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3 Attitudes Toward U.S. Foreign Assistance: Perception and Reality The industrialized nations' traditional contribution to improving global health has been in the form of foreign aid donations. As the previous chapter indicated, however, our nation's stake in global health goes far beyond the giving of foreign aid and is likely to increasingly involve other activities, such as research into health problems of global significance. Nevertheless, within that component of global health that does require foreign aid, public misperceptions within the United States have been a significant barrier to positive action that would benefit the nation, as this chapter shows. In 1995 the United States spent about 0.1 percent of its gross national product (GNP) on foreign assistance, a lower percentage than any of the other members of the Organization for Economic Cooperation and Development's (OECD) Development Assistance Committee. Yet nationwide surveys indicate that the American public vastly overestimates U.S. spending on global health assistance. These same polls also indicate that when informed of the current limited U.S. participation in global health activities, Americans strongly endorse spending levels above those currently budgeted, and that they do so based on both traditional humanitarian values and enlightened self-interest. SURVEY FINDINGS The arrival of the 104th Congress in November 1994 provoked extensive reexamination of U.S. federal spending, including expenditures for global health assistance and development. Congressional criticism of foreign assistance focused on its perceived inefficiencies and on bipartisan concern that foreign assistance has traditionally followed the whims of shifting political alliances. A belief was also voiced that the American public feels that foreign aid provides no benefit to the United States and is akin to pouring money down a drain. A poll to test these assumptions was conducted in January 1995 by the Program on International Policy Attitudes, a joint program of the Center for the Study of Policy Attitudes (CSPA) and the Center for International and Security Studies at Maryland of the University of Maryland's School of Public Affairs. The study results were surprising. Far from opposing foreign assistance, the Americans polled both Republicans and Democrats-overwhelmingly supported the principle of giving foreign assistance, provided that it is directed toward 19

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20 MECCA 'S VITAL INTE=STIN GLOBAL HEALTH helping the needy rather than merely funding political allies; promotes self-reliance rather than relief; ensures that the money goes to the individuals In need rather than to corrupt governments; and places a high priority on democratic governance and respect for human rights. Another striking lesson from this poll was that Americans erroneously believe that the United States is spending far more on foreign aid than it is, and it is this misperception that underlies the public's opposition to foreign aid. . . Far from opposing foreign assistance, the Americans polled both Republicans and Democrats~verwhelm- ingly support the principle of giving foreign assistance. A second recent poll of 1,514 randomly selected adult Americans conducted by the Washington Post, the Henry J. Kaiser Family Foundation, and Harvard University indicated that nearly 6 in 10 people believe that the United States spends more on foreign aid than on Medicare. When asked to guess, 58 percent of the Americans polled believed the United States spent more on foreign aid, while only 27 percent of those polled believed more money was spent on Medicare. When asked what an "appropriate" amount of foreign aid would be, the median level proposed by those polled by CSPA was 15 percent of the federal budget, an amount 15 times greater than the amount actually spent. Medicare, for comparison, accounts for about 13 percent of federal spending (Washington Post et al., 1996~. Overall, those who voiced the greatest opposition to foreign assistance were the respondents who believed the amount to be higher than it is (CSPA, 19953. Americans erroneously believe that the United States is spending vastly more on foreign aid than it is. . Until the early 1990s, when the United States slipped behind Japan, America was the world's largest foreign aid donor. In 1995, for the first time, Japan ($14.5 billion), France ($8.4 billion), and Germany ($7.5 billion) each provided more overseas assistance than the United States ($7.3 billion) (OECD, 1996~. As Figure 3-1 starkly demonstrates, some members of the OECD Development Assistance Committee, such as Ireland, Spain, and Portugal, contribute proportionately more generously to overseas assistance than the United States, and do so with considerably smaller economies (OECD, 19969. In 1994, while the United States expended more than $900 billion on domestic health care, it spent $9.9 billion (0.14 percent) of its GNP on overseas assistance (OECD, 1996~. Of this $9.9 billion, only $1 billion (10 percent) was earmarked for health, primarily child survival and AIDS (U.S. Congress, 1994~. Thus, U.S. expenditures on global health assistance in 1994 represented only 0.010 percent of GNP.

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22 AMERICA 'S VITAL INTERESTIN GLOBAL HEALTH Last year, for the first time, Japan ($14.5 billion), France ($8.4 billion), and Germany ($7.5 billion) each provided more overseas assistance than the United States. The CSPA poll generated two other findings of note. First, support for spending on behalf of poor countries stems from the belief that the world is now so interconnected that it is in the economic interest of the United States to promote development of the neediest countries. Second, Americans support foreign assistance based on their belief that the United States has a moral obligation to help nations in need; an overwhelming majority rejected the notion that the United States should give aid only when it promotes U.S. national interests. The findings of this poll and others (~Washington Post, et al., 1996) provide strong evidence that the American public, when accurately informed of the limited U.S. participation in global health activities and the opportunities available to shape future directions, will endorse spending levels above those currently budgeted, and will do so based on both traditional humanitarian values and enlightened self- interest. Beyond the value implicit in humanitarian assistance, the Americans polled understood that the globalization of health requires active U.S. engagement in international health activities to protect the health, economy, and security of the United States and its people. The following three chapters argue that support for global health is justified on these rationales, and would provide an enduring global good that would benefit the U.S. directly, even in the absence of an established foreign aid program.