Back to the fuzzy future in global health

Analysis

The global health community seems at a loss these days, as indicated by two conferences yesterday I web-participated in devoted to coming up with a future game plan for the field. I’ll get to those, but first some context:

I am long-in-tooth enough to remember when ‘global health’ didn’t exist, not by name anyway, before Bill Gates got into philanthropy and when the only ‘Third World’ disease most of us in the West cared about was AIDS.  And we cared only because that disease figured out how to spread beyond its original confines in Africa. Today, it can seem like everybody and their mother wants a piece of the global health bandwagon.

Or they did anyway, when funding for fighting diseases of poverty in poor communities (my definition of global health, which is debatable) was increasing at the rate of Starbucks franchises.

Global health’s golden age began somewhere around the year 2000 and was due in part to the meteoric rise of the Bill & Melinda Gates Foundation. I think it’s fair to say the Seattle philanthropy revolutionized and resurrected many neglected areas of international health by greatly expanding efforts in children’s immunizations worldwide as well as reinvigorating many moribund fields like malaria and tuberculosis research.

But it wasn’t just because of the Gates Foundation that global health took off. The now almost unimaginable toll taken by AIDS in Africa and other parts of the developing world had become intolerable, at least for many AIDS activists, human rights groups and public health experts.

After 1996, the rich world had drugs that could save lives and prevent HIV infections from turning into AIDS, but poor people weren’t getting them – in part because they were too expensive but also because some ill-informed policy makers thought poor people too dumb to manage the medications correctly.

To make a complex and fascinating story brutally short, AIDS activists and some of the poorer countries dealing with this medical inequity decided to take action, ignore the patent laws that made these drugs so expensive and make the drugs generically available for their citizens. This threat eventually got the drug industry to do the right thing (on AIDS drugs anyway) and provide the life-saving drugs to the poor at a steep discount.

That’s what allowed the international community to launch the Global Fund for Fight AIDS, TB and Malaria (which, I would argue, was somewhat modeled after the lesser-appreciated but precursor Global Alliance for Vaccines and Immunization, launched by Gates and PATH). That’s also what prompted President George W. Bush to launch Pepfar, the Presidents Emergency Plan for AIDS Relief. Millions of lived were saved by these two initiatives alone. And they only got the ball rolling really, as other initiatives aimed at other health challenges got launched. Universities all started global health programs. A revolution for health seemed in the making and funding for this health-based war on poverty soared.

Then, as the graphic above shows, funding stalled thanks in part to Wall Street screwing up the global economy. But the global health momentum also seems to have stalled. Part of that stall has been blamed on the leveling off or even decline in funding for global health. But part of it can, and perhaps should, be blamed on the apparent disinterest the Obama Administration has taken in matters of global health.

Yesterday, the Kaiser Family Foundation held a teleconference for journalists to discuss the Obama Administration’s proposed spending plan for global health in 2015 as part of the foreign assistance budget. The proposal is to cut global health spending by about 4 percent. You may think, from the above graph, that this doesn’t seem like a big deal given how much we’ve increased spending on this front over the past decade-and-a-half. Well, think again.

As the graph from Kaiser at left shows, the U.S. government has increased its spending on global health from practically nothing – as a percentage of the federal budget – to just a bit more than practically nothing. Do you think $8 billion is a lot? We spend something like $50 billion on dog food. So no, it’s not a lot.

Getting back to AIDS, millions of lives have been saved but tens of millions of people with HIV are still not getting life-saving drugs. So there’s an argument right there to beef up spending – following through on our commitment for this one disease.

The folks at Kaiser did a great job explaining where we’re at. But nobody wanted to answer the questions I put to them: Why is the Obama Administration so disinterested in global health? Do they think we can just coast now? Isn’t this ‘drift’ in US policy on global health harmful?

It’s clear that just focusing on AIDS, on one disease or even one category of disease, isn’t the popular thing to do anymore. This was also demonstrated yesterday at a confab put on by the Center for Global Development along with PSI, PATH, Devex and other folks from various NGOs who held a conference in Washington, D.C. to explore Best Buys in Global Health.

I watched the CGD-hosted discussion on the web because the participants and speakers are many of the leading lights in the global health strategosphere. But hoo-boy, what a fuzzy mess that turned out to be! I was reminded of Bill Clinton trying to claim he didn’t really have sex with Monica Lewinsky as I listened to the experts debate what the word ‘best’ means and on what basis we should establish the criteria upon which to judge what is most effective in global health.

As Amanda Glassman, an emcee for the event and a leading global health policy wonk at the CGD, said: “It’s not just about lives saved … Best buys can be defined in many ways.”

So I eagerly waited for them to try to define and come up with a list of the best buys, something that is definitely needed right now as the international community debates what to do after 2015, when the anti-poverty and development agenda was largely set by the creation, in 2000, of the Millennium Development Goals – many of which were focused on achieving specific health goals like reducing child mortality by two-thirds worldwide.

What came out of that two-hour confab was not so much a clear list of the most effective things to do in global health but a statement, based on an accompanying survey of experts done by PSI and PATH, that decided ‘health systems strengthening’ should be the top priority. Here’s a snapshot and some reports about the survey results.

Medical News Net Strengthening Health Systems Most Critical Investment in Global Health

Huffington Post Best Buys in Global Health: Striking the Effective Balance

PR Newswire Best Buys in Global Health 2014

Many would agree that improving health systems in poor communities, increasing ‘country ownership’ of these systems and improving ‘service delivery’ are critical to long-term success in global health. But this is hardly a new or ‘innovative’ idea (see the Declaration of Alma Ata, circa 1978, for example). And it’s pretty grand and vague lingo – that smells a bit like the rich world trying to tell poor countries they need to take over now.

Meanwhile, many people in poor communities are still dying for lack of a cheap drug, a vaccine, clean water or good food. Don’t get me wrong; I think health systems strengthening is, in fact, critical to success in global health. And this has been neglected, if not undermined, by focusing on disease-specific targeted interventions as well as aid agencies and philanthropists being loathe to provide financing to anything that isn’t simple and measurable.

And yet, until everyone with HIV has ready access to drugs and we can actually declare mission accomplished with regard to the original MDGs, I vote for sticking with simple and clear global health goals first. These grander and fuzzier goals should also be on the list, but further down – at least until we actually pick all the obvious, low-hanging fruit still out there.