Chapter 002. Global Issues in Medicine (Part 2) pps

Chapter 002. Global Issues in Medicine
(Part 2)

The optimism born of the world's first successful disease-eradication
campaign invigorated the international health community, if only briefly. Global
consensus regarding the right to primary health care for all was reached at the
International Conference on Primary Health Care in Alma-Ata (in what is now
Kazakhstan) in 1978. However, the declaration of this collective vision was not
followed by substantial funding, nor did the apparent consensus reflect universal
commitment to the right to health care. Moreover, as is too often the case, success
paradoxically weakened commitment. Basic-science research that might lead to
effective vaccines and therapies for TB and malaria faltered in the latter decades
of the twentieth century after these diseases were brought under control in the
affluent countries where most such research is conducted. U.S. Surgeon General
William H. Stewart declared in the late 1960s that it was time to "close the book
on infectious diseases," and attention was turned to the main health problems of
countries that had already undergone an "epidemiological transition"; that is, the
focus shifted from premature deaths due to infectious diseases toward deaths from
complications of chronic noncommunicable diseases, including malignancies and
complications of heart disease.
In 1982, the visionary leader of UNICEF, James P. Grant, frustrated by the
lack of action around the Health for All initiative announced in Alma-Ata,
launched a "child survival revolution" focused on four inexpensive interventions
collectively known by the acronym GOBI: growth monitoring; oral rehydration;
breast-feeding; and immunizations for TB, diphtheria, whooping cough, tetanus,
polio, and measles. GOBI, which was later expanded to GOBI-FFF (to include
female education, food, and family planning), was controversial from the start, but
Grant's advocacy led to enormous improvements in the health of poor children
worldwide. The Expanded Programme on Immunization was especially successful
and is thought to have raised the proportion of children worldwide who were
receiving critical vaccines by more than threefold—i.e., from <20% to almost 80%

(the target level).
For many reasons (including, perhaps, the success of the UNICEF-led
campaign for child survival), the influence of the WHO waned during the 1980s.
In the early 1990s, many observers argued that, with its vastly superior financial
resources and close if unequal relationships with the governments of poor
countries, the World Bank had eclipsed the WHO as the most important
multilateral institution working in the area of health. One of the stated goals of the
World Bank was to help poor countries identify "cost-effective" interventions
worthy of international public support. At the same time, the World Bank
encouraged many of these nations to reduce public expenditures in health and
education as part of (later discredited) structural adjustment programs (SAPs),
which were imposed as a condition for access to credit and assistance through
international financial institutions such as the Bank and the International Monetary
Fund (IMF). One trend related, at least in part, to these expenditure-reduction
policies was the resurgence in Africa of many diseases that colonial regimes had
brought under control, including malaria, trypanosomiasis, and schistosomiasis.
Tuberculosis, an eminently curable disease, remained the world's leading
infectious killer of adults. Half a million women per year died in childbirth during
the last decade of the twentieth century, and few of the world's largest
philanthropic or funding institutions focused on global health.
AIDS, first described in 1981, precipitated a change. In the United States,
the advent of this newly described infectious killer marked the culmination of a
series of events that discredited the grand talk of "closing the book" on infectious
diseases. In Africa, which would emerge as the global epicenter of the pandemic,
HIV disease further weakened TB control programs, while malaria continued to
take as many lives as ever. At the dawn of the twenty-first century, these three
diseases alone killed an estimated 6 million people each year. New research, new
policies, and new funding mechanisms were called for. Some of the requisite
innovations have emerged in the past few years. The leadership of the WHO has
been challenged by the rise of institutions such as the Global Fund to Fight AIDS,

Tuberculosis, and Malaria; the Joint United Nations Program on HIV/AIDS
(UNAIDS); and the Bill & Melinda Gates Foundation and by bilateral efforts such
as the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Yet with its
193 member states and 147 country offices, the WHO remains preeminent in
matters relating to the cross-border spread of infectious and other health threats. In
the aftermath of the SARS epidemic of 2003, the International Health
Regulations—which provide a legal foundation for the WHO's direct investigation
of a wide range of global health problems, including pandemic influenza, in any
member state—were strengthened and brought into force in May 2007.
Even as attention to and resources for health problems in resource-poor
settings grow, the lack of coherence in and among global health institutions may
seriously undermine efforts to forge a more comprehensive and effective response.
While UNICEF had great success in launching and sustaining the child survival
revolution, the end of James Grant's term at UNICEF upon his death in 1995 was
followed by a lamentable shift of focus away from immunizations; predictably,
coverage dropped. The WHO has gone through two recent leadership transitions
and is still woefully underfunded despite the ever-growing need to engage a wider
and more complex range of health issues. In another instance of the paradoxical
impact of success, the rapid growth of the Gates Foundation, while clearly one of
the most important developments in the history of global health, has led other
foundations to question the wisdom of continuing to invest their more modest
resources in this field. We may indeed be living in what some have called "the
golden age of global health," but leaders of major organizations such as the WHO,
the Global Fund, UNICEF, UNAIDS, and the Gates Foundation must work
together to design an effective architecture that will make the most of the
extraordinary opportunities that now exist. To this end, new and old players in
global health must invest heavily in discovery (relevant basic science); in the
development of new tools (preventive, diagnostic, and therapeutic); and in a new
science of implementation, or delivery.