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1 ~ ~ ~ ~ Summary Distinctions between domestic and international health problems are losing their usefulness and often are misleading. Health and disease are universal human concerns. The health of all people is profoundly affected by economic, social, behavioral, political, scientific, and technological factors, many of which are changing at an unprecedented pace both in the United States and abroad. Since the end of the Cold War, the world economy has become increasingly interconnected and globalized; increased competition, trade, and communication have brought benefits to people in virtually every country and have created a remarkable degree of mutual interdependence. Yet these changes have also brought risks that frequently cannot be addressed adequately within traditional national borders and have created problems that have spread among nations at an accelerating pace. The movement of 2 million people each day across national borders and the growth of international commerce are inevitably associated with transfers of health risks, some obvious examples being infectious diseases, contaminated foodstuffs, terrorism, and legal or banned toxic substances. Burdens of illness vary among countries according to their economic, social, and climatic conditions; these circumstances and disease patterns vary markedly among different populations within a country as well. Poverty and violence impose major burdens on health, burdens that are shared by people in developing and developed countries alike. Due to the ease of rapid international travel, emerging and drug-resistant infectious diseases in one country represent a threat to the health and economies of all countries. Changes in demography, particularly increased life expectancy, are dramatically altering patterns of disease epidemiology (see Table 1-1~. Health problems, issues, and concerns that transcend national boundaries, and may best be addressed by cooperative actions, represent what is encompassed, in this report, by the term "global health." The aging of populations also entails major increases in chronic cardiovascular and neuropsychiatric diseases in all populations around the world and expands the need for adequate care. With ever-growing public demands for health, the need to balance private and public-sector responsibilities in health, assess and improve the

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2 AMENCA 'S VITAL INTE~STIN GLOBAL HEALTH quality of health care, control costs, and establish rational and humane priorities for health resource allocations are problems with which the United States and every other government in the world are currently struggling. In this report, the term "global health" refers to health problems, issues, and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions. The report argues that the direct interests of the American people are best served when the United States acts decisively to promote health around the world. This country has a strong humanitarian tradition, and the American people have long supported efforts to improve the health of people around the world. Yet the United States now contributes a lower percentage of its gross domestic product (GDP) to foreign assistance than any of the other top 20 industrial nations. Foreign assistance, in any case, can be only one small component of America's contribution to improving global health. In a context of rapid worldwide change, other activities, such as research into major global health problems, are equally important. Many players contribute, including numerous governmental agencies, nongovernmental agencies, and international organizations, yet coherent and effective leadership is lacking. The report recommends that the United States exert greater leadership in global health by taking full advantage of its strength in science and technology. In so doing, the United States will fulfill its national responsibility to protect Americans' health, enhance U.S. economic interests, and project U.S. influence internationally. The direct interests of the American people are best served when the United States acts decisively to promote health around the world. PROTECTING OUR PEOPLE The U.S. government has a vital responsibility to protect all its citizens its resident population, its soldiers, and its travelers. It must be aware of threats posed by emerging infectious diseases and the potential for biological and chemical terrorism, and must be prepared to respond. Food safety and security, violence, poverty, and natural disasters can all threaten the health and well-being of Americans at home and abroad and represent common problems to be solved. Some of the medical and scientific knowledge needed to protect the health of our people is uniquely available or acquired most cost-effectively through the study of populations abroad. In addition, knowledge of differing national experiences with health care systems and financing, and the analysis of novel approaches to solving problems of health care delivery, access, cost-containment, and quality are critical for infonning health policies within the United States.

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SUMMARY TABLE 1-1 Projected Change in the Rank Order of Disease Burden for 15 Leading Causes, Worldwide 1990-2020 1990 Rank Disease or Injury Order 2020 Disease or Injury Lower respiratory infections Dia~Theal diseases Conditions arising during perinatal period Unipolar major depression Ischemic heart disease Cerebrovascular disease Tuberculosis Measles Road traffic accidents Congenital anomalies Malaria Chronic obstructive pulmonary disease Falls Iron-deficiency anemia Protein-energy malnutrition 2 4 s 6 7 Ischemic heart disease Unipolar major depression Road traffic accidents Cerebrovascular disease Chronic obstructive pulmonary disease Lower respiratory infections Tuberculosis 8 War 9 Diarrheal diseases 1 0 HIV 11 Conditions arising during perinatal period Violence 12 Congenital anomalies Self-inflicted injuries Cancers of trachea, lung, arid bronchus - NOTE: Disease burden is measured in disability-adjusted life years (DALYs), a measure that combines the impact on health of years lost due to premature death arid years lived with a disability. One DALY is equivalent to one lost year of healthy life. SOURCE: Murray and Lopez, 1996. ENHANCING OUR ECONOMY Clearly, it is desirable in itself that all populations achieve better health. But healthier populations abroad would also constitute more vibrant markets for U.S. goods and services. 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. U.S. businesses are adapting to meet the rapid globalization of the world economy, and demands for health and medical services are growing in the many countries with a rising standard of living. Political and regulatory barriers, however, deter the United States and other industrial countries from developing drugs, vaccines, and medical devices for these markets. These distortions need to be overcome if U.S. markets are to expand effectively overseas and compete in the area of health goods and services. Examples of current constraints include failure to

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4 AMERICA 'S VITAL INTERESTIN GLOBAL HEALTH respect and enforce intellectual property rights, pricing restrictions, patent infringements, and lack of harmonization in regulatory and enforcement standards. ADVANCING OUR INTERNATIONAL INTERESTS Governments are no longer the sole agents acting in He global health arena. Beyond national programs, the global health system now includes (1) the private or commercial sector, including multinational corporations; (2) the independent sector and nongovernmental organizations (NGOs), such as universities, private foundations, and relief and advocacy organizations; (3) the multilateral sector, including multinationally funded organizations such as the World Health Organization, the United Nations development agencies and regional health organizations, and the regional development banks and the World Bank; and (4) the bilateral sector, involving entities such as the U.S. Agency for International Development that are funded by single governments or regional partners. With this pluralism comes a strong need and opportunity- for active U.S. engagement in global health issues. Despite popular misconceptions about the size of U.S. foreign aid, the importance and value of improving the health of people around the world is supported by a majority of the American public (see Chapter 3), spanning broadly differing political, social, and cultural perceptions. U.S. commitment to democratic principles, our active foreign policy, and our continued support for human rights form the historical basis for U.S. leadership in this effort, and our scientific and economic capabilities provide the practical basis for concerted, productive engagement. The failure to engage in the fight to anticipate, prevent, and ameliorate global health problems would diminish America's stature in the realm of health and jeopardize our own health, economy, and national security. The failure to engage in the fight to anticipate, prevent, and ameliorate global health problems would diminish America's stature in the realm of health and jeopardize our own health, economy, and national security. LEADING FROM STRENGTH The scientific and technical expertise of the United States is unsurpassed in the health sector. The capabilities of science to enhance both life expectancy and the quality of life are unprecedented. As Figure 1-1 shows, over the decades ofthe past century, an income of any given amount has steadily bought more years of life. This suggests that, while income growth is important for enhancing people's chances of survival and health, the explosion of lalowledge about health and its determinants and the application of public health measures have also played a significant role in increasing life expectancy.

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SUMMARY 80 70 - a) >, 60 Lax 50 _ a_ 40 30 -.i :930 / About 1900 1990 0 5,000 10,000 15,000 20,000 25,000 Income per Capita (1991 international dollars) FIGURE 1-1 Knowledge pays: A given income buys a longer life in 1990 chart in 1910, thanks to research and public health measures. NOTE: International dollars are derived from national currencies, not by use of exchange rates, but by assessment of purchasing power. The effect is to raise the relative incomes of poorer countries, often substantially. SOURCE: World Bark, 1993. Reproduced with permission. The United States in partnership with other nations and international organizations should lead from its strengths in medical science and technology to play a central role in global health. The basic medical knowledge being accrued by the National Institutes of Health and the expertise in disease surveillance and prevention of Be U.S. Centers for Disease Control and Prevention are unique national resources that help to create and sustain the international public good. In addition, the U.S. pharmaceutical, medical device, and vaccine industries and academic sector are among the most innovative and productive in the world. The U.S. government should engage these institutions to provide leadership in global health in at least five areas, as follows. The United States should lead from its strengths in medical science and technology. Research and Development. The United States must continue to invest in global health research in order to maximize the many opportunities to understand, prevent, or control diseases that threaten the American people. The United States should also broaden the scope of its research and development activities to include health problems that impose the greatest burden of disease around the world, toward whose alleviation we can make important contributions. These problems include those infectious diseases that remain a major health burden in the

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6 AMERICA 'S VITAL INTERESTIN GLOBAL HEALTH developing world, particularly for children; noncommunicable diseases such as heart disease, cancer, and depression; substance abuse; injuries; and the effects of violence. Expanded research and development in these and related areas would provide means for disease prevention and control that could also be directly applied to improving the health of the U.S. population. Surveillance. The United States should contribute to the creation of a global surveillance network for emerging and resurgent infectious diseases and drug- resistant pathogens. Efforts should build on the 1996 Presidential Directive that instituted a new national public health policy on infectious disease prevention and control (see Chapter 4~. The successes of global surveillance networks for influenza and polio indicate that such networks are feasible and of critical importance to our nation's health. These same systems should be adapted to include early warning systems for lapses in the safety of the global food supply, for the possible release and spread of chemical and biologic agents, for environmental stresses, and for other global health threats. Education and Training. Long-term investments made by the United States in the education and training of physicians and other health care providers, scientists, and policymakers around the world have contributed substantially to health and biomedical science. America's commitment to health education and training both of its own scientists, researchers, clinicians, and public health professionals at home and abroad and of those from overseas studying in the United States must be maintained to ensure the development of a competent global health infrastructure. Well-trained health professionals and leaders with an understanding of global health issues working in the United States and abroad can improve the identification and monitoring of diseases threatening the U.S. and other populations and can enhance opportunities for shared learning about the best means for preventing, detecting, and treating disease. Global Partnerships. To deal adequately and efficiently with the complexity of changing health problems and policies, new partnerships will have to be forged between the U.S. government and multinational and multilateral public and private agencies. Creative, mutually beneficial partnerships can leverage expertise and increasingly scarce resources for global disease surveillance; prevention, control, and elimination of specific diseases; and health care policy analysis. Effective partnerships can also enhance research and development of new generations of vaccines, drugs, and diagnostics for preventing and treating major diseases in the United States and abroad. Coordination and Leadership. These opportunities for advancing U.S. leadership in global health should take advantage of America's strengths in science and technology to achieve our health goals in a constructive and humanitarian way. Many TJ.S. government agencies have statutory responsibilities for, and could make major contributions to, global health

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SUMMARY 7 activities particularly the Department of Health and Human Services, Department of State, U.S. Agency for International Development, Food and Drug Administration, and the Departments of Defense, Commerce, and Agriculture-and the U.S. role is clearly too complex to be fulfilled by any single agency. However, as noted previously, serious legal and organizational obstacles-fragmentation of governmental responsibilities, divisions of authority between domestic and international health activities, and lack of coordination among U.S. governmental agencies and with the nongovernmental sector impede progress toward global health. Enhanced coordination of the activities of the many U.S. federal agencies with responsibility for global health; clearer mandates, lines of authority, and responsibility among agencies; and stronger collaboration with the nongovernmental and corporate sectors would enable more cost-effective, productive policies and programs. In addition, there is a fundamental need for strong leadership to coordinate the missions of the agencies within the U.S. government and to integrate this work with the activities of NGOs and international organizations to ensure that the limited resources available to improve global health including the health of Americans are used more effectively and efficiently. The Board on International Health, therefore, recommends establishing an Interagency Task Force on Global Health within the U.S. government to anticipate and address global health needs and to maximize global health opportunities for the United States and the world in a coordinated and strategic fashion. Because solutions to global health problems increasingly demand new and expanded scientific and technical approaches, the board further recommends that additional resources and specific authority be allocated to the U.S. Department of Health and Human Services because of its unique scientific and technical expertise- exemplified by the National Institutes of Health, Centers for Disease Control and Prevention, and the Food and Drug Administration. This would enable the department to coordinate global health strategy and priority setting across the U.S. federal agencies represented in the Interagency Task Force and to act as lead agency in establishing liaison with academia, NGOs, industry, and international agencies. The globalization of health problems, needs, and risks represents an urgent international challenge and an extraordinary opportunity for the United States, given its scientific and technical expertise, to benefit the American people and global humanity. Our nation's vital interests are clearly best served by an active, sustained, and strengthened engagement in global health.

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