4
Creating a Framework for Progress

Globalization’s emerging transnational social organization and epidemiological structure have transformed national public health into an international issue and necessitated the development of global health policy and governance. This chapter summarizes the workshop presentations and discussions on how sovereign states and nations must adopt a global public health mind-set. Also emphasized was the need for a new organizational framework to exploit the opportunities and overcome the challenges created by globalization and build the capacity needed to respond effectively to emerging infectious disease threats.

The trend toward increased funding for international health, such as that made available through the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) and President Bush’s recently proposed Millennium Challenge Account (MCA), suggests that global public health is finally receiving the political attention it deserves, largely by virtue of its implications for economic development and national security. Global public health is no longer perceived as a costly charity endeavor; rather, it is increasingly being viewed as a cost-effective way of doing business, with countries poised to take action on selected diseases when there is an economic benefit to doing so.

Nonetheless, this increased funding and focus do not necessarily mean enough is being done collectively to enhance the global capacity to respond to either intentionally or naturally introduced infectious disease threats. As one workshop participant noted, global infectious disease control demands new approaches, and despite the welcome recent influx of funding, a fully coordinated and effective response will require even more money. Others



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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary 4 Creating a Framework for Progress Globalization’s emerging transnational social organization and epidemiological structure have transformed national public health into an international issue and necessitated the development of global health policy and governance. This chapter summarizes the workshop presentations and discussions on how sovereign states and nations must adopt a global public health mind-set. Also emphasized was the need for a new organizational framework to exploit the opportunities and overcome the challenges created by globalization and build the capacity needed to respond effectively to emerging infectious disease threats. The trend toward increased funding for international health, such as that made available through the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) and President Bush’s recently proposed Millennium Challenge Account (MCA), suggests that global public health is finally receiving the political attention it deserves, largely by virtue of its implications for economic development and national security. Global public health is no longer perceived as a costly charity endeavor; rather, it is increasingly being viewed as a cost-effective way of doing business, with countries poised to take action on selected diseases when there is an economic benefit to doing so. Nonetheless, this increased funding and focus do not necessarily mean enough is being done collectively to enhance the global capacity to respond to either intentionally or naturally introduced infectious disease threats. As one workshop participant noted, global infectious disease control demands new approaches, and despite the welcome recent influx of funding, a fully coordinated and effective response will require even more money. Others

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary admonished, however, that a lack of money should not be used as an excuse for not moving forward. This chapter begins with a summary of the workshop discussion on the economic, national security, and other factors responsible for the changing perception of international health. This is followed by a summary of presentations and comments regarding some of the sources of and concerns about increased funding for international public health. The Global Fund and the MCA were discussed in some detail. The participants also briefly discussed the potential public health role of interim debt relief. Despite the promises of new funds and potential sources of even more funding, participants expressed many concerns, particularly with regard to how the funds would be used and whether they would be sustainable. Questions about the role of money also led to a brief discussion regarding the relative value of evidence-based public health and good governance. With regard to the newer approaches required for global infectious disease control, several different but overlapping ideas were discussed. In addition to the need for consortia of financiers, such as the Global Fund, which are bigger and more flexible than individual agencies, most of the discussion focused on the need for public–private collaborations among states, interstate and regional organizations, nongovernmental organizations (NGOs), multinational corporations, and various other nonstate actors. Not only does the increasingly interconnected world provide opportunities for public–private collaborative responses on an international scale never before possible, but the intensifying cross-border traffic of microbes characteristic of globalization also demands that this opportunity be seized. Greater interaction and fluidity between the developed and developing worlds, as exemplified by the bidirectional training programs discussed in Chapter 3, were also identified as a vital component of any effort to improve global public health. Throughout the workshop, participants discussed the most effective and sustainable ways to approach and manage collaborations with institutions, governments, and other partners in the developing world. Although some of these comments were included in the discussion of multinational research and training initiatives in Chapter 3, others are presented here. Most of the public–private and other partnerships discussed during the workshop have been or are being designed to address the urgent and critical public health needs of the developing world and other countries with particular needs, such as Russia. Thus there was some discussion of the need to continue addressing U.S. domestic public health needs as well, especially the rise of antimicrobial resistance. Another important component of global public health identified by participants was the concept of public health as a global public good, especially with regard to product development and the dissemination of knowledge. The former was touched upon during the

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary discussion on access to and delivery of antiretroviral agents in sub-Saharan Africa, as summarized in Chapter 3. As globalization creates new governance challenges with respect to infectious disease prevention and control, the role of international law in infectious disease control policy has been shifting in important but uncertain ways. The chapter includes a summary of presentations on the revised International Health Regulations (IHRs) and the changing role of international law. The chapter ends with a summary of the discussion pertaining to the need to study and understand the emergence of infectious disease threats within the larger social and political context. Historically, study of the emergence of infectious diseases has been restricted to the realm of biology. The political ecology of disease provides a new conceptual framework for understanding the public health consequences of globalization, including, for example, investment decisions that lead to environmental alterations, changing vector ecologies, and increased risk of the emergence and spread of infectious diseases. THE CHANGING PERCEPTION OF INTERNATIONAL HEALTH1 A significant change in the perception of international health has occurred over the past decade. If asked 10 years ago to think about where international health dollars were being spent, most people would probably have thought of charity or the work of Mother Theresa or Albert Schweitzer. Today, international health is no longer perceived as a costly charity endeavor. Rather, as noted above, it is increasingly being perceived as a cost-effective investment with national security implications. The political and economic instability of sub-Saharan African countries with high HIV infection rates, for example, threatens the potential for strong international trade partnerships and poses a serious national security risk to the United States. Although the renewed interest in international public health can be attributed mainly to economic and national security concerns, numerous other factors are at play. One participant described this renewed interest as a convergence of economic, humanitarian, and other ideals and strategic interests, including the following: Diplomacy—Public health is playing an increasingly important and constantly evolving role in international relations. Addressing the burden of 1   This section is based on the workshop presentations by Adeyi (2002), Gardner (2002), Gordon (2002), and Patz (2002).

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary FIGURE 4-1 Impact of HIV on economic growth for 80 developng countries, 1990–1997. SOURCE: The World Bank (2000). disease in other countries by developing training and research programs, as described in Chapter 3, builds bridges of friendship and trust between U.S. and international scientists and fosters a deeper understanding and mutual respect between the United States and its partner nations. This represents a form of diplomacy with tremendous economic potential. Economic development—The global burden of infectious disease, which accounts for about 42 percent of the total global burden of disease, is not just about disease but also about money. The causal links among improved health status, an improved standard of living, and economic development are well established. The impact of HIV on economic growth in developing countries, for example, has been tremendous (see Figure 4-1). According to predictions by economist Jeffrey Sachs (WHO, 2000), if malaria had been eliminated 35 years ago, up to $100 billion would have been added to sub-Saharan Africa’s 2002 gross domestic product of $300 billion. Because large-scale epidemics generally increase expenditures, reduce revenues, and raise the cost of doing business, businesses do what they can to minimize those impacts and avert lost productivity. Thus, for purely economic reasons, the private sector has taken a renewed interest in international public health, as have many governments. Unfortunately, increases in morbidity and mortality do not, by themselves, always tell a compelling story until the data are translated into economic terms. Money—not inci-

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary dence and prevalence rates—is the language finance ministers and treasury secretaries understand. Increased opportunities for international trade—By investing in the public health systems of developing countries, the United States can develop valuable trading partners, thereby fostering its own economic growth. International political stability—Better health, improved economies, and stronger diplomatic relationships all foster stronger ties between the United States and its international partners and contribute to the latter’s political stability. U.S. national security—Much of the renewed interest in global public health in the United States stems from concerns about national security. This was true even before the 2001 anthrax attacks. As one participant suggested, it is imperative for policy leaders and key decision makers to realize that global public health and infectious disease control are critical to preserving national and international economic and political security. In 1998, 200,000 people in Africa died in wars, and 2.2 million died from AIDS. In some countries, more than 30 percent of the military and 40 percent of teachers are infected with HIV. The national security implications of the growing global threat of infectious diseases were highlighted in a recent National Intelligence Council (NIC, 2000) publication, The Global Infectious Disease Threat and Its Implications for the United States.2 The report contained several predictions and warnings, and since its publication, some of its predictions have clearly begun coming true: Infectious diseases are on the rise, and their potential costs are likely to be very high and far-reaching. Growing international concerns about infectious disease are likely to lead to travel- and trade-related frictions among countries. There is a growing risk of a bioterrorist attack against U.S. targets, both at home and abroad. HIV/AIDS will cause major demographic disruptions, perhaps to the point of undermining political stability in the poorest, hardest-hit, and most vulnerable countries. HIV infection rates among members of the armed forces are likely to be high enough that some militaries will be weakened and their ability to support U.S. peacekeeping missions limited. 2   The primary responsibility of the National Intelligence Council, a U.S. government strategic think tank, is the production of long-term strategic intelligence analysis for the President of the United States and other members of the President’s national security team. The report can be viewed online at http://www.cia/gov/cia/publications/nie/report/nie99-17d.html.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary Opportunities made available by advances in technology—Some cause for optimism comes from the existence of proven or promising technologies that can potentially be used for the prevention and control of infectious diseases. Vaccines, radiation therapy, and insecticide-impregnated bed nets are just a few examples. Confidence that comes from the recognition of past successes—Smallpox eradication demonstrated what global partnerships can achieve, given the necessary political will. The effort to control onchocerciasis in West Africa is another success story. Humanitarian concerns—The world is increasingly recognizing the inequity of a situation in which a tiny fraction of the world’s population enjoys relatively robust health while the vast majority live from day to day with serious, avoidable morbidity and premature mortality. Improved U.S. public health—Lessening the burden of communicable diseases globally reduces the risks of importing diseases such as polio and tuberculosis (TB) into the United States. In addition, research advances made abroad often guide improvements in health care in the United States. The use of oral rehydration therapy (ORT) to treat the effects of severe cholera in overseas settings is an excellent example of how research advances abroad can lead to health improvements at home (i.e., the use of ORT to treat dehydration secondary to diarrhea, regardless of the cause). ORT is a low-tech scientific discovery that did not attract the notice of national research interests in the United States. The rule of law on a global level—One participant pointed out that most of the workshop discussion appeared to revolve around the notion of health as a humanitarian, economic, or national security goal. He called attention to the notion of health as an inalienable human right. Thus for a number of reasons, infectious disease issues are being viewed as requiring a unified, global response despite differences in local interests. In March 2002, U.S. Senators William Frist and Jesse Helms announced plans to seek $500 million in additional funding for the fight against HIV/AIDS as part of the Bush Administration’s emergency supplemental funding request for the war against terrorism and homeland security. In the Untied States, the need for international health expenditures is the subject of broad political consensus. Likewise, to the extent that internationally agreed-upon goals, such as the development goals of the MCA, signify international consensus on the need to strengthen efforts to combat infectious diseases, such efforts are central to the global agenda as well. Public health is prominent among the MCA development goals, and infectious diseases are key elements of those public health goals. For example, one of the goals is to reduce by two-thirds the mortality rate among children under age five between 1990 and 2015. Another is to reverse the spread of HIV/AIDS, malaria, and TB.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary However, the political attention that emerging infectious diseases are finally garnering does not necessarily mean that enough is being done collectively. For example, a number of countries are off track with regard to achieving a two-thirds reduction in the child mortality rate by 2015. This is especially true of the sub-Saharan African region, and of countries within other regions (including Eastern Europe and Central Asia, the Middle East and North Africa, and Southeast Asia) to varying degrees. This is not a country-specific or even a regional but rather a global concern. INCREASED FUNDING FOR GLOBAL INFECTIOUS DISEASE CONTROL: SOURCES AND CONCERNS3 Although the renewed political commitment to international public health has led to increased funding for global infectious disease control, many workshop participants expressed concern regarding the sustainability of the funds, the realization of promised federal funding, the way the funds will be used, and whether the funds are sufficient to support the effort. According to 2001 estimates from the World Health Organization (WHO) Commission on Macroeconomics and Health, the price tag for new country-level programs, research and development, and the provision of other global public goods is $27 billion per year until 2007 and $38 billion per year by 2015. Current commitments total less than $7 billion. Recent increased funds for global infectious disease control are coming largely from the U.S. government, for example, through greater expenditures on international health by the National Institutes of Health (NIH) and the U.S. contribution to the Global Fund. These funding sources are described below, along with President Bush’s recently proposed MCA. In addition to their financial contributions to global infectious disease control, the Global Fund and the MCA exemplify the strong trend toward public– private partnerships within the context of global public health. Private-sector investments, such as funding from the Bill and Melissa Gates Foundation and Ted Turner’s gift to the United Nations Foundation, have also contributed to the effort and are fueling a much greater awareness of the importance of these issues. In addition to U.S. public and private investments, international organizations, such as Médecins sans Frontières (Doctors without Borders) and the Global Fund, are contributing to the effort. In fact, Europe and Japan each devote more of their gross national product to international health than does the United States. 3   This section is based on the workshop presentations by Cash (2002), Gardner (2002), Kurth (2002), LeDuc (2002), Steiger (2002), and Widdus (2002).

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary NIH Funding Although NIH funding for visiting overseas scientists has remained steady, direct foreign research awards have grown and are expected to continue to rise rapidly, and the foreign component of domestic NIH awards has risen about four-fold over the last six or seven years. Expenditures for NIH training grants are also beginning to increase slightly. In fiscal year 2002, overall NIH expenditures in the area of tropical infectious disease totaled $255,400,000. In late 2002, this figure was probably above the $300 million mark. The Millennium Challenge Account4 On March 14, 2002, President Bush proposed the MCA—$5 billion of new and additional resources to complement the current bilateral assistance program of the U.S. Agency for International Development (USAID). The purpose of the MCA is to encourage greater responsibility and commitment by host governments to practice good governance, address social problems, and engage in a number of other efforts to improve their economy and standard of living. A number of criteria for eligibility and funding availability are being developed. The goal is to involve as many partners as possible, including the private sector. The basic principle behind the MCA initiative is to shift from dispensing international assistance merely for geopolitical or political purposes toward directing resources to countries that have the greatest potential to make progress and the best policies in place, or to those whose policies the United States expects to change and improve over time. When the President announced the program, he enunciated three criteria for investment: Governance issues—Does the country have good policies in place for democracy, transparency, openness, and political participation? Investing in people—Does the country have, on its own, adequate policies for investing in education and health? Issues of economic freedom—Does the country have good macro-economic and fiscal policies in place? What is its stance with regard to trade liberalization and privatization? The program is in the process of developing a set of indicators for measuring a country’s progress in terms of these criteria and, perhaps over time, translating this progress into eligibility to receive funding. This is 4   Updated information on the MCA can be found at the website http://www.usaid.gov/mca/.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary being done on an interagency basis, led by the U.S. Departments of State and Treasury and USAID. Program developers are seeking input on how to apply these three criteria and determine which countries are the most deserving of the additional assistance over and above what is provided by current international assistance programs, such as those of USAID and the U.S. Department of Health and Human Services (DHHS). The grants will be used as rewards for encouraging the development of good policies and making positive changes. The decision to base the new grants on accomplishments rather than need was heavily influenced by work done at The World Bank showing that assistance has been effective in countries with better health policies and ineffective in countries with poor policies. A participant noted that the MCA represents an attempt to bring many of the issues discussed at the workshop into the arena of international development assistance in a way new to the U.S. government. In fact, the MCA and the Global Fund both serve as models for how the United States and perhaps other governments can revamp their models of foreign assistance in ways that better account for the role of public health in economic development. At the same time, workshop participants raised some concerns about the proposed MCA. First, what impact will it really have on fighting infectious disease? The President has indicated that this is a general fund, not a health fund. By mentioning both health and education in his announcement, the President signaled that both sectors will receive substantial portions of the funds, but the amounts have not been determined. At this point, only an unspecified amount will be made available for HIV/AIDS and possibly other health concerns, such as TB and malaria. Moreover, while the scale of the MCA is quite significant compared with previous investments, and while the money to address these critical problems is potentially of enormous value, the details of implementation will ultimately prove the worth of the initiative. It is important to note that, according to the President, the MCA will be independent of U.S. contributions to the Global Fund, and regardless of how the MCA is structured, the U.S. commitment to the Global Fund will continue. Whether the MCA is being created for humanitarian reasons or to serve U.S. interests, it reflects an increased appreciation for the importance of global health and the need for the United States to make real commitments to improving health in other parts of the world. A second major concern regarding the MCA is the notion of performance-based funding. Globalization has led many to believe that capitalism works, that public health should learn from business, and that public health practitioners should operate in the same way as business-people. Although this may be true to a certain extent, some question whether public health practitioners should adopt the approaches of business through-

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary out the international public health arena. The idea of performance-based funding has its positive aspects, and rewarding results is good practice. However, performance-based funding must not divert attention from the need to help those populations that have been failed by their governments. The Global Fund to Fight AIDS, Tuberculosis, and Malaria The concept of an international fund to fight HIV/AIDS, TB, and malaria was first proposed at the July 2000 Group of Eight (G8) Summit. By 2001, many governments and international agencies began discussing a variety of ideas for a global fund, including commodity purchase funds, advance-purchase commitment funds, broad health-sector interventions, funds for HIV/AIDS, and funds for a number of other specific diseases. Nothing crystallized, however, until May 11, 2001, when President Bush, along with the Secretary General of the United Nations (UN), announced that the United States would be the first donor to a global fund for HIV/ AIDS, TB, and malaria. The original contribution was $200 million. Since then the United States has increased its pledge to $500 million, including $200 million for fiscal year 2003. This commitment—about 25 percent of the $2 billion total pledged to date—represents by far the largest commitment by any government or institution to support the global fund concept. Priorities of the Global Fund When the President and the UN Secretary General announced the original commitment from the United States, the President outlined five principal priorities and emphases. As of this writing, the Global Fund has already achieved considerable progress toward meeting these five goals. 1. The Global Fund must be an independent, international public– private partnership, representing a new way of doing business and a new paradigm for foreign assistance. The United States and others had no interest in simply recreating the UN or even housing a new program within one of the UN agencies. Nor was the intent to divert attention from the important work done by the UN; rather, there was a frank recognition that there are limits to the work multilateral organizations as currently structured can do. In particular, there was a perceived need for a vehicle that would be attractive to both the nonprofit, nongovernmental private sector and the corporate private sector, as well as philanthropic organizations. The Global Fund is incorporated as a nonprofit foundation under Swiss law. The governing board includes representatives of seven donor governments (the United States, Japan, the European Commission, Italy, France,

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary the United Kingdom, and Sweden, the last three of which represent constituencies of smaller donors); seven developing-country governments, one from each of the seven WHO regions (Nigeria, Uganda, Brazil, Ukraine, Thailand, Pakistan, and China), plus an extra seat for Africa; and four private-sector entities, including an NGO from the northern hemisphere (a medical missionary organization from Germany), an NGO from the southern hemisphere (a community-based organization from Uganda), the Bill and Melinda Gates Foundation (which has contributed $100 million to the effort), and McKinsey and Company, which represents a broad coalition of for-profit private-sector actors. The private-sector representatives have been involved in structuring the Fund’s secretariat, recruiting candidates for chief executive officer, and providing advice on the strategy and structure of the staff of the Fund. The board has four ex officio seats: The World Bank as trustee; WHO, which will be providing administrative support; the Joint United Nations Programme on HIV/AIDS (UNAIDS); and an additional NGO representing infected people and people affected by the three diseases. The President intended the Global Fund to be a lean organization and a financial institution, not an implementing agency. It is a mechanism designed to move money to, not to operate, programs and partnerships. However, some internal functions will require personnel if the Fund is to achieve all of its goals. Along with the notion of partnership, the intent was for the Global Fund to operate under a bottom-up approach. The Fund is not interested in dictating to countries how to spend their money or how to design their programs. Rather, countries are to inform the donors and international community of their priorities. During the current proposal process, the Fund is hearing about local needs and ways in which community organizations can work with their governments to develop and implement strategies. 2. The Global Fund should adopt an integrated approach. A critical priority is to achieve a balance among regions, the three diseases, the prevention and treatment of each disease, and the care and support of those afflicted. Judging from the many proposals that have been recommended for funding thus far, the Fund has achieved a good balance; nevertheless, there is more work to be done. 3. The Global Fund must adopt a performance mind-set and be financially and programmatically accountable. The Fund must ensure that the money is well targeted and well spent and that funded interventions have meaningful impacts on reducing morbidity and mortality. A key component of this goal is monitoring and evaluation of the Fund’s performance over time. 4. The Global Fund will evaluate proposals through an independent technical review process. The independent, impartial vetting of proposals by public health, scientific, and development experts is key to ensuring that

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary The information for real-time management is to be compiled from various IHR documents, such as regulations, annexes, and technical guides; the WHO-coordinated Global Outbreak Alert and Response Network (see the section on the use of the World Wide Web in international surveillance and response in Chapter 3); WHO-based epidemic intelligence; and IHR focal points in every country. A key component of the real-time event management aspect of the revised IHRs is confidential, or provisional, notification. Countries can enter into a dialogue with WHO regarding the best way to control a situation without the dialogue becoming general knowledge. Other real-time management features of the revised IHRs include WHO’s ability to accept information from unofficial sources, after which verification would be obtained from the country; WHO’s provision of network response support; and the availability of a template of recommendations and measures based on risk assessments for particular events. Under the new IHRs, each country is required to maintain core surveillance capacities, as defined in the IHRs, including the ability to detect and report infectious diseases and to respond at both the local public health and national levels. Initially, this will be a target capacity for many countries, and WHO will need to work with these countries to develop their capacities. Each country will receive technical guidelines for the establishment of early-warning systems. The criteria for reporting under the new IHRs include “public health emergencies of international concern.” WHO and the Swedish Institute of Infectious Diseases have been developing an algorithm for determining when a public health emergency may have an international effect and thus whether WHO should be notified. Following notification of WHO, consultation and collaboration between the country and WHO will be used to determine the appropriate response. The four main components of the algorithm are as follows: Is this event serious? Is it unexpected? Could it or has it spread internationally? Is there a risk of international sanctions? Of course, even the revised IHRs will face numerous challenges: Convincing countries that notification of urgent public events under the new IHRs is to their advantage. Ensuring that international reactions to events are appropriate and that other countries do not impose inappropriate sanctions. Developing the national political will to detect, investigate, and control problems instead of ignoring them and waiting for them to disappear (which has often been the case in the past for those diseases not required to be reported). Developing the national capacity for surveillance and response.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary International Law and Emerging Infectious Diseases The public health challenges created by globalization can be categorized conceptually as either vertical or horizontal. Vertical challenges represent problems countries face within their own borders, such as weak surveillance capabilities. Horizontal challenges are the public health problems that arise from increased cross-border traffic of microbes resulting from the greater speed and volume of international trade and travel. Public health strategies against infectious diseases can be similarly categorized. A vertical strategy is an attempt to reduce the prevalence of an infectious disease inside a single country from within that country. In contrast, a horizontal strategy is an attempt to create cooperation among countries to minimize disease exportation and importation. Usually, the onus of implementing both types of strategies falls on the individual country. After all, public health is a public good, which means it is the government’s responsibility; private-sector actors have neither the resources nor the incentives to do what is necessary to protect the public’s health. Thus, the individual country is a critical component of the governance response to emerging and reemerging infectious disease threats. It can operate within one of three overlapping governance frameworks: A national governance response occurs within a country’s territory and under its own laws, and as such is a vertical strategy. For example, national quarantine practices in the first half of the nineteenth century took place without international cooperation; each country managed its own strategy with regard to infectious disease threats. An international governance response is the classic intergovernmental cooperation that occurs, for example, in WHO or the World Trade Organization (WTO). International governance is aimed primarily at creating horizontal public health strategies regarding disease exportation and importation. The IHRs are an example of such a response. A global governance response involves nonstate actors—including multinational corporations and NGOs—all of which play a significant and sometimes formal role in handling issues at the global level. At this level, the multinational corporations and NGOs are effectively built into the governmental response mechanisms. The primary strategic emphasis of global governance is vertical. The attempt is to reach down to the local level, and there is little interest in intergovernmental cooperation. The role of international law in global governance is not structural; rather, it is to provide norms that influence vertical public health strategies. The Global Fund is an example of global governance. The first century of international health diplomacy, which began in the mid-1800s, witnessed the creation of three primary horizontal interna-

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary tional legal regimes relating to infectious diseases: the classical, organizational, and trade regimes. The classical regime dates back to the inception of the early International Sanitary Convention in 1851, which was replaced by the International Sanitary Regulations in 1951 and then renamed the IHRs in 1969. The IHRs’ stated purpose—“to ensure the maximum protection against the international spread of disease with minimum interference with world traffic”—captures the essence of the classical regime, which constitutes the central and most important use of international law in infectious disease governance at the international level, at least within the first 100 years of international health diplomacy. The organizational regime represents the various state-created international health organizations (IHOs), beginning in 1902 with the Pan American Sanitary Bureau. This regime involves the use of international law to create permanent IHOs, such as today’s WHO, in an effort to facilitate intergovernmental cooperation on infectious diseases and other international public health problems. In contrast with the classical regime, the organizational regime’s legal responsibilities for infectious disease control have been shallow at best. The best example of the trade regime, which represents efforts to liberalize trade among states, is the General Agreement on Tariffs and Trade (GATT), adopted in 1947. Although its explicit purpose is not infectious disease control, GATT includes rules that allow states to restrict trade to protect human, plant, and animal life and health. Thus, it figures in the use of international law in the international governance of infectious disease control. Over the last five decades, there have been several important shifts in governance with important implications for infectious disease control. First, within the realm of horizontal international governance, there has been a shift in emphasis from the classical to the trade regime. This was evident in the number of times WTO was mentioned during the workshop and is referred to in this report—far more times than either the IHRs, which represent the classical regime, or WHO, which represents the organizational regime. The classical regime has been widely recognized as failing to achieve its objective of maximum protection against the international spread of disease with minimum interference with world traffic, for several reasons (see the preceding section on the IHRs). WTO came into existence in 1995, almost simultaneously with WHO’s recognition that the IHRs were inadequate to deal with the challenges posed by globalization. Since its inception, WTO has become the central horizontal regime for international law on infectious diseases. Two WTO agreements in particular have garnered attention: the Agreement on Trade-Related Aspects of Intellectual Property Rights (the TRIPS agreement) and the Agreement on the Application of Sanitary and Phytosanitary Measures (SPS Agreement) in connection with food safety.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary This shift from the classical to the trade regime raises some questions with regard to WHO’s revision of the IHRs. Participants suggested that there was some indication that a revised set of IHRs might not even be necessary. For example, with regard to maximum protection against the spread of infectious disease, there has been a shift away from relying on the binding legal duty to provide notification of specific diseases to a reliance in WHO on new information technologies. This shift is epitomized by WHO’s Global Outbreak Alert and Response Network, which is being used to gather global epidemiological information outside the framework of the IHRs. It is unclear whether the IHRs are necessary for WHO to make progress on global epidemiological surveillance. As another example and with regard to minimum interference with traffic and trade, many irrational trade-restricting health measures are sometimes instituted when countries report real or supposed disease outbreaks (see Chapter 3). Despite WHO’s attempt to give the IHRs more teeth to deal with the issue, WHO is no longer the most important player, but WTO. Not only does this shift from the classical to the trade regime raise questions about the usefulness of the IHRs and the need to develop revised IHRs, but it also raises the question of whether we are witnessing the rejuvenation of the classical regime or its death. A second change that has occurred over the past several decades with regard to the governance of infectious diseases is the evolution after World War II of vertical international regimes that influence global strategies on infectious disease much more dramatically than do the traditional horizontal approaches. Although these regimes—the soft-law regime, the environmental regime, and the human rights regime—are not international, their objectives are to deal with issues that concern individual countries and to improve conditions inside countries; their purpose is not necessarily to regulate intergovernmental cooperation. For example, the soft-law regime, which includes WHO’s development of norms, principles, guidelines, and best practices on infectious disease control (e.g., the DOTS strategy for TB control), is not legally binding on WHO member states (hence the term “soft law”). Indeed, voluntary compliance is an important aspect of how WHO has historically worked. Adoption of these norms and practices generally has a beneficial impact inside the country for both the government and the public health system. Unfortunately, compliance with soft-law guidance from WHO is not very good, as the lack of compliance with DOTS illustrates. The environmental regime, another development after World War II, is an attempt to improve environmental practices inside countries so that their populations can enjoy better environmental conditions. Thus, to many people’s surprise, it is also an international body of law concerned with the protection of human health. One of its weaknesses with respect to infectious disease, however, is that it focuses very little if at all on local air and

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary water pollution, two of the greatest environmental sources of morbidity and mortality from infectious disease. The human rights regime, which imposes obligations on governments in connection with their treatment of persons living within their territories, also has the potential to have a significant effect on public health. Respect for human rights, including the right to health, has been part of strategies for dealing with a number of public health crises, including the HIV/AIDS pandemic, as well as treaties such as the UN Convention on the Rights of the Child. This regime is now quite powerful. A third critical change in governance of infectious disease over the last 50 years is the development of global governance mechanisms that support the new trade and vertical public health strategies. Again, unlike international governance, which involves only states, global governance involves states, intergovernmental organizations, and nonstate actors, and the strategy is vertical, not horizontal. The involvement of NGOs and multinational corporations is a key component of these new mechanisms, whose strategic objective is to produce global public goods that states, especially developing countries, can use within their own territories to reduce the rates of morbidity and mortality from infectious disease. Currently, one of the most prominent features of these new global governance mechanisms is the development of public–private partnerships, such as the Global Fund. As another example, infectious disease surveillance, especially via the Global Outbreak and Alert Response Network (see Chapter 3), is often fueled by the participation of nongovernmental actors who acquire their information from nongovernmental sources, such as the press, the online website ProMED, and NGOs. One of the most controversial developments in the infectious disease arena as regards global governance is the development of the new access regime, which arose from a clash between the trade and human rights regimes. The objective of the access regime is to improve access to essential drugs, vaccines, and medicines in developing countries; the regime is being driven largely by nonstate actors, as opposed to intergovernmental organizations or states, and is characterized by the heavy involvement of NGOs (e.g., the Global Fund and the Global Alliance for Vaccines and Immunization). The emergence of the access regime was marked by the dramatic adoption of the Declaration on the TRIPS Agreement and Public Health at the WTO Doha Ministerial Meeting in November 2001. The declaration clearly supports placing public health objectives, especially access to medicines, above the trade-related goal of increasing patent protection for pharmaceuticals. Experts view the declaration as a victory for the human right to health and for public health governance generally. Another development involves arguments that infectious diseases represent national security threats, and as such should be a priority on foreign

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary policy agendas. In contrast to the movement toward vertical global governance characteristic of the access regime, these arguments seek to reconnect infectious disease control with national and international governance by reengaging the great powers in international public health. Should these arguments take hold, one might foresee reinvigorated national and international governance on infectious disease. However, it would be prudent to be cautious about arguments that infectious diseases represent national security and foreign policy threats. Historically, the great powers have not hesitated to bend, break, or abandon international law when they believed national security was being threatened. Although the United States has focused energy and new funding on homeland security against bioterrorism, it has rejected multilateral efforts to strengthen international governance as it pertains to the threat of biological weapons. Many experts are concerned about what appears to be a rejuvenated U.S. unilateralism in an area in which public health plays a strategic role. At the same time, the tepid and tardy responses to the HIV/AIDS catastrophe in sub-Saharan Africa hardly suggest that infectious disease problems in faraway countries have risen high on many national security and foreign policy agendas. The shift from binding commitments in international governance efforts to nonbinding, voluntary participation in global governance efforts may suit the narrow public health interests of the great powers at the expense of strengthening national and international governance of infectious disease. Never before has the role of international law been so important in infectious disease control. At the same time, there is a great deal of uncertainty about where these new developments will lead and whether they will really have an impact on improving the ability to prevent and control infectious disease at the global level. THE NEED FOR A SOCIAL SCIENTIFIC FRAMEWORK FOR UNDERSTANDING INFECTIOUS DISEASE EMERGENCE8 Attempts to understand the etiology of the emergence of infectious diseases cannot be restricted to a purely biological approach. Rarely, if ever, is the emergence of an infectious disease caused exclusively by biological factors. The word “syndemic” was recently introduced into the English language to refer to the convergence of factors that typically contribute to 8   This section is based on the workshop presentations by Mayer (2002) and Patz (2002); see also Appendix C.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary the emergence of infectious diseases (Singer, 1994). This is perhaps no better illustrated than by the emergence of West Nile virus in New York City, an event that was the culmination of the convergence of a number of different human ecological factors. Only by studying the complex interplay among the social, environmental, and biological factors that underlie the emergence of infectious disease can one hope to gain an understanding of disease distribution patterns and changes. In the original IOM (1992) report on microbial threats, Emerging Infections: Microbial Threats to Human Health in the United States, five of the six factors identified as contributing to the emergence of infectious disease are explicitly social in nature (i.e., human demographics and behavior, technology and industry, economic development and land use, international travel and commerce, and a breakdown in public health), and the sixth (microbial adaptation and change) is partly the result of social behavior and social change.9 The effects of dam construction, land clearance projects, and other environmental modifications on vector ecology illustrate the necessity of adopting a social approach to understanding the global emergence of infectious diseases. To understand the effects of globalization on vector ecology, one must study not only vector ecologies per se, but also the role of human activities and behaviors. Despite the vital role of social factors in the etiology of infectious disease emergence and the fact that the literatures of many of the social sciences, such as demography and political geography, could inform our understanding of infectious disease emergence, the vast preponderance of research and policy on the emergence of infectious diseases has been explicitly biological in nature. Little social science has been incorporated into epidemiological, public health, or infectious disease research and policy. One of the consequences of the failure to take a social scientific perspective in attempting to understand the emergence of infectious diseases has been a restrictive definition of globalization in public health—a definition that tends to focus only on surface phenomena, such as the movement of people and commodities. Even within the workshop, as summarized in Chapter 1, most of the descriptions of phenomena that characterize the globalization of infectious disease revolved around the movement and interaction of people and goods. There was comparatively little discussion on the movement of capital and the critical role of political and economic 9   In the IOM (2003) report that was the successor to the 1992 report, Microbial Threats to Health: Emergence, Detection, and Response, 10 of the 13 identified factors in emergence are explicitly social in nature; the other three (microbial adaptation and change, climate and weather, and changing ecosystems) are at least partly the result of social behavior and social change.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary decision-making power that transcends national borders. Yet understanding the relationships between changing vector ecologies, for example, and globalization necessitates an understanding of how political and economic decisions, particularly those that alter the landscape, change human– environment relations at the local, regional, and global levels. Failure to recognize the importance of the latter could compromise efforts to strengthen the global capacity to prevent and control emerging and reemerging infectious diseases. How can a social scientific perspective be incorporated into the study of emerging and reemerging infectious diseases? Classic geographic disease ecology has been developing since about the time of World War II, when Jacques May, a French surgeon who practiced in French Indochina, became intrigued by the role of the interaction of local social, cultural, and environmental conditions in the development of patterns of contagion for a number of infectious diseases. He eventually gave up his surgical career to become the medical geographer at the American Geographical Society in New York City, where he produced numerous volumes and papers on disease ecology, including a monumental 30-volume collection of works demonstrating how disease ecology could be understood from a more integrated and less purely biological perspective (May, 1958). As significant as his work was, however, May did not consider the impact of other regions on local conditions. Thus, even though interregional patterns of commodity shipments, cultural contact, and cultural change are aspects of global interdependency that were apparent decades ago, May did not incorporate them in his descriptions and analyses. Nor did he consider the effects of power and politics on local disease conditions. That tradition has continued to today. Even when social factors are considered, disease ecologists tend to focus only on isolated regions and generally fail to consider regional hierarchies and interregional interactions and flows, such as the migration of people and the movement of capital. The political ecology of disease may provide the best way yet to conceptualize the impact of these factors on local disease ecologies. Political ecology, which is based on a combination of political economy and cultural ecology, is “the attempt to understand the political sources, conditions, and ramifications of environmental change” (Bryant, 1992, p. 13). It can and has been used as a way to understand the unintended consequences of environmental decisions, particularly those, such as dam building, that alter human–environment relations and affect emerging infectious diseases (Mayer, 2000). In addition to adopting a political ecology approach, another means suggested for improving the conceptual framework for understanding the emergence of infectious diseases is to strengthen the type of interdisciplinary research that addresses key knowledge gaps related to how factors of

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary emergence converge and interact. This will be a challenging task, as it will require long-term cross-disciplinary collaboration. As an example of the current failure of cross-disciplinary communication, not a single climatologist was included in a recent multiauthored paper on climate and malaria in the African Highlands published in the journal Nature, even though the work was essentially a climate study and made use of an extant climate database (Hay et al., 2002). Indeed, the climatologist whose climate database was used in the study prepared a rebuttal for publication in the journal pointing out how the database was used inappropriately and how the results are flawed. If a climatologist had been part of the original research team, this situation could have been avoided. As the impacts of dam construction and land modification projects on emerging infectious diseases attest (see Chapter 1), the need to understand emergence within the larger social and political context is clearly not just an academic exercise. Human activity associated with the expansion of free-market capitalism threatens to destroy ecosystems and opens the door to the rapid emergence of new diseases. If left unchecked, the current economic model that allows such environmental devastation will likely lead to future public health crises. Moreover, recent research suggests that scarcities of vital environmental resources—especially cropland, freshwater, and forests—contribute to violence in many parts of the world, a phenomenon that feeds back into and amplifies the effect of the devastation. As the competition for scarce resources increases, environmental devastation worsens, the potential for economic prosperity decreases, and public health deteriorates. REFERENCES Adeyi O. 2002 (April 17). Considerations for Shaping the Agenda. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Bryant RL. 1992. Political ecology: An emerging research agenda in third world studies. Political Geography 11(1):12–36. Cash R. 2002 (April 16). Impediments to Global Surveillance and Open Reporting of Infectious Diseases. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. CDC (Centers for Disease Control and Prevention). 2002. Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy. Atlanta, GA. [Online]. Available: http://www.cdc.gov/globalidplan/global_id_plan.pdf [accessed September 12, 2005]. Cleghorn F. 2002 (April 16). Considering the Resources and the Capacity for the Response. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary Fidler D. 2002 (April 16). International Law, Infectious Disease, and Globalization. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Gardner P. 2002 (April 17). New Directions in Capacity Building. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Gordon D. 2002 (April 16). The Global Infectious Disease Threat. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Hay SI, Cox J, Rogers DJ, Randolph SE, Stern DI, Shanks GD, Myers MF, Snow RW. 2002. Climate change and the resurgence of malaria in the East African Highlands. Nature 415(6874):905–909. IOM (Institute of Medicine). 1992. Emerging Infections: Microbial Threats to Health in the United States. Washington, D.C.: National Academy Press. IOM. 2003. Microbial Threats to Health: Emergence, Detection, and Response. Washington, D.C.: The National Academies Press. Kimball AM. 2002 (April 16). Invited Discussion: Considering the Resources and Capacity for the Response. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Klaucke D. 2002. Globalization and Health: A Framework for Analysis and Action. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Kurth R. 2002 (April 17). The Global Application of Tools, Technology, and Knowledge to Counter the Consequences of Infectious Diseases: A Discussion of Priorities and Options. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Leaning J. 2002 (April 16). Health, Human Rights, and Humanitarian Assistance: The Medical and Public Health Response to Crises and Disasters. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. LeDuc J. 2002 (April 17). The Global Application of Tools, Technology, and Knowledge to Counter the Consequences of Infectious Diseases: A Discussion of Priorities and Options. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. May JM. 1958. The Ecology of Human Disease. New York: M.D. Publications. Mayer JD. 2000. Geography, ecology, and emerging infectious diseases. Social Science and Medicine 50(7-8):937–952. Mayer JD. 2002 (April 16). The Global Movement of Populations, Products, and Pathogens. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. NIC (National Intelligence Council). 2000. National intelligence estimate: The global infectious disease threat and its implications for the United States. Environ Change Secur Proj Rep 2(6):33–65.

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The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities - Workshop Summary Patz J. 2002 (April 16). Invited Discussion: Considering the Resources and Capacity for the Response. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. Singer M. 1994. AIDS and the health crisis of the U.S. urban poor: The perspective of critical medical anthropology. Social Science and Medicine 39(7):931–948. Steiger W. 2002 (April 17). The Global Fund: A Brave New World. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. WHO (World Health Organization). 2000 (April). Economic Costs of Malaria Are Many Times Higher Than Previously Estimated. Press Release WHO/28, 25. Joint report issued by the World Health Organization, Harvard University, and the London School of Hygiene and Tropical Medicine at the African Summit on Roll Back Malaria in Abuja, Nigeria. [Online]. Available: http://www.who.int/inf-pr-2000/en/pr2000-28.html [accessed September 12, 2005]. Widdus R. 2002 (April 17). Partnering for Success: The Role of Private-Public Sector Collaboration. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. World Bank. 2000. Economic Analysis of HIV/AIDS. ADF 2000 Background Paper. AIDS Campaign Team for Africa. Washington, D.C.: The World Bank.