The goal of the Harvard School of Public Healthís panel is to explore the relationship between global health and U.S. national interests and to examine whether and where American involvement in global health could promote or diminish U.S. interests. The existence of a link between global health issues and U.S. national interests has, in recent years, become widely accepted. Beyond establishing this link, however, much remains open to debate. The extent and importance of the relationship, the magnitude of the interests or threats faced by the U.S., and the parameters of our involvement (why, how and when) generate a great diversity of views. The dichotomy between disease prevention and treatment, and the technology gap between rich and poor countries represent underlying themes of these discussions. Our panel will explore the potential threats and opportunities that face the U.S. as a result of global health concerns, as well as potential U.S. foreign policy responses. Specifically, we will examine: (1) the global spread of infectious disease, (2) decreased global security and involvement of the U.S. military, (3) emerging economic markets, (4) the global pharmaceutical market, and (5) public support for U.S. leadership in humanitarian affairs.

The range of foreign policy responses can be categorized by governmental motivation. Governments may act out of narrow self-interest (placing national interests first and foremost, minimal concern for others), out of a sense of ëenlightenedí self-interest (the belief that improvements in the global system positively affect all indirectly), or out of humanitarian concern (altruism). All three frameworks have relevance when considering potential U.S. responses to global health concerns.

I. Background: The Increasing Rich-Poor Divide World-Wide

The growing global income gap is relevant to our discussion for two reasons: (1) there is an inextricable although complex link between poverty and health; and (2) U.S. national interests are often affected by changes in global economics (1). Consequently, the scope and magnitude of the global rich-poor divide provide a critical backdrop to our discussion. Though the context varies, the influence of the growing global income gap pervades consideration of potential political, moral, military and/or economic responses to global health concerns.

Whether measured on the basis of income, income growth, or relative poverty, the gulf between the poorest and richest countries has grown in the last several decades. In 1960, "per capita GDP in the 20 richest countries was 18 times that in the poorest 20 countries. By 1995 this gap had widened to 37 times, a phenomenon often referred to as divergence" (2). The gap between rich and poor is also illustrated by relative share of consumption: 20 percent of people living in high-income countries consume 86 percent of the world's goods and services, and the poorest 20 percent consume 1.3 percent (3). There are currently 1.2 billion people in extreme poverty in the world (living on less that $1 per day), and almost 2.8 billion people living on less than $2 a day (4).

II. Infectious Disease: Global Management and Potential Spread to U.S.

The link between poverty and poor health is widely accepted for both domestic and international populations (5). Poverty has been established as the single most important predictor of poor health for children (6). The growth of global economic inequity contributes to and is paralleled by the growth of global health inequity.

Illustrative examples include the inability of impoverished nations to provide basic subsistence needs (especially access to clean water and sanitation) and to manage infectious disease. Nearly 2.4 billion people worldwide have no acceptable means of sanitation, and more than a billion people in developing countries lack access to safe drinking water (7). Every year over 5 million people die from illnesses related to contaminated or unsafe drinking water (8). Less than half of the population in the world's LDCs (least developed countries) have access to clean water and sanitation (9). Over 1.7 billion people, more than two-thirds of the world's urban population, live in the developing world (10). Overcrowding in urban areas with poor sanitation leads to an increased exposure to disease vectors, which combines with a deteriorating health infrastructure to contribute to the emergence and reemergence of infectious diseases (11).

The management of infectious disease in developing countries is a formidable challenge. Globally, infectious diseases are the leading cause of death, killing over 17 million people per year (12). Infectious diseases strike hardest in the developing world, where a combination of environmental, demographic and economic conditions promotes the spread of infection and illness and renders populations particularly vulnerable to disease. As these infectious diseases wreak havoc in the developing world, and as international mobility increases, some argue that the direct threat to the U.S. population is increasing (13). The potential spread of both drug-resistant (i.e., MDR-TB) and/or untreatable (i.e., Ebola virus) human and animal infectious diseases across increasingly porous international borders begs the question: is there any place too far removed, any individual too remote, to pose a potential threat to the domestic U.S. population (14)?

III. Decreased Global Security and Direct Engagement of U.S. Military

In the last decade, the concept of human security has emerged as a critical element of international political and economic debates. In its simplest terms, human security is the extent to which individuals feel secure in their daily lives. Widely believed to be necessary for sustainable human development, human security results "from the social, psychological, economic, and political aspects of human life that in times of acute crisis or chronic deprivation protect the survival of individuals" (15).

Global security in the coming decades is likely to be affected, among other things, by demographic changes within populations. The U.S. intelligence community has accepted that rapid population increases in regions of the world that are least able to sustain them will be a primary source of threats to U.S. security interests (16). In the coming decade, 95 percent of global population growth will take place in developing nations, many of which will experience a phenomenon known as the "youth bulge" (17). This phenomenon is characterized by a rapid growth in population aged 18 to 25, many of whom reside in urban areas without sufficient economic opportunities to engage in constructive employment. The phenomenon has "historically been a key factor in instability," as the restless energy of this community is often channeled into violence (18).

Changing demographics represent one piece of the security puzzle; economic trends are another complex and subtle factor to be considered. Economic factors often contribute to and influence ethnic conflict, though a direct causal link remains tenuous (19). The Central Intelligence Agency and the Defense Intelligence Agency agree that the disparity in global distribution of wealth and its attendant strain on public health and infrastructures will be a primary driver of threats to U.S. national security (20). As mentioned previously, public health crises include managing epidemic disease and providing for basic subsistence needs. Individually and cumulatively, these public health crises are exacerbated by poverty and result in a decline in human security. In early 2000, the United Nations Security Council debated Africa's ability to maintain regional peace and security in the face of an overwhelming public health crisis ‚ namely, the spread of HIV/AIDS. Consideration of the AIDS crisis in Africa raises a currently burning question: what is the potential for global health crises to influence human and global security in areas defined as strategic for U.S. interests?

IV. Global Health, Emerging Markets, and Investment Opportunities

Enlightened self-interest is the notion that improvements in the developing world strengthen the global system, which in turn benefits the U.S. (21). Links have been established between good health and increased human security, political stability, and economic prosperity, the global increase of which would likely benefit the U.S. (22). Public health scholars have argued that by investing in global health the U.S. protects its own citizens, advances its international interests and strengthens future economic markets (23).

The global HIV/AIDS pandemic provides a striking case example of the relationship between global health crises and the loss of potential U.S markets. The most recent global estimates place the total number of people living with HIV/AIDS at 36.1 million, with nearly 25.3 (70%) living in sub-Saharan Africa (24). The spread of HIV has been linked to a wide variety of behavioral and socio-cultural factors, but disease progression (that is, the development of illness once the virus has been acquired) is exacerbated by circumstances directly related to poverty, both for the individual and the community. The lack of economic resources, especially in communities in the developing world, leads to a deteriorating health infrastructure, which in turn prevents individuals from obtaining regular health care and life-prolonging drug therapy. This dynamic invokes a vicious cycle in which a disease exacerbated by poverty leads to a nationwide public health crisis, which in turn has a devastating impact on the economy, reducing foreign investment and stalling economic growth.

Dr. Gro Harlem Brundtland, Director-General of the World Health Organization, and a graduate of the Harvard School of Public Health, recently stated: "A few main diseases, such as malaria, HIV/AIDS, tuberculosis... are biting into the economic growth of poor countries. There is an increasing recognition of the sheer difficulty faced by developing nations as they seek to counter these health threats" (25). The continued spread of the HIV/AIDS crisis around the globe, along with other global health crises, has the potential to result in the loss of burgeoning markets and potential U.S. trading partners around the world.

V. U.S. Expansion into Global Biotech and Pharmaceutical Markets

Does addressing the public health crises of the world present a potentially huge, largely untapped market for U.S. pharmaceutical and medical equipment companies? More than 80% of tuberculosis (TB) cases, a treatable disease that claims over 3 million lives annually, occur in 22 developing nations (26). AIDS and malaria that afflict over 100 million people, disproportionately burden the worlds poor (27).

Currently, approximately 75% of pharmaceuticals exported to the developing world are European, largely because European producers are more likely to sell products to poor nations at close to the marginal cost of production (28). Historically, American producers have been influenced by the need to recuperate fixed and fairly significant costs of research and development, and consequently have been less willing to sell their products at reduced rates. American pharmaceutical companies are often unable to predict a return on investment, especially given the short average patent life in the pharmaceutical industry (11 years) and widespread intellectual property violations (estimated to cost the global industry as much as $12 billion annually) (29). These factors result in U.S. products constituting only 13% of the global pharmaceutical export market (30).

Expansion into the developing world market is often seen as fiscally impractical or disadvantageous. Some have argued that creating a more lucrative market for U.S. pharmaceutical industries would not be prohibitively expensive (31). The creation of a U.S. government subsidy contingent upon the development of a successful vaccine, for example, could prove lucrative to the U.S. pharmaceutical industry and protect U.S. national interests by proactively eliminating infectious disease threats (32). Others have argued that vaccine development has not received an investment commensurate with its importance because the diseases that are investigated (AIDS, TB, and malaria) affect the non-developed world disproportionately (33). Recent events suggest that the developed world is beginning to pay more attention to the unmet health needs of the developing world. Developments in the international pharmaceutical industry have proffered a plausible range of initiatives regarding global drug access. The issue of differential pricing between the industrialized and poor nations, once unacceptable to the pharmaceutical and vaccine industries, is now being seriously considered (34).

Recently, three major international pharmaceutical companies (Merck & Co., Bristol-Myers Squibb, and GlaxoSmithKline) announced plans to drastically reduce the cost of AIDS drugs in the developing world, offering discounts nearing 90% of first-world costs (35). The startling mid-March announcement that Bristol-Myers Squibb would not prevent generic drug makers from selling one of its AIDS drugs in Africa has brought the issue of generic drug production and access in the developing world to the forefront of the industry (36). These developments, praised by the international humanitarian community, will undoubtedly influence the future landscape of the U.S. pharmaceutical industry.

VI. Public Support for U.S. Leadership in Humanitarian Affairs

Despite a widespread belief that the American public has become more isolationist in the last few decades, a majority of Americans today feel that U.S. economic assistance abroad is both necessary and appropriate; in fact, support for international aid is at an all-time high (37).

In the year 2000, 22.3 million people around the world were characterized as comprising a "Population of Concern" to the United Nations High Commissioner for Refugees in the year 2000 (38). Of these, 11.7 million were refugees living outside their country, unable to return due to a "well-founded fear of prosecution" (39). The remainder of the population of concern is comprised primarily of internally displaced people (refugees within a nationís borders), returned refugees still at risk, and asylum seekers. The vast majority of refugees and internally displaced people leave their homes fleeing persecution and conflict. When they do, they become impoverished refugees, often residing in overcrowded refugee camps (where they become vulnerable to sickness, demonstrating again the complex interrelationship between security, poverty and disease).

Evidence suggests that the American public believes strongly in providing assistance to this population. American support for foreign aid is professed to be a result of altruistic or humanitarian motives, more than fear or enlightened self-interest (40). In addition, Americans erroneously believe that the U.S. federal budget appropriates far more for foreign aid than it actually does (41). The communications revolution and the 24-hour newscast allow for nearly instantaneous transmission of powerful and disturbing images of international humanitarian crises, which can profoundly influence the opinion of the American public.

VII. Inescapable Decisions: Global Health and U.S. Engagement

The impact of global health will be an inescapable component of U.S. foreign policy debate in the coming decades. Many believe that for the United States, the leading country in global health research and product development, to consistently fail to uphold treaty obligations to the World Health Organization and United Nations compromises its ability to be recognized as a responsible leader in global health. The extent and nature of U.S. involvement is likely to be influenced by a number of factors, including the scale and acuteness of the problem, political pressures and alliances, and the perceived threat to U.S. national interests (42). This panel will explore the coming debate, which is likely to pose difficult questions for the new administration and foreign policy officials for decades to come. What are the roles and responsibilities of the US in global health, and what is, and should be the role of global health concerns in shaping US foreign policy?

VIII. References

(1) World Development Report 2000, World Bank. New York: Oxford University Press, 2000; Montgomery, LE, Kiely, JL, Pappas, G. The Effects of Poverty, Race and Family Structure on US Childrenís Health: Data from the NIHS, 1978 through 1980 and 1989 through 1991. Am J Public Health. 1998; 86: 1401-1405; World Health Organization, Press Release 26 Jan 2000, WHO/6 and Press Release 3 Oct 2000, WHO/63 (www.who.int).

(2) World Development Report 2000, World Bank. New York: Oxford University Press, 2000: 51.

(3) Crossette, B. Most Consuming More, and the Rich Much More. The New York Times, 31 September 1998.

(4) World Bank Group, Global Economic Prospects and the Developing Countries 2001 (Data available at http://www.worldbank.org/poverty/data/trends/income.htm); Human Development Report 2000: Human Rights and Human Development, United Nations Development Programme. New York: Oxford University Press, 2000.

(5) World Development Report 2000, World Bank. New York: Oxford University Press, 2000; Montgomery, LE, Kiely, JL, Pappas, G. The Effects of Poverty, Race and Family Structure on US Childrenís Health: Data from the NIHS, 1978 through 1980 and 1989 through 1991. Am J Public Health. 1998; 86: 1401-1405; World Health Organization, Press Release 26 Jan 2000, WHO/6 (www.who.int).

(6) Montgomery, LE, Kiely, JL, Pappas, G. The Effects of Poverty, Race and Family Structure on US Childrenís Health: Data from the NIHS, 1978 through 1980 and 1989 through 1991. Am J Public Health. 1998; 86: 1401-1405.

(7) Human Development Report, 2000: Human Rights and Human Development, United Nations Development Programme. New York: Oxford University Press, 2000: 4; World Health Organization, Press Release, 22 November 2000: Almost Half the Worldís People Have No Acceptable Means of Sanitation (www.who.int).

(8) World Health Organization, Fact Sheet #122, 1996: Cities and Emerging or Re-emerging Diseases in the 21^st Century (www.who.int).

(9) World Health Organization, Fact Sheet, #91, 1995: Intensified Cooperation with Countries (www.who.int).

(10) World Health Organization, Fact Sheet #122, 1996: Cities and Emerging or Re-Emerging Diseases in the 21^st Century. (www.who.int).

(11) World Health Organization Fact Sheet #97, 1998: Emerging and Re-emerging Infectious Diseases (www.who.int).

(12) World Health Organization, Fact Sheet #122, 1996: Cities and Emerging or Re-emerging Diseases in the 21^st Century (www.who.int).

(13) Americaís Vital Interest in Global Health. Board on International Health, Institute of Medicine. Washington, D.C.: National Academy Press, 1997.

(14) Ibid.

(15) Leaning, J., Arie, S. Human Security in Crisis and Transition: A Background Document of Definition and Application. Publication Forthcoming, USAID/Tulane CERTI.

(16) Global Security Assessment, American Forces Information Service Defense Viewpoint, Vol. 12, No. 17A (prepared remarks by Lt. Gen. Patrick M. Hughes, USA, Director, Defense Intelligence Agency, to the Senate Armed Services Committee, Feb. 6, 1997). (http://www.defenselink.mil/speeches/1997/di1217.html); The CIA in the New World Order: Intelligence Challenges Through 2015 (remarks by John C. Gannon, Chairman, National Intelligence Council, representing Director George Tenet to the Smithsonian Associatesí "Campus on the Mall," 02/01/00), (http://www.odci.gov/cia/public_affairs/speeches/dci_speech_020200smithson.html).

(17) Ibid.

(18) Ibid.

(19) Nelson, J. Poverty, Inequality, and Conflict in Developing Countries. New York: Rockefeller Brothers Fund, Inc., 1998.

(20) Ibid.

(21) Bloom, D, Kassalow. The United States and Global Health. Publication forthcoming by River Path Associates.

(22) Ibid.

(23) Howson, CP, Fineberg, H, Bloom, B. The Pursuit of Global Health: The Relevance of Engagement for Developed Countries. Lancet 1998; 351: 586-590.

(24) AIDS Epidemic Update: December 2000, Joint United Nations Programme on AIDS/World Health Organization. Geneva: UNAIDS/WHO, 2000.

(25) World Health Organization, Press Release, 3 October 2000: WHO Calls for Massive Effort Against Diseases of Poverty (www.who.int).

(26) Global Tuberculosis Control, WHO Report 2000. Geneva: World Health Organization, 2000.

(27) World Health Organization, Fact Sheet #104, 2000: Tuberculosis (www.who.int).

(28) Americaís Vital Interest in Global Health. Board on International Health, Institute of Medicine. Washington, D.C.: National Academy Press, 1997.

(29) Ibid.

(30) Ibid.

(31) Sachs, J. Helping the Worldís Poorest. The Economist 14-20 Aug 99; (CID Policy Paper #3, http://www.cid.harvard.edu/cidsocialpolicy/sf9108.html).

(32) Ibid.

(33) Letvin, NL, Bloom, BR, Hoffman, SL. Prospects for Vaccines to Protect Against AIDS, Tuberculosis, and Malaria. JAMA, 285 (5): 606-611

(34) http://www.globalhealth.org/assets/pdf/WTOA4.pdf; Americaís Vital Interest in Global Health. Board on International Health, Institute of Medicine. Washington, D.C.: National Academy Press, 1997.

(35) Peterson, M, McNeil, D.G. Maker Yielding Patent in Africa for AIDS Drug. The New York Times, 15 March 2001; Reuters, G7 Leaders to Tackle AIDS Drug Access at Summit. The New York Times, 21 March 2001.

(36) Peterson, M, McNeil, D.G. Maker Yielding Patent in Africa for AIDS Drug. The New York Times, 15 March 2001

(37) Adamson, DM, Belden, N, DaVanzo, J, Patterson, S. How Americans View World Population Issues. Washington, D.C.: Rand, 2000.

(38) The State of the Worldís Refugees 2000. United Nations High Commissioner for Refugees. Oxford University Press: New York, 2000.

(39) Ibid.

(40) Bloom, D, Kassalow. The United States and Global Health. Publication forthcoming by River Path Associates.