Public Health

Public Health

Despite medical advances and improvements in water and sanitation, nutrition, housing, and education, poor health still plagues hundreds of millions around the world.

"National boundaries don't mean much to microbes and viruses.  In the world of public health, when one community or individual is at risk, we're all vulnerable."

-Helene Gayle, CEO and President of CARE

Birth of International Public Health

Victorian public disinfectors sanitize the streets after an outbreak of smallpox. (John Thomson/Getty Images)

First International Sanitary Conference

The first formal attempt of collective action on public health was the International Sanitary Conference, held in Paris in 1851. Convened to streamline quarantine procedures put in place to prevent the transmission of disease through trade, the conference negotiated and adopted a convention, but not enough states ratified the document for it to enter into force.

Florence Nightingale organized a hospital unit during the Crimean War. (AP Photo)

Crimean War: Nursing on the battlefront

The Crimean War, fought among the Russians, British, French, and Ottoman Turks on the Crimean Peninsula in the mid-nineteenth century, was one of the earliest documented examples of nursing interventions on the battlefront. Mary Seacole, a British nurse, was one of the first to provide care and disease control to soldiers on all sides during combat. Florence Nightingale, also a British nurse, recognized the benefits that proper sanitation, nutrition, and healthcare staffing had on the condition of the wounded. Both women set precedents for the way health and humanitarianism are addressed during conflict.

Almost 150 years after it was founded, the International Red Cross continues to deliver aid in devastated regions in February 2006. (REUTERS/Thierry Roge)

International Red Cross established

Founded in 1863 in Geneva, Switzerland, the International Committee of the Red Cross (ICRC) was created, largely through the efforts of Henri Dunant, to protect victims of international and internal armed conflicts. One of the first international civil society organizations to address health issues on an international scale, the ICRC has since been one of the most widely recognized humanitarian organizations in the world. It works, among many other efforts, to ensure medical assistance, healthcare, and clean water for victims affected by armed conflict.

Clara Barton was well-known for her service on the battlefields during the Civil War and for her work establishing the American Red Cross. (AP Photo/National Archives)

American Red Cross founded

The American Red Cross, established by the International Committee of the Red Cross, provided medical care to fallen soldiers from opposing armies during the Battle of Bull Run in the American Civil War. Based on the International Committee of the Red Cross’s model of neutral humanitarian care, the American Red Cross aids victims of war and devastating natural disasters, processes and distributes blood, and facilitates health educational programs.

Customs and immigration officials inspect a plane at quarantine on the water on August 13, 1928. (AP Photo)

National Institutes of Health established

The National Institutes of Health (NIH) traces its roots to a one-room laboratory within the Marine Hospital Service (MHS). In 1887, the MHS was charged by Congress with examining passengers on arriving ships for clinical signs of infectious diseases, such as cholera and yellow fever, to help prevent epidemics.

Today the NIH is an agency of the U.S. Department of Health and Human Services and is chiefly responsible for medical and behavioral research. Global health research is an important component of the work of the NIH and is administered through the Fogarty International Center, established in 1968 by President Lyndon Johnson.

Major Walter Reed was a U.S. Army surgeon and head of the U.S Army Special Yellow Fever Board. (AP Photo)

First permanent intergovernmental health organization founded

Established in the wake of a yellow fever outbreak that spread from Latin America to the United States, the Pan American Sanitary Bureau (PASB) was the first permanent intergovernmental organization in the health field. Headquartered in Washington, DC, the organization focused on research and education efforts. In 1949, PASB was incorporated into the United Nations as a regional office for the World Health Organization, though it remains autonomous in its role as an intergovernmental agency among pan American countries as well. In 1958, its name was changed to the Pan American Health Organization.

Vessels dock to exchange cargo in a London port on July 4, 1939. (AP Photo)

Eleventh International Sanitary Conference

On the heels of a series of similar sessions, the Eleventh Sanitary Conference, held in Paris, produced the International Sanitary Convention in 1903, which continued and incorporated the earlier agreements from 1892, 1893, 1894, and 1897.

The convention was originally signed by twenty countries—including the United States, many European nations, Turkey, and Egypt—and established regulations regarding infectious diseases, especially the plague, cholera, and yellow fever.

Surgeons in a Paris operating theatre illustrate the precautions taken to ensure a sterile environment. (Hulton Archive/Getty Images)

Office International d'Hygiene Publique created

Based in Paris, the Office International d’Hygiene Publique (OIHP) was established by delegates from twelve nations in Rome on December 9, 1907. A multilateral international health organization, the OIHP was charged with maintaining and reporting epidemiological data, coordinating quarantine measures, and convening international sanitary conferences. It included a permanent secretariat and a committee of senior public health officials. At its dissolution in 1946, its epidemiological service was absorbed into the World Health Organization.

Industrialist John D. Rockefeller sits for a photograph in 1894. (AP Photo/Standard Oil)

Rockefeller Foundation funds global health initiatives

One of the earliest and most influential examples of private philanthropy working to address global health concerns, the Rockefeller Foundation, located in New York City, established the world’s first school of public health at Johns Hopkins University in 1916 and the Harvard School of Public Health in 1922. Most of the foundation’s early work was in Latin America, where it supported research on hookworm, malaria, and yellow fever. Among its most ambitious schemes was a mid-twentieth-century attempt to identify all of the infectious viruses of Latin America, and to find cures, vaccines, or antisera for each one.

Influenza victims crowd into an emergency hospital at Fort Riley in Kansas in 1918. (AP Photo/National Museum of Health and Medicine, Armed Forces Institute of Pathology)

Influenza pandemic

The influenza outbreak of 1918 was the deadliest pandemic of the twentieth century. The virus spread around the world in three deadly waves over just eighteen months. An estimated one-third of the world’s 1.6 billion people were infected, and rough estimates put the death toll between fifty and one hundred million. Although commonly referred to as the Spanish flu, it actually originated in Asia. The second deadly wave began in the United States and was spread to Europe by U.S. soldiers during World War I.

The League of Nations meets in Geneva in 1921. (AP Photo)

Health Organization of the League of Nations established

The League of Nations was established in 1919 to reduce armed conflict, and build institutions of cooperation and global trade. Founded a year later, the Health Organization of the League of Nations (HOLN) focused on ending leprosy, malaria, and yellow fever, and organized educational campaigns to prevent typhus epidemics. The HOLN also worked closely with the Rockefeller Foundation, which provided a substantial portion of its funding.

The headquarters of the Wellcome Trust, established after the death of Sir Henry Wellcome in 1936. (Photo by SSPL/Getty Images)

Wellcome Trust funds health research

The Wellcome Trust, an independent charity based in London, was established to fund research for improved human and animal health. Endowed in 1936 by pharmaceutical entrepreneur Sir Henry Wellcome, the trust supports a broad range of biomedical research, from the sequencing of the human genome to neglected tropical diseases. Artemisinin, an antimalarial drug now considered part of standard care, was developed with support from the trust.

International Health Governance

Representatives of fifty countries gather at the United Nations Conference on International Organization to create the UN Charter. (AP Photo)

United Nations established

Between April and June 1945, fifty allied nations attended a conference in San Francisco to draft the charter for a new international organization. The United Nations (UN) officially succeeded the League of Nations on October 24, 1945, on ratification of the UN Charter by fifty-one member countries. The UN’s goals are to maintain international peace and security, develop friendly relations among nations, and promote health, social progress, better living standards, and human rights. The charter identified health as a focus for international cooperation and as one of the issues the UN would be directed to address.

The World Health Organization (WHO) headquarters in Geneva. (Harold Cunningham/Getty Images)

International Health Conference

New York City hosted the International Health Conference, the first international conference convened by the United Nations (UN). The session, which ran four weeks, produced the constitution for the World Health Organization (WHO), which was created to replace the Office International d’Hygiene Publique (OIHP) and the Health Organization of the League of Nations (HOLN). On July 22, 1946, UN member states created an interim commission to prepare for the first session of the World Health Assembly, the WHO’s governing body.

An orphan receives a medical examination in Geneva on December 9, 1945, at the end of World War II. (AP Photo)

United Nations Children's Fund established

The aftermath of World War II left many of Europe’s children orphaned, homeless, and susceptible to disease. In response, on December 11, 1946, the UN General Assembly created what was first the United Nations International Children’s Emergency Fund and is now the United Nations Children’s Fund to provide food and healthcare to orphaned and abandoned children.

A doctor holds a bottle of small pox vaccine at the Centers for Disease Control and Prevention (CDC) in Atlanta in March 2003. (REUTERS/Tami Chappell TLC)

U.S. Centers for Disease Control and Prevention formed

On July 1, 1946, the Communicable Disease Center (CDC) was established in Atlanta, Georgia. Its primary focus during its early years was the eradication of malaria from the United States through the National Malaria Eradication Program. This goal was officially accomplished in 1951, cementing the CDC’s place as a global leader in public health. In 1992, the organization was redesignated the Centers for Disease Control and Prevention (though it is still referred to by the initials CDC).

The World Health Organization headquarters is seen in Geneva on November 9, 2009. (REUTERS/Denis Balibouse)

World Health Organization founded

The World Health Organization (WHO) officially came into being on April 7, 1948, the first World Health Day. Headquartered in Geneva, the WHO replaced the Health Organization of the League of Nations and the Office International d’Hygiene Publique in providing global leadership on health issues.

The WHO is governed by the World Health Assembly, a forum made up of WHO member states. Its decisions are passed by majority vote and are not legally binding. Created to be the leading institution for global health, the WHO aims to gather disparate states to confront public health threats. The WHO also publishes health guidelines, monitors the International Health Regulations (formerly International Sanitary Regulations), and conducts disease surveillance, eradication efforts, and various health-related campaigns.

The UN General Assembly at the Palais de Chaillot in Paris adopts the Universal Declaration of Human Rights on December 12, 1948. (STF/AFP/Getty Images)

Universal Declaration of Human Rights

To more clearly articulate the fundamental rights identified in the UN Charter, the Universal Declaration of Human Rights was drafted on December 10, 1948. This document consists of thirty articles. Article 25 affirms health as a human right and calls for an adequate standard of health for all (particularly mothers and children).

Refugee cholera patients from New Delhi arrive at an infectious disease hospital in October 1947. (Margaret Bourke-White/Time & Life Pictures/Getty Images)

World Health Organization adopts International Sanitary Regulations

Established in accordance with Article 21 of the World Health Organization constitution, the International Sanitary Regulations sought to limit the spread of six major infectious diseases—smallpox, typhoid fever, relapsing fever, yellow fever, cholera, and the plague—without unnecessarily hindering world trade and travel. The regulations, based on the International Sanitary Convention of 1851, established guidelines for disease monitoring and notification, as well as for dealing with infected goods and people. In 1969, the regulations were renamed the International Health Regulations, and their scope limited to cholera, plague, and yellow fever.

Scientific warfare is waged against mosquitoes responsible for the spread of malaria in Italy in 1946. (AP Photo)

Global Malaria Eradication Campaign

In 1955, the World Health Organization (WHO) launched the Global Malaria Eradication Campaign at the eighth World Health Assembly. The effort aimed to eradicate malaria by indoor residual spraying, primarily with the controversial pesticide dichlorodiphenyltrichloroethane (DDT). The campaign eliminated malaria in thirty-seven of 143 endemic countries, but prohibitive costs, negative publicity, anti-DDT sentiments, and program complexity led the WHO to abandon the campaign in 1969.

Police, firemen, and deputy sheriffs receive Asian flu vaccines in August 1957. (AP Photo)

Flu pandemics

The Asian influenza (H2N2) pandemic of 1957 caused some two million deaths worldwide, seventy thousand of those in the United States. Technological advancements, early detection, and quick identification of H2N2 led to the relatively early availability of vaccines and a consequently lower death rate than the flu of 1918. Just eleven years later, the Hong Kong flu (H3N2) pandemic killed one million globally and thirty-four thousand in the United States. Although similar to the 1957 strain, the H3N2 may have been less lethal because of existing immunities. It is considered the last major pandemic of the twentieth century.

A doctor gives out milk to malnourished children in a refugee camp in southern Nigeria in August 1968. (AP Photo)

Medecins Sans Frontieres founded

In response to famine plaguing the Biafra region of Nigeria, a small group of French doctors and journalists established Medecins Sans Frontieres (MSF), a nongovernmental organization that would go on to provide emergency medical services to people in humanitarian emergencies, conflict-affected countries, and postconflict areas. MSF was founded in the tradition of the International Committee of the Red Cross (ICRC) as a civil society organization of health professionals serving victims of conflict. But, unlike the ICRC, MSF also reports on human rights abuses and advocates for victims of conflict and humanitarian disasters.

Russian Ambassador Anatoly Dobrynin talks with U.S. Secretary of Defense Melvin Laird at a signing of the biological weapons treaty on April 10, 1972. (AP Photo)

Biological and Toxin Weapons Convention

Following a joint agreement between the United States and the Soviet Union to disarm biological weapons programs, the Biological and Toxin Weapons Convention was opened for signature in 1972. Since its inception and through September 2010, the agreement has been ineffective, widely ignored, and broken several times by signatory states. Although the convention includes a provision under which issues can be taken to the United Nations Security Council (UNSC) for resolution, the UNSC is not involved with it on a regular basis. The convention is difficult to monitor because biological weapons can be manufactured with a minimal footprint (and most of the needed equipment and raw materials can be found in the private sector). The United States signed the convention in 1972 and ratified it in 1975.

A Red Cross doctor checks the intravenous needle in the arm of a malnourished Cambodian girl in November 1979. (AP Photo)

Declaration of Alma-Ata

The Declaration of Alma-Ata, adopted at the 1978 International Conference on Primary Health Care, marked a decisive point in the evolution of international health governance. It declared that primary healthcare should be the main focus of government health systems and underscored its importance to socioeconomic development and the reduction of health and income disparities.

Moreover, the declaration also recognized the role of nonhealth sectors in attaining good health, as well as the responsibility of wealthy countries to assist poor countries in achieving good health among their populations. The principles of common responsibility, a global commitment to health, and basic health services for all as articulated at Alma-Ata (now Almaty, Kazakhstan) supported the idea of development assistance for health.

However, the health systems and primary care emphasis of Alma-Ata were never realized. The global health community instead pursued campaign-driven approaches focused on single diseases, which resulted in a long debate over the merits of "vertical" versus "horizontal" health programs.

An Indian child displays the results of smallpox in June 1974. (AP Photo/Santosh Basak)

Smallpox eradicated

In 1950, the World Health Organization’s (WHO) regional office for the Americas, the Pan American Health Organization (PAHO), set out to eradicate smallpox in the Western Hemisphere. By 1959, PAHO was successful at doing so in all but four countries. In 1967, at the suggestion of the Soviet Union, the WHO launched the Intensified Smallpox Eradication Program. Through monitoring, surveillance, and "ring vaccination"—the isolation of cases and vaccination of those living in the vicinity—smallpox became the first human infectious disease to be eradicated after the last naturally occurring case was identified, and cured, in Somalia in 1977.

A woman breastfeeds her baby in India while a little girl picks lice from her hair. (Cal TV Film Prod Centre/Keystone/Getty Images)

International Code of Marketing of Breast Milk Substitutes

In response to unethical and medically unsound marketing claims aimed at mothers in developing countries by manufacturers of breast milk substitutes, a coalition of governments, the World Health Organization (WHO), United Nations Children’s Fund, the International Baby Food Action Network, and nongovernmental organizations campaigned for effective marketing codes. In 1981, the WHO and concerned parties adopted the International Code of Marketing of Breast Milk Substitutes, which prohibited most forms of marketing of breast milk substitutes. The code is not legally binding unless incorporated into a state’s national legislation, and, as of 2008, only sixteen countries had fully adopted its policies.

Luc Montagnier, Jean-Claude Chermann, and Francoise Barre-Sinoussi helped discover the causes of AIDS in April 1984. (Michel Clement/AFP/Getty Images)

HIV/AIDS identified

On June 5, 1981, the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report published the first reports of a rise in Kaposi’s sarcoma cases among otherwise healthy gay men in Los Angeles and New York. This triggered reports of similar findings in other parts of the world among populations with similar demographics.

Initially known as Gay-Related Immune Deficiency (GRID), the disease was formally renamed Acquired Immune Deficiency Syndrome (AIDS) in 1982. In 1983, French scientist Dr. Francoise Barre-Sinoussi was the first to isolate what became known as Human Immunodeficiency Virus (HIV), the virus that causes AIDS. By late 1984, researchers proved that the so-called slim disease of eastern Africa, a wasting syndrome spreading in Haiti, and pediatric deaths in New York and New Jersey were all caused by HIV/AIDS.

A gay Task Force presents information at an international conference on AIDS in Philadelphia in April 1985. (Thomas S. England//Time Life Pictures/Getty Images)

First International AIDS Conference

In April 1985, the Centers for Disease Control and Prevention, National Institutes of Health, Food and Drug Administration, World Health Organization, and other organizations held the first International AIDS Conference in Atlanta, Georgia. The conference marked an important turning point in the dialogue on HIV/AIDS, as more than eighteen hundred scientists gathered with nongovernmental organizations and activists to gain a better understanding of the disease.

A health volunteer administers an oral polio vaccine to a child in New Delhi during a country-wide campaign to eradicate the disease in January 1999. (KK/JIR)

Fight against polio begins

In 1985, Rotary International launched PolioPlus, a polio eradication initiative with an initial pledge of $120 million. By 1988, Rotarians had raised $247 million for this effort. PolioPlus inspired the World Health Organization to launch the Global Polio Eradication Initiative in 1988.

Jonas Salk’s development of the Salk vaccine in 1954 was monumental in the fight against polio, but it was Albert Sabin’s oral polio vaccine that led to the rapid reduction in the incidence of polio around the world after 1988. In 1994, polio was certified as eradicated from the Western Hemisphere, due in large part to efforts by Pan American Health Organization (PAHO). An initial goal of eradicating polio by 2000 was not met, and polio remains endemic in three countries: Afghanistan, Nigeria, and Pakistan.

Dr. Jonathan Mann, a pioneer in AIDS research, founded the World Health Organization’s Global Program on AIDS. (REUTERS/HO Old)

Global Program on AIDS launched

Describing AIDS as "a health disaster of pandemic proportions," the World Health Organization (WHO) established the Global Program on AIDS to combat the disease on worldwide and national levels. The program helped develop model strategies for countries to fight AIDS, and sought to create a network of scientists to work toward a solution. The program also stressed education efforts on the disease and used experts outside of the public health realm to analyze the social and behavioral effects of the disease. The program continues today as an instrument to provide comprehensive AIDS support to WHO member countries.

U.S. President William Jefferson Clinton talks with former secretary of state James Baker at a White House event urging passage of the Chemical Weapons Convention in April 1997.

Chemical Weapons Convention

The Chemical Weapons Convention, established in 1993, is an international effort to prohibit the "development, production, acquisition, stockpiling, retention, and use of chemical weapons" through control of the weapons themselves and of certain chemicals that may be used to create them. Currently, 188 of the 192 countries recognized by the United Nations are parties to the convention.

Over a third of all fatalities among HIV-positive people—including these patients in a women’s ward in Thailand—are from tuberculosis. (AP Photo/WHO/Thierry Falise).

Tuberculosis declared an emergency

The World Health Organization (WHO) declared tuberculosis (TB) a worldwide emergency, stating that the disease would cause thirty million deaths in the subsequent ten years without significant action to curtail its spread. This was the first time the WHO declared a public health emergency.

Since 1995, the WHO has adopted the Directly Observed Treatment Short Course (DOTS) program to combat TB, a program that has treated thirty-six million patients. The battle against TB is part of the United Nations Millennium Development Goals, which aim to "halt and begin to reverse the incidence of TB by 2015." Despite these efforts, recent estimates put TB deaths in 2008 at 1.3 million.

In 2006, an outbreak of highly drug-resistant tuberculosis was discovered in Tugela Ferry, South Africa. The strain was dubbed XDR-TB and has now spread worldwide. As of March 2010, fifty-eight countries had reported at least one case of XDR-TB.

Dinarosa Belleri was the fifth Italian nun from the Sisters of the Poor order to die from the deadly Ebola virus, to the cemetery in Kikwit May 14. (REUTERS/Corinne Dufka)

Infectious diseases prompt revision of International Health Regulations

The spread and reemergence in 1994 of the plague in India, cholera in Peru, and Ebola in Africa led international health experts to convene and reassess the International Health Regulations. The changes made included a new structure to facilitate quicker reporting and notification, and limits to unnecessary control measures on international trade.

The seven members of the Appellate Body of the World Trade Organization pose after their first meeting in Geneva in December 1995. (AP Photo/Donald Stampfli)

World Trade Organization established

The World Trade Organization, created in 1995, ushered in a range of new agreements that continue to play a role in global health governance, specifically the transfer of medicines and intellectual property regarding health.

The Agreement on the Application of Sanitary and Phytosanitary Measures aimed to ensure that national health and food protection regulations fall within certain standards. The Agreement on Technical Barriers to Trade sought to establish conformity of trade regulations and procedures to limit obstacles to trade among nations. The General Agreement on Trade in Services established a multilateral system aimed at developing trade equity in the service sector. The Agreement on Trade-Related Aspects of Intellectual Property Rights established baselines for regulating intellectual property transfer among nations, but has been criticized for limiting the availability of copyrighted medicines to developing nations.

Era of Global Health

AIDS casts a long shadow over life in Africa where UN figures show that infections have been underestimated.(REUTERS/Str Old)

United Nations Program on HIV/AIDS created

To harmonize the uncoordinated HIV activities of various agencies, UN leadership created the Joint United Nations Program on HIV/AIDS (UNAIDS). UNAIDS is notable for its structure—a one-of-a-kind UN program with a single disease focus—as well as its role within global health governance as the locus of HIV advocacy, disease surveillance, and leadership.

International AIDS Vaccine Initiative President Dr. Seth Berkley answers questions about an orally administered AIDS vaccine by the Institute of Human Virology in May 2000. (AP Photo/Gail Burton)

International AIDS Vaccine Initiative established

The International AIDS Vaccine Initiative (IAVI) supports research and clinical assessments of candidate vaccines against HIV. Launched in 1996 and backed by financial support from the Gates Foundation and other private donors, IAVI helped create an innovative model for global collaboration between public and private research sectors and convinced all participants to agree to uncommon patent protocols, guaranteeing that poor countries would be able to afford access to a vaccine once the product is developed.

Michael Willis sorts out his AIDS medication at his Baltimore apartment in August 1998. (AP Photo/Roberto Borea)

Highly active antiretroviral HIV/AIDS treatment found effective

Beginning in 1996, highly active antiretroviral therapy (HAART) became widely recognized as an effective treatment for HIV/AIDS, considerably boosting the survivability rates of those stricken. Although the therapy does not completely eliminate the disease, it has changed its outlook from a death sentence to a manageable chronic illness. The treatment continues to be used today and as it becomes less costly, it becomes more available to those infected in developing countries.

Veterinarians from the Agriculture and Fisheries Department inspect a chicken at a Hong Kong border checkpoint. (REUTERS/Larry Chan)

H5N1 emerges

The first human case of H5N1, a strain of avian influenza, was detected in Hong Kong in 1997. Typically found in wild birds, H5N1 spread rapidly among domesticated chickens and turkeys in the late 1990s. Although asymptomatic in wild birds, its mutation in domesticated chickens and turkeys proved deadly, killing millions of domesticated birds in more than fifty countries since 1997. By the end of that year, there were eighteen reported cases of H5N1 in humans, six of which were fatal. According to the World Health Organization, a total of 648 human cases of H5N1 have been confirmed since 2003, resulting in 384 deaths.

The Merck and Company Pharmaceutical and Services building in Duluth, Georgia, July 8, 2002. (REUTERS/Tmmi Chappell)

Pharmaceutical companies donate medicines

In 1998, the pharmaceutical company Merck and Co., Inc. partnered with GlaxoSmithKline to donate a treatment to any sufferers of elephantiasis, a rare disease caused by parasites transmitted by mosquitoes. Since 1998, Merck also donated mectizan, a treatment for river blindness. River blindness has been particularly endemic in West Africa and parts of Latin America. The effort represents the largest donation program and public-private partnership in the pharmaceutical industry and was estimated to reach 100 million annual treatments by 2010.

Nelson Mandela, former president of South Africa, shakes hands with Bill Gates, chairman and CEO of Microsoft Corporation, at a global health discussion in Seattle in December 2008. (REUTERS/Jeff Christensen)

Bill & Melinda Gates Foundation formed

Bill Gates, the former president of Microsoft Corporation, founded the William H. Gates foundation in 1994. In 2000, he and his wife Melinda combined this and two other family foundations to form the wealthiest charitable foundation in the world, the Bill & Melinda Gates Foundation.

Today, the Gates Foundation donates more money annually to global health-related issues than all but a handful of wealthy nations. In 2006, billionaire businessman Warren Buffet pledged the equivalent of $30 billion in stock to the Gates Foundation. As of 2010, the foundation had an endowment of $33 billion.

A young child receives an immunization at a health post on the outskirts of Dakar, Senegal. (AP Photo/Christine Nesbitt)

Global Alliance for Vaccines and Immunization created

Throughout the 1990s, the gap in childhood immunization rates between developing and developed countries widened at an alarming rate. The Global Alliance for Vaccines and Immunization (GAVI Alliance) was created at the World Economic Forum in Davos, Switzerland, in 2000 to bridge this gap through increased vaccine access in poor nations.

The GAVI Alliance is unique in its efforts to guarantee a market for vaccines when they are developed. The alliance supports work in over seventy countries and consists of the World Health Organization, United Nations Children’s Fund, the World Bank, the Bill & Melinda Gates Foundation, donor governments, and nongovernmental organizations. The Gates Foundation is the top donor to GAVI.

World Health Organization (WHO) Director-General Lee Jong-wook introduces UN Secretary-General Kofi Annan at the WHO Strategic Health Operations Centre. (AP Photo/ Denis Balibouse)

Global Outbreak and Response Network created

In 2000, the World Health Organization (WHO) Department of Global Alert and Response resolved to create a global network to deal with the threat of international epidemics. The resultant body, the Global Outbreak and Response Network (GOARN), is a collection of existing institutions and networks that pool human and technical resources for the rapid identification, confirmation, and response to outbreaks of international importance. The GOARN mission is to quell the spread of outbreaks across borders, establish a quick response to threats through technical assistance, and develop long-term organizational readiness.

Leaders of the Group of Eight (G8) pose in front of Shuri Castle during a family photo session. (REUTERS/Toshiyuki Aizawa)

Group of Eight prioritizes global health

The 2000 Group of Eight (G8) summit in Okinawa, Japan, marked the first time global health ranked among the highest priorities of the forum, which brings together the world’s advanced industrial nations. The meeting also produced the first G8 declaration on infectious diseases, which committed the developed world to assist in tackling infectious disease, especially in Africa. The declaration also launched talks to create a global fund to channel these resources.

The UN Security Council votes unanimously to intensify AIDS education among peacekeepers on July 17, 2000. (REUTERS/Peter Morgan)

United Nations Security Council Resolution 1308

On July 17, 2000, the United Nations Security Council (UNSC) unanimously adopted UNSC Resolution 1308, declaring HIV/AIDS a security threat if left unchecked. This was the first time the UNSC had addressed a health issue, recognizing that violence and instability exacerbated the pandemic (and vice versa). The resolution called for increased international cooperation in prevention, for the exchange of best practices and policies, and for United Nations peacekeepers to become advocates for awareness and prevention of HIV transmission.

Callisto Madavo, vice president of the World Bank for Africa, speaks to the media on the eve of the thirteenth International Conference on AIDS in South Africa.(AP Photo/Obed Zilwa)

World Bank Multi-Country HIV/AIDS Program for Africa (MAP)

In September 2000, the World Bank launched the Multi-Country HIV/AIDS Program for Africa (MAP) in thirty-five countries across the continent. MAP made an initial $500 million commitment to fund HIV/AIDS efforts and since 2000 has disbursed more than $1.9 billion for civil society mobilization, AIDS prevention, and care and treatment programs. This makes it the third largest donor to HIV/AIDS after the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) and the President’s Emergency Plan for AIDS Relief (PEPFAR).

Children play around a communal tap near Cape Town in August 2002. (REUTERS/Mike Hutchings)

Millennium Development Goals

Adopted unanimously by United Nations member states at the Millennium Summit in September 2000, the Millennium Development Goals (MDGs) set concrete development goals in the areas of health, education, environmental sustainability, and poverty reduction. Three of the eight MDGs deal directly with health:

Four of the remaining five MDGs address social determinants important to health, such as development, hunger and poverty, the environment, and women’s rights.


Singapore army personnel investigate a suspicious material during a nuclear, biological, and chemical weapons exercise in October 2007. (REUTERS/Kim Kyung-Hoon)

Biological and Toxin Weapons Convention negotiations fail

An effort to update and establish a verification process for the Biological and Toxin Weapons Convention began in 1995, but stalled after six years of negotiations. The United States, wary of the new protocol’s potential effect on its national security interests, refused to agree to the proposed changes, effectively disrupting progress toward an update to the agreement.

A traffic policeman puts on his gloves among the vehicles in Beijing in November 2006. China statistically has some of the world’s most dangerous roads. (REUTERS/Jason Lee/Files)

World Health Organization develops road traffic injury prevention strategy

Recognizing traffic accidents as the tenth leading cause of death, the World Health Organization established a five-year plan [PDF] to reduce road traffic injuries and fatalities. The strategy aimed to reduce these high numbers by incorporating road safety programs and awareness into national public health systems.

Malian President Alpha Kounare and Ghanaian President John Kuffour arrive at an African summit on HIV/AIDs, tuberculosis, and related infectious diseases in Abuja, Nigeria, in April 2001. (REUTERS/George Esiri)

World Reacts to AIDS Emergency

At an April 2001 meeting in Nigeria, African heads of state devised the Abuja Declaration on HIV/AIDS, Tuberculosis, and Other Related Infectious Diseases, which declared a state of emergency regarding HIV/AIDS (given its impact on regional development, stability, and public health). Signatories pledged to make resources available to fight HIV/AIDS and other infectious diseases and to allocate 15 percent of their annual national budgets to the improvement of the health sectors in their countries.

Three months later, UN secretary-general Kofi Annan convened a special session of the General Assembly on HIV/AIDS, which marked the first such session dedicated to a health issue. Officials produced the Declaration of Commitment on HIV/AIDS as a blueprint to meet the sixth Millennium Development Goal (MDG). The session also called for a new financing system for HIV/AIDS, which ultimately led to the creation of the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) in 2002.

In 2010 it was estimated [PDF] that thus far only six out of fifty-three African Union (AU) member states including Rwanda, Botswana, Niger, Malawi, Zambia, and Burkina Faso have met the Abuja Commitment to spend 15 percent of their budget towards health.

The Norwegian director-general of the World Health Organization (WHO), signs an agreement for the supply of antimalarial drugs with the chairman of the pharmaceutical company Novartis AG, in May 2001. (AP Photo/Donald Stampfli)

Doha Declaration increases access to essential medicines

The Doha Declaration on Trade-Related Aspects of Intellectual Property Rights and Public Health (TRIPS) was negotiated and adopted by all World Trade Organization members in November 2001. It aims to facilitate access to essential medicines in developing countries by clarifying previous provisions in TRIPS about the ability of countries to produce patented medicines for distribution within their borders. Given the lack of domestic pharmaceutical manufacturing capacity in many developing countries, the declaration also addressed the problem of third-party compulsory licensing, starting the process that led to an amendment in 2005 to permit the importation of generic drugs in qualified nations.

Public Health: A Global Priority

French Health Minister Bernard Kouchner meets with UN secretary-general Kofi Annan during a board meeting of the Global Fund To Fight HIV/AIDS, Malaria, and Tuberculosis.

Global Fund to Fight AIDS, Tuberculosis, and Malaria established

After being urged by Group of Eight leaders in Okinawa, Japan, in 2000 and African leaders at the summit in Abuja, Nigeria, in 2001, former United Nations secretary-general Kofi Annan called for a new global fund to channel additional resources for HIV/AIDS prevention and treatment. Officially established in January 2002, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) mobilizes resources from public and private sources as well as individuals, and channels them into grants to fight HIV/AIDS, tuberculosis, and malaria. The fund supports programs that are designed and submitted from recipient countries through a grant application process. This differentiates the fund from many other assistance initiatives that design programs and seek out recipients.

Since its inception in September 2010, the GFATM committed $19.3 billion, providing antiretroviral therapy to 2.8 million people in 144 countries. It also distributed 122 million insecticide-treated bed nets to prevent malaria and provided tuberculosis treatment to seven million people with active cases of the disease. It now faces a significant funding shortfall. A press release in March 2010 notes that $20 billion in funding is needed to continue and improve current programs which would allow for more rapid progress towards achievement of the health-related "Monterrey Consensus". Thus far only $6 billion has been pledged by donors for the 2011-2013 funding cycle. Although further contributions will likely be donated, it is assumed that the desired funding of $20 billion will not be met.

A child plays an accordion for change in March 2002 in Monterrey, Mexico.

Monterrey Consensus

On March 22, 2002, the Monterrey Consensus was adopted by the United Nations (UN) General Assembly at the UN International Conference on Financing for Development in Monterrey, Mexico. The consensus recognizes the need for developing countries to take responsibility for their own poverty reduction and for wealthy nations to support this endeavor with more open trade and increased financial aid. It outlines six areas in which participants can help finance development: mobilizing domestic financial resources in developing countries, allocating 0.7 percent of gross national incomes in donor countries to official development assistance, increasing international financial and technical cooperation, encouraging international trade, relieving external debt, and addressing systematic issues.

A follow up conference was hosted in Doha in 2008 and concluded with the adaptation of the Doha Declaration on Financing for Development. The declaration committed developed countries to maintaining their assistance targets.

Chinese women wear masks in southern China in April 2003.

SARS outbreak

Severe Acute Respiratory Syndrome (SARS) was first identified in China in November 2002. It was not until February 2003, however, that the Chinese government admitted to an outbreak in Hong Kong and not until April 2003 to a widespread domestic epidemic. By February 2003, cases of SARS were already being identified in Canada. By March, cases were also seen in Thailand and Singapore.

During its peak, between November 2002 and July 2003, SARS infected 8,098 people and killed 774 in eleven countries. China's reluctance to cooperate with international officials early on is widely regarded as having exacerbated the spread of SARS, for which the Chinese government has since officially apologized.

A follow up conference was hosted in Doha in 2008 and concluded with the adaptation of the Doha Declaration on Financing for Development. The declaration committed developed countries to maintaining their assistance targets.

U.S. Secretary of State Colin Powell holds a copy of President George W. Bush's Emergency Plan for AIDS Relief at a press briefing in Washington in February 2004.

President's Emergency Plan for AIDS Relief

In May 2003, President George Bush signed into law the President's Emergency Plan for AIDS Relief (PEPFAR) that allocated $15 billion over five years to fight HIV/AIDS in fifteen developing countries. The program marked the largest commitment in history made by any nation to combat a single disease.

PEFPAR funds prevention, care, and treatment initiatives for individuals living with HIV/AIDS, as well as care for orphans and vulnerable children. It also channels funds to nongovernmental organizations through the U.S. Agency for International Development, Centers for Disease Control and Prevention, and the Department of Defense.

The 2008 reauthorization of PEPFAR allocated the expenditure of up to $48 billion between 2009 and 2013, devoting $4 billion of the total funding to fight tuberculosis, $5 billion to fight malaria, and $2 billion to the Global Fund to Fight AIDS, Tuberculosis, and Malaria.

Polio victims in Nigeria gather near a workshop run by polio sufferers in February 2004. 

Polio spreads from Nigeria

In 2003, fears over the safety of immunizations led leaders of three states in northern Nigeria to stop vaccinating against polio for nearly a year. Although the ban on vaccinations was eventually lifted, concerns over the side effects of immunization continued, allowing the disease to reemerge. As a result, the disease spread to several once polio-free countries in the region, ruining the World Health Organization's goal of eradicating polio worldwide by 2005.

By 2010, there had been a nearly 100 percent decline of polio cases in Nigeria; however the disease reappeared in Angola and the Democratic Republic of the Congo.

European Union Commissioner for Health and Consumer Protection David Byrne signs the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in Geneva in June 2003.

Framework Convention on Tobacco Control

The Framework Convention on Tobacco Control (FCTC) was the first convention of the World Health Organization (WHO) adopted under Article 19 of the WHO constitution. The convention was developed in response to adverse health effects associated with tobacco and emphasized the importance of demand reduction strategies, as well as supply issues, in the development of a regulatory strategy to address tobacco.

The convention commits signatories to banning or restricting tobacco advertising, placing graphic health warnings on cigarette packs, and protecting nonsmokers from secondhand smoke, among other things. It is overseen by the Conference of the Parties (COP) to the WHO Framework Convention on Tobacco Control, which holds regulatory sessions every two years.

Gina Munguia prepares medicine for her son in November 2003 after discovering that both of them are HIV-positive. (AP Photo/Ginnette Riquelme)

3 by 5 Initiative

By 2003, more than forty million people were living with HIV/AIDS worldwide; however, in poor nations, fewer than 8 percent of those in need of immediate antiretroviral therapy (ART) were receiving it. On December 1, 2003, the World Health Organization (WHO), along with the Joint United Nations Program on HIV/AIDS (UNAIDS), introduced the 3 by 5 Initiative as a global treatment target, aiming to provide ART to three million people living with HIV/AIDS by the end of 2005. The WHO and UNAIDS would not distribute ART themselves, but instead created a five-pillar strategy, including developing global advocacy; providing country support; simplifying standardizing tools; creating an effective, reliable supply of medicines and diagnostics; and rapidly identifying and reapplying new knowledge and successes. None of the pillars included vaccination.

By the end of 2005, because of funding gaps and poor implementation mechanisms, the initiative failed to achieve its treatment target, and only one million patients in the developing world were on ART. The campaign, however, did help motivate global action to increase access to HIV treatment, and the goal was achieved by 2008.

A man walks past the New York Stock Exchange in August 2009. Obesity remains a major health concern in the United States. (REUTERS/Lucas Jackson)

World Health Organization addresses noncommunicable diseases

Citing the growth of chronic and noncommunicable diseases (NCDs), the World Health Organization (WHO) announced in 2004 its Global Strategy on Diet, Physical Activity, and Health [PDF]. The plan states four main objectives: to limit the factors of chronic disease; to raise awareness of the risks; to establish action plans on the global, regional, and national levels; and to encourage research on the issue. A 2010 WHO report [PDF] cited physical inactivity as the fourth leading cause of death globally.

Former U.S. president William Clinton visits the patients of a HIV/AIDS research center in Kigali, Rwanda, in July 2005.

Clinton Foundation established

In 2002, President Bill Clinton established the William J. Clinton Foundation to find solutions to challenges in global health, poverty reduction, climate change, and sustainable development. The Clinton Foundation HIV/AIDS Initiative (CHAI) has worked to make HIV/AIDS treatment affordable and implement large-scale prevention, care, and treatment programs. CHAI has also negotiated prices with pharmaceutical companies for affordable AIDS drugs. The reduced prices are available in seventy countries, and in many countries, the cost of first-line treatments was reduced by 50 percent, pediatric medicines by 90 percent, and second-line HIV/AIDS medicines by a cumulative 30 percent. It has to date enabled access to HIV treatment for more than two million people. 

Laborers sleep next to baskets of chickens in Jakarta in November 2005.

International Health Regulations

Since their creation in 1903, the International Sanitary Regulations (ISR) have been updated numerous times, most recently in 2005, and are now known as the International Health Regulations (IHR). A major step in helping the international community adapt to the public health challenges of the twenty-first century, their scope is now broadened to involve all illnesses and issues of health, a mandate for state parties to develop "minimum core health capacities," and procedures for the World Health Organization (WHO) director-general to determine a "public health emergency of international concern." Governments are also required to develop response plans to disease outbreaks and report them within twenty-four hours.

The IHR were adopted by all members of the WHO and entered into force on June 15, 2007. Although legally binding, they are not enforceable. In addition to requiring the report of any outbreaks, they also give the WHO a stronger mandate to respond and to use media and data from nongovernmental organizations, making them less reliant on the official information shared among member states.

Leaders from the Group of Eight (G8) pose at the end of the G8 summit in Gleneagles, Scotland.

Gleneagles Summit

Health and development in Africa were a focus at the 2005 Group of Eight (G8) summit in Gleneagles, Scotland. The summit proposed universal access to HIV/AIDS treatment in Africa to all those who needed it by 2010, as well as continued efforts to combat malaria and tuberculosis in accordance with the Millennium Development Goals. Summit participants also pledged $25 billion to African aid, and committed to erasing $40 billion in African debt.

Despite these commitments, critics report that the G8 members have yet to deliver the full amount of pledged aid. In December 2010, United Nations Secretary-General Ban Ki-moon criticized G8 members, saying, "If these promises are not met, the poor will suffer and, indeed, die in large numbers."

French former president Jacques Chirac shakes hands with members of the medical staff as he pays a visit to the Pasteur Institute in Dakar in December 2007.

Foreign Policy and Global Health Initiative

In 2006, the ministers of foreign affairs of Brazil, France, Indonesia, Norway, Senegal, South Africa, and Thailand came together to create the Foreign Policy and Global Health Initiative aimed at increasing awareness of the links between the two issues. In 2007, they issued a statement that included the initiatives' goals: to develop "new partnerships" and "new paradigms of cooperation," to involve global health issues in foreign policy discussions and calculations, to strengthen the effort at a multilateral and global level, and to reinforce health's role in fighting poverty and achieving the United Nations Millennium Development Goals.

A subsequent UN General Assembly resolution [PDF] asked the UN secretary-general to submit a report to the General Assembly on "challenges, activities and initiatives related to foreign policy and global health." The secretary-general's report [PDF], recognizing these challenges and "strategic opportunities," was released in September 2009.

An Indonesian worker vaccinates a chick on a farm to protect thousands of healthy chickens from bird flu virus in West Java.

Indonesia claims "viral sovereignty" on avian flu

Indonesia, one of the first countries to deal with the spread of avian flu (H5N1), refused to share samples of the disease with the World Health Organization (WHO) and other governments. As the outbreak continued, it also failed to report new instances of the disease in the country. Indonesia's health minister claimed that the disease, despite its global ramifications, was the property of Indonesia.

Without accurate notification or adequate samples to provide a basis for the identification and prevention of the disease, other countries and international institutions could not react quickly and a global health crisis followed. The WHO responded by sponsoring negotiations to reform the status quo for virus- and benefit-sharing aimed at creating a more stable and predictable system.

In May 2008, a malnourished child is fed in Uganda’s Karamoja region, where over one million people face starvation due to prolonged drought. (REUTERS/James Akena)

Global crises: financial, food security, and energy

In January 2009, the World Health Organization (WHO) gathered experts to discuss the ramifications of the global financial crisis on world health issues. The group concluded [PDF] that every country’s health system would be affected, with the brunt falling on those countries most dependent on outside aid. To offset these challenges, the WHO called for continued spending in the health sector, and in particular on maintaining donor commitments.

Alongside the global financial crisis, 2008 saw food and energy crises that led to price hikes and shortages for basic commodities and foods. Although felt around the world, the crises imposed significant burdens on developing countries. The United Nations Standing Committee on Nutrition [PDF] reported that the food crisis caused fifty million more people to go hungry, having distinct nutritional ramifications for those in sub-Saharan Africa and Asia, especially with regard to child and maternal health.

Men enter the Arlington Convention Center to receive their H1N1 flu vaccinations in November 2009.

H1N1 pandemic

In April 2009, the first widespread transmission of a new strain of influenza virus, H1N1, was detected in Mexico. It quickly spread across the world, creating an international public health scare. Swine flu, as it was labeled, is a reassortment of four known strains of influenza virus: one endemic to humans, one endemic to birds, and two endemic to pigs.  As of September 2010, a total of 214 countries had reported confirmed cases of H1N1 and 18,449 related deaths. It had been officially declared a pandemic on June 11, 2009, when the World Health Organization (WHO) raised its pandemic alert to phase six, indicating widespread human infection. The WHO declared an end to the H1N1 pandemic on August 10, 2010.

As of September 2011, countries in the Northern hemisphere suffered low or undetectable influenza activity. Australia reported a cluster of twenty-five cases, while the tropical countries of Cuba, Honduras, Cameroon and Senegal, Bangladesh and Thailand acknowledged continued transmission.

The WHO's handling of the H1N1 pandemic and its six-phase alert system eventually came under severe scrutiny and attack for causing undue panic about a virus that was ultimately less deadly than anticipated.

In response, an external review [PDF] of the WHOís handling of the pandemic was released in May 2011. The report focuses on appraising the efficiency of the International Health Regulations in dealing with the pandemic and other world health events, and evaluates the role of the WHO secretariat during the period as well as the response and preparedness of other global actors. Taking into account these lessons learned, the report also issued recommendations aimed at strengthening preparedness and efficient response mechanisms for future crises.

A girl collects water from a pond used by animals in a drought-affected region of Ethiopia in June 2009.

Climate change named biggest health threat

A report [PDF] released by the British medical journal Lancet and the University College London Institute for Global Health named climate change the biggest danger to global health in the twenty-first century. The report cited the specific threats associated with climate change as changing patterns of disease, water, and food insecurity; vulnerable shelter and human settlements; extreme climatic events; and population growth and migration. The report called for international cooperation and for countries to engage in policies aimed at reducing climate change, as well as to act on the conditions that directly affect human health and well-being.

World leaders gather at the Group of Eight (G8) summit in June 2010. (REUTERS/POOL New)

International community prioritizes maternal and child health

The Bill & Melinda Gates Foundation announced a $1.5 billion donation for maternal and child health programs for developing countries in June. The majority of the funds will go toward family planning, nutrition efforts, and training health care personnel and be distributed to countries that suffer from high maternal mortality rates, such as India or Ethiopia.

Also in June 2010, the Group of Eight (G8) launched the Muskoka Initiative, which pledged $5 billion for the developing world over the next five years to reduce deaths during maternity, childbirth, and early childhood. The G8 projects that this initiative, paired with additional funding from other countries, will save 1.3 million children under the age of five and 64,000 mothers, in addition to providing family planning services to twelve million couples. The G8 summit document also expressed continued support for a United Nations Joint Action Plan to Improve the Health of Women and Children.

Anti-retroviral (ARV) drugs sit on a shelf in the pharmacy at the Ubuntu clinic in Cape Town on February 15, 2010. (REUTERS/Finbarr O’Reilly)

New medicines show promise

Unveiled at the 18th International AIDS Conference, a study [PDF] of a new microbicide gel showed that the treatment could stop HIV transmission to women. The gel, containing the antiretroviral drug tenofovir, proved between 39 and 54 percent effective in preventing HIV contraction among women. While tenofovir does not completely destroy the virus, it does significantly inhibit its growth, limiting the chances of the advancement of the disease.

Additionally, in July 2010, federal researchers released findings of antibodies that were effective at neutralizing 90 percent of HIV strains that lead to AIDS. The discovery inspired optimism that a vaccine might soon be achieved.

Also developed were new vaccines for bacterial meningitis and pnuemonia. The meningitis vaccine promises to protect more effectively than—and at a fraction of the cost of—previous treatments. The pneumonia vaccine only costs $3.50 a dose, but the GAVI Alliance estimates that there is a $800 million gap in funding for implementing immunizations.

A woman walks past a board promoting HIV/AIDS awareness during World AIDS day in Athens December 1, 2010. (REUTERS/Yiorgos Karahalis)

UN sees progress in AIDS fight

The 2010 Global Report on HIV/AIDS [PDF], published by the Joint United Nations Program on HIV/AIDS (UNAIDS), cited a decrease in new infections and an increase in access to anti-HIV treatment. In 2009, 2.6 million new people were infected with HIV, a decrease in 19 percent from 1999. The total number of people receiving antiretroviral treatment rose by 1.2 million in 2009 to 5.2 million total.

In March 2011, UN secretary-general Ban Ki-Moon launched the UN’s third major initiative to address the global HIV/AIDS crisis: "Uniting for universal access: towards zero new HIV infections, zero discrimination and zero AIDS-related deaths" [PDF]. The report set a target of zero new infections and zero AIDS-related deaths by 2015, and outlined recommendations that were subsequently adopted at the June 2011 high-level meeting on AIDS convened by the General Assembly. As a result of the renewed international attention, in July 2011, the UN proctored the first agreement between a pharmaceutical company and the Medicines Patent Pool regarding HIV/AIDS antiretroviral medicine, illustrating the growing potential for private sector collaboration to advance the availability of medicine in developing countries.

An Acehnese boy cries as he gets a measles vaccination in Panga. (Darren Whiteside/ Courtesy Reuters)

Billions pledged toward childhood vaccinations

The United Nations Foundation and the Global Alliance for Vaccines and Immunization (GAVI) pledged $4.3 billion toward vaccinating 250 million children by the year 2020. This represents a substantial global initiative aimed at eliminating the deaths of millions of children each year in developing countries due to preventable life-threatening diseases such as diarrhea and pneumonia.

A general view shows world leaders during a joint news conference in a BRICS summit in Sanya.

First meeting of BRICS health ministers

Universal access to medicine was a primary topic of discussion at the first meeting of health ministers from Brazil, Russia, India, China, and South Africa (BRICS) in Beijing. BRICS represent forty percent of the global population and nearly one-third of all people living with HIV/AIDS in the world. The five BRICS countries face similar health challenges, including the double burden of communicable and noncommunicable diseases, as well as inequitable access to health services as part of increasing health care costs.

A malnourished child is seen inside a ward at Banadir hospital in Somalia's capital Mogadishu.

Famine and cholera epidemic in East Africa

The worst drought in over fifty years has consumed Somalia, parts of Ethiopia and northern Kenya. It is estimated that nearly 50 percent of the population suffers from acute malnutrition. The famine has been aggravated by the prolonged absence of a central government in Somalia, and the presence of al-Shabaab, a militant Islamist group in the south that has diverted or expelled international assistance. As hundreds of thousands of refugees stream into overflowing camps, dirty water, poor sanitation, and crowded settlements have given rise to a cholera epidemic, according to the World Health Organization. In addition, poor conditions and extremely limited food supplies have also led to a steep increase in children dying from measles.

Flags fly in front of the United Nations Headquarters in New York on July 31, 2008. (Brendan McDermid/ Courtesy Reuters)

UN High-Level Meeting on Noncommunicable Diseases

Coming off the heels of the World Health Organization ministerial meeting on noncommunicable diseases, the United Nations held its first Noncommunicable Disease (NCD) Summit to address the threat posed by NCDs within low- and middle-income countries (LMICs) in September 2011. Cardiovascular disease, diabetes, chronic respiratory diseases, and cancer contribute to 35 million deaths annually, most of which occur within developing nations. Although the summit presented an opportunity for NCDs to gain prominence within the global health community, the lack of an outcome disappointed many public health experts who had hoped for concrete and time-specific goals for reducing the prevalence of NCDs. This conference is part of the 2008-2013 Action Plan [PDF] for the Global Strategy for the Prevention and Control of Noncommunicable Diseases [PDF]. One year later, Turkey is hailed as a success story, having made substantial efforts to reduce the prevalence of NCDs. Six years prior, more than one-third of adults in Turkey used tobacco products, greatly increasing the risk of cardiovascular disease, lung cancer, and chronic respiratory disease. By 2012, a study found that more than half of Turkish health managers had given up tobacco in the past four years and that this was a reflection of progress being made on a greater scale throughout the country.

Kenyan nurses weigh a child before she is given an injection as part of a malaria vaccine trial in November 2010 (Courtesy Reuters/Joseph Okanga).

Progress toward malaria vaccine

Preliminary results from a clinical trial of fifty thousand children in seven African countries indicate that a new vaccine against malaria, "RTS,S," cuts the incidence of malaria by 50 percent in the twelve-month period following vaccination. Caused by a parasite transmitted through the bites of infected mosquitoes, an effective vaccine for malaria has eluded scientists for decades. The disease disproportionately affects children in sub-Saharan Africa, where malaria accounts for an estimated 20 percent of all childhood deaths. If RTS,S continues to yield positive results, the World Health Organization could recommend and begin employing the vaccine in 2015.

Indian paramedic administers polio vaccine to a child in 2004 (Courtesy Reuters/Raj Patidar).

India reaches major milestone in the fight against polio

Once considered the global epicenter of polio, India celebrated the passage of one year since the last case of polio in the country on January 12, 2012. Until 1995, India had witnessed between fifty thousand and one hundred and fifty thousand cases of polio per year. Following a massive human and financial mobilization effort, India conducted highly successful vaccination and education campaigns, as well as pledged more than $2 billion to eradicate polio for worldwide efforts. According to the World Health Organization, more than one hundred and seventy million children under the age of five in India receive a polio vaccine each year.

The number of countries with endemic polio is now at a historic low of three countries: Afghanistan, Nigeria, and Pakistan. Although India is unquestionably a public health success story, health experts cautioned against complacency and called on Indian officials to remain vigilant against resurgences of the disease.

Bill and Melinda Gates attend a session at the World Economic Forum in Davos (Courtesy Reuters/Christian Hartmann).

Contributions toward childhood vaccinations

The Bill & Melinda Gates Foundation announced a pledge of an additional $750 million to the Global Fund to Fight AIDS, Tuberculosis, and Malaria, in a show of solidarity for the organization mired in a recent corruption scandal. The new pledge more than doubles the Gates Foundation’s previous commitment of $650 million, and is designed to help fill the gap between donor commitments and payments. The backlash from donors over the corruption charges led to the resignation of the executive director as well as the cancellation of more than $1 billion in spending to expand the Global Fund’s programs. In his high-profile announcement of the new pledge at the 2012 World Economic Forum, Gates issued a call to arms: "These are tough economic times, but that is no excuse for cutting aid to the world’s poorest."

Six months earlier, the United Nations Foundation and the Global Alliance for Vaccines and Immunization (GAVI) pledged $4.3 billion toward vaccinating 250 million children by the year 2020.

Health workers in Ghana administer vaccines to children through a partnership with the Global Alliance for Vaccines and Immunization (Courtesy Reuters/Handout).

Ghana's historic vaccine rollout

The government of Ghana—a country highly afflicted by infectious and neglected diseases—partnered with the Global Alliance for Vaccines and Immunization (GAVI) to organize a high-profile rollout of vaccines to combat diarrhea and pneumonia. Ghana is the first country in sub-Saharan Africa to introduce two vaccines at the same time, which together are projected to save thousands of lives of children under the age of five. Diarrheal diseases and pneumonia are among the leading causes of all infectious disease deaths around the world, the majority of which are concentrated in sub-Saharan Africa.

A premature baby sleeps in an incubator in the natal intensive care unit of a public maternity hospital in Gatire, Venezuela (Courtesy Reuters/Jorge Silva).

First global report on premature births

A report jointly produced by the World Health Organization (WHO), March of Dimes, Save the Children, and over fifty other organizations is the first-ever national, regional, and global comparison of preterm births. Born Too Soon assesses the current global situation of premature births and proposes recommendations for policymakers and nongovernmental organizations to reduce the mortality rate of premature babies. It reports that an estimated fifteen million babies are born too early, one million of which die shortly thereafter. The report also found that the percentage of U.S. premature births is similar to that of developing countries, although the U.S. mortality rate for preterm babies is dramatically lower. The region most highly afflicted is sub-Saharan Africa, which accounts for roughly 60 percent of preterm births worldwide.

A women and her son wear face masks to protect themselves from a deadly strain of H5N1 in a train station in Cairo, Egypt (Courtesy Reuters/Asmaa Waguih).

Controversial H5N1 studies published

After months of negotiations and deliberation between the academic and policy communities, the U.S. National Science Advisory Board for Biosecurity (NSAAB) voted unanimously to allow publication of a paper on H5N1 by Yoshihiro Kawaoka of the University of Wisconsin. The paper, published by the science journal, Nature, discusses a manmade strain of the H5N1 virus (otherwise known as avian flu) that could be easily transmitted among human beings. The report’s findings sparked a controversy over the "dual-use dilemma," or technological advancements that could be potentially manipulated for beneficial or malicious aims. In particular, the NSAAB was concerned that the paper posed a bioterrorism threat.

Several months later, NSAAB also voted to publish a similar study from Erasmus Medical Center. Currently, the H5N1 virus is typically lethal in humans, but it does not transmit easily between humans. The paper, published in Science, identified five mutations that would allow for the virus to spread easily among humans.

Volunteers form a red ribbon during a HIV/AIDS awareness campaign in front of historic Taj Mahal on World AIDS Day (Courtesy Reuters/Stringer India).

International AIDS conference hails successes, notes challenges

Nearly twenty-four thousand officials, experts, scientists, and civil society participants convened in Washington, DC, in July to attend the nineteenth International AIDS Conference. The conference celebrated global progress to combat HIV/AIDS. According to UNAIDS, the global incidence of HIV infections has stabilized and begun to decline, largely due to advancements in antiretroviral drugs. Between 1997 and 2010, the number of annual new HIV infections declined by 21 percent. However, the conference also highlighted worrisome trends in Central Asia and Eastern Europe, where the number of HIV infections and HIV-related deaths continue to rise. According to the executive director of UNAIDS, the opportunity to eradicate HIV/AIDS hinges on sustained and increased funding by donors and governments.

In December 2011, U.S. President Obama announced $50 million to fund new initiatives to combat HIV in the United States, where 1.2 million Americans are currently living with the disease. He also pledged to increase access to antiretroviral drugs to six million people around the world—two million more than the original target—with a particular focus on countries most afflicted by the virus.

U.N. Secretary General Ban Ki-moon read out the results of the report noting a $167 billion shortfall in MDG funding (Courtesy Reuters/Bryan McDermid).

Funding shortfalls threaten progress toward health MDGs

In a new report, UN secretary-general Ban Ki-moon warned of a $167 billion shortfall needed to reach the Millennium Development Goals (MDGs) and called on donors to increase aid. For the first time in nearly a decade, official development assistance declined, raising concerns that the international community will be unable to sustain critical gains in child mortality and access to safe drinking water, among others. The report also concluded that most countries will be unable to meet the MDGs by 2015.

Such findings echo earlier shortcomings to track and assess progress toward achieving the MDGs. In a high-level meeting held in November 2010, world leaders cited uneven progress across the eight issue areas, particularly in improving maternal health.

An electron microscope image of a coronavirus is seen in this picture by the Health Protection Agency in London. (Health Protection Agency/Courtesy Reuters).

Public health leaders celebrate release of major study on global health data

The Institute for Health Metrics and Evaluation (IMHE), an independent global health research center supported by the Bill & Melinda Gates Foundation, published the 2010 Global Burden of Diseases, Injuries, and Risk Factors Study (GBD 2010). The GBD 2010 is the most comprehensive effort ever to produce global disease estimates. The 2,300-page study is the culmination of years of research involving 486 researchers in fifty countries. More expansive in scope than the first GBD report (published in 1990), the GBD 2010 evaluates the global burden of 291 diseases and injuries and sixty-seven risk factors in 187 countries over a twenty-year period (1990-2010). While the study may not mobilize greater levels of foreign aid, as CFR Senior Fellow Thomas Bollyky notes, it could become a crucial source of accountability for national governments.

The new Action Plan will revolutionize healthcare for those suffering with Alzheimer’s and other mental illnesses (Courtesy Reuters/Edgard Garrido).

WHO drafts Global Mental Health Action Plan

The World Health Organization (WHO) opened discussions on the latest draft of a new Global Mental Health Action Plan, which, when voted on in May, would set goals for progress and improve accountability for projects to improve mental healthcare worldwide. The plan aims to "promote mental well-being, prevent mental disorders, provide care, enhance recovery, promote human rights and reduce the mortality, morbidity, and disability for persons with mental disorders."

People gather at Novartis India headquarters in Mumbai on April 1, 2013. (Courtesy Reuters/Vivek Prakash)

Top Indian court rejects patent protection for Swiss drugmaker

The Indian Supreme Court rejected patent protection for Glivec, a major cancer drug produced by Swiss drugmaker Novartis. The ruling paves the way for local Indian manufacturers to continue providing cheap generics to large swaths of the developing world. India is one of the world’s leading producers of generic medicines, and as such has received credit for broadening access to life-saving drugs for millions of people. Whereas Glivec can cost up to $70,000 per year, for instance, an Indian generic version of the drug can cost as little as $2,500 per year.

A child receives polio vaccination drops as others stand in a line during an anti-polio campaign on the outskirts of Jalalabad on February 11, 2013 (Courtesy Reuters/Parwiz).

Global health groups commit $5.5 billion to eradicate polio

The World Health Organization and partner organizations affiliated with the Global Polio Eradication Initiative released a $5.5 billion vaccination and monitoring plan to eradicate polio within the next five years. Since the mid-1980s, when polio eradication efforts began in earnest, the incidence of the disease has dropped to record lows. Polio is now endemic in only three states—Afghanistan, Pakistan, and Nigeria—with a mere nineteen cases reported so far in 2013. The plan calls for vaccinating over 250 million children where the disease still lingers, as well as disease monitoring and surveillance in over seventy countries.

Biobank, located in northern England, has the world’s largest blood and urine sample freezer. (Courtesy Reuters/Phil Noble).

Public health partners forge global coalition on data sharing

Dozens of health groups in over forty countries have created a global alliance [PDF] to better facilitate the sharing of genetic and clinical information across borders. As the cost of genome sequencing continues to plummet, scientists and researchers fear that, without coordination, an exponential proliferation of genetic data may impede the advancement of treatments. The goal of the new group is to standardize the data, in accordance with strict ethics rules, and make it widely accessible to health practitioners and institutions around the world.

Issue Brief

Scope of the Challenge

Despite medical advances and improvements in sanitation, water supply, nutrition, housing, and education, poor health continues to plague many countries in the world today. Infectious diseases kill approximately fifteen million people each year, and more than four million die from AIDS, malaria, or tuberculosis alone. A disproportionate share of this suffering occurs in developing countries. New threats, such as severe acute respiratory syndrome (SARS) and recombinant flu strains, continue to arise. Meanwhile, health conditions traditional to wealthier nations—including tobacco consumption, obesity, diabetes, and other noncommunicable diseases (NCDs)—are increasingly prevalent in the developing world. Global public health continues to be undermined by negative environmental, political, and economic factors from pollution to violent conflict to limited food production, and even a new, man-made threat—the specter of biological attacks.

The expansive and evolving nature of global health challenges exerts constant pressure on national governments charged with safeguarding citizens’ health and on the international institutions engaged in controlling the cross-border spread of disease and curbing dangers from noncommunicable diseases. Public health actors are generally motivated by a mix of development, humanitarian, economic, and security interests.

Public attention to global health has grown at an unprecedented pace over the past half century. A surge in both funding and staffing has helped successfully eradicate smallpox, decrease AIDS mortality, and raise average global life expectancy from forty to sixty-five years. The shift has rightly been called a public health revolution.

The surge in funding has spawned numerous organizations dedicated to improving public health worldwide. Some, though, have overlapping mandates, and coordination efforts are at times limited. Additionally, programs focused on alleviating specific diseases can often siphon resources from local infrastructure and reduce comprehensive health services.

More needs to be done to coordinate actors and improve coherence across the global health landscape. Through centralized fora like the World Health Organization (WHO), countries should clarify priorities for the global health agenda, allocate more attention to health-related needs, advocate for greater accountability among nongovernmental organizations, and improve the monitoring and evaluation of global health initiatives.

Meanwhile, as the global economic slump continues to linger, international institutions need to help ensure sustained financing for global health, improve alignment of recipient- and donor-country priorities, increase harmonization of multiple donor efforts, and engage the private sector to help mitigate persistent inequities in the development and delivery of resources to meet global public health challenges.

Strengths & Weaknesses

Overall assessment

Overall assessment: Unprecedented focus and funding, yet anarchic

The institutional landscape for global health is more populated, diverse, and better resourced than it was twenty years ago. The traditional multinational institutions that first dominated after World War II—primarily the World Health Organization (WHO)—have been joined by a panoply of new multilateral initiatives, public-private partnerships, foundations, faith-based organizations, and nongovernmental organizations. Yet the effectiveness of this increase in players and resources is often diluted by an uncoordinated and incoherent system.

The WHO remains the primary organization involved in global health, responsible for health-related activities within the United Nations (UN). It plays a leadership role, spearheading research, policy, and country-level training and support.

But the array of new players with expertise on global health is staggering. Within the UN, the Joint United Nations Program on HIV/AIDS (UNAIDS) and the UN Children’s Fund (UNICEF) focus on particular global health issues. Other international organizations and programs with at least a partial mandate to address global health matters include the Food and Agriculture Organization (FAO), World Trade Organization (WTO), International Labor Organization (ILO), UN Environment Program (UNEP), and the World Bank. Multilateral funding mechanisms have also appeared, such as the Global Alliance for Vaccines and Immunization (GAVI), and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund).

Regional organizations, including the European Union (EU), the Association of Southeast Asian Nations (ASEAN), the African Union (AU), and the Pan American Health Organization (PAHO)—have also become players in global health. Their combined work has strengthened systems, ensured universal health accessibility, and facilitated dialogue among member states, international institutions, and nonstate actors. Meanwhile, donor governments have launched major bilateral global health efforts (such as the U.S. President’s Emergency Plan for AIDS Relief, or PEPFAR, and a growing number of departments, including military and security agencies (such as the U.S. Department of Defense), have become involved in global health. All these official actors share space with a burgeoning number of nongovernmental organizations (NGOs), faith-based organizations, and foundations dedicated to advancing global health.

A rise in global health initiatives has accompanied this proliferation of actors. Three of the eight UN Millennium Development Goals (MDGs) focus squarely on health objectives, and another four relate to the social determinants of health. The Group of Eight (G8) now regularly places public health on its annual summit agenda, and the new Group of Twenty (G20) prioritzed global health at its 2011 summit in France. In 2000, the UN Security Council declared HIV/AIDS a threat to international peace and security. The multilateral Health Eight (H8)—a group of eight organizations working on global health issues—was also established to coordinate global health initiatives and determine uniform international health priorities.

In all, more than forty bilateral donors, twenty-five UN agencies, twenty global and regional funds, and ninety global initiatives target health activities and assistance. This institutional richness creates huge coordination challenges, not least for developing countries on the receiving end of outside attention. As a partial response, the International Health Partnership and related activities (the so-called IHP+) seeks to coordinate the activities and funding commitments of outside actors around country-led strategies.

New treaties have been negotiated to help strengthen aspects of the global health regime. The revised International Health Regulations (IHR 2005) established rules and processes that allow the WHO and its member states to identify and respond to international public health emergencies more effectively. The regulations require state parties to report significant disease events and to develop and maintain core public health surveillance and response capacities. Similarly, the Framework Convention on Tobacco Control (FCTC), adopted by the WHO in 2003, is the first international convention under Article 19 of the WHO Constitution. It has helped to mobilize an unprecedented, worldwide anti-tobacco movement. In addition, the Global Code of Practice on the International Recruitment of Health Personnel [PDF], adopted by the WHO in 2010, aims to mitigate the imbalances of health workers between developed and developing countries.

Much-needed funding has also increased. International financial support for global health efforts ballooned from $5.6 billion in 1990 to over $27 billion in 2010, thanks in part to the development of innovative financing mechanisms. Of special note is the prominent role that NGOs, including philanthropic foundations and private corporations, play in championing and financing public health programs. The Bill and Melinda Gates Foundation, in particular, provides approximately 5 percent of all funding for global health assistance. This surge in resources has contributed to several notable successes, including expanded access to medicines, improved disease detection, and growing community participation.

Despite this progress, several significant weaknesses are apparent. First, inadequate coordination and leadership threaten the efficacy of today’s global health institutions. Although effective coordinating bodies have sprung up, much of the activity in the field of global health reflects poorly integrated, donor-driven, disease-specific initiatives, often with weak accountability. Such a patchwork has led one prominent scholar to describe the system not as a regime, but as a loosely configured complex.

Second, increases in funding and the proliferation of organizations and initiatives have not adequately addressed continued health disparities between affluent and poor countries. Many of the benefits derived from globalization have disproportionately accrued to wealthy countries, leaving poor nations vulnerable to acute and chronic health threats. Given these challenges, progress toward achieving the health-related MDGs—including a 75 percent reduction in maternal mortality between 1990 and 2015—has been slow.

Additional weaknesses in global health governance include inadequate disease surveillance, inequitable access to vaccines and other essential medicines, a focus on single diseases rather than public health systems, and comparatively little donor attention and resources devoted to noncommunicable diseases.

Moving forward, the United States and stakeholders worldwide face three main challenges: first, to reinvigorate the resources needed to address an expanding agenda; second, to minimize health disparities between rich and poor countries; and, third, to correct an absence of coordination and leadership.

Noncommunicable diseases

Targeting noncommunicable diseases: Growing awareness, but still too little

Noncommunicable diseases have traditionally received little attention from the international community, yet they pose an important and growing threat to public health. In 2008, the World Health Organization (WHO) reported that chronic, noncommunicable diseases are the leading cause of death globally, despite being mostly preventable. As a result, the WHO is increasing its efforts to target noncommunicable diseases around the world.

Traditionally, noncommunicable disease—cardiovascular problems, diabetes, cancer, and chronic respiratory illness, to name a few—have been considered diseases of affluence because they reflect ill health resulting from improved living standards. Today, their prevalence is more global. They correspond to shifts in diet and nutritional standards as well as to aging, because older populations have higher levels of cardiovascular disease and cancer. Although noncommunicable diseases remain the leading cause of death in the West, risk factors stemming from tobacco and alcohol consumption, unhealthy diets, and physical inactivity are increasingly driving mortality rates in poor countries, hampering socioeconomic conditions for growth and development. In the South Pacific region, for instance, noncommunicable diseases account for 75 percent of annual fatalities. In countries with a burgeoning middle class—namely, India and China—food consumption patterns have changed in favor of a higher protein-filled diet, but this has been accompanied by a massive increase in per capita consumption of salt, sugar, and trans fats, which contribute to the onset of noncommunicable diseases.

Aware of the growing threat, the WHO created the Global Strategy on Diet, Physical Activity, and Health [PDF] (DPAS) in 2004, aimed at raising awareness and reducing the health risk factors associated with sedentary lifestyles and a poor diet. The DPAS has engaged relevant figures around the world, including national governments, private actors, and United Nations agencies—such as the Food and Agricultural Organization (FAO) and the Codex Alimentarius Commission—to promote awareness of the harmful effects of poor lifestyle choices and to incorporate health policies at the country level. Implementation, however, has been slow as the WHO also continues to allocate a substantial amount of resources to a multitude of other international health concerns. This is especially so among low- and middle-income countries, where noncommunicable diseases compete for resources allocated to prevalent infectious diseases. The DPAS also prompted controversy from companies concerned about adopting restrictions on marketing certain food and beverage products.

The WHO has also begun to focus on obesity and alcohol consumption. For the latter, based on consultations with states, it has drafted a global strategy [PDF] on harmful use of alcohol. In January 2010, the WHO executive board adopted a resolution recommending the World Health Assembly adopt this strategy. On obesity, the WHO has recognized the problem as growing and in some countries acute. Its efforts, however, are limited to advocacy and the collection and analysis of relevant data. In some cases, it has joined forces with regional organizations. One such example is the European Union (EU), which adopted measures to counteract obesity (drafted by the WHO regional office for Europe) within the EU Charter.

The private sector has started to take a more active role in responding to the noncommunicable epidemic. Companies like Pepsi and Nestle are making efforts to limit sugar, salt, trans fats, and net calories in their food and drink products. According to Derek Yach, Pepsi’s director of global health policy, major companies are also showing leadership [PDF] in developing products based on organic ingredients and using their marketing capital to promote a healthy lifestyle and diet.

Despite roadblocks, significant progress has also been made in rallying global support against tobacco. The WHO’s most significant achievement has been the Framework Convention on Tobacco Control (FCTC)—the first convention adopted under Article 19 of the WHO Constitution—which came into force in 2005 and as of 2010 has more than 160 state parties. The FCTC requires signatories to restrict the influence of the tobacco industry on national health policies and ensure that safeguards are in place to protect the public from secondhand smoke. Other provisions include limiting or banning advertising and ensuring clear health warnings on tobacco products. The WHO has developed guidelines for meeting obligations and provided assistance to enable implementation. According to the WHO, most parties have "passed or are renewing and strengthening national legislation and policies" related to the treaty. That said, raw figures point to an uphill battle on tobacco use. Given rising populations in developing countries, overall tobacco use is increasing and efforts to curtail it remain underdeveloped.

Further showing its commitment to combat NCDs, in September 2011, the United Nations held its first Noncommunicable Disease Summit to address the threat posed by NCDs within developing, low-, and middle-income countries (LMICs). Although the summit presented an opportunity for NCDs to gain prominence within the global health community, the lack of outcome disappointed many public health experts who had hoped for concrete and time-specific goals to reduce the prevalence of NCDs. This conference was part of the World Health Organization’s 2008-2013 Action Plan [PDF] for the Global Strategy for the Prevention and Control of Noncommunicable Diseases.

The battle against HIV/AIDS

Continuing the battle against HIV/AIDS: Unprecedented support, but still inadequate

Responding to the Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) pandemic has been a critical challenge for nearly three decades. In 1986, the World Health Organization (WHO) created the Global Program on AIDS (GPA). Initially, GPA—and the Joint United Nations Program on HIV/AIDS—tried to create national AIDS commissions in every country, run at the highest levels of government. These strategies, however, were not effective in stemming the growth of the pandemic.

In 1996, research showed the efficacy of highly active antiretroviral therapy (HAART), marking a turning point in the HIV/AIDS pandemic. By 1999, the HIV battle shifted away from prevention toward treatment, and in particular to getting HAART into poor countries. This prompted attacks on provisions of the World Trade Organization (WTO) Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) on the grounds that the high cost of patented HAART—then averaging from $10,000 to $20,000 per patient annually—was immoral. Accordingly, Merck initiated efforts to promote universal access to HIV treatment, and later the William J. Clinton Foundation negotiated dramatic price reductions and generic manufacturing of antiretroviral drugs (ARVs). The efforts have brought the annual cost of treatment to less than $300 per patient. Further reductions are expected.

Multilateral action on the disease accelerated in 2001, with a groundbreaking UN declaration that instructed all countries to fight HIV/AIDS through prevention, treatment, and long-term care. This new attention spurred the establishment of the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) at the Genoa Summit of the Group of Eight (G8) in 2001. Along with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and World Bank’s Multi-Country HIV/AIDS Program (MAP) for Africa, the Global Fund has been an important advocate of prevention, counseling, care, and treatment programs.

But economic difficulties in major donor countries have intensified debates about how best to spend existing resources in the face of increasing demand. After committing to help achieve "universal access" to HIV treatment—defined as ten million people by 2010—and to double aid for health and poverty reduction to $50 billion per year, the G8 backed off its pledge and restated its goal in June 2011 as fifteen million people by 2015. Despite these setbacks, funding for HIV/AIDS has suffered the least from contracted foreign aid budgets. A record 1.4 million began treatment in 2010, reflecting the conintued increase in access to care for HIV/AIDS.

Private actors have helped bridge some of the gaps in financing. Sustained efforts by foundations, faith-based organizations, and nongovernmental organizations, for example, have been critical in achieving the yearly decrease in new infections globally. Independent organizations, such as the International AIDS Vaccine Initiative and the Global HIV Vaccine Enterprise, have also contributed to the effort of developing an HIV vaccine.

Growing evidence, however, indicates that prevention efforts have been too limited. HIV incidence in the United States rose by nearly 50 percent between 2005 and 2009. The large numbers of new infections globally each year—2.5 million in 2011—are increasing the number of people in need of ARVs, even as the availability of ARVs stagnates or declines. Intravenous drug users continue to be at high risk, and antinarcotics politics complicate prevention. In Africa, Asia, and Eastern Europe, blood supplies remain unsafe and syringes are often reused. Furthermore, failure to tightly integrate tuberculosis and HIV diagnosis and treatment has sparked a tuberculosis pandemic, marked by increasing rates of drug-resistance in tuberculosis strains. In response, the Joint United Nations Program on HIV/AIDS has called for a "prevention revolution" [PDF] to halve the number of infections by 2015.

Secretary-General Ban Ki-moon hailed an overall global decline in HIV infections in the 2011 Report on AIDS. At the release of the report, the UN also launched its third major initiative to fight HIV/AIDS that set a target of zero new infections and zero AIDS-related deaths by 2015. However, Secretary-General Ban Ki-moon acknowledged financial hurdles, noting that resources to fund AIDS relief plateaued at $16 billion in 2007.

In May 2009, the World Bank published an independent evaluation of its $2.46 billion HIV/AIDS portfolio, which included 106 projects in sixty-two countries. A quarter of the programs were deemed unsatisfactory or moderately unsatisfactory. The report concluded that the World Bank had underinvested in prevention programs for high-risk groups, inadequately monitored projects, and overestimated the capacity of nongovernmental organizations to design and implement AIDS interventions. The report recommended bolstering health ministries and civil society organizations, as well as more diligently monitoring and evaluating.

Over the past five years, life-saving drugs have been made more available by a factor of one hundred due to increased donor funds; defiance of HIV drug patents by the governments of Brazil, Thailand, and South Africa; and continued activism by civil society groups. New initiatives and medicine also show promise. A new study of a microbicide gel showed that the treatment could stop HIV transmission to women in 39 and 54 percent of cases. Additionally, in July 2010, federal researchers released findings of antibodies that were effective at neutralizing 90 percent of HIV strains that lead to AIDS, inspiring optimism that a vaccine might soon be achieved.

In addition, the Medicines Patent Pool was set up in July 2008 and aims to increase access to treatment by promoting price reductions of existing antiretroviral drugs, stimulating the production of newer first- and second-line drugs and increasing the number of generic producers of these medicines. The first major agreement between a pharmaceutical company and the Patent Pool was finalized in July 2011, with assistance from the United Nations. Recently, Johnson and Johnson agreed not to enforce its patents on darunavir, a common retroviral, amid calls for other HIV medicines to be added to the Patent Pool. UNAIDS also enacted Treatment 2.0 [PDF], a new approach to simplify treatment and increase access to medicine, in order to decrease costs, reduce the burden on health systems, and improve the quality of life for people living with HIV. Modeling suggests that, compared with current treatment approaches, Treatment 2.0 could avert an additional 10 million deaths by 2025.

Still, two broad challenges persist. First, the demand for ARVs far exceeds the supply. Approximately 5.2 million [PDF] people have accessed HIV treatment in low and middle-income countries, up 30 percent from 2009, but more than double that need treatment immediately. Furthermore, price reductions for treatment have been negotiated for only a small subset of drugs, while newer, simpler, and more palatable formulations remain unaffordable in most high-prevalence countries, including Swaziland and Botswana. Finding a balance between market-driven innovation that creates new drugs and the imperative to ensure access to HIV/AIDS medicine and vaccines in low- and middle-income countries remains elusive. With that said, international efforts, led by UNAIDS, to provide universal access to HIV treatment by 2015 remain on track.

Acute pandemics

Management of acute pandemics: Testing surveillance and alert systems; response systems under stress

Pandemic preparedness requires a standardized outbreak alert system linked to concrete actions by national and local health authorities. In 2000, the World Health Organization (WHO) established the Global Outbreak Alert and Response Network (GOARN)—a decentralized network of technical experts and regional surveillance programs from the United Nations, civil society partners, and academic centers—designed to detect and coordinate the response to disease outbreaks.

The WHO also established a six-level pandemic alert system for influenza based on the geographic spread of the disease and its human transmissibility. This system, however, has been criticized for failing to consider the severity of each virus, to link threat levels to tangible actions, and to harmonize existing country alert systems. By contrast, the U.S. alert system has five threat levels that correspond to deaths from infection, but fails to consider human-to-human transmission or geographic spread. Efforts to improve and synchronize the alert systems are underway, and will ideally convey the severity of infection, risk of death, geographic spread, and contagiousness in a combined metric, as well as suggest clear actions linked to threat levels.

Following the severe acute respiratory syndrome (SARS) and H5N1 (avian flu) outbreaks, the WHO redoubled efforts to modernize its surveillance and warning systems. In 2007, WHO member states adopted the International Health Regulations (IHRs) for pandemic preparedness and response. The regulations have helped facilitate coordination among states, but pandemic management is still relatively haphazard.

The revised IHRs require governments to report public health emergencies of international concern to the WHO within twenty-four hours, permit use of nongovernmental disease detection data to supplement government data, and obligate countries to improve their capacity to respond to health crises. The revisions—which require all signatories to comply with core surveillance and response capacity requirements by 2012—are legally binding but contain no provisions for enforcement.

Country compliance with the IHRs has been mixed. In the 2009 H1N1 (swine flu) outbreak, Mexico exceeded IHR obligations by implementing a rapid domestic response, communicating with neighboring states and the WHO, and sharing viral samples with other national and multinational health authorities. Unfortunately, Indonesia performed less admirably during the various H5N1 (avian flu) outbreaks. Even after the revised IHRs went into force, Indonesia refused to report new cases. Fearing that multinational corporations would use the samples to develop a vaccine (and turn a profit by selling it back to affected countries), the Indonesian minister of health justified his refusal to share samples by invoking "viral sovereignty"—the principle that infectious diseases belong to the countries in which they are discovered endemic. This is a troubling principle that could undercut timely international cooperation and monitoring in future crises. The episode underscored the need for mechanisms to persuade recalcitrant states to cooperate on critical matters of global health.

But the WHO has also been criticized for sounding false alarm bells. Critics have attacked its handling of the 2009 H1N1 pandemic for causing undue panic. The Council of Europe investigated [PDF] the WHO on grounds of misconduct, finding that the WHO exaggerated the dangers of the pandemic and above all lacked transparency throughout the process. The WHO was also under investigation by the Review Committee established under the revised IHRs for its use of the revised regulations and its overall actions during the 2009 pandemic. The committee ultimately concluded that the adoption of IHR 2005 helped make the world better prepared to cope with public health emergencies, even though the core national and local capacities called for in the IHR are incomplete and nonexistent in many regions around the world.

Disputes over intellectual property protection are another major obstacle to combating acute pandemics. Emerging market countries—notably Indonesia, Thailand, China, India, Brazil, and Malaysia—have criticized the World Trade Organization’s (WTO’s) Trade-Related Aspects of Intellectual Property Rights (TRIPS) provisions, which are frequently blamed for drug and vaccine pricing that keeps some medicines out of the reach of much of the world’s population. Since the Doha Declaration in 2001, the same criticisms have been levied against the European Union, United States, and Japan to insert enhanced intellectual property provisions into trade agreements, most notably the Anti-Counterfeiting Trade Agreement.

Neglected tropical and other infectious diseases

Addressing neglected tropical and other infectious diseases: Growing attention, but still addressed weakly

The global health agenda has not adequately focused on some of the infectious diseases that continue to plague, debilitate, and kill millions in the developing world. Diarrheal and enteric diseases include some types of hepatitis, salmonella, cholera, typhoid, and an array of other viral, bacterial, and parasitic pathogens. They remain the second-leading cause of fatality for children, killing nearly 1.7 million every year, and are the greatest contributor to childhood malnutrition. Worldwide, diarrheal diseases account for 4 percent of all deaths and 5 percent of health-related disabilities. Yet, unlike HIV/AIDS, these diseases pose no serious threats to the national interests of powerful countries, perhaps accounting for the neglect.

Relative to the global impact of these diseases, funding and dedicated advocates have been lacking historically. The situation, however, is improving. The Bill and Melinda Gates Foundation is investing in research and development for new treatments, along with improved delivery for existing interventions, such as making vaccine distribution and administration less costly. The foundation is also trying to promote and implement structural solutions, such as improved access to fresh water, sanitation systems, and nutrition. Advances have also been made in vaccination, with the Global Alliance for Vaccines and Immunizations leading the way. In July 2011, the United Nations Foundation and GAVI pledged $4.3 billion toward vaccinating 250 million children by the year 2020. These vaccines will help protect against a variety of preventable, life-threatening diseases, including vaccines against diarrhea and pneumonia, which are not readily available to children in developing countries. Vaccine pledges are a significant step toward ensuring comprehensive global childhood immunization, which is one of the most cost-effective and sustainable methods for improving health worldwide.

Another subset of problematic infections is known as neglected tropical diseases (NTDs). NTDs thrive in specific climates, are often linked with impoverished environments, and tend to be spread by insects, contaminated water, or infested soil. They currently affect more than one billion [PDF] of the world’s poorest people, many of whom suffer from multiple NTDs. In the past few years, great strides have been made in understanding the complexity and character of NTDs. Their direct link to poverty has led the World Health Organization (WHO) to consider poverty control [PDF] part of its global health strategy.

The WHO has also launched a comprehensive Preventive Chemotherapy and Transmission Control (PCT) program that works with national governments to train health specialists and advocate disease control measures. In partnership with the WHO, numerous NGOs have begun to develop initiatives to eradicate and eliminate NTDs. The Carter Center, for instance, has helped eradicate Guinea worm in some twenty countries and eliminate onchocerciasis (river blindness) in much of the Americas. The Gates Foundation has also prioritized NTDs. In addition, the Mectizan Donation Program, established by Merck in 1987, began donating mectizan for treatment of onchocerciasis, and Merck has since partnered with GlaxoSmithKline to provide albendazole to treat lymphatic filariasis (elephantiasis) in coinfected individuals.

As part of its new Global Health Initiative (GHI), the U.S. government has pledged to increase funding for research and treatment of NTDs, and it plans to increase funding from $15 million in 2006 to $155 million in 2011. Targeted diseases include trachoma, schistosomiasis, onchocerciasis, lymphatic filariasis, and soil-transmitted helminthiases. However, this new focus on NTDs and other initiatives, combined with the effects of the economic crisis in donor countries, has meant the potential shift of resources away from other health efforts.

NTDs are starting to make their way onto the global health agenda, but the crux of the problem is in delivering [PDF] needed medications and therapies to affected communities and addressing infrastructure issues. For the most part, NTD drugs are inexpensive, but serious supply shortages and distribution challenges persist. Additionally, financing to purchase existing drugs is often limited. Despite commitments by the donor community and the Group of Eight, these tropical infections and their underlying causes will need additional, sustained focus and funding.

Managing biosecurity

Managing biosecurity: Rudimentary mechanisms

The international community continues to lag in its efforts to deter—and prepare for—the use of biological weapons. Existing governance mechanisms reflect Cold War concerns about state proliferation of weapons, rather than the threat of terrorism by nonstate actors. The stakes of such negligence are high. Depending on the severity of the pathogen, a biological agent deployed as a weapon—whether improvised or stolen—could conceivably kill millions, bring global commerce to a grinding halt, and have lingering effects for generations. Smaller-scale attacks, like the 2001 anthrax scare, can cause widespread panic and disruption, even when the death toll is relatively low.

Managing biological weapons is made more complex by the nature of the threat. Even if existing multilateral agreements were entirely effective, biological agents cannot be managed without local controls and cooperation among nonstate actors. Most biological agents are manufactured and housed in the private sector (particularly in laboratories, hospitals, and universities), which requires enhanced coordination with each of type of facility. Inspections are all the more difficult because the equipment, materials, and agents used for weapons are often also appropriate for legitimate commercial use.

Despite calls from United Nations (UN) secretary-general Kofi Annan in 2006, no global forum convenes all the relevant actors to promote a dialogue on safeguards for biological agents. Moreover, the rapid dissemination of weapons-manufacturing information and the ease with which materials can be obtained have rendered the threat of biological weapons more diffuse. Over the last decade, it has become simpler to manipulate viral and bacterial genes to increase their harmfulness and transmissibility. A movement is also growing that promotes in-house production of life forms and open-source sharing of biological "recipes" online.

On the positive side, arrangements to counter the threats of biological weapons have emerged. These include UN Security Council Resolution 1540, which obligates UN member states to prohibit nonstate actors from acquiring, pursuing, or obtaining weapons of mass destruction. Additionally, the Global Health Security Initiative, which is an informal partnership among national health ministries from eight countries (including the United States), the European Commission, and the World Health Organization (WHO) seeks to strengthen global preparedness against biological threats. The reporting requirements of the revised IHRs now apply to acts of biological terrorism, and Interpol has bolstered its efforts to prevent bioterrorism. In the United States, the Obama administration has released a National Strategy for Countering Biological Threats and a first-of-its-kind National Health Security Strategy.

Under the leadership of WHO, the international community increasingly recognizes the importance of public health surveillance and intervention capabilities in countering the biological weapons threat. The WHO’s Global Outbreak and Response Network (GOARN) is part of a global early warning and surveillance network that can identify unusual disease events rapidly, although it does not provide specific response protocols.

The main international legal instruments relevant to combating bioattacks at the global level remain the 1925 Geneva Protocol and the 1972 Biological and Toxin Weapons Convention (BTWC), both of which ban states from using biological weapons but are widely considered inadequate and flawed. The Geneva Protocol prohibits use of biological weapons in warfare, but lacks [PDF] any institutional capacity to monitor compliance. The BTWC goes further in banning development, production, acquisition, and stockpiling of biological weapons but also lacks the rigorous system of inspections that would be necessary for monitoring compliance. Efforts to add a protocol to the BTWC, which would address this shortcoming by establishing a mechanism for information exchange and routine inspections of facilities, have failed. Currently, only about half of BTWC signatories submit voluntary monitoring reports.

Unlike the nuclear and chemical weapons regimes, the BTWC lacks a permanent institutional structure that could help implement the convention and promote peaceful use of biotechnology. It includes a provision whereby a state party can appeal to the UN Security Council to enforce the convention against an alleged violator; however, no state has yet done so. The BTWC has an Implementation Support Unit (ISU), but it has a limited mandate and a staff of only three. Discussions on modernizing the BTWC—through new lab safety standards, new reporting requirements, increased enforcement of safety measures, and bolstering of the ISU—have failed to translate into concrete revisions of the convention.

Nearly ten years after the 2001 U.S. anthrax attacks, controversy continues to surround the Federal Bureau of Investigation’s handling of the matter, indicating the need for greater U.S. government—as well as global—attention to biosecurity issues. It will be imperative at the Seventh Review Conference of the BTWC in December 2011, to agree on new security standards for laboratories that work with high-risk agents and enforce standards more rigorously. Yet such steps are fraught with technical and practical complexities. These include how to define potential biological agents, how to surmount the financial and legal burdens associated with implementation, and how to balance these goals with other objectives, such as development of medical countermeasures and disease surveillance.

Health systems in poor countries

Developing health systems in poor countries: Minimal progress

Poor countries often suffer from inadequate health systems. These weaknesses typically include shortages of health professionals, chronic underfunding, dilapidated or nonexistent infrastructure, and a persistent lack of access to essential medicines, including vaccines. Margaret Chan, director general of the World Health Organization (WHO), has identified weak health systems as the greatest threat to global health goals. Although most countries have adopted the principle of health as a fundamental human right, too few developing nations have actually strengthened their health systems.

A significant portion of global health financing today is dedicated to vertical, disease-specific programs and initiatives. These include the President’s Emergency Plan for AIDS Relief (PEFPAR), the President’s Malaria Initiative (PMI), the Global Fund for AIDS, Tuberculosis, and Malaria (Global Fund), and several Bill and Melinda Gates Foundation initiatives. PEPFAR alone is contributing $48 billion to research, care, prevention, and treatment of HIV over a period of five years. In 2011 President Obama’s proposed budget included almost $7 billion for PEPFAR, representing a 1.8 percent increase on the previous year. However, according to some activists, this increase actually represents a ’step backwards’ due to increasing demand for treatment and inflation. Furthermore, additional focus has been placed toward improving MDGs 4 and 5 relating to maternal and child health. A 2010 MDG Summit and a 2010 G8 Summit further committed to providing additional funding to support childbirth, maternity, and early childhood health.

But such programs often reflect donor priorities rather than local needs and are often independent, uncoordinated, and unaccountable, either to their intended beneficiaries or to taxpayers. Rather than respond to host country requests, donors often impose their own funding priorities, and programs tend to be poorly integrated into local public health systems. Funders and implementers have a vested interest in minimizing failures, and host countries are wary of holding donors to account for fear of driving away badly needed resources. What accountability exists comes in the form of self-regulation, uneven oversight from funders, and monitoring by (typically overstretched) health ministries in host countries. In sum, incentives for honest evaluations are few.

Some argue for greater coordination between vertical—or disease-specific—and horizontal programming. One initiative, known as fifteen by 2015, aims to reallocate 15 percent of current funding by 2015. Meanwhile, President Obama in 2009 launched the Global Health Initiative (GHI), which targets health systems as well as single diseases. In March 2011, the Obama Administration released the GHI Strategy Document [PDF], illuminating key aspects of the GHI approach and strategy. The report emphasized shifting U.S. health to an impact-based approach and focusing on areas where large, substantial health gains can be achieved.

Unfortunately, health systems in most developing countries depend on volatile donor funds. In 2006, donors supplied more than 40 percent of health system funds in eight African countries; many more African nations rely on external funding for more than 30 percent of their budgets. Donor support for health systems is critical, but donors must beware of generating negative, unintended consequences. Governments receiving development assistance for health tend to invest 43 percent fewer of their own resources for health-related activities according to a Lancet  study. To combat this risk, donors’ governments will need to expand their country-level monitoring of how assistance impacts healthcare.

The emigration of qualified health professionals can also undermine health systems. The WHO warns that countries with fewer than 2.3 health professionals per thousand inhabitants will struggle to provide essential primary care services. The relevant figures for Africa and Southeast Asia are 1.3 and 1.7, respectively. Most low- and middle-income countries train far too few health professionals annually, and many locals who are trained immigrate to countries with higher salaries and better working conditions. For example, between 1993 and 2002, half of the doctors and one-third of all nurses educated in Ghana emigrated immediately. According to Michael Clemens at the Center for Global Development, 15 percent of registered nurses and 30 percent of doctors from sub-Saharan African work outside the continent.

There is no easy solution to this brain drain. Restricting health worker emigration is not logistically feasible, and everyone has the right to pursue a better life. In May 2010, the World Health Assembly adopted the Global Code of Practice on the International Recruitment of Health Personnel [PDF] that aims to balance the interests of health workers with those of countries that lose them and receive them. Another initiative, the Global Health Workforce Alliance, seeks to develop country coordination and a code of ethical international recruitment.

A few attempts have been made to regulate migration of health professionals at national and regional levels. South Africa and the United Kingdom signed a Memorandum of Understanding (MOU) in 2003, in which the UK agreed to ethical recruitment practices, technical assistance, partnerships between hospitals, and time-limited placements of staff trained in South Africa. Countries in the Caribbean established uniform professional qualification standards for health workers and created a common market that permits their free movement in the region. Pending rigorous assessments, these approaches may provide models for developing countries.

Facilitating access to vaccines

Facilitating access to vaccines: Record progress, but more attention needed

Vaccines are often effective in preventing disease. The H1N1 (swine flu) pandemic revealed how rapidly a vaccine could be developed and manufactured on a large scale with the support of major developed economies. Nonetheless, the 2009 scare also highlighted critical gaps in financing and in the equitable distribution of much-needed vaccines around the world.

International efforts to control disease through vaccination are not new. In 1974, the World Health Organization (WHO) launched the Expanded Program on Immunization (EPI) to help vaccinate children in developing countries. Since 1970, the program has provided regular vaccinations through regional WHO branches. The most successful WHO achievement has been on smallpox, which in 1979 became the first infectious disease to be eradicated. More recently, international commitment has been jumpstarted by a joint WHO-United Nations Children’s Fund initiative, the Global Immunization Vision and Strategy (GIVS), which looks to increase vaccine coverage by 2015 to meet the Millennium Development Goals [PDF].

According to the WHO’s flagship publication on the issue, the last decade showed remarkable progress for vaccines. Some 120 vaccine products are now on the market, and eighty more are in the late stages of research and development. Moreover, scientific improvements (such as adjuvant compounds) have extended short supplies more than tenfold by stimulating the immune systems of recipients, making them more likely to ward off targeted infectious diseases (measles, polio, diphtheria, and the like). Newer vaccines—like those recently adopted to combat meningitis and pneumonia are becoming more effective and cheaper to produce and disseminate.

Financing for vaccines has increased dramatically in the last few years, due partly to innovative financing and partly to new contributions. Most recently, at the 2010 World Economic Forum, the Bill and Melinda Gates Foundation announced a pledge of $10 billion over the next decade for research, development, and delivery of vaccines for poor countries. Such new financing has helped alleviate some shortfalls, but more funds are needed. According to the United Nations, national governments support about 40 percent of the costs for routine immunizations. For many developing countries, sustaining this commitment will be difficult. Multilateral funding is not enough to close the gap. The Global Alliance for Vaccines and Immunizations (GAVI) was able to overcome its $4.3 billion funding shortfall in June 2011 at its first pledging conference. The pledges bring GAVI’s total available resources for the period 2011 to 2015 to $7.6 billion.

Yet, the pharmaceutical industry relies on a handful of firms to produce all the vaccines needed to meet global demand. Declining profitability from production suggests the need for stronger manufacturer incentives. In response, the Center for Global Development, in partnership with public and private donors, helped promote the Advance Market Commitments (AMCs) for Vaccines. These firm commitments from multilateral donors incentivize manufacturers to develop vaccines that might otherwise be ignored. GAVI’s Advance Market Commitment is piloting a new vaccine for pneumococcal disease (a common cause of pneumonia), though it has been criticized for protracted distribution timelines, and even accused of coercing developing countries to accept the new vaccine instead of an existing, less expensive alternative.

Another innovative financing mechanism launched by GAVI (with the World Bank as treasurer) is the International Finance Facility for Immunization (IFFIm). The mechanism makes use of pledges to issue bonds that generate readily available cash for immunization needs. To date, it has raised $5.9 billion in pledges to be paid over twenty years.

Inequities in access to resources for pandemic management unfortunately persist. The 2009 swine flu outbreak is the most recent reminder. At first, access to H1N1 vaccine was largely restricted to high-income countries. Almost a year elapsed between the emergence of H1N1 in North America and the first population-based distribution of H1N1 vaccines in Africa. By the spring of 2010, the pandemic had petered out in high-income countries, which were then willing to donate unused stocks to poor countries.

Additionally, negotiations on sharing viruses and the benefits from their use have not progressed. Multilateral talks have been deadlocked, which only increases the challenge of vaccine distribution, particularly in developing countries.

Progress in developing vaccines for pandemics also continues to be a major challenge. Established in 1996, the International AIDS Vaccine Initiative (IAVI) develops and assesses candidate HIV vaccines and addresses previous impediments to developing vaccines. To date, IAVI has six vaccines in early-stage clinical trials in eleven countries. GlaxoSmithKline and the PATH Malaria Vaccine Initiative (MVI) have been working toward a vaccine targeted for infants and children in sub-Saharan Africa since 2001. The vaccine, known as RTS,S is in the final stage of trials and, if results remain positive, will be ready for distribution by 2015.

Ensuring effective and sustainable financing

Ensuring effective and sustainable financing: Significant progress, but uncertain future and fragmented focus

Development assistance for global health more than doubled between 2001 and 2007. The budget reached [PDF] $27 billion in 2010, fueled primarily by new financing mechanisms, though the growth rate has plateaued in the wake of the financial crisis. The current regime, however, may be neither sustainable nor appropriate given the lingering effects of the global recession, escalating deficits, domestic healthcare shortfalls in developed countries, shifting priorities, and a greater donor focus on climate change.

The multitude of health actors does raise awareness and funding for global health, but activity lacks coordination and monitoring. Of the five largest financing mechanisms, one is bilateral (the President’s Emergency Plan for AIDS Relief, or PEPFAR), one is multilateral (the World Bank), one is a private foundation (the Bill and Melinda Gates Foundation), and two are public-private partnerships (the Global Alliance for Vaccines and Immunizations, or GAVI, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, or Global Fund).

Perhaps the biggest challenge is identifying sustainable, predictable, and adaptable funding streams. Most international health financing comes from national governments, which are unpredictable from year to year and complicate long-term, strategic approaches. As a result, efforts taken to increase funding from national governments for domestic health priorities must continue as they have in Rwanda, India, China, and Indonesia.

In principle, the donor community has committed to work with developing countries to implement the 2005 Paris Declaration, a set of guidelines to improve the effectiveness of development assistance. The emphasis is on developing country priority-setting, aligning donor funds to grantee agendas, harmonizing donor initiatives, monitoring program results, and establishing accountability between donors and recipients. A recent study of the declaration’s impact, however, found that only 45 percent of development aid arrived on time and that many development programs continued to undermine local program work. In 2011, the Busan Outcome Document [PDF] of the High-Level Forum on Aid Effectiveness recommitted governments to the Paris Declaration’s core principles of strengthening country ownership and developing partnerships and, for the first time, included emerging countries such as the BRICS as well as civil society organizations and private funders. However, despite monitoring mechanisms such as the 2011 Survey on Monitoring the Paris Declaration, many original goals of the Paris Declaration have not been met.

In 2007, several initiatives were launched to enhance coordination among major donors. The International Health Partnership and related initiatives (IHP+) aims to expand on the Paris Declaration principles and provide recipient governments with a greater stake, by focusing donor assistance on a centralized national health plan and budget. Similarly, the Health Eight (H8) partnership brings together eight major health organizations (the World Health Organization, United Nations Children’s Fund, United Nations Population Fund, United Nations Joint Program on HIV/AIDS, Global Fund, GAVI, the Gates Foundation, and the World Bank) to strengthen efforts toward achieving the Millennium Development Goals (MDGs).

Progress, however, remains mixed. The 2011 MDG report indicated [PDF] that nutrition, universal primary education, and child mortality were in danger of falling short of their 2015 targets. In early 2011, WHO Director General Margaret Chan highlighted "serious funding shortfalls" in a speech addressing how to more effectively use existing financing.

Continued economic difficulties in major donor countries have intensified the debate about how best to spend increasingly scarce resources. While the global financial crisis did not freeze increases in health funding, it has slowed its growth—from 13 percent annually in 2004 to 2008 to 6 percent in 2009 and 2010. Given that major new financing is unlikely in the near term, progress in providing health services in developing countries will require efficiencies in existing assistance levels, including through better alignment of donor and recipient priorities, enhanced coordination among the largest programs and institutions, rational divisions of labor at the national and local levels to reduce redundant services, and an improved evidence base to identify cost-effective interventions.

Some innovative financing approaches exist. The intergovernmental group UNITAID seeks to improve treatments for HIV/AIDS, malaria, and tuberculosis (primarily in low-income countries) through more affordable mechanisms. Since 2006, UNITAID has also committed more than $955 million [PDF] to partners worldwide. Additionally, in March 2010, the Millennium Foundation launched Massive Good to help raise more funds for UNITAID. The initiative centers on the travel industry, giving anyone who buys an airline ticket online the option to donate to UNITAID. By November of 2011, however, the campaign was discontinued. The International Finance Facility for Immunization of GAVI, mentioned earlier, was also innovative in raising quick cash for global health needs.

U.S. and International Global Health Policy Issues

Develop an integrated, coherent global health strategy

Should the United States develop an integrated, coherent global health strategy?

Yes: An integrated approach is necessary in today’s interconnected world. Programs that focus on a wide range of diseases and help bolster other countries’ health infrastructures are the only way to combat the litany of global health threats. Efforts will be ineffective without supporting national health systems, and funding must be given to programmatic issues that focus on maternal and child health to prevent diseases before they start. President Obama’s Global Health Initiative—with its goals to improve health systems and fight diseases in coordination—is a step in the right direction but if it falls short, then it must be replaced with a coherent alternative. Important single-issue programs will remain a significant portion of the budget, but the strategy on the whole will be more flexible and more capable of addressing multiple issues—not only disease, but human rights, women’s rights, country ownership of health issues, and international health governance as well.

No: A broad strategy takes away focus and funding from what single-issue programs already do well. The President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative have succeeded because of their relatively narrow focus, and the guarantee that funding would go directly to combating the targeted disease. Also, a mandate on a single disease does not mean that a program does not have an integrated approach. In PEPFAR’s case, for example, efforts have involved childcare, hiring additional healthcare workers, and addressing the challenges of food and nutrition in addition to direct treatment. If single-issue programs are embedded in a broader strategy, there is no guarantee that such an integrated approach to disease will result, and critics contend that PEPFAR may end up competing with other diseases and issues for funding. In the end, a single comprehensive program with a large budget may face more funding challenges than multiple, smaller, single-issue programs where less money can have a more direct effect.

Broader institutional focus to combat noncommunicable diseases

Should the United States push for a broader institutional focus to combat noncommunicable diseases (NCD) across the globe?

Yes: In 2008, the World Health Organization (WHO) reported that chronic, noncommunicable diseases are the leading cause of death globally, despite being mostly preventable. As a result, the United States should join forces with the WHO in increasing its efforts to target noncommunicable diseases around the world. Noncommunicable diseases also remain the leading cause of death in the West, as risk factors stemming from tobacco and alcohol consumption, unhealthy diets, and physical inactivity are increasingly driving mortality rates. In the United States alone, NCDs and other chronic diseases such as stroke account for 70 percent of deaths, limit the activities of tens of millions more Americans, and cost the U.S. economy over 1.5 trillion annually. According to the U.S. State Department, six strategies need to be implemented by the United States in order to curb the growth of NCDs in the United States and across the globe: collaboration across policy sectors, prioritizing high-impact and affordable strategies, knowledge sharing, greater scale and geographic spread for NCD programs, and an enhanced media presence.

No: Unlike illnesses caused by a mosquito, a virus or an infection, noncommunicable diseases (NCD) are linked to factors like food, tobacco, environmental pollution and a lack of exercise. Therefore, many people believe that NCDs are developed as a result of irresponsible personal choices, and thus governmental money should not be allocated towards alleviating these self-inflicted diseases. In addition, the U.S. budget has little room to fund initiatives targeting the elimination of NCDs as the financial crisis drags on and should prioritize more pressing issues. At the same time, others believe that the private sector, such as the recent initiatives launched by Pepsi and Nestle to limit sugars, is a more efficient and cost-effective medium to prevent the spread of NCDs in the United States and abroad.

G20 leadership on the global health agenda

Should the G20 assume leadership in setting the global health agenda for the donor community?

Yes: In September 2009, the Group of Twenty (G20) replaced the Group of Eight (G8) as the world’s premier economic forum, raising speculation that the G20 would become the steering group for other areas, including global health. Some proponents of the change note that the G20 includes developing countries—including South Africa, India, Brazil, and China—with health concerns not currently represented by the G8. Others note that the G8 has been neglecting its health agenda since the global recession. If the G8 continues to wane [PDF] in momentum and legitimacy, the G20 might become a natural forum for setting the global health agenda, ensuring the involvement of important nontraditional donors, and play a role beyond donor coordination. In 2004, the WHO’s assistant director general outlined [PDF] three areas where G20 engagement would benefit the global health agenda: drawing attention to country and regional health crises; raising awareness for neglected health priorities; and holding leaders accountable for their health commitments.

No: The G8 remains the source of the overwhelming majority of official development assistance, including global health, and thus should remain the focal point for such efforts. The G8 also has a consistent record of prioritizing global health over the past decade, even if G8 members have sometimes failed to follow through on financial commitments. In the absence of firm leadership from the World Health Organization, the G8 has routinely driven the agenda for response mechanisms needed to address the most pressing global health problems. In 2001, G8 leaders supported the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria, backed initiatives to relieve debt in developing countries, and endorsed Kofi Annan’s call to fight infectious diseases at a rate of $7 to 10 billion annually. In 2005, the G8 summit held at Gleneagles, Scotland, promised "universal access" to HIV treatment—defined as 10 million people by 2010—and a doubling of aid for health and poverty reduction to $50 billion per year.

These impressive commitments have proven difficult to recreate in the G20, which has to balance the interests of a larger and more diverse membership. While commitments were not met on time due to the financial crisis, the G20 is even more unlikely to build such unified pledges from its membership and ensure follow through.

Ratify the WHO Framework Convention on Tobacco Control

Should the United States ratify the World Health Organization Framework Convention on Tobacco Control?

Yes: The World Health Organization Framework Convention on Tobacco Control (FCTC) is the first international treaty adopted under Article 19 of the WHO Constitutive Act. It views tobacco use as a global problem that demands coordinated solutions, and seeks to reduce both supply and demand for tobacco products by limiting advertising and indoor smoking, encouraging states to raise tobacco taxes, placing prominent warnings on cigarette packages, and preventing smuggling. According to the Centers for Disease Control and Prevention (CDC), more deaths occur annually due to tobacco use than by all deaths from human immunodefiency virus (HIV), illegal drug use, motor vehicle injuries, suicides, and murders combined. All state parties to the FCTC are required to harmonize their national tobacco regulations to certain minimum standards.

Former president George W. Bush signed the FCTC in 2004, but the U.S. Senate has not yet ratified it. The WHO argues that ratification could give further strength to existing domestic efforts to reduce tobacco use and exposure, which according to the Centers for Disease Control and Prevention causes approximately 443,000 deaths annually, and is the leading cause of preventable death in the United States. The FCTC would provide an additional opportunity for the United States to lead by example. As a nonparty, the United States cannot participate in implementing and shaping the FCTC.

No: Since its entry into force in 2005, the FCTC has encountered problems related to national implementation. Of the nearly 174 parties to the treaty, only a handful have enacted full indoor smoking bans. In short, the success of the convention remains unproven and tobacco use is still a leading preventable cause of death worldwide. Some critics add that FCTC goals could be accomplished by national governments on their own and that the most effective way to achieve anti-tobacco goals like those in the FCTC is through domestic regulation. Finally, given the enormous size of the U.S. tobacco industry, ratification requirements for strict regulations in tobacco-growing U.S. states could also translate to job losses.

Intellectual property rights for pharmaceuticals

Should the United States maintain its leadership role in promoting intellectual property rights for pharmaceuticals?

Yes: Intellectual property rights give the pharmaceutical industry incentives to innovate, research, and develop new medicines. Without protection from the United States Trade Representative [PDF], the industry would not be able to pay for developing new drugs and conducting clinical trials. Moreover, the debate between intellectual property rights and health equity distracts from a discussion of the real obstacles to universal access to essential medicines, which include weak financing, procurement, and distribution systems in many countries. The vast majority of drugs on the essential medicines list is already off patent and has been for years. Patent pooling for essential medicines is therefore unlikely to improve access.

No: U.S. regulations supporting intellectual property deprive access to essential medicines, particularly for new drugs needed in pandemic emergencies either through local manufacturing or parallel importing. Preferential trade policies shackle medical innovation and protect monopolies that do not favor fair competition and pricing. In essence, policies that prevent developing countries from importing generics more cheaply or manufacturing drugs locally raise concerns about health equity and justice. Some experts have argued for a more nuanced approach that balances the protections offered by patents with more robust public health considerations within the intellectual property system.

Recent Developments

India eradicates polio

January 2014

India reported 741 cases of polio in 2009—making it the country with the highest number of reported cases of the disease in the world at that time. It has now been three years since the last reported case was a patient who contracted polio in 2011. Several factors contributed to India’s success including the use of a bivalent oral polio vaccine beginning in 2010 and the tailoring of vaccine delivery campaigns to particular areas of the country. The Indian government also integrated these strategies with a “holistic approach” into community health work with initiatives to encourage local adoption of regular hand-washing and other critical hygiene and sanitation practices. 

Global health investment fund

September 2013

JPMorgan Chase & Co. and the Bill & Melinda Gates Foundation partnered to launch the Global Health Investment Fund in September 2013. The Fund will provide individual and institutional investors with the chance “to finance late-stage global health technologies” that could prove to be lifesaving in developing countries. It has already procured $94 million in pledged funds to date from a combination of groups including the Children’s Investment Fund Foundation, Grand Challenges Canada, and the German Ministry for Economic Cooperation and Development. 

New coronavirus spreads

June 2013

The novel coronavirus (nCoV), responsible for the emergence of the Middle East Respiratory Syndrome, also known as MERS, has spread from Saudi Arabia, where it originated in June 2012, to six other countries including France, Italy, and the United Kingdom. The virus has infected fifty-four people to date, over half of whom have died. MERS is genetically related to the Severe Acute Respiratory Syndrome (SARS), which killed about 774 people in a global epidemic in 2003. However, a total of eight thousand people were infected with SARS at that time, underscoring concern over the high mortality rate of MERS. At the closing of the sixty-sixth World Health Assembly, WHO Director General Margaret Chan warned state regulators over the new threat. "Any new disease that is emerging faster than our understanding is never under control," said Chan. "These are alarm bells and we must respond. The novel coronavirus is not a problem that any single affected country can keep to itself or manage all by itself." From June 4-9, a joint mission between the Saudi government and World Health Organization met in Riyadh to assess the disease’s patterns of transmission.

Price cut for cervical cancer vaccines

May 2013

Cervical cancer vaccines for poor countries will now cost less than $5 per dose, under an agreement negotiated between the GAVI Alliance and two major pharmaceutical firms that produce human papillomavirus (HPV) vaccines, Merck and GlaxoSmithKline. More than 85 percent of women who die from cervical cancer each year reside in low-income countries, where vaccines are far too expensive for most people to afford. The reduced cost of the vaccines, which run about $130 per dose in the United States, will allow millions of girls to protect themselves against deadly strains of HPV. While the price cut will apply first to demonstration sites in Africa and Southeast Asia, the GAVI Alliance aims to make the reduced price available to 30 million girls worldwide by 2020.

Deadly bird flu rattles China

May 2013

A new strain of deadly bird flu rattled China in the spring of 2013. A total of 129 people were infected and 32 of those who contracted the disease died, as of mid 2013. The new virus, H7N9, largely affects poultry but spreads more easily to humans than previous bird flus. Moreover, Chinese authorities and health experts suspect that human-to-human transmission already has taken place. While officials from the World Health Organization and U.S. Centers for Disease Control and Prevention emphasize the lack of evidence for an imminent pandemic, there is no certainty that the virus could not mutate, causing widespread contagion.

$5.5 billion pledged to eradicate polio

April 2013

The World Health Organization (WHO) and partner groups affiliated with the Global Polio Eradication Initiative (GPEI) released a $5.5 billion vaccination and monitoring plan to eradicate polio within the next five years. Funders have already pledged three-fourths of the total cost: the Bill & Melinda Gates Foundation agreed to give $1.8 billion; a handful of donor governments—including Britain, Germany, Nigeria, Norway, and Pakistan—offered just over $2 billion; and a small assembly of private foundations has supplied an additional $335 million. Since the mid-1980s, when polio eradication efforts began in earnest, the incidence of the disease has dropped to record lows. The disease is now endemic in only three states—Afghanistan, Pakistan, and Nigeria—with a mere nineteen cases reported so far in 2013. The plan calls for vaccinating over 250 million children where the disease still lingers, as well as establishing monitoring and surveillance systems in over seventy countries. "After millennia battling polio," said WHO Director-General Margaret Chan, "this plan puts us within sight of the endgame."

India rejects patent protection for drugmaker

April 2013

The Indian Supreme Court rejected patent protection for Glivec, a major cancer drug produced by Swiss drugmaker Novartis. The ruling paves the way for local Indian manufacturers to continue providing cheap generics to large swaths of the developing world. India is one of the world’s leading producers of generic medicines, and as such has received credit for broadening access to life-saving drugs for millions of people. Whereas Glivec can cost up to $70,000 per year, for instance, an Indian generic version of the drug can cost as little as $2,500 per year.

Options for Strengthening the Global Public Health Regime


U.S. and international action is needed to ensure aggressive pursuit of health agendas, improved representation of health issues in international fora, and increased coordination between donors and recipients.

These recommendations reflect the views of Stewart M. Patrick, director of the program on international institutions and global governance, and Laurie A. Garrett, senior fellow for global health.

Recommit to development

Strengthen commitment toward development goals

As the global economic slump lingers, and as the United States and Europe confront sovereign debt challenges, it has become virtually certain that most health-related United Nations Millennium Development Goals (MDG) will fail to achieve their desired targets. While President Obama addressed these concerns in his speech at the 2010 MDG review summit, it is unknown as of yet whether his promise for more effective U.S. leadership and his call for greater global participation in development will be fruitful. The United States and other world actors should avoid the temptation either to give up on the MDGs or to spin the breakdown of the 2015 target as a success. Instead, they should set a realistically achievable 2020 target with definite strategy and clear financing. The lessons of the first MDG project need to be applied to future endeavors, and the United States can take a lead role.

Health on the G20 agenda

Include global health on G20 agenda

Global economic realities have forced the rise of the Group of Twenty (G20) over the Group of Eight (G8) as the most prominent forum for multilateral cooperation on financial and economic issues. Over time, the G20 agenda should gradually expand to address global health issues. To date, the new grouping has focused overwhelmingly (and understandably) on the response to the economic crisis, leaving health and broader development matters to the G8.

Going forward, the G8 will likely retain an important role as a forum for major donor countries, including mobilizing major pledges of health-related development assistance. At the same time, the G20 offers an important forum for engaging an emerging set of nontraditional donors—including China, India, and Brazil—in forging global agreement on standards of development cooperation. As evidenced by the meeting of health ministers from Brazil, Russia, India, China, and South Africa (BRICS) in Beijing in July 2011 where those nations pledged support, emerging nations are increasingly active in developing countries. The G20 would serve as an ideal forum to leverage their support and integrate their efforts into a global strategy drawing on developed and emerging nations alike. The G20 also offers an opportunity to extend multilateral cooperation well beyond the limits of foreign assistance.

Evidence-based interventions

Expand the evidence base for health interventions

Disappointingly, only limited monitoring, evaluation, and reporting on global health programs and interventions have been undertaken to date. Little is therefore known about nonmedical interventions, models of care, and program implementation. The United States should insist on an empirical assessment of all global health programs to improve the evidence base for the efficacy of interventions and encourage its development partners to do the same. Programs should collect and report process indicators as well as data on outcomes. Partners should be encouraged to conduct implementation research and share results to better capitalize on successes and learn from mistakes. A recent Lancet article showed disappointing effectiveness in major child health campaigns in West Africa led by UNICEF, highlighting the need for regular monitoring and evaluation of health programs.

Bolster regional action

Strengthen regional approaches and cooperation on health 

Although regional organizations have over the past fifteen years begun to engage in health issues, their efforts remain uneven. Some regions, such as Latin America and Europe have strong systems, while others are far too weak. This often means continued reliance on global structures and initiatives that limit rapid and effective response to health emergencies.

Global health initiatives should help build and employ regional capacity, tapping the strengths of existing regional organizations where possible to reinforce and consolidate ongoing efforts and to develop more inclusive objectives. For example, some experts advocated shifting more control of avian influenza outbreaks away from the World Health Organization and toward the Asia-Pacific Economic Cooperation forum and the Association of Southeast Asian Nations, which have the regional clout, political trust, and financial capacity necessary to manage vaccine stockpiles and encourage viral sharing for pandemics concentrated in the Asia region.

Climate change's impact on health

Anticipate effects of climate change on health

Countries and international institutions need to understand the impact of climate change on global health and prepare for the anticipated consequences. As weather patterns change, major storm events multiply and temperatures increase, likely triggering an increase in instances of drowning and heat stroke. These will add pressure to the emergency response mechanisms of even the most developed countries. Food insecurity and changing patterns of infectious disease (such as malaria) will also tax health systems. In some cases, population relocation may often be the only viable preventive option. In 2008, the World Health Organization’s (WHO’s) World Health Day focused on the health implications of climate change, but much more research and negotiation are needed to generate the necessary knowledge, infrastructure, agreements, and institutions to prepare for the health effects of climate change. The potentially devastating correlation between climate and health can be seen with the Somalia famine in which crop failure as part of prolonged drought has given rise to a cholera epidemic and has contributed to nearly 50 percent of the population suffering from acute malnutrition.

Strengthen IHRs

Strengthen the International Health Regulations to address pandemics

The revised International Health Regulations (IHRs) aim to bolster global pandemic preparedness and response among 194 state parties, both in the interest of public health and to minimize interruptions to global travel and commerce. The regulations have helped facilitate international coordination, but pandemic management is still haphazard. The United States should work to further strengthen the IHRs and harmonize pandemic alert systems. Country compliance with the IHRs has been mixed, underscoring the need for additional mechanisms to persuade recalcitrant states to cooperate and ease the flow of crucial information and viral samples for potential pandemic emergencies.

New patent regime outside WTO

Develop a new pharmaceutical R&D and patent regime outside the WTO

The World Trade Organization (WTO) is no longer at the forefront of discussions on intellectual property issues related to health. The Doha Round of trade negotiations invested little time on Trade-Related Aspects of Intellectual Property Rights (TRIPS) provisions or on intellectual property right issues more broadly. The international health community should shift its attention toward trade agreements through TRIPS+ provisions and non-WTO forums that include intergovernmental negotiations on benefit sharing and virus sharing. These new mechanisms will help bolster research and development and use external funding to price essential medicines affordably.

U.S. self-sufficiency in medical training

Become self-sustaining in meeting U.S. domestic health worker demand

The most recent estimates indicate that approximately 25 percent of all doctors in the United States are foreign trained, and 66 percent of these are from low and middle-income countries. According to an Association of American Medical Colleges (AAMC) report, the United States will reach a shortage of 91,500 doctors by 2020. The AAMC predicts Americans will need an additional 45,000 primary care physicians and 46,000 surgeons and medical specialists. These estimates are higher than previously expected and is the combined result of an aging baby boom generation and increasing health care costs.

The demand for healthcare workers will only increase now that the U.S. health reform bill has passed, putting thirty to fifty million more citizens on insurance or public rolls in the United States. The United States, arguably the best in the world at professional health training and tertiary education, should set a target for self-sufficiency in the education of health professionals. Building this capacity plays to a major U.S. strength.

Organizations, Institutions and Agencies



For more information, including membership; mandate; gaps and weaknesses; implementation, compliance and enforcement; and U.S. policy stance, download the full report. 

International Labor Organization (ILO) (1919)

Flagship United Nations organization on labor issues dedicated to improving working conditions and advancing employment opportunities. Created the Code of Practice on HIV/AIDS and the World of Work providing principles for policy development and practical guidelines on: (1) prevention of HIV, (2) management and mitigation of the impact of AIDS on the world of work, (3) care and support of workers infected and affected by HIV/AIDS, and (4) elimination of stigma and discrimination on the basis of real or perceived HIV status.

World Organization for Animal Health (OIE) (1924)

Intergovernmental organization for global animal health. Created in the wake of a major epizootic disease crisis, seeks to promote international collaboration to quell similar outbreaks. Addresses transparency, scientific information, sanitary safety, promotion of veterinary services. Sets standards regarding food safety and animal welfare.

United Nations (UN) (1945)

UN Security Council passed Resolution 1308 emphasizing the threat to security posed by AIDS. Former UN Human Rights Commission resolved that access to HIV/AIDS treatment was essential to the realization of the right to health. Launched the Joint United Nations Program on HIV/AIDS. Established Millenium Development Goals, which include three targets for health.

Food and Agriculture Organization (FAO) (1945)

Preeminent UN agency on food and nutrition. Works to reduce and eliminate world hunger. Monitors cross-border animal trade, flu outbreaks in animal populations, and livestock quarantine and vaccination.

United Nations Children’s Fund (UNICEF) (1946)

Works to improve child health and provide humanitarian, emergency, and long-term assistance. Home to UNICEF Innocenti Research Center, which researches and promotes solutions to child welfare challenges.

World Health Organization (WHO) (1948)

Leading health body of United Nations. Provides leadership on global health matters, shapes health research, sets norms and standards, provides technical support to countries, and monitors and assesses health trends. Defines health as a shared responsibility, involving equitable access to essential care and collective defense against transnational threats. Approves international conventions, which are binding, though members can opt out. Early-warning system for pandemics. Rumor outbreak website keeps track of info on disease outbreaks. Contributed to eradication of smallpox in 1979.

Codex Alimentarius Commission (Codex) (1961)

Created to establish codes, rules, and guidelines for Joint Food and Agriculture Organization/WHO Food Standards Program. Provides an agreed-upon international referral point for food standards and trade.

United Nations Population Fund (UNFPA) (1969)

Promotes rights for health and equal opportunity. Uses population data to create policies and programs to reduce poverty, promote safe pregnancy and birth, ensure young persons are free of HIV/AIDS, and ensure women are treated with dignity and respect. Program of Action goals to achieve by 2015 are universal access to reproductive health services, reducing maternal mortality by 75 percent, reducing infant mortality, increasing life expectancy, and reducing HIV infection rates. Member of Joint United Nations Program on HIV/AIDS.

Group of Eight (G8) (1975)

Forum for world’s major industrialized democracies. Has addressed public health issues since 1997. Outcome documents from 2008 G8 Summit affirm member states’ commitment to achieving the Millennium Development Goals and promoting other aspects of global health, including combating infectious disease and improving maternal health. Reaffirmed commitment to maternal health through Muskoka Initiative [PDF].

European Union (EU) (1993)

Economic and political union, ensures protection of public health for all of its citizens. Coordinated health standards, funding, and emergency response among member nations.

World Trade Organization (WTO) (1995)

International organization dealing with the rules of trade between nations. Helps producers of goods and services, exporters, and importers conduct their business. The WTO agreements and Public Health joint publication with World Health Organization explains how WTO agreements relate to different aspects of health policies. Established, through Doha Declaration on Trade-Related Aspects of Intellectual Property Rights (TRIPS) and its amendments, a structure for the flow of licensed medicines between countries.

U.S. Department of Defense (DOD) Global Emerging Infections Surveillance and Response System (GEIS) (1996)

Fights infectious disease threats through the use of global surveillance, training, and research.

Joint United Nations Program on HIV/AIDS (UNAIDS) (1996)

First UN institution organized around a specific disease. Prevents new HIV infections, cares for people living with HIV/AIDS, and mitigates the impact of the epidemic. Ensures better coordination among partners in UN system, governments, civil society, donors, private sector, and others. Engages sectors and partners from government and civil society.

World Bank: Health, Nutrition & Population Program (HNP) (1997)

World Bank’s global health arm. Focuses on strengthening countries’ overall health systems. Supports training, infrastructure, regulatory frameworks, and governance.

World Bank: Multi-Country HIV/AIDS Program for Africa (MAP) (2000)

Aims to increase access to HIV/AIDS prevention, care, and treatment, with emphasis on vulnerable groups. Directly supports community organizations, nongovernmental organizations, and private sector on local HIV/AIDS initiatives. Initial commitment of $500 million to assist in scaling up African countries’ HIV/AIDS efforts. Additional $500 million in financing approved in 2002 for second stage of MAP.

President’s Emergency Plan for AIDS Relief (PEPFAR) (2003)

Five-year $15 billion commitment to fifteen countries to fight HIV/AIDS. At launch largest commitment by any nation to combat a single disease in history. Reauthorized in July 2008 for $48 billion for 2009–2013 to combat HIV/AIDS, malaria, and tuberculosis. In the fall of 2008, the Obama administration incorporated PEPFAR into the Global Health Initiative.

UNITAID (2006)

Promotes international drug purchase facility established to provide "reduced prices of drugs and diagnostics" for HIV/AIDS, malaria, and tuberculosis treatment in poor countries. Achieved 40 percent price reduction on antiretroviral treatment for one hundred thousand AIDS-infected children. Helps fund treatment for 150,000 children with tuberculosis.

Core Documents



For more information, including membership; mandate; gaps and weaknesses; implementation, compliance and enforcement; and U.S. policy stance, download the full report. 

Universal Declaration of Human Rights (1948)

Affirms health as a human right (Article 25): "Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, medical care, necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond control." Gives special status to motherhood and childhood: "All children, whether born in or out of wedlock, shall enjoy the same social protection."

World Health Organization (WHO) Constitution (1948)

Establishes World Health Organization as the directing authority on international health and defined its objectives as "the attainment by all peoples of the highest possible level of health." Lays out functions, membership, budget, and governance.

Biological and Toxin Weapons Convention (BTWC) (1975)

Bans development, stockpiling, acquisition, retention, and production of biological agents, toxins, and weapons for reasons other than peaceful purposes.

International Covenant on Economic, Social, and Cultural Rights (1976)

Multilateral treaty commits parties to grant their citizens economic, social, and cultural rights to health, education, and an adequate standard of living. Article 12 recognizes the right of everyone to enjoy the highest attainable standard of physical and mental health. States must ensure citizens have access to clean water, sanitation, food, nutrition, and a comprehensive system of healthcare. Article 12.2 requires parties to improve the health of their citizens by reducing infant mortality, improving child health, and controlling and treating epidemic diseases.

Declaration of Alma Ata (1978)

Defines health as a fundamental human right and primary health care as fundamental to achieving health for all. First international declaration outlining importance of primary care. Calls for all people to have by 2000 a certain level of health that allows them to live socially and economically productive lives.

Ottawa Charter for Health Promotion [PDF] (1986)

Launched at first International Conference for Health Promotion. Defined health promotion as "the process of enabling people to increase control over and improve their health." Participants pledged to advocate for a clear political commitment to health, respond to widening health gaps, and recognize health and its maintenance as a major social investment.

Manhattan Principles for Animal and Human Health (2004)

Focuses on preventing, surveying, monitoring, and controlling potential movements of diseases among human, domestic animal, and wildlife populations.

Framework Convention on Tobacco Control (FCTC) (2005)

First treaty negotiated under auspices of World Health Organization. Commits to banning all tobacco advertising, placing graphic health warnings on cigarette packs, protecting nonsmokers from secondhand smoke, increasing prices of tobacco products, combating cigarette smuggling, and regulating the contents of tobacco products.

International Health Regulations (IHR) (2007)

WHO-sponsored regulations that aim to "prevent, protect against, control, and provide a public health response to the international spread of diseases" while avoiding unnecessary interferences with international traffic and trade. Allows WHO to use media and nongovernmental organization data for biostatistics, making it less reliant on official information-sharing with member states.

Kampala Declaration (2007)

States that health is a fundamental human right that must be supported by a fair and sustainable health financing system. Affirms that out-of-pocket spending should be minimized and prepayments expanded to reduce impoverishment of households and move toward universal access to quality healthcare.

Beijing Declaration (2008)

Focus on traditional medicine. Recognized role of traditional medicine in improvement of public health and calls for member states to integrate conventional and traditional medicine into national health policies.

Global Code of Practice on the International Recruitment of Health Personnel [PDF] (2010)

Establishes principles for member states to follow addressing imbalances in health workers between developed and developing countries, the rights and responsibilities of health personnel, and ethical practices for their recruitment. Also promotes data exchange and information collection.

The Global Strategy for Women and Children’s Health (2010)

Launched during the UN Leaders’ Summit for the Millennium Development Goals (MDGs) in 2010, with approximately $40 billion pledged towards women’s and children’s health and the achievement of MDGs 4 and 5--to reduce child mortality and improve maternal health.

BRICS Health Ministers’ Meeting Beijing Declaration (2011)

Declaration emphasizes "the importance of technology transfer among the BRICS countries, as well as with other developing countries, to enhance their capacity to produce affordable medicines and commodities. The Declaration also emphasizes the critical role of generic medicines in expanding access to antiretroviral medicines for all."

General Agreement on Trade in Services (GATS) (1995)

Legal framework through which WTO members progressively liberalize trade in services. Covers four modes, all of which affect health: cross-border supply, consumption abroad, foreign commercial presence, and movement of persons.

Doha Declaration on Trade-Related Aspects of Intellectual Property Rights (TRIPS) and Public Health (2001)

Stipulates that TRIPS should not impede developing countries from protecting public health and accessing essential medicines. Allows developing countries to obtain compulsory licenses to produce and provide patented medicines in cases of national emergencies or other circumstances of extreme urgency.

Resolution on Health and Trade (WHA59.24) (2006)

Calls on World Health Organization to support member efforts to integrate trade and health policies, pass relevant legislation, and ensure that health ministries are involved in trade decisions. Calls for global cooperation on research and development efforts in areas that most affect developing countries.

Trade-Related Aspects of Intellectual Property Rights (TRIPS) Amendment on Compulsory Licensing (2005)

Allows generic drugs to be produced and exported to developing countries without domestic production capacity, even if doing so violates TRIPS’ compulsory licensing provisions.

Resolution on Public Health, Innovation, and Intellectual Property (PDF) (WHA.60.30) (2007)

Calls on World Health Organization to provide technical and policy support to developing countries in using TRIPS/Doha Declaration to gain access to medicines and promote new forms of funding and research and development.

Global Strategy and plan of action on public health, innovation and intellectual property (WHA 61.21) (2008)

Promotes a strategy and 108 corresponding actions that include: a) prioritizing research and development b) building innovative capacity c) transfer of technology d) improving delivery and access e) promoting sustainable financing mechanisms.

Cairo Declaration on Population and Development (1994)

One of the first documents to address the issue of reproductive rights, health, and maternal and child morbidity and mortality. 179 countries adopted the accompanying program of action.

Millennium Development Goals (MDGs) (2001)

Three relate directly to health. Other five address interconnectedness of poverty, education, sanitation, and health outcomes. Goal 4 seeks to reduce child mortality, including a two-thirds reduction of the under-five mortality rate by 2015. Goal 5 aims to improve maternal health, including a 75 percent reduction of maternal mortality ratio and universal access to reproductive health by 2015. Goal 6 seeks to combat HIV/AIDS, malaria, and other major diseases, specifically achieving by 2010 universal access to HIV/AIDS treatment for all those in need, and by 2015, halting and reversing the spread of HIV/AIDS, malaria, and other major diseases. Goal to halt and begin to reverse spread of HIV/AIDS reaffirmed in Joint United Nations Program on HIV/AIDS (UNAIDS) Political Declaration on HIV/AIDS (2006).

Monterrey Consensus (2002)

Recognizes need for developing countries to take responsibility for their own poverty reduction and for rich nations to support this endeavor with more open trade and increased financial aid. Reaffirmed in 2008 in the Review Conference Outcome Statement.

World Summit Outcome Document (2005)

Agreed on at follow-up summit meeting to the United Nations (UN) 2000 Millennium Summit, which led to the Millennium Declaration of the Millennium Development Goals (MDGs). Established Human Rights Council and Peacebuilding Commission.

The Paris Declaration (2005)

Five principles to more efficiently manage aid efforts: ownership, alignment, harmonization, managing for results, and mutual accountability.

The Least Developed Countries (LDC) Civil Society Forum Istanbul Declaration (2011)

Establishes a guideline for member states to improve public health in Least Developed Countries (LDCs). Calls for need to strengthen and ensure functional health systems to help reach MDGs, and calls for governments and donors to "give a new priority to water and sanitation for all by 2020."

Declaration of Commitment on HIV/AIDS (2001)

Declares AIDS pandemic a "global emergency." Sets ten priorities for action and nonbinding commitments to prevent, treat, and combat HIV/AIDS and ensure the Millennium Development Goal of halting and beginning to reverse the HIV pandemic is met by 2015. Recognizes need for multisectoral action by addressing global, regional, and country-level responses.

Abuja Declaration on HIV/AIDS, Tuberculosis, and Other Related Infectious Diseases (2001)

Declares state of emergency for AIDS pandemic and pledges to make resources available to fight it and other infectious diseases.

Political Declaration on AIDS (2006)

Provides a comprehensive review of the progress in achieving targets set out in the Declaration of Commitment on HIV/AIDS. Calls for an evidence-based and tailored approach to HIV/AIDS.

Global Code of Practice on the International Recruitment of Health Personnel (2010)

Establishes principles for member states to follow addressing imbalances in health workers between developed and developing countries, the rights and responsibilities of health personnel, and ethical practices for their recruitment. Also promotes data exchange and information collection.

Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases (NCD) (2008-2013)

Calls for urgent attention to address the health problems associated with noncommunicable diseases including cancer, which represent the world’s largest cause of death and the world’s largest threat to human health and development.

Global Status Report on Noncommunicable Diseases (NCD) (2010)

Offers a descriptive, analytical approach toward the global burden that is caused by noncommunicable diseases.

Noncommunicable Disease (NCD) Alliance Plan (2010)

The plan outlines key goals for the September 2011 United Nations Summit and will help promote a unified civil society movement for NCDs.

UNAIDS AIDS at 30, Nations at the Crossroads (2010)

Reports on achievements and disappointments with AIDS/HIV research since the disease was discovered in 1981. Calls for new approaches to combat AIDS epidemic.

Political Declaration on AIDS (2011)

Incorporates requirements for effective prevention of HIV/AIDS.

Foundations and NGOs



For more information, including membership; mandate; gaps and weaknesses; implementation, compliance and enforcement; and U.S. policy stance, download the full report. 

Pasteur Institute (1887)

Private foundation with global institution network, postgraduate education, research, and medical centers. Body for education, research, and action on public health. Goals include treatment and prevention of infectious diseases, encouraging research programs, and preserving institutional independence. Responsible for first isolating HIV virus in 1983.

International Committee of the Red Cross (ICRC) (1863)

Independent and neutral humanitarian organization mandated under international law to "take impartial action for prisoners, the wounded and sick, and civilians affected by conflict."

Rockefeller Foundation (1913)

Independent philanthropic organization that works to "promote the well-being of humanity." Makes modern health systems stronger, more affordable, and more accessible in poor and vulnerable communities worldwide. Established first U.S. schools of public health in early 1900s. Funded research that led to the discovery of a vaccine to prevent yellow fever.

International Federation of Red Cross and Red Crescent Societies (1919)

Federation of national societies. In addition to the mandate given to the International Committee of the Red Cross to respond in times of conflict, the International Federation works to promote "humanitarian principles and values, disaster response, disaster preparedness, and health and care in the community."

Save the Children Foundation (1919)

Independent organization providing relief and support for children in developing countries. Coordinates emergency efforts to help ensure global childhood health. Mandate includes a large focus on maternal health.

Catholic Medical Mission Board(1928)

Christian organization that seeks to support health systems in developing countries, specifically those affected by HIV/AIDS.

Wellcome Trust (1936)

Independent nongovernmental charity organization focused on biomedical research. Significant proportion of funding invested in technology transfer so that innovations are translated into new health products. Developed antimalarial drug artemisinin and works to identify genes associated with diseases.

Oxfam International (1942)

Nongovernmental organization that works to alleviate human poverty and injustice. Health initiatives focus on making visits to local clinics and hospitals, providing access to medicine, supporting affordable care in refugee villages and emergency situations, encouraging developing countries to invest in health services, and working to train and support home-based volunteers to enable them to care for those with HIV/AIDS.

Care (1945)

Humanitarian organization that campaigns against global poverty. Focuses on addressing three primary areas: health, children, and hunger. Also focuses on education, HIV/AIDS, and emergency relief and preparedness.

World Vision (1950)

Christian organization focused on alleviating poverty, responding to disasters, and ensuring well-being of children.

MAP International (1954)

Christian organization that acts to provide essential medicine, promote community health development, and prevent and mitigate disease, disaster and other threats to the health of the world’s poorest populations.

Project Hope (1958)

Humanitarian organization working toward establishing "long-term sustainable health care" around the world. Targets infectious diseases, most notably tuberculosis and HIV/AIDS. Provides emergency disaster assistance.

Aga Khan Foundation (1967)

Nongovernmental organization that works to improve lives of the poor with an emphasis on remote locations. Its health agenda aims to achieve sustainable improvements in health of members of vulnerable groups, especially women of childbearing age and children under five.

Population Services International (PSI) (1970)

International nongovernmental organization that targets malaria, tuberculosis, child survival, clean water, HIV prevention, and reproductive health.

Medecins Sans Frontieres (1971)

Humanitarian organization that supports doctors and other healthcare personnel in providing emergency treatment for people in crisis. Advocates for the poor and sick in developing countries. Responsible for Access to Essential Medicine Campaign. Cofounder of Drugs for Neglected Diseases Initiative (DNDI), which pushes for increased research for medicines and vaccines for diseases that predominately affect people in poor countries.

Management Sciences for Health (1971)

Internationally active nonprofit global health organization. Expertise in health services leadership, human resources, pharmaceutical management, and care financing. Collaborates with international partners and policymakers to distribute medicines and improve health training and leadership.

Global Health Council formerly National Council of International Health (1972)

Nonprofit networking organization that identifies world health problems and reports on them to the U.S. public, legislators, international and domestic government agencies, academic institutions, and the global health community. Works to address health concerns worldwide in five core issues: women’s health, child health, HIV/AIDS, infectious diseases, and emerging threats.

Jpiego (1974)

Brings quality health care to rural woman and families. Emphasis on maternal and reproductive health. Communicable, noncommunicable, and country specific health problems are included.

Marie Stopes International (1976)

Nonprofit organization promoting sexual health in remote and less-developed communities. Provides counseling and medical services aimed at preventing unintended pregnancies and unwanted births. Clinics and outreach teams seek to prevent unwanted pregnancies and unsafe abortions in cities, rural communities, and refugee camps in more than forty countries.

Medical Teams International(1979)

Christian health organization that aims to build a faith-based global health movement. Projects focus on community and child health, HIV/AIDS, emergency disaster relief, and medical training.

The Carter Center (1982)

Independent foundation that seeks to advance human well-being. Works to provide health programs and treatment for afflictions that are preventable. Also works to strengthen training of countries’ public health professionals and reduce stigma and discrimination against people with mental illness. Formed the International Task Force for Disease Eradication in 1988. Evaluates disease control and examines the potential for eradicating certain diseases. Specific initiatives focus on river blindness, trachoma, malaria, lymphatic filariasis, and schistosomiasis.

Family Care International (1986)

Non-profit, maternal health care organization dedicated to making pregnancy and childbirth safer throughout the world. Active programs in 18 countries. Attention focus on maternal mortality.

International HIV/AIDS Alliance (1993)

Works with local organizations to reduce the impact of HIV/AIDS and improve access to medicines. Alliance supports local programs by providing medicine, technical expertise, fundraising, and policy advocacy.

United Nations Foundation (1998)

Advocates for the United Nations (UN) and helps take UN ideas to scale through advocacy, partnerships, constituency building, and fund-raising. Works with the World Health Organization, United Nations Children’s Fund, and other UN organizations to develop and expand major initiatives to improve child health.

Bill and Melinda Gates Foundation (1999)

Independent foundation that works to alleviate poverty and improve livelihoods. Global Health Program is one of three major initiatives. Focuses on preventing disease through increased access to vaccinations and on developing and ensuring access to new health technologies.

William J. Clinton Foundation (2001)

Independent foundation. Operates seven initiatives. Only the Clinton HIV/AIDS initiative focuses on global health issues. Other six deal with economic and environmental sustainability and development. The Clinton Global Initiative, which brings together leaders from government, nongovernmental organizations, and the private sector "to effectively confront the world’s greatest global challenges," also often deals with global health issues. The Alliance for a Healthier Generation focuses on reducing obesity in the United States.

Pangea Global AIDS Foundation (2001)

Partnership that uses technical cooperation, research, and policy advocacy to promote nationally-led, sustainable, and comprehensive HIV treatment and prevention strategies.

Global Health Initiatives



For more information, including membership; mandate; gaps and weaknesses; implementation, compliance and enforcement; and U.S. policy stance, download the full report. 

World Health Organization: Global Influenza Surveillance Network (1952)

Allows World Health Organization (WHO) to make biannual recommendations on the effectiveness of influenza vaccination campaigns.

World Health Organization: Smallpox Eradication (1958–1980)

World Health Organization (WHO) program that led to eradication of smallpox. Coordination approach seen as model for other disease-specific initiatives.

Carter Center Guinea Worm Eradication Program (1986)

In 1986, guinea worm infection prevalent in twenty African countries, with 3.5 million infected. As of 2009, only 3,190 known cases. Targets guinea worm and strives towards eradication. If successful, would be the first parasite eradication.

Merck MECTIZAN Donation Program (MDP) (1987)

Established by Merck. Donates treatments for river blindness to all who needed it for as long as needed. Largest ongoing disease-specific drug donation program and public-private partnership in pharmaceutical industry. Expanded in 1998 to include prevention of lymphatic filariasis (elephantiasis).

Global Polio Eradication Initiative (GPEI) (1988)

International initiative to immunize more than two billion children against polio. Reduced infection rate from one thousand new cases per day in 1988 to fewer than two thousand total cases worldwide in 2006.

World Health Organization (WHO) Global Task Force on Cholera Control (1992)

Launched by WHO Resolution with goals to decrease fatalities associated with cholera and to reduce adverse socioeconomic impact of outbreaks.

International AIDS Vaccine Initiative (IAVI) (1996)

Public-private partnership that invests in research and clinical assessment of vaccines against strains of HIV that are prevalent in the developing world. Has developed six vaccine candidates. Conducts education programs and upgrades clinics and laboratories in developing countries. Recently established the AIDS Vaccine Development Laboratory in New York to examine new HIV vaccine candidates. Involves private sector in research and advocates for policy ensuring that any successful vaccines will be produced swiftly.

Roll Back Malaria Partnership (RBM) (1998)

International partnership that seeks to realize the health-related Millennium Development Goal of reducing malaria mortality by half by 2015. Leads advocacy campaigns to mobilize resources to combat malaria and coordinates action between partners.

Medicines for Malaria Venture (MMV) (1999)

Public-private partnership dedicated to fighting malaria "by discovering, developing, and facilitating delivery of new, effective, and affordable antimalarial drugs." Recently launched its first product Coartem® Dispersible, a pediatric dispersible tablet, in collaboration with Novartis.

PATH Malaria Vaccine Initiative (MVI) (1999)

Goals include creation and widespread use of a first-generation malaria vaccine (30 percent efficacy) by 2015 and a second-generation malaria vaccine (80+ percent efficacy) by 2025. Involved in development and trial of GlaxoSmithKline’s phase 3 vaccine, RTS,S, in seven African countries.

Stop TB Partnership (2000)

Network of international organizations, nongovernmental organizations, public and private donors, and countries that work toward eliminating and eradicating tuberculosis (TB).

Clinton Health Access Initiative (CHAI) (2002)

Nongovernmental organization that works to lower prices for AIDS treatment in developing countries by brokering deals with drug companies. Applying model to malaria medications. Works to improve national health care systems by increasing human resource capacity to deliver care and treatment.

Global HIV Vaccine Enterprise (2003)

Cooperative body of organizations, funders, and researchers aimed at developing "a shared scientific strategic plan, increased resources, and greater collaboration" in the cause of finding an HIV vaccine.

The "Three Ones" Principle (2004)

Developed by the Joint United Nations Program for HIV/AIDS, United Kingdom, and United States, the principle commits to harmonizing and aligning global HIV/AIDS efforts at the national level: one action framework for coordinating partners; one national coordinating authority with a broad-based multisectoral mandate; and one country-level system for monitoring and evaluation.

International Partnership on Avian and Pandemic Influenza [PDF] (IPAPI) (2005)

Launched by former president George W. Bush as a partnership among governments, international institutions, nongovernmental organizations, and private companies. Designed to supplement current efforts to combat avian and pandemic influenza by coordinating national activities, promoting awareness and preparedness, and improving response capabilities.

(RED) Campaign (2006)

Red partners make donations to AIDS victims in Africa every time someone purchases one of their products. Donations passed to pre-selected aid programs in Africa through the Global Fund.

Bloomberg Initiative to Reduce Tobacco Use (2003)

Grants program that supports tobacco control initiatives chosen from the proposals of national governments and nongovernmental organizations.

Global Business Coalition on HIV/AIDS, Tuberculosis, and Malaria (GBC) (2001)

Private-sector coalition that combats global pandemics threatening workforce productivity. Promotes information sharing and best practices among members, organizes collective private-sector action, and collaborates with public and nonprofit sectors. Private-sector delegation to the Global Fund to Fight AIDS, Tuberculosis, and Malaria.

The Global Fund to Fight AIDS, Tuberculosis, and Malaria(GFATM) (2002)

International partnership that provides innovative financing mechanism to mobilize and allocate funds for governments to combat AIDS, tuberculosis (TB), and malaria. "Provides one-quarter of all international financing for AIDS, two-thirds of TB, and three-quarters of malaria." Supported antiretroviral treatment for 2.5 million people, TB drugs to 6 million people, and 104 million insecticide-treated nets to prevent malaria. As of December 2009, prevented an estimated 4.9 million deaths from disease since inception.

Drugs for Neglected Diseases Initiative (DNDi) (2003)

Nonprofit initiative formed to research and develop drugs for neglected diseases. Created in response to drug companies’ efforts to avoid research on diseases in the developing world.

Global Network for Neglected Tropical Diseases (2006)

Advocacy initiative of the Sabin Vaccine Institute. First global effort to combat neglected tropical diseases (NTDs). Works to control and eliminate the most deadly and debilitating NTDs by 2020. Mobilizes resources to fight NTDs in Latin America, advocates to raise awareness of NTDs, and works to achieve the Millennium Development Goals. Working to eliminate trachoma—the leading cause of preventable blindness in the developing world—in Ghana by 2011.

World Health Organization (WHO) Preventive Chemotherapy and Transmission Control (2006)

Supports preventive chemotherapy treatments for cysticercosis, blinding trachoma, dracunculiasis, foodborne trematode infections, lymphatic filariasis, onchocerciasis, schistosomiasis, and soil-transmitted helminthiasis.

World Health Organization (WHO) Global Health Workforce Alliance (GHWA) (2007)

Created as a "common platform to address the crisis" of unbalanced health worker migrations that causes shortages in developing countries. Developed in response to calls by the World Health Assembly, Group of Eight, and leaders of African nations. Seeks to establish data, provide guidance, and develop policies to assuage the problem.

Health 8 (H8) (2007)

Clarifies core responsibilities of each agency and brings coherence and alignment to their activities to eliminate duplication of efforts and competition for funding. Attempts to bring a global focus to achieving the health-related Millennium Development Goals.

Foreign Policy and Global Health Initiative (FPGH) (2006)

Aimed at building awareness of the intersection between foreign policy and issues of global health within the United Nations (UN), specifically the World Health Organization.

15 by 2015 (2008)

Campaign that seeks boosted funding for health systems and pushes donor countries and foundations to pledge 15 percent of their funding toward "sustainable comprehensive primary health care that is accessible and affordable in all regions of the world."

Mexico City Policy on Reproductive Health (1984)

Required nongovernmental organizations (NGOs) receiving federal funding to refrain from performing or promoting abortion services in other countries, except in cases of "rape, incest, or life-threatening conditions."

White Ribbon Alliance for Safe Motherhood (WRA) (1999)

Promotes public awareness on making pregnancy and childbirth safe for all women and newborns through education, seminars, and working groups. Organizes policy efforts and supports developing countries to create national WRA.

International Partnership for Microbicides (IPM) (2002)

Nonprofit product development partnership that works to accelerate the development and availability of a safe and effective microbicide for women in developing countries.



The 2010 H1N1 flu pandemic—widely known as swine flu—was first detected in Mexico in March 2009. Suffering from enormous international pressure, Mexico mobilized its military and put in place a presidential order calling for a five-day shutdown of all businesses, schools, and public offices. By July 2010, the country registered [PDF] 72,548 confirmed cases and 1,316 deaths from the illness. The economic costs were also extensive, resulting in a loss of 0.3 percent of Mexico's gross domestic product, or $2.3 billion. More recently, a spring 2011 outbreak of the virus occurred in the Mexican state of Chihuahua with approximately thirty-five respiratory infections and six deaths confirmed to be the result of the H1N1 flu.

Swine flu eventually spread to 214 countries and territories. Classified as a severe respiratory disease caused by a strain of influenza type A virus, the illness resulted in over 18,398 deaths worldwide. At the height of the crisis, the World Health Organization declared the situation a "public health emergency of international concern," and raised its influenza pandemic alert to phase six—the highest on the scale. The WHO announced the end of the H1N1 pandemic on August 10, 2010.


A major risk factor for the onset of some noncommunicable diseases—such as Type 2 diabetes, cardiovascular disease, and certain types of cancers—is obesity. In no region is the condition more urgent than in the South Pacific, which is host to eight of the top ten overweight countries. In the small island state of Nauru, close to 80 percent of the population is classified as obese. Growing levels of obesity in the developing world are taxing already stretched medical systems and resulting in lost productivity and injuries among workforces.

Obesity is driven largely by unhealthy diets and physical inactivity. According to the World Health Organization, in 2008 over 200 million men and nearly 300 million women were obese. Additionally, in 2010 nearly 43 million children under the age of five were overweight.


Countries of the former Soviet Union rank among the most prevalent tobacco users. Over one-third of all Russians—and over half of that country's adult males—smoke. An estimated 330,000-400,000 Russians die [PDF] each year from tobacco use, helping explain why life expectancy in Russia is some ten years lower than in the average Western European country.

Tobacco is the number one cause of noncommunicable diseases worldwide and is a risk factor for six out of eight of the world's leading causes [PDF] of death. Deaths from tobacco are estimated at 5.4 million people worldwide per year.

Brain Drain-Zimbabwe

Low-income countries often suffer from a lack of trained health care professionals. This brain drain is especially damaging in Zimbabwe, where 25 percent of trained nurses and midwives now work in developed countries. Between 2000 and 2004, Zimbabwe housed approximately 16 physicians [PDF] per 100,000 people.

The World Health Organization estimates that, of the fifty-seven nations with a critical shortage of personnel, thirty-six [PDF] are in sub-Saharan Africa. Many health care professionals leave the developing countries where they trained for opportunities in developed countries, which exacerbates the problem.

Biosecurity-United States

In the weeks following the terrorist attacks of September 11, 2001, letters containing anthrax spores were mailed to U.S. Senate offices and media outlets. More than twenty people developed anthrax infections and five died. Hundreds of millions of dollars were spent decontaminating affected buildings, and alarm ensued over the availability of antibiotics. Nearly ten years later, controversy continues to surround the handling of the matter, highlighting the need for greater attention to biosecurity issues within the United States and abroad.

The use of a biological agent as a weapon could conceivably kill millions, halt global commerce, and have lingering effects for decades. Even small biological attacks can cause widespread panic and disruption. Since the end of World War II, there have been three documented biological attacks worldwide.

Smallpox - Somalia

For many centuries, smallpox was a major cause of death and disability throughout the world, with a fatality rate of up to 30 percent. Initial vaccination programs were instituted in Europe, the United States, British India, and the Philippines in the nineteenth century, eventually reducing incidence of the disease in many countries.

After a ten-year, aggressive vaccination effort, the World Health Organization declared the disease to be successfully eradicated in 1979. The last naturally occurring case of smallpox was reported in Somalia in 1977. Smallpox remains the only human disease to ever be fully eradicated, and the smallpox virus now exists only in laboratories.

Guinea Worm - India

India began a Guinea Worm eradication program in 1983, when the country suffered from almost 45,000 cases of infection. In 1996, India had successfully stopped its transmission, and the World Health Organization certified eradication in 2000.

Guinea worm is a parasite that was once prevalent in the rural communities of developing countries. Contracted by drinking from contaminated water sources, the disease incapacitates its sufferers for months at a time. In 1986, the Carter Center began providing assistance to other countries where the parasite pervaded. With parallel efforts on the national, regional, and global levels, the Carter Center has made steady progress toward eliminating the disease, which now exists only in Sudan, Ghana, Mali, and Ethiopia.

Merck Donation Program - United States

Since 1988, the pharmaceutical company Merck & Co., Inc. has donated mectizan, a treatment for river blindness, to all those who suffer from the disease for as long as they require it. River blindness has been particularly endemic in West Africa and parts of Latin America. This effort represents the largest donation program and public-private partnership in the pharmaceutical industry. Partnering with GlaxoSmithKline in 1998, Merck expanded the program to include treatment for elephantiasis. The program is estimated to reach 100 million annual treatments for these neglected tropical diseases by 2010.



Thomas J. Bollyky, Senior Fellow for Global Health, Economics, and Development

Laurie Garrett, Senior Fellow for Public Health

Yanzhong Huang, Senior Fellow for Global Health


2010 Millennium Development Goals Summit outcome document

New York Times: Donald McNeil, Jr., "As the Need Grows, the Money for AIDS Runs Far Short"

Huffington Post Op-ed: Peter Navario and Scott Rosenstein, "H1N1’s Teachable Moment"

Newsweek: Laurie Garrett, "Swine Flu: How the H1N1 Virus Got its Start"

Washington Post Op-ed: Laurie Garrett, "The Challenge of Global Health"

Financial Times: Andrew Jack, "Global Health Programmes Adjust to Hard Times"

CFR Working Paper: The Challenges of Global Health Governance

CFR Report: HIV and National Security:Where are the Links?

Expert Brief: G8, G20: Questions for Global Health

Foreign Affairs: The Next Pandemic?

Foreign Affairs: How to Promote Global Health

PLoS Medicine: Health Diplomacy and the Enduring Relevance of Foreign Policy Interests

Institute for Health Metrics and Evaluation: Financing Global Health 2009

Kaiser Family Foundation: U.S. Global Health Policy [PDF]

WHO: Task Shifting: Global Recommendations and Guidelines – Treat, Train, Retain [PDF]

WHO: World Health Reports


David Fidler, SARS, Governance and the Globalization of Disease (Palgrave Macmillan, 2004)

Laurie Garrett, Betrayal of Trust: The Collapse of Global Public Health (Hyperion, 2000)

Laurie Garrett, The Coming Plague, (Penguin, 1995)

Ichiro Kawachi and Sarah Wamala, Globalization and Health (Oxford, 2007)

Richard Skolnik, Essentials of Global Health (Jones and Bartlett, 2008)

Paul Farmer, Pathologies of Power: Health, Human Rights, and the New War on the Poor (University of California Press , 2005)

William Easterly, The White Man’s Burden: Why the West’s Efforts to Aid the Rest Have Done So Much Ill and So Little Good (Penguin, 2006)

Jeffery Sachs, The End of Poverty (Penguin, 2006)


Center for Strategic and International Studies: Smart Global Health

Center for Global Development

International Policy Network