A New Direction for Global Health

NEW YORK – It is easy to be discouraged about the state of international cooperation today, but global health remains an area in which the world has come together to do significant good. Over the last dozen years, international initiatives have delivered HIV/AIDS treatment to millions, expanded childhood immunization, and spurred a dramatic increase in global support for addressing other health challenges, from malaria to maternal health.

International support for global health is an investment in developing countries’ future prosperity and the wellbeing of their people. It is an investment that the world’s richest countries can well afford.

For example, the United States is the leading contributor of global health aid, which accounted for just 0.23% of US spending in 2013. The returns on that investment have been remarkable. Child mortality is plunging. Millions who would have otherwise perished from HIV/AIDS are still alive. Countries that were aid recipients are increasingly self-sufficient – and have become better trade and strategic partners as a result.

But the health needs of low- and middle-income countries are now shifting. Dramatic changes in urbanization, global trade, and consumer markets – which occurred over decades in wealthy countries – are happening at a faster rate, and at a much larger scale, in still-poor countries. These trends have brought substantial health benefits, such as better sanitation and increased food production, but have given rise to significant challenges as well.

Ebola is one high-profile example. Prior to this year, Ebola had killed fewer than 2,000 people, all in Central Africa, since it was first identified in 1976. The virus has killed more than three times that number in 2014, with enough cases spreading internationally to dominate nightly news broadcasts and spook voters in recent US state and local elections.

A major reason is the growth of small- and medium-size cities. Urbanization is increasing in West Africa at a rate of 3% per year (compared to 0.2% and 0.3%, respectively, in North America and Europe). The result has been the proliferation of settlements of a million people or fewer living with limited public-health infrastructure.

These cramped cities are ideal incubators for outbreaks of emerging infectious diseases like Ebola. With greater trade and travel to the region, outbreaks are likely to spread before international containment can coalesce.

Another example of changing global health needs is the stunningly fast increase of heart disease, cancers, and other noncommunicable diseases (NCDs) in low- and middle-income countries. Once thought to be challenges for affluent countries alone, these diseases have quickly become the leading cause of death and disability in developing regions, killing nearly eight million people before their 60th birthdays in 2013.

In a recent report sponsored by the Council on Foreign Relations, we highlight the contrast between rising rates of heart disease, cancer, diabetes, and other NCDs in developing countries and the success of international efforts on HIV/AIDS and other infectious diseases. From 1990 to 2010, death and disability from NCDs in low-income countries increased 300% faster than the rate of decline in infectious diseases.

Some of the same factors at work in the recent Ebola outbreak drive the high rates of NCDs. Inhabitants of densely packed urban areas in emerging economies often face both indoor and outdoor pollution, and are less likely to have access to adequate nutrition. Most health systems in these countries are not built for chronic or preventive care and lack basic consumer protections. From 1970 to 2000, cigarette consumption tripled in developing countries. Diseases that in high-income countries are preventable, like cervical cancer, or treatable, such as diabetes, are often death sentences in developing countries.

International investments have not yet adjusted to changing global health needs, especially with respect to NCDs. In 2010, $69.38 of international aid was spent for each year lost to death or disability from HIV/AIDS (as measured in disability-adjusted life years, or DALYs), $16.27 was spent per DALY lost to malaria, and $5.42 per DALY lost to poor maternal, newborn, and child health. But only $0.09 was spent per DALY lost to heart disease, cancer, and other NCDs.

Meanwhile, the emerging NCD epidemic is worsening. Indeed, the World Economic Forum is predicting $21.3 trillion in losses from these diseases in developing countries by 2030.

Yet progress on NCDs is possible. Despite much higher rates of obesity in high-income countries, premature death and disability from heart disease, cancers, and other NCDs have declined substantially. Most of the tools and policies underlying this success are cheap, but not widely implemented in developing countries. They include low-cost drugs to reduce heart attacks, vaccines to prevent cervical cancer, and the same tobacco taxes and advertising rules that dramatically cut smoking rates throughout Europe and the US. Pilot programs have successfully integrated these tools and policies into donor-funded programs on HIV/AIDS and other infectious diseases in low- and middle-income countries.

If, over the next decade, low- and middle-income countries could improve NCD prevention and treatment at the same rate as the average rich country from 2000 to 2013, they would avert more than five million deaths. That return is comparable to the most successful global health investments in HIV and childhood immunization, and it is an investment worth making for the same reason: a peaceful, inclusive global economy presupposes healthier, more productive lives.