making many of those advances accessible to developing countries. The United States has long experience in bringing a diversity of perspectives both public and private-together with disciplined science to solve complex and critical problems. Without active U.S. engagement and coordination, in concert with the complementary efforts of other nations, the struggle to ensure health around the globe threatens to fragment or falter, with the likely outcome that our own national health, economic viability, and security will suffer. This report outlines the compelling case for America's active engagement in global health and offers recommendations on how this may best be achieved. This report contains six chapters and one appendix. Chapter 1 summarizes the reasons for active U.S. engagement in global health. Chapter 2 describes how health and disease increasingly transcend national borders and covers the changing nature of global health governance. Chapter 3 describes common misperceptions of Americans about U.S. investment in foreign aid, while confirming their underlying support for active, rational engagement. Chapters 4, 5, and 6 offer the rationale for U.S. engagement in the fight against global disease threats. The Appendix describes major U.S. departments, agencies, and other organizations currently engaged in global health activities.

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~ ~ ~ ~ Acknowledgments The board is grateful to the many individuals who contributed to this project. In particular, the board thanks the following presenters at a workshop in November 1995 who provided information central to this report: Jo Ivey Boufford, Department of Health and Human Services; Gary Christopherson, Department of Defense; Joseph Cook, The Edna McConnell Clark Foundation; Nils Daulaire, U.S. Agency for International Development; Joe Davis, Centers for Disease Control and Prevention; Catherine Michaud, Harvard Center for Population and Development Studies; and Harold Varmus, National Institutes of Health. The board also extends its gratitude to the following workshop participants: Ruth Berkelman, Centers for Disease Control and Prevention; Seth Berkley, The Rockefeller Foundation; John Boright, National Academy of Sciences; A. David Brandling-Bennett, Pan American Health Organization; Constance Carrino, U.S. Agency for International Development; Daniel Colley, Centers for Disease Control and Prevention; Terri Damstra, National Institute of Environmental Health Sciences; Jonathan Davis, Department of State; Cathleen Enright, Department of State; Saskia Estupinan-Day, Pan American Health Organization; Arlene Fonaroff, National Institutes of Health; Phyllis Freeman, University of Massachusetts; Michael Greene, National Academy of Sciences; John Haaga, National Academy of Sciences; Andrea Johnson, Carnegie Corporation of New York; Deborah Keimig, Armed Forces Medical Intelligence Center; Stuart Nightingale, Food and Drug Administration; David Cot, U.S. Agency for International Development; Seymour Perry, Medical Technology and Practice Patterns Institute, Inc.; Linda Reck, National Institutes of Health; and Philip Schambra, National Institutes of Health. The board also thanks Octavio Gomez-Dantes, Mexican Commission for Health Research, and Michael J. McGinnis for their contributions to Chapter 2, and Jo Ivey Boufford, Department of Health and Human Services; Nelle Temple Brown, World Health Organization; Martin Cetron, Centers for Disease Control and Prevention; Cindy Dudzinski, Congressional Budget Office; Robert Eiss, National Institutes of Health; Grace Emori, Centers for Disease Control and Prevention; Marilyn Field, Institute of Medicine; David Goodrich, Parsons Process Group, Inc.; Anne Harrington, Department of State; Polly Harrison, Institute of Medicine; Peter Henderson, National Research Council; Prabhat Jha, The World Bank; Patrick Kachur, Centers for Disease Control and Prevention; Gloria Kelly, Centers for Disease Control and Prevention; Mike McGeary, consultant; Stephen . . V11

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. . . V111 A CKNO WLEDGMENTS Ostroff, Centers for Disease Control and Prevention; Ellen K. Silbergeld, University of Maryland; George Silver (retired), Yale University School of Medicine; Michael Snyder, National Institutes of Health; Linda Staheli, National Institutes of Health; Robert Tauxe, Centers for Disease Control and Prevention; Fred Tenover, Centers for Disease Control and Prevention; Linda Vogel, Department of Health and Human Services; Susan Waisner, Centers for Disease Control and Prevention; Roy Widdus, World Health Organization; and Derek Yach, World Health Organization, for their help in preparing this report. The board expresses its appreciation to the IOM staff who facilitated its work: Christopher Howson, director; Kimberly Brewer, research assistant; Stephanie Smith, administrative/research assistant; Delores Sutton, project assistant; Jamaine Tinker, financial associate; Mona Brinegar, financial associate; Sharon Galloway, financial associate; Michael Edington, managing editor; Claudia Carl, administrative associate for report review; and Christina Pham, intem. The board gratefully acknowledges the special contribution to this report by the editor, Caroline McEuen. The board is especially indebted to Phyllida Brown for her substantive revision of the report. The board also thanks Kenneth Shine, IOM president, and Karen Hein, IOM executive officer, for their encouragement and support. This project was funded by the Carnegie Corporation of New York, the National Institute for Environmental Health Sciences, the Rockefeller Foundation, and the Institute of Medicine of the National Academy of Sciences. The board is deeply appreciative of their support.

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Contents 1 Summary Protecting Our People, 2 Enhancing Our Economy, 3 Advancing Our International Interests, 4 Leading from Strength, 4 PART I America and Global Health Change The Globalization of Health: Common Problems, Common Needs 11 Economic Globalization and the Transfer of Risks, 11 Demographic Change and the Epidemiologic Transition, 13 Poverty and Health, 15 Rising Costs of Health Care and the Need for Health System Reform, 16 Changes in International Health Agencies, 17 Attitudes Toward U.S. Foreign Assistance: Perception and Reality 19 Survey Findings, 19 PART II Doing Well by Doing Good: The Rationale for Increased U.S. Involvement 4 Protecting Our People Threats to the American People, 25 Infectious Diseases, 25 Biologic and Chemical Weapons, 27 Spiraling Health Care Costs, 28 Violence, 29 Opportunities to Protect Our People, 29 Investing in Surveillance and Communications Networks to Save Lives and Money, 29 Sharing Information for Better Health Services, 31 1X 25

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x CONTENTS Obtaining Value for Money in Acquiring Knowledge Mom International Research and Clinical Trials, 32 Preventing Violence, 32 Summary of Recommendations for Protecting Our People, 33 Enhancing Our Economy A Market with Unfulfilled Potential, 35 Lack of Economic Incentives, 36 Options for Increasing Investment in Products for Developing Countries, 37 Multitiered Pricing, 37 Intellectual Property Rights and the Problem of Piracy, 38 Public-Private Cooperation, 39 Harmonization of Regulatory Standards, 39 Summary of Recommendations for Enhancing Our Economy, 39 35 6 Advancing Our International Interests: Leading from Strength 40 Investment in Science Has Paid High Returns and Promises More, 40 U.S. Leadership in Science and Technology, 41 The Changing Role of the International Health Organizations: An Opportunity for America to Shape the Future, 42 U.S. Leadership to Strengthen Health and Health Institutions, 44 Expanded Investment in Biomedical R&D, 44 U.S. Support for Education and Training in the Health Sciences, 44 Effective International Cooperation, 45 Creating a High-Level Focus for Health Leadership Within the U.S. Government, 46 Toward a Coherent Strategy for U.S. Involvement in Global Health, 46 Summary of Recommendations for Advancing Our International Interests, 50 References Appendix Major U.S. Agencies and Organizations Engaged in Global Health Activities Abbreviations and Definitions 51 55 61