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Garrett on Global Health

Dear Friends and Colleagues;

It would be comforting to conclude, as the World Health Assembly did in 2013, that infectious disease threats have drastically diminished, allowing governments and multilateral institutions to shift their resources to noncommunicable diseases. But the facts do not justify such a rash conclusion. The microbes refuse to cooperate.

The UN endorsement of seventeen Sustainable Development Goals (SDGs), one of which guarantees health for all, signals worldwide commitment to ambitious aspirations, including treatment of the entire spectrum of diseases, both infectious and noncommunicable. On an individual basis, this care is meant to be affordable, thanks to universal health coverage (UHC). For governments, the goal is to identify resources to pay for UHC, train millions of health-care workers, and build facilities for both routine primary care and sophisticated tertiary treatment; together, this will pose an enormous challenge.

Meeting all seventeen SDGs will cost $3.9 trillion, according to the United Nations, which is a sum nearly triple the amount of money spent by nations and donors combined on comparable health, development, climate change, and antipoverty efforts. It is probably also a gross underestimate. The Rockefeller Foundation has initiated a "Zero Gap" campaign that aims to raise funds for the climate-related SDG targets through innovative financing that taxes or rewards carbon-generating or carbon-reducing companies and cities. But such innovative financing (e.g., UNITAID) in the health sector has never generated funds equivalent to more than a minute portion of annual global health assistance from the U.S. government. (For example, between 2007 and 2012, UNITAID generated and disbursed $1.9 billion for global health programs. Over the same period, the U.S. government spent $38.3 billion on just one global health program, PEPFAR, and billions more for everything from bankrolling the World Health Organization to polio vaccination in Kabul.) The governments of Norway, Canada, and the United States have pushed for the creation of a Global Financing Facility (GFF) specifically for maternal and child health, to be nested inside the World Bank. The Obama administration recently kicked off the GFF with a donation of $50 million (not billion, much less trillion).

It has never been safe to assume that one health problem set (infectious diseases) would fade into obscurity, allowing resources to shift to another problem set (noncommunicable ailments and chronic disease care); the only rational approach involves lifting all boats. Make no mistake about this: the price tag will be in the trillions of dollars. The most optimistic cost, offered by the "Grand Convergence" panel headed by Harvard economist Larry Summers, reckons 130 million lives can be saved between now and 2030 with this calculus:

"For the years 2015, 2020, 2025, and 2030, the incremental costs of convergence in LIC [low-income countries] would be (U.S. billion) $24.3, $21.8, $24.7, and $27, respectively; in LMIC [lower-middle-income countries], the incremental costs would be (U.S. billion) $34.75, $38.9, $48.7, and $56.3, respectively."

That works out to a total of $252 billion. And that’s the optimistic reckoning, which focuses on health-care provision, lowballs drugs costs on the assumption everything will be generically manufactured, and assumes the basics of infectious disease prevention will be realized by other SDG targets for the elimination of extreme poverty. There are many reasons to be skeptical about that last assumption. Chris Murray, director of the Institute for Health Metrics and Evaluation, reckons about 63 percent of the $200 billion in funds used in the fight for the Millennium Development Goals (MDGs) came from external donors, such as the U.S. government and the Bill & Melinda Gates Foundation. Since 1990, in particular due to the drive to reach child health targets under the MDGs, deaths among children under five have fallen by 50 percent, and neonatal mortality has decreased 42 percent.

Can the provision of health for all humans on Earth be financed by donors? Of course not. The designers of the SDGs argue that most of the seventeen goals focus on achieving greater prosperity, lifting humanity out of extreme poverty, and creating vibrant national economies that can provide tax revenues and other sources of domestic funds to finance health and other SDGs in even the poorest nations. The Economist has labelled the premise a "bad and hideous" pursuit of "stupid development goals" that are too ambitious and therefore "unsustainable goals." Charles Kenny of the Center for Global Development (CGD) has been only slightly less negative, simply labeling the SDGs "a mess" with fellow staff at CGD calling them "kinky development goals."


The most basic ingredient of "health" is clean water, and the scale of that need is overwhelming and growing—thanks to excessive aquifer extraction, pollution, and climate change. UNICEF estimates only 42 percent of health-care facilities in thirty-eight African countries have access to safe water.

According to UNICEF, "Child survival remains an urgent concern. It is unacceptable that about 16,000 children still die every single day—equivalent to 11 deaths occurring every minute. Without any further acceleration to the current pace of reduction in under-five mortality, a projected 69 million children—more than the current population of Thailand—will die before they reach their fifth birthday between now and 2030, the SDG target year, with 3.6 million of these lives lost in the year 2030 alone." Nearly 10 percent (1,400) of that daily burden of child death is attributable to diarrheal diseases, mostly thanks to filthy water use or consumption.

Researchers from the Center for Global Development, the Bill & Melinda Gates Foundation, and Johns Hopkins University recently suggested that the key to tackling the SDG health goals on behalf of children and newborns is setting obvious markers to measure and monitoring success over the next fifteen years.

I can think of no more obvious sign of improvement than guaranteeing that nobody in the world is exposed to microbes or toxins in a health-care setting.

And the second clear measure? No child should eat uncooked contaminated food or drink toxically polluted or microbially infested fluids derived from contaminated water sources used for drinking, food preparation, or irrigation. Nobody should drink from and defecate in the same water system. Every child in the world should have access to clean water and soap with which to wash his or her hands, and be taught the basics of toilet and dining hygiene.

The SDGs do call for clean water, with the health SDG #3 insisting on elimination of epidemics of "water-borne diseases" and telling countries they should "substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination." And SDG #6 reads, "Ensure availability and sustainable management of water and sanitation for all."

On November 2, I published in Foreign Policy an analysis of the rapidly expanding cholera epidemic, now stretching from Mozambique up through East Africa to the war-torn Middle East and its refugee populations. I noted that the region’s last great cholera epidemic, which sickened two hundred thousand people from 1997 to 1998, was driven by El Niño climate conditions, and spread largely by the travel and trade activities of people who carried the Vibrio cholerae in their bodies, and passed the bacteria into local water systems, which were used for drinking and irrigation. Nearly twenty years later, those water systems remain unsafe and have worsened in the Middle East, due to warfare and the diminished flushing of the Tigris and Euphrates Rivers resulting from upstream dams in Turkey and in territory controlled by the self-declared Islamic State in Iraq.

In the ten days since releasing the Foreign Policy article, the cholera situation has worsened. Two additional states of Mozambique have reported outbreaks, as well as two more states of Tanzania, and the U.S. Centers for Disease Control issued an East African travel advisory warning for Americans. Kuwait, Bahrain, war-rife Syria, and Oman have cases, but Iraq’s Ministry of Health claims the scale of the region’s outbreak has been exaggerated. Since mid-September, at least 2,200 Iraqis have been sickened with cholera—20 percent of them children. With the Shi’ite observance of Arbaeen approaching in December, millions of pilgrims are expected to visit sacred sites in Iraq.

Opening the dams that block much of the flow of the Fertile Crescent’s great rivers would help cleanse the systems of Vibrio, flushing the rivers and the bacteria into the Persian Gulf. But Turkey and the Islamic State are unlikely to relinquish their controls on regional water, especially amid a record El Niño–driven drought.

The UN Refugee Agency (UNHCR) maintains three million Syrians are living as refugees in the Middle East; another 6.5 million are internally displaced inside Syria; 1.8 million Iraqis have fled the Islamic State and live as refugees in Kurdish-controlled areas or elsewhere in the region; 140,000 refugees have fled Libya; and at least 330,000 Yemenis have fled war in their country. Combined, at least 12 million internally displaced people and refugees are living in varying degrees of insecurity and squalor.

In its recent report on the SDGs, Save the Children demonstrates that the lion’s share of child and infant mortality is in places such as Syria, Yemen, Iraq and other fragile states and war-torn parts of the world. It is becoming increasingly true that the basic elements of child health—vaccines, good food, safe drinking water, and hygiene—are denied to children because perpetrators of violence target neutral players, such as Médecins Sans Frontières (also known as Doctors Without Borders), the Red Cross/Red Crescent, UNICEF, and hundreds of other humanitarian and medical relief organizations. Eliminating such vile violence could go a long way toward meeting the SDGs.

On November 7, and then again three days later, war-ravaged Yemen was slammed by two record-breaking cyclones, displacing thousands more Yemenis from their homes. The El Niño system this year in the Pacific is the largest warming bulge in the ocean ever recorded. It has so radically altered global weather that a companion hot water bulge has emerged in the Arabian Sea—the hottest ever recorded. This Arabian Sea surface-temperature chart, shows the dramatic ocean warming trend. Warmer seas fuel hurricanes and cyclones, and the two that recently slammed Yemen were the first to hit that country since 1960.


Rising Surface Temperature of the Arabian Sea


Source: Eric Blake, National Hurricane Center, National Oceanic and Atmospheric Administration


The United Nations has been sharply criticized for creating a SDGs laundry list of seventeen wishes and 169 targets that seems to address everything in the world, all at once. But as the cholera outbreak now threatening East Africa and the Middle East demonstrates, nothing in 2015 global health is simple. El Niño, climate change–induced ocean warming, refugee crises, war, dammed river systems, lack of safe drinking water, fragile states, and terrorism all combine to put people at risk for the ancient disease, which mortally claims child victims.


This week, the World Health Organization declared Sierra Leone Ebola-free, leaving only Guinea with cases of the disease. It seems reasonable to assume that the region will be fully free of Ebola before Christmas, meaning the epidemic will have lasted two full years.

But the case of Scottish nurse Pauline Cafferkey, who was just released on November 12 from her hospitalization in London, offers a strong note of caution. Cafferkey volunteered to help with the battle in Sierra Leone, and came down with Ebola ten months ago. She was treated aggressively in London with a battery of drugs, plasma, and palliative care not available in Africa, and she survived and was declared cured in April. But in October, Cafferkey developed life-threatening meningitis, caused by previously undetected Ebola viruses that had hidden in her central nervous system (CNS). The Cafferkey case brings into sharp relief two issues of concern. First, Ebola finds reservoirs to hide in, including the CNS, semen, breast milk, the eyes. Survivors may carry virus that can be sexually transmitted, vertically spread via mothers’ milk, or passed to unprotected health-care workers during routine examinations. For the West African countries, this means caution is advised: outbreaks might return. And for the survivors, this creates terrible angst that adds to their grief, survivors’ guilt, stigmatization, and financial insecurities.

The second issue the Cafferkey case raises is about all the treatments thrown at American and European Ebola victims: Did the non-curative medications mask hidden viruses? Many different experimental treatments were used on Doctors Without Borders volunteer Dr. Craig Spencer and others, with mixed results. There was a completely understandable desire to urgently try everything, even untested therapies, and to demand their access for Liberians, Guineans, and Sierra Leoneans as a matter of social equity and justice. But I have spoken with many SARS 2003 survivors who wished they hadn’t undergone high-dose steroid treatment to stop their immune systems’ attacks on their lungs, because years later they continue to suffer side effects. HIV drugs effectively prevent AIDS, but do not eliminate the virus from patients’ bodies: a break in taking the drugs will send HIV surging through their bloodstreams.

Many lessons abound from the Ebola experience, and several reports assessing the global response to the epidemic are now surfacing. My CFR colleague Yanzhong Huang recently hosted Australian analyst Adam Kamradt-Scott, coauthor of the new report, "Saving Lives: The Civil-Military Response to the 2014 Ebola Outbreak in West Africa." Kamradt-Scott offers a detailed account of the mobilization and activities of U.S., UK, and regional military forces deployed to the epidemic in 2014 and 2015, and assesses their contributions to the disease control effort. He concludes that military deployments were beneficial, and ought to be considered in future epidemic crises.

A good deal of attention has focused on the WHO’s response to the Ebola outbreak, and, in particular, on Director General Margaret Chan’s formal declaration of a public health emergency of international concern on August 8, 2014. The outbreak began in Guinea in December 2013, yet the emergency declaration waited nine months. Why?

In a recent interview with Science, Chan offers this clue: "I'm the equivalent of the CEO of a company. So member states are like the board members. I said to them: ‘If you want WHO to be strong and fit for purpose, keep your promises. Put your money where your mouth is.’ But many governments support a zero nominal-growth policy [for their contributions]. Maintaining that policy for 10 years has reduced the purchasing power of my budget by about one-third."

In other words, Chan blames the U.S. government policy, albeit indirectly, for Ebola—the country whose Congress years ago passed a "zero nominal-growth policy" regarding donations to the WHO, as well as other UN institutions, based on concern for demonstrated improvements in operations and anticorruption practices. It is true that the Obama administration has not increased base assessment payments to the WHO. But the U.S. government is responsible for nearly half of the WHO’s extra-budgetary support equaling 80 percent of the WHO’s financing. Combined with funds from the Bill & Melinda Gates Foundation, the United States is keeping the WHO on life support, providing about two-thirds of its extra-budgetary money. It is therefore curious that Chan would choose to level criticism at the United States.

On November 23, the Independent Panel on the Global Response to Ebola will publish its final report in the Lancet and release its findings at the Royal Society in London. I served on the panel, along with CFR Adjunct Senior Fellow David P. Fidler. When the Lancet’s embargo is lifted on November 23, I will be at liberty to discuss the panel’s findings and ten recommendations.

Those of you who are members of the Council on Foreign Relations may have partaken in several not-for-attribution meetings convened over the past five months about the global response. I thank all participants for their sharp insights.

The National Academy of Medicine (formerly known as the Institute of Medicine) will release its assessment of the performance of the WHO and other international actors in December. Also due to be released next month are the conclusions of the so-called Kikwete Panel, organized by UN Secretary-General Ban Ki-moon. All of these assessments will be available to the WHO’s Executive Board when it convenes for its annual meeting in Geneva in January.

I will be in Ottawa this weekend, addressing the annual meeting of the Trudeau Foundation, with a focus on global governance of health. With the recent election of Justin Trudeau as prime minister of Canada, the Trudeau Foundation gathering promises to be fascinating.

As always, I will endeavor to keep you informed on these and other pressing issues in global health and U.S. foreign policy.

Laurie Garrett

Laurie Garrett
Senior Fellow for Global Health
Council on Foreign Relations