America’s Vital Interest in Global Health Globalization Brings New Diseases to U.S.

Released exclusively in Washington, D.C.

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Barry Bloom, Ph.D., co-chair of the Board on International Health, will be in Washington and available for interviews on June 20. Harvey Fineberg, M.D., Ph.D., co-chair of the Board, will be available in Boston for interviews, including telephone interviews. Please call 703-820-2244 to schedule a time.

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The United States and other countries around the world face massive new health threats stemming from globalization, the free movement of trade and travel, says a new report.

The largest threats come from the re-emergence of infectious diseases like TB — especially new disease strains resistant to all available drugs; food-borne diseases; imported in contaminated food and tainted consumer goods; introduced by terrorism; and environmental toxic wastes, says America’s Vital Interest in Global Health, a new report issued by the Institute of Medicine’s Board on International Health.

The report states that science and technology provide the best methods to meet these threats and that the United States is the world leader in these fields, yet neither the American government nor the U.S. private sector is responding adequately to protect the American people, as well as the populations of other countries.

The report, funded by the Carnegie Corporation, the Rockefeller Foundation, the National Institute for Environmental Health Sciences and the Institute of Medicine (IOM), and calls for the creation of single global surveillance system to detect the threats and organize international responses, and suggests that the Department of Health and Human Services is the best agency to coordinate U.S. foreign assistance in the health field. The Edna McConnell Clark Foundation hosted a meeting on March 31 during which a preliminary draft of the report was presented to sponsors as well as to other interested organizations such as the World Health Organization (WHO) and the United Nations Development Programme.

The free movement of trade and travel is accelerating. International trade, with the collapse of the Cold War and the movement to free market economies, has grown from $882.4 billion in 1975 to $3.7 trillion in 1993. Throughout the world, some two million people cross an international border each day. Annually, more than 27 million Americans and Canadians travel to developing countries, and growing numbers of visitors come to the United States — 115.5 million in 1996 alone.

“The United States has the best technology to prevent these threats, but we have to do a better job of putting it to work globally, especially in developing countries,” says Harvey V. Fineberg, M.D., Ph.D., co-chair of the Board on International Health (part of the private, non-profit National Academy of Sciences’ Institute of Medicine), and Dean of the Harvard School of Public Health. “We should do this not only to help other countries, but also ourselves. Already, drug-resistant TB, which developed overseas, has become one of our major health problems in America, and this will occur with other diseases, one after the other, unless we act now.”

Globalization has brought unprecedented freedom and prosperity to more people than ever, but has also accelerated a wide range of medical threats that were previously unknown or thought conquered, which include:

  • The emergence of AIDS, which originated in Africa, as the number one killer of young men aged 15-45 in the United States;
  • New threats such as cyclospora, a protozoan that came to New York and California from raspberries from Guatemala, sickening many people;
  • The danger of aggressive and deadly new infections jumping quickly from remote areas of the earth to the most modern cities of the industrialized world. The Ebola virus recently was carried by a physician from Gabon to Johannesburg, South Africa, where it killed a nurse before doctors recognized it;
  • Travelers picking up age-old diseases such as malaria, on trips overseas. Forest Sawyer, the ABC correspondent, is a recent malaria victim;
  • Long-known diseases such as tuberculosis re-emerging with new force and in strains highly resistant to antibiotics;
  • Mosquitoes capable of carrying dengue fever, viral encephalitis and yellow fever which were introduced to the United States in 1985 through tires imported from Asia;
  • Pesticides banned in the United States which have been found on imported food; high levels of lead which have been found in imported crayons from China, cosmetics from India, and canned food from Latin America.

One of the most important factors in the increased emergence of infectious diseases, especially in the United States, is the excessive and indiscriminate use of antimicrobial drugs in both developing and industrial countries, a practice that has promoted the emergence of drug-resistant organisms.

For example acute respiratory infections are a major cause of death worldwide. The major causative pathogen, Streptococcus pneumoniae, is estimated to be responsible for 1.9 million deaths a year worldwide, mostly of children. Infections caused by this organism have been effectively treatable by penicillin-like drugs until recently. Emergent new bacteria are now showing resistance to these drugs, both in the U.S. and elsewhere.

An even greater potential danger was just recently announced in Japan, with the first ever report of a strain of Staphylococcus aureus, the most common cause of post surgical infection, that is resistant to the last available drug that is effective to treat it, vancomycin.

“Because we are running out of drugs to treat these resistant infections, we will need new drugs once this infection makes its way to America, or surgery as we know it will have to change,” says Barry R. Bloom, Ph.D., co-chair of the Board and a clinical professor at the Howard Hughes Medical Institute, Albert Einstein College of Medicine, in New York. “It also illustrates one of the main dangers that globalization has brought us — of drug-resistant strains rapidly spreading across the globe, the result of the mis-use and over-use of the few remaining available drugs.”

As this globalization threat has accelerated, U.S. government financial and scientific commitments to international health has been decreasing. The U.S. also refuses to pay its full dues to the WHO.

Overall, U.S. foreign assistance has fallen to its lowest level since 1950, as a percentage of its gross domestic product (GDP), and represents the lowest proportion of aid given by the 20 richest industrial countries. In 1995, for example, the United States gave $7.3 billion in overseas assistance, compared to Japan’s $14.5 billion, France, $8.4 billion, and the United Kingdom, $3.2 billion — all nations with far fewer people.

“Recent polls provide strong evidence that the American public, when informed of the limited U.S. participation in global health activities and the opportunities available to shape future directions will endorse foreign aid spending levels above those currently budgeted, and will do so based on both traditional humanitarian values and enlightened self-interest,” says Dr. Fineberg.

The United States is one of the few countries that can really make a difference in global health because of American dominance in science and technology, the report says. The United States is failing to utilize these advantages, which hurts both global health and America’s economic standing.

“The U.S. pharmaceutical, vaccine and medical device industries are the most innovative and productive in the world,” says Dr. Bloom. “In addition, the basic medical knowledge gathered by the National Institutes of Health and the expertise in disease surveillance and prevention of the U.S. Centers for Disease Control and Prevention are unique national resources that can help to create and sustain major gains in international public health.”

U.S. medical leadership will also help because risks to health are becoming more alike in both the developing and developed worlds. In 1990, the most important global health risks were: lower respiratory infections, diarrheal diseases and conditions arising during perinatal periods. By 2020, major global health threats will match those in the United States and other industrial countries — heart disease, major depression, traffic accidents and cerebrovascular disease.

Besides making the world healthier, U.S. investments in global health make solid economic sense. The global eradication of smallpox, for which the United States invested $32 million, is returned to America every 26 days, by the savings from smallpox vaccines that no longer must be given domestically.

Globally, WHO estimates that the eradication of polio will bring $500 million in savings by the year 2000, which will increase to $3 billion annually by the year 2015. Every dollar spent on the vaccine against measles, mumps and rubella saves $21, and every dollar spent on the vaccine against diphtheria, tetanus and pertussis saves $29.

Enhancing the Economy

The global market for pharmaceuticals, vaccines and medical devices is a large one, with annual expenditures in 1990 on pharmaceuticals alone coming to more than $220 billion; on medical devices, more than $71 billion; on vaccine, more than $2 billion. In all, the developing world buys a surprisingly large percentage of this market, more than $44 billion annually.

“Innovation, rather than price, is the principal reason why pharmaceuticals succeed, which gives the United States, with its strong base in science and technology, a clear advantage internationally,” says Dr. Bloom. “The United States invests more in R&D than other countries. It also has more new drugs under development. Yet despite these strengths, the U.S. share of the market in developing countries is surprisingly small. The European Union provides about 75 percent of all drugs exported to developing countries, while the United States has just 13 percent of the global pharmaceutical export market.”

In developing countries, the domestic pharmaceuticals industry is comparatively small and faces significant constraints on its growth. These constraints include a relative lack of infrastructure and capacity for R&D and import restrictions on raw materials. With the exception of China, no developing country is self-sufficient in essential pharmaceuticals. It is estimated that as many as 2.5 billion people have little or no regular access to essential drugs. For the foreseeable future, then, the introduction of new drugs in developing countries will be dependent on the pharmaceutical and vaccine industries in the United States and other industrialized countries.

The diseases that currently dominate the needs of developing countries — including tuberculosis, malaria and acute respiratory infections — remain relatively neglected by the pharmaceuticals industry. For example, 225 million new cases of malaria appear each year globally, killing nearly one million children alone annually. Yet the Board has not found a single major Western pharmaceutical company that is now developing new drugs for malaria.

“The question is how to make it economically feasible for the best of American science, technology and industry to address such major global health problems such as malaria,” says Dr. Fineberg.

The disincentives to investment in this field are serious, the report says. For many diseases affecting people primarily in developing countries, R&D investments cannot be returned with the current average patent life of nine years in the pharmaceutical industry. New incentives are therefore clearly needed to enable industry to develop and market the needed drugs.

The changes needed to make such investments attractive include:

  • Multi-tiered Pricing — The selling of a product at different prices in different markets is essential if vaccines and drugs that are expensive to manufacture are to be made available to the vast majority of people in developing countries. For vaccines, multi-tiered pricing has enabled the vaccination of more than 80 percent of the world’s children against the major childhood infections, up from five percent in 1974. The report says that U.S. congressmen “savaged” the American vaccine industry during 1982 hearings for allegedly subsidizing vaccines for poor children of the developing world by charging high costs to U.S. families and taxpayers. As a result, U.S. vaccine manufacturers have declined to bid for U.N. vaccine programs ever since.
  • Intellectual Property Rights and the Problems of Privacy — National failure to respect and enforce these rights leads to the pirating of drugs, vaccines and medical devices, especially in India and China, which costs the global industry some $12 billion a year.
  • Parallel and reverse trade — In this practice, drugs sold by a company to a country at an agreed price are resold — back to the country of manufacture or to a third country — at a different price that competes with the same drug in those markets and siphons off the manufacturer’s rightful profits. A recent estimate said that parallel trade from a single European country cost the seven leading drug companies some $300 million in 1996.
  • Public-Private Cooperation — The Board calls for joint public-private efforts to research, manufacture and field test limited numbers of new drugs, vaccines, diagnostics and other products for significant and neglected health problems of developing countries.
  • Harmonization of Regulatory Standards — The efforts of the International Congress of Harmonization to establish standard regulations on quality control, quality assurance, good manufacturing practices, and practices for animal and human testing should be accelerated, to ensure that any new drug meeting its guidelines can be safely licensed anywhere in the world.

Main Recommendations

The Board on International Health calls on the U.S. Government to form partnerships with the private sector and with international organizations, with the U.S. providing global health leadership in at least five areas, which are:

  • Surveillance — A first step should be the creation of a global surveillance network for emerging and resurgent infectious disease and drug-resistant pathogens. Efforts should build on the 1996 Presidential Decision Directive that instituted a new national public health policy on infectious disease prevention and control. The success of global surveillance networks for influenza and polio indicate that such networks are feasible and of critical importance to America’s health.
  • Research and Development — The United States must continue to invest in global health research in order to maximize the many opportunities to prevent and control diseases that threaten the American people. The United States should also broaden the scope of its research and development activities to include health problems that impose the greatest burden of disease around the world. These problems include those infectious diseases that remain a major health burden in the developing world, particularly for children, noncommunicable diseases such as heart disease, cancer and depression; substance abuse; injuries; and the effects of violence.
  • Education and Training — Long-term investments made by the United States in the education and training of physicians and other health care providers, scientists and policymakers around the world have contributed substantially to health and biomedical science and should continue.
  • Global Partnerships — America cannot be responsible for the rest of the world’s health, but real progress in global health cannot be achieved without U.S. leadership. To deal adequately and efficiently with the complexity of changing health problems and policies, new partnerships will have to be forged between the U.S. government and multinational, multilateral, public and private agencies. Creative, mutually beneficial partnerships can leverage expertise and increasingly scarce resources for global disease surveillance; prevention, control, and elimination of specific diseases; and health care policy analysis.
  • Coordination and Leadership — These opportunities for advancing U.S. leadership in global health should take advantage of America’s strengths in science and technology to achieve American health goals in a constructive and humanitarian way. Many U.S. government agencies have statutory responsibilities for and could make major contributions to global health activities — particularly the Department of Health and Human Services, Department of State, U.S. Agency for International Development, Food and Drug Administration, and the Departments of Defense, Commerce and Agriculture.

“The United States must recognize that the solution to these global health problems will be increasingly dependent on advances in science and technology,” adds Dr. Bloom. “Although the United States is the leader in these fields, we have not given the agencies with the greatest scientific and technological expertise — the Department of Health and Human Services, the National Institutes of Health and the Centers for Disease Control and Prevention — the resources and authority to take charge and lead the new world war against disease.”

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