The Challenge of Global Health

Laurie Garrett

From Foreign Affairs, January/February 2007

Summary:  Thanks to a recent extraordinary rise in public and private giving, today more money is being directed toward the world's poor and sick than ever before. But unless these efforts start tackling public health in general instead of narrow, disease-specific problems -- and unless the brain drain from the developing world can be stopped -- poor countries could be pushed even further into trouble, in yet another tale of well-intended foreign meddling gone awry.

Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations and the author of Betrayal of Trust: The Collapse of Global Public Health.

As concern regarding the threat of pandemic influenza has risen worldwide over the last two years, so has spending to bolster the capacities of poor countries to control infected animal populations, spot and rapidly identify human flu cases, and isolate and treat the people infected. It has become increasingly obvious to the donor nations that these tasks are nearly impossible to perform reliably in countries that lack adequate numbers of veterinarians, public health experts, laboratory scientists, and health-care workers. Moreover, countries need the capacity to coordinate the efforts of all these players, which requires the existence of a public health infrastructure.

At a minimum, therefore, donors and UN agencies should strive to integrate their infectious-disease programs into general public health systems. Some smaller NGOs have had success with community-based models, but this needs to become the norm. Stovepiping should yield to a far more generalized effort to raise the ability of the entire world to prevent, recognize, control, and treat infectious diseases -- and then move on to do the same for chronic killers such as diabetes and heart disease in the long term. Tactically, all aspects of prevention and treatment should be part of an integrated effort, drawing from countries' finite pools of health talent to tackle all monsters at once, rather than dueling separately with individual dragons.

David de Ferranti, of the Brookings Institution, reckons that meeting serious health goals -- such as getting eight million more people on ARVs while bringing life expectancies in poor countries up to at least the level of middle-income nations and reducing maternal mortality by 15-20 percent -- will cost about $70 billion a year, or more than triple the current spending.

Even if such funds could be raised and deployed, however, for the increased spending to be effective, the structures of global public health provision would have to undergo a transformation. As Tore Godal, who used to run the neglected-diseases program at the WHO, recently wrote in Nature, "There is currently no systemic approach that is designed to match essential needs with the resources that are actually available." He called for a strategic framework that could guide both donations and actions, with donors thinking from the start about how to build up the capabilities in poor countries in order to eventually transfer operations to local control -- to develop exit strategies, in other words, so as to avoid either abrupt abandonment of worthwhile programs or perpetual hemorrhaging of foreign aid.

In the current framework, such as it is, improving global health means putting nations on the dole -- a $20 billion annual charity program. But that must change. Donors and those working on the ground must figure out how to build not only effective local health infrastructures but also local industries, franchises, and other profit centers that can sustain and thrive from increased health-related spending. For the day will come in every country when the charity eases off and programs collapse, and unless workable local institutions have already been established, little will remain to show for all of the current frenzied activity.

DOC-IN-A-BOX As a thought experiment, the Council on Foreign Relations' Global Health Program has conceived of Doc-in-a-Box, a prototype of a delivery system for the prevention and treatment of infectious diseases. The idea is to convert abandoned shipping containers into compact transportable clinics suitable for use throughout the developing world.

Shipping containers are durable structures manufactured according to universal standardized specifications and are able to be transported practically anywhere via ships, railroads, and trucks. Because of trade imbalances, moreover, used containers are piling up at ports worldwide, abandoned for scrap. Engineers at Rensselaer Polytechnic Institute converted a sample used container into a prototype Doc-in-a-Box for about $5,000, including shipping. It was wired for electricity and fully lit and featured a water filtration system, a corrugated tin roofing system equipped with louvers for protection during inclement weather, a newly tiled floor, and conventional doors and windows. Given economies of scale and with the conversions performed in the developing world rather than New York, it is estimated that large numbers of Doc-in-a-Boxes could be produced and delivered for about $1,500 each.

Staffed by paramedics, the boxes would be designed for the prevention, diagnosis, and treatment of all major infectious diseases. Each would be linked to a central hub via wireless communications, with its performance and inventory needs monitored by nurses and doctors.

Governments, donors, and NGOs could choose from a variety of models with customizable options, ordering paramedic training modules, supplies, and systems-management equipment as needed. Doc-in-a-Boxes could operate under a franchise model, with the paramedics involved realizing profits based on the volume and quality of their operations. Franchises could be located in areas now grossly underserved by health clinics and hospitals, thus extending health-care opportunities without generating competitive pressure for existing facilities.

On a global scale, with tens of thousands of Doc-in-a-Boxes in place, the system would be able to track and respond to changing needs on the ground. It would generate incentives to pull rapid diagnostics, easy-to-take medicines, new types of vaccines, and novel prevention tools out of the pipelines of biotechnology and pharmaceutical companies. Supplies could be purchased in bulk, guaranteeing low per-unit costs. And the sorts of Fortune 500 companies that now belong to the Global Business Coalition on HIV/ AIDS, TB, and Malaria would be able to provide services and advice.

Over time, Doc-in-a-Boxes could emerge as sustainable local businesses, providing desperately needed health-care services to poor communities while generating investment and employment, like branches of Starbucks or McDonald's.

{Footnote 1} In the original version of "The Challenge of Global Health," the view that "foreign aid efforts suck all the air out of local innovation and entrepreneurship" was incorrectly attributed to Steven Radelet.