A time for global health

The life expectancy of the 642 million people in sub-Saharan Africa is 51 years, 27 years less than that of those who live in rich countries. Mortality among those aged under 5 is 25 times higher in Africa than in rich countries. The World Health Organization's Commission on Macroeconomics and Health, which reported at the end of 2001, estimates that by 2010 about 8 million lives a year could be saved in low income countries by investing large sums and acting through simple and effective interventions.¹,² But will it happen? The rich countries have a poor record in fulfilling their promises to poor countries. Nevertheless, a small group of people with considerable influence on global health who met recently in California agreed that the lives might be saved. Raising expectations too high could lead to huge disappointment, but the opportunities for substantial improvement in global health are probably better now than at any time in the past 20 years.

Perhaps because of the report of the Commission on Macroeconomics and Health health is “fashionable” with world leaders in a way that it never has been before. Some 60 world leaders—including both Fidel Castro and George Bush—vied with each other to emphasise their commitment to health at the recent meeting on development financing in Monterrey, Mexico. The general assembly of the United Nations for the first time last year devoted a session to a health topic—HIV and AIDS. The last four summit meetings of the G8 (the rich countries' club) have included more debates on infectious disease than on nuclear safety.

The interest of world leaders in health is being driven by increasing recognition that investment in health is a motor for development and that global health and global security are inextricably intertwined. The Commission on Macroeconomics and Health was dominated by economists and financiers, not health experts—so giving greater credibility to its conclusion that an investment of $119bn (£158bn) in health each year by 2015 will produce a return of $360bn a year. It will do this by saving lives, allowing people to be economically productive, and by spurring economic growth through a variety of mechanisms including a faster demographic transition to lower fertility rates, higher investments in human capital, increased household saving, increased foreign investment, and greater social and macroeconomic stability.¹ The evidence base for some of this is weak,² but few dissent from the fundamental notion that investment in health is not “a nice extra” but essential for economic growth. Certainly, no investment in health is likely to mean no growth.

Rich countries as well as poor countries would benefit from this economic growth. Some of the thinking that led to the commission was that both rich donors and governments of poor countries would be more likely to invest in health if what might be called “a business plan” showed economic return. Since the commission began, however, and since the attacks of September 11 the world has come to worry as much about security as about economic growth. There is as yet no commission on global security and health, but security experts are concerned about health, particularly AIDS, malaria, and drug resistant tuberculosis. The United States, which gives a much lower proportion of its gross national product in aid than any other rich country, may well be persuaded to increase aid by anxieties about its own security. This has already begun, and as one contributor to the California meeting said: “I'd much rather they gave me aid because they feared me rather than pitied me.” But then again, if security is the reason for giving aid the money may well not go to those who suffer the most but rather to those who present the biggest threat.

The commission's formula for improving health is in essence investment by both rich countries and poor countries plus reform. There is often debate about which should come first with the poor countries preferring money from the rich and the rich favouring reform in the poor countries. The commission concludes that both are needed simultaneously, but much of the world's current inadequate aid is unspent, and too many of the world's poorest countries are run by gangsters who care little for their people, particularly women and children. Little satisfaction is to be had from watching a corrupt government use aid to feed its soldiers to keep the corrupt in power. Aid, just like medicines, can sometimes make problems worse rather than better. Some countries are in such disarray that little can be achieved. The chances, for example, of rolling back malaria in Sierra Leone in the next five years are probably non-existent, whereas much might be achieved in more stable countries such as Ghana or Tanzania. Should aid therefore be given first to such countries? These are difficult questions.

One never ending debate in international health is how much should be spent on sector wide reform, trying to improve the whole health system, and how much on specific (vertical) programmes aimed at producing improvement with particular problems—perhaps AIDS or malaria. Again, both are needed. Vertical programmes will be unsustainable without well functioning healthcare systems, but vertical programmes on, for example, immunisation can achieve a great deal rapidly. A related debate is how much money should be channelled through existing United Nations organisations, such as the WHO, and how much through new initiatives such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria.³ Ironically, the WHO, which founded the Commission on Macroeconomics and Health, is not trusted by many governments of rich countries because it can be held captive politically. Politics gave it a poor leader for many years, and politics has led to silly decisions in its African region—over, for example, the placing of the regional office. Reform is needed not only in poor countries but also in international organisations.

Globalisation, concluded the commission, is on trial. It may mean the rich continuing to neglect and exploit the poor, spending huge amounts on their own defences to keep out the poor, and allowing deterioration in global health and further environmental degradation. In that case, riots will continue at the meetings of global leaders, and the world may become steadily more unpleasant for all of us, rich and poor. Alternatively, globalisation through increasing openness and recognition of interdependence could lead to dramatic reductions in poverty and improvements in health. Finding political commitment to use the best of modern science and technology and the huge wealth of the rich world to improve health would, says the commission, inspire and unite peoples all over the world.