JAMA Special Theme Issue: Dimensions of Global Health, 2012

May 16, 2012, Vol 307, No. 19

The Cover | May 16, 2012
Dimensions of Global Health, 2012
Thomas R. Frieden, MD, MPH; Richard M. Garfield, RN, PhD
JAMA. 2012;307(19):2006-2006. doi:10.1001/jama.2012.2984

Human health has improved more in our lifetimes than it did in the preceding thousand years. Since 1970, the number of infants who die has decreased by more than half worldwide, and maternal mortality has fallen dramatically in virtually every region of the world. Facing today’s enormous global health challenges, we often lose sight of such advances. Health has improved for several reasons. First and foremost, economic growth improves people’s life chances. In 1970, close to half the world’s population lived in extreme poverty; now one in seven people lives in poverty. More people have access to clean water, immunizations, and basic health services because of the work of governments, charitable groups including faith-based organizations, international organizations, the private sector, and public and private development assistance. Wider dissemination of information and increasing citizen participation make it possible for many lower-income people to make better-informed decisions about their health.

This week’s cover of JAMA highlights major layers that determine global health status. Underlying all is a clean and safe environment: uncontaminated food, water, and air. The economy—the generation and distribution of products and services—makes essential goods available. Policies can decrease inequalities in the distribution of these goods and services. Research develops better tools and strategies. Applied research shows how to use advances to improve health. Recent advances in vaccines, malaria, and HIV prevention and treatment have been translated into practice and have saved millions of lives.

The new and crucial frontiers for global health to cross in the coming years are both infectious and noninfectious. Some global health activities, such as international trade and disease reporting agreements and restrictions on marketing of dangerous products such as counterfeit medicines, tobacco, and controlled substances, are in the interest of all countries. Surveillance of diseases with epidemic potential protects rich and poor alike. The eradication of smallpox did—and eradicating polio and guinea worm will—serve all of humanity. When the Global Polio Eradication Initiative was launched by Rotary International, the World Health Organization, UNICEF, and the Centers for Disease Control and Prevention (CDC) in 1988, the virus disabled nearly 1000 children every day. In all of 2011, polio affected fewer than 1000 children worldwide. Yet polio eradication remains elusive, with ongoing, widespread transmission in several countries and continued importations to others. Disease eradication is the ultimate achievement for both sustainability and equity—it is forever and for everyone. Future generations will judge us by whether we carried polio eradication over the finish line—or dropped the ball.

In noninfectious diseases, reducing tobacco use and improving control of high blood pressure will be among the world’s greatest health challenges in the next decade. Most low-income countries have not yet adopted effective programs to stop smoking and to prevent and treat hypertension. Tobacco control is within reach—WHO’s MPOWER package of evidence-based tobacco control policies has reduced tobacco use everywhere it has been implemented, and progress is accelerating—but scaling up to reach most people must happen much more rapidly. Exposure to second-hand smoke in workplaces and other public places remains common, implementation of evidence-based tobacco control policies is increasing only gradually, the tobacco industry is intensifying its already aggressive marketing and lobbying in many countries, government and private funding remains limited, and in many countries there continues to be insufficient political leadership to address the tobacco epidemic, which will kill 1 billion people in this century unless urgent action is taken now.

Between 1990 and 2007, global assistance for health development rose from about $6 billion to nearly $22 billion. Some middle-income countries are starting to become regional donors, and many governments in low-income countries are increasing their budgetary commitments to health. The world has recently made important technological progress, including in the areas of HIV, malaria, vaccinations, and diagnostics, as well as in mobile computing and communications technologies. Many more technological advances are in the pipeline.

The biggest challenge in global health is the growing gap between the effective and cost-effective actions we know work and what we actually do. Unless we close this implementation gap, billions of people will become ill, injured, or disabled or will die of conditions that could be easily and inexpensively prevented. Accurate and timely monitoring systems are crucial to close this gap. The CDC is working with countries and international organizations to strengthen the coverage and quality of disease surveillance and epidemiologic analysis in low- and middle-income countries so that these countries can better design, monitor, defend, and improve programs. These efforts will require additional investments in both human resources and public health institutions. Closing the implementation gap can prevent literally hundreds of millions of premature deaths in the decades ahead.

Viewpoint | May 16, 2012
Primary Health Care in Low-Income Countries – Building on Recent Achievements
Jeffrey D. Sachs, PhD
JAMA. 2012;307(19):2031-2032. doi:10.1001/jama.2012.4438

Small investments in improved health of the poor have a remarkable return in reduced morbidity and mortality. While the developed economies grapple with health systems that cost several thousand dollars per person per year and often spend hundreds of thousands of dollars on a treatment to eke out an additional few months of life, outlays of just a few dozen dollars per person per year in impoverished countries can add several years to life expectancy. In the least developed countries, approximately 112 of every 1000 children die before their fifth birthday, as opposed to 8 per 1000 in the developed countries.1 With a concerted science-based effort, the under-5 mortality rate of the least developed countries could be reduced to less than 30 per 1000 by 2020. Such low under-5 mortality rates have already been achieved, for example, by the Dominican Republic (28 per 1000), Mexico (17 per 1000), and Thailand (13 per 1000)

Viewpoint | May 16, 2012
Policy Making With Health Equity at Its Heart
Michael G. Marmot, FRCP
JAMA. 2012;307(19):2033-2034. doi:10.1001/jama.2012.3534

…Economic and financial issues have been dominating global policy making. Health and inequalities in health should feature more strongly. This should be done not to enable physicians or ministers of health to have greater authority, but because economic and social developments have profound effects on health inequalities. Moreover, so crucial are economic and social policy decisions for health and the fair distribution of health, health equity should be an important measure of the effectiveness of social and economic policy making. Progress toward achievement of health equity is a measure of success.

I use the term health equity to have a specific meaning: systematic inequalities in health between social groups that are deemed to be avoidable by reasonable means.1 Therefore any policies that retard action to reduce these avoidable health inequalities are unfair..

Viewpoint | May 16, 2012
Achieving Equity in Global Health – So Near and Yet So Far
Zulfiqar A. Bhutta, FRCPCH, PhD; K. Srinath Reddy, MD, DM (Card)
JAMA. 2012;307(19):2035-2036. doi:10.1001/jama.2012.4659

Few issues have generated as much passion and imagination over the last few decades as the challenge of global health. From major studies on the global burden of disease1 to the recognition of the global epidemic of human immunodeficiency virus, AIDS, and tuberculosis, health has been center stage of the global development debate. Issues, which once remained within the purview of health advocacy and policy circles, found their way into the center stage of debates in the World Economic Forum and onto agendas for G8 and G20 summit meetings. The groundbreaking reports from the Commission for Macroeconomics in Health and Social Determinants of Health highlighted the importance of appropriate resource allocations for health as well as focusing on issues that determine population health, but are frequently beyond the purview of ministries of health. Even as the world contends with a worldwide recession, there is clear recognition that health of populations everywhere must be protected and promoted, not only as a developmental commitment to equity but also as an imperative for economic growth and security…

Special Communication | May 16, 2012
A Framework Convention on Global Health – Health for All, Justice for All
Lawrence O. Gostin, JD
JAMA. 2012;307(19):2087-2092. doi:10.1001/jama.2012.4395

Health inequalities represent perhaps the most consequential global health challenge and yet they persist despite increased funding and innovative programs. The United Nations is revising the Millennium Development Goals (MDGs) that will shape the world for many years to come. What would a transformative post-MDG framework for global health justice look like? A global coalition of civil society and academics—the Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI)—has formed an international campaign to advocate for a Framework Convention on Global Health (FCGH). Recently endorsed by the UN Secretary-General, the FCGH would reimagine global governance for health, offering a new post-MDG vision. This Special Communication describes the key modalities of an FCGH to illustrate how it would improve health and reduce inequalities. The modalities would include defining national responsibilities for the population’s health; defining international responsibilities for reliable, sustainable funding; setting global health priorities; coordinating fragmented activities; reshaping global governance for health; and providing strong global health leadership through the World Health Organization…

Editorial | May 16, 2012
Health, Economics, and the 2012 G8 Summit
Howard Bauchner, MD; Julio Frenk, MD
JAMA. 2012;307(19):2102-2104. doi:10.1001/jama.2012.4874

Health and economics are inextricably linked. Health constitutes a vigorous sector of the economy, with effects on inflation, employment, and competitiveness. The World Health Organization estimates that health systems worldwide absorb approximately 10% of the world economy—about US $6 trillion.1 Differences in health expenditures, however, are huge. For instance, the United States spends more than $7000 per capita on health, whereas Eritrea spends less than US $10. For low- and middle-income countries, committing more financial resources to health is a complicated and difficult decision, because most nations face many competing priorities. Nor will improving the health of the world’s population be possible unless there is global economic recovery. Enlightened ministers of finance realize that better health contributes to sustainable economic growth through its effects on improved productivity.

Indeed, interest in global health has increased significantly over the past 2 decades. Modern travel and the Internet have made the world a far more intimate place, and health risks and benefits more easily travel the world. Examples of the increasing global transfer of health risks are the human immunodeficiency virus (HIV)/AIDS pandemic, the 2002-2003 severe acute respiratory syndrome outbreak, and the recent H1N1 influenza crisis. But opportunities are also spreading. Access to health care as a basic human right has been vigorously endorsed by governments and international agencies, leading to a global movement toward universal health coverage. Substantially more resources from governments and foundations have been committed to the international effort to improve the health of the world’s population.2 Numerous journals have given a powerful voice to the global health movement.3 – 4 As a reflection of this increasing interest, more than 100 partnerships are now active in global health.

This global health theme issue of JAMA, published to coincide with the May 2012 G8 Summit in the United States, provides new information and insights directly relevant to the related issues of health, economics, and global well-being. This issue begins with 4 Viewpoints from individuals with long and rich commitments to global health. Sachs5 provides insights about the role of economics in health care, emphasizing the need to develop primary health care in low-income countries. Marmot6 addresses health disparities and the potential role of economics in alleviating them. Bhutta and Reddy7 focus on issues related to maternal and child health. Marrero and colleagues8 report on the recent high-level meeting of the United Nations that focused on noncommunicable diseases, signaling the global importance of cardiovascular disease, chronic respiratory disease, diabetes, and cancer. In a Special Communication, Gostin9 details the creation of a Framework Convention on Global Health that “would reimagine global governance for health, offering a new post-[Millennium Development Goals] vision.”…