International And Global Health
It is said that we inhabit a shrinking planet. Technology has rendered borders and time zones irrelevant; most industries routinely operate in a globalcontext. The number of people traveling abroad has reached more than 2million a day.
People in New York, Paris, Nairobi and Tokyo eat much of the same fast foods, wear the same designer clothes, watch the same TV shows.
And one way or another, they are linked by many of the same health issues. In a world where virtually everything has become globalized, it is hardly surprising that healthcare providers, research scientists and pharmaceutical companies have brought the eradication and treatment of disease into the global arena. Wherever they may work, whatever their chosen area of focus, every public health professional is part of an extraordinary global enterprise.
But exactly what is global health? The Washington, D.C.-based Institute of Medicine (IOM) deﬁnes it as “health problems and concerns that transcend national boundaries, may be inﬂuenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions. ” The operative word is transcend: Global health is not the same as international health, which operates within and across borders and is always acutely conscious of them.
Rather, global health connotes a world where health problems and their solutions are increasingly borderless. To be sure, local political, economic and infrastructural realities must be acknowledged and dealt with, nation-by-nation. While environmentally related illnesses affect the whole world, there is no denying that they are more virulent and widespread in developing nations, where regulations are likely to be lax and sanitation facilities primitive. Nonetheless, Africa’s AIDS epidemic, air pollution in Mexico City, childhood malnutrition in India, river blindness in Latin America, the specter of tainted beef in Europe all must be addressed as global problems, demanding globally coordinated efforts and the free exchange of information and ideas irrespective of borders.
Yet, whatever new ills it has inﬂicted upon the world, globalization made global health a far more pressing concern to political leaders. As recently as a decade ago, public health was rarely discussed at meetings of the G8 — the world’s major industrialized nations. Today, says Dr. Nils Daulaire, president of the Global Health Council, “it is one of the fastest rising topics, and it’s going to be one of the central issues in the future.” Public health organizations have begun to acknowledge the futility of decrying the rapid march of globalization, he says, and that it is more important “to learn how to harness its forcesfor the beneﬁt of the needy.” At the same time, the world at large has begun to awaken to a reality that public health professionals have always recognized that health is a prerequisite for economic growth, human dignity, the fulﬁllment of human rights, and world peace.
That isn’t to suggest that health should over shadow all other concerns. But most of the world’s luminaries, from rock stars and athletes to business leaders and heads of state, understand today that good health and, more to the point, a global approach to public health is essential for the secure future of the planet. Clearly, global health is a work in progress. While substantial headway hasbeen made against many of the most widespread and intractable healthproblems — communicable and infectious diseases like plague and inﬂuenza,substance abuse, environmental health, mental illness — they are still verymuch part of the global landscape.
The good news is that organizations and individuals working across politicaland geographic boundaries have scored some remarkable successes. Forexample, immunization programs have reduced and in some cases eliminatedthe presence of polio and other childhood diseases worldwide; by 1980, the
World Health Organization (WHO) had succeeded in eradicating smallpox.
But as old problems are solved, new ones emerge and spread across borders, driven by behavioral or demographic changes, natural disasters, war and bioterrorism. Smallpox and other ancient diseases may have been banished, but in their place comes a new wave of universal scourges — HIV/AIDS, epidemic tuberculosis, food-borne diseases, and man-made environmental horrors such as acid rain and global warming. They affect the world in general, but reserve the bulk of their malevolence for developing nations.
For example, malaria is on the increase in tropical countries because even one degree of global warming allows mosquitoes to breed in areas they could never have previously inhabited.
What is especially striking about today’s global health picture are the ways in which human behavior is changing around the world, and the impact of those changes on people’s health. At one end of the risk-factor scale lie conditions such as poverty, undernutrition, unsafe sex, unsafe water, poor sanitation and hygiene, iron deﬁciency and indoor smoke from solid fuels.
These rank among the 10 leading causes of disease, and they are far more prevalent in the poorest countries and communities.
At the other end of the scale, one sees the price to pay for unhealthy con- sumption and the abuses of afﬂuence. Excessive consumption of fat, sugar and salt lead to high blood pressure and high blood cholesterol, which are widely implicated in cardiovascular and cerebrovascular diseases. Smoking, obesity and excessive alcohol consumption heighten the danger. These factors are known all too well in the developed world; they are commonly viewed as middle and upper-income afﬂictions. The real drama is that they are becoming more prevalent in developing communities, where they lay a double burden on top of the infectious diseases that always have been the lot of poorer countries, according to Dr. Derek Yach, head of communicable diseases and mental health at the World Health Organization.
While tuberculosis today is the world’s second most lethal infectious disease, claiming two million lives a year, its impact has been surpassed by tobacco, whichcauses close to four million deaths a year.
That number will double by 2020, according to WHO projections, with 70 percent of smoking-related
fatalities occurring in developing countries.
Yet there is cause for optimism. The mapping of the human genome, com pleted in 2001, lays the groundwork for the development of new therapies for long-intractable diseases; the power of information technology is being harnessed more and more to deal with epidemics and other threats to global health. Disease persists, certainly, but there is no denying the world is a healthier place than it was a generation ago. Consider: During the past three decades, attention has focused on micronutritional issues the roles of vitamins and minerals and how they can be delivered to nutrition-poor populations. Iodine deﬁciency in particular was a major cause of preventablemental retardation in millions of children in developing nations. But teams of scientists, health workers, policymakers and others working in close collaboration devised effective ways to introduce iodine into children’s diets.
Admittedly, not all global health problems have responded so readily. The prevalence of AIDS, for example, has slowed many otherwise improving global health trends, such as infant, childhood and adult mortality rates.
But the world is ﬁnally dealing with AIDS in an organized way, focusing on strategies that will provide access to short-term tools such as microbicides while it continues to fund research that will hopefully lead to cures or a vaccine.
Many international agencies and organizations are working to improve global health. Paramount among these is the World Health Organization, created in 1948 for the purpose of guaranteeing “the attainment by all people of the highest possible level of health.” WHO’s mission has translated into direct interventions and assistance whenever and wherever they are necessary, as evidenced most recently by its participation in ﬁghting the outbreak of Ebola virus in Gabon in 2001. The United Nations Children’s Fund (UNICEF), meanwhile, has done an outstanding job of focusing on the health problems of the world’s children. In the early 1980s, UNICEF launched its “GOBI” initiative. “GOBI” stands for growth monitoring, oral rehydration, breastfeeding and immunizations; the agency boldly asserted that these four simple interventions could dramatically reduce the death toll of children worldwide. And they have been proven correct, time and again. In a real sense, the terms “public health” and “global health” have become interchangeable. “In a world where nations and economies are increasingly interdependent, ill health in any population affects all peoples, rich and poor,” notes the Institute of Medicine.
As WHO director-general Dr. GroHarlem Brundtland elegantly reminds us, the rampant spread of infectious diseases such as AIDS, malaria and the West Nile virus give evidence that “in a globalized world, we all swim in a single microbial sea. Of course, public health has become globalized because disease has become globalized and that fact underscores the necessity of working beyond the local level. That is, every community, large and small, can expect to be called upon to furnish resources and people to advance the global effort. In a world of easy travel and vanishing trade restrictions, it is in the interests of developed countries to assist their developing neighbors. It isn’t a simple matter of altruism or noblesse oblige but, rather, an understanding that the problems of one community threaten the whole world. “The world’s nations, the United States included, now have too much in common to consider health as merely a national issue,” notes the IOM.
The simple fact is that global action against health risks in one country can help protect all people in all countries. That is the essence of global health in the 21st century.
Six billion people share a small and increasingly fragile planet, confronted by global health problems that may seem overwhelming. But they are all solvable problems. Global health professionals will be an integral part of the solution, whether working in a large urban hospital in Los Angeles, a rural clinic in the Midwest, or a ﬁeld laboratory in Botswana.
The preceding essay is dedicated to global health pioneer William Foege, MD, MPH, who ﬁgured centrally in the effort to eradicate smallpox in the 1970s and later served as director of the U.S. Centers for Disease Control and Prevention.
An epidemiologist by training, Dr. Foege graduated from Paciﬁc Lutheran University and subsequently earned an MD from the University of Washington Medical School in 1961 and an MPH from Harvard University in 1965. For the next decade, Dr. Foege’s career carried him across the world in the ﬁght against infectious diseases. After working in the campaign to eradicate smallpox in the 1970s, Dr. Foege became Chief of the Smallpox Eradication Program, and was appointed Director of the U.S.
Centers for Disease Control and Prevention in 1977. Dr. Foege served as Director of the U.S. Centers for Disease Control and Prevention from 1977 to 1983.
In 1984, Dr. Foege and several colleagues formed the Task Force for Child Survival, a working group for the World Health Organization, UNICEF, The World Bank, the United Nations Development Program and the Rockefeller Foundation. Its success in accelerating childhood immunization led to an expansion of its mandate in 1991 to include addressing other issues that diminish the quality of life for children.
Dr. Foege was executive Director of the Carter Center from 1987 to 1992, where he remains a fellow and a senior health advisor. In January 1997, he joined the faculty of Emory University as Presidential Distinguished Professor of International Health at the Rollins School of Public Health. In September 1999, Dr. Foege became a Senior Medical Advisor for the Bill and Melinda Gates Foundation.
Dr. Foege holds honorary degrees from numerous institutions, and was named a fellow of the London School of Tropical Medicine and Hygiene in 1997. He is the author of more than 125 professional publications.