Pierce Gardner Aron Primack Joshua P Rosenthal and Kenneth Bridbord

One of the most positive aspects of globalization has been a burgeoning recognition of and interest in global health, and a sharp increase in resources and programs committed to addressing the health disparities that exist between rich and poor nations.

A broadened base of support has been nurtured by a variety of factors:

1. The traditional focus on humanitarian assistance has been strengthened by the power of the media and other forms of communication to focus attention on the enormity of global health problems and stir the moral conscience of the wealthy countries to respond.

2. There is increasing concern about protecting our country against the importation of health threats as exemplified by SARS, influenza, and the recent re-emergence of poliomyelitis.

3. There is an increasing consensus that good health is a driving force in economic development, and that efforts to improve global health will build partners in world trade.

4. Diseases such as HIV/AIDS can be so disruptive as to threaten political, economic, and civil stability, and thus global health is considered a factor in our national security.

5. Health and science have long been recognized as venues for bridge-building among disparate societies, and global health assistance has become an important component of diplomacy in our foreign policy.

6. Expert knowledge of global health is valuable in advising and treating US international travelers as well as immigrants from other countries.

Finally, science conducted in the developing world may have unique benefits for the developed world. For example, because HIV/AIDS vaccine trials are best done in areas of high HIV endemicity, the road to a successful vaccine will be through developing countries. As another example, the pathophysiology of cholera and the development of the oral rehydration mixtures, which are used the world around, were largely accomplished by research in Bangladesh and India.

Thus, the heightened appreciation of the value of investing in global health has broadened the constituency of support well beyond the humanitarian base, to include economists, scientists, diplomats, politicians, the military, national security advisors, and many others.

How has this wellspring of interest been manifest? Recent years (especially since 2000) have seen a dramatic increase in global health expenditures across the entire spectrum of organizations and activities (prevention, therapy, research, and support). Bilateral programs (e.g. the United States Agency for International Development, USAID, and the President's Emergency Plan for AIDS Relief, PEPFAR), multilateral agencies (e.g. the United Nations, the World Health Organization, the Pan American Health Organization, and others), development banks, other multilateral efforts from the European Community and the Global Fund to Fight AIDS, Tuberculosis and Malaria, and private non-profit organizations (e.g. the Bill and Melinda Gates Foundation, the Rockefeller Foundation and many others) in the aggregate provide in excess of $12 billion per year in development assistance for global health. Not included in this figure is the increased funding of global health research by the National Institutes of Health (currently in excess of $500 million per year), the international activities of the Centers for Disease Control and Prevention, and the growing commitment of universities (including medical schools, schools of public health, and other professional schools) to major activities in global health research and training. Similar efforts are taking place in other donor countries.

Significant landmarks of international cooperation are:

• the Group of Eight (G-8) agreements to address global health and to reduce the indebtedness of low income countries

• the United Nation's adoption of eight Millennium Development Goals designating specific targets (three in health) to be achieved in the decade ending 2015.

However, in general the global health assistance activities can be characterized as independent efforts, which have not been well coordinated within an overarching plan or organizational structure (see also Chapter 16).

In the poorest nations, the health disparities and needs are enormous, urgent, and worsening. Many of the social forces discussed in other chapters of this book (e.g. explosive urban growth, social dislocation, and sexual mores) have abetted a deterioration of health-care systems, diminished life expectancy, and also threaten societal unrest in these vulnerable populations. The density of the total health workforce in Africa is less than one-tenth of that in the Americas (see Table 17.1). An estimated global shortfall of more than four million health-care workers exists, with one million of this shortfall in sub Saharan Africa, where the already overburdened workers are further taxed by the added clinical and public health burden of the growing numbers of persons with HIV/AIDS and its complications. Stress, occupational risk of infection, poor working conditions, and low pay have led many health workers to seek improved conditions and opportunities by migrating to other positions or locations, with the result that attrition exceeds the output of new graduates into the workforce in many of the poorest countries.

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