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Appendix
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Major U.S. Agencies and Organizations Engaged in
Global Health Activities
Efforts in global health have given rise to an enormously complex and varied
system. Global health is affected by biologic changes, climatologic changes,
economic status, national policies, population migration, warfare and violence,
environmental changes, industrial products and wastes, information systems, and
many other factors. Many organizations and agencies multinational, national, and
nongovernmental make significant contributions to improving global health. Here
we detail the responsibilities of some of the major agencies within the U.S.
government and prominent foundations and nongovernmental organizations
(NGOs) that have made contributions to global health. The list is not inclusive, but
represents data from presentations made before the Board on International Health
in November 1995.
U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT
The United States Agency for International Development (USAID) of the
Department of State is the principal agency of the U.S. government in the provision
of foreign assistance. For the past 40 years its agenda has largely been to use
foreign assistance as a bulwark against global communism. With the fall of
communism, USAID has undergone a period of introspection and restructuring in
an effort to develop a new mission relevant to the times. That mission is now
broadly defined as producing assistance to promote sustainable development and
global interdependence. Its budget in 1995 was $12 billion. The recently defined
major global strategies of USAID are to: (1) stabilize world population and protect
human health, (2) encourage economic growth, (3) protect the environment, (4)
build democracy, and (5) provide humanitarian aid for postcrisis transitions. Of its
$12 billion budget, USAID spends $1.15 billion in the health sector. Its largest
program is Family Planning and Reproductive Health for Women. After population
matters, child survival is the largest expenditure category, and the focus has been
on interventions aimed at the causes of greatest mortality: diarrhea, acute
respiratory infections, immunizable diseases, malaria, and critical micronutrient
deficiencies. Funding for the health programs at USAID, and for the agency in
general, has declined over the past several years. There has been a 20 percent
decline in finding for development assistance over the past 3 years, and the budget
for 1996 requires a further $1.5 billion reduction. Because numerous USAID
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APPENDIX
programs activities in Egypt, Israel, and Russia; disaster assistance; and Title I
and Title III food programs are congressionally mandated, and the funds
earmarked, the 15 percent overall budget cut translates into a 35~5 percent cut in
the remaining humanitarian programs. One of the consequences of this
retrenchment is that assistance for future development activities, particularly
programs that require substantial research in developing countries, has been
drastically reduced, and now represents only about 6 percent of the development
assistance program.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
The Department of Health and Human Services (DHHS) is a domestic agency
with a limited legislative authority in international health. It is specifically
authorized to spend funds abroad "to advance the status of the health sciences and
thereby the health of the American people." Its Office of International and Refugee
Health in the Office of the Secretary is largely responsible for representing the
United States in the governance of international organizations, including the World
Health Organization, the Pan American Health Organization, and the United
Nations Children's Fund. When asked to tackle global health problems, DHHS
must generally seek funding from USAID and other federal sources. The
international activities of DHHS are carried out primarily through the Centers for
Disease Control and Prevention (CDC), National Institutes of Health (NIH), and
Food and Drug Administration. In addition, the Agency for Health Care Policy and
Research, Indian Health Service, Human Health Resources and Services
Administration, and Substance Abuse and Mental Health Services Administration
are periodically engaged in international activities, particularly when their expertise
is requested. These activities are primarily supported by USAID. However, USAID
funding for international activities carried out by DHHS has declined from $33
million in fiscal year (FY) 1994 to $15 million in FY 1995, and $10 million in FY
1996.
Centers for Disease Control and Prevention
The CDC is the premier institution for epidemiology and disease surveillance
in the world. This designation was earned through such international activities as
the eradication of smallpox, early family planning work, HIV research in Africa
early in the study of the infection, and efforts to promote child survival in Africa.
The CDC, with the exception of the poliomyelitis eradication campaign, is not
formally authorized to carry out international health activities with funds
appropriated to DHHS, except to protect health in the United States. The principal
mission of the CDC is improvement of health through disease prevention. It
functions internationally to build a science base for public health and to develop
new analytical tools to strengthen the global health infrastructure for disease
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APPENDIX
57
control and prevention, to strengthen the programs of international organizations
and bilateral partners, and to develop and maintain networks among international
institutions, universities, and NGOs. In that capacity, its principal activities are in
polio eradication; surveillance of new and emerging infectious diseases;
tuberculosis control; and operational research in malaria, HIV/AIDS, and
micronutrient deficiencies, where the work can only be-or is most
appropriately-carried out overseas. Spending on global health activities in 1995
was only slightly in excess of $40 million, primarily for polio eradication. In the
1980s and early l990s, roughly half of global health program funding derived
internally from CDC's appropriated funds and half from USAID. With the decrease
in federal support for USAID, only about 25 percent of such funds came from
USAID in 1995 (approximately $11 million of the $40 million spent). Most of the
remainder came from the CDC budget and the NIH.
The National Institutes of Health
The NIH is the premier institution in the world for biomedical research. It
comprises 24 institutes, centers, and divisions. The institutes and centers fund
biomedical and behavioral research on the NIH campus and at universities and
other research institutions throughout the world. This work is supported by
competitive grants, contracts, and fellowships, as well as through international
agreements. The total budget of NIH in 1995 was $12.6 billion. Because the
outcome of NIH biomedical research is knowledge of human disease, and most of
the diseases studied for example, cardiovascular and infectious diseases, cancers,
and mental disorders-afflict people of all nations, the knowledge gained from
NIH biomedical research programs helps create and sustain the international public
good. Although it is difficult to define the efforts of NIH that can be explicitly
identified as international, NIH spends about $186 million on programs that are
identified as international health, about 1.7 percent of the 1995 budget.
Approximately half of those funds are spent on training and half on research
projects. NIH supports research scientists from many countries in work on the NIH
campus in Bethesda, Maryland, and in NIH-funded laboratories on campuses
across the United States. Research grants and contracts that support international
projects are awarded to foreign institutions and, more frequently, to U.S.
institutions to collaborate with their foreign counterparts. The National Cancer
Institute is the largest spender on international research at NIH ($39.4 million in
1995), followed by the National Institute for Allergy and Infectious Diseases
($20.4 million in 1995~. Most ofthe institutes spend between 1 and 2.5 percent of
their budgets on international programs. The Fogarty International Center is the
only component of DHHS with an authorization dedicated to international
programs. The majority of center's programs support international research
training. Among the leading recipient countries for NIH-supported biomedical
research grants, contracts, and cooperative agreements are Canada, Israel, Italy,
Japan, Sweden, and the United Kingdom, countries with very advanced programs
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APPENDIX
in biomedical science. A smaller amount of Finding is granted for research that
primarily involves countries in the developing world. NIH spends about $5 million
for cooperation with Africa; $10 million for work with Asia, exclusive of China;
$13 million for efforts with Eastern and Central Europe; and $10 million for
cooperation with Latin America and the Caribbean.
DEPARTMENT OF DEFENSE
A principal medical responsibility of the Department of Defense (DoD) is to
protect the health of American military personnel worldwide through preventive
medicine and medical countermeasures. For the past 40 years, a significant
portion of DoD's efforts have been directed toward medically countering the
threats of both tactical ground-based warfare and strategic nuclear warfare; more
recently, it has focused on the threats of biologic and chemical warfare and
terrorism, which have been given a high national priority. DoD spends
approximately $15 billion on its health activities, the largest portion to Ad the
health care operations for prevention, diagnosis, and treatment of over 8 million
beneficiaries. While the amount used to fund international health activities
directly is relatively small, it has a significant payoff through reduction in the
numbers of military personnel and their families who need diagnostic and
treatment services. Included is research on diseases that can affect the military
personnel abroad, including tropical and parasitic diseases such as malaria and
dengue fever, as well as HIV/AIDS. With technical expertise in U.S. facilities
and bases located around the world, DoD has often been helpful in training local
medical and health ministry personnel in epidemiology and research targeted to
improve public health in areas where the United States has a national interest.
DoD has, and is continuing to develop, critical information databases on
infectious diseases and climate changes that relate to vector-born diseases and
environmental hazards. DoD prefers to utilize its knowledge of health around the
world in an open and collaborative way with the other major agencies, including
the Department of State, USAID, and DHHS, and to make information on
infectious diseases and environmental hazards widely available. In a related
effort, DoD is developing a strengthened infectious disease surveillance and
response system to support its people worldwide and to coordinate its efforts
with the Department of State, USAID, and DHHS in developing an international
global surveillance and response system.
NONGOVERNMENTAL ORGANIZATIONS AND FOUNDATIONS
Foundations and NGOs and have historically played a pivotal role in the
international health activities of the United States. Data on 14 foundations were
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59
provided for this paper.* Among these, the Rockefeller Foundation was
responsible for the sharp reduction in hookworm in the United States and in many
countries of the world and for the development of the vaccine against yellow fever.
It is a major trainer of epidemiologists through its International Clinical
Epidemiology Network. The Edna McConnell Clark Foundation has been
responsible for a research program in helminthic diseases, schistosomiasis, and
trachoma, which primarily afflict people in developing countries. The MacArthur
Foundation supported a major biomedical program in parasitic diseases for a time,
and now cosponsors a program with WHO's Tropical Diseases Research Program
to genetically engineer mosquitoes to render them nonpermissive for transmission
of plasmodia, the parasite that causes malaria. Among the other NGOs active in
international health, Rotary International has made a major contribution to the
elimination of polio worldwide, the Kellogg Foundation supports health in Latin
America and southern Africa, the Kaiser Family Foundation operates only in South
Africa, and the Ford Foundation has made a major contribution to population
health. The Howard Hughes Medical Institute has launched an international
program in support of biomedical research and funds researchers in developing
countries and in Mexico, and shortly will extend this program to five countries in
Latin America. A new foundation is the Burroughs-Wellcome Fund in the United
States, which spends perhaps $1.2 million explicitly on international health
research by young investigators. The Kellogg Foundation is concerned largely with
research training. Other NGOs, such as CARE, Oxfam, Save the Children, Catholic
Relief, American Friends Service Committee, Medecins sans Frontieres, Merck
Foundation, American Medical Association, and American Red Cross, to name a
few, have important overseas missions in developing countries and are critical to
emergency relief, health care delivery, and infrastructure development in many
countries.
The past two decades have seen a diminution in global health funding by U.S.
foundations. While the total spending for international health activities of the 14
foundations listed above is only $119.3 million (an average of 8.2 percent of total
foundation spending), these organizations have great flexibility, which enables
them to initiate innovative programs and leverage larger support from federal
agencies, governments, and international organizations.
*The American Health Foundation, Burroughs-Wellcome Fund, Carnegie
Corporation, China Medical Board, Edna McConnell Clark Foundation, Ford
Foundation, Oilman Foundation, Howard Hughes Medical Institute, Kaiser Family
Foundation, W. K. Kellogg Foundation, MacArthur Foundation, Pew Charitable Trusts,
Rockefeller Foundation, and Thrasher Research Fund.
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Representative terms from entire chapter:
international health
