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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
