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 funding for development assistance over the past 3 years, and the budget for 1996 requires a further $1.5 billion reduction. Because numerous USAID 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 35-45 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 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 1990s, 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 of the 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 in biomedical science. A smaller amount of funding 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 fund 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 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, Médecins sans Frontières, 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.