Global Health—Targeting Problems and Achieving Solutions

A Call for Papers

KEYWORDS:
• developing countries
• public health
• world health

Global health is a challenge to define, even more to improve. But just as a global village has no boundaries, and "all problems . . . become so intimate as to be one's own,"¹ global health is everyone's concern and problem to address.

The Institute of Medicine defines global health as "health problems, issues, and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions."² This broad definition poses seemingly insurmountable obstacles to measuring and improving health. Trying to narrow this definition to include measurable goals and targets is not a simple task, and addressing the problems at a local level while maintaining a global perspective is an even greater challenge.

The 21st century began with many paradoxes for global health. Advances in science and technology have enabled the treatment, cure, and potential eradication of many of the world's illnesses, yet preventable and avoidable diseases continue to claim lives prematurely and to undermine health on a large scale.^3-4 Calls reaffirming health as a basic human right are widespread,⁵ but the gap between those with and those without access to effective health care services persists and in some countries is widening.^{3, 6-7} Moreover, only a small fraction of funds for biomedical research is dedicated to research that affects mostly the poor or supports research conducted by resource-poor scientists and for the benefit of resource-poor populations.^6-7

Thus, the contemporary era of globalization, which was anticipated to capitalize on advances in technology, science, communication, and cross-national interdependencies, has been accompanied by gaps in access to these opportunities and wide disparities in societal resources.⁸ Health for all simply cannot be achieved while large segments of the world are burdened by substantial health deficits. Clearly, to achieve global health the means to define, measure, and advance health for everyone must be identified, subjected to sound scientific research, and systematically prioritized, but this cannot be done without targeting the inequities⁹ and without focusing resources, research, and interventions on the developing world. Furthermore, setting and implementing the research agenda must occur at local or regional levels and not be imposed by paternalistic or colonial influences. The approach must be comprehensive, yet appropriate to local country- and community-level needs; it must capitalize on effective North-South, West-East partnerships (including public-private partnerships^10-11) yet engender local ownership, capacity strengthening, and institution building; it must encourage prioritization of limited resources yet enable sustainability^{9, 12-14}; and it must be informed by the best available evidence and must be scientifically sound.

A critical step to address global health has been the identification of major causes of the global disease burden and ways to measure these as they evolve over time.^15-16 Challenges range from differences in tracking and comparable reporting of diseases and deaths across countries to the fact that surveillance and valid reporting mechanisms simply do not exist in some countries. A number of organizations have been addressing these challenges for decades, including the United Nations Development Programme,³ World Health Organization,⁴ World Bank,¹⁶ Global Forum for Health Research,⁶ Global Health Council,¹⁷ and the Centers for Disease Control and Prevention,¹² and they have prioritized a number of measurable and achievable goals and targets that are directly relevant to the health of the world's populations. Common concerns identified by these groups include emerging infectious diseases; vaccine-preventable diseases; HIV/AIDS, sexually transmitted diseases, tuberculosis, malaria, and other neglected infectious diseases; maternal and child mortality; population growth; health promotion and chronic disease prevention; tobacco use; malnutrition; and injury.

These problems affect all populations throughout the world. However, despite major advances in science and technology and improved understanding of the interdependence of all countries' economies and social infrastructures, the developing world maintains a disproportionate burden of these problems and inequitable resources to address them. According to the Global Health Research Forum, "Every year more than US $70 billion is spent on health research and development by the public and private sectors. But only about 10% of this is used for research into 90% of the world's health problems. This is what is called the 10/90 gap. The human and economic costs of such misallocation of resources are enormous if we consider that good health is essential for economic growth and development, the fight against poverty, and global security."⁶

Investing in global health is a necessity.^{15, 18} As noted in the Report of the Commission on Macroeconomics and Health, a few health conditions, such as those listed above, are responsible for much of the world's health deficit even though these conditions can be prevented and treated.⁴ According to the commission, a well-focused program targeting HIV/AIDS, malaria, tuberculosis, childhood infectious diseases, maternal and prenatal conditions, tobacco-related illness, and micronutrient deficiencies could avert about 8 million premature deaths per year by 2010.⁴ However, this investment must include a commitment to facilitating collaboration of local governments, health care institutions and professionals, and the communities they serve to produce effective systems that contribute to health gain. A narrow focus on disease alone is unlikely to be successful.

Plans to target such conditions on a global scale are "often dismissed as overly ambitious and rarely achieved."³ Yet, many such goals have been achieved. For example, among infectious diseases, achievements include eradicating smallpox in 1977, reducing childhood diarrheal deaths by half in the 1990s, eliminating polio in more than 175 countries, eliminating guinea worm disease in all but 14 countries, and immunizing 80% of infants before their first birthday against major childhood diseases in about 70 countries.³ At the beginning of the 21st century, childhood mortality was reduced by at least one third in 63 countries, with more than 100 countries reducing childhood deaths by 20%, and life expectancy increased to 60 years in 124 of the 173 targeted countries that previously fell below this threshold.³

However, some goals have proven more difficult to achieve, and indicators have worsened in some areas. For example, although success was achieved in Asia and Latin America, the malaria eradication program of the 1960s mostly bypassed Africa, even though Africa has the largest malaria burden.³ While hunger and malnutrition in developing countries declined 17% between 1980 and 2000, in sub-Saharan Africa 27 million more people were undernourished in the 1990s than in previous years.³ Most concerning, development assistance from developed nations as a fraction of their gross national product has declined, and in the 1990s only 4 countries (Denmark, the Netherlands, Norway, and Sweden) achieved the United Nations' 0.7% target.³ Key impediments to achieving longer-term objectives have been disease, conflict and insecurity, and economic disruption and decline, particularly in marginalized areas within and across countries and continents.

Developed nations cannot afford to ignore the world's problems. According to the United Nations Development Programme, "54 countries are poorer now than in 1990. In 21, a larger proportion of people is going hungry. In 14, more children are dying before age 5. . . . In 34, life expectancy has fallen. Such reversals in survival were previously rare."² In addition, for 21 countries the human development index (a summary measure of 3 dimensions: healthy life expectancy, education, and standard of living¹⁹) has decreased.³ Many of the world's poorest nations face endemic problems related to geographical and other factors that are often overlooked in development strategies and research conducted in developing countries but intended to benefit the developed world.

For those still skeptical about the importance of global health, a number of recent events—such as the attacks of September 11 and continued threats of terrorism, severe acute respiratory syndrome (SARS), and the increasing incidence, yet again, of HIV/AIDS—readily demonstrate that developed nations do not exist in isolation and cannot afford to believe they do.²⁰ Some of the problematic and poorly conceived approaches of the past can be avoided. Researchers and policy makers are in a better position now to know what works and to develop effective policies and systems to promote change. The challenge for the 21st century is to maintain and improve life expectancy and the quality of life for all, which includes achieving for the developing world what was achieved for much of the world's population in the previous century.¹²

To focus research, attention, and the awareness of the medical community on this challenge, JAMA plans to publish a theme issue on global health that targets the world's major health problems and focuses on developing countries. Thus, we invite papers that address avoidable and preventable health problems and diseases within the developing world. Reports of research and outcomes-based assessments of reductions in risk and exposure, interventions, programs, and health services to address these problems within developing countries will be given highest priority. Research aimed at improving local and global surveillance systems, tools, knowledge, and expertise to monitor, control, and prevent disease and promote health in locally relevant, affordable, and sustainable ways are welcome. We also encourage the submission of manuscripts that address ways to improve and sustain local research capacity and technology and knowledge transfer. Such studies must include locally defined and relevant applications and practice at national or community levels, and they should consider the potential for broader—global—applications of such research.

The JAMA theme issue on global health will be published in June 2004. Papers submitted by January 15, 2004, will have the best chance for acceptance. All submitted manuscripts will undergo THE JOURNAL's usual, rigorous editorial evaluation and peer review; acceptance cannot be guaranteed. Please follow the JAMA Instructions for Authors²¹ for manuscript preparation and submission.

To assist THE JOURNAL in this effort, we have assembled an international advisory group of experts in global health, which is listed below.