The Impact of Globalization on Infectious Disease Emergence and Control Exploring the Consequences and Opportunities: Workshop Summary (2006) / Chapter Skim
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4 Creating a Framework for Progress
4 Creating a Framework for Progress
Pages 125-174
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From page 125... ...
Also emphasized was the need for a new organizational framework to exploit the opportunities and overcome the challenges created by globalization and build the capacity needed to respond effectively to emerging infectious disease threats. The trend toward increased funding for international health, such as that made available through the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund)
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This is followed by a summary of presentations and comments regarding some of the sources of and concerns about increased funding for international public health. The Global Fund and the MCA were discussed in some detail.
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The political ecology of disease provides a new conceptual framework for understanding the public health consequences of globalization, including, for example, investment decisions that lead to environmental alterations, changing vector ecologies, and increased risk of the emergence and spread of infectious diseases. THE CHANGING PERCEPTION OF INTERNATIONAL HEALTH1 A significant change in the perception of international health has occurred over the past decade.
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Thus, for purely economic reasons, the private sector has taken a renewed interest in international public health, as have many governments. Unfortunately, increases in morbidity and mortality do not, by themselves, always tell a compelling story until the data are translated into economic terms.
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The national security implications of the growing global threat of infectious diseases were highlighted in a recent National Intelligence Council (NIC, 2000) publication, The Global Infectious Disease Threat and Its Implications for the United States.2 The report contained several predictions and warnings, and since its publication, some of its predictions have clearly begun coming true: -- Infectious diseases are on the rise, and their potential costs are likely to be very high and far-reaching.
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Likewise, to the extent that internationally agreed-upon goals, such as the development goals of the MCA, signify international consensus on the need to strengthen efforts to combat infectious diseases, such efforts are central to the global agenda as well. Public health is prominent among the MCA development goals, and infectious diseases are key elements of those public health goals.
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These funding sources are described below, along with President Bush's recently proposed MCA. In addition to their financial contributions to global infectious disease control, the Global Fund and the MCA exemplify the strong trend toward public– private partnerships within the context of global public health.
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In fiscal year 2002, overall NIH expenditures in the area of tropical infectious disease totaled $255,400,000. In late 2002, this figure was probably above the $300 million mark.
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government. In fact, the MCA and the Global Fund both serve as models for how the United States and perhaps other governments can revamp their models of foreign assistance in ways that better account for the role of public health in economic development.
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1. The Global Fund must be an independent, international public– private partnership, representing a new way of doing business and a new paradigm for foreign assistance.
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4. The Global Fund will evaluate proposals through an independent technical review process.
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The Fund must respect such rights and the need for innovation in the next generation of therapies and must find a way to respect international law and agreements within the context of the Doha Declaration. March 2002 Global Fund Board Meeting The Global Fund board members met in March 2002.
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DHHS, through the Centers for Disease Control and Prevention (CDC) , provided technical assistance in the preparation of five or six proposals worldwide, although only one of these made it through the technical review process.
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138 IMPACT OF GLOBALIZATION ON INFECTIOUS DISEASE tions on proposal preparation should be provided. The board needs to decide whether resources for planning grants should be invested up front or whether seed money should be provided to help partnerships prepare their proposals in a better way.
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For this to occur, the for-profit sector must be comfortable with the Fund and recognize it as en entity with which it would like to do business. Questions and Concerns About the Global Fund As with the proposed MCA, workshop participants cited several concerns about the details and potential effectiveness of the Global Fund.
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. Other Possible Funding Sources for Global Infectious Disease Control In addition to the above-described sources of new or increased funding for international public health, there are a variety of other potential funding sources, including international credit finance; domestic, nonpublic sources; and public budgets within countries, including debt relief.
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Answers Other Than Money Despite the clear call for more funds and greater flexibility in how those funds are used, many workshop participants agreed that money is not a cure-all. They warned that funding must not become an overriding issue in the discussion of what steps need to be taken next with regard to the prevention and control of emerging and reemerging infectious diseases on a global scale.
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The funding needed to address these underlying problems should not be underestimated, and care must be taken not to let aspects of globalization that exacerbate public health problems detract from meeting this need. Some participants expressed concern that too great an emphasis on evidence-based public health, as is the case with the Global Fund, could deflect attention from underlying problems that play a more fundamental, etiological role in the growing global threat of emerging and reemerging infectious diseases.
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(The issue of governance was also discussed within the context of the changing role of international law in the global public health arena, as summarized at the end of this chapter.) THE ROLE OF PUBLIC–PRIVATE PARTNERSHIPS5 One of the recurring themes of the workshop was the vital role of public–private partnerships in building the global capacity to prevent and control emerging and reemerging infectious disease threats, whether intentionally or naturally introduced.
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For example, the WHO program Roll Back Malaria involves working with oil companies (e.g., ExxonMobil and Eni) to extend medical assistance to surrounding communities in the countries in which they operate; with mining companies (e.g., Placer Dome and World Alliance for Global Health, BHP Billiton)
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Public–private collaborations cannot substitute for governments, both rich and poor, that properly fulfill their responsibilities to build and maintain the necessary public health infrastructure and ensure that their citizens receive proper health care services. A participant noted that the use of these partnerships in a global effort to improve public health capacity requires adoption of a bottom-up, grass-roots approach whereby all agencies, organizations, and persons involved maintain a global mind-set and focus on how they can work together to better address the many issues they must confront.
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. suicide in Eastern Europe, started supporting hotlines so teenagers could talk about their problems; ExxonMobil funds the Medicines for Malaria Venture, a public–private partnership dedicated to the development of new antimalaria drugs; a South African power company, Eskom Enterprises, supports AIDS prevention efforts; and Apple Computer has, through various programs, donated both hardware and software to educational institutions.
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. A significant proportion of deaths from infectious diseases that occur in the poorest parts of the world are preventable by cheap, satisfactory, off-patent medications that exist but are inaccessible to people disadvantaged by poverty and a weak public health infrastructure.
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Partnerships Involving Nongovernmental Organizations Because the globalization of infectious diseases requires a highly coordinated and yet highly diversified response on the part of many public- and private-sector partners, it was suggested that the U.S. public health community and government tap the expertise of NGO leaders.
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FIGURE 4-3 Many people still lack access to essential drugs.
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Involving Multinational Corporations in Global Public Health Given the obvious role of multinational corporations in public–private partnerships, workshop participants discussed at length how to engage the interest of these companies more fully in global infectious disease control. The question was raised of what incentives exist for multinationals to maintain healthy workforces and otherwise contribute to dealing with global public health crises.
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Others noted, however, that several groups, such as the World Economic Forum and the International Chamber of Commerce, are encouraging business programs to combat infectious diseases, including HIV/AIDS, TB, and malaria, and some strategies that are already known may be worth examining or revisiting. For example, it might be possible to learn from examining the histories of companies that have long provided health care for their employees, as was done during the era of plantation medicine.
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The company intends to engage in discussions with other major companies in South Africa, as well as the South African government, before moving forward. A participant suggested that the diverse market interests of different companies could be exploited to provide opportunities for improving global public health in some basic ways.
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Perhaps there is something to be learned from the environmental movement. Industry as an Educational Resource A few participants commented on the innovative roles that private industry could potentially play in global infectious disease control.
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In recognition of the accelerating pace of globalization, CDC has prepared a document, Protecting the Nation's Health in an Era of Globalization: CDC's Global Infectious Disease Strategy, which is meant to serve as a framework for enhancing, consolidating, and focusing CDC's efforts to prevent and control infectious diseases on a global scale. The document begins by stating, "it is not possible to adequately protect the health of our nation without addressing infectious disease problems that occur elsewhere in the world" (CDC, 2002, p.
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Accurate information about emerging infectious diseases must travel at least as rapidly as the diseases themselves, which in this day of jet travel is quite rapid indeed. To remain one step ahead of multiple epidemic waves, public health authorities worldwide are increasingly relying on modern, rapid laboratory diagnostics; electronic connectivity; and communications networks.
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To carry out its mission, CDC must engage in implementation research that translates science into meaningful differences in the rates of morbidity and mortality from infectious diseases on a global scale and in a timely manner. A good example of the kind of proven public health tool addressed by this priority area is the insecticide-impregnated bed net, which has been shown in many field trials to reduce rates of morbidity and mortality from malaria.
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Although CDC has been involved in international public health training and capacity building for many years, its involvement in terms of financial resources has not been as great in this area as in some others. Nonetheless, there have been some significant successes, such as Field Epidemiology Training Programs and International Emerging Infectious Diseases Laboratory Fellowships.
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Response to the 2001 Anthrax Attacks: An Example of Effective Cooperation Bioterrorism continues to shape and reshape both domestic and global public health agendas. Within hours of the first reports of bioterrorismrelated anthrax in the United States, public health agencies around the world were faced with a myriad of questions from the highest levels of their governments, their clinicians and laboratory scientists, the media, and their citizens.
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First, past experience has shown that one of the critical prerequisites for a successful international health collaboration is for all involved to be treated as equal partners, especially when there are major disparities in resources. It is extremely important, whether the dialogue is about health or some other global issue, for developed countries to listen to their partners in developing countries and ask those involved to describe their problems and how interested developed countries can help resolve them.
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As another example, clinicians in developed countries are ill prepared to address the multitude of infectious diseases that emerge among refugees or migrants from other parts of the world. Programs such as the Gorgas Course provide important training opportunities for clinicians from developed countries to see and observe first-hand diseases endemic to the developing world.
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This low mortality rate is due to a cooperative effort among scientists, academicians, politicians, public health workers, and the local community. Infectious Disease Problems in the United States Problems with emerging and reemerging infectious diseases are not confined to developing countries.
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Public health capacity aside, unilateral efforts by individuals countries to manage public health threats that arise from crossborder microbial traffic can have only a limited impact when the source of the problem is beyond the jurisdiction and sovereignty of the affected country. Therefore, international law is a critical mechanism for facilitating an internationally cooperative public health response to the globalization of infectious disease.
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Their stated purpose, however, would remain the same: to "ensure the maximum security against the international spread of disease with a minimum interference with world traffic." The decision to revise the regulations was based on two major factors: (1) the public health need for more effective IHRs with respect to both emerging and reemerging infectious disease threats and vectors and the development of new technologies and approaches for controlling these diseases, and (2)
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Other real-time management features of the revised IHRs include WHO's ability to accept information from unofficial sources, after which verification would be obtained from the country; WHO's provision of network response support; and the availability of a template of recommendations and measures based on risk assessments for particular events. • Under the new IHRs, each country is required to maintain core surveillance capacities, as defined in the IHRs, including the ability to detect and report infectious diseases and to respond at both the local public health and national levels.
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The Global Fund is an example of global governance. The first century of international health diplomacy, which began in the mid-1800s, witnessed the creation of three primary horizontal interna
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, beginning in 1902 with the Pan American Sanitary Bureau. This regime involves the use of international law to create permanent IHOs, such as today's WHO, in an effort to facilitate intergovernmental cooperation on infectious diseases and other international public health problems.
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Not only does this shift from the classical to the trade regime raise questions about the usefulness of the IHRs and the need to develop revised IHRs, but it also raises the question of whether we are witnessing the rejuvenation of the classical regime or its death. A second change that has occurred over the past several decades with regard to the governance of infectious diseases is the evolution after World War II of vertical international regimes that influence global strategies on infectious disease much more dramatically than do the traditional horizontal approaches.
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The involvement of NGOs and multinational corporations is a key component of these new mechanisms, whose strategic objective is to produce global public goods that states, especially developing countries, can use within their own territories to reduce the rates of morbidity and mortality from infectious disease. Currently, one of the most prominent features of these new global governance mechanisms is the development of public–private partnerships, such as the Global Fund.
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THE NEED FOR A SOCIAL SCIENTIFIC FRAMEWORK FOR UNDERSTANDING INFECTIOUS DISEASE EMERGENCE8 Attempts to understand the etiology of the emergence of infectious diseases cannot be restricted to a purely biological approach. Rarely, if ever, is the emergence of an infectious disease caused exclusively by biological factors.
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Despite the vital role of social factors in the etiology of infectious disease emergence and the fact that the literatures of many of the social sciences, such as demography and political geography, could inform our understanding of infectious disease emergence, the vast preponderance of research and policy on the emergence of infectious diseases has been explicitly biological in nature. Little social science has been incorporated into epidemiological, public health, or infectious disease research and policy.
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Failure to recognize the importance of the latter could compromise efforts to strengthen the global capacity to prevent and control emerging and reemerging infectious diseases. How can a social scientific perspective be incorporated into the study of emerging and reemerging infectious diseases?
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If a climatologist had been part of the original research team, this situation could have been avoided. As the impacts of dam construction and land modification projects on emerging infectious diseases attest (see Chapter 1)
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2000. Geography, ecology, and emerging infectious diseases.
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. The Global Fund: A Brave New World.
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