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6
· · · ·
Advancing Our International Interests:
Lea(ling from Strength
As this report has shown, all nations face converging health problems of
growing complexity. Effective global solutions to these problems are increasingly
likely to rely on scientific and technological knowledge, a resource that the United
States is particularly strongly positioned to offer. The United States has the
potential to lead global efforts for better health, but has yet to demonstrate its
willingness to do so. This chapter sets out the rationale for a scientific response to
global health challenges and the need for a strategic response involving the
international health organizations and suggests some ways in which the United
States might take the lead, with tremendous potential benefits for itself as well as
for the rest of the world.
INVESTMENT IN SCIENCE HAS PAID HIGH RETURNS
AND PROMISES MORE
The dramatic health gains of the twentieth cenhuy owe much to research and
demonstrate the value of investing in new knowledge and technologies. Figure 6-1
demonstrates that knowledge about health and its determinants has played a crucial
role in increasing life expectancy worldwide (World Bank, 19939.
The figure shows life expectancy in selected countries at 30-year intervals
over this century as a function of normalized per capita income. Two important
inferences can be derived from this graph. First, growing incomes improve
health: for the very poor, even very small increases in income or purchasing
power greatly increase life expectancy. Second, comparison of life expectancies
in 1900 and 1990 argues that the relationship between per capita income and life
expectancy shifted upward during each successive 30-year period, so that more
health was realized for any given income level. In other words, a given income
could "buy" more years of health in the later decades than in the earlier decades.
The reason for this improvement is that countries now have the knowledge and
capacity to promote health-through R&D and cost-effective application of
preventive public health measures and medical and surgical interventions that
were simply not available in earlier years.
Support for this observation comes from a comparison of income and life
expectancy in Chile and the United States in 1900 and 1992. These data indicate
that in 1992, the annual adjusted per capita income of Chile was $5,019,
40
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ADVANCING OUR INTERNATIONAL INTERESTS
41
essentially the same as that of the United States in 1900. Yet life expectancy at
birth in America in 1900 was only 49 years, compared with 74 years in Chile in
1992 (World Bank, 1993~. This finding suggests that knowledge about health
and its determinants, rather than income alone, contributed to the observed
increase of 25-35 years in healthy life expectancy, a return on investment that
few would doubt is extraordinarily favorable.
There is now the knowledge and a capacity to promote
health through R&D and cost-effective application of
preventive public health measures and medical and
surgical interventions-that were simply not available in
earlier years.
Opportunities to expand the health knowledge base are increasing rapidly as
a result of advances in biomedical science for example, our growing
understanding of the human genome, new insights into the brain and the
implications for understanding human behavior, expanding knowledge of genetic
correlates of human cancers, and pathogenesis of disease. The exploitation of
these new scientific discoveries by the biotechnology and pharmaceutical
industries offers the promise of new tools and techniques to prevent and treat
diseases.
-
Researchers who have participated in the NIH Visiting
Program have contributed to such advances in biological
research as the discovery of the Al DS virus, the
development of an HIV diagnostic kit, and the
development of a vaccine against bacterial meningitis in
infants.
U.S. LEADERSHIP IN SCIENCE AND TECHNOLOGY
The United States is currently the global leader in biomedical research.
Together with Canada, in 1993, it was responsible for 45 percent of the peer-
reviewed biomedical research published worldwide and accessible on
international databases and 41 percent of the total clinical research (UNESCO
19963. It is one of the leading producers of new drugs, vaccines, and medical
devices (OTA, 1996~. The intellectual basis of its leadership derives principally
from the longtime commitment of the U.S. public sector to support the
fundamental research of the NIH and other federal laboratories and to fund
academic and university research facilities. This same critical public-sector
investment-calculated to be $36-$40 billion for innovative research, or 0.6
percent of GDP, in 1994 provides the knowledge base for the innovation that
underlies almost all new advances in the pharmaceutical, vaccine, and medical
devices industries (NAS, 1995~.
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42
AMENCA 'S VITAL INTE~STIN GLOBAL HEALTH
80
70
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0 5,000 10,000 15,000 20,000 25,000
Income per Capita
(1991 international dollars)
FIGURE 6-1 Knowlege pays: A given income buys a longer life in 1990
than 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.
Another way in which the United States traditionally has led in science and
technology for health is by training researchers and health professionals. For
example, approximately 20 percent of all doctorates in the biological and health
sciences in the United States were awarded to non-U.S. citizens with temporary
visas in the years 1990-1995 (NRC, 1996~. U.S. support of collaborative
research with foreign scientists has also been vigorous. Since 1950,
approximately 16,000 foreign scientists have participated in the NIH Visiting
Program, which provides opportunities to train and conduct collaborative
research in NIH laboratories. Researchers supported by the Visiting Program
have contributed to such important advances in biological research as the
discovery of the AIDS virus, the subsequent development of an HIV diagnostic
kit, and the recent development of a vaccine to prevent bacterial meningitis in
infants. In fiscal year 1995, 2,193 foreign scientists were supported at NIH
through this program, at a total cost of $70.4 million (Dr. Philip Schambra,
National Institutes of Health, personal communication, 1996~.
THE CHANGING ROLE OF THE INTERNATIONAL HEALTH
ORGANIZATIONS: AN OPPORTUNITY FOR AMERICA
TO SHAPE TlIE FUTURE
America's world-leading position in science and technology has yet to be
tapped to its fullest potential for improving global health. The opportunities for
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ADVANCING OUR INTERNATIONAL INTERESTS
43
our nation to contribute more, while benefiting its own international interests at
the same time, may now be greater than ever. The global health institutions,
which include the UN system, the Bretton Woods institutions, and a range of
nongovernmental organizations, are currently in a state of flux, as discussed in
Chapter 2, and reforms are being actively discussed. This section points to ways
for the United States to help shape the future of these critically important
institutions.
The biggest overall change in the international health institutions in the past
decade has been the growth in influence, both financial and intellectual, of the
Bretton Woods institutions, while WHO's role appears to have been
diminishing. While the World Bank committed $2.5 billion in loans for health in
1996, WlIO's total budget for the same year was just $0.95 billion. The world
community is uncertain of how prudently and effectively WHO is balancing its
critical normative functions, such as the setting of international standards, with
its operational functions, such as providing emergency medical assistance.
A second major change is the increasingly important and diversified roles
that nongovernmental organizations have taken in health and social
development. They are particularly skilled at gaining access to local
communities and working with those communities in ways that governments
have found difficult. They have also played a direct and practical role in some
major initiatives for disease control: for example, Rotary International has
provided vaccines for the worldwide eradication of polio. Nevertheless, several
major foundations, including the Kaiser, Kellogg, MacArthur, Pew, and
Rockefeller Foundations, have reduced their support for, or are reevaluating,
their international health activities (Joseph Cook, Edna-McConnell Clark
Foundation, presentation to the IOM Board on International Health, November
1995~.
There is widespread recognition of the need for a more effective system of
global health leadership that can meet the serious challenges ahead. Changing
circumstances and the need for stronger and more inclusive global partnerships
offer America a voice and an opportunity in building policies that could greatly
affect world health, economic growth, and security. The countries of the
Organization for Economic Cooperation and Development (OECD) have stated
that health is a top priority on their foreign assistance agendas. Our nation thus
has an opportunity to work with the other industrial countries, using its particular
advantage in science and technology, to leverage intellectual and financial
capital on behalf of global health. Clearly, the challenges cannot and should not
be met by the U.S. alone, but the effective reform of the global health system and
an improved capacity to anticipate and prevent global health threats cannot be
accomplished without its active engagement.
There is currently no effective, single locus for U.S.
government activities directed toward fundamental and
developmental research and application in support of
global health.
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44
AMERICA 'S VITAL INTERESTIN GLOBAL HEALTH
However, the potential of United States to deliver solutions for health is
currently compromised, both at home and abroad. At home, an effective public
policy in health is impeded within our government by fragmentation of
responsibilities, division of authority between domestic and international health
activities, and lack of coordination among U.S. government agencies. There is
currently no effective, single locus of government activities directed toward
fundamental and developmental research and application in support of global
health. As a result, government-funded activities remain disarticulated, there is
no overall strategy in place, and there is inadequate communication and
coordination among those carrying out research and development in international
health in government, academia, and industry (see, for example, IOM, 1996c).
The health consequences of this fragmentation are profound.
Abroad, the influence of the United States is also weakened and its
effectiveness blunted, not only by the lack of involvement and leadership in
global health, but also by America's failure to meet its treaty obligations to the
major ION organizations. At the time of the drafting of this report (January
1997), the United States is $1.7 billion in arrears in its assessed contribution to
the UN and an estimated $145 million in arrears to WHO (assuming payment of
$87 million toward the 1996 arrears of $107 million), a major share of the total
arrears to both agencies. In contrast, all of the other major industrial nations
make full and timely payment of their obligations to these organizations. It is
difficult for America to have its views respectfully considered by the
international community or to exert leadership on the global stage when it has
unilaterally defaulted on its commitments to the major international institutions.
U.S. LEADERSHIP TO STRENGTHEN HEALTH AND
HEALTH INSTITUTIONS
The board believes that the United States should build on its strengths and
seize the unprecedented opportunities to work with its international partners to
improve health worldwide. Some practical steps for doing so are suggested
below.
Expanded Investment in Biomedical R&D. The United States must
engage in biomedical research that will address major global health problems,
such as the growing burdens of mental illness and cardiovascular disease and the
continuing threat of infectious disease, through expanded partnerships and cost-
sharing with other governments and international donors. Expanded investment
in biomedical R&D by both the public and the private sectors is essential for the
maintenance of U.S. leadership in health.
U.S. Support for Education and Training in the Health Sciences. Given
the rapid advances in technology and the growing complexity of health threats,
the board believes that education and training are important means of exerting
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ADVANCING OUR INTERNATIONAL INTERESTS
45
global leadership in health at two levels. First, there is a need to prepare U.S.
scientists and health professionals for the global challenges of the twenty-first
century, which range from sometimes unfamiliar infectious diseases to the
emerging epidemics of violence, injury, and mental health problems and other
noncommunicable diseases. Sensitizing U.S. scientists and health professionals
to the health needs and goals of other countries will help promote linkages that
are mutually productive, cost-effective, and sustainable.
Second, there is an urgent need to develop sustainable scientific and medical
infrastructures in developing countries. America should continue to educate and
train scientists and health professionals from developing countries, since most
will return to their home countries, provide leadership and training, and
contribute to the improvement of their own people's health.
It is critical that America continue to educate and train
scientists and health professionals from other countries.
-
Training health professionals and researchers from the developing world in
the United States would have other benefits as well. Health professionals who
would return home with knowledge of state-of-the-science methods and medical
technologies would be in a position to take scientific advances from the United
States and make them relevant to their own countries. This would provide
opportunities for U.S. medical products and technologies to enter the overseas
markets. Again, it is clear that improving global health makes sound economic,
as well as humanitarian, sense.
Effective International Cooperation. To be able to exert effective
leadership, the United States must settle its past obligations to WHO and the
UN, and perhaps renegotiate its future level of commitment with other member
nations in the interest of sustaining both its international credibility and its
influence in shaping global health policies. The board welcomes the recent
report that the Clinton Administration will ask Congress for $1 billion to
discharge most of the U.S. debt to the UN as part of a substantial overall
spending increase for international affairs (Lippman, 1997~. The board strongly
encourages bipartisan support for this measure. America should also work with
WHO and other partners to ensure that vital global normative fimctions for
example, in data collection, research, and the provision of technical advice to
countries are maintained and strengthened in the context of available budgetary
resources.
More broadly, the United States should seek to develop strategic
partnerships both at home and abroad with multinational, multilateral, and
public and private-sector agencies involved in global health. It should seek to
leverage its scientific expertise and funding in support of programs and policies
for global disease prevention and control, including activities in carrying out
disease surveillance; establishing priorities for health R&D; reexamining and
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46
AMERICA 'S VITAL INTERESTIN GLOBAL HEALTH
correcting disincentives to fuller participation in health by industry; and
analyzing health care policy.
Creating a High-Level Focus for Health Leadership Within the U.S.
Government. The United States should create a mechanism to bring together the
authority and responsibility for coordinating activities of the many federal
agencies contributing to global health activities, foster collaboration among
them, and communicate policies and plans with other vested constituents,
including the public. More effective mechanisms are required for both public-
private collaborations within the country and for collaborations with
international agencies and institutions to encourage private-sector development
of pharmaceuticals, vaccines, and medical devices of global importance and to
ensure that these will be accessible worldwide. Given the changing global health
threats and opportunities described in Chapters 2, 4, and 5, there is a need for
systematic acquisition of data and information on each area of concern, as well
as for the capacity to link this information to policy.
We cannot overemphasize that global health problems whether they are in
the areas of emerging infections or the coming epidemics of mental health
problems and other chronic, noncommunicable diseases increasingly rely for
their solution on a scientific and technical foundation. The basic scientific
knowledge generated by the National Institutes of Health, the expertise of the
Centers for Disease Control and Prevention in disease surveillance, and the
knowledge of the Food and Drug Administration and Department of Agriculture
in product safety are unique national resources and represent an international
public good. The U.S. academic and private-sector pharmaceutical, medical
devices, and vaccine industries also have much to contribute. The United States
has the critical elements for a rational, enlightened, and effective foreign policy
in health, and the safety of America and its future economic strength depend on
its realization. The U.S. government's strongest scientific institutions should,
therefore, be charged with greater responsibility and provided with appropriate
support to exert the leadership needed in global health.
Our government's strongest scientific institutions should be
charged with greater responsibility and provided with appropriate
support to exert the leadership needed in global health.
Toward a Coherent Strategy for U.S. Involvement in Global Health. It
is important that the United States be guided by a coherent strategy as it works to
solve the global health issues that are of crucial importance to the people of
America and the world. This report has taken the view that global health problems
affect all peoples in all countries and transcend national boundaries, levels of
development, and political systems.
Multiple U.S. government agencies have statutory responsibilities for global
health activities (see Table 6-1 and the Appendix). The U.S. role in global health is
clearly too complex to be fulfilled by any single agency each has something
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ADVANCING OURINTERNATIONALINTERESTS
47
important to contribute. The immediate challenge is to coordinate these multiple
roles and create a coherent, effective U.S. approach to global health that serves the
current and anticipated needs of this country, contributes to the improvement of
health here and abroad, and permits America to serve the world community from a
position of strength and leadership.
The board, therefore, recommends establishing an Interagency Task Force
on Global Health within the U.S. government to anticipate and address global
health needs and to take advantage of global health opportunities in a coordinated,
strategic fashion. Because solutions to global health problems will increasingly
demand new and expanded scientific and technical approaches, the board
recommends further that additional resources and specific authority be allocated to
the U.S. Department of Health and Human Services because its unique scientific
and technical expertise exemplified by NIH, Centers for Disease Prevention and
Control, and Food and Drug Administration would enable it to coordinate global
health strategy and the setting of priorities across the agencies represented in the
task force and to act as the lead agency in establishing liaison with academia,
NGOs, industry, and international agencies. The globalization of health problems,
needs, and risks is a major international challenge and an extraordinary
opportunity for the United States to work with other countries in a way that could
significantly benefit the people of America and the world. Our nation's vital
interests are clearly best served by sustained and strengthened U.S. engagement in
global health.
OCR for page 48
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OCR for page 50
so
AMERICA 'S VITAL INTE=STIN GLOBAL HEALTH
SUMMARY OF RECOMMENDATIONS FOR ADVANCING OUR
INTERNATIONAL INTERESTS
The U S. government should:
. increase its investment in R&D in biomedical science related to major
global health problems through expanded partnerships and cost-sharing with other
Governments and international donors
· continue federal support for the education and training of health
researchers and practitioners from other countries as an international public good
toward health leadership that benefits both our own nation and others
. pay its dues to the UN system in order to regain influence in the urgently
needed reform of the system
. form global partnerships for health with government, the private sector,
and others
. form an Interagency Task Force on Global Health within the government
to anticipate and address global health needs and to take advantage of
opportunities in a coordinated and strategic fashion
. allocate resources and specific authority to the U.S. Department of
Health and Human Services because of its unique scientific and technical
expertise, gained through institutions such as the National Institutes of Health
and the Centers for Disease Control and Prevention to enable it to coordinate
global health strategies and the setting of priorities across the agencies
represented in the task force and to act as the lead agency in establishing
liaison with academia, NGOs, industry, and the international agencies.
_
Representative terms from entire chapter:
international health
