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2 Scale Up Existing Interventions to Achieve Significant Health Gains The global health community has reached a critical juncture. Knowledge, innovative technologies, and proven tools to help millions of people are within reach. Yet despite demonstrated success in tackling certain health issues, the gap continues to grow between what can be done with existing knowledge, and what is actually being done in disadvantaged communities. Existing interventions are not widely used even though many are inexpensive and easy to administer (Bryce et al., 2003; Jamison, 2006). In the area of child mortality, for example, the tremendous gains made in child survival over the past half-centuryâdue to interventions such as vaccinations and dietary supplementation strategiesâhave actually slowed or been reversed since the mid-1990s (Ahmad et al., 2000). At the same time, chronic diseases such as diabetes and heart disease have joined the list of infectious diseases traditionally found in low- and middle- income countries, in an extraordinary global epidemiologic transition (Abegunde et al., 2007; Jamison, 2006; Laxminarayan et al., 2006; Omran, 1971). Steps are thus required to address this double burden of disease, as well as to com - bat emerging infectious threats such as pandemic flu. If the global community neglects its responsibilities at this critical moment, health outcomes for the most vulnerable populations will remain static or decline, progress achieved in poverty reduction thus far will be threatened, and the poorest countries will continue to be left behind. ACHIEVE THE MILLENNIUM DEVELOPMENT GOALS BY 2015 The globally recognized Millennium Development Goals (MDGs) were adopted by Member States of the United Nations (UN) in 2000 to achieve demon-
0 THE U.S. COMMITMENT TO GLOBAL HEALTH strable reductions in poverty and improve specific health outcomes by 2015. Three of the eight goals pertain directly to health (Goals 4, 5, and 6); the other five, indirectly (see Box 2-1). Although progress has been made, as discussed below, the MDG targets remain a distant goal for many countries, particularly in sub-Saharan Africa and parts of South Asia (UNICEF, 2008). MDG 4: Reducing Child Mortality Global child mortality rates have dropped steadily over the last 50 years. Between 1960 and 1990, the rates of decline in worldwide child mortality aver- aged 2.5 percent per year. By contrast, from 1990 to 2001, the rates of decline averaged 1.1 percent per year. Although this deceleration might be expected in regions that had already achieved low mortality rates, such slowing has also occurred in high-rate regions (Black et al., 2003; SepÃºlveda et al., 2006). Between 1990 and 2006, about 27 countriesâthe large majority in sub- Saharan Africaâmade little or no progress in reducing childhood deaths (see Figure 2-1) (UN, 2008b). In 2005, only 7 of the 60 countries that account for more than 94 percent of child deaths in the world were on track to reach MDG 4 (Bryce et al., 2006). While progress has been made in important areasâfor example, deaths from measles fell by two-thirds between 2000 and 2006 due to dramatically improved vaccination programs covering 80 percent of children in BOX 2-1 United Nations Millennium Development Goals Goal 1 Eradicate Extreme Hunger and Poverty Goal 2 Achieve Universal Primary Education Goal 3 Promote Gender Equality and Empower Women Goal 4 Reduce Child Mortality â¢ arget 1: Reduce by two-thirds the under-5 mortality rate T Goal 5 Improve Maternal Health â¢ arget 1: Reduce by three-quarters the maternal mortality ratio T â¢ arget 2: Achieve by 2015 universal access to reproductive health T Goal 6 Combat HIV/AIDS, Malaria, and Other Diseases â¢ arget 1: Halt and begin to reverse the spread of HIV/AIDS T â¢ arget 2: Achieve, by 2010, universal access to treatment for HIV/ T AIDS for all those who need it â¢ arget 3: Halt and begin to reverse the incidence of malaria and other T major diseases Goal 7 Ensure Environmental Sustainability Goal 8 Develop a Global Partnership for Development SOURCE: UN, 2008a.
SCALE UP EXISTING INTERVENTIONS CIS, Europe 27 17 45 Eastern Asia 24 Latin America and 55 the Caribbean 27 82 Northern Africa 1990 2006 Target 35 77 South-Eastern Asia 35 69 Western Asia 40 79 CIS, Asia 47 85 Oceania 66 120 Southern Asia 81 184 Sub-Saharan Africa 157 0 20 40 60 80 100 120 140 160 180 200 Rate per 1,000 FIGURE 2-1 MDG 4: Deaths of children under 5 per 1,000 live births (1990, 2006, and 2015 target). Now 2xa.eps SOURCE: UN, 2008b. low- and middle-income countries (UN, 2008b)âthe lack of well-functioning health systems in these countries severely constrains the delivery of many essen - tial health interventions (Bryce et al., 2003). As a result, despite substantial atten- tion from global health agencies, mortality of children less than 5 is projected to decline by only 27 percent between 1990 and 2015, substantially less than the MDG target of 67 percent (Murray et al., 2007). While the causes of child death differ substantially from one country to another and therefore require a greater understanding of the epidemiology of child health at the country level (Black et al., 2003; Jones et al., 2003; Lawn et al., 2004), six causes account for 73 percent of the yearly deaths of children younger than 5: pneumonia (19 percent), diarrhea (18 percent), malaria (8 per- cent), neonatal pneumonia or sepsis (10 percent), preterm delivery (10 percent), and asphyxia at birth (8 percent); undernutrition is an underlying cause of more than half of all child deaths (Bryce et al., 2005). Diarrhea and pneumonia alone
THE U.S. COMMITMENT TO GLOBAL HEALTH account for 4 million child deaths each year, while an additional 11 million to 20 million children are hospitalized annually for pneumonia (Rudan et al., 2004). At least one effective intervention is available for preventing or treating each main cause of death among children younger than 5 (apart from birth asphyxia) (Jones et al., 2003), and about 20 proven interventions available today are fea- sible for implementation in low-income countries at high levels of population coverage (Bhutta et al., 2008; Bryce et al., 2006; Darmstadt et al., 2005; Jones et al., 2003). Overall, existing health interventions could reduce child mortality by as much as 63 percent if they could reach those in needâchildren in the 42 countries that accounted for 90 percent of all childhood deaths in 2000 (Jones et al., 2003). These simple and cost-effective measures include promotion and support for breastfeeding; the management of diarrhea with low-osmolarity oral rehydration salts and zinc; the prevention of pneumonia and meningitis with Haemophilus influenzae type b (Hib) vaccine; the use of insecticide-treated bed nets; and supplementation with vitamin A, among others. Achieving MDG 4 does not require a wait for new vaccines, drugs, or technologyâalthough these should remain on the agenda in order to improve efficiency and effectiveness in the future; the requisite interventions are avail- able now. MDG 5: Improving Maternal Health Outreach services can achieve impressive results when providing interven- tions such as vaccinations, but they offer little assistance in other medical cases such as childbirth or pregnancy complications, which require a functioning health service. Although maternal deaths represent only 1 percent of global mortality, 500,000 such deaths every year constitute a serious indictment of public health systems (Beaglehole and Bonita, 2008). Maternal death rates are the largest inequity in health and vary enormously across countries, ranging from as low as 4 per 100,000 live births in Australia to 2,100 per 100,000 in Sierra Leoneâa greater than five hundredfold difference (Beaglehole and Bonita, 2008; Gwatkin, 2004). Ninety-nine percent of maternal deaths occur in low- and middle-income countries (see Figure 2-2). Progress has been slower for this MDG than for the others, especially in sub- Saharan Africa, suggesting that this issue is not yet firmly on the global agenda despite decades of effort (Shiffman and Smith, 2007). Only 47 percent of births in sub-Saharan Africa and 40 percent in South Asia are attended by a skilled professional. Meanwhile, progress in North Africa and Southeast Asia has been remarkable, demonstrating that substantial improvements are possible even in low- and middle-income countries (UN, 2008b). Increasing the coverage of key maternal health provisions, including access to family planning services, skilled birth attendance, and obstetric services, would go a long way toward achieving MDG 5 (Ronsmans and Graham, 2006;
SCALE UP EXISTING INTERVENTIONS 95 Eastern Asia 50 58 CIS 51 180 Latin America and the Caribbean 13 0 1990 2005 Target 250 Northern Africa 16 0 19 0 Western Asia 16 0 450 South-Eastern Asia 30 0 550 Oceania 430 620 Southern Asia 49 0 920 Sub-Saharan Africa 90 0 0 100 200 300 40 0 500 600 700 800 900 10 00 Deaths per 10 0,000 live births FIGURE 2-2 MDG 5: Maternal deaths per 100,000 live births (1990, 2005, and 2015 target). Now 2xb.eps SOURCE: UN, 2008b. UN, 2008a). In low- and middle-income countries, about one-fourth of pregnan - cies are unintended (Haub and Herstad, 2002), highlighting the need for ways of avoiding them. Ensuring access to family planning and reproductive health for all women could help avoid up to 35 percent of maternal deaths (Belhadj and TourÃ©, 2008). A commitment is also required to establish countrywide systems of quali - fied and adequately equipped personnel, along with an effective infrastructure that allows women to be referred and transported for emergency obstetrical care (Campbell and Graham, 2006; Ronsmans and Graham, 2006). Without these, one in six women living in the worldâs poorest settings will continue to die from treatable or preventable complications in pregnancy and childbirth (Ronsmans and Graham, 2006).
THE U.S. COMMITMENT TO GLOBAL HEALTH MDG 6: Combating HIV/AIDS, Malaria, and Other Diseases Recently, HIV/AIDS, malaria, and tuberculosis (TB)âoften termed âthe big threeâ because of their significant disease burdenâhave benefited from increased political commitments from the U.S. governmentâs bilateral program PEPFAR (Presidentâs Emergency Plan for AIDS Relief); the international financing insti - tution, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund); and the World Bankâs Multi-Country HIV/AIDS Program for Africa, among others. A growing recognition of the enormous global impact of these three diseases has also led to an increase in research efforts, with philanthropies (such as the Bill & Melinda Gates Foundation) and U.S. government agencies (including the Centers for Disease Control and Prevention, the National Insti - tutes of Health, and the U.S. Agency for International Development) galvanizing research that specifically targets the needs of populations in the worldâs poorest settings. HIV/AIDS Epidemic Continues to Be a Leading Cause of Death Worldwide AIDS continues to be the leading cause of death in Africa and the sixth- largest killer worldwide (WHO, 2008b). Recent expansion of antiretroviral treat - ment for HIV-infected individuals through PEPFAR and the Global Fund, among others, has succeeded in reversing the direction of AIDS mortality; between 2005 and 2007, the number of people who died annually from AIDS declined from 2.2 million to 2 million (UNDP, 2008). However, in 2007, 2.7 million people were newly infected with HIV, signaling a failure to prevent the spread of the disease (UN, 2008b). Despite the knowledge of successful, cost-effective strategies to prevent the transmission of HIVâcondom use, reduction in the number of sexual partners, male circumcision, the prevention of mother-to-child transmission, and protec - tion of the blood, organ, and tissue supplyâthe disease continues to spread at an alarming rate, especially among women in low- and middle-income countries (UNAIDS, 2008). Continued efforts to disseminate messages that motivate peo- ple to adopt these effective risk-reducing behaviors and interventions are critical (Coates et al., 2008; Potts et al., 2008; Wilson and Halperin, 2008). New tools and strategies to prevent HIV infection through sexual transmis- sion are also essential for halting the spread of the disease. Although condom effectiveness in preventing HIV transmission ranges from 80 percent (Weller and Davis-Beaty, 2002) to 94 percent (Hearst and Chen, 2004; Pinkerton and Abramson, 1997; Rutherford, 2008), sexual intercourse and condom use dur- ing the sex act are not always controlled by women. The development of HIV prevention products that do not require the cooperation or consent of oneâs partner is thus critical (WHO, 2009c). Two experimental biomedical products that would greatly empower women (and men) to protect themselves and their
SCALE UP EXISTING INTERVENTIONS partners are microbicidesâa compound that can be applied inside the vagina or rectum to protect against sexually transmitted infections, including HIVâand pre-exposure prophylaxisâa single drug, or a combination of drugs, to prevent infection (Lagakos and Gable, 2008). A vaccine to protect against HIV infection, while possibly decades away, would fundamentally alter the global response to the epidemic. Malaria Results in One Million Deaths Every Year Globally, more than 2 billion people are at risk of malaria each year (Snow et al., 2005). Despite dramatic reductions in malaria incidence and mortality in many parts of the world in recent years, approximately 500 million people still contract the disease, resulting in 1 million deaths annually (Greenwood et al., 2008). The threat of malaria has declined in many countries with high rates of infection due to the increased availability and accessibility of artemisinin- containing antimalarial drugs, and antimosquito measures such as long-lasting insecticide-treated nets (LLINs) and indoor residual spraying. A 2008 World Health Organization (WHO) report on the impact of LLINs and artemisinin-based combination therapies (ACTs) in four African countries found âstrong initial evi - denceâ in Rwanda and Ethiopia that the mass distribution of LLINs to children under 5 years of age, in combination with the distribution of ACTs nationwide, resulted in a dramatic decline of more than 50 percent in both in-patient malaria cases and malaria deaths (WHO, 2008d). Nevertheless, new infections and re-infection continue, making a malaria vaccine of utmost importance. The vaccine candidate RTS,S has been found to reduce malaria incidence among children by more than 50 percent in two Phase II field trials.1 This vaccine, which can be administered safely with other child - hood immunizations, functions by halting malaria parasite replication in the liver (Abdulla et al., 2008; Bejon et al., 2008). Should the upcoming large-scale Phase III trials be successful, the RTS,S vaccine could be licensed by 2011 and avail - able by 2012, providing a powerful tool in conjunction with additional malaria interventions (Engel, 2008). Tuberculosis Demands Improved Prevention, Diagnostic, and Treatment Options Despite the slow global decline in TB incidence per capita (less than 1 percent each year), the disease still kills 1.7 million people annually (WHO, 2008c). Between 1990 and 2003, the incidence of TB remained stable in all regions except Africa and the former Soviet republics and even rapidly declined 1 The RTS,S vaccine was developed in 1987 by the Walter Reed Army Institute of Research and GlaxoSmithKline (Basu, 2007) and later received support from the PATH Malaria Vaccine Initiative and the Bill & Melinda Gates Foundation.
THE U.S. COMMITMENT TO GLOBAL HEALTH in emerging market economies such as Latin America and Central Europe (Dye et al., 2005; WHO, 2008c). Rates in Africa increased in part due to co-infection with HIV (Corbett et al., 2003), and in Eastern Europe due to economic decline and the general failure of health services (Dye and Floyd, 2006). Since 2003, the number of new tuberculosis cases per capita has continued to fall worldwide. This decline can partly be attributed to the successful imple- mentation of drug treatment programs (Dye et al., 2005). PEPFAR supported TB treatment for more than 395,400 HIV-infected patients through September 2008 (PEPFAR, 2009), while the Global Fund provided 4.6 million people with effective TB treatment through December 2008 (Global Fund, 2009). How- ever, if global targets for tuberculosis control are to be met, Africa, China, and Indiaâwhich collectively account for more than two-thirds of undetected TB casesâwill have to improve both the extent and the timeliness of diagnosis of active TB and increase the rate of successful treatment (UN, 2008b). Successful diagnosis remains a major challenge in the control of tuberculosis; for example, the number of multidrug-resistant TB cases successfully diagnosed and notified in 2006 represented less than 5 percent of the nearly half million cases estimated to exist worldwide (WHO, 2008c). The current class of TB drugsâthe most recent of which was introduced in the 1960sâimposes a long and complex regimen on those burdened with the disease. Although effective, the treatment regimen itself is one of the greatest obstacles to controlling the disease. Because of the length of treatment and its negative side effects, patient compliance is often poor, ultimately resulting in drug resistance. A factor that vastly complicates diagnosis and treatment is the extremely drug-resistant form of tuberculosis, XDR-TB, which leaves patients (including many with HIV) virtually untreatable with currently available drugs (WHO, 2006c). TB treatment also involves considerable health system costs in terms of direct patient observation, amounting to more than $4 billion a year worldwide. This further handicaps TB control programs, fueling drug resistance and preventing the systematic treatment of latent TB infectionâthe reservoir for the epidemic (see Box 2-2). Neglected Diseases of Poverty Exacerbate the Burden of the Poor AIDS, TB, and malaria are familiar names, but few U.S. citizens are acquainted with the other infectious diseases that commonly plague poor families in low- and middle-income countries. Often termed the neglected diseases of poverty, these scourges have afflicted the worldâs poorest since ancient times and continue to be common among the estimated 2.7 billion people living on less than $2 a day. These conditions frequently result in long-term disability and poverty (Hotez et al., 2007) and carry disease burdens that are grossly underestimated and may be comparable to those of HIV, malaria, and TB (Hotez et al., 2006a, 2006b; Savioli et al., 2006).
SCALE UP EXISTING INTERVENTIONS BOX 2-2 Drugs and Vaccines for Tuberculosis Research In 1995, the directly observed treatment, short-course (DOTS) control strategy for TB was launched (WHO, 2008f). DOTS is an inexpensive and highly effective means of treating patients already infected with TB, while preventing new infec- tions and the development of drug resistance. In many low-income countries, DOTS costs only $3 to $7 for every healthy year of life gained (World Bank, 2003). The DOTS strategy provides diagnosis, patient registration, and a six-month multidrug treatment regimen, where the patientâs compliance with treatment is âdirectly observedâ even as he or she is free to work, go to school, and be with family. By combining individual patient outcome evaluation to ensure cure and cohort evaluation to monitor overall program performance, DOTS forms the core of the WHOâs Stop TB Strategy (Floyd and Pantoja, 2008). A shorter or otherwise simpler treatment regimen would greatly help to improve patient compliance and to lower toxic side effects, thereby increasing cure rates. A shorter treatment would also reduce the costs of TB treatment, both for patients and for health systems. New and faster-acting drugs could radically transform the fight against tuberculosis by accelerating DOTS, treating multidrug-resistant TB (MDR-TB), improving the treatment of latent infection, and reducing TB transmis- sion. Effective treatment of latent TB is particularly important for patients co- infected with HIV (Bornemann et al., 2002). The Global Alliance for TB Drug Development, a public-private product develop- ment partnership, has the primary goal of developing within a decade new anti-TB drugs that shorten and/or simplify treatment, are effective against MDR-TB, and address both active and latent forms of the disease. A central stipulation for any new drug is that it be accessible and affordable for all who need it (Bornemann et al., 2002). No vaccine yet exists that is truly effective against adult pulmonary tuberculo- sis, the strain that accounts for most of the disease burden worldwide (Stop TB Partnership, 2009). The bacille Calmette-GuÃ©rin (BCG) vaccine, created in 1921, is currently the only available vaccine against TB. The vaccine is effective against severe forms of pediatric TB, but is unreliable against adult pulmonary TB. BCG is the most widely administered vaccine in the world, yet more than one-third of the worldâs population carries the disease (WHO, 2007b). A modern, safe, and effective vaccine is therefore urgently needed to prevent all forms of TB, including drug-resistant strains, in all age groups and particularly among people with HIV. In recent years, a number of new vaccine candidates for tuberculosis have been developed and shown promising results when tested in animals. Aeras TB, a nonprofit biotechnology company, has recently entered a new vaccine candidate human safety trial in South Africa (Aeras, 2009). Two common groupings of these neglected infectious diseases are helminth infections and kinetoplastid infections (Hotez et al., 2008; Stuart et al., 2008). Helminth infections, caused by parasitic worms, are the most common clinical conditions among the âbottom billionââthe worldâs poorest people living on
THE U.S. COMMITMENT TO GLOBAL HEALTH less than $1 per day (Collier, 2007)âand include parasites such as roundworm, hookworm, onchocerciasis, and schistosomiasis. Children and adolescents suffer the highest burden of worm diseases, experiencing growth and developmental delays that result in deficits in intelligence and cognition. Hookworm and schis - tosomiasis are common infections that cause anemia among women in their reproductive years. Because of their pronounced impact on maternal and child health, the disease burden caused by helminths is exceedingly high (Collier, 2007; Hotez et al., 2006b). Kinetoplastid infections are caused by related parasites and include three diseases: trypanosomiasis, Chagas disease, and leishmaniasis. These infections are less common, but being vector-borne, they could increase as a consequence of climate change and other environmental influences (IOM, 2008b). Neglected infectious diseases are often treated on a mass scale with vari - ous drugs; for example, mass administration of diethylcarbamazine and selec - tive treatment or administration of diethylcarbamazine-medicated salt have succeeded in interrupting the transmission of lymphatic filariasis in the Pacific region (Ichimori et al., 2007). Vector control, followed by mass treatment with ivermectin, led to the control of onchocerciasis in 10 west African countries (Amazigo et al., 2006). Azithromycin treatment and the SAFE (surgery, antibiot - ics, face cleanliness, and environmental improvement) strategy have eliminated blindness-causing trachoma in Morocco (Cook, 2008), and multidrug treatment has eliminated leprosy as a public health problem in more than 93 countries (Molyneux, 2008). The efficacy of mass treatment was confirmed in a systematic review of ran- domized controlled trials (Reddy et al., 2007). Because the major multinational pharmaceutical companies provide many of the drugs used for mass treatment free of charge, this approach is one of the most cost-effective global public health control measures (Hotez et al., 2007). The efficiency and effectiveness of mass treatment could be increased through the integration of several vertical disease control programs (Brady et al., 2006; Hotez et al., 2006b, 2007; Molyneux, 2008) since integration provides cost savings of almost 50 percent (Brady et al., 2006). In 2005-2006, a low-cost rapid-effect package of four drugs was developed to simultaneously target the seven major neglected tropical diseases (Hotez et al., 2006b, 2007). To launch an integrated global assault with the rapid-effect pack- age, about $2 billion to $3 billion will be needed over the next five to seven years, or roughly 40 to 50 cents per person per year (Hotez et al., 2007, 2009). New technologies and interventions developed for diseases that are found overwhelmingly or exclusively in low- and middle-income countries are usually serendipitous, as when a veterinary medicine developed by Merck (ivermectin) proved to be effective in the control of African river blindness (onchocerciasis) in humans (Campbell, 2005). Similarly, eflornithineâoriginally intended as a cancer treatment and also known to be highly effective against a strain of African sleeping sickness (trypanosomiasis)âwas initially abandoned by drug manu -
SCALE UP EXISTING INTERVENTIONS facturers until it was discovered to be effective in preventing unwanted facial hair (see Box 2-3). Yet for many of these infections, genomes for the parasites and vectors have been completed; increased investment in the mining of these genomes could result in breakthrough discoveries of new diagnostic, drug, and BOX 2-3 Human African Trypansomiasis: Diagnosis and Treatment Human African trypanosomiasis, or sleeping sickness, is spread by infected tsetse flies (Glossina genus). Although sleeping sickness is not fatal, it can be grossly debilitating by affecting the central nervous system, causing changes in personality, and creating difficulty in walking and talking. WHO estimates that there are currently 50,000 to 70,000 cases of African sleeping sickness, responsible for an estimated 1,525,000 disability-adjusted life-years (DALYs) (DNDi, 2008; WHO, 2006a). Case detection requires major human, technical, and material resources, such as blood samples and spinal tap. Diagnosis becomes even more difficult because the disease primarily affects poor rural populations with little access to health facilities. New, accurate, and simple diagnostic tests that could determine the stage of disease are required, along with drugs that could be administered orally (CIPIH, 2006). Currently there is no vaccine or drug available to prevent infection. While drugs to treat the disease are available, they are old, difficult to administer under poor conditions, and not always successful. Pentamidine is the first-stage treatment for the Trypanosoma brucei (T.b.) gambiense strain of African trypanosomiasis, and although it has a few side effects, it is generally well tolerated by patients (WHO, 2006a). Eflornithine is a highly effective treatment for the T.b. gambiense strain of Af- rican trypanosomiasis, particularly in the late-stage disease. It is safer and more effective than other treatments, such as melarsoprol, but the dosing regimen is strict and the drug is expensive. It was originally intended as a cancer treatment, but was registered for African trypanosomiasis in 1989. Highly expensive, eflorni- thine was largely abandoned by drug manufacturers until it was discovered to be an effective treatment against unwanted facial hair. Due to extensive lobbying by Medicins Sans Frontieres in 2001, Sanofi-Aventis (formerly Aventis), the patent holder, agreed to provide $12.5 million worth of the drug to WHO over five years. Now that this five-year period is over, Sanofi-Aventis has agreed to transfer the technology and assist other manufacturers that are willing to develop eflornithine; the Indian Institute of Chemical Technology (Hyderabad, India) and ILEX Oncol- ogy (Texas, USA) are both working on cheaper ways to produce the drug (CIPIH, 2006). Targeted research on human African trypanosomiasis has revealed new and more promising treatments. A Phase III studyâmade possible by a public-private partnershipâconfirmed that eflornithine in combination with nifurtimox is a safe, effective treatment for stage 2 patients with the disease, and even more practical than eflornithine alone. This combination drug was added to the WHO Essential Medicines List in May 2009.
0 THE U.S. COMMITMENT TO GLOBAL HEALTH vaccine targets, leading to the development of new tools to combat them (Hotez et al., 2008; Stuart et al., 2008). Determinants of Health and the Other MDGs The remaining five MDGs do not deal exclusively with health issues, but are indirectly linked to health outcomes. The health sector should be a powerful voice in supporting governments and encouraging donors to give more funding to water and sanitation, nutrition, and other sectors that contribute to health outcomes. Water and Sanitation (MDG c: Reduce by half the proportion of people without sustainable access to safe drinking water and basic sanitation) More than 1 billion peopleâa sixth of the worldâs populationâlack access to safe drinking water, and 2.6 billion people lack access to basic sanitation services (MDG 7) (Bartram et al., 2005). These figures have âhardly changed for almost two decades because any improvements in provision have barely kept up with population growthâ (Lancet, 2008b). When both the direct (diarrheal illnesses) and the indirect (water-borne and water-related illnesses) health consequences are taken into account, 9.1 percent of the global burden of disease could be prevented by improving water, sanitation, and hygiene; in the 32 worst-affected countries, this figure jumps to 15 percent (Lancet, 2008a; PrÃ¼ss-ÃstÃ¼n et al., 2008). One and a half million children die every year from preventable diarrheal illnesses, and many thousands more are disadvantaged by wide-reaching health and edu - cational consequences because of these failings in water and sanitation services (PrÃ¼ss-ÃstÃ¼n et al., 2008). Poverty and Nutrition (MDG c: Reduce by half the proportion of people who suffer from hunger) In low- and middle-income countries, one out of every four children under 5 years old is underweight due to lack of nutritious foods (MDG 1) (UN, 2008b). Undernutrition is caused by a poor dietary intake that may not provide sufficient nutrients and/or by common infectious diseases, such as diarrhea (Black et al., 2008). The attribution of more than one-thirdâ3.5 millionâof all child deaths and more than 10 percent of total global disease burden to maternal and child undernutrition demonstrates the huge importance of these prevalent risk factors to international health goals (Black et al., 2008; Horton, 2008). Malnutrition not only retards growth, but also leads to weak cognitive functioning, with conse- quences for the progress of whole societies. An estimated 200 million children under the age of 5 fail to reach their potential in cognitive development due to poor nutrition, poverty, and deficient care (Grantham-McGregor et al., 2007).
SCALE UP EXISTING INTERVENTIONS Unfortunately, there is no one technological intervention that can solve undernutrition. While one in seven people already suffers from food scarcity and 25,000 people die every day from hunger-related causes (including one child every 5 seconds) (Sheeran, 2008), the threat of climate change is further increasing the risk of crop failure, livestock losses, and subsequent food shortages (MDG 7) (FAO, 2008). In addition to improving consistent access to nutritious food, long-term investments in empowering womenâin educational, economic, social, and political termsâcan lead to sustainable improvements in maternal and child nutritional status and in the health of families more generally (Horton, 2008). Educational, Economic, and Gender Inequity (MDGs and ) Educational and economic opportunities are out of reach for many of the poor, especially young women. Among primary school-age children worldwide, more than 90 percent attend school, but 38 million children in sub-Saharan Africa do not (MDG 2). Low rates of school enrollment and attendance are especially devastating to girls because they are linked to their future income, personal health status, and the health status of their future children and families (MDG 3) (UN, 2008b; UN Millennium Project, 2005). Gender inequality influences the health of both mothers and babiesââan influence that seems to continue many decades laterâ (Osmani and Sen, 2003). To avoid this intergenerational cycle of poor health and lack of education, gender gaps should be closed in all areas of development, such as primary and second- ary education, womenâs access to economic opportunities and health services, and equal participation in governance (Belhadj and TourÃ©, 2008). The field of global womenâs health has recently expanded to include a range of womenâs health issues unrelated to reproduction, with a focus on identifying and correcting gender differentials and inequities in health (BuvinÃc et al., 2006). Overcoming the gender and power imbalance between men and women in communities and households around the world would yield rich rewards in terms of the health of millions of women and girls (and their children) (Belhadj and TourÃ©, 2008). Recommendation 2-1. As part of a comprehensive approach to develop- ment and poverty reduction, the United States, both its governmental and its nongovernmental sectors, should support the UNâs Millennium Development Goals. In particular, the United States should partner with countries to pro - mote and finance the application of existing knowledge and tools to achieve the health-related MDGs by 2015 with special attention to areas that are lagging behind. (See Recommendation 5-1 for funding proposal.)
THE U.S. COMMITMENT TO GLOBAL HEALTH PREPARE FOR EMERGING CHALLENGES OF THE TWENTY-FIRST CENTURY While the MDGs are useful guides for mobilizing and focusing aid resources, much more will have to be done to attain the goal of global health. Investments need to go beyond well-recognized infectious diseases such as HIV/AIDS and malaria and take a more comprehensive view of health in low- and middle- income countries. Globalization and UrbanizationâOpportunity and Barrier to Global Health Dramatic changes have occurred in the last century: population growth; migration into previously uninhabited areas; rapid urbanization; environmental degradation; and the misuse of antimicrobials that has disrupted the equilibrium of the microbial world. Globalization has changed the way that nations should protect and promote health, in part due to the growing number of health hazards and solutions that increasingly cross national borders. While globalization has brought innumerable benefits to society, it has also generated resource depletion, environmental pollution, unhealthy living conditions, and the circulation of dan - gerous and unhealthy goods (Marmot et al., 2008). Infectious diseases are now emerging at the historically unprecedented rate of one per year. With airlines now carrying more than 2 billion passengers annu- ally and systems of trade more interconnected than in any time in human history, the opportunities for the rapid international spread of infectious agents and their vectors have vastly increased (WHO, 2007c). Chronic diseases are also increasing as a result of globalization and urbaniza- tion (Dodgson et al., 2002; Lee, 2003; Lee et al., 2002). Cities are already home to half of the worldâs 6.6 billion people (Ash et al., 2008). City dwellers tend to have more expendable income than their rural counterparts; they live more sedentary lives and have easier access to low-cost, low-fiber, high-energy, high- fat food. Unhealthy imports, such as tobacco and processed foods, heighten the risk of many noncommunicable and chronic diseases (Dodgson et al., 2002; Lee, 2003; Lee et al., 2002). The nutritional transition that results from urbanization contributes to todayâs rapidly rising rates of obesity, with implications for the incidence of diabetes, heart disease, cancer, and stroke (Dye, 2008). Climate Change to Play a Role in Global Health Climate change poses a unique challenge to global health efforts and the âinvoluntary exposureâ experienced in many societies and represents possibly the largest health inequity of our time (Patz et al., 2007). Ironically, in the last 30 years, the regions least responsible for causing greenhouse gas warming of the planet have been experiencing the greatest increases in diseases attributable to
SCALE UP EXISTING INTERVENTIONS temperature rise (Costello et al., 2009; Patz et al., 2007). Additionally, 88 percent of the disease burden attributable to climate change afflicts children under age 5âan innocent portion of the population. Not only is the health burden from climate change itself greatest among the worldâs poor, but some of the major miti- gation approaches to reduce the degree of warming may produce negative side effects disproportionately among the poor. For example, competition for land for biofuel production can create pressure on food prices. Efforts to reduce the extent of global warming and its associated impacts should seek equitable solutions that first protect the most vulnerable populations (Patz et al., 2007). Climate change was responsible for 5.5 million disability-adjusted life-years (DALYs) lost in 2000 when taking into account deaths caused by cardiovascular diseases, diarrhea, malaria, accidental injuries in coastal floods and inland floods or landslides, and the unavailability of recommended daily calorie intake (an indicator of malnutrition) (Costello et al., 2009). Infectious disease transmission patterns are altered by the effects of climate change (IOM, 2008b). In Africa, major contributors to child mortality, such as malaria and diarrhea, vary with temperature change and rainfall. Other vector-borne diseases, including schisto - somiasis, yellow fever, sleeping sickness, and Rift Valley and East Coast fevers, are sensitive to seasons and other climatic conditions. Flooding increases the risk of water-borne diseases, while droughts force people and their animals to move to new environments, further increasing the risk of disease from microbes to which they have not previously been exposed (ILRI, 2008). Infectious Pandemic Threats Throughout human history, infectious diseases have threatened lives and livelihoods; increasingly, they challenge the health security of nations. Major pandemics such as the Influenza Pandemic of 1918-1919, which killed more people in 3 weeks than HIV/AIDS has killed in 24 years (HHS and CDC, 2006), demonstrate the potentially catastrophic impacts of emerging infections such as pandemic flu. Despite dire warnings, the global health arena currently faces a lack of specific effective antiviral agents and antibiotics (targeting emerging resistant bacteria), integrated health surveillance and management systems, and trained health personnel (IOM, 2005; WHO, 2007c). Even high-income countries are ill equipped to handle mass outbreaks of infectious diseases, including those that could arise from the intentional use of biological agents. The U.S. government has spent more than $30 billion over five years to counter these threats, but so far, the drug development cycle for anti-infective drugs and vaccines has not kept pace with disease-response demands (Grotto and Tucker, 2006). Emerging pandemic threats such as avian and H1N1 (swine) flu, which can spread with alarming rapidity in todayâs globalized world, need urgent prepa - ration. Infectious disease outbreaks have significantly increased over the last several decades (IOM, 2003) and are dominated (60 percent) by zoonoses, or
THE U.S. COMMITMENT TO GLOBAL HEALTH diseases contracted from animals (Jones et al., 2008). This increase in the emer- gence of infectious diseases reflects many factors, including climate change (IOM, 2008b) and anthropogenic and demographic changes that increase and alter contact between humans and animals (Jones et al., 2008). Zoonotic Disease Threats Are Increasing Today, conditions for the development of zoonotic diseases that have the potential to become pandemics are already well entrenched (IOM, 2008a). Zoo - notic diseases arise out of an expanding convergence of factors such as climate change, population growth, and consumer demand for food of animal originâall of which increase the risks of disease transmission from wildlife to livestock and from both to humans (IOM, 2008a). Animal populations are reservoirs for several infectious diseases that infect humans, including West Nile virus (birds), Ebola hemorrhagic fever (bats), avian influenza (birds), and H1N1 influenza (pigs) (Grotto and Tucker, 2006). Since animals are more commonly affected by many zoonotic diseases than humans, in some instances they can provide an early warning of impending human epidemics (Rabinowitz et al., 2006). Unfortunately many health systems, including those of high-income countries, lack an inte - grated zoonotic disease surveillance system capable of monitoring both animal and human populations. Once zoonotic pathogens have developed into agents capable of human-to-human transmission, they can spread with alarming rapid - ity, striking with deadliest effect in less wealthy nations that are least equipped to monitor, control, and detect emerging diseases (IOM, 2008a). In a matter of months between 2002 and 2003, more than 8,000 people in 26 countries became sick and 774 died (WHO, 2003) due to severe acute respiratory syndrome (SARS)âa zoonotic disease thought to have first been transmitted from bats to humans in south China (Lau et al., 2005). The global economic impact of this epidemic was estimated to be as much as $30 billion (HM Govern- ment, 2008). Compared to outbreaks of other infectious diseases, this epidemic is considered to have been contained by one of the more successful international response efforts, owing to model multinational, collaborative, and coordinated surveillance, research, and containment measures (IOM, 2004). At the same time, the newness of the disease and the demonstrated speed of its global spread high - lighted the need for vigilance and continued investments in integrated response systems against emerging diseases. Two such response systems are the Global Outbreak Alert and Response Net- work (GOARN) and the Global Emerging Infections Sentinel Network (GeoSen - tinel). GOARN connects more than 115 organizations around the world; this network greatly aided WHO during the initial SARS outbreaks (IOM, 2004). GeoSentinel consists of travel and tropical medicine clinics around the world that monitor geographic and temporal trends in morbidity among travelers and other globally mobile populations; its rapid worldwide query-and-response function
SCALE UP EXISTING INTERVENTIONS electronically links providers around the world (GeoSentinel, 2008). A relatively new tool for tracking and predicting potential outbreaks is HealthMapâa freely accessible, automated real-time system that monitors, organizes, integrates, fil - ters, visualizes, and disseminates online information about emerging diseases (Freifeld, 2009). Food-Borne Diseases Demand Attention Globalization of the food supply further exposes a greater proportion of people to the risk of food-borne diseases. Although preparing nations to address natural and intentional biological threats is a formidable challenge, understanding these twin threats and the characteristics they share encourages shared strategic preparations for surveillance, diagnosis, outbreak investigation, and medical response systems (IOM, 2006). Food-borne diseases have wide-ranging repercussions for consumers, gov - ernments, and the food industry. They can arise both unintentionally and through deliberate contamination. Outbreaks of food-borne illness damage trade and tour- ism, lead to loss of earnings, destroy the commercial credibility of suppliers, and affect consumer confidence (FAO, 1999). Despite the risk of terrorist attacks on food supplies, the likelihood of accidental food-borne illnesses surpasses inten - tional contamination by approximately 10,000 to 1 (IOM, 2006). Since the late 1990s, the incidence of various illnesses associated with food- borne microorganisms in the United States has remained steady or decreased. However, challenges in food inspection, sampling, and surveillance abound and demand further progress (HHS and FDA, 2007). As new food sources increase, production and distribution methods advance, and imports respond to growing consumer demand, food protection strategies should adapt to these changes. Among the challenges are establishing internationally standardized food safety systems, particularly in low- and middle-income countries, not only because food exports from these countries are on the increase (with approximately 15 percent of the overall U.S. food supply volume now imported) (HHS and FDA, 2007), but also because the introduction of debilitating food-borne pathogens from advanced economies has increased in low- and middle-income countries. International Health Regulations Strive for Early Detection of International Threats The revised International Health Regulations (IHR), which entered into effect in June 2007, bind 192 countries across the globe and help the international com - munity to report and respond to major epidemics in an integrated, harmonized, and holistic way. The IHR expand the focus of collective defense from just a few quarantinable diseases to include any emergency with international repercus - sions for health, including outbreaks of emerging and epidemic-prone diseases,
THE U.S. COMMITMENT TO GLOBAL HEALTH outbreaks of food-borne diseases, natural disasters, and chemical or radionuclear events, whether accidental or deliberate (Fidler and Gostin, 2006). In a significant departure from the past, the revised IHR call for a strategy of proactive risk management, rather than a focus on passive barriers at borders, air- ports, and seaports. The new strategy is aimed at detecting an event early, before it has a chance to become an international threat, and stopping it at its source (WHO, 2007c). It calls for notification of WHO within 24 hours of any event that has the potential to become a public health emergency of international concern (PHEIC). The term PHEIC now more broadly covers accidental or deliberate releases of biological, chemical, or radiological agents that could harm more than one country. The IHR also mandate that all participating countries work closely with partners and strengthen national core capabilities for public health surveil - lance and response within five years (WHO, 2005a). More private sector involvement is needed to improve the quality of early- warning systems for the detection of disease outbreaks and to support advancing biomedical research in the development of safe, cost-effective vaccines capable of treating a broad spectrum of infectious diseases (Grotto and Tucker, 2006). Public-private partnerships can play a pivotal role in developing new antibiotics, diagnostics, and other means of combating infectious disease. Such partnerships could also help to establish regional networks and build appropriate infrastructure to implement the global health standards mandated by the IHR (Kimball et al., 2008). Chronic and Noncommunicable Diseases The rising tide of chronic and noncommunicable diseases in both high- income and low- or middle-income countries cannot be ignored any longer. In an extraordinary global epidemiologic transition, chronic conditions such as cardiovascular disease and diabetes have joined the list of infectious diseases traditionally seen in less affluent regions (Laxminarayan et al., 2006; Omran, 1971). Remarkably, 80 percent of chronic disease deaths now occur in low- and middle-income countries (WHO, 2005b). In 2001, cardiovascular disease had become the leading cause of death in low- and middle-income countries (as it had been in industrialized countries since the mid-1990s) (Mathers et al., 2006). Smoking, which greatly increases the risk of acquiring conditions such as heart and lung disease and many cancers, is an increasingly common addiction in many low- and middle-income countries. Unless large numbers of adults quit, smoking will account for 1 billion deaths this century (Jha et al., 2006). Increased mortality from chronic disease is not merely a result of fewer deaths from infectious disease. In East Asia and the Pacific, for example, the anticipated increase in death rates from chronic disease will be more than five times the predicted decrease in mortality rates from infectious disease (Stuckler, 2008). Both emerging infectious threats and chronic diseases are increasing glob-
SCALE UP EXISTING INTERVENTIONS ally, resulting in the so-called dual burden of disease, whereby significant infec - tious and chronic diseases burden the same country or region (see Figure 2-3). For example, some low- and middle-income countries are experiencing a protracted and polarized epidemiologic transition with high levels of malnutrition alongside high levels of obesity (Frenk et al., 1989). This mix of health challenges demands new approaches that integrate both infectious and chronic disease interventions. The prevention and treatment of chronic and noncommunicable diseases should therefore become a priority in global health. Chronic diseases have received significant research attention in the United States, resulting in impor- tant advances that focus on individual risk factors and specialized treatments. However, the scale and urgency of these diseases in low- and middle-income countries require solutions that are tailored to a different, much less understood reality, encompassing cost-effective and population-based methods, rather than individualized ones (Batniji, 2007). Although noncommunicable diseases are not included in the MDGs (Fuster and VoÃ»te, 2005), WHO has called for a global commitment to reduce chronic disease death rates by an additional 2 percent annually, or to 36 million deaths by 2015 (Strong et al., 2005). Cardiovascular Disease Is Increasing in Low- and Middle-Income Countries Cardiovascular disease (CVD) is the leading cause of death worldwide. At the beginning of the twentieth century, CVD was responsible for less than 10 per- 10 0% 90 % 80 % 70 % 60 % 50 % 40 % 30 % 20 % 10 % 0% Africa South East The Eastern Europe Western High Asia Americas Mediterranean Pacific Income Communicable, maternal, and nutritiona l conditions Noncommunicabl e disease Injuries FIGURE 2-3 Burden of disease in disability-adjusted life-years (DALYs) by cause and 2xc.eps WHO region (2004). SOURCE: Committeeâs calculations based on WHO, 2008b.
THE U.S. COMMITMENT TO GLOBAL HEALTH cent of all deaths, but by 2001 the figure was 30 percent. About 80 percent of the global burden of CVD deaths occurs in low- and middle-income countries. And while other causes of death, such as injuries, respiratory infections, nutritional deficiencies, and HIV/AIDS, collectively still play a predominant role in certain regions, CVD is now a significant cause of mortality in all regions. Nearly 50 percent of all deaths in high-income countries and about 28 percent of deaths in low- and middle-income countries are the result of CVD (Gaziano et al., 2006; Mathers et al., 2006). Working-age adults account for a high proportion of the CVD burden in low- and middle-income countries. Premature deaths in this population have a significant social and economic impact on societies, especially in already impov - erished settings (Gaziano et al., 2006; Greenberg et al., 2005). Cancer Should Be Raised onto the Global Health Agenda Cancer receives less attention on the health agendas of low- and middle- income countries than it does in high-income countries, even as other chronic diseases have gained attention. Yet cancer is common everywhere and growing as a share of the burden of disease. Of the 11 million cases of cancer that occur annually worldwide, 6 million are in low- and middle-income countries, where they cause 4 million deaths (1 million more than from AIDS) (IOM, 2007). Very recently, a vaccine against oncologic strains of human papilloma virus (HPV)â the leading cause of cervical cancerâwas developed and is being delivered in the United States and other advanced economies. Its use in low- and middle-income countriesâhome to more than 80 percent of cervical cancer deathsâcould save the lives of millions of women (see Box 2-4). Whereas the majority of cancers in high-income countries are those associ - ated with more affluent lifestylesâcancers of the lung, colon and rectum, breast, and prostateâcancers related to infectious agents are more common in low- and middle-income countriesâcancers of the liver, stomach, esophagus, and cervix. Investments in cancer diagnosis and treatment, however, should vary depending on resources available in the country. A temptation that high-income countries should resist is focusing on exporting the latest, most expensive technologies that may be appropriate for wealthy countries, but for which alternatives exist that may be preferred in low- and middle-income countries. Partnerships are needed between high-income and other countries in developing resource-appropriate strategies (IOM, 2007). Diabetes Reaching Epidemic Levels Obesity is escalating worldwide at an alarming pace, along with rates of type 2 diabetes, hypertension, and lipid abnormalities associated with obesity. More than 1 billion adults are now overweight, and 300 million are clinically obese
SCALE UP EXISTING INTERVENTIONS BOX 2-4 Cancers That Affect Only Women Breast cancer is the most common cancer among women worldwide. Its inci- dence is much higher in high-income countries, where more than half of all cases are diagnosed. However, breast cancer is increasing everywhere, even more so in places where rates have historically been low. Between 1990 and 2002, the global increase was about 0.5 percent per year. In China, however, annual increases of 3 to 4 percent are reported. If these rates are representative, 1.5 million cases of breast cancer are expected worldwide in 2010 (IOM, 2007). The Breast Health Global Initiative (BHGI) is an ongoing international col- laboration that produces detailed guidelines for low- and middle-income countries to improve breast health outcomes, from early detection through palliative care. BGHI has begun to work with low- and middle-income partners to develop experi- ence in adapting and applying policy and programmatic guidelines (IOM, 2007), including effective communication interventions for early detection through breast self-examination and timely diagnosis (BHGI, 2009). Cervical cancer is the second most common cancer among women. More than 493,000 women are diagnosed each year, and approximately 274,000 women die annually from this disease (Ferlay et al., 2004). More than 80 percent of these deaths occur in low- and middle-income countries (Stewart and Kleihues, 2003; WHO, 2006b). Most women in low-income countries do not have access to care that can prevent the onset of cervical cancer; once diagnosed, few can afford the lifesaving surgery and radiotherapy. Cervical cancer incidence and mortality thus disproportionately burden women in less affluent settings. The continuing high mortality rate demonstrates a lack of awareness and advocacy aimed at this disease. WHO (2006b) developed the Comprehensive Cervical Cancer Control: A Guide to Essential Practice report as a âhow-toâ manual for cervical cancer, aimed at low- and middle-income countries in terms of the technologies addressed (IOM, 2007). The report gives recommendations that are feasible in less affluent settings, including visual screenings and availability of appropriate medications (WHO, 2006b). Deployment of the recently developed HPV vaccine, now used in high-income countries, would go a long way toward stemming cervical cancer disease burden in these low- and middle-income countries. (Gaziano et al., 2006). As some low- and middle-income countries undergo rapid urbanization, childhood obesity has increased dramatically, while the prevalence of type 2 diabetes has reached epidemic levels and is expected to increase in East Asia and the Pacific (Narayan et al., 2006). Because the health consequences of this epidemic threaten to overwhelm health systems in these regions, action is urgently needed to encourage lifestyle changes (Yoon et al., 2006). Studies such as the Diabetes Prevention Programme (Knowler et al., 2002), Da Qing study (Pan et al., 1997), Finnish Diabetes Prevention Study (Tuomilehto et al., 2001),
0 THE U.S. COMMITMENT TO GLOBAL HEALTH Japan lifestyle study (Kosaka et al., 2005), and Indian Diabetes Prevention Pro - gramme (Ramachandran et al., 2006) have shown that lifestyle changes and some medications are effective in preventing type 2 diabetes in at-risk individuals. Public health strategies aimed at prevention of weight gain and obesity will be more cost effective than treatment of the consequences of these conditions such as diabetes (Yoon et al., 2006). Mental HealthâGreat Source of Disability Globally Mental disorders affect millions of people worldwide; about 14 percent of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol use and substance use disorders, and psychoses. Although most of the burden attributable to mental disorders is disability-related, premature mor- tality from suicide is also significant. Further, mental disorders increase the risk for communicable and noncommunicable diseases and contribute to unintentional and intentional injuries. Conversely, many health conditions increase the risk of mental disorder, and comorbidity complicates help seeking, diagnosis, and treat - ment (Prince et al., 2007). Most mentally ill people are not treated (Kohn et al., 2004; Wang et al., 2007). It has been estimated that among severe mental disorders such as schizo- phrenia, one out of three people does not receive any treatment at all, while for less severe disorders, one person out of two is not treated. In low- and middle- income countries, 90 percent of mental illness is untreated (Maselko, 2008). Resources for mental health are scarce, inequitably distributed, and ineffi - ciently allocated, with most being spent on psychiatric hospitals and institutional care rather than primary and community care. Scaling up a package of cost- effective treatments for a core group of three mental disorders (schizophrenia, depression, bipolar affective disorder) and one risk factor (hazardous alcohol use) would cost about $2 per person per year in low-income countries and $3 to $4 per year in lower-middle-income countries (Chisholm et al., 2007). However, one-third of low- and middle-income countries have no mental health budget at all. Of those that do, 20 percent spend less than 1 percent of their health budget on mental healthâand this almost entirely on psychiatric hospitals in urban areas (Saxena et al., 2007). Finally, health services are not provided equitably to people with mental disorders, and diagnosis with mental disorder can influence prognosis. Psycho - social interventions that can be integrated into infectious and noncommunicable disease management need to be developed and evaluated (Prince et al., 2007). The shortage of mental health professionals, the low capacity and motivation of nonspecialist health workers to provide quality mental health services, and the stigma associated with mental disorder are some of the key challenges to address- ing mental health needs (Patel et al., 2007).
SCALE UP EXISTING INTERVENTIONS Injuries and Violence Are on the Rise Other health hazards (beyond diseases), such as intentional and unintentional injuries, are also more prevalent in low- and middle-income countries. Together, unintended injuries and violence kill more than 5 million people worldwide and harm millions more each year (Hyder et al., 2009; WHO, 2009a). Injuries and violence account for 9 percent of global mortality and are a threat in every coun - try of the world (WHO, 2009a). Morbidity and mortality from injuries are on the rise. Eight of the fifteen leading causes of death for people age 15 to 29 are related to injuries, through road traffic accidents, suicides, homicides, drowning, burns, war, poisonings, and falls (WHO, 2008a). Unintentional injuries are the leading cause of child - hood death after the age of 9; 95 percent of these child injuries occur in low- and middle-income countries (WHO, 2008e). Yet proven interventions for preventing child injuries exist, such as car seats, cycling helmets, child-resistant packaging for medications, fencing around swimming pools, hot water tap temperature regulation, and window guards (WHO, 2008g). Other cost-effective interven - tions to prevent deaths and injuries include motorcycle helmets, seat belts, and enforcement of alcohol and driving limits, and speeding laws (Beaglehole and Bonita, 2008). Traffic accidents have increased dramatically with the increase in motor vehicles in low- and middle-income countries. They now claim 1.2 million lives each year (Morris, 2006) and are the leading cause of death among young people between 10 and 24 years (Toroyan and Peden, 2007). The greatest burden of such injuries and fatalities is borne disproportionately by poor people in low- and middle-income countries, mostly pedestrians, cyclists, and the passengers of buses and minibuses (Nantulya and Reich, 2002). For every death, it is estimated that there are dozens of hospitalizations, hundreds of emergency department visits, and thousands of doctorsâ appointments. A large proportion of those who survive their injuries incur temporary or permanent disabilities (WHO, 2009a). Roadway improvements and better onsite emergency response systems can help prevent deaths from traffic accidents (Beaglehole and Bonita, 2008). Violence is another problem worldwide, resulting in the death of more than 1.6 million people each year (WHO, 2002). Almost half of these deaths, about 800,000 annually, result from suicide; additionally, 35 percent are due to interpersonal violence and 11 percent to collective violence, which can include organized violence, forms of war, and gang violence (IOM, 2008c; WHO, 2002). For women, in particular, the prevalence of lifetime physical or sexual violence (or both) by an intimate partner ranges from 15 to 71 percent (WHO, 2005c). Womenâs health suffers further from a persistent violation of their rights through harmful practices on the basis of gender, such as female genital mutilation or cutting, early marriage, sexual violence, or forced prostitution. Violence is heightened and health is negatively impacted during conflicts
THE U.S. COMMITMENT TO GLOBAL HEALTH (Belhadj and TourÃ©, 2008). Aside from the immediate effects of armed conflict, death, and injuries, war threatens the future of public health through âthe dis - placement of populations, the breakdown of health and social services, and the heightened risk of disease transmissionâ (Murray et al., 2002). In Liberia, 14 years of civil war devastated the governmentâs health system and left more than a million people without running water, electricity, or sanitation systems (Huerga et al., 2009). In particular, conflicts that involve genocide result in higher rates of post-conflict death and disability (Hoddie and Smith, 2009), and war has acutely detrimental effects for child development (CSDH, 2008). Recommendation 2-2. The United States should partner with the global community to prepare for emerging challenges of the twenty-first century by increasing attention to pandemic infectious threats, noncommunicable diseases, and injuries. The U.S. government should demonstrate leadership in this area by adopting clear goalsâsuch as improving global disease surveil - lance, decreasing deaths from tobacco-related illnesses, and reducing injuries from accidentsâto guide U.S. global health investments. (See Recommenda- tion 5-1 for a detailed funding proposal.) ADDRESS NEGLECTED HEALTH SYSTEMS A functioning health system, as defined by WHO, should include access to adequate financing; essential medical products, vaccines, and technologies; a well-performing health workforce; reliable and timely health information; and strategic policy frameworks to provide effective analysis, oversight, and gover- nance (WHO, 2007a). Many low-income countries lack such a system, undermin- ing progress toward the health-related MDGs and other health outcomes (Travis et al., 2004; UNICEF, 2008). Because health systems are highly context-specific, no single set of best practices can be put forward as a model for improved performance. In fact, many low-income countries today have two health systems running parallel: a government delivery system and a privately financed market system. The relative proportions of care delivered by each system vary significantly by country. Yet health systems that function well have certain shared characteristics. They have procurement and distribution systems that deliver interventions to those in need. They are staffed with sufficient health workers having the right skills and moti - vation. They also operate with financing systems that are sustainable, inclusive, and fair, and do not impose costs that force impoverished households even deeper into poverty (WHO, 2007a). Most government systems were created in the last century and are character- ized by centralized budgeting and planning, civil service staffing, and publicly owned infrastructure. In many countries, these public systems have been inad -
SCALE UP EXISTING INTERVENTIONS equately resourced (Lagomarsino and Kundra, 2008). Government assistance for health in low-income countries is only 29 percent of the total expenditure on health compared to 65 percent in high-income countries; in fact, the poorer the country, the lower the proportion of government money devoted to health (Got - tret and Schieber, 2006). In general, giving more money to health systems requires a reallocation of funds from different government sectors, which can encounter political resis - tance (WHO, 2007a). In addition, public delivery systems tend to have weak governance structures that can lead to âpolitical influence on decisions, weak incentives to work for the benefit of the poor, lack of transparency in financial and procurement processes, and corruptionâ (Lagomarsino and Kundra, 2008). As a result, public systems have been shown to allocate resources poorly. For example, studies of African health expenditures have shown that public health funds disproportionately benefit wealthier populations (Lagomarsino and Kundra, 2008; Preker and Carrin, 2004). Individuals who do gain access to public health care are often confronted by a shortage of quality medical personnel and essential drugs (Mills, 2007). For example, WHO estimates that 57 countries (36 of which are in sub-Saharan Africa) have critical health workforce shortages (WHO, 2006d) and nearly 2 billion people do not have regular access to essential medicines (WHO, 2004). These shortages often stem from larger policy failures, such as a lack of capac - ity to train, recruit, and retain health workers; manage a drug supply system; or anticipate healthcare needs (Mills, 2007). The lack of reliable and timely statistics on births and deaths (including the medical causes of death) poses a serious obstacle to planning and decision mak - ing to improve health systems (AbouZahr et al., 2007). Most people in Africa and Asia are born and die without leaving any legal records or official statistics (Setel et al., 2007; Szreter, 2007). Each year, nearly 50 million births are not registered worldwide (UNICEF, 2005), and half of the countries in Africa and Southeast Asia record no âcause-of-deathâ data at all (Mathers et al., 2005; Setel et al., 2007). This lack of information, coupled with a general dearth of managerial capacity at all levels of health systems, increasingly threatens the achievement of the MDGs and other health outcomes (Egger et al., 2007). In the face of such inefficiencies in public systems, market systems offering health care have evolved in many countries. Yet even as these private systems offer solutions to patients for some of the problems of public delivery systems, such as lack of convenience and availability, they create a host of additional challenges that exacerbate the inequities in health outcomes in low- and middle- income countries. Underperforming market health systems are characterized by a lack of incentives for quality and for serving the poor, asymmetries of information between providers and patientsâa characteristic of health systems everywhereâ and weak government capacity to regulate the quality of providers (Lagomarsino and Kundra, 2008; Sekhri and Savedoff, 2006; WHO, 2007a).
THE U.S. COMMITMENT TO GLOBAL HEALTH These conditions lead to particularly insidious outcomes such as price goug - ing and unnecessary or harmful care. An âinadequate pooling of risk and the lack of subsidies for the poor, combined with high prices for private sector ser- vices, lead to high (often crippling) out-of-pocket paymentsâ (Lagomarsino and Kundra, 2008). Such payments represent the most inequitable type of financing because they disproportionately hurt the poor and provide no protection from the costs of catastrophic illness (Gottret and Schieber, 2006). Countries facing the complex challenges of a mixed healthcare system have a number of policy choices as they attempt to strengthen their health financing and delivery, though the appropriate role for each of these sectors remains controver- sial (Hanson et al., 2008). For some, it may make sense to focus on introducing reforms to strengthen their publicly financed government systems, but many low- and middle-income countries have already evolved toward disproportion- ately âmarketizedâ systems, with a large portion of health expenditures financed privately and many services delivered by private providers. In India, for example, more than 80 percent of the countryâs total expenditure on health is comprised of out-of-pocket payments (Mahal et al., 2001). In some instances, healthcare service delivery has been improved by using public funds to contract with nonstate entities, such as nongovernmental orga - nizations, universities, or private providers. A review of programs to contract out the delivery of primary care demonstrates that the practice has potential and should be explored further, but no robust conclusions to influence policy makers can be drawn without more extensive and higher-quality evidence (Liu et al., 2008; Loevinsohn and Harding, 2005; Patouillard et al., 2007). Although social insurance constitutes less than 2 percent of total spending in low-income countries (Gottret and Schieber, 2006), several countries have implemented expanded or universal insurance programs with positive results. In Thailand, a gradual program to expand subsidizedâand eventually freeâsocial insurance resulted in a significant reduction of child mortality rates and reduced inequalities between child mortality rates of the rich and poor by 50 percent (WHO, 2007a). Results from three studies evaluating the effect of universal health insurance in Colombia reported a significant increase in access to and use of health care and lowered catastrophic health spending (Giedion and Uribe, 2009). The Dutch nongovernmental organization PharmAccess is currently devel- oping low-income health insurance products for a variety of low-income workers in about 30 African countries (Gaag and Gustafsson-Wright, 2007). The evalua- tion of the effectiveness of community- and employer-based insurance models in improving quality and access to health care in low-income countries is still too sparse to inform widespread policy.
SCALE UP EXISTING INTERVENTIONS Leverage Disease-Specific Programs to Build Health Systems In response to the weak performance of many public and private health systems in low-income countries, the global health community has long debated the most effective approach to strengthening health systems and delivering health aid (SepÃºlveda, 2006). While the Alma Ata declaration of 1978 promoted a com - prehensive approach to improving health with an emphasis on building health systems âfrom the bottom upâ through primary health care, this vision was chal - lenged by those who argued that to achieve a measurable effect, it was necessary to focus on a limited number of cost-effective interventions (Travis et al., 2004; Wagstaff and Claeson, 2004). This debateâbetween horizontal and vertical, 2 comprehensive and selective, and top-down and bottom-up approachesâhas been a major topic in global health, with few programs or agencies bridging the gap and insufficient evidence to distinguish either approach as more valuable than the other (Lawn et al., 2008). Over the past decade, the drive to produce results for the MDGs has led many donors to focus on their disease priority first and to adopt verticalâdisease- specific or service-specificâinitiatives that focus on a limited number of inter- ventions. Given the emergency conditions prompting the initial global response to AIDS, for example, donors even chose to circumvent existing weak components of national health systems to set up programs devoted to achieving immediate and demonstrable results. Given the need to expand antiretroviral (ARV) treatment, voluntary counseling and testing, and other HIV/AIDS interventions rapidly in the face of poor data, weak supply chains, and human resource constraints, AIDS donors choseâsome more purposefully than othersâto set up separate systems to achieve their programmatic goals. For example, the three global AIDS donorsâPEPFAR, the Global Fund, and the World Bankâs Multi-Country HIV/ AIDS Program for Africaâdecided to support procedures for provision of ARVs that are separate from those for other essential medicines because of the critical importance of avoiding shortness of ARV drugs and the weaknesses in national drug distribution systems (Oomman et al., 2008). While the focus on specific diseases has led to significant improvements in health outcomes related to these diseases, the programs may have sacrificed opportunities to strengthen local health systems. Within the disease-specific pro - grams, an implicit assumption exists that the implementation of targeted interven - tions will strengthen the system more generally. However, experience suggests that if health systems are âlacking capabilities in key areas such as the health workforce, drug supply, health financing, and information systems,â they may 2 Vertical approaches refer to focused, proactive, disease-specific interventions on a massive scale that often use planning, staffing, management, and financing systems that are separate from other existing services, whereas horizontal programs refer to more integrated, demand-driven, resource- sharing health services that work through existing health system structures (SepÃºlveda, 2006; Travis et al., 2004; Wagstaff and Claeson, 2004).
THE U.S. COMMITMENT TO GLOBAL HEALTH not be able to respond adequately to opportunities to be strengthened through disease-specific programs (Travis et al., 2004). Furthermore, âalready weak systems may be further compromised by over- concentrating resources in specific programs,â leaving many other areas further under-resourced (Travis et al., 2004). For example, a study of overall care for pregnant women before and after implementation of targeted HIV programs illus- trates the dilemma perfectly. In this study, antenatal syphilis testing rates actually declined when prevention of mother-to-child HIV transmission programs were instituted, due to swamping of nurses whose workloads rose for HIV prevention without adequate support to maintain their prior duties such as syphilis screen - ing. These results highlight the need for health policy makers and researchers to plan explicitly for how targeted programs can have a broader primary care impact (Potter et al., 2008). Unfortunately, we cannot now be sure how the increase in resources for disease-specific programs, such as those to prevent and treat HIV/AIDS, might or might not be affecting health system capacity because little is known about how the programs are interacting with parts of existing health systems. A lack of such factual knowledge limits our ability to investigate the cause and effect of vertical programs on health system strengthening (Oomman et al., 2008). The choice between vertical and horizontal is itself a false dilemma. In reality, few interventions are delivered through totally stand-alone or totally integrated approaches, with most operating through a complex patchwork of arrangements (SepÃºlveda, 2006; Travis et al., 2004; Wagstaff and Claeson, 2004). Donors should move beyond the horizontal-versus-vertical debate and focus on leverag- ing both approaches to improve and sustain health outcomes. One way to make improved outcomes sustainable through health systemsâ strengthening is for donors to take a disease-specific approach without creating a parallel structure for care delivery. As an example, donors could coordinate information systems by having their own information needs flow through national health management information systems. By strengthening the health information systems of the government, donors could reduce information system fragmenta - tion, minimize duplicative and burdensome reporting for scarce health sector staff, and improve local data quality and analysis. Similarly, donors could use their programs to strengthen local health systems by utilizing national supply chains and strengthening human resources employed by the public sector (Oom - man et al., 2008). The committee contends that donors should make existing global health programs less formulaic and more performance-based, to permit resources to be used more easily within individual national health systems. This would require disease-specific strategies to explicitly take care to strengthen health systems. Having an explicit âhealth systemsâ strategy does not mean abandoning priori - ties, losing a focus on outcomes, or trying to do everything at once. It simply
SCALE UP EXISTING INTERVENTIONS means recognizing that health systems are vital not only to achieving health out - comes but also to sustaining them (Mills, 2007; Travis et al., 2004). Successful models do exist and there are opportunities to learn from these experiences. âChild Healthâ days, which began as an important approach to reach rural or other marginalized families with polio immunization, have now been expanded in many countries to include other immunizations as well as different interventions, such as deworming, family planning, and health education mes - sages (WHO, 2009b). Likewise, countries have used a selective set of programs, initially focused on child health, to build a pathway to a more comprehensive health system (Rohde et al., 2008; SepÃºlveda et al., 2006). For instance, the Tanzania Essen - tial Health Interventions Project was instituted to test innovations in planning, priority setting, and resource allocation at the district level, in the context of the reform and decentralization of Tanzaniaâs healthcare system (IDRC, 2009). Improved local health system planning and priority setting, together with mod - est investments in health services and increased coverage of key child-survival interventions, contributed to significant reductions in infant and child mortality in Tanzania (Bennett, 2007). The most recent demographic and health survey in 2005 showed a 24 percent improvement in child survival, with mortality rates among children younger than 5 down from 147 deaths per 1,000 for 1994-1999 to 112 deaths per 1,000 for 2000-2004 (Masanja et al., 2008). For the U.S. government, this would mean that even disease- and intervention- specific programs, such as PEPFAR and the Presidentâs Malaria Initiative, should contribute to wider health outcomes by working with countries to incorporate pro - grammatic best practices into health service delivery. The committee commends the language in the 2008 reauthorization of PEPFAR, which calls for expanded efforts to strengthen health systems and human resources and to collaborate with other programs, such as child and maternal health, clean water, food and nutri - tion, and education (PEPFAR, 2008). Leveraging the successes in implementing PEPFAR to support broader national health priorities would go far in making even greater improvements in health outcomes. Ultimately, this approach would allow U.S. health investments to go beyond merely treating a patient for a single disease and support the delivery of more comprehensive primary health care. When a woman brings her child with acute malaria to see a health worker for treatment in Zambia, for example, appropri - ate treatment will usually prolong the childâs life. However, a comprehensive approach to careâby using that same health worker and drug supply chain to provide malaria treatment as well as preventive measures such as oral rehydration salts, deworming, and inoculation against polio and measlesâcan immeasurably improve the childâs health. Strengthening primary health care to include services for the mother can extend the benefits even further: the mother visiting a health clinic because of her sick child could gain access to cervical cancer screening,
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