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World health
The pursuit of global health: the relevance of engagement fordeveloped countries Christopher P Howson, Harvey V Fineberg, Barry R Bloom The globalisation of the world economy and the consequent increase in commerce, travel, and communication havebrought benefits to virtually every country. But these changes also bring risks that cannot be addressed adequatelywithin traditional national borders. These risks include emerging infectious diseases, resulting in part from increasedprevalence of drug-resistant pathogens; exposure to dangerous substances, such as contaminated foodstuffs, and bannedand toxic substances; and violence, including chemical and bioterrorist attack. By investing in global health, industrliasedcountries will not only benefit populations in desperate and immediate need of assistance, but also themselves—throughprotecting their people, improving their economies, and advancing their international interests. This paper describes therationale for involvement of industrialised countries in global health, and suggests a means for its coordination.
In April, 1997, the Board on International Health of the economic, social, behavioural, political, scientific, and US National Academy of Sciences’ Institute of Medicine technological factors, many of which are changing at an published a report entitled, America’s Vital Interest in unprecedented rate in both the industrialised and Global Health (in which the term “global health” referred developing worlds. Globalisation of the world economy to health difficulties, issues, and concerns that transcend and the resulting increase in commerce, travel, and national boundaries; may be influenced by circumstances communication have benefited almost every country. But or experiences in other countries; and are best addressed these changes also carry risks that cannot be contained or through cooperative actions and solutions). The Board addressed adequately within traditional national borders.
argued that through investment in global health, the USA International trade and labour markets, deepening poverty, will protect its own people, improve its economy, and political instability, and environmental degradation have advance its international interests. The purpose of this increased the movement of people across national borders paper is to extend this argument one step further—by to 1 million per day.1 Consequently, the industrialised proposing that all developed countries can benefit similarly countries face new threats, including emerging infectious through active and coherent engagement in global health.
diseases, reflecting, in part, the increasing prevalence of (The terms “developed country” and “industrialised country” have evolved over time to include 23 countries: substances, such as contaminated foodstuffs, and banned Australia, Austria, Belgium, Canada, Denmark, Finland, and toxic substances; and violence, including chemical and Luxembourg, the Netherlands, New Zealand, Norway,Portugal, Spain, Sweden, Switzerland, the UK, and the Changes in demography, particularly increased life USA; the newly industrialised Asian economies—Hong expectancy, are dramatically altering patterns of disease Kong, Korea, Singapore, Taiwan, and China—are still epidemiology and disease burden in all countries of the classified as developing economies.) We believe that with world. As life expectancy increases in the world’s poorer their combined human and financial resources, and their nations, chronic diseases of adulthood, such as heart experience in the biomedical and health sciences, disease and depression, are imposing new demands on industrialised countries can, and must, have a key role in health-care systems. With ever-growing public demands for providing solutions for the increasingly complex and health—spending on health care worldwide in 1990, for widespread health difficulties the world now faces. This example, took up 8% of the world’s economic output2— paper describes the rationale for the involvement of the need to balance private-sector and public-sector industrialised countries in global health, and suggests a responsibilities in health, to assess and improve quality of health care, to control costs, and to establish rational andhumane priorities for health-resource allocations are difficulties with which every national government is Human health worldwide is profoundly affected by Board on International Health, Institute of Medicine, National All developed countries have a vital and direct stake in the Academy of Sciences, 2101 Constitution Avenue, NW Washington, health of people around the world; this stake derives both DC 20418 (C P Howson PhD); Harvard University, Massachusetts from enduring traditions of humanitarian concern and Hall, Boston, MA (H V Fineberg PhD); and Howard Hughes Medical from compelling reasons of enlightened self-interest.
Institute, Albert Einstein College of Medicine, Department ofMicrobiology, 1300 Morris Park Avenue, Bronx, NY 10461, USA Considered involvement can serve to protect citizens, improve indigenous economies, and advance national and Correspondence to: Dr Christopher P Howson regional interests on the world stage.
THE LANCET • Vol 351 • February 21, 1998 conditions. In 1900, for example, roughly 5% of the Panel 1: Factors contributing to disease re-emergence andexamples of associated infections world’s people lived in cities with populations exceeding100 000. Today, an estimated 45%—more than 2·5 billion people—live in large urban centres. The UN expects this proportion to rise to 61% of the world’s population by the year 2025. As Linden argues, “the health of cities in the developed world depends in some measure on developingnations’ efforts to control new diseases and drug-resistant strains of old ones incubating in their slums. The developed world ignores at its peril the problem of Third Chemical and biological terrorism—the 1995 terrorist release of toxic sarin gas in the Tokyo subway systemturned the civilian risk of chemical and biological terrorism from a threat into reality. Authorities discovered that the Aum Shinrikyo cult in Japan had stockpiles of biological agents and bacterial-culture media. A new generation ofchemical and biological terrorists has emerged with theability to strike anywhere and with the necessary Improvement of national and regional economies For all populations to achieve better health is desirable initself. But healthier populations in the developing world alsoprovide more vibrant markets for the goods and services of industrialised countries. Investment in health, such as diphtheria, whoopingcough (pertussis), cholera education, can help break cycles of poverty and politicalinstability worldwide, and thus contribute to national Source: adapted from Committee on International Science, Engineering, andTechnology (CISET), 1995.
economic development and the growth of such markets.
The global market, however, retains untapped potential, particularly for vaccines, drugs, and medical devices. In 1992, expenditure on pharmaceuticals was US$220 billion, All countries have a responsibility to protect their or $40 per person, whereas expenditure on vaccines was citizens—residents, soldiers, and travellers. To do this, about $2 billion, and that on medical devices and countries must be aware of developing threats to health, equipment roughly $71 billion.6 As the markets of many both inside and outside national borders. Examples of developing countries continue to expand rapidly—such as the middle-class markets of Asia and Latin America—theirneeds and potential purchasing power are also increasing.
Emerging and resurgent infectious diseases—AIDS has In most developing countries, however, the domestic taught the world that the battle against infectious diseases pharmaceuticals industry is small, and faces significant is far from over. The 1919 pandemic of another infectious constraints on its growth: such as lack of scientific and disease, influenza, killed 20 million people worldwide—a technical infrastructure, and low capacity for research and greater death toll than that of World War I. Prominent development; import restrictions on raw materials; lack of factors associated with the resurgence of infectious diseases quality control; price restrictions; and weak distribution (panel 1 and table) include: (a) increasing mobility of theworld’s population—given the growing movement of people, goods, and services around the globe, no site is too remote, no person too removed, and no organism too isolated to guarantee human safety from infectious diseases; (b) inappropriate and indiscriminate use of antimicrobials—this has occurred in both developing and developed countries, and has promoted the selection of drug-resistant organisms. For example, the case-fatality rate of multidrug-resistant tuberculosis in immuno- competent people can be as high as 30–40%. Perhaps the greatest cause for concern is the 1995 report of the emergence of vancomycin-resistant Staphylococcus aureus in Japan—since staphylococcus infections are common after surgical procedures, and few effective drugs are available against organisms resistant to penicillin, methicillin, and people as a result of war, civil disorder, and economic need *Resistance to isoniazid, rifampicin, and/or other drugs.
Source: Martin Cetron, Grace Emori, Patrick Kachur, Gloria Kelley, and Robert Tauxe, has led to an increase in refugees from 38 million to 60 US Centers for Disease Control and Prevention, personal communication, 1996.
million during this decade, and to a growing migration to Drug-resistant infectious agents and percentage of infections urban areas, often resulting in overcrowded living that are drug resistant, by country or area THE LANCET • Vol 351 • February 21, 1998 systems.6,7 With the exception of China, no developing importance of global surveillance systems that can alert the country is self-sufficient in essential pharmaceuticals. One international communities to outbreaks of infectious consequence is that as many as 2·5 billion people are diseases. The necessary information and communications estimated to have little or no regular access to essential technology are available, yet no formal infectious-disease surveillance system exists on a global scale.
For the foreseeable future, therefore, the introduction of If such a system were in place, even small-scale new drugs and vaccines in developing countries will outbreaks of infectious diseases could be quickly identified.
depend on the pharmaceutical and vaccine industries in Such networks could also be adapted to serve as early- industrialised nations. Moreover, the rising costs of warning systems for chemical or bioterrist attack, or for research and development will require these companies to breakdowns in the safety of the global food supply.
pursue growth in emerging markets as aggressively as Laboratory capabilities for the monitoring of emerging drug resistance of conventional pathogens are crucial to the constraints are deterring industrial countries from assessments of threats and to the development of developing products that could benefit the health of people alternative control strategies. Critical technical assistance in the developing world. These constraints—which could then be efficiently mobilised in response. Global include failure to respect and enforce intellectual-property infectious-disease experts, for example, could be brought rights, drug piracy, pricing restrictions, and lack of to the site or could use modern communication networks consistency in standards of regulation and enforcement— to assist in diagnosis and to support local authorities in must be overcome if markets in the industrialised nations their prevention and control measures. Clinical specimens are to expand effectively to compete and provide needed could be sent to centralised reference laboratories for disease identification and to strengthen early-responsemeasures. A surveillance system would help to identify Advancement of national and regional interests outbreaks of previously unrecognised syndromes or Governments are no longer the sole agents in the global- diseases, making possible scientific approaches for rapid health arena. Beyond national programmes, the global- identification of the causative agent, for development of health system now contains the private or commercial diagnostic tools, and, eventually, for better means of independent sector and non-governmental organisations, The value of shared information for better health such as universities, private foundations, and relief and services—every country must face the difficulty of how to advocacy organisations; the multilateral sector, including provide improved health care at lower costs. Many are multinationally funded organisations such as WHO, the experimenting with new approaches. The international comparative study of health-service delivery and financing organisations, and the World Bank and regional can offer lessons about how countries—industrialised and development banks; and the bilateral sector, which involves developing alike—might better achieve improved health various government and overseas-development agencies and more effective, affordable, and equitable health that are funded by single governments or regional partners.
services for their populations. As life expectancy rises in all This pluralism brings a strong need, and opportunity, for countries, health difficulties become increasingly common active national engagement in global-health issues. The to all—particularly the burden of chronic, non- commitment of the most developed countries to communicable diseases, such as cardiovascular disease, democratic principles, and their traditions of humanitarian psychiatric illness, and neoplastic disease. National and development assistance in foreign policy—from the experiments with programmes addressing issues of Marshall Plan to the current reconstruction activities in the violence, injury, and substance abuse provide important Balkans—form the historical basis for national leadership opportunities to learn. Each country must gather and share in this effort. What is less appreciated is the value and information on the burden of disease; and international power of the developed world’s scientific and economic and national institutions must analyse the risks that capabilities to provide a practical basis for coordinated contribute to premature death and disability and assess improvement of the health of all people—most critically, cost-effective interventions to address the greatest health perhaps, of the poorest people in the world. To fail to burdens. For developed countries to actively participate in anticipate, prevent, and relieve global health difficulties, such efforts is clearly in their direct interests.
and to accept widening gaps in health between the Value for money in acquisition of knowledge from developed and developing worlds, diminishes national international research and clinical trials—investment in stature, compromises the credibility of the national research and development abroad has benefited all governments and international organisations, and neglects countries profoundly. International collaboration in the probably the most direct opportunity to address the eradication of smallpox, for example, disposes of the global fundamental issue of global equity—the health of people.
need to spend US$1 billion annually to vaccinate travellersand other citizens. Transmission of paralytic poliomyelitis no longer occurs in the western hemisphere, and the global campaign to eliminate polio and measles worldwide will save millions of lives and vast resources. Many do not Global surveillance and communication networks—the appreciate that these successes required international trials recent outbreaks of Ebola in Zaire, haemorrhagic Dengue and research. Several diseases (malaria and cholera, for fever in southern Mexico, drug-resistant tuberculosis in example, and certain cancers and genetic diseases) can be New York City, USA, and in large parts of the developing world, bubonic plague in India, cholera in Peru, and collaboration—either because the number of people E coli O157:H7 in Japan and Scotland, underline the affected is greater in certain overseas regions, or because THE LANCET • Vol 351 • February 21, 1998 appropriate registries and databases are available only in Panel 2: Landmark discoveries derived from internationalcooperation in biomedical sciences others. In terms of efficient acquisition of scientificknowledge and value-for-money assessment of the effectiveness of new medical interventions, international scientific collaborations are essential (panel 2).
Improvement of national and regional economiesHealthy populations abroad represent growing markets for businesses of the industrial world. If developed countries invest in improving the health of other populations— through the study and development of treatments for their major illnesses, for example—their economic returns will pharmaceutical and medical products need to be engaged; currently, some 2·5 billion people worldwide have little or no access to essential drugs.8 At the same time, with pressures to contain health costs in industrialised nations, increasing opportunities exist to expand industry into emerging markets in developing countries. For example, pharmaceutical drugs rose from US$17 in 1975 to $29 in 1990.6 With life expectancy increasing in almost all countries, demand for health is growing worldwide. At the pharmaceuticals to the developing world is concentrated in a limited number of industrialised nations; ten countries— eight from western Europe plus the USA and Japan— produce roughly 90% of the new pharmaceuticals vaccine soon to be licensed byWyeth/Lederle field tested in introduced since 1960, with the European countries responsible for 75% of all drugs exported to developingcountries.6 If people in developing nations are to have a greater access to essential drugs, vaccines, and medical devices, and if industrialised countries are to take advantage of the expanding markets in these nations,national governments and international agencies must undertake certain measures in response. Mechanisms to increase incentives for industries to invest in research and development on products that would primarily benefit poor populations are needed most. Incentives could development; safeguards on intellectual-property rights; patents to increase development; and, when necessary, the forging of partnerships between public and private sectors, or the establishment of trust funds to ensure development partly owing to internationalcollaborative studies Advancement of national and regional interests Each developed country has unique strengths to help improve global health. Yet the potential of many, including the USA, has not been fulfilled. We believe that with the end of the Cold War, industrialised nations have much to contribute in the battle against disease and the social and economic inequities that exist in health. To improve thehealth of all populations should be a significant component in the foreign policy of all industrialised countries, because they possess the scientific and technological capability to inhibitors—from extracts of plantscollected in Ghana, Malaysia, and make such improvement possible. To assure future leadership in health, we believe that the most developedcountries investment in biomedical research on major global healthproblems; create incentives to make possible thedevelopment and provision of medical advances for thepoorest countries; forge expanded partnerships and cost- *Alexis Shelokov, Salk Institute, USA, personal communication, 1996.
Source: Philip Schambra and Robert Eiss, National Institutes of Health, sharing with other governments and international donors; and invest in the education and training of physicians, THE LANCET • Vol 351 • February 21, 1998 researchers, and health-care workers from around the globe.
World Bank. World development report 1993: investing in health. New The industrialised countries should also support collabora- York: Oxford University Press, 1993.
tive international and regional action—for example, to Committee on International Science, Engineering, and Technology.
Global microbial threats in the 1990s: report of the NSTC Committee strengthen WHO, the World Bank, and efforts by regional on International Science, Engineering, and Technology (CISET) development banks to promote health and sustained working group on emerging and re-emerging infectious diseases.
development and to partner with industry in ways that Washington DC: National Science and Technology Council.
could accelerate development of drugs and vaccines needed Linden E. The exploding cities of the developing world. Foreign Affairs in developing countries (drugs for malaria and HIV-1 and AIDS, for example). By investing in global health, Kaplan DE, Marshall A. The cult at the end of the world. New York: developed nations will be able to improve the health of their Ballance R, Pogany J, Forstner H. The world’s pharmaceutical own populations, advance their respective economies, and industries: an international perspective on innovation, competition and promote humane values and moral leadership in a world of policy. Prepared for UN Industrial Development Organization opportunities and profound health needs.
Institute of Medicine. Pharmaceutical innovation and the needs of developing countries. Washington DC: National Academy Press, 1979.
Garrett L. The return of infectious disease. Foreign Affairs 1996; UN Development Program. Human development report. New York: Public health
Public health at the crossroads: which way forward? Public health represents society’s organised and publicly supported efforts to improve the health status of the entirepopulation; its focus is on the reduction of health inequalities by optimising the underlying determinants of health andpreventing disease. But public health is under threat and needs to be strengthened so that it is at the centre ofhuman endeavour—locally, nationally, and worldwide.
sanitation, food supplies, and urbanisation are also Major improvements in the health of human populations important determinants of health status that interact with have occurred this century, with the pace of change accelerating in developing countries since the 1950s.
More people live in poverty today than 20 years ago.
About a fifth of the world’s population, 1·3 billion people, live on a daily income of less than US$1.5 Although most behavioural factors that affect population health, have of the world’s poor live in South and East Asia, sub- contributed to these improvements. Declining death rates Saharan Africa has the fastest growing proportion of people are important, but relative inequalities in health status who live in poverty. But poverty is not confined to among and within countries are a major social concern.1 developing countries; in situations where absolute poverty Improvements in life expectancy are not universal and, as is rare, relative deprivation becomes more important.6 has been noted in several central and eastern European More generally, in no society are women treated equally countries, such gains have been reversed with the rapid to men, and women, children, and older people are at increase in death rates among middle-aged men.2 The greatest risk of poverty. Global population growth is about 90 million per year, and about 90% of future growth will unacceptable state of vital statistics worldwide, the occur in the developing world. The health of people in less importance of premature mortality in developing countries, developed countries is at risk from environmental hazards, most of which is preventable, and the growing burden of such as unsafe food and water, as well as from hazards non-communicable disease and injury.
associated with modern lifestyles, for example, air and The main variations in health status among countries result from environmental, socioeconomic, and cultural Population growth interacts with two global threats to factors, and medical care is of secondary importance.
public health: global environmental degradation and Poverty is the most important cause of preventable death, economic globalisation.8 The continued over-consumption disease, and disability, although only a low level of income of the world’s resources by wealthy countries is a major per person is required to achieve acceptable life expectancy contributor to environmental degradation. But it is at the national level.4 Literacy, access to housing, safe water unreasonable to expect the growing populations ofdeveloping countries to resist the pressures to consume,without drastic action to reduce the ecological demands of Departments of Community Health (Prof R Beaglehole MD) and Economic globalisation leads to uneven economic Medicine (R Bonita MD), Faculty of Medicine and Health Science,University of Auckland, Private Bag 92 019, Auckland, growth and increased economic inequality. Trade is the driving force for globalisation which expresses itself in a THE LANCET • Vol 351 • February 21, 1998

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