Existential Challenges To Global Health: New York University

NEW YORK UNIVERSITY
i CENT ER ON I N TERN A T IO N A L CO O P E R A T IO N
Existential Challenges to Global Health
Laurie Garrett
August 2013
NEW YORK UNIVERSITY
CENTER ON INTERNATIONAL COOPERATION
The world faces old and new security challenges that are more
complex than our multilateral and national institutions are
currently capable of managing. International cooperation is ever
more necessary in meeting these challenges. The NYU Center on
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responses to conflict, insecurity, and scarcity through applied
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and the wider policy community.
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Table of Contents
Existential Challenges to Global Health
by Laurie Garrett
Introduction 2
The Effects of the 2008 Financial Crisis 6
The Current Landscape 8
The Five Existential Challenges 11

Challenge One: Sustainable Financing 11
Challenge Two: The World Wealth Disorder 14
Challenge Three: The Global Health Architecture versus Its New Mission 19
Challenge Four: The World Food Supply 21
Challenge Five: Climate Change 25
What Is To Be Done? 30
Existential Challenges to Global Health By the early 1980s the moniker “global health” gained
popularity, reflecting a vision of worldwide solidarity in
Introduction which solutions and actions for health defied the 20th
Century obstacles of the Cold War, imperialism, colonialism
Regardless of which priorities are adopted as targets and traditional North/South divides. As the 1990s super-
for the post-2015 world, the constellation of agencies charged “Davos World” of globalized economics surged
and initiatives that constitute “Global health” face five forward, the phrase “global health” came to signify
existential challenges, any one of which could torpedo movement of technology and resources on a massive
the lofty, often extraordinarily successful goals and scale from wealthy nations to poor, to eliminate a set of
achievements of the collective endeavors. Two of these diseases, especially HIV/AIDS, malaria and tuberculosis.
challenges boil down to money: The search for sustainable Those global health ambitions were solidified in 2000
support; and the impact inequitable access to funds has with United Nations endorsement of the Millennium
on individual health. A third challenge concerns the Development Goals, three of which were clear health
increasingly obvious mismatch between the structure of targets; two more had obvious impact on human health.
“Global health” and the mission’s looming priorities. And
the fourth and fifth possibly insurmountable challenges From 1990 to the present, the constellation of actors
reflect the planetary environment within which global involved in global health has changed dramatically: from
health practitioners are operating. Leaders and institutions domination by the UN’s World Health Organization (WHO),
that are key to Global health have barely recognized these to a confused network of global actors, to reliant on the
five existential threats, much less develop policy solutions US government and Gates Foundation. Today – in the
or adaptations. midst of negotiations for what follows the MDGs – these
2 actors face five existential challenges, any one of which
Global health is a comparatively new multilateral could torpedo the lofty, often extraordinarily successful
enterprise, built atop a far less ambitious, poorly funded set goals and achievements of the collective endeavors. Two
of mid-20th Century programs that fell under the rubrics of these challenges boil down to money: The search for
of “tropical medicine” and “international health,” largely sustainable support; and the impact inequitable access to
overseen or guided by the World Health Organization funds has on individual health. A third challenge concerns
(WHO). Tropical medicine was a colonial field, executed the increasingly obvious mismatch between the structure
by well-intended wealthy governments, physicians and of “global health” and the mission’s looming priorities. And
scientists from the northern hemisphere, working in the the fourth and fifth possibly insurmountable challenges
colonized outposts of the southern. Tropical medicine reflect the planetary environment within which global
aimed its science and public health ventures at ailments health practitioners are operating. Leaders and institutions
not then plaguing temperate northern hemisphere climes: that are key to global health have barely recognized these
Malaria and other parasitic diseases, pellagra, vaccine- five existential threats, much less develop policy solutions
preventable childhood scourges and the like. Over time or adaptations.
those involved in international health envisioned a
less condescending, post-colonial political world, and
recognized that the notion of disease targets as “tropical”
was ecologically limiting and medically incorrect. Though
it straddled the Cold War, international health conceived
of grand targets, such as polio and smallpox eradication,
executed from the top (Geneva, Moscow, Washington and
London) down to poor countries all over the world.
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Figure 1 - Development assistance for health (US$ Billions)
The Evolution of the Global Health Architecture Centers for Disease Control) and Washington, to the rest of
the less-wealthy world.1
In 1990 the global health world was dominated by the
World Health Organization, both in terms of funding and However, though HIV had been claiming lives all over the
strategic planning and guidance. The total global health world for more than a decade, and the AIDS pandemic was
budget, including contributions made by poorer countries clearly out of control, the global HIV budget was less than
for their own people’s healthcare and disease prevention, $300 million. Prevention of the virus’ spread was such a
totaled $5.6 billion. Most of the targets were public health low priority at WHO that the agency’s staff openly attacked 3
goals, such as provision of safe drinking water, parasite funding for AIDS programs as robbing higher concerns,
control, vector eradication, child immunization and such as child diarrheal disease control. In 1994, WHO
nutrition. Of the roughly $5.6 billion dedicated to global officially abandoned the AIDS pandemic, shutting down
health in 1990 the WHO garnered almost $1.2 billion – just its Global Program on AIDS. There were an estimated 15
over 20 percent. million people living with HIV infection that year, nearly a
million died of the disease in 1994, and 3.2 million were
No other institution came close to claiming such resources, newly-infected. The virus had spread over the entire world,
or delineating the strategic and scientific directions of the pandemic was surging almost without any sign of
global health. Combined, the various US government hope on the medical, scientific or prevention fronts – yet,
foreign assistance agencies and Centers for Disease WHO walked away from it.
Control ran about $850 million worth of health programs,
mostly on a bilateral basis. France ranked third in funding In 1995 the United Nations AIDS Programme (UNAIDS) was
and influence, with a government budget of nearly $600 born: the first of many new multilateral agencies that would
million. Nongovernmental and private sector donors, come to challenge the authority and funding of WHO,
combined, expended about $500 million on global health created out of the necessity to address the catastrophic
in 1990, and the remainder of the externally applied pandemic. UNAIDS bridged the activities of seven UN
support of health in poor countries came from other agencies in an effort to create a harmonious, urgent
UN agencies, Japan, Italy and Sweden. The architecture response to the pandemic. The following year researchers
of global health in 1990 was quite simple: Nearly every from multiple drug companies and academic institutions
scheme and modicum of financing flowed from the top, announced to standing ovations at the International AIDS
down: From Geneva, Atlanta (headquarters of the US Conference in Vancouver that various combinations of
1. The chart is available online at: http://www.healthmetricsandevaluation.org/tools/data-
visualization/development-assistance-health-channel-assistance-global-1990-2011#/overview/
explore
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anti-HIV drugs, taken in daily cocktails, brought the burden In 2000 former South African President Nelson Mandela
of viruses in individuals’ bodies down to zero-detectable, characterized African access to anti-HIV medicines as
offering hope of effective treatment of the disease, if not a fundamental moral imperative, calling for both drug
a cure. Within weeks tens of thousands of Americans and price reductions and donor support for AIDS prevention
Europeans that had been facing certain death to AIDS and treatment efforts. By the time Mandela delivered
went on the new therapies, with miraculous results. By his remarks a vast, far-flung activist community was
1997 it was obvious that HIV+ men, women and children demanding universal, affordable access to anti-HIV
in wealthy countries could survive the disease, perhaps drugs. Among the chief targets of this growing activism
even live normal life expectancies, but the complexity of were the Western pharmaceutical companies that
the treatments and drug costs were tens of thousands of held patents on the life-sparing drugs, setting anti-
dollars beyond the thresholds of attainability for Africans, HIV treatment costs prohibitively high for most of the
Asians and Latin Americans living with the disease. world’s needy populations. For many of its adherents,
including ACT UP, Médecins sans Frontières and OXFAM,
Since then the landscape of actors involved in global “global health” became synonymous with defiance
health has transformed. American philanthropists Bill of the World Trade Organization’s patent protection
and Melinda Gates launched a foundation in 1998 that provisions: Confrontations between health activists and
named global health as its primary concern, dispersing the innovative pharmaceutical industry would become a
$1.2 billion for health the following year. Though the source of division for nearly all aspects of global health.
Foundation aimed its generosity at a long list of health
Figure 2 - Funding from 1994 to Present
targets, its chief one was child immunization. The Gates Two years later US President George W. Bush stunned the
were personally moved to create their foundation after world, announcing creation of a multibillion dollar US HIV
seeing African children suffering and dying from diseases effort, executing much of what Mandela had called for
that no longer plagued the wealthy world, especially in 2000. The President’s Emergency Plan for AIDS Relief,
vaccine-preventable ones such as measles and polio. or PEPFAR, unrolled swiftly, bringing anti-HIV drugs to
Overnight the philanthropic world was awed by the scale more than a million people by early 2004, and 5+ million
and ambition of the Gates Foundation. By 2003 Bill Gates by 2011. Simultaneously a new multilateral – the Global
would be the keynote speaker at the annual World Health Fund to Fight AIDS, Tuberculosis and Malaria (The Global
Assembly, with many at the Geneva gathering speculating
that the computer billionaire might hold more sway over
global health policy than the WHO.
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Figure 3 - International AIDS Assistance: Donor Governments as Share of Global Fund Contributions by
Donor Governments, 2010
Fund) was born, offering an unprecedented mechanism PEPFAR, Global Fund, developing country tax-derived
for channeling billions of dollars into country and NGO increases, and all other donor support, reached some $26
programs.2 billion, or roughly five-fold the total for 1998. 5
On a separate track, WHO created the Commission on The heady, jaw-dropping pace of growth in financial
Macroeconomics and Health, which in 2001 released a support spawned two fundamental changes in the
landmark analysis of global health trends and the costs architecture of global health governance. First, WHO was
various diseases levied upon societies. When the Report supplanted from its top leadership position, and its stature
was released, total global health spending pegged at and share of donor support have steadily diminished since
$6 billion, according to its authors, who insisted the real 2002. And second, thousands of new NGO and UN-related
spending need was $27 billion annually by 2007. (By 2007 players entered the field, spawning confusion, complexity,
global health spending would reach $20.4 billion.) The even anarchy in the governance of global health.
Report was instrumental in design of the Millennium
Development Goals, setting targets for conquest of HIV and The spectacular growth of global health was propelled
estimating the economic burden of malaria worldwide. by urgency and activism, chiefly directed to the AIDS
pandemic. Metrics of success typically focused on funding,
Excitement over global health reached the annual Davos and victories were declared when the US Congress
meeting of the World Economic Forum, the UN General approved multi-billion dollar expenditure or former US
Assembly, the G8 annual summits and dozens of other President Bill Clinton rallied a few hundred million dollars’
gatherings of the wealthiest and most powerful people worth of corporate commitments. Missing from the
on Earth. By 2004 every major gathering of ministers of metrics of success was the primary target of health: Lives
finance, the World Bank and global leadership included saved. The paucity of clear standards of prevention and
world health issues on its agenda, with HIV and malaria care for targeted diseases and health problems, coupled
programs at the front of the queue. By mid-2008 annual with disappointing, poor, even absent, outcomes data left
dispersements for global health, combining private, the burgeoning global health enterprise vulnerable to
2. http://www.actupny.org/reports/durban-mandela.html attack. By 2008 it could be characterized as anecdotally
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Figure 4 - Very Generous Growth 2000-2007
Figure 5 - Funds Decline Sharply
enormously successful, but statistically, concretely, unable years in the neighborhood of $26 billion, but the sources
to account for precisely donor funds saved lives, prevented of support shifted more heavily toward the US as Europe
ailments, or averted epidemics. Nobody was clearly in faced dissolution of its economic union, and the potential
charge, and many NGOS and multilaterals openly battled bankruptcies of some of its states. By early 2011 the two
one another over reputations and cash. Hooked on growth, Washingtons – Seattle and the District of Columbia –
global health had become a political movement, expert at were calling the shots. The Gates Foundation was the
lobbying the G8 and OECD for cash, and determined to undisputed leader of all private support, and the US
reap larger financial harvests every single year. government thoroughly dominated public sector giving.
The Effects of the 2008 Financial Crisis As funding declined3, global health implementers have
focused on efficiency and integration, finding ways to
The financial crash of September 2008 sowed panic across
3. http://blogs.worldbank.org/health/putting-humpty-dumpty-back-together-again, and http://
global health programs, though actual funding for most www.businessweek.com/news/2012-01-17/financial-crisis-may-kill-in-congo-as-global-health-
aid-stalls.html
programs did not decline for two more years. The overall and http://www.irinnews.org/report.aspx?ReportId=94781
and http://www.un.org/apps/news/story.asp?NewsID=41059&Cr=UNICEF&Cr1
net of global health support remained over those two and http://content.healthaffairs.org/content/31/1/228.full.pdf+html
and The other crisis the economics and financing.pdf
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Figure 6
get more programmatic success out of every donor cut, the ambitions of programs were scaled back, and
dollar (or yen or euro). Scandal rocked the Global Fund, the institution struggled to define its missions. Making 7
which was unable to account for how millions of dollars matters worse for the two Geneva-based organizations,
had been spent in several countries. The Fund closed currency speculators ran from the US and Euro-zone
2010 $5 billion short of meeting its grant commitments. recessions, selling off dollars and euros and snapping up
In 2011 the Fund’s leadership requested $4.5 billion in Swiss francs. In the summer of 2011 the value of the franc
replenishment for 2012 from donors, and an overall $20 soared 32 percent, making it difficult for the institutions to
billion to achieve the MDG targets by 2015. Angry donors make payroll and cover school fees for Switzerland-based
committed just $11.7 billion for 2012-15 and called for employees. Morale within both WHO and the Global Fund
reform. Financial support dropped precipitously, and plummeted, as the once-heady momentum of 2000-2007
the Global Fund’s Board was compelled to cease review screeched into reverse gear.
of new grants, topple its executives, and dramatically
reorganize. However, the Fund was responsible for two- The decline, overall, in global health funding forced
thirds of all malaria prevention and treatment programs in heightened efficiency and accountability for all its actors,
the world, and three-quarters of tuberculosis efforts. Many from tiny NGOs to the mighty multilaterals. The key
countries’ dependency on the Fund was so great that its exception was GAVI – the Global Alliance of Vaccines and
possible collapse was simply unconscionable: Millions of Immunization. GAVI grew in the early 2000s thanks to
lives would be lost, especially to malaria and tuberculosis. strong support from the Gates Foundation, and faced its
own leadership and structural scandals before the world
Meanwhile, the WHO (which operates on 2-year budget financial crunch was fully felt in health circles. By the time
cycles) also faced a shattering financial crunch. Its 2011/12 WHO and the Global Fund were reeling from scandal and
budget had a shortfall of more than $1 billion, and declining donor support, GAVI had restructured, hired
Director General Margaret Chan was forced to lay off 20 a popular new CEO, and created transparent databases
percent of her staff. Throughout the WHO spending was offering evidence of its achievements, framed as children
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vaccinated and lives saved. As a result, in 2011 GAVI The Current Landscape
won far stronger support from donors than it requested,
thanks in large part to UK Prime Minister David Cameron’s Though most NGOS, Ministries of Health and the
decision to shift much of the UK’s foreign assistance to the multilateral players struggle to deliver more services
vaccination alliance. with less money, and improve their accountability and
outcomes measurements, two very striking lessons have
Despite a drop in funding, a number of laudable emerged from this decade’s experience. First, dependency
improvements have resulted from the 2008 financial crisis. is a terrible thing, especially when it is overwhelmingly
There have also been rocky shake-ups, especially at the directed at a single source or nation. Secondly, spectacular
Global Fund to Fight AIDS, Tuberculosis and Malaria, and changes in the architecture and aspirations of global
a raft of leadership changes across the nongovernmental health can occur swiftly, without rational discourse, and
sector. While times have proven challenging4, have unforeseen, sometimes difficult, impacts.
the aggregate impact so far on these international
organizations has been improvement, with major The most effective political fights for global health
donors striving to enhance recipient-country ownership funding were waged in the US, which saw its foreign
and engagement in health programs, NGOs generally expenditures swell from roughly $500 million during the
demonstrating attention to waste and exorbitant second Bill Clinton Administration to a FY2012 budget
overhead, and more policy focus given to universal health appropriation of $8,167,860,000 – approved by a deeply
coverage and health systems infrastructure. In parallel, divided Congress during an American recession. (Of that
many poorer countries that were key targets for global sum, $5.54 billion was earmarked for HIV/AIDS programs
health programs in the early 2000s have prospered post- and support of the Global Fund.) Other donors were not as
8 2008 due to resource extraction industries, South/South steadfast. The World Bank and IMF struggled to find means
investments, shifting cheap labor markets and the success to support health, while pushed by donors to play their
of some local development schemes, allowing some usual austerity strategies. In the face of recession, most
increases in country spending on public goods, including European support of global health either disappeared, in
health. the case of southern countries, or diminished6, increasing
pressure on the US. America now faces a major domestic
However, the longer-term challenges for all aspects of showdown over central government spending, the
poor country health promise to outpace the adjustments national debt, annual deficits and taxation schemes.
made by global health leadership in the post-2008
era. Without significant and rather radical change in The first two years of the Obama Administration were
the entire perspective of global health, particularly wasted with in-fighting and debate over the future of all
regarding its funding dependencies, the post-2015, foreign assistance, culminating in 2010 creation of the
post-MDGs era could be grim. While some large scale Global health Initiative, a State Department-run melding
restructuring ideas have been suggested by prominent of programs operated by multiple American agencies.
leaders in the field, they do not go far enough because In late 2011 Secretary Hillary Clinton called for an “AIDS-
they fail to come to grips with the staggering changes Free Generation” and signaled impatience with the GHI
now unfolding5 on the world stage. effort: it was abandoned entirely in the summer of 2012.
In December 2012 Clinton shifted control over global
health operations into the hands of US Ambassadors,
4. SIXTY-FIFTH WORLD HEALTH ASSEMBLY A65/29 Add.1, Provisional agenda item 16.2 5 April
2012, ANNEX, Voluntary, contributions by fund and by donor for the financial period 2010–2011; creating the Office of Global health Diplomacy to oversee
SIXTY-FIFTH WORLD HEALTH ASSEMBLY A65/30
Provisional agenda item 16.3 5 April 2012, Status of collection of assessed contributions, including all HIV, malaria, TB, health systems, and other health-
Member States in arrears in the payment of their contributions to an extent that would justify
invoking Article 7 of the Constitution Report by the Secretariat related programs. Polls show that Americans strongly
5. Also see 6. http://www.trust.org/alertnet/news/funding-cuts-imperil-european-fight-against-tb-hiv/
http://www.aicpa.org/research/cpahorizons2025/globalforces/downloadabledocuments/ And http://www.ghd-net.org/sites/default/files/Health percent20Diplomacy percent20Monitor
globaltrends.pdf percent20Volume percent203 percent20Issue percent204.pdf
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Figure 7
support spending taxpayer money on HIV treatment in some that had traditionally played roles in global health
Africa, child health in Bangladesh and the like. But they are withdrew or decreased their commitments, feeling the
deeply confused about how much of the federal budget Gates Foundation was filling the space. This would remain
is dedicated to such foreign aid, imagining it devours a consistent problem for the Gates Foundation, though
as much as 25 percent of the budget, versus the actual the Seattle-based organization would try to collaborate
less-than-1 percent. This combination of Administration with other donors as it grew both in size and influence. Its 9
shuffling of priorities and structure of global health vast out-scaling of other actors nevertheless means that
operations, with public confusion regarding their cost to the Gates Foundation has enormous influence on setting
taxpayers, renders the entire mission highly vulnerable to the global health agenda and directing initiatives, creating
budget slashes. a danger that certain issues will be left out of the fray.
Regardless of what compromises are reached for the Sustainability cannot throughout the remainder of the
FY 2013 budget, the long-term fiscal forecast calls for 21st century impinge on a single political legislature or the
reduced US spending on everything, including foreign generosity of one family. The “Two Washingtons” dilemma
assistance programs. Though there has been discussion is dangerous, both because it puts too much policy power
of broadening the donor base for global health programs, in too few hands, and because it renders global health
bringing in larger support from the BRICS nations and financing vulnerable to the personal whims of a family,
developing innovative financing schemes, none of these and political vagaries of a Congress that is so deeply
efforts are likely to bear timely fruition at a scale that could divided that its 2011 and 2012 sessions marked the least
conceivably offset the loss of billions of dollars’ worth of productive in the history of the US.
US backing. Moreover, most of the innovative financing
schemes, such as the Robin Hood Tax or a currency trading The architecture and aspirations lesson is less discussed
fee, would create funds for which health would have to by global health advocates, but in the long run is surely
compete against hundreds of other worthy initiatives, as dangerous. The primary driver that propelled health
from climate change adaptation and girls’ education to budget growth was the demand for equity in access to HIV
agricultural development and anti-poverty programs. treatment, and the lions’ share of funding has been directed
to that end. In the process, without any serious planning or
The overwhelming influence of the Gates Foundation
presents a related problem. After its dramatic entrance,
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strategic discussion, “global health” was transformed from Architecturally the expansion and then collapse of funding
a classic public health mission, to one aimed at provision for global health caused a radical realignment of power and
of life-long treatment of chronic disease. Global health influence. Not only has WHO’s influence steadily declined,
was, in short, medicalized. eclipsed by new multilaterals, but the targeted priorities of
global health have changed, following the flow of dollars.
This transformation placed immediate and severe burdens Today a fundamental realignment is underway, without a
on health care systems at a time when the world had single word of public debate.
a deficit of some 4.7 million healthcare workers – sub-
Saharan Africa’s health human resources deficit was at least Though it is likely the US government will decrease its
one million. As a result, the period of greatest expansion financial commitments and the size of its bilateral health
programs, it will remain the largest single donor for the
Figure 8
10
of HIV treatment services was marked by rising tension foreseeable future. The Gates Foundation has steadily
and competition between competing medical and public increased its support, and is likely to do so for years to
health needs, fighting over access to doctors, nurses, come, with the bulk of is health funding focused on
hospital rooms and all skilled medical services. Though to development of new technologies and their innovative
some degrees these tensions have eased as governments implementation. The Global Fund has experienced a
have learned how to integrate healthcare services, sharp decline in support, but with reorganization and new
the strategic discussions about how best to execute leadership is likely to enjoy a stable, albeit smaller, base of
medicalization of global health are still in their infancy. donor backing. WHO cannot hope to reverse its financial
The 2011 United Nations General Assembly session on decline without far more core program revenue, which
noncommunicable diseases has exacerbated these health can only come through increased taxation of its member
systems tensions, increasing demand for human resources states – a move the World Health Assembly is unlikely to
and infrastructure to tackle diabetes, cardiovascular approve.
diseases and cancer, and further medicalizing the very
concept of global health. Overall, this realignment, driven by shifts in donor support,
suggests a world community prepared to tackle a handful
of health silos or initiatives: HIV, TB and malaria treatment
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Figure 9
and prevention, child immunization, health technology nations, especially those lacking extraction industry
research and development and to far lesser extents, resources, are unlikely over the next decade to achieve
11
maternal mortality, general child survival and perhaps such lofty self-sustaining goals. Domestic taxes are least
health systems strengthening. likely to meet needs precisely where health exigencies are
the greatest: the Middle East, South and East Asia and sub-
Entirely missing from this architecture is clear leadership Saharan Africa.
and expert guidance for the most likely post-2015
Millennium Goal for health, Universal Health Coverage, or Even the economic superpowers of our time continue to
UHC. receive aid, and demonstrate conflicting patterns. China,
for example, received $2.1 billion in ODA in 2005, but only
The Five Existential Challenges $646 million in 2010, when the nation actually gave back
$109 million in multilateral support. In contrast, India’s
Challenge One: Sustainable Financing
ODA receipts more than doubled between 2007 and 2010,
despite strong GDP growth, reaching $2.8 billion, about 20
Several countries that have been highly dependent on
percent from multilateral institutions including the Global
external support for their public goods, especially for
Fund. Brazil’s ODA receipts jumped five-fold between 2006
health, are now trying to transition to self-sustaining
and 2010, though the net was just $551 million, about
implementation based on domestically generated
eight percent derived from multilateral donors. If these
revenues. Leading this charge is South Africa, which aims
three fast-growing economies remain dependent on
to have its entire national health effort, featuring universal
external donors for health and development support, it
access to healthcare, off external support by 2020 and
should not be surprising that far poorer nations continue
perhaps as early as 2015. South Africa received about nine
to struggle with self-sufficiency.
percent less ODA (Overseas Development Aid) in 2010
compared to its 2008 peak, reflecting the decline in the
country’s demand/dependency level. But the poorest
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Figure 10 - Total potential tax increase by region (annual amounts)
Source : GEA 2012, chapter 19, Shonali Pachuari
Figure 11 - Options for domestic HIV financing in Africa
12
Source : Estimates for UNAIDS by Oxford Policy Management, 2012
Indeed, there is considerable debate over the impact, remains abysmal, nearly half the nation’s children suffer
positive or negative, that the surge in global health chronic malnutrition and stunted growth, and announced
funding has had on recipient countries’ willingness to schemes for healthcare reform flounder amid debate over
maintain or increase its own financial commitments to national versus local responsibility.
health programs. India has come under particular scrutiny
as its economy has ballooned over the last decade, creating A number of donors have sought to improve self-
48 individual billionaires – 10 percent of the number that sufficiency through innovative funding options focused
reside in the US, but an enormous jump for a country on revenue generation. UNAIDS has identified domestic
that ranked two decades ago among the world’s poorest. revenue targets for sub-Saharan African countries that
Despite the stunning rise in Indian wealth both the quality could generate about $15.5 billion annually if fully
and affordability of healthcare for most of its population implemented. But they share problematic features: They
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Figure 12 - Options for Development Financing and Spending
Source : World Bank, United Nations, International Monetary Fund, African Development Bank, World Health Organization,
International Food Policy Research Institute, Bill and Melinda Gates Foundation estimates
13
Source : Estimates for UNAIDS by Oxford Policy Management, 2012
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require creation of non-corrupt mechanisms for tracking blood so dramatically that overall contagion will plummet.
and taxing specific products and services, and they Pay now, the agency argues, so that you will not have to
assume ministers of finance will agree that all revenues pay later. Recent data on the slowing pandemic supports
be dedicated to health, as opposed to dozens of other both UNAIDS arguments.
legitimate public goods needs or military and grand
infrastructure. In addition, taxes levied on such services as Increasingly global health agencies and advocates
mobile phones and domestic airlines are often regressive, are improving their metrics for measuring operational
imposing disproportionate financial burdens on poor success, and correlating dollars with lives saved. UNAIDS,
populations. for example, argues that 7.4 million lives can be saved over
the next 17 years at a cost of $4,090/life. Expression of such
The World Bank and the Bill and Melinda Gates Foundation a calculus, assuming its credibility, forces would-be donors
have parsed several innovative funding options, including to ask, “What is a life worth?”
increased taxation of tobacco and alcohol products, the so-
called Robin Hood tax, and a variety of currency schemes. Challenge Two: The World Wealth Disorder
But even if sufficient political will could be generated to
The nature of world order and economics is transforming
implement these innovations, and to direct their revenues
radically, manipulated by supra-national wealthy interests
to global health needs, financial needs for existing health
that live all over the planet and control of the lion’s share
silos and expanded health systems and UHC targets,
of global capital and wealth. In the world of 2012 a
totaling roughly $211 billion annually, could not be met.
billionaire in Shanghai had far more shared interest and
Combined, they might generate $165 billion annually.
political harmony with financial counterparts in London,
14 UNAIDS has suggested four innovative programs not Abu Dhabi, Rio de Janeiro, London and Los Angeles than
he did with most of his fellow Chinese.
included in the Gates/Bank estimates that might generate
an additional $258 billion annually, bringing the potential
Citi Bank/Knight Frank’s The Wealth Report 2012, which
pool of resources up to $428 billion – more than enough
underscores the “relentless growth of ‘plutonomy’
money to theoretically meet large global health needs.
economics, a phenomenon that sees the wealth of the
But all of these schemes have also been suggested
richest 1 percent growing far quicker than that of the
as sources of income for competing world programs
general population.” The Report documents the increase
to address other pressing issues, including climate
in individuals labeled “centa-millionaires,” whose personal
change programs, core funding for the United Nations
wealth can be calculated in the hundreds-of-millions:
system and peacekeeping operations. Even if – and it is
Collectively in 2011 they possessed $39.9 trillion of an
a large “if” – political will could be mobilized to support
estimated total global wealth of $231 trillion. Their ranks
implementation of these international tax systems, global
are forecast to increase by 37 percent by 2016, chiefly
health would have to get into a long beggars’ queue.
swelling in China, India, Russia, Singapore, Hong Kong
UNAIDS is pushing two arguments specifically in favor of
and Brazil. By 2050, Citi predicts, the world will have been
increased support of HIV treatment and prevention, and
turned upside down with all money, and the power that
that disease’s ongoing exceptional financing. First, the
goes with it, shifted. India will rank #1 with a GDP of some
agency argues that infusion of billions of dollars into care
$86 trillion; China #2 with $80 trillion; the US a distant
and treatment today is lowering country costs in the long
third at $39 trillion followed by, in order, Indonesia, Brazil,
run by keeping people healthy, contributing to national
Nigeria, Russia, Mexico, Japan and Egypt. Missing entirely
productivity and not requiring expensive hospitalization.
from the projected top tier is Europe.
And secondly, UNAIDS insists that saturating the HIV+
world population with anti-HIV medicines will reduce the
While absolute national wealth measurement will display
numbers of people that have high levels of viruses in their
this radical shake-up in the world order, measurement
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15
of GDP per capita and purchasing power parity will by much of Southeast Asia, as the respective economies grow,
2060 rank the world very differently, according to the but their collective wealth is insignificant compared to the
OECD. The US will rank #1, followed in order by Canada, amount of wealth within the top 1 percent. The middle
Germany, the UK, Japan and France. At the bottom of classes are running to catch up, but the goal posts of the
the Top 20 economies, when ranked in this manner, will rich keep moving.7
be China, followed by India. Much of the future of global
health, climate change, resource access and dozens The source of this top-1 percent wealth growth in the
of other transnational issues will be decided by which US is what Nobel laureate Michael Spence calls the
macroeconomic metric proves a more decisive reflection “nontradeable sector” where services such as financial
of global power – absolute national wealth, or the relative management and insurance are not traded overseas
equity of wealth distribution. (versus “tradeable” production such as planes, trains,
automobiles, computer chips and furniture). The result is
Overall the world is witnessing a widening wealth gap in divorcing employment and stock dividends from economic
most countries, with assets concentrating in an oligarch prosperity. In the US, for example, corporate profits have
top 1 percent, or even 0.1 percent of the population. soared since 2008, while unemployment has remained
Middle classes in Western societies are shrinking both in high and stock dividends have sunk. Wealth expansion for
size and comparative personal wealth. In contrast, the the top 1 percent in the emerging economies is derived
middle classes are swelling in China, India, Indonesia and
7. Chart source http://www.economist.com/node/21564414
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from two principle resources: Cheap labor, and extraction accurate, 13 percent of world wealth is out of circulation,
of energy, mineral, forestry and food resources. creating no jobs, products or tangible assets. In addition,
emerging market economies that have grown in the post-
This set of macroeconomic trends poses a conundrum for 2008 world have cautiously stowed liquidity in sovereign
global health and development efforts, which have long funds, spending modest sums in recent years. By 2010
painted countries as poor, emerging, or wealthy. A more these funds totaled $3.5 trillion, and had expanded by 9
accurate painting of the planet finds the colors blended percent in a single year. The largest funds were held by
within nations, and few countries easily designated “poor” Asian and Middle Eastern countries, and about half of
or “rich.” Dr. Bernhard Schwartlander, chief scientist for the world’s sovereign wealth was “parked” in 2010 in real
UNAIDS, told the XIXth International AIDS Conference estate investments, including vast agricultural land-grabs
this summer that, “in 2000, when we began the fight for across fertile regions of the world. By 2012 the funds had
universal access to prevention and treatment and the soared in size, topping $4.6 trillion. As the world struggles
creation of the Global Fund, 70 percent of people with HIV with localized recessions, is threatened with worldwide
lived in low income countries. Eight years from now, it will stagnation, some 15 percent of global capital is out of
be only 13 percent. circulation.
“In this new and complex world, although poverty is as big The next stage of the battle for global health must
a problem as ever, the days when we had a simple world abandon what has essentially been an old-fashioned
of rich countries and poor ones are gone,” Schwartlander North-to-South charity mindset. Impoverishment of
continued. “And with it, we should abandon the concepts public goods may become universal, in wealthy and poor
of dependency and charity, as well as habitual ways of countries, alike, as capital and wealth concentrate in an
16 thinking and acting.” ever-smaller percentage of the planet’s population. Where
development has succeeded, the health needs have grown
As money shifts worldwide, concepts of public goods
more complex and costly amid rising noncommunicable
and global governance are similarly transforming,
disease challenges.
predominantly in despairing forms. The super-rich are
investing in tangible goods that do not generate significant A UNICEF survey of its field officers worldwide found
employment, such as art, real estate, jewelry and yachts. dire concern that the expanding wealth gap in societies
Absent the Warren Buffet/Bill Gates phenomenon, the new constitutes the paramount threat to child health in this
super-rich are not philanthropically inclined to prioritize second decade of the 21st Century. The prominent NGO
problems like diarrheal diseases in Southeast Asia, malaria Save the Children issued a report in late 2012 stating that,
in West Africa, HIV treatment in sub-Saharan Africa or “in our 32 sample countries, children in the richest decile
diabetes management for poor Latina Americanas. While have access to 35 times the income that is available to
they may give generously to their local art museum or children in the poorest decile…The richest 10 percent of
cancer-fighting group, the nouveau riche is not inclined to people has access to 17 times the incomes of the poorest.”8
underwrite causes that are highly complex, benefit poor
people located far away, or are viewed as government Another recent analysis discovered a clear correlation
responsibilities. between widening wealth disparity and child survival
rates, demonstrating that concentration of wealth in
Finally, the world is in a liquidity trap, as both super-rich ever-smaller segments of populations was actually killing
individuals and emerging market countries have removed youngsters in poor families.9
cash assets from the global economy. A recent McKinsey
Company estimate reckons as much as $32 trillion is
8. chart comes from this report: http://www.savethechildren.org.uk/sites/default/files/images/
currently hidden in tax havens, representing the personal Born_Equal.pdf
9. chart comes from this report: http://www.savethechildren.org.uk/sites/default/files/images/
wealth of just 10 million individuals. If the estimate is Born_Equal.pdf
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Figure 15 - Labor and Dividend Income 1959-2011
Figure 16 - Economic growth is rapidly changing the world order - 2020
17
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Figure 17 - Aggregate Sovereign Wealth Fund Assets under Management, 2008-2012
Figure 18 - Correlation between income inequality and the UNICEF index of child wellbeing
in 23 rich countries
18
Source : Pickett KE and Wilkinson R G, British Medical Journal, 2007; 335:1080
A 2012 World Bank survey of 70 countries offers a distinct services available to those with greatest ability to pay a
challenge to proponents of health equity. In contrast more important measure of society’s medical success than
to expert opinions, populations within rich and poor the equitable distribution of those services.
countries tend to place higher priority on the quality
and innovation in health services, versus equity of access This tendency to evaluate the quality of medical services
to said services. As the study authors put it, “Our results based on provision of high technology, versus equitable
indicate that residents of these countries may not favour access to care, poses a tremendous challenge to global
the prioritization of within-country health equality and health advocates in regions hard hit by economic
fairness to the same degree as residents of high-income recession. The perspective has long explained American
countries.” Populations seem to consider the quality of public opinion surveys, which consistently find the
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Figure 19 - The widening gap between rich and poor in effective available income per child since
the 1990s (%)
Source : Calculations on World Development Indicators and Demographic Health Systems data
population favoring the assertion that the US has the by the US National Intelligence Council (NIC) predicts
greatest healthcare in the world, while simultaneously two, seemingly contradictory trends: Rising numbers of
acknowledging that some 50 million people have no middle class around the world even as the Gini Coefficient
access to health insurance and medical costs are the worsens, amid widening disparities. “Middle classes most
primary cause of bankruptcy in the country. The effects everywhere in the developing world are poised to expand
of this have been felt throughout Western countries in substantially in terms of both absolute numbers and the
the wake of the 2008 financial crisis. In Greece, several percentage of the population that can claim middleclass
19
rounds of austerity measures imposed by the IMF and the status during the next 15-20 years,” the NIC forecasts. Yet
EU led to massive reductions in public health and medical the middleclass worldwide could collectively possess little
services starting in early 2009. By 2012 the Greek suicide compared to the spectacular wealth held by the top 2
and mental illness crisis rate had soared, pharmaceutical percent richest individuals, resulting in a scenario the NIC
outages were reported all over the country10, hospital labels “Gini Out-of-the-Bottle,” wherein, “inequalities within
hygiene and basic services had reached such low levels countries and between rich and poor countries dominate.
that doctors advised patients not to seek inpatient care, The world becomes wealthier—as global GDP grows—
HIV incidence was climbing, malaria was widespread for but less happy as the differences between the haves and
the first time since World War II11, and dengue spread have-nots become starker and increasingly immutable.
for the first time in nearly a century. Mortality increased The world is increasingly defined by two self-reinforcing
in Portugal, and basic services such as kidney dialysis have cycles—one virtuous leading to greater prosperity, the
become unaffordable for the country’s huge unemployed other vicious, leading to poverty and instability. Political
population In the US 2012 polling shows that 26 percent and social tensions increase. Among countries, there are
of Americans faced grave financial difficulties due to clear-cut winners and losers.”
medical costs, suicide rates rose with the recession, and
58 percent delayed treatments due to their inability to pay In the nearer term, angry pressure is rising all over the
out-of-pocket expenses or insurance co-pays. world in favor of higher taxation on the very-rich. The rich
have in most countries responded to these calls by off-
Will this wealth challenge persist, even worsen, over the shoring assets, hiring lots of smart tax lawyers to legally
coming decade? The Global Trends 2030 report issued hide assets, and financially supporting anti-taxation (and
10. http://www.nature.com/nm/journal/v18/n12/full/nm1212-1719.html?WT.ec_id=NM-201212 anti-Big Government) political movements. In the US the
11. http://www.episouthnetwork.org/sites/default/files/bulletin_file/eweb_241_31_10_12.pdf;
http://wwwnc.cdc.gov/travel/notices/outbreak-notice/malaria-greece-sept-2012.htm Tea Party wing of the Republican Party made the Federal
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budget the election’s primary focus, demanding reduced must persist lest the infectious diseases resurge, most of
overall spending, no increase in taxation, and scheduled humanity will require a very different set of preventive and
severe declines in both deficit spending and the national treatment priorities.
debt. These goals cannot be attained without radical
reductions in all public goods, including those for health, “In 2010, there were 52·8 million deaths globally,” the
both domestic and foreign. Though Republican defeat Global Burden of Disease Study (GBD) 2010 summarizes.
in the 2012 US elections has been interpreted as a signal “Communicable, maternal, neonatal, and nutritional
that “government” and its public goods can be protected causes were 24·9 percent of deaths worldwide in 2010,
from such attack it would be short-sighted and unwise to down from 34·1 percent in 1990. This decrease was largely
assume that the very-wealthy worldwide are prepared to due to decreases in mortality from diarrheal disease (from
cede control of their mounting assets in favor of health 2·5 to 1·4 million), lower respiratory infections (from 3·4 to
and medical services for the world’s needy. 2·8 million), neonatal disorders (from 3·1 to 2·2 million),
measles (from 0·63 to 0·13 million), and tetanus (from 0·27
Challenge Three: The Global Health Architecture to 0·06 million). Deaths from HIV/AIDS increased from 0·30
versus Its New Mission million in 1990 to 1·5 million in 2010, reaching a peak of 1·7
million in 2006. Malaria mortality also rose by an estimated
The Global Burden of Disease Study (GBD) 2010 survey, 19·9 percent since 1990 to 1·17 million deaths in 2010.
representing the largest scientific review of health trends Tuberculosis killed 1·2 million people in 2010. Deaths from
in the world ever conducted, was released at the end of non-communicable diseases rose by just under 8 million
2012. It demonstrates dramatic changes underway all between 1990 and 2010, accounting for two of every three
over the world, with the world population living longer in deaths (34·5 million) worldwide by 2010.” The data argues
20 nearly every region, but suffering poor health and chronic for focus on tobacco control, diet, and health systems
disease through most of its gained years of life. Thanks in capable of handling millions of chronically ill individuals
large part to the great successes of global health programs, suffering from diabetes, cancer, cardiovascular disease,
the burden of infectious disease mortality plummeted mental illnesses and senility.
between 1990-2010, fewer children perished before the
age of five, and more of humanity is now living into its As debate over the post-2015 Millennium Development
seventh and eighth decades. Goals advances, the front-runner health target is Universal
Health Coverage(UHC). In December 2012 the UN General
This dramatic shift in life expectancy and causes of death Assembly formally endorsed UHC, in much the same form
argues for radical new directions in global health efforts. as was backed in 2011 by the World Health Assembly.
While targeted, disease specific measures to control HIV, Should UHC targets be set for the 2020s, most countries
TB, malaria and childhood vaccine-preventable diseases
Figure 20 - Main causes of global DALYs and top five risk factors for poor health in 1990 and 2010
Source : Data from Murray and colleagues and Lim and colleagues. DALYs = disability adjusted life years
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in the world will need guidance for their achievement, and mosquitoes in West Africa are, through mysterious
covering such things as retention and training of means, “learning” how to outwit bed nets.
healthcare workers, health systems management, medical
financing and insurance, outpatient services and chronic Public health wars are rarely won; they are merely pushed
diseases’ care. to low level stalemates with the enemies. Any relaxation
in humanity’s defenses will result in resurgence of old
But the architecture of global health currently mirrors scourges, often in new, deadlier forms. It would be sheer
disease-specific silos of financing for HIV/AIDS, tuberculosis, folly for the world community to repeat the great error
malaria, maternal health, and the like. WHO has a very thin made in the late 1970s by American public health leaders,
bench of expertise in health management and financing, declaring infectious diseases defeated, even as HIV lurked
and even the World Bank lacks the intellectual power at unnoticed in the country’s gay community and blood
this time to help countries meld public and private health supply.
services, affordable insurance models and quality care with
disease prevention and healthy living priorities. Prior to Challenge Four: The World Food Supply
the 2010 scandals at the Global Fund there was discussion
As the real estate and stock bubbles expanded in late
of transforming that institution into an all-health provider,
2007, worried investors cast about in search of safer
but that would seem, given its weaknesses, to be unwise.
havens for their wealth. In the final quarter of the year food
If the UN ultimately settles on UHC as its next major commodities markets witnessed an unprecedented surge
health target a spectacular reorganization of the entire in the volume of investment, particularly in crop futures
architecture of the multilateral sector in health will be markets, and in the speed of investment cycling. Hedge
necessary. Politically, such a reshuffling will be extremely funds and speculation investment companies surged into
churning reckonings on the forecasts for rice, wheat, corn,
21
controversial, particularly regarding donor/recipient
relations and the future of HIV, TB and malaria control soybeans and other essential grains. The UN’s Food and
efforts. Agriculture Organization (FAO) watched helplessly as basic
grain prices rose alarmingly, reaching a crisis in December
History demonstrates that with increasing attention to 2007 when India capped all rice trade, hedging against a
medical care delivery the power and prioritization of global crisis. The world rice market responded with instant
public health deteriorates. Given the fragility and brevity inflation, spawning yet another Indian hording edict,
of success in such classic public health efforts as child followed by similar action by the Vietnamese government.
immunization, water safety, well baby interventions, By March of 2008 rice prices had risen as much as 200
epidemic detection and response, basic nutrition and percent in parts of Asia, riots broke out in several countries
smoking eradication it would seem premature, even and the World Bank said more than 100 million people had
dangerous, to shift global health a priori to worldwide been driven back into subsistence poverty.
medical care delivery. Despite all rhetoric people are still
dying of AIDS in New York City, regardless of fully insured, Since 2008 the world has faced three more food inflation
sophisticated medical care. Tuberculosis multidrug crises13, and though prices have come down after each,
resistance is on the rise, not decline, so that the absolute they have reset at a “new normal” that is higher than each
burden of TB cases may be ebbing, but the numbers dying successive pre-crisis pricing. In other words, food is on an
of virtually untreatable disease are soaring. And grand upward trajectory, though in roller coaster fashion. The FAO
achievements in malaria control and treatment have been predicts an unstoppable inflationary trend, mitigated only
UJPnZ2-zKSo; http://www.google.com/hostednews/afp/article/ALeqM5ijTS9DbmC8eNgSiFCQB
made, thanks largely to use of artemisinin combination 24TuPU6Ww?docId=CNG.912a8ea62413e194b938a5ec89ba4598.2d1
therapies and bed net distribution, but disturbing pockets 13. http://professional.wsj.com/article/SB10000872396390444301704577631081721558666.
html?mod=googlenews_wsj&mg=reno64-wsj
and http://www.google.com/hostednews/afp/article/ALeqM5gZqt-rYvcWve1UAE_
of parasite resistance12 to the newer drugs have emerged, ljqAj0kLS8g?docId=CNG.e4b1f2cf455cdc265fd51d4f1268045b.231
12. http://www.iol.co.za/scitech/science/news/drug-resistant-malaria-on-the-rise-1.1416104#.
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Figure 21 - Price rises in a single year, March 2007-March 2008
Figure 22
22
Figure 23 - May 2010 FAO Food Price Index
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Figure 24 Figure 25
23
by careful policies that may stave off famines and global production. The outcome was overproduction of corn14, at
malnutrition. Clearly access to appropriate, nutritious food the expense of cropland use for other foods, and diversion
is essential to human health, but to date the global health of some 40 percent of US corn to fuel gas tanks instead of
architecture has failed to absorb food issues in any but a stomachs. Even as corn production rose, stocks of edible
rhetorical fashion. Harmonizing long term strategies and supplies plummeted. Similar climate change mitigation
planning with major food and development programs efforts have unfolded across Europe, resulting in wider
would seem wise, bringing such entitites as OXFAM, use of arable lands for ethanol production, and declines in
WHO, FAO, World Bank and thousands of food-related food crop yields. The BRICS nations, particularly Brazil and
humanitarian and NGO groups into a shared vision. But no China, are also diverting cropland to ethanol production
such drive has emerged in practical terms. and buying up arable resources in poorer countries for
largescale plantings of sugar cane, rapeseed, corn and
There are mutiple drivers behind food price inflation, other crops easily converted to ethanol fuel.
variously amenable to mitigation. Global health advocates
should understand these trends and work as allies with Net food demand is rising alongside both human
food and agriculture organizations to achieve reasonable population increase and relative prosperity. On the overall
food secruity protections for the 9 billion food consumers demand side there is debate15 in agricultural development
of the mid-century. Some of the causes of food inflation and investment circles regarding the global capacity to
are also drivers of the leading sources of poor health, and produce food, amid declining water resources, shrinking
therefore constitute obvious shared targets. arable lands, climate change-induced temperature shifts
14. source for chart on corn prices http://www.economist.com/node/21526383
15. http://www.globalchange.umich.edu/globalchange2/current/lectures/food_supply/food.
Prior to the 2008 first food inflation crisis the George W. htm
and http://www.fastcoexist.com/1679338/what-the-global-food-supply-will-look-like-in-2021
Bush Administration legislated significant subsidies, luring and http://www.scientificamerican.com/article.cfm?id=foley-global-food-production-reduce-
environmental-damage-maps
American corn growers to divert crops for biofuels/ethanol
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Figure 26 Figure 27
and the slow pace of modernization of farming practices. fish-eating cultures. Rising demand for meat places
Africa, in particular, shows striking inability to improve the greater strain on cereal, land and water resources further
basic conditions of farming, and the Indian subcontinent exacerbating efforts to increase crop production for
remains extraordinarily inefficient and wasteful in its human consumption.
inability to get crops to marketplaces in a timely fashion.
According to FAO, productivity (measured as tons of cereal Increasing meat demand has at least two direct impacts
24 harvested per acre) jumped in the US from just under 1 on human health. First, consumption of fatty red meats is
ton in 1961 to almost 3 by 2009 – a tripling in productivity. associated with cardiovascular disease, primarily through
China soared from 0.5 tons in 1961 to 2; Europe from 0.5 their contribution to increasing LDL cholesterol levels.
to 1.5 tons. Even India has doubled its crop productivity More perniciously, “monoculture” livestock practices, in
since 1961. But African productivity has barely budged, which genetically bred cows, chickens, swine or other
remaining at less than half a ton per acre in 2009. animals are raised in captivity in claustrophobic settings,
promote emergence of microbial diseases, particularly
The G20 recognized the food inflation crisis in its 2009 in drug resistant forms. The 2009 H1N1 zoonosis spread
L’Aquila Summit, reaching a series of resolutions aimed from American swine factory-farms, and control of the
at improving agricultural development and standards H5N1 avian flu virus is hampered by poultry practices
of foreign assistance, especially for Africa. None of the throughout Asia. Multiple studies have demonstrated that
L’Aquila commitments on food investment were realized widespread use of antibiotics as growth promoters in the
as promised. livestock industry is the primary driver of emergence of
drug-resistant bacterial diseases in human beings. Such
In addition to there being more mouths to feed, the bat viruses as SARS and Nipah have spread to humans via
rise in prosperity links directly to meat and net caloric livestock animals and live animal markets.
consumption. According to FAO the Chinese average diet
has more than doubled its net caloric intake since 1980, Meat prices are inflating faster than cereals and grains, and
with 59 kg per capita in the form of meat consumed in 2005, will for the foreseeable future be the dominant driver of
versus 13 kg in 1980. The World Bank has demonstrated overall food price inflation. Pressure on cereals and grains
a direct correlation between per capita income levels diversion to feed livestock will increase. Combined with
and meat consumption in every major country in the the other pressures described above, the food inflation
world except Japan and Norway – both, predominately spiral has become an alluring investment opportunity for
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Figure 28 Figure 29
Figure 30
commodity speculators, further driving costs. With each
weather-related (and probably climate change associated)
disaster that impacts crop yields the commodities markets
since 2008 have spiked. Thus, Global health finds its
exigencies in confluence with those concerned about
agricultural development and climate change. Thanks in
25
large part to the efforts of Dr. David Nabarro, working as
a special envoy on behalf of UN Secretary-General Ban Ki-
Moon, strong bridges between food, veterinary and health
multilaterals have been maintained to counter the threat
of zoonotic emergence of pandemic diseases, such as
H5N1 bird flu, SARS and drug-resistant bacterial infections.
Learning from, and building upon these successes would
seem an obvious first step toward practical, meaningful
collaboration across sectors for life-saving food and
agricultural policies and actions.
another potential bridging point. The NGO and academic-
Finally, the same pressures on the global ecology that are driven ONE campaign seeks to bring scientists and health
promoting emergence of human and animal pathogens specialists together in common pursuit of emerging
are wrecking havoc with the agricultural world. Among the diseases.
most worrying is a new mutant form of wheat rust, dubbed
There is suggestion that elimination of growth stunting
Ug99, that first emerged out of eastern Africa a decade ago,
would make an ideal target for bringing these three forces
quickly spreading across the Middle East and into Asia. It
together in common purpose. A growth-stunted child is a
has mutated recently into an even more virulent form with
malnourished young person, suffering for lack of proper
a gene conferring resistance to pesticides, rendering this a
food. Though the physical image of stunting is short
plague for wheat crops. Though control methods of crops
stature due to inadequate calcium and protein intake to
versus people and animals differ, the roots of emergence
fuel skeletal development, its invisible toll is on the brain
and their predictability have much in common, offering
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and the ability of the child to learn and develop skills, thus Figure 31
having direct impact on society’s future human potential
and productivity. At present there is no logical place in the
global health architecture to realize effective targeting of
stunting in appropriate collaboration with the agricultural
and climate communities: Such a space should be created
on an urgent and intellectually admirable basis.
Challenge Five: Climate Change
In16 addition to the food challenges described above in

association with climate change, a host of crises related to
global health present themselves as the planet’s CO2 levels
rise. The global health community’s key focus in climate
debates has been on the likely impact rising temperatures
and rainfall will have/are having on vector populations,
particularly mosquitoes. Of all likely outcomes of a 2 of microscopic sea creatures such as copepods, which
degree Celsius mean rise in global temperatures the health thrive in organically contaminated warm waters. As sea
corollary that has received the most rigorous attention is levels rise, and mean temperatures go up, cholera and
malaria. For about a decade public health experts have other dysentery-causing microbial diseases are emerging
warned that planetary warming would allow disease- in temperate regions, and the seasonality of the disease
26 carrying mosquitoes to thrive at higher altitudes, and is extending into once-colder months of the year. Many
increases in flood and monsoon activities would enhance scientific agencies around the world have made long
breeding opportunities for the insects. Both assertions lists of microbial diseases that they believe are likely to
have proven correct, and the phenomena are now surge in new locations or with different seasonality as the
unfolding. For example, Madagascar in 2012 experienced world warms. Some of these lists have been published by
record numbers of malaria illnesses and deaths amid the World Health Organization, the US CDC and national
changing climate conditions. An East African survey has health agencies.
demonstrated vast increases in mosquito terrain due
to warming in mountainous regions. Recent discovery Already proving to be of far greater consequence are
of malaria in Alaskan birds has startled the research climate-associated violent storm events and heat waves.
community. The resurgence of malaria to southern In 2012 global warming trends followed the high side of
Europe, decades after its eradication from the region, has prior projections, hastening the pace of ice melting and
also spawned concern. atmospheric effects well beyond UN projections. Many
scientists now predict that the Arctic will be free of ice
Though malaria has received the most attention, a in summer months, perhaps before 2016. As ice melts18
number of other diseases are likely to be affected by from the Arctic and glacial regions of the world the albedo
climate change. Dengue Fever, a mosquito-carried viral refractive effect, bouncing heat off the planet and into the
disease that can present in deadly hemorrhagic form, has atmosphere, is reduced, and acidic fresh water pours into
emerged in Portugal17 for the first time in nearly a century, the saline oceans. The pH interaction, temperature mixing
and can be found in many locations worldwide where it of water systems, and escalating water precipitation have
either has never previously been seen, or has reemerged a combined, but poorly understood, impact on promotion
after a long hiatus. Cholera vibrio are carried by a number of violent weather events, as well as sea level rise19. The
16. Graphic comes from: http://www.sciencedirect.com/science/article/pii/S1471492202023747 18. http://blogs.scientificamerican.com/guest-blog/2012/09/21/arctic-sea-ice-what-why-and-
17. http://www.theglobaldispatch.com/madeira-dengue-fever-outbreak-tops-2000- what-next/
cases-76522/ 19. http://www.economist.com/node/21563278
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Figure 32 Figure 33
summer of 2012 saw record melt of Arctic20 ice systems, facets of CO2-induced planetary change, not whether
exceeding the ice disappearance rates forecast by the or not climate change is playing a role at all. There is
United Nations. strong evidence that the storm was fueled by 2012 record
warming of Atlantic sea surfaces. Climate modelers felt
All over the world glacial systems21 were stressed and sadly vindicated when damage from Sandy – particularly
melting rapidly, with direct impact on river systems.
Amid shifting weather patterns and rising atmospheric
the extent of storm surge and flooding – followed almost 27
perfectly a 2007 forecast.24 Following Sandy the New York
temperatures droughts22 hit most of North America and Times asked, “Is This The End?”
the Indian Subcontinent in 2012, and violent storms were
recorded in many regions. There is increasing evidence CO2 levels are rising far more sharply than forecast, and
linking sea warming with hurricane activity in the Atlantic hit record heights in 2012. A World Bank report released in
region. Insurance companies are no longer waiting for 2012 predicts a 4 degree Celsius global temperature rise
more scientific evidence: The link between climate change would displace hundreds of millions of coastal residents
and violent weather is, from their corporate perspective, a and severely damage food supplies. Even a less gloomy
done deal. temperature forecast, imagining merely a 1.5 degree
rise, would force coastal displacement of some 6 million
Hurricane Sandy demonstrated that rising sea levels and Americans, alone. Adaptation25 to climate change in North
climate change hold dire implications for coastal cities America will require spectacular infrastructure spending.
and for national security.23 Though there is considerable For much of the world, especially the Pacific Islands
debate among modelers regarding Hurricane Sandy and nations, the only adaptive response may be migration,
the role climate change played in its generation, most of abandoning countries all together. The costs of adaption
the argument is about relative contributions of various are already being felt, largely in emergency responses.
And http://www.sciencemag.org/content/338/6109/881.full
And http://www.sciencemag.org/content/338/6109/864.4.short The World Bank estimates the annual toll is $1.2 trillion –
And http://www.sciencemag.org/content/338/6109/864.3.short
And http://www.nature.com/nature/journal/v491/n7423/full/nature11566.html a number derived before Hurricane Sandy slammed the
20. www.msnbc.msn.com/id/50063002/ns/technology_and_science-science/
And http://www.sciencemag.org/content/338/6111/1172.abstract
eastern seaboard of North America.
21. http://www.nature.com/nclimate/journal/v2/n10/full/nclimate1592.html?W
24. and http://www.nytimes.com/2012/09/11/nyregion/new-york-faces-rising-seas-and-slow-
And http://www.nature.com/nature/journal/v488/n7412/full/488468a.html
city-action.html?pagewanted=1&hp&pagewanted=all
25. http://blogs.cgdev.org/globaldevelopment/2012/10/how-to-decide-which-countries-
22. http://www.politico.com/news/stories/0912/81276.html
should-get-climate-adaptation-finance.php?utm
23. http://americansecurityproject.org/featured-items/2012/climate-security-report/
and http://www.eurekalert.org/pub_releases/2012-10/uoca-cva102212.php
and Climate variability and conflict risk in East Africa, 1990-2009.pdf
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Figure 34 Figure 35
Figure 37
28
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Figure 36
Hospital26 and emergency resilience after 2005 Hurricane scientists cannot parse the relative weight of the causes:
Katrina, Sandy27 and other severe weather events shows Over-fishing, pollution and waste dumping, changes in
few medical facilities are prepared to withstand prolonged salinity/acidity, temperature shifts, churning storms and a
flooding, loss of electrical power, or large scale surges in long list of other complex contributors.
trauma patient numbers. WHO warns that health systems
will be taxed all over the world by climate-induced From a human health perspective the issue is less causality
storms, rich and poor alike. World Bank President Jim Kim than the absolute loss of sea-derived food, coupled with
announced willingness in 2012 to entertain proposals the sewer-like ecology of many coastal waters, in which 29
linking adaptation to climate change with global health a range of microbes may thrive. Heat, coupled with
issues and HIV programs. drought, may constitute a “new normal” across much
of the Indian Subcontinent. Monsoons have come later
Rising sea levels, violent storms and catastrophes constitute annually, temperatures have risen, and extreme drought
the most obvious challenges to health systems, particularly has shattered agricultural production in parts of India,
in poor countries with vast sea level populations, such as Pakistan and Bangladesh.
Bangladesh. But an equally devastating impact on human
health may come from heat, itself. For human beings the insidious effect of heat, per se on
the body may be the most under-appreciated cause of
Shifting heat and salinity patterns are altering the marine elevated deaths associated with climate change. In 2012
ecology28 that directly impacts fisheries, and the food the US space agency NASA showed that the world has
Pacific Island nations, Japan and many Indian and South experienced a steady increase since 1951 in the volume
China Sea populations rely upon. Shifting salinity is and severity of severe heat events with temperatures
directly affecting drinking water, and therefore human sustained at levels that are above safe tolerance for
health and agriculture, in much of the world. The ocean human beings. While temperatures vary on a classic bell-
ecologies are changing so rapidly and dramatically that shaped curve, NASA found that the median of that curve
26. http://www.nejm.org/doi/full/10.1056/NEJMp1213843 has shifted toward higher extremes every year. In 2003,
and http://www.nejm.org/doi/full/10.1056/NEJMp1213844
and http://www.nejm.org/doi/full/10.1056/NEJMp1213486 when Europe experienced a record-breaking sustained
and http://www.nejm.org/doi/full/10.1056/NEJMp1213492
27. http://www.fas.org/sgp/crs/homesec/R42804.pdf heat wave, France lost more than 11,000 people to heat
and http://www.eurekalert.org/pub_releases/2012-11/nu-ddb110212.php
and http://www.nature.com/news/hurricane-sweeps-us-into-climate-adaptation-de- stroke .In 1995 a 50-day heat wave killed 692 people in
bate-1.11753
28. http://www.pnas.org/content/109/43/17633.abstract and http://www.nature.com/nature/
Chicago, mostly poor, African-American and/or elderly. A
journal/v491/n7422/full/491010d.html?WT.ec_id=NATURE-20121101
And http://www.pnas.org/cgi/doi/10.1073/pnas.1208160109
third of the New Orleans deaths during and after Hurricane
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Figure 38 Figure 39
Katrina were due to heat stroke. A recent Harvard School Asia may be at particular human health risk because of
of Public Health study found that elderly individuals that the density of populations living along coastal and river
have underlying chronic ailments are the most likely to systems. But another contributor cannot be ignored:
perish under high heat conditions. Overall, the researchers soaring industrialization and energy production,
30 concluded that for every degree increase in the average particularly from China. Because of its dependency on
peak summer heat in the US, 10,000 senior citizens will coal, China is now the world’s largest soot-producer,
perish. In a sense their work offers a dose/response curve emitting gigatons of carbon pollutants that blanket the
between climate change and one type of human mortality. Himalayan glaciers and contribute to planetary CO2.
Recent reappraisals of China’s emissions indicate it is the
The Global health community has not responded to the world’s #1 CO2 producer.
challenge of climate change in a meaningful manner.
Beyond explicative work, health advocates and their What Is To Be Done?
multilateral agencies have steered clear of climate debates,
spent little financial or intellectual capital in confronting The boom in global health funding, organizations and
the problem, and provided virtually no concrete agenda governments’ interest saved lives. In a remarkably short
for health system and population adaptation to severe amount of time the resources, however chaotically
weather, heat or other likely outcomes of rising CO2 levels. administered and unaccountably they may have been
spent, saved tens of millions human beings. In 1960,
One critical opportunity to scientifically parse the impact when the world population was 3 billion, some 20 million
of CO2 emissions and air pollution on global human children under 5 years of age died annually, mostly from
health was the 2008 Beijing Olympics, when the Chinese infectious diseases. By 2010, with a world population of
government cleared the region’s air but shutting down some 6.8 billion, the child death numbers had plummeted
much of the manufacturing and coal firing in northeastern to about 8 million annually. The Bill & Melinda Gates
China for the duration of the sporting event. Comparison Foundation reckons that persistent effort and sustained
of pre-Olympics, during the Olympics and post-Olympics funding for vaccination, malaria prevention, nutritional
air in the US researchers showed that China’s air is America’s support, elimination of mother-to-child HIV transmission
air. The human health impact of carbon pollution is and proper management of pediatric pneumonia and
global.29
29. Source for chart is http://jama.jamanetwork.com/article.aspx?articleid=1157472
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Figure 40 Figure 41
diarrheal disease can push that death toll down below 5 In just four years the US PEPFAR program saved 740,000
million children a year in 2025, when the world population lives, mostly in Africa, according to a Johns Hopkins
will top 8 billion people. University study. By comparing mortality rates in PEPFAR-
aided countries in Africa to neighbouring nations that were
In 2000 about a million people died of malaria, most not recipients of the US program’s support the researchers 31
of them children under 12 years old. By 2009 the global divined the US government’s impact.
mobilization of resources and malaria control programs
brought that death toll down to 781,000, according to the Attention to making pregnancy a safe experience
WHO. It could then be argued that about a half million worldwide and the comparatively modest donor support
lives were saved over nine years. for maternal mortality programs have also paid off,
saving millions of lives. Since 1990 maternal death tolls
The UNAIDS Programme estimates about 6 million people have plummeted 47 percent, falling even in countries
were taking anti-HIV medicines by the end of 2011, 2.3 where women enjoy few reproductive rights, and give
million of them living in sub-Saharan Africa. Since the birth to more than five children per mother. According
global response to HIV began to escalate in 2001, UNAIDS to Save the Children’s Mothers in 2012 the lion’s share of
says, the incidence of new infections worldwide has maternal deaths, on a per capita basis were concentrated
plummeted by 50 percent, and AIDS-related deaths in in Afghanistan and nine poor sub-Saharan African nations.
Africa have fallen by a third. “In some of the countries which
have the highest HIV prevalence in the world, rates of new The 2012 Global Burden of Disease survey offers more
HIV infections have been cut dramatically since 2001; by proof that global health works. In 1990, for example,
73 percent in Malawi, 71 percent in Botswana, 68 percent tuberculosis ranked #9 for worldwide causes of loss of
in Namibia, 58 percent in Zambia, 50 percent in Zimbabwe disability-adjusted life. By 2010 TB had fallen to the #13
and 41 percent in South Africa and Swaziland,” UNAIDS position. Measles ranked #16 in 1990: by 2010 vaccination
announced in November 2012. More than 500,000 fewer programs had pushed it down to #27. Overall in 1990 seven
people died of AIDS in 2011 compared to 2005, meaning of the top ten killers were infectious diseases; by 2010 only
more than a million lives were saved overall. 4 of the top ten were communicable ailments.
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Figure 42 Figure 43
The challenge for Global health in 2013 is to find a way to

maintain, even accelerate these successes while shifting Figure 44
focus to the chronic disease killers, and forming working
partnerships with organizations tackling food security
and climate change. Pursuit of UHC, if clearly defined and
32 measured with realistic metrics, offers hope of building
resilient, accessible health systems designed to tackle
a broad range of threats to human health and well-
being. But without fundamental alterations in the basic
architecture of global health, and radical shifts/escalations
in funding support, UHC and resilience are pipe dreams for
most of the world.
Political mobilization to save the large mission of human

survival requires a shared definition of “global health.”
The conversation that might produce such a definition
has begun, in chaotic fashion, largely as an outcome of Some of this exercise will transpire amid negotiations
financial panic. What is needed is a far more deliberate over the post-2015 UN targets, but the process is hardly
debate, in a context outside of the World Health Assembly inclusive. The majority of the world population that would,
or donor/recipient negotiations. Since 2000 funding or should, be the targets of the UN agenda know nothing
streams have defined the mission, and the largest donors about it, and have no input. The multilateral agencies, their
have wielded the greatest influence over the policy and prime donors and allied NGOs will lead the debate.
best practices agenda. The Obama Administration’s years
of hand-wringing over the structure of the US foreign In tough fiscal and economic times it is difficult to step
assistance program reflects an earnest attempt to give away from pocketbook exigencies to seek a guiding vision
recipient countries more control over their own public for the future. One piece of the vision has, however, already
health and medical missions. But “global health” should fallen into place: Cessation of the “charity” component of
not be defined by the US government, regardless of the global health. The notion that has driven the early 21st
scale of its financial commitment to the mission. Century surge in global health action and funding was
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spawned by many players, including economist Dr. Jeffrey
Sachs who famously in 2000 framed the entire mission in
terms of American entertainment. Combined, he argued,
HIV, TB and malaria could all be conquered if every North
American and European gave up annually the equivalent
cost of a movie ticket and a box of popcorn. Sachs chastised
the World Bank and US Congress for their parsimony, and
insisted an unprecedented multibillion dollar flow of cash
from the northern hemisphere rich world to the southern
hemisphere poor was the key to global health.
Activism gelled around the concept, and the pipeline of

funds poured forth. The money has, indeed, saved millions
of lives. But a sustained sense of victory of infection,
coupled with new visions for health systems, climate and
food security and noncommunicable disease prevention
will require far more than charity. Countries must politically
embrace the challenges themselves, commit to the
healthy survival of their populations, and build permanent
structures and governance for change.
33
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More information about these and other recent publications can be found at cic.nyu.edu.
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NEW YORK UNIVERSITY

Existential Challenges to Global Health

CENTER ON INTERNATIONAL COOPERATION

CIC’s programs and research activities span the spectrum of

Existential Challenges to Global Health

The Current Landscape 8

The Five Existential Challenges 11

Challenge Two: The World Wealth Disorder 14

Challenge Four: The World Food Supply 21

Challenge Five: Climate Change 25

Figure 2 - Funding from 1994 to Present

Figure 5 - Funds Decline Sharply

Source : GEA 2012, chapter 19, Shonali Pachuari

Figure 11 - Options for domestic HIV financing in Africa

Source : Estimates for UNAIDS by Oxford Policy Management, 2012

Source : Estimates for UNAIDS by Oxford Policy Management, 2012

Figure 16 - Economic growth is rapidly changing the world order - 2020

Source : Pickett KE and Wilkinson R G, British Medical Journal, 2007; 335:1080

Figure 23 - May 2010 FAO Food Price Index

Challenge Five: Climate Change

In16 addition to the food challenges described above in

The challenge for Global health in 2013 is to find a way to

Political mobilization to save the large mission of human

Activism gelled around the concept, and the pipeline of

Annual Review of Global Peace Operations 2012

Review of Political Missions 2012

Shaky Foundations | An Assessment of the UN’s Rule of Law Support Agenda

Engagement on Development and Security: New Actors, New Debates

Building on Brahimi: Peacekeeping in an Era of Strategic Uncertainty

Strategic Trends, Dilemmas, and Developments in Global Peace Operations

Robust Peacekeeping: The Politics of Force

Implications of Peacebuilding and Statebuilding in United Nations Mandates

Mandates and Modalities

U.N. Peace Operations and State-building: A Case Study of Haiti

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