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.

BEWARE WHAT YOU WISH FOR

Less than a decade ago, the biggest problem in global health seemed to be the lack of resources available to combat the multiple scourges ravaging the world's poor and sick. Today, thanks to a recent extraordinary and unprecedented rise in public and private giving, more money is being directed toward pressing heath challenges than ever before. But because the efforts this money is paying for are largely uncoordinated and directed mostly at specific high-profile diseases -- rather than at public health in general -- there is a grave danger that the current age of generosity could not only fall short of expectations but actually make things worse on the ground.

This danger exists despite the fact that today, for the first time in history, the world is poised to spend enormous resources to conquer the diseases of the poor. Tackling the developing world's diseases has become a key feature of many nations' foreign policies over the last five years, for a variety of reasons. Some see stopping the spread of HIV, tuberculosis (TB), malaria, avian influenza, and other major killers as a moral duty. Some see it as a form of public diplomacy. And some see it as an investment in self-protection, given that microbes know no borders. Governments have been joined by a long list of private donors, topped by Bill and Melinda Gates and Warren Buffett, whose contributions to today's war on disease are mind-boggling.

Thanks to their efforts, there are now billions of dollars being made available for health spending -- and thousands of nongovernmental organizations (NGOs) and humanitarian groups vying to spend it. But much more than money is required. It takes states, health-care systems, and at least passable local infrastructure to improve public health in the developing world. And because decades of neglect there have rendered local hospitals, clinics, laboratories, medical schools, and health talent dangerously deficient, much of the cash now flooding the field is leaking away without result.

Moreover, in all too many cases, aid is tied to short-term numerical targets such as increasing the number of people receiving specific drugs, decreasing the number of pregnant women diagnosed with HIV (the virus that causes AIDS), or increasing the quantity of bed nets handed out to children to block disease-carrying mosquitoes. Few donors seem to understand that it will take at least a full generation (if not two or three) to substantially improve public health -- and that efforts should focus less on particular diseases than on broad measures that affect populations' general well-being.

The fact that the world is now short well over four million health-care workers, moreover, is all too often ignored. As the populations of the developed countries are aging and coming to require ever more medical attention, they are sucking away local health talent from developing countries. Already, one out of five practicing physicians in the United States is foreign-trained, and a study recently published in JAMA: The Journal of the American Medical Association estimated that if current trends continue, by 2020 the United States could face a shortage of up to 800,000 nurses and 200,000 doctors. Unless it and other wealthy nations radically increase salaries and domestic training programs for physicians and nurses, it is likely that within 15 years the majority of workers staffing their hospitals will have been born and trained in poor and middle-income countries. As such workers flood to the West, the developing world will grow even more desperate.

Yet the visionary leadership required to tackle such problems is sadly lacking. Over the last year, every major leadership position on the global health landscape has turned over, creating an unprecedented moment of strategic uncertainty. The untimely death last May of Dr. Lee Jong-wook, director general of the World Health Organization (WHO), forced a novel election process for his successor, prompting health advocates worldwide to ask critical, long-ignored questions, such as, Who should lead the fight against disease? Who should pay for it? And what are the best strategies and tactics to adopt?

The answers have not been easy to come by. In November, China's Dr. Margaret Chan was elected as Lee's successor. As Hong Kong's health director, Chan had led her territory's responses to SARS and bird flu; later she took the helm of the WHO's communicable diseases division. But in statements following her election, Chan acknowledged that her organization now faces serious competition and novel challenges. And as of this writing, the Global Fund to Fight AIDS, Tuberculosis, and Malaria remained without a new leader following a months-long selection process that saw more than 300 candidates vie for the post and the organization's board get mired in squabbles over the fund's mission and future direction.

Few of the newly funded global health projects, meanwhile, have built-in methods of assessing their efficacy or sustainability. Fewer still have ever scaled up beyond initial pilot stages. And nearly all have been designed, managed, and executed by residents of the wealthy world (albeit in cooperation with local personnel and agencies). Many of the most successful programs are executed by foreign NGOs and academic groups, operating with almost no government interference inside weak or failed states. Virtually no provisions exist to allow the world's poor to say what they want, decide which projects serve their needs, or adopt local innovations. And nearly all programs lack exit strategies or safeguards against the dependency of local governments.

As a result, the health world is fast approaching a fork in the road. The years ahead could witness spectacular improvements in the health of billions of people, driven by a grand public and private effort comparable to the Marshall Plan -- or they could see poor societies pushed into even deeper trouble, in yet another tale of well-intended foreign meddling gone awry. Which outcome will emerge depends on whether it is possible to expand the developing world's local talent pool of health workers, restore and improve crumbling national and global health infrastructures, and devise effective local and international systems for disease prevention and treatment.