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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.

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

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A prominent role for health in U.S. foreign policy

Much has changed since the 1997 IOM global health report. In the past decade, global health has drawn record funding, both from the U.S. government and from private sources, becoming a very visible part of U.S. foreign policy. Repeated polls during this period have shown that health now ranks among Americans’ top priorities for development assistance—not merely to protect U.S. interests, but also as a way of promoting human development worldwide.3

Even during this time when the U.S. economy is under some 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.

Unprecedented commitments to global health

The promise of potential solutions to global health problems has captured the interest of a new generation of philanthropists, students, scientists, private sector leaders, and citizens—eager to make a difference in this interconnected world. During the last decade, extraordinary philanthropic commitments have been made to develop and support strategies to combat disease and resolve health care delivery problems. The most notable example has been the nearly $3 billion spent on global health by the Bill & Melinda Gates Foundation, now the world’s largest charitable organization.4 On American university campuses, global health initiatives have burgeoned, with a globally oriented student body demanding a curriculum that reflects its interests and career aspirations.5 Through new models of collaboration, the private sector is responding to pressures and opportunities to apply technology and business acumen to enduring social problems. The convergence of public and private commitments has produced an unprecedented level of interest in global health on the part of the American people.

During the last decade, the U.S. government has mirrored this public interest with record commitments to global health. In 2008, U.S. government funding for health-related foreign assistance was more than $7.5 billion—an all-time high.6 This extraordinary increase in the percentage of U.S. aid for health was driven mostly by new models of assistance, such as the Global Fund to fight AIDS, Tuberculosis, and Malaria (GFATM), the President’s Emergency Plan for AIDS Relief (PEPFAR), and the President’s Malaria Initiative.

PEPFAR constitutes the largest commitment ever by any nation for a global health initiative dedicated to a single disease.7 Between 2001 and 2003, the United States spent $3.5 billion on the global fight against AIDS; since the inception of PEPFAR in 2004, the United States has spent a combined total of more than $18 billion on AIDS, both through PEPFAR and GFATM.8 Very few countries could have mobilized this level of resources so quickly to deliver a complex treatment and prevention regimen to millions of people across multiple countries. PEPFAR’s achievement—bringing lifesaving drugs to 1.73 million people and tripling the number of HIV-infected people receiving treatment in sub-Saharan Africa alone9—also demonstrated the success the United States is capable of achieving when it seriously commits to improving health outcomes.

In addition to development assistance for global health, the importance of the U.S. commitment to health research cannot be overemphasized. One half of the world’s health research can be attributed to investments by the American taxpayer (especially through funding of the National Institutes of Health [NIH]) and the U.S. private sector.10 Yet only 8 percent (or $9.3 billion) of the total U.S. investment made by public and private entities in health research ($116 billion) is devoted to solving global health problems.11

Investments in global health reflect American values

Undertaking investments and activities in global health is not only a matter of protecting Americans’ health from overseas threats or enhancing U.S. economic interests. Today, U.S. leadership in global health reflects the values of many Americans—generosity, compassion, optimism, and a wish to share the fruits of U.S. technological advances with others around the world who can benefit from them. In addition to supporting U.S. government efforts to save lives, the American people also value the goal of enabling healthy individuals, families, and communities everywhere to live more productive and fulfilling lives. Resources dedicated to improving health play a crucial role in the broader mission of reducing poverty, building stronger economies, promoting peace, and restoring U.S. credibility in the world today.

In today’s market crisis, the financial policies and practices of the most developed 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 country’s population worsens due to lowered household income and reduced access to health care.12 The poor in low-income countries are most affected because they pay a large portion of their health care costs out-of-pocket, without the benefit of social safety nets.13 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.14 Numerous studies have demonstrated that as people benefit from the positive economic aspects of globalization, 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 in Argentina, Chile, China, Ecuador, Honduras, India, Kenya, Peru, Thailand, Uganda, and Vietnam descend into poverty.15 Poor health not only reduces economic productivity and earning potential, it also reduces personal resources by imposing higher health care costs and diminishing savings.16 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 economies around the world. One study shows that more than half of Africa’s 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.15 The Commission on Macroeconomics and Health of the WHO estimated that 8 million lives saved from the leading causes of death in sub-Saharan Africa—infectious diseases and nutritional deficiencies—would save approximately $186 billion per year.17 China, India, and the Russian Federation could each forego between $200 billion and $550 billion in national income during the next 10 years as a result of heart disease, stroke, and diabetes.18

Investments in health can also demonstrate U.S. commitment to avert conflict and promote a more peaceful world.20 Most of the people living in the societies of the world’s poorest billion people are either currently engaged in a civil war or have recently been through one.21 Implementing disease control and public health activities—which help break the cycle of poverty, conflict, and poor health—is particularly challenging in fragile states and countries that have experienced conflict.22 For example, countries with the highest infant and child mortality rates are those most likely to be engaged in war;23 in both 1990 and 2005, Afghanistan, Angola, and Sierra Leone—three war-torn countries—had the highest mortality rates in the world for children under 5, even during times of relative peace.24 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. Public opinion polls following U.S. aid efforts in the aftermath of the Pakistan earthquake25 and the South Asian tsunami showed an improvement in how America is viewed.26 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,27 the region that has received the most U.S. foreign aid in health.28 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 21st century, such as nuclear disarmament and climate change.

Global health is a responsibility and an opportunity to seize

Given the importance of health in building stable and prosperous communities, the committee encourages the new President to make a bold public statement that global health 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 the United States’ successful investments in this arena and propose new means for pursuing global health objectives in a committed, cooperative, and nonpartisan manner. In a public 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 an 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 placing priority on humanitarian needs over politics. In developing sanctions at the UN and elsewhere, food, medicine, and other health necessities should not be included among the areas of denied trade or assistance.

Copyright © 2009, National Academy of Sciences.
Bookshelf ID: NBK32621

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