Global Health
and the Future Role of
the United States
Committee on Global Health and the Future of the United States
Board on Global Health
Health and Medicine Division
A Consensus Study Report of
THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This activity was supported by BD (Becton, Dickinson and Company), Medtronic, Grant No. CCO-160111-015127 from the Merck Foundation, the National Institutes of Health, Grant No. 2016 AVH 305 from The Rockefeller Foundation, Grant No. APC-6M-0002 from the U.S. Agency for International Development, Grant No. HHSP233201400020B/HHSP23337049 from the U.S. Centers for Disease Control and Prevention, Grant No. HHSP233201400020B/HHSP23337048 from the U.S. Food and Drug Administration, and The U.S. President’s Emergency Plan for AIDS Relief. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-45763-7
International Standard Book Number-10: 0-309-45763-7
Digital Object Identifier: https://doi.org/10.17226/24737
Library of Congress Control Number: 2017950553
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2017. Global health and the future role of the United States. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24737.
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COMMITTEE ON GLOBAL HEALTH AND THE FUTURE OF THE UNITED STATES
JENDAYI E. FRAZER (Co-Chair), Council on Foreign Relations, Washington, DC
VALENTIN FUSTER (Co-Chair), Mount Sinai Medical Center, New York, NY
GISELA ABBAM, General Electric Healthcare, London, United Kingdom
AMIE BATSON, PATH, Seattle, WA
FREDERICK M. BURKLE, JR., Harvard University, Kailua, HI
LYNDA CHIN, Institute for Health Transformation, University of Texas System
STEPHANIE L. FERGUSON, Lynchburg College and Stanford University, Amherst, VA
LIA HASKIN FERNALD, School of Public Health, University of California, Berkeley
PETER LAMPTEY, FHI 360, Accra, Ghana
RAMANAN LAXMINARAYAN, Centers for Disease, Dynamics, and Policy, New Delhi, India
MICHAEL H. MERSON, Duke Global Health Institute, Duke University, Durham, NC
VASANT NARASIMHAN, Novartis, Basel, Switzerland
MICHAEL T. OSTERHOLM, Center for Infectious Disease Research and Policy, University of Minnesota, Minneapolis
JUAN CARLOS PUYANA, University of Pittsburgh, PA
Study Staff
MEGAN SNAIR, Study Director
CECILIA MUNDACA-SHAH, Senior Program Officer
EESHAN KHANDEKAR, Research Associate
ELAINE HYNDS, Senior Program Assistant
PATRICK KELLEY, Director, Board on Global Health (until August 2016)
JULIE PAVLIN, Director, Board on Global Health (from November 2016)
Consultants
RONA BRIERE, Arlington, VA
ANNA NICHOLSON, Chapel Hill, NC
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Reviewers
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
Cynthia Beall, Case Western Reserve University
Paul Biondich, Regenstrief Institute
Charles Carpenter, Brown University
Barbara J. Culliton, The Culliton Group
Sue Curry, University of Iowa
Christopher Elias, Bill & Melinda Gates Foundation
Amanda Glassman, Center for Global Development
Clarion Johnson, Private Consultant
Jennifer Kates, Kaiser Family Foundation
Rebecca Katz, Georgetown University
Ilona Kickbusch, Graduate Institute Geneva
J. Stephen Morrison, Center for Strategic and International Studies
Loyce Pace, Global Health Council
Gerald W. Parker, Texas A&M AgriLife Research
Jeffrey Sturchio, Rabin Martin
Charles D. Wells, Sanofi
Gavin Yamey, Duke Global Health Institute
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by David Challoner, University of Florida, and Martin Philbert, University of Michigan. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
Preface
The U.S. government has long been at the forefront of shaping the international policy agenda and establishing institutions like The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, which make the world safer for America’s citizens by improving health and producing more stable societies in other countries, and more humane for millions of people facing heavy disease burdens. The United States has worked with other nations to create Gavi, the Vaccine Alliance, which played an important role in reducing mortality from vaccine-preventable disease (a major contributor to the Millennial Development Goals). Working with philanthropies, the United States has also supported the creation of the Global Polio Eradication Initiative, which has brought the world to the brink of declaring permanent victory over the polio virus. Furthermore, U.S. industry, foundations, and nongovernmental organizations have been on the frontlines in responding to global health emergencies and advancing the research and innovation that has helped curtail the world’s most dangerous pathogens.
Collaborative international efforts, especially strengthening the capacity of national health systems, are essential to prevent and prepare for an array of threats, from infectious disease pandemics to the silent killers of chronic noncommunicable diseases. The committee grappled with striking the right balance in fulfilling its mandate to examine the United States’ role on the future of global health while reflecting that the United States—as a member of the global community of states—has common challenges and lessons to learn from others to influence our future.
The committee prioritized global health challenges with the potential for catastrophic loss of life and impact on society and the economy—such as pandemics, persistent communicable diseases (HIV/AIDS, tuberculosis, and malaria), and noncommunicable diseases (cardiovascular health and select cancers)—as well as areas where significant U.S. investment has created gains that should be consolidated and sustained—such as promoting women’s and children’s health, building capacity, and global health innovation and implementation. The Committee on Global Health and the Future of the United States concluded that the U.S. government should maintain its leadership position in global health as matter of urgent national interest and as a global public benefit that enhances America’s international standing.
While additional investment is required, more money alone is not the answer. The report offers 14 significant recommendations to strengthen U.S global health programs, recognizing that many other areas are worthy of attention. In order to maximize work toward the prioritized global health challenges (see Chapters 3 to 6) the committee focused on how to better leverage U.S. resources by doing business differently, especially through the use of improved research and development processes and digital health (see Chapter 7), smart financing mechanisms to maximize returns on U.S. investments (see Chapter 8) and demonstrating leadership within the global health architecture and governance (see Chapter 9).
We would like to thank the members of the committee for their devotion of time and energy to this project. It was a privilege and a pleasure to work with our fellow committee members, to learn from them in their respective areas of expertise, and to engage with them in hearty discourse about the issues at hand. Many other experts also gave generously of their time and expertise to contribute to our information gathering, and their contributions are deeply appreciated. Specific participants in this process are listed in the acknowledgments on the following page. We would like to add a special note of gratitude to the National Academies of Sciences, Engineering, and Medicine and especially to Megan Snair, Cecilia Mundaca-Shah, Eeshan Khandekar, Elaine Hynds, and other members of the project staff for their laudable efforts shepherding and supporting the committee through every aspect of the process.
Jendayi Frazer and Valentin Fuster, Co-Chairs
Committee on Global Health and the Future of the United States
Acknowledgments
This Consensus Study Report would not have been possible without the invaluable contributions from many experts and stakeholders dedicated to global health. The committee would like to thank all of the speakers (whose full names and affiliations are found in Appendix C) and participants who played a role in the public workshops, as well as the many others who provided valued insight and responded to rapid requests for information to accommodate our short and demanding timeline, many of whom are listed below:
Soji Adeyi, World Bank
Daniel Bausch, Tulane University School of Public Health and Tropical Medicine
Deborah Birx, The U.S. President’s Emergency Plan for AIDS Relief
Robert E. Black, Johns Hopkins Bloomberg School of Public Health
Matthew Brown, National Institutes of Health
Robert Einterz, AMPATH Consortium
Amanda Glassman, Center for Global Development
David Hohman, Office of Global Affairs
Jennifer Kates, Kaiser Family Foundation
Kamiar Khajavi, U.S. Agency for International Development
Ron Klain, Revolution LLC
Joseph Larsen, Biomedical Advanced Research and Development Authority
Ruth Levine, Hewlett Foundation
Timothy K. Mackey, University of California, San Diego, School of Medicine
Thomas Mampilly, U.S. Centers for Disease Control and Prevention
Michael Miller, Kyle House Group
Troy Moon, Vanderbilt University School of Medicine
Thomas Novotny, U.S. Department of Health and Human Services
Dykki Settle, PATH
Maria “Bea” Spadacini, U.S. Agency for International Development
The committee would also like to thank the sponsors for their generous financial support: the Merck Foundation, the National Institutes of Health, The Rockefeller Foundation, the U.S. Agency for International Development, the U.S. Centers for Disease Control and Prevention, the U.S. Food and Drug Administration, and The U.S. President’s Emergency Plan for AIDS Relief, with additional support from BD (Becton, Dickinson and Company) and Medtronic. Finally, deep appreciation goes to the Lauren Shern and Porter Coggeshell on the Report Review Committee; Daniel Bearss and Ellen Kimmel at the Research Center of the National Academies of Sciences, Engineering, and Medicine for their assistance in fact checking the report; Patrick Kelley, for envisioning this consensus study; and Victor Dzau, for his assistance and support of this project.
Contents
Historical Context for This Study
Study Charge, Approach, and Scope
2 INVESTING IN GLOBAL HEALTH FOR AMERICA
Why Global Health Funding Protects U.S. Interests
Existing U.S. Global Health Spending
A Changing World: Effects of Globalization
Looking to the Future: How to Better Invest U.S. Funds
PART 1:
SECURING AGAINST GLOBAL THREATS
The Global Health Security Imperative
A New Approach to Meeting the Challenges of Global Health Security
4 ADDRESSING CONTINUOUS THREATS: HIV/AIDS, TUBERCULOSIS, AND MALARIA
Public Health Complacency and Resistance: A Rationale for Continued Investment
PART 2:
ENHANCING PRODUCTIVITY AND ECONOMIC GROWTH
5 INVESTING IN WOMEN’S AND CHILDREN’S HEALTH
Global Development Agenda Shift: Women and Children
Current State of Women’s and Children’s Health
Current Efforts to Promote Women’s and Children’s Health
Survive: Continuing to Decrease Mortality Rates
Thrive: Meeting Development Potential and Building Country Futures
6 PROMOTING CARDIOVASCULAR HEALTH AND PREVENTING CANCER
The Rising Economic Burden of Noncommunicable Diseases
The Rising Epidemiological Burden of Noncommunicable Diseases
Motivation for U.S. Involvement
Cost-Effective and High-Impact Global Interventions
Transforming Health Systems for Noncommunicable Diseases
Enabling Innovation: Accelerating the Development of Medical Products
Enabling Innovation: Digital Health
Key Approaches for Global Health Investment
Changes to Global Health Financing Methods
Priorities for U.S. Global Health Programs
Global Health Architecture and Governance
U.S. Approach Toward Global Health Diplomacy
A Place for Health in Foreign Service
10 SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS
Changing the Way the United States Engages
Boxes, Figures, and Tables
BOXES
1-2 Language Used to Solicit Input on U.S. Global Health Policies and Programs
3-1 Case Study: H7N9 Outbreak in China
3-2 Case Study: A “Nightmare” Bacterium in Nevada
3-3 Case Studies of Infectious Disease Resurgence
3-4 Examples of Stockpile Shortages and Supply Chain Breakdowns
4-1 The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Achievements to Date
4-2 The Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe Women (DREAMS) Initiative
5-1 Case Studies of Nurturing Care Components Across the Globe
6-2 Case Studies on Integration of Services for Communicable and Noncommunicable Diseases
6-3 Impacts of the Pink Ribbon Red Ribbon Initiative
7-1 Mechanisms for Expedited Review
7-2 Applications of Digital Global Health Tools
7-3 Global Digital Health Index
8-1 Case Study: 116E Rotavirus Vaccine
8-2 Long-Term Investment and Payoff: Smallpox Eradication
8-3 Case Studies of Private Investment in Global Health
9-1 Definition and Role of Health Attachés
FIGURES
1-1 Overview of the report structure
2-1 Global health programs (GHP) account, by program FY2017
2-2 Net overseas development aid in 2015 as a percentage of gross national income (GNI)
2-3 Domestic revenues and U.S. aid to sub-Saharan Africa
4-1 Countries with a high burden of TB, TB/HIV coinfection, and MDR-TB
5-1 Invest in girls and women: The ripple effect
5-2 Results of the Saving Mothers, Giving Life program in Zambia after 4 years
6-1 Global costs of cardiovascular disease
8-1 Social impact bond flow diagram
9-1 Global health governance along three political spaces
TABLES
S-1 Committee Recommendations and Corresponding Actions
1-1 U.S. Program Successes for Global Health
2-1 U.S. Global Health Spending on Priority Areas in 2016
3-1 Health Threats and Vulnerabilities Associated with Globalization
6-1 Morbidity (DALY) Ranking of Top NCDs and Communicable Diseases
6-2 Mortality Ranking of Top NCDs and Communicable Diseases
6-3 Cost-Effective Interventions for NCDs in Resource-Constrained Environments
6-4 Cost–Benefit Analysis of Increasing Coverage of Interventions
6-5 Private Companies Investing Their Own Resources in NCDs in Developing Countries
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Acronyms and Abbreviations
AMC |
Advanced Market Commitment |
AMPATH |
Academic Model Providing Access to Healthcare |
AMR |
antimicrobial resistance |
ASPR |
Assistant Secretary for Preparedness and Response |
BARDA |
Biomedical Advanced Research and Development Authority |
CARB-X |
Combating Antibiotic-Resistant Bacteria Pharmaceutical Accelerator |
CDC |
U.S. Centers for Disease Control and Prevention |
CDER |
Center for Drug Evaluation and Research |
CEPI |
Coalition for Epidemic Preparedness Innovation |
CGD |
Center for Global Development |
CIADM |
Centers for Innovation in Advanced Development and Manufacturing |
COPD |
chronic obstructive pulmonary disease |
CVD |
cardiovascular disease |
DAH |
development assistance for health |
DALY |
disability-adjusted life year |
DART |
disaster assistance response team |
DCA |
Development Credit Authority |
DHS |
U.S. Department of Homeland Security |
DIB |
development impact bond |
DoD |
U.S. Department of Defense |
DOTS |
directly observed treatment, short-course |
DREAMS |
Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe |
DRM |
domestic resource mobilization |
DRR |
disaster risk reduction |
EOC |
emergency operating center |
EPMCD |
Ending Preventable Maternal and Child Deaths |
ESTH |
environment, science, technology, and health officer |
FAO |
Food and Agriculture Organization |
FDA |
U.S. Food and Drug Administration |
FEMA |
U.S. Federal Emergency Management Agency |
FETP |
Field Epidemiology and Training Program |
FSO |
foreign service officer |
FY |
fiscal year |
G7 |
Group of Seven |
GAIN Act |
Generating Antibiotic Incentives Now Act |
Gavi |
Gavi, the Vaccine Alliance |
GBAS |
global bidding and assignment system |
GBV |
gender-based violence |
GDL |
Global Development Lab |
GDP |
gross domestic product |
GFF |
Global Financing Facility |
GHE-S |
government health expenditure as a source |
GHI |
Global Health Initiative |
GHP |
global health programs |
GHSA |
Global Health Security Agenda |
Global Fund |
Global Fund to Fight AIDS, Tuberculosis and Malaria |
GMEP |
Global Malaria Eradication Program |
GNI |
gross national income |
HESN |
Higher Education Solutions Network |
HHS |
U.S. Department of Health and Human Services |
Hib |
Haemophilus influenza serotype b |
HIV/AIDS |
human immunodeficiency virus/acquired immunodeficiency syndrome |
HPP |
Hospital Preparedness Program |
HPV |
human papillomavirus |
IFFIm |
International Finance Facility for Immunization |
IHR |
International Health Regulations |
IMCI |
Integrated Management of Childhood Illness |
IOM |
Institute of Medicine |
JEE |
joint external evaluation |
LMIC |
low- and middle-income country |
LSDI |
Lubombo Spatial Development Initiative |
MDB |
multilateral development bank |
MDG |
Millennium Development Goal |
MDR-TB |
multidrug-resistant tuberculosis |
MEPI |
Medical Education Partnership Initiative |
MERS-CoV |
Middle East respiratory syndrome coronavirus |
NASEM |
National Academies of Sciences, Engineering, and Medicine |
NCD |
noncommunicable disease |
NEPI |
Nursing Education Partnership Initiative |
NGO |
nongovernmental organization |
NIAID |
National Institute of Allergy and Infectious Diseases |
NIH |
National Institutes of Health |
NTD |
neglected tropical disease |
ODA |
overseas development aid |
OECD |
Organisation for Economic Co-operation and Development |
OFDA |
Office of U.S. Foreign Disaster Aid (USAID) |
OGA |
Office of Global Affairs (HHS) |
OGHD |
Office of Global Health Diplomacy (U.S. Department of State) |
OIE |
World Organisation for Animal Health |
OTA |
Other Transaction Authority |
PACCARB |
Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria |
PCAST |
President’s Council of Advisors on Science and Technology |
PEER |
Partnerships for Enhanced Engagement in Research |
PEF |
Pandemic Emergency Financing Facility |
PEPFAR |
The U.S. President’s Emergency Plan for AIDS Relief |
PHEIC |
public health emergency of international concern |
PHEMCE |
Public Health Emergency Medical Countermeasure Enterprise |
PHEP |
Public Health Emergency Preparedness |
PMI |
President’s Malaria Initiative |
PPE |
personal protective equipment |
PPP |
public–private partnership |
PrEP |
pre-exposure prophylaxis |
PRRR |
Pink Ribbon Red Ribbon |
PRV |
Priority Review Voucher |
R&D |
research and development |
RBF |
results-based financing |
RBM |
Roll Back Malaria |
RCT |
randomized controlled trial |
SARS |
severe acute respiratory syndrome |
SDG |
Sustainable Development Goal |
SFI |
Sustainable Finance Initiative |
SIB |
social impact bond |
TB |
tuberculosis |
TFAH |
Trust for America’s Health |
TOSSD |
total official support for sustainable development |
UKAID |
United Kingdom Department for International Development |
UN |
United Nations |
UNAIDS |
Joint United Nations Programme on HIV/AIDS |
UNICEF |
United Nations International Children’s Emergency Fund |
USAID |
U.S. Agency for International Development |
USDA |
U.S. Department of Agriculture |
VIA |
visual inspection with acetic acid |
WEF |
World Economic Forum |
WHA |
World Health Assembly |
WHO |
World Health Organization |
XDR-TB |
extensively drug-resistant tuberculosis |