When health goes global

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“The impressive improvements in health status worldwide over the last century are a cause for celebration” proclaim Colin Mathers and Ruth Bonita in the second edition of “Global Public Health: a new era” (1). This statement says it all: improving the health and well-being of humans is a long and difficult process involving scientific discoveries, policy management, and coordinated cooperation between different communities (including the medical and scientific community, policy makers and those at different levels of government).

Since ancient times, health issues have posed a continuous challenge for human civilization, threatening the very stability and safety of cultural and societal institutions on which we depend. In recent decades, international cooperation addressing health issues has grown immensely, especially since the creation of such official organizations as the World Health Organization (WHO) and the International Institute for Global Health (IIGH), to name a few. Interestingly, the concept of “Global Health” appeared not long after the term “Globalization” and was defined in part, in opposition to Public Health. These distinct concepts of health strategies share the goal of improving human health and well-being across a range of scales and target populations. Most im¬portantly, they must not compete with, but rather complement and reinforce, one another (2).

While human health has improved remarkably over the course of recent history, closer examination rapidly reveals many opportunities for improvement. Inequality between countries, and between socioeconomic groups within countries, is a continuing contributer to global dis-parities in access to quality healthcare. Rich and poor countries alike face their share of health issues and healthcare system flaws. Differences in healthcare regulations and policies between countries; and enforcement challenges due to insufficient resources constitute significant obstacles particularly to collaborations with significant potential for the resolution of health issues affecting immigrant populations.

Who sets the priorities of the global health agenda?
Funding allocation decisions, and the agenda they serve, constitute major ethical questions facing the Global Health community. It is therefore important to ask where the onus for choosing and championing a particular Global Health agenda lies? In her review, “Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the Setting(s) of the International/Global Health Agenda”, AE Birn (3) examines this question in the con-text of two of the largest philanthropic organisations that have significantly influenced this agenda over the past century. Is it possible to divorce funds from the agenda of those that provide them? In some cases, it would appear that the funders’ priorities yield campaigns that are inappropriate to the context of the populations they are meant to help. Prabhat Jha makes a compelling argument in his opinion paper, “Counting the dead is one of the world’s best investments to reduce premature mortality,” (4) for the adaptation of a vital statistics system. Such a system has proven transformative in the management of healthcare priorities in developed countries, and could help elucidate the realities of developing countries, including challenges facing the implementation of specific strategies intended to improve Global Health.

Are developed countries committing a fatal error by presuming that they hold the solutions to Global Health challenges, and that it is their moral duty to share them with, or impose them upon, less devel-oped countries that they deem in need of help? Could they, in fact, learn something from these countries? In their opinion paper, “Mismanagement of tuberculosis in India: Causes, consequences, and the way forward,” Bhargava, Pinto, and Pai (5) discuss the lessons learned from the various private and public efforts to control tuberculosis in India, many of which can be extrapolated to other Global Health initiatives worldwide.

Unspoken factors impacting global health
The most urgent Global Health issues occur largely in developing countries, while resources required to implement solutions tend to lie in more developed nations. What is the responsibility of developed nations towards resolving the health issues of their developing counterparts? Is it a moral responsibility? Based upon a spirit of the “right” thing to do? Or is there a more cynical and unmentioned motivation? It is clear that influencing a country’s healthcare is tantamount to influencing the country itself, whatever the underlying reasons.

All countries may expect to benefit from increased political and social stability resulting from improved health in developing countries, but one may envisage a more self-serving reason to improve the health of potentially incoming populations. The current unprecedented ease of global travel resulting in record rates of human migration, also enables the spread of non-endemic, or worse, the re-emergence of “thought-to-be-eradicated,” diseases. Recent changes by the Canadian government to healthcare funding for refugee claimants within its borders restricts coverage for rejected refugee claimants, or claimants from designated countries of origin, to only those products or services required to diagnose, prevent, or treat a disease posing a risk to public health or a condition of public safety concern (6). The Japanese Global Health strategy is based on potential economical interests (7). Such a strategy might overlook certain countries because they are not economically valuable to Japan. The US Global Health strategy, on the other hand, is more complex, considering political, security, and economic outcomes (8).

A shift in global health priorities
Scientific advances have resulted in the eradication of some diseases, while trans¬forming others from acutely devastating to chronic. Consequently, Global Health priorities must adjust to address the most urgent current issues. US President Obama’s 6-year Global Health Initiative, announced in 2009, included initiatives to maintain the US commitment to fighting previously prioritised diseases such as malaria and AIDS, but also to scale up programs in maternal and child health, family planning, and neglected tropical diseases (9). Non-communicable diseases such as diabetes and cancer are also gaining attention. Despite this shift, a recent editorial in The Lancet proposes that the focus on health issues is waning, and that global efforts in the near future will focus rather on sustainability (10). Of course, the two are synergistic improvements in sustainability which will almost certainly engender improvements in Global Health, even if they are not the primary goal.

Should global health strategies rely solely on cutting edge science?
Solutions to Global Health challenges are as varied as the circumstances of issues they seek to resolve. However, they may be divided into 2 broad categories: solutions involving new technologies and discoveries, and those resulting from the adaptation of existing technologies.

Global Health solutions through novel technologies and discoveries promise tantalizing results:

  • A malaria vaccine could provide protection from a disease that threatens half the world’s population (11).
  • New drugs for neglected tropical diseases could drastically improve the lives of more than 1 billion people worldwide (11).

These efforts possess the potential to revolutionise health challenges, but their extended timeline provides little immediate relief for pressing problems that exist today. Considerable time and money must be invested without guarantee of positive outcomes, in pursuit of potential scientific and technological solutions to Global Health problems. Efforts to develop these solutions are, of themselves, exciting endeavours that push back the frontiers of science. In his article, “Can Synthetic Biology Tackle Global Health Issues?” (12), Carlos G. Acevedo-Rocha argues that synthetic biology constitutes one such tool that may allow scientists to discover novel solutions to Global Health issues that are inadequately addressed with existing technologies. He rationally evaluates the risks and benefits of this rather new field and its potential impact on the future of Global Health.

The other broad category of healthcare solutions involves the adaptation or improved availability of existing technologies, some of which are very simple, to specific contexts. Some examples of this approach include promoting breastfeeding, providing bicycles to healthcare professionals, distributing mosquito nets, and promoting improved sanitation such as hand washing. These solutions have the advantage of being immediately available for implementation. They are also often highly cost effective, providing con-siderable benefit to many people with investment of relatively few resources. In their article “A global health project: creating sustainable solutions to address anemia at Munsel-ling school in rural northern India” B. Brar, et al. (13) describe how they involved the local community and adapted solutions from other communities in initiatives to resolve a local health issue.

Conclusion
What role should the scientific community play in the development and application of Global Health solutions? Scientists in conventional research institutes are perhaps more inclined to participate in the development of new technologies and the discovery of novel scientific solutions. One could argue that the current competitive paradigm of academic research selectively rewards and therefore favours the pursuit of new discoveries over the unsung application of existing technologies to Global Health challenges. However, the science under-pinning the adaptation and application of existing technologies should not be overlooked or unfunded, capitalizing upon their efficacy despite their apparent simplicity.

The selection of such pragmatic approaches will surely be further favoured by their smaller requirement for financial investment. This is especially important given the crisis that continues to hinder the global economy, greatly diminishing the resources of countries that have typically funded much of the research into Global Health initiatives.

References

  1. Beaglehole, R. and R. Bonita. “Global public health : a new era.” 2nd ed. 2009, Oxford: Oxford University Press. xx, 311 p. ISBN: 97801992366262.
  2. Fried, L.P., et al. “Global health is public health.” Lancet. 375 (9714): p. 535-7. http://dx.doi.org/10.1016/S0140-6736(10)60203-6 PMID:20159277
  3. Anne-Emanuelle Birn. “Philanthrocapitalism, past and present : The Rockefeller Foundation, the Gates Foundation, and the Setting(s) of the International/ Global Health Agenda.” Hypothesis Journal. In press.
  4. Prabhat Jha. “Counting the dead is one of the world’s best investments to reduce premature mortality.” Hypothesis Journal 10.1 (2012). Web. http://www.hypothesisjournal.com
  5. Bhargava, Anurag, Lanceot Pinto, and Madhukar Pai. “Mismanagement of tuberculosis in India: Causes, consequences, and the way forward.” Hypothesis Journal 9.1 (2012). Web. http://www.hypothesisjournal.com
  6. Health Canada website: http://www.cic.gc.ca/english/refugees/outside/ arriving-healthcare.asp, accessed July 9, 2012
  7. Maguire, Corrine. “Global Health in Japan: A Moral and Economic Dilemma.” Harvard College global health review. Panorma. Spring 2011. Web http://www.hcs.harvard.edu/hghr/2012/02/01/global-health-in-japan-a-moral-and-economic-dilemma/
  8. Harley Feldbaum, Kelley Lee, and Joshua Michaud. “Global Health and Foreign Policy.”Epidemiol Rev 2010; 32 : 82ñ92. doi: 10.1093/epirev/mxq006 http://dx.doi.org/10.1093/epirev/mxq006
  9. www.globalhealth.org
  10. Global health in 2012: development to sustain¬ability. Lancet. 379 (9812): p. 193. http://dx.doi.org/10.1016/S0140-6736(12)60081-6
  11. Global Health Technologies Coalition. http://www.ghtcoalition.org/about-health -technologies.php, accessed July 9, 2012
  12. Carlos G. Acevedo-Rocha, “Can Synthetic Biology Tackle Global Health Issues.” Hypothesis Journal. In review.
  13. Brar B., et al., “A global health project: creating sustainable solutions to address anemia at Munsel-ling school in rural northern India.” Hypothesis Journal. In press. Health Canada website: http://www.hypohesisjournal.com accessed July 9, 2012

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