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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 an >~ 60 C' CO a) 'I 50 ~a) ._ 40 _ , ,, }990 ~ i_ 1960 I. . ~ ~ .-,F2! _ About 1930 Ye,' ,5/~ About 1900 (; . . 30 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.

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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. _