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7 Call to Action A PROMINENT ROLE FOR HEALTH IN U.S. FOREIGN POLICY At this historic moment, the United States has the opportunity to advance the welfare and prosperity of people around the globe through intensified and sustained attention to better health. Especially during this time when the global economy is under pressure, attention to global health is essential. Working with partners in other countries and building on previous commitments, the United States has the opportunity to demonstrate global leadership by fulfilling its responsibility to save lives and improve the quality of life for millions around the world, and there are a variety of reasons to do so. U.S. leadership in global health reflects many motives: the national interest of protecting U.S. residents from threats to their health; the humanitarian obligation to enable healthy individuals, families, and communities everywhere to live more productive and fulfilling lives; and the broader mission of U.S. foreign policy to reduce poverty, build stronger economies, promote peace, and enhance the U.S. image in the world. Protecting Health at Home Requires Transnational Attention The 1997 Institute of Medicine (IOM) report Americaâs Vital Interest in Global Health emphasized Americaâs self-interest in solving global health prob - lems (IOM, 1997). The report suggested that the United States could reap eco - nomic benefits and provide security to its citizens through increased attention to global health. The messages of that report still hold true and perhaps are even more pressing. The 2009 H1N1 (swine) influenza illustrates that Americans do have a stake in the health and healthcare systems of low- and middle-income countries.
0 THE U.S. COMMITMENT TO GLOBAL HEALTH Twelve years after the initial IOM global health report, globalization has increased the urgency and changed the way in which nations must protect and pro- mote health, in part due to the growing number of health hazards that increasingly cross national boundaries (Dodgson et al., 2002; Lee, 2002, 2003). These threats include infectious diseases, such as avian flu, swine flu, and severe acute respi- ratory syndrome (SARS), as well as unhealthy imports, such as tobacco, which heighten the risk of many noncommunicable and chronic diseases (Dodgson et al., 2002; Lee, 2003; Lee et al., 2002). Common, modifiable risk factorsâunhealthy diet, physical inactivity, and tobacco useâunderlie the major chronic diseases and explain the vast majority of premature deaths from chronic diseases, among men and women, in all parts of the world (Donaldson and Banatvala, 2007). No country, acting alone, can adequately protect the health of its citizens or significantly ameliorate the deep problems of poor health in low- and middle- income countries. Mitigating the spread of disease and the import of unhealthy consumer goods into already burdened, low-resource societies depends on inter- national cooperation and assistance. Globalization also demands creative solu - tions to complex problems in areas such as trade and the environment that affect the determinants of health (Dodgson et al., 2002). Leveraging solutions to address our âsharedâ global disease burden is essen - tial. In low- and middle-income countries, the purchasing power of investments in health is amplified by local ingenuity, as well as lower labor costs and over- head. (Goldman Sachs estimates that research and development in India costs 12.5 percent of R&D in wealthy countries [Gardner et al., 2007].) The emerging markets increasingly function as big global âlabs;â for example, countries such as China, India, and Mexico are experiencing huge variations of diseases like diabetes and obesity within their populations and provide ideal conditions for large-scale drug trials. Investments in Global Health Reflect American Values Despite the economic downturn, a large majority of Americans support U.S. efforts to improve health in low- and middle-income countries. This support is grounded in both an altruistic concern for the poor and an understanding that in todayâs interconnected, globalized world, a health crisis in any country can impact Americans. In fact, a greater share of Americans support global health spending because it is âthe right thing to doâ than because it will advance U.S. national objectives (KFF, 2009; WorldPublicOpinion.org, 2009). In todayâs market crisis, the financial policies and practices of high-income nations, including the United States, are seen as the cause of painful economic spillovers in low- and middle-income countries. During economic downturns, the health of a countryâs population worsens due to lowered household income and reduced access to health care (Hopkins, 2006; Pongou et al., 2006; Waters et al., 2003). The poor in low-income countries are most affected because they pay a large portion of their healthcare costs out-of-pocket, without the benefit of social
CALL TO ACTION safety nets (Gottret and Schieber, 2006; Hopkins, 2006). It is therefore crucial for the reputation of the United States that the nation live up to its humanitarian responsibilities, despite current pressures on the U.S. economy, and assist low- income countries in safeguarding the health of their poorest members. Good health is a necessary condition for economic development and global prosperity (Bloom and Canning, 2000; Feachem, 2002). Numerous studies have demonstrated that as people benefit from the positive economic aspects of global- ization, good health is important in keeping them from falling back into poverty. Ill health has been shown to be one of the leading reasons that individuals and families descend into poverty in countries such as Argentina, Chile, Ecuador, Honduras, India, Kenya, Peru, Uganda, and Vietnam (Baeza and Packard, 2006; Eggleston et al., 2006; Krishna, 2007a, 2007b). Poor health not only reduces economic productivity and earning potential, it also reduces personal resources by imposing higher healthcare costs and diminishing savings (WHO, 2005; World Bank, 2007). Without investments in health, prosperity from economic growth will be tenuous, especially among the poor. Improvements in health are thus a core investment in stable and vibrant econ- omies around the world. One study shows that more than half of Africaâs growth shortfall, relative to the high-growth countries of East Asia, can be explained by disease burden, demography, and geography, rather than by the more traditional variables of macroeconomic policy and political governance (Bloom and Sachs, 1998; WHO, 2001). The Commission on Macroeconomics and Health of the World Health Organization (WHO) estimated that 8 million lives saved from infectious diseases and nutritional deficiencies would save approximately $186 billion per year (WHO, 2001). China, India, and the Russian Federation could each forgo between $200 billion and $550 billion in national income over the next 10 years as a result of heart disease, stroke, and diabetes (WHO, 2005). Investments in health can also demonstrate a U.S. commitment to avert conflict and promote a more peaceful world (Hotez, 2001). Many of the worldâs poorest societies either are currently engaged in a civil war or have recently been through one (Collier, 2007). Indeed, countries with the highest infant and child mortality rates are those most likely to be engaged in war (Hotez, 2001); in both 1990 and 2005, Afghanistan, Angola, and Sierra Leoneâthree war-torn countriesâhad the highest mortality rates in the world for children under 5, even during times of relative peace (UNICEF, 2008). Implementing disease control and public health activitiesâwhich help break the cycle of poor health, poverty, and conflictâis particularly challenging in these fragile states, especially under conditions of conflict (Hotez et al., 2007). However, by improving health and restoring human dignity, the United States can help avoid or reverse the social fragmentation, economic decay, and political instability that often cause, prolong, or result from devastating conflict. The expansion of U.S. government investments in global health has the potential to change perceptions that the United States is indifferent to the plight of the global poor. Health is a highly valued, visible, and concrete investment.
THE U.S. COMMITMENT TO GLOBAL HEALTH Public opinion polls following U.S. aid efforts in the aftermath of the Pakistan earthquake and the South Asian tsunami showed an improvement in how America is viewed (Terror Free Tomorrow, 2005, 2006). In fact, while the recent opinion of the United States has been negative in most regions of the world, the U.S. image has remained consistently positive in Africa (Ray, 2008), the region that has received the most U.S. foreign aid for health (U.S. Department of State, 2007). Saving and improving lives worldwide will help to rebuild global trust in U.S. leadership and make possible the global cooperation required for the critical challenges of the twenty-first century, such as nuclear disarmament and climate change. Global Health Is a Responsibility and an Opportunity to Be Seized Given the importance of health in building stable and prosperous communi - ties, the committee encourages the new President to make a bold public statement that global health not only is important for protecting the health of Americans, but is an essential component of U.S. foreign policy. This could be confirmed by a major speech early in his tenure to pledge support to successful U.S. investments in this arena and propose new means for pursuing global health objectives in a committed, cooperative, and nonpartisan manner. In this address, the President should declare that the dominant rationale for U.S. government investments in global health is that the United States has both the responsibility as a global citizen and the opportunity as a global leader to contribute to improved health around the world. The U.S. government should act in the global interest, recognizing that long- term diplomatic, economic, and security benefits for the United States will follow. Priorities should be established on the basis of achieving sustained health gains most effectively, rather than on short-term strategic or tactical U.S. interests. Government efforts should focus on reducing deaths and disabilities among the most vulnerable and marginalized populations in regions with the greatest need, in countries that possess the capacity to effectively use financial and technical resources. Equally important, health resources should not be withheld from people in countries where the United States takes an unfavorable view of the governing regime. The U.S. offer of cyclone assistance to Myanmar in February 2008 was a good example of prioritizing humanitarian needs over politics. In developing sanctions at the United Nations (UN) and elsewhere, food, medicine, and other health necessities should not be included among the areas of denied trade or assistance. Recommendation 7-1. The President should highlight health as a pillar of U.S. foreign policy. The U.S. government should act in the global interest, recognizing that long-term diplomatic, economic, and security benefits for
CALL TO ACTION the United States will follow. Priorities should be established on the basis of achieving sustained health gains most effectively, rather than on short-term strategic or tactical U.S. interests. INCREASE COORDINATION AND COHERENCE WITHIN THE U.S. GOVERNMENT If health is to hold a more prominent position in U.S. foreign policy, the U.S. government will have to increase coordination among the multiple agencies and departments engaged in global health promotion. Through greater coordination, the U.S. government can vastly enhance its own effectiveness, mobilize a criti - cal mass of the nongovernmental sector, and also be an example for the global health community. The administration should take this opportunity to examine whether the existing architecture, investments, and activities of the U.S. global health enterprise are best geared to achieving sustainable and measurable global health gains. To this end, the committee examined two aspects of the U.S. enterprise: (1) the governance structures across U.S. government agencies and departments that engage in global health, either by providing financial and technical resources to countries to expand public health infrastructure or through research focusing on health problems endemic to poor countries, and (2) the relationship of the United States to nonstate actors within and beyond U.S. borders. Need for Coherent Strategy for U.S. Government Involvement in Global Health More than 20 U.S. government agencies work internationally, with many of them contributing to some aspect of human development. Seven executive branch departments, four independent federal agencies, and numerous departmental agencies and operating units contribute to single- and multiagency initiatives that operate in more than 100 countries. More than 15 congressional committees have jurisdiction or oversight over global health programs (see Figure 7-1) (Kates et al., 2009). Despite the involvement of multiple government agencies and the growth in the global health budget, to date, the committee is not aware of any efforts to broadly coordinate U.S. actions in global health across even the major govern- ment agencies, let alone the smaller agencies less directly involved in health. A governing body to help guide U.S. investments in global health across the U.S. government does not exist. Not only are health programs not well coordinated within the U.S. govern - ment, but âat times their efforts appear to be at odds, competing for resources and attention on the groundâ (Garrett, 2009). Agencies are often working in the same country on the same agenda and contracting out to the same organization
THE U.S. COMMITMENT TO GLOBAL HEALTH C The White House O N State HHS OGHA OGAC G MCC OPHS OES Ambassador s R Missions CDC E USAID NIH Bureaus for: Global Health ; Defense Economic Grow th, Agriculture S and Trade; Democracy, FDA Conflict and Humanitarian S Assistance USDA HRSA Homeland Security PMI PEPFAR EPA KEY NTD Labor Water for Department Peace Corps Poor Ac t Independent Agency Commerce Avian Influenza Dept. O peratin g Unit Ac tion Group Multi-Agency Initiative FIGURE 7-1 U.S. government global health architecture. 5xb.eps SOURCE: Kates et al., 2009. without any coordination, either among themselves or with U.S.-based private sector health actors. Such duplication is both inefficient and wasteful and should be prevented, especially in an increasingly competitive environment for limited resources. To ensure that the U.S. government is working in a strategic fashion and having the greatest possible impact to improve health globally, the government should inventory current U.S. efforts as a baseline and should track, measure, and coordinate future investment across different federal agencies and departments both at home and on the ground within countries. This strategy should consult the increasingly important nongovernmental sector. It is within this context that the committee suggests governance reforms to the U.S. government global health enterprise. Appoint a Senior White House Official and an Interagency Committee on Global Health The 1997 IOM global health committee called for the establishment of an Interagency Task Force on Global Health within the U.S. government to antici - pate and address global health needs and to maximize global health opportuni - tiesâfor both the United States and the worldâin a coordinated and strategic fashion (IOM, 1997). The 1997 committee further recommended that the U.S.
CALL TO ACTION Department of Health and Human Services (HHS) coordinate global health strategy and priority setting across the federal agencies represented in the Inter- agency Task Force and act as the lead agency in establishing liaison with the private sector and international agencies. While this recommendation has yet to be implemented, the potential benefits of formalizing cooperation and coordina - tion across government agencies and departments engaged in the important task of achieving global health can be realized. This IOM committee supports the concept of the 1997 IOM recommendation, but finds that the interagency group should be located more centrally, in the White House. Locating the effort in the White House, potentially within the National Security Council (NSC), and report - ing to the President through the NSC adviser would give it convening authority among agencies and the ability to make policy recommendations directly to the President. Any other reporting line would not have the coordinating power that comes with the direct presidential chain of authority. Moreover, housing the interagency group in one of the major departments or agencies, such as the State Department, the U.S. Agency for International Development (USAID), or HHS, might imply that one group is more relevant than others, when several have an important and unique role in global health improvements; for example, while the State Department may be the development and diplomacy arm of the U.S. government, health expertise rests with HHS. The committee recommends that the President create a White House Inter- agency Committee on Global Health to lead, plan, prioritize, and coordinate the budgeting for U.S. government global health programs and activities. The interagency committee, which would consist of heads of major U.S. departments and agencies involved in global health activities, would play the crucial role of ensuring that the U.S. government has a coherent strategy for ongoing invest - ments in global health, including the means to achieve measurable, significant, and sustained health gains. This interagency committee would be the primary structure for bringing together the diverse and widespread global health efforts cutting across multiple government operations. While some agencies, such as HHS, the Office of Management and Budget (OMB), the State Department, and USAID, would be ongoing participants, other agencies such as the Department of Defense, the Department of Homeland Security, the Environmental Protection Agency (EPA), and the Food and Drug Administration (FDA) could participate as appropriate. The interagency committee should work with OMB to create a review mech- anism for global health funding across the major contributing agencies. The inter- agency committee and the OMB could review agency proposals to ensure that the U.S. government is meeting its overarching policy goals, to reduce duplication of efforts, and to fill gaps. The committee also recommends that the President designate a senior offi - cial at the White House (Executive Office of the President, potentially within the NSC) at the level of deputy assistant to the President to chair the interagency
THE U.S. COMMITMENT TO GLOBAL HEALTH committee. The deputy assistant to the President for global health should serve as the primary adviser at the White House on global health, attend all NSC meetings that deal in any way with global health issues, and work with the national secu- rity adviser, the director of management and budget, and the Presidentâs science adviser in carrying out his or her responsibilities. The deputy for global health should be an individual of recognized accom - plishment, with a significant background in health issues and programs, and should have the stature to play a leading role in formulating U.S. global health policy. A staff of three to five officers should support his or her work at the White House. Finally, if the deputy for global health and the interagency committee are to be effective, individuals who directly oversee global health activities within the various government agencies should be strong and effectual leaders with signifi- cant experience and success in global health programming. Designate Nongovernmental Advisory Committee on Global Health As previously mentioned, the nongovernmental sector is playing an increas - ingly significant role in global health financing and programming. To acknowl - edge its role and create a formal feedback mechanism, the deputy for global health should create a small committee of nongovernmental advisers to oversee the work of the interagency committee. The nongovernmental advisory committee would be a first step to formally involve civil society, academia, and private industry in discussions regarding global health activities and programs across the U.S. government. By engaging this sector, the U.S. government would help to resolve the deficit of its represen - tation on intergovernmental bodies such as the UN and WHO, which are driven by the interests of their member countries. The U.S. government could further involve nonstate actors by consulting with the nongovernmental sector in forming the U.S. platform on global health policies at UN agencies, such as WHO. Coordinate U.S. Government Response to Global Health Research Federal agencies in the United States have played a critical role in global health research; their work has helped to transform the understanding, prevention, and treatment of diseases that disproportionately affect populations in low- and middle-income countries. The National Institutes of Health (NIH) has been a world leader in studying the basic biology of infectious diseases and developing strategies for vaccines and drug treatments. For example, work by intramural and extramural NIH-funded scientists is responsible for the sequencing of genomes of many pathogens responsible for infectious diseases prevalent in the developing world and for much of the progress that has been made against HIV and AIDS. DOD, spurred by the exposure of field personnel in tropical countries, has con - tributed to the development of biomedical technologies that also benefit the global
CALL TO ACTION poor, such as its trailblazing work in malaria. The Centers for Disease Control and Preventionâthe worldâs premier public health agencyâhas developed suc- cessful programs and partnerships in many countries over many years, especially epidemiological research to improve the surveillance and control of diseases and conditions from avian influenza to road traffic safety. With decades of field expe - rience and a presence in more than 70 countries, USAID is uniquely positioned to integrate health research into foreign assistance programs, help strengthen health systems, collaborate with partner agencies, and provide leadership for programs in the field (USAID, 2006). Government agencies such as the EPA and the FDA may be poised to play a more prominent role in global health. For example, the FDA recently launched guidelines to clarify its role in the development of vaccines to protect against global infectious diseases (FDA, 2008). Given that regulatory authori- ties in many low- and middle-income countries lack the capacity to review new biomedical interventions, the FDA can play a major role in the registration of safe and effective interventions for diseases with direct impact on global health, through its âguidances,â expertise, and experience. This is particularly important in light of the maturing pipeline of drugs from global health product development partnerships. The committee recognizes that the full potential for contributions of the U.S. agencies to research on global health has yet to be tapped and will require addi - tional financial support and coordinated efforts. Given the importance of the U.S. government contribution to health research, increased coordination between and among the various U.S. government agencies involved in global health research is critical to create the desired synergies. The Interagency Committee on Global Health can be an important forum for coordinating global health research across these agencies and others. Such coor- dination may avoid wasteful duplication of efforts, identify promising research opportunities that are not being effectively pursued, and create a global health enterprise in which the advantages and skills of each agency are appropriately tapped and supported. Such an interagency committee, under the leadership of the deputy for global health, can recommend a coherent plan for advancing and financing global health research, and this plan can be reflected in the Presidentâs budget. Address Overlap Between Health Sector and Other Fields The interagency committee would also play the critical role of making sure health is taken into account when setting U.S. foreign policy in others areas, such as trade, environment, and security. Public health is currently underrepresented in many key areas of international economic and trade policy (Friel et al., 2008). The growing overlap between the health sector and other fields presents a number of tensions that could impede global health objectives, as well as synergies that could be utilized to improve health.
THE U.S. COMMITMENT TO GLOBAL HEALTH For example, increased trade liberalization, one of the driving forces behind globalization, may well improve economic prosperity generally, while the increased trade in health-related goods, services, and people offers numerous opportunities to economies around the world (Blouin et al., 2009). Yet trade can also bring challenges by spreading disease across borders, advertising unhealthy lifestyles, and potentially limiting access to medicines under restrictive trade rules. The health sector itself also has a significant impact on the trade sector. Dis - eases such as SARS and avian flu can have a powerful economic impact on travel, tourism, and commerce (Drager and Sunderland, 2007; Gostin and Mok, 2008; Helble et al., 2009). The interlinkages between trade and health are complex and require debate and new rules. Because the two sectors bring entirely different philosophies, institutions, and laws, their intersection can raise larger questions. For example, In the event of tension or a conflict, which philosophy, institution, or legal system should prevail, and why (Gostin and Mok, 2008)? Support for the International Health Regulations to protect the health of Americans and commu - nities abroad is an important step in mitigating the negative health consequences associated with increased systems of trade. Environment and health are clearly linked, with environmental deterioration leading to insufficient potable water, indoor smoke, road traffic, urban air pollu - tion, unintentional poisonings, and lead exposure (Smith et al., 1999). Climate variability causes disease and death through natural disasters such as droughts and tsunamis, as well as longer-term problems such as food security (Confalonieri et al., 2007). These environmental factors especially affect the most vulnerable populations, placing most of the burden on children under the age of 5 and those living in low- and middle-income countries (Smith et al., 1999). U.S. govern - ment efforts to participate in global agreements to curtail climate change have important consequences for human health. In the past, health was thought to be of âlittle importance in the hierarchy of foreign policy objectivesâ (Fidler, 2007). However, recent pandemics such as H1N1 (swine) flu and national security threats from bioterrorism have dramati - cally elevated the status of health on foreign policy agendas. The international community now links health and foreign policy in relation to three key areas: (1) national security (i.e., the need to protect from external threats); (2) trade, economic prosperity, and political stability; and (3) globalization and develop - ment (Owen and Roberts, 2005). As previously discussed, global healthâwhen done well and in the global interestâcan bring long-term diplomatic, economic, and security wins to the United States. Recommendation 7-2. Within the first year of his administration, the Presi- dent should create a White House Interagency Committee on Global Health to lead, plan, prioritize, and coordinate the budgeting for major U.S. govern -
CALL TO ACTION ment global health programs and activities. The President should also desig - nate a senior official at the White House (Executive Office of the President, potentially within the National Security Council) at the level of deputy assis- tant to the President for global health to chair the interagency committee. CALL FOR SUMMIT TO HIGHLIGHT U.S. COMMITMENT TO GLOBAL HEALTH In recognition of the partnership needed to achieve the health-related Millen- nium Development Goals and meet the global burden of disease for the twenty- first century, the President should call together world leaders for a summit at the UN General Assembly in the fall of 2009 to announce the U.S. commitment to work with the global community to support global health and other major devel - opment initiatives, such as food and water security. The President should take this opportunity to highlight the importance of health in building stable and prosper- ous communities and should pledge to assist low- and middle-income countries in safeguarding the health of their poorest members. The President should announce the U.S. commitment to the overall fund - ing levels recommended in this report ($15 billion spent annually by 2012) and ask heads of state of other wealthy countries to recommit to their financial promises on global health. In the interest of sovereignty and sustainability, the President should also ask low- and middle-income countries to commit publicly to providing additional resources by 2012 to finance their own health initia - tives. Despite temporary setbacks to the growth of their gross domestic product, the commitment by low- and middle-income countries to leverage additional resources for health is particularly important given the emerging data on health financing showing that with external assistance, the financing pie often does not get bigger; countries merely shift expenditures out of government spending onto donors, defeating the goal of increasing overall health spending to ensure long-term sustainability. Undertaking investments and activities in global health is not only a matter of protecting Americansâ health from overseas threats or leveraging global know- how to solve our shared disease burden. Today, U.S. leadership in global health reflects the values of many Americansâgenerosity, compassion, optimism, and a wish to share the fruits of U.S. technological advances with others around the world who can benefit from them. Resources dedicated to improving health also play a crucial role in the broader mission of U.S. foreign policy to reduce poverty, build stronger economies, promote peace, and enhance the U.S. image in the world today. Working with partners around the world and building on previous commitments, the United States has the responsibility and chance to save and improve the lives of millions; this is an opportunity that the committee hopes the United States will seize.
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