Global Health: Priority Agenda for the 21st Century

At the core of the United Nations Millennium Declaration of 2000 are the Millennium Development Goals (MDGs) for 2015, which recognize that global health is a priority agenda for the twenty-first century. Achieving the MDGs is essential for world peace and economic stability, and for addressing the critical issues of human rights, equality, and equity.
Never in human history have people of different national and geographic origins been as interdependent as in the twenty-first century. Globalization and the degree and speed of human mobility have created circumstances under which the health concerns of poor countries are de facto concerns of rich countries. These considerations, and others to be discussed below, emphasize the centrality of the MDGs in an interdependent world.
Global health and the global economy are intricately linked. In its 1995 report, the Commission of Global Governance stated: "As economies become more interdependent, it is not only the opportunity for wealth creation that is multiplied, but also the opportunity for destabilizing shocks to be transmitted from one country to another." Pandemics are a perfect example of such "destabilizing shocks". The Severe Acute Respiratory Syndrome epidemic of 2003 brought the vibrant Hong Kong economy rapidly to its knees, reducing consumption of goods, tourism, and air travel.1 It is expected that an avian influenza pandemic would cause much worse economic and social dislocation worldwide, with a potential impact of $2 trillion to $3 trillion on the world economy and the loss of tens of millions of lives.2 But the linkage between global health and the global economy goes beyond the effect of pandemics. The global market economy is increasingly dependent on a healthy, productive global workforce, especially since the thirty member nations of the Organisation for Economic Co-operation and Development move much of their manufacturing and service industries to low- and middle-income countries.
Even as we strive to achieve the MDGs by 2015, the heightened attention and greater public and private investment in global health in recent years is paying dividends. As documented by the Living Proof Project of the Bill and Melinda Gates Foundation, child mortality decreased by 27 per cent between 1990 and 2007.3, 4 Despite earlier gloomy assumptions, maternal mortality has dropped by 35 per cent over the past twenty-eight years -- an encouraging progress towards achieving MDG 55 on improving maternal health. The immunization programme of the Global Alliance for Vaccines and Immunisation is credited with preventing an estimated 3.4 million deaths in the past decade.6 The United States President's Emergency Plan for AIDS Relief is estimated to have saved 1.2 million lives.7 By 2008, about 3 million people were receiving anti-retroviral drugs.8 Similarly, thanks to the combined efforts of the Global Fund and the US President's Malaria Initiative, malaria prevention and treatment services have been significantly expanded. Since 2000, reported malaria cases and/or deaths have declined by at least half in twenty-five countries around the world.9 This is all good news -- and there is more of it.
Nevertheless, global health faces several great challenges. Most sub-Saharan countries will not achieve the MDGs. One important reason for this is the lack of functional health systems due to a shortage in the health workforce, management incompetence, inadequate infrastructure, and health care financing. The World Health Report 2006 estimates a global deficit of 2.3 million doctors, nurses, and midwives. Critical health workforce shortages exist in fifty-seven countries, of which thirty-seven are in sub-Saharan Africa. It is hard to see how these countries can possibly achieve those MDGs relating to health. Emphasis on vertical or disease-specific programmes such as HIV/AIDS, malaria, and tuberculosis may have further weakened the already fractured health systems, thus making delivery of general health care in low-income countries that much more difficult. Unfortunately, neither the governments of these countries nor the global donor community have invested adequately in capacity building.
There are more challenges facing global health. Prominent among these are the development of microbial resistance to antibiotics and disinfectants, along with the prevalence, in epidemic proportions, of non-communicable diseases and injuries in low- and middle-income countries. Tackling these challenges is also a priority agenda for global health in the twenty-first century.
Several important questions beg for answers: Is the generous aid given by the donor community to poor countries optimally utilized? How do we balance investment in technological solutions with those in capacity building? Have we adequately engaged all the available talent pool to solve the complex problems in global health? In response to the last question, I believe the expertise of academic institutions in both poor and rich countries has been inadequately tapped. Effective collaborations among governments, non-governmental agencies, and academia will be key to addressing the health workforce crisis and to training the leadership that health care requires.
An important global health priority agenda for the twenty-first century is achieving the MDGs. Unfortunately, many of the low-income countries are unlikely to achieve these goals, primarily because of critical shortages of health workers and weak health care systems. Beyond the achievement of the MDGs, other priority agenda items are developing effective vaccines and drugs for HIV/AIDS, malaria, tuberculosis, and other infectious diseases, addressing microbial resistance, and preparing a worldwide coordinated response to inevitable pandemics. A balanced funding strategy for vaccine and drug discovery on the one hand, and capacity building on the other, will determine how well and how fast we will achieve the MDGs and address the other global health priorities for the twenty-first century.

Notes

1 A.K.F. Siu, Y.C.R. Wong, "Economic Impact of SARS: The Case of Hong Kong", Asian Economic Papers 3:1, MIT Press, (2004): pp.62-83.
2 M.T. Osterholm, "Preparing for the next pandemic". N Engl J Med. (2005) May 5;352(18): 1839-42
3 United Nations Population Division: http://esa.un.org/unpp/
4 D. You, T. Wardlaw, P. Salama, G. Jones, "Levels and trends in under-5 mortality, 1990 -- 2008". The Lancet, Published online September 10, 2009, DOI:10.1016/S0140-6736(09)61601-9
5 M. C Hogan, K. J Foreman, M. Naghavi, S. Y. Ahn, M. Wang, S. M. Makela, A. D. Lopez, R. Lozano, C. J. L. Murray, "Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5", The Lancet, Early Online Publication, April 12, 2010,DOI:10.1016/S0140-6736(10)60518-1
6 GAVI Alliance Global Results: http://www.gavialliance.org/performance/global_results/index.php
7 E. Bendavid, J. Bhattacharya, "The President's Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes", Annals of Internal Medicine, May 19 (2009), vol. 150 no. 10 688-695
8 Celebrating Life: The U.S. President's Emergency Plan for AIDS Relief 2009 Annual Report to Congress. http://www.pepfar.gov/documents/organization/113827.pdf
9 WHO, World Malaria Report, September 2008: http://whqlibdoc.who.int/publications/2008/9789241563697_eng.pdf