WORLD HEALTH

World health

The pursuit of global health: the relevance of engagement for

developed countries

Christopher P Howson, Harvey V Fineberg, Barry R Bloom

The globalisation of the world economy and the consequent increase in commerce, travel, and communication have
brought benefits to virtually every country. But these changes also bring risks that cannot be addressed adequately
within traditional national borders. These risks include emerging infectious diseases, resulting in part from increased
prevalence of drug-resistant pathogens; exposure to dangerous substances, such as contaminated foodstuffs, and banned
and toxic substances; and violence, including chemical and bioterrorist attack. By investing in global health, industrliased
countries will not only benefit populations in desperate and immediate need of assistance, but also themselves—through
protecting their people, improving their economies, and advancing their international interests. This paper describes the
rationale for involvement of industrialised countries in global health, and suggests a means for its coordination.

In April, 1997, the Board on International Health of the
US National Academy of Sciences’ Institute of Medicine
published a report entitled, America’s Vital Interest in
Global Health (in which the term “global health” referred
to health difficulties, issues, and concerns that transcend
national boundaries; may be influenced by circumstances
or experiences in other countries; and are best addressed
through cooperative actions and solutions). The Board
argued that through investment in global health, the USA
will protect its own people, improve its economy, and
advance its international interests. The purpose of this
paper is to extend this argument one step further—by
proposing that all developed countries can benefit similarly
through active and coherent engagement in global health.
(The terms “developed country” and “industrialised
country” have evolved over time to include 23 countries:
Australia, Austria, Belgium, Canada, Denmark, Finland,
France, Germany, Greece, Iceland, Italy, Japan,
Luxembourg, the Netherlands, New Zealand, Norway,
Portugal, Spain, Sweden, Switzerland, the UK, and the
USA; the newly industrialised Asian economies—Hong
Kong, Korea, Singapore, Taiwan, and China—are still
classified as developing economies.) We believe that with
their combined human and financial resources, and their
experience in the biomedical and health sciences,
industrialised countries can, and must, have a key role in
providing solutions for the increasingly complex and
widespread health difficulties the world now faces. This
paper describes the rationale for the involvement of
industrialised countries in global health, and suggests a
means for its coordination.
Background
Human health worldwide is profoundly affected by
economic, social, behavioural, political, scientific, and
technological factors, many of which are changing at an
unprecedented rate in both the industrialised and
developing worlds. Globalisation of the world economy
and the resulting increase in commerce, travel, and
communication have benefited almost every country. But
these changes also carry risks that cannot be contained or
addressed adequately within traditional national borders.
International trade and labour markets, deepening poverty,
political instability, and environmental degradation have
increased the movement of people across national borders
to 1 million per day.1 Consequently, the industrialised
countries face new threats, including emerging infectious
diseases, reflecting, in part, the increasing prevalence of
drug-resistant pathogens; exposure to dangerous
substances, such as contaminated foodstuffs, and banned
and toxic substances; and violence, including chemical and
bioterrorist attack.
Changes in demography, particularly increased life
expectancy, are dramatically altering patterns of disease
epidemiology and disease burden in all countries of the
world. As life expectancy increases in the world’s poorer
nations, chronic diseases of adulthood, such as heart
disease and depression, are imposing new demands on
health-care systems. With ever-growing public demands for
health—spending on health care worldwide in 1990, for
example, took up 8% of the world’s economic output2—
the need to balance private-sector and public-sector
responsibilities in health, to assess and improve quality of
health care, to control costs, and to establish rational and
humane priorities for health-resource allocations are
difficulties with which every national government is
struggling.

Lancet 1998; 351: 586–90 Rationale for vigorous engagement

Board on International Health, Institute of Medicine, National
Academy of Sciences, 2101 Constitution Avenue, NW Washington,
DC 20418 (C P Howson PhD); Harvard University, Massachusetts
Hall, Boston, MA (H V Fineberg PhD); and Howard Hughes Medical
Institute, Albert Einstein College of Medicine, Department of
Microbiology, 1300 Morris Park Avenue, Bronx, NY 10461, USA
(B R Bloom PhD)
Correspondence to: Dr Christopher P Howson
All developed countries have a vital and direct stake in the
health of people around the world; this stake derives both
from enduring traditions of humanitarian concern and
from compelling reasons of enlightened self-interest.
Considered involvement can serve to protect citizens,
improve indigenous economies, and advance national and
regional interests on the world stage.

586 THE LANCET • Vol 351 • February 21, 1998

 WORLD HEALTH

Panel 1: Factors contributing to disease re-emergence and
examples of associated infections
Contributing factors
Human demographics and
behaviour
Technology and industry
Economic development
and land use
International travel
and commerce
Associated infectious diseases
Dengue/dengue haemorrhagic
fever, sexually transmitted
diseases, giardiasis
Toxic shock syndrome,
nosocomial (hospital-acquired)
infections, haemorrhagic
colitis/haemolytic uraemic
syndrome
Lyme disease, malaria, plague,
rabies, yellow fever, Rift Valley
fever, schistosomiasis
Malaria, cholera,
pnemococcal pneumonia
conditions. In 1900, for example, roughly 5% of the
world’s people lived in cities with populations exceeding
100 000. Today, an estimated 45%—more than 2·5 billion
people—live in large urban centres. The UN expects this
proportion to rise to 61% of the world’s population by the
year 2025. As Linden argues, “the health of cities in the
developed world depends in some measure on developing
nations’ efforts to control new diseases and drug-resistant
strains of old ones incubating in their slums. The
developed world ignores at its peril the problem of Third
World cities”.4
Chemical and biological terrorism—the 1995 terrorist
release of toxic sarin gas in the Tokyo subway system
turned the civilian risk of chemical and biological terrorism
from a threat into reality. Authorities discovered that the
Aum Shinrikyo cult in Japan had stockpiles of biological
agents and bacterial-culture media. A new generation of
chemical and biological terrorists has emerged with the
ability to strike anywhere and with the necessary
knowledge of microbiology. This new generation
represents a global danger.5

Microbial adaptation and change Influenza, HIV-1/AIDS, malaria,
S aureus infections
Breakdown of public-health Rabies, tuberculosis, trench fever,
measures diphtheria, whooping
cough (pertussis), cholera
Source: adapted from Committee on International Science, Engineering, and
Technology (CISET), 1995.
Protection of citizens
All countries have a responsibility to protect their
citizens—residents, soldiers, and travellers. To do this,
countries must be aware of developing threats to health,
both inside and outside national borders. Examples of
serious health threats follow.
Emerging and resurgent infectious diseases—AIDS has
taught the world that the battle against infectious diseases
is far from over. The 1919 pandemic of another infectious
disease, influenza, killed 20 million people worldwide—a
greater death toll than that of World War I. Prominent
factors associated with the resurgence of infectious diseases
(panel 1 and table) include: (a) increasing mobility of the
world’s population—given the growing movement of
people, goods, and services around the globe, no site is too
remote, no person too removed, and no organism too
isolated to guarantee human safety from infectious
Improvement of national and regional economies
For all populations to achieve better health is desirable in
itself. But healthier populations in the developing world also
provide more vibrant markets for the goods and services of
industrialised countries. Investment in health, such as
education, can help break cycles of poverty and political
instability worldwide, and thus contribute to national
economic development and the growth of such markets.
The global market, however, retains untapped potential,
particularly for vaccines, drugs, and medical devices. In
1992, expenditure on pharmaceuticals was US$220 billion,
or $40 per person, whereas expenditure on vaccines was
about $2 billion, and that on medical devices and
equipment roughly $71 billion.6 As the markets of many
developing countries continue to expand rapidly—such as
the middle-class markets of Asia and Latin America—their
needs and potential purchasing power are also increasing.
In most developing countries, however, the domestic
pharmaceuticals industry is small, and faces significant
constraints on its growth: such as lack of scientific and
technical infrastructure, and low capacity for research and
development; import restrictions on raw materials; lack of
quality control; price restrictions; and weak distribution
Pathogen Drug Country/area Percentage
of drug-
resistant
infections

diseases; (b) inappropriate and indiscriminate use of Streptococcus pneumoniae Penicillin USA, 10–35
Asia, Chile, Spain 20
antimicrobials—this has occurred in both developing and Hungary 58
developed countries, and has promoted the selection of S aureus Methicillin USA 32
drug-resistant organisms. For example, the case-fatality Vancomycin USA 0
Mycobacterium tuberculosis Any drug USA 13
rate of multidrug-resistant tuberculosis in immuno-
New York City 16
competent people can be as high as 30–40%. Perhaps the Isoniazid+rifampicin* USA 2
greatest cause for concern is the 1995 report of the New York City 5
emergence of vancomycin-resistant Staphylococcus aureus in Plasmodium falciparum Chloroquine Kenya 65
malaria Ghana 45
Japan—since staphylococcus infections are common after Zimbabwe 59
surgical procedures, and few effective drugs are available Burkina Faso 17
against organisms resistant to penicillin, methicillin, and Mefloquine Thailand 40
Shigella dysenteriae Multidrug Burundi, Rwanda 100
vancomycin;3 (c) rapid urbanisation—displacement of
*Resistance to isoniazid, rifampicin, and/or other drugs.
people as a result of war, civil disorder, and economic need Source: Martin Cetron, Grace Emori, Patrick Kachur, Gloria Kelley, and Robert Tauxe,
has led to an increase in refugees from 38 million to 60 US Centers for Disease Control and Prevention, personal communication, 1996.
million during this decade, and to a growing migration to Drug-resistant infectious agents and percentage of infections
urban areas, often resulting in overcrowded living that are drug resistant, by country or area

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WORLD HEALTH
systems.6,7 With the exception of China, no developing
country is self-sufficient in essential pharmaceuticals. One
consequence is that as many as 2·5 billion people are
estimated to have little or no regular access to essential
drugs.8
For the foreseeable future, therefore, the introduction of
new drugs and vaccines in developing countries will
depend on the pharmaceutical and vaccine industries in
industrialised nations. Moreover, the rising costs of
research and development will require these companies to
pursue growth in emerging markets as aggressively as
possible.6 Yet significant political and regulatory
constraints are deterring industrial countries from
developing products that could benefit the health of people
in the developing world. These constraints—which
include failure to respect and enforce intellectual-property
rights, drug piracy, pricing restrictions, and lack of
consistency in standards of regulation and enforcement—
must be overcome if markets in the industrialised nations
are to expand effectively to compete and provide needed
health goods and services.
Advancement of national and regional interests
Governments are no longer the sole agents in the global-
health arena. Beyond national programmes, the global-
health system now contains the private or commercial
sector, including multinational corporations; the
independent sector and non-governmental organisations,
such as universities, private foundations, and relief and
advocacy organisations; the multilateral sector, including
multinationally funded organisations such as WHO, the
UN development agencies and regional-health
organisations, and the World Bank and regional
development banks; and the bilateral sector, which involves
various government and overseas-development agencies
that are funded by single governments or regional partners.
This pluralism brings a strong need, and opportunity, for
active national engagement in global-health issues. The
commitment of the most developed countries to
democratic principles, and their traditions of humanitarian
and development assistance in foreign policy—from the
Marshall Plan to the current reconstruction activities in the
Balkans—form the historical basis for national leadership
in this effort. What is less appreciated is the value and
power of the developed world’s scientific and economic
capabilities to provide a practical basis for coordinated
improvement of the health of all people—most critically,
perhaps, of the poorest people in the world. To fail to
anticipate, prevent, and relieve global health difficulties,
and to accept widening gaps in health between the
developed and developing worlds, diminishes national
stature, compromises the credibility of the national
governments and international organisations, and neglects
probably the most direct opportunity to address the
fundamental issue of global equity—the health of people.
Priorities of industrialised nations for
involvement
Protection of people
Global surveillance and communication networks—the
recent outbreaks of Ebola in Zaire, haemorrhagic Dengue
fever in southern Mexico, drug-resistant tuberculosis in
New York City, USA, and in large parts of the developing
world, bubonic plague in India, cholera in Peru, and
E coli O157:H7 in Japan and Scotland, underline the
588
importance of global surveillance systems that can alert the
international communities to outbreaks of infectious
diseases. The necessary information and communications
technology are available, yet no formal infectious-disease
surveillance system exists on a global scale.
If such a system were in place, even small-scale
outbreaks of infectious diseases could be quickly identified.
Such networks could also be adapted to serve as early-
warning systems for chemical or bioterrist attack, or for
breakdowns in the safety of the global food supply.
Laboratory capabilities for the monitoring of emerging
drug resistance of conventional pathogens are crucial to the
assessments of threats and to the development of
alternative control strategies. Critical technical assistance
could then be efficiently mobilised in response. Global
infectious-disease experts, for example, could be brought
to the site or could use modern communication networks
to assist in diagnosis and to support local authorities in
their prevention and control measures. Clinical specimens
could be sent to centralised reference laboratories for
disease identification and to strengthen early-response
measures. A surveillance system would help to identify
outbreaks of previously unrecognised syndromes or
diseases, making possible scientific approaches for rapid
identification of the causative agent, for development of
diagnostic tools, and, eventually, for better means of
prevention and treatment.
The value of shared information for better health
services—every country must face the difficulty of how to
provide improved health care at lower costs. Many are
experimenting with new approaches. The international
comparative study of health-service delivery and financing
can offer lessons about how countries—industrialised and
developing alike—might better achieve improved health
and more effective, affordable, and equitable health
services for their populations. As life expectancy rises in all
countries, health difficulties become increasingly common
to all—particularly the burden of chronic, non-
communicable diseases, such as cardiovascular disease,
psychiatric illness, and neoplastic disease. National
experiments with programmes addressing issues of
violence, injury, and substance abuse provide important
opportunities to learn. Each country must gather and share
information on the burden of disease; and international
and national institutions must analyse the risks that
contribute to premature death and disability and assess
cost-effective interventions to address the greatest health
burdens. For developed countries to actively participate in
such efforts is clearly in their direct interests.
Value for money in acquisition of knowledge from
international research and clinical trials—investment in
research and development abroad has benefited all
countries profoundly. International collaboration in the
eradication of smallpox, for example, disposes of the global
need to spend US$1 billion annually to vaccinate travellers
and other citizens. Transmission of paralytic poliomyelitis
no longer occurs in the western hemisphere, and the global
campaign to eliminate polio and measles worldwide will
save millions of lives and vast resources. Many do not
appreciate that these successes required international trials
and research. Several diseases (malaria and cholera, for
example, and certain cancers and genetic diseases) can be
studied most effectively through international
collaboration—either because the number of people
affected is greater in certain overseas regions, or because
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Panel 2: Landmark discoveries derived from international
cooperation in biomedical sciences
Discovery
Recombinant tissue
plasminogen (tPA) to limit
muscle damage in
heart-attack victims
Oral rehydration therapy
as low-cost, highly effective
treatment for severe
diarrhoea
Monoclonal antibodies
yielding reagents of
unprecedented specificity in
all aspects of biological
science and increasingly of
value as therapeutic agents
Vaccines
Oral polio (sabin)
Hepatitis virus
Cholera
Rotavirus
Identification of genetic
mutation that causes
Huntington’s chorea
Establishment of firm links
between DNA viruses and
cancer, and confirmations
of risk of heterosexual and
perinatal transmission
of HIV-1
Development of novel
therapeutics through study
of indigenous biological
resources
*Alexis Shelokov, Salk Institute, USA, personal communication, 1996.
Source: Philip Schambra and Robert Eiss, National Institutes of Health,
personal communication, 1996.
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Nature of international cooperation
Collaboration between University of
Louvain, Belgium, and Washington
University, USA; clinical trials funded
by Genentech
Developed at International Center for
Diarrhoeal Disease Research
(ICDDR,B), Bangladesh, with
international funding
Initial collaboration between
Cambridge University, UK, and Salk
Institute, USA
First tested in former Soviet Union
in more than 15 million children*
First non-serum hepatitis-B vaccine
field tested in China and Senegal;
one of hepatitis-A vaccines field
tested in Thailand
Whole-cell vaccine licensed
for use in USA tested at ICDDR,B
Rhesus reassortant quadrivalent
vaccine soon to be licensed by
Wyeth/Lederle field tested in
Finland and Venezuela
Studies of large kindred of
Huntington’s patients living in
Venezuela
Cooperation with scientists at
University of Makerere and University
of Ibadan, Nigeria, and in other sub-
Saharan African sites helped confirm
causal link between Epstein-Barr virus
and Burkitt’s lymphoma, early
evidence of role of DNA virus in
cancer; range of infectious agents
now associated with human cancers,
partly owing to international
collaborative studies
Discovery of anti-cancer properties of
plant indigenous to Madagascar—
rosy periwinkle; plant contains
two alkaloids, vinblastine and
vincristine, that can cure Hodgkin’s
disease and acute lymphocytic
leukaemia
Discovery of important class of
antihypertensive agents—ACE
inhibitors—from extracts of plants
collected in Ghana, Malaysia, and
Costa Rica
ARTICLES
appropriate registries and databases are available only in
others. In terms of efficient acquisition of scientific
knowledge and value-for-money assessment of the
effectiveness of new medical interventions, international
scientific collaborations are essential (panel 2).
Improvement of national and regional economies
Healthy populations abroad represent growing markets for
businesses of the industrial world. If developed countries
invest in improving the health of other populations—
through the study and development of treatments for their
major illnesses, for example—their economic returns will
be increased. Manufacturers of vaccines and
pharmaceutical and medical products need to be engaged;
currently, some 2·5 billion people worldwide have little or
no access to essential drugs.8 At the same time, with
pressures to contain health costs in industrialised nations,
increasing opportunities exist to expand industry into
emerging markets in developing countries. For example,
on a per-person basis, world consumption of
pharmaceutical drugs rose from US$17 in 1975 to $29 in
1990.6 With life expectancy increasing in almost all
countries, demand for health is growing worldwide. At the
present time, the manufacture and export of
pharmaceuticals to the developing world is concentrated in
a limited number of industrialised nations; ten countries—
eight from western Europe plus the USA and Japan—
produce roughly 90% of the new pharmaceuticals
introduced since 1960, with the European countries
responsible for 75% of all drugs exported to developing
countries.6 If people in developing nations are to have a
greater access to essential drugs, vaccines, and medical
devices, and if industrialised countries are to take
advantage of the expanding markets in these nations,
national governments and international agencies must
undertake certain measures in response. Mechanisms to
increase incentives for industries to invest in research and
development on products that would primarily benefit
poor populations are needed most. Incentives could
include reduced regulatory barriers to product
development; safeguards on intellectual-property rights;
patents to increase development; and, when necessary, the
forging of partnerships between public and private sectors,
or the establishment of trust funds to ensure development
of essential products.
Advancement of national and regional interests
Each developed country has unique strengths to help
improve global health. Yet the potential of many, including
the USA, has not been fulfilled. We believe that with the
end of the Cold War, industrialised nations have much to
contribute in the battle against disease and the social and
economic inequities that exist in health. To improve the
health of all populations should be a significant component
in the foreign policy of all industrialised countries, because
they possess the scientific and technological capability to
make such improvement possible. To assure future
leadership in health, we believe that the most developed
countries should take several measures: increase
investment in biomedical research on major global health
problems; create incentives to make possible the
development and provision of medical advances for the
poorest countries; forge expanded partnerships and cost-
sharing with other governments and international donors;
and invest in the education and training of physicians,
589
PUBLIC HEALTH
researchers, and health-care workers from around the globe.
The industrialised countries should also support collabora-
tive international and regional action—for example, to
strengthen WHO, the World Bank, and efforts by regional
development banks to promote health and sustained
development and to partner with industry in ways that
could accelerate development of drugs and vaccines needed
in developing countries (drugs for malaria and HIV-1 and
AIDS, for example). By investing in global health,
developed nations will be able to improve the health of their
own populations, advance their respective economies, and
promote humane values and moral leadership in a world of
opportunities and profound health needs.
References
1 Garrett L. The return of infectious disease. Foreign Affairs 1996;
January/February: 66–79.
Public health
Public health at the crossroads: which way forward?
Robert Beaglehole, Ruth Bonita
Public health represents society’s organised and publicly supported efforts to improve the health status of the entire
population; its focus is on the reduction of health inequalities by optimising the underlying determinants of health and
preventing disease. But public health is under threat and needs to be strengthened so that it is at the centre of
human endeavour—locally, nationally, and worldwide.
Global health trends and determinants
Major improvements in the health of human populations
have occurred this century, with the pace of change
accelerating in developing countries since the 1950s.
Public health, and more broadly the improved
understanding of the social, environmental, and
behavioural factors that affect population health, have
contributed to these improvements. Declining death rates
are important, but relative inequalities in health status
among and within countries are a major social concern.1
Improvements in life expectancy are not universal and, as
has been noted in several central and eastern European
countries, such gains have been reversed with the rapid
increase in death rates among middle-aged men.2 The
Global Burden of Disease study3 emphasised the
unacceptable state of vital statistics worldwide, the
importance of premature mortality in developing countries,
most of which is preventable, and the growing burden of
non-communicable disease and injury.
The main variations in health status among countries
result from environmental, socioeconomic, and cultural
factors, and medical care is of secondary importance.
Poverty is the most important cause of preventable death,
disease, and disability, although only a low level of income
per person is required to achieve acceptable life expectancy
at the national level.4 Literacy, access to housing, safe water
Lancet 1998; 351: 590–92
Departments of Community Health (Prof R Beaglehole MD) and
Medicine (R Bonita MD), Faculty of Medicine and Health Science,
University of Auckland, Private Bag 92 019, Auckland,
New Zealand
590
2 World Bank. World development report 1993: investing in health. New
York: Oxford University Press, 1993.
3 Committee on International Science, Engineering, and Technology.
Global microbial threats in the 1990s: report of the NSTC Committee
on International Science, Engineering, and Technology (CISET)
working group on emerging and re-emerging infectious diseases.
Washington DC: National Science and Technology Council.
4 Linden E. The exploding cities of the developing world. Foreign Affairs
1996; January/February: 52–65.
5 Kaplan DE, Marshall A. The cult at the end of the world. New York:
Crown, 1996.
6 Ballance R, Pogany J, Forstner H. The world’s pharmaceutical
industries: an international perspective on innovation, competition and
policy. Prepared for UN Industrial Development Organization
(UNIDO). UK: Edward Elgar, 1992.
7 Institute of Medicine. Pharmaceutical innovation and the needs of
developing countries. Washington DC: National Academy Press, 1979.
8 UN Development Program. Human development report. New York:
Oxford University Press, 1991.
sanitation, food supplies, and urbanisation are also
important determinants of health status that interact with
poverty.
More people live in poverty today than 20 years ago.
About a fifth of the world’s population, 1·3 billion people,
live on a daily income of less than US$1.5 Although most
of the world’s poor live in South and East Asia, sub-
Saharan Africa has the fastest growing proportion of people
who live in poverty. But poverty is not confined to
developing countries; in situations where absolute poverty
is rare, relative deprivation becomes more important.6
More generally, in no society are women treated equally
to men, and women, children, and older people are at
greatest risk of poverty. Global population growth is about
90 million per year, and about 90% of future growth will
occur in the developing world. The health of people in less
developed countries is at risk from environmental hazards,
such as unsafe food and water, as well as from hazards
associated with modern lifestyles, for example, air and
water pollution and traffic accidents.7
Population growth interacts with two global threats to
public health: global environmental degradation and
economic globalisation.8 The continued over-consumption
of the world’s resources by wealthy countries is a major
contributor to environmental degradation. But it is
unreasonable to expect the growing populations of
developing countries to resist the pressures to consume,
without drastic action to reduce the ecological demands of
developed countries.
Economic globalisation leads to uneven economic
growth and increased economic inequality. Trade is the
driving force for globalisation which expresses itself in a
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