Chapter 002. Global Issues in Medicine (Part 13) ppt

Chapter 002. Global Issues in Medicine
(Part 13)

Conclusion: Toward a Science of Implementation
Public-health strategies draw largely on quantitative methods—from
epidemiology and biostatistics, but also from economics. Clinical practice,
including internal medicine, draws on a rapidly expanding knowledge base but
remains focused on individual patient care; clinical interventions are rarely
population-based. In fact, neither public-health nor clinical approaches alone will
prove adequate in addressing the problems of global health. There is a long way to
go before evidence-based internal medicine is applied effectively among the
world's poor. Complex infectious diseases such as AIDS and TB have proven
difficult but not impossible to manage; drug resistance and a lack of effective
health systems have further complicated such work. Beyond communicable
disease, in the arena of chronic diseases (e.g., cardiovascular disease), global
health is a nascent endeavor. Efforts to address any one of these problems in
settings of great scarcity need to be integrated into broader efforts to strengthen
failing health systems and to alleviate the growing personnel crisis within these
systems.
For these reasons, scholarly work and practice in the field once known as
international health and now often designated global health equity are changing
rapidly. Such work is still informed by the tension between clinical practice and
population-based interventions, between analysis and action. Once metrics are
refined, how might they inform efforts to lessen the premature morbidity and
mortality registered among the world's poor? As in the nineteenth century, human
rights perspectives have proven helpful in turning attention to the problems of the
destitute sick; such perspectives may also inform strategies of delivering care
equitably. A number of university hospitals are developing training programs for
physicians with interests in global health. In medical schools across the United
States and in other wealthy countries, interest in global health has been exploding.
An informal survey at Harvard Medical School in 2006 revealed that nearly one-

quarter of the 160 entering students either had significant global health experience
or were planning a career in global health. A similar sea-change among trainees
has been reported at other medical schools. Half a century or even a decade ago,
such high levels of interest would have been unimaginable.
Persistent epidemics, improved metrics, and growing interest have only
recently been matched by an unprecedented investment in addressing the health
problems of poor people in the developing world. Ours is a moment of
opportunity. To ensure that the opportunity is not wasted, the basic facts need to
be laid out for specialists and laypeople alike. More than 12 million people die
each year simply because they live in poverty. An absolute majority of these
premature deaths occur in Africa, with the poorer regions of Asia not far behind.
Most of these deaths occur because the world's poorest do not have access to the
fruits of science. They include deaths from vaccine-preventable illness; deaths
during childbirth; deaths from infectious diseases that might be cured with access
to antibiotics and other essential medicines; deaths from malaria that would have
been prevented by bed nets and access to therapy; and deaths from water-borne
illnesses. Other excess mortality is attributable to the inadequacy of efforts to
develop new tools. Those funding the discovery and development of new tools
typically neglect the concurrent need for strategies to make them available to the
poor. Indeed, some would argue that the biggest challenge facing those who seek
to address this outcome gap is the lack of practical means of distribution in the
regions most heavily affected.
The development of tools must be followed in short order by their equitable
distribution. When new preventive and therapeutic tools are developed without
concurrent attention to delivery or implementation, we face what are sometimes
termed perverse effects: even as new tools are developed, inequalities of
outcome—less morbidity and mortality among those who can afford access, with
sustained high morbidity and mortality among those who cannot—will grow in the
absence of an equity plan to deliver the tools to those most at risk. Preventing such
a future is the most important goal of global health.

Further Readings
Cohen J: The new world of global health. Science 311:162, 2006 [PMID:
16410496]
Desjarlais R et al (eds): World Mental Health: Problems and Prio
rities in
Low-Income Countries. New York, Oxford University Press, 1995
Farmer PE: Infections and Inequalities: The Modern Plagues
, 2d ed.
Berkeley, University of California Press, 2001
———
: From "marvelous momentum" to healthcare for all. Response to
Garrett L: The challenge of global health. Foreign Affairs 86:155, 2007
Fauci AS et al: Emerging infectious diseases: A 10-
year perspective from
the National Institute of Allergy and Infectious Diseases. Emerg Infect Dis 11:519,
2005 [PMID: 15829188]
Garrett L: The challenge of global health. Foreign Affairs 86:14, 2007
Hotez PJ et al: Neglected tropical diseases and HIV/AIDS. Lancet
368:1865, 2006 [PMID: 17126708]
Jamison DT et al (eds):
Disease Control Priorities in Developing
Countries, 2d ed. Wash
ington, DC, Oxford University Press and The World Bank,
2006
Kim JY et al (eds):
Dying for Growth: Global Inequality and the Health of
the Poor. Monroe, ME, Common Courage Press, 2000
Lopez AD et al: Global and regional burden of disease and risk factors
,
2001: Systematic analysis of population health data. Lancet 367:1747, 2006

[PMID: 16731270]
Murray CJL, Lopez AD
(eds): The global burden of disease: A
comprehensive assessment of mortality and disability from diseases, injuries, and
risk factors in 19
90 and projected to 2020. Cambridge, MA, Harvard University
Press, 1996
Sachs J, Malaney O: The economic and social burden of malaria. Nature
415:680, 2002 [PMID: 11832956]
World Bank: World Development Report 1993: Investing in Health
. New
York, Oxford University Press, 1993
World Health Organization:
Macroeconomics and Health: Investing in
Health for Economic Development
. Geneva, Commission on Macroeconomics and
Health, 2001
———: World Health Report 2006: Working Together for Health
. Geneva,
World Health Organization, 2006