Global Health Security: A Long-Term Prescription

January 05, 2009

By Dr. Julie E. Fischer

The Challenge

We need a coherent global health strategy that looks beyond each crisis to the bigger picture. The 2003 SARS outbreak, when a new and virulent pneumonia spread by international travelers killed hundreds and wreaked havoc on Asian economic growth, illustrated the vulnerability of even developed nations to emerging infections. The ongoing HIV/AIDS epidemic highlighted intractable cycles of poverty and disease. In response, the US invested billions of dollars in confronting health threats abroad - one disease at a time.

The Context

The economic and human costs of the anthrax assaults, SARS epidemic, and simmering outbreaks of an avian influenza strain with pandemic potential catapulted public health issues onto the US national security agenda. A new appreciation of the impact that HIV/AIDS and other disease burdens might have on socioeconomic and political stability in fragile states simultaneously catalyzed a new focus on the nexus of health, development, and security. US policymakers have created dozens of global health initiatives and appropriated previously unprecedented sums to fund them, including the largest single health assistance program in history: the President's Emergency Plan for AIDS Relief (PEPFAR) with a commitment of $15 billion over 5 years. Concerns about the likely impact of pandemic influenza prompted the US to pledge to strengthen disease detection and response capabilities in nations where conditions might favor emerging diseases. Responsibility for planning and implementing the hugely amplified US global health mission remains spread among various agencies, with different interagency coordinating and oversight bodies for specific diseases and no clear mechanism for resolving competing priorities.

The new Administration and Congress face a set of complex health security challenges, including how to reconcile competing health and security demands, define metrics of success, cultivate expertise within government agencies, and define US global health leadership. Global health concerns are also deeply intertwined with a much broader set of issues that include food security, access to clean water, energy demands, environmental use and degradation, and climate change.

Where to Start

• Approach health systems holistically rather than lurching from disease to disease or crisis to crisis

Current US global health strategies treat emerging health concerns, such as potential bioterrorism or pandemic influenza, as threats distinct from each other as well as from challenges such as HIV/AIDS and malaria, creating disease-centered programs stove-piped in operation and leadership. This reinforces perceptions that programs aimed at securitized threats such as pandemic influenza compete against (rather than synergize with) "pro-poor" strategies such as maternal-child health promotion that may strengthen health systems across the board, leading to desirable outcomes and better host-nation buy-in. Vertical programs not only fail to build health systems consistent with local needs, but may bypass opportunities to reap additional benefits at modest cost - for example, by creating an infrastructure to deliver anti-retroviral therapy AND childhood immunizations. The costs of the largest US vertical program, the current PEPFAR treatment strategy, could grow to as much as $12 billion a year before 2018, a dependency that can be neither sustained nor abandoned without serious repercussions.

The US benefits from new international health regulations that require all states to build capacity to detect and report health threats to the WHO in real time. US commitments to help nations meet these obligations and local priorities simultaneously by strengthening health systems should help nations prepare for unexpected and predictable threats, and avert resentment against a "responsibility to detect" perceived as a service to benefit wealthy states. A horizontal approach to health would also allow the US to consider noncommunicable diseases when weighing the most effective points for global health interventions. While the growing burden of non-infectious diseases in developing nations may not pose a direct threat to US citizens at home and abroad, the cost of treating these chronic conditions over decades may destabilize economies and governments as surely as any outbreak.

• Identify a single focal point within the White House to set global health strategy and coorindate priority setting and funding allocation

The State Department's special representatives for HIV/AIDS and avian and pandemic influenza have been charged with coordinating all US government efforts to confront these two diseases abroad, with input from the Homeland Security Council as well as other agencies. The Departments of Health and Human Services, Homeland Security, Defense, Commerce and Agriculture and USAID provide technical expertise, transfer resources, and help shape health dialogues with other nations and multilateral organizations. Rapid expansion of US global health programs spurred ongoing inter- and intra-departmental reorganization, with no single authority to harmonize global health policies and actions, nor consensus on a central goal. As the US moves from an "emergency" plan for AIDS relief to the long haul and public clamor for an effective shield against pandemic influenza waxes and wanes, effective senior global health leadership is needed to reconcile US defense, development, and diplomatic goals as effectively as possible.

• Strengthen US commitment to working in concert with, rather than parallel to, multilateral organizations with similar global health missions

US programs often duplicate the efforts of other donor nations, the World Health Organization (WHO), and public-private partnerships such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Competing health programs create administrative burdens that further drain human resources in nations already strained by workforce shortages. In its multilateral health engagements, the US has also emphasized policies to satisfy domestic political constituencies (for example, restricting harm reduction strategies that can limit HIV transmission) over evidence-based practices likely to yield the greatest health security benefits. The US exerts tremendous influence through experts from agencies such as the Centers for Disease Control and Prevention (CDC), but large-scale philanthropy from organizations such as the Gates Foundation will allow public-private partnerships and multilateral organizations increasing independence of the US in global health decision-making. To maintain the credibility of its leadership in global health, the new US Administration should lead efforts within WHO, UNAIDS, and other international forums to share information on health aid and technical data on health crises transparently and promptly, and to identify universally acceptable evidence-based metrics for health assistance programs with similar goals.

• Look at the bigger picture: contribute US expertise to analyzing global health trends in the context of climate change, energy demands, environmental conditions, and food and water shortages

Policy decisions regarding global health are not made in a vacuum. Health status is deeply intertwined with other issues. The ripple effect of policy decisions in one of these deeply intertwined areas is vividly illustrated by the recent biofuels near-debacle: the decision by governments in several developed nations to shift enormous resources into biofuels due to rising oil prices and the political popularity of environmentally friendly policies created a massive and sudden market for biofuel crops such as corn and sugarcane. The abrupt diversion of agricultural resources from food supplies into more lucrative biofuel crops exacerbated a growing food security problem for the world's poorest populations as food prices rose precipitously. Poor nutrition increases vulnerability to infectious disease outbreaks at the population level and maternal mortality, and can hamper intellectual and physical development in children. The clamor for biofuels, a short-term solution to meet energy demands, may have perpetuated a health crisis that will endure long past the return of lower oil prices.

In addition to posing direct threats to health, such as expanding regions hospitable to mosquitoes that carry malaria and other diseases, climate change will exacerbate existing global health challenges. Regardless of the outcome of future climate change negotiations, the US must commit its considerable scientific and technical expertise to anticipating and analyzing these interdependent challenges, and endorse efforts by experts working under the aegis of UN agencies to predict the long-term health impacts of climate change, energy, and food security policies.

What's on the Line

In the absence of clear leadership and vision on global health issues, the US risks investing enormous sums that ultimately fail to protect its interests at home and abroad. Narrow disease reporting systems shored up in partner states might offer a false sense of security, even as the next SARS or HIV takes root to claim American lives and fracture interdependent economies. Humanitarian crises, including millions of ultimately preventable deaths, will continue to ripple through strategically critical regions burdened by HIV/AIDS and other scourges. Moreover, a continued US focus on bilateral, vertical programs rooted in a state-centered security framework may further damage the legitimacy of US leadership as the international community leans toward collaborative global health solutions.