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Institute of Medicine (US) Committee on the US Commitment to Global Health. The US Commitment to Global Health: Recommendations for the New Administration. Washington (DC): National Academies Press (US); 2009.

Cover of The US Commitment to Global Health: Recommendations for the New Administration

The US Commitment to Global Health: Recommendations for the New Administration.

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Advance U.S. strengths in global health knowledge

Investing in the health of people today (through better delivery of existing approaches) and in the health of people tomorrow (by making new discoveries to understand and combat disease) produces measurable improvements in health. Investments in research to understand diseases, devise new interventions, and implement them widely pay rich dividends in improving global health. The United States has a distinguished record in research, spending more in this area than any other country, and conducting 50 percent of health research worldwide.141 The U.S. government should continue to advance America’s traditional strength in the global health field—the generation of knowledge.

Rectify underfunding of research on health problems of the global poor

Despite being a leader in health research, the United States devotes very little money to ailments of the world’s poorest populations. These issues are neglected in poor countries too because of the limited capacity for research in the public sector, and the inadequate commercial incentives for the private sector, in any country, to undertake research on diseases that have little or no viable financial market. For example, the NIH spends $350 million annually (less than 1 percent of its budget) to tackle parasitic and bacterial diseases, such as malaria, sleeping sickness, and lymphatic filariasis,142 which are virtually unknown in the United States, but are among the most common infections of the world’s poorest billion people.143 In the absence of commercial markets to treat such diseases, the pipeline for any new drugs has virtually dried up during the past three decades.144 Public–private partnerships have emerged in response, using cutting-edge drug discovery technology in addition to traditional drug development to explore new ways of addressing some of the world’s most devastating scourges.145

Certain global health challenges, such as AIDS, have recently received substantial research funding and will likely be met, in part by the successful deployment of innovative biomedical and behavioral strategies. Effective vaccines against AIDS, TB, and malaria could prove as essential as past technological breakthroughs in combating polio and smallpox.146 Improved diagnostics and drugs in these critical areas are also important in light of increased drug resistance resulting from poor adherence to treatment regimens.147

As global disease burden shifts, and noncommunicable diseases become more prevalent in low- and middle-income countries, the line between global and domestic U.S. health research is increasingly blurred. Many noncommunicable diseases, such as cardiovascular disease, have received significant research attention, resulting in important advances that focus on individual risk factors and individual treatments. However, the scale and urgency of such diseases in low- and middle-income countries require population-based methods, which are currently little understood or studied.148 A challenge for the coming decade is to understand how successful interventions in the United States can translate globally to low-resource settings.

It also needs to be recognized that the full benefits of existing knowledge and technologies are far from completely realized. In fact, current challenges reflect, to a large extent, the inability to deploy existing technologies more fully and effectively, especially in low-resource settings.149 Surveys of deaths among children under 5 years of age in 42 low-income countries revealed that while improved technology could potentially avert 22 percent of deaths, the improved utilization of existing methods could avert 63 percent of these deaths.150

Although most research focuses on interventions—97 percent of the grants awarded by the two largest research funders in recent years were for the development of new technologies151—little is known about the characteristics of delivery strategies capable of achieving and maintaining high coverage for specific interventions in various epidemiological, health system, and cultural contexts. A systematic program of research to answer questions about how best to deliver interventions is urgently needed.152

Research on both delivery and utilization mechanisms (as well as new technologies) is needed to achieve the goal of global health. The committee recommends that Congress continue to fund research in important areas—such as new interventions for the prevention and treatment of infectious diseases—but also allocate a portion of the funding levels recommended in this report to increase funds for three purposes: to study the basic mechanisms of diseases that disproportionately affect poor countries; to identify means to control noncommunicable diseases that are applicable in low-resource settings; and to conduct health systems research to improve the delivery of existing interventions.

Given the tight budgets for research, there is now, more than ever, a need for increased coordination, transparency, and accountability in the use and distribution of funds to the various U.S. government agencies funding global health research. The Interagency Committee on Global Health can be an important forum for coordinating global health research across these agencies and avoiding any duplication of efforts. The Interagency Committee, under the leadership of the Deputy for Global Health, can recommend a strategic and coherent plan for financing global health research funding, which can be reflected in the President’s budget.

Strengthen research partnerships and build capacity

The United States has been a leader in global health innovation because of its extensive expertise in science and biomedical research, its strong financial commitments, and the synergies that exist when the government works in partnership with other entities. An example of such a partnership can be found in the Global Alliance for TB Drug Development, a public–private product-development venture that receives funding from the Bill & Melinda Gates Foundation, NIH, USAID, and pharmaceutical companies. The Global Alliance is effectively harnessing the strengths of many participants to discover and develop new drugs for TB. Several such partnerships have emerged during the past decade to deal with global health challenges,153 creating an infrastructure that future investments can build on. Increasingly, these new models of collaboration have included entities in low- and middle-income countries. The Drugs for Neglected Diseases initiative, for example, is a partnership that capitalizes on virtual networks of scientists in Africa, Asia, and Latin America to address diseases of poverty.

Once dominated by health experts from advanced economies, the field of global health now reflects a more diverse and globally representative group of experts and organizations. Much of the international community’s work in building the capacity of public health in the developing world has borne noticeable results. Twenty-five years ago, global health experts gave guidance to health officials in low-income countries; today, the relationship is more a partnership than a tutorial. Low- and middle-income countries have global health experts of their own who not only sit at the same table, but are often better informed and better aware of the health status and specific needs of their country or region than their international partners.

The NIH’s Fogarty International Center has played a pivotal role in building the capacity of researchers in low- and middle-income countries. Fogarty’s highly successful AIDS International Training and Research Program provides training in multi-disciplinary biomedical and behavioral research at institutions that address the AIDS epidemic in their particular countries. More recently, Fogarty built on this model and designed the Millennium Promise Awards, a program that builds research capacity in low- and middle-income countries in fields related to cancer, cerebrovascular disease, lung disease, obesity, lifestyle factors, and genetics as related to chronic diseases.154

The United States can increasingly expect to find institutions in middle-income countries that are among the world’s centers of excellence on public health and science, thereby enabling the establishment of meaningful partnerships. Public spending on health research by developing countries now exceeds $2 billion a year.155 In an example of an emerging economy taking the lead in global health research, the International Vaccine Institute in Seoul, Korea, is conducting vaccine research to help children in poor countries with funding from numerous public and private donors including the NIH, the National Science Foundation, and USAID.156 Another example is provided by Brazil’s recent plan to invest $23 million in a pharmaceutical factory in Mozambique that will use raw materials from India to produce much-needed antiretrovirals for Africa.157

Federal Executive Branch agencies and departments should strengthen existing partnerships with the private sector and explore new collaborations with the public and the private sectors in low-income and emerging economies. Through sustained research partnerships with low- and middle-income countries, the U.S. government can further strengthen the local capacity of researchers, practitioners, and policy makers, as well as their respective institutions.

Harness information technology and promote access to knowledge

Increasingly, research is being conducted on a global scale through virtual communities of geographically dispersed scientists. This highlights the need to foster access to information in low-resource settings through a global network to exchange ideas and scientific tools, promote sustainable cross-country research partnerships, and enable the timely dissemination of best practices. A unique opportunity now exists for the U.S. government to invest in information technology and infrastructure that will encourage more efficient and effective communication among the multiple players in the global health arena.

The tools of the modern digital world—in conjunction with novel technologies, especially those in the biological and medical sciences—have dramatically changed the potential for obtaining and using new information. In the field of global health, the benefits can be seen in many ways: how medical research is conducted; how new information is published, stored, retrieved, and used; how scientists and clinicians communicate with each other; how diseases are monitored and tracked; and how medicine is practiced.

Ideally, everyone in the field of global health would have access to the digital tools that would allow them to benefit from these advances. In reality, developing countries lag far behind. Despite some improvements, the use of the Internet and mobile technologies that allow access to information remains very uneven. For example, only 3 percent of the African population uses the Internet, as opposed to 60 percent in North America.158 It is clear, therefore, that continued commitment is needed for long-term investments in infrastructure to bring more people around the world “online.”

The results and data of publicly funded global health research and evaluation also need to be made fully accessible in the public domain, for the benefit of all. Developments in electronic publishing have greatly reduced the cost of production, distribution, and storage of scientific work. Access to these resources can be greatly enhanced by the creation of public digital libraries and open access publishing. The major funders of biomedical research now require that all reports resulting from their support be made freely accessible through existing online libraries, such as NIH’s PubMed Central, within 6 months or a year after publication. Since much of global health research is either publicly funded or funded through philanthropic endeavors with the aim of achieving social benefits, its results should be placed in the public domain as quickly as possible. Where feasible, data generated through publicly funded research should also be made available for reanalysis and other purposes.

Personal communication, S. Levy, National Institute for Allergy and Infections Diseases, funding for Neglected Tropical Diseases, November 12, 2008.

Copyright © 2009, National Academy of Sciences.
Bookshelf ID: NBK32620
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