DR. Keiji Fukuda
Antibiotics have been miracle drugs for several decades, saving millions of lives from infections and providing the safety net from infections needed for complex surgeries, cancer chemotherapy and conditions such as diabetes.
The use of antiparasitic and antiviral drugs to prevent and treat malaria and HIV have been life-saving and life-changing for millions. Moreover, antibiotics have been critical tools for farmers to protect livestock, poultry, and fish from infectious diseases, and to help meet a growing global demand for protein-rich food. But the continual capacity of these medicines to work: in keeping people healthy, and in supporting sustainable food, is being lost. The widespread use, overuse, and misuse of these medicines in both health, and agriculture is driving up levels of antimicrobial resistance.
Antimicrobial resistance, or AMR, is when infection causing microbes become increasingly resistant to the antimicrobial medicines used in treatment. The implications of this phenomenon should not be underestimated. AMR is occurring in all parts of the world, both through local use of antimicrobial medicines, as well as through travel or trade, of resistant microbes. It is happening now, and is affecting many common infections. Every year, drug-resistant infections kill an estimated 700,000 people worldwide—most of these in developing countries. Recent estimates suggest that by 2050, the death toll from AMR may rise to 10 million—more than the number of people who currently die from cancer.
By threatening the health and lives of people, especially vulnerable populations such as newborns, children, and women; by creating escalating costs through the need for prolonged or more complex health care, the loss of productive lives, and by undermining critical social needs such as sustainable food and agriculture, AMR is more rightly seen as a broad social and development challenge, and not a health challenge alone. Unless major steps are taken to change the way we use these medicines in humans and animals, AMR is projected to cause a loss of $100 trillion from global GDP over the next 35 years. Developing countries will disproportionately suffer, with the poorest populations suffering the most.
The problem is compounded by a prolonged lack of sufficient research to develop new antibiotics. No new class of antibiotics has been discovered in more than three decades, to replenish the current, eroding armament.
On 21 September, leaders from around the world will gather at a dedicated high level meeting at the United Nations General Assembly in New York to commit to tackling AMR. The purpose of such a meeting reflects growing recognition beyond the health and agricultural sectors that AMR poses a major challenge to achieving the Sustainable Development Goals (SDGs)—the roadmap to end poverty and fight inequality by 2030 adopted at the UN General Assembly last September. Several SDGs depend upon the sustained availability of and access to affordable and effective antimicrobials. Furthermore, it reflects recognition that
without the high-level political commitment needed to enable and foster rapid, comprehensive and multisectoral action, we will continue the slide towards, what has been termed, a “post-antibiotic era”.
Some of the key elements needed to address AMR are in place. A Global Action Plan was adopted by governments at the World Health Assembly in May 2015, and supported by the governing bodies of the Food and Agriculture Organization of the United Nations (FAO) and the World Organization for Animal Health (OIE). The plan provides a technical blueprint for countries to adapt, to meet their specific needs. Other technically solid guidelines are also available. Broader engagement is finally being recognized as necessary. On 5 September 2016, the G20 Leaders’ Summit in Hangzhou, China, acknowledged the seriousness of the threat posed by AMR to global economic growth and stability. They requested WHO, FAO, OIE, and the OECD to work together to fight antimicrobial resistance, including the economic aspects, and to report back on options at the July 2017 G20 Summit in Hamburg, Germany. Perhaps most fundamentally, the private sector, particularly those in the food sector are paying attention to consumers and are taking their own actions by paying much greater attention to whether the food they serve contains antibiotics.
In this context, political commitments by heads of state and governments can further catalyze and intensify the actions needed. This is only the fourth time a health issue has been taken up (the others were HIV, noncommunicable diseases, and Ebola) by the UN General Assembly. The expected outcome of the high-level meeting is a political declaration and not a technical roadmap. But even the UNGA high-level meeting is not the complete answer. Real change will depend on what people do, and what governments do through effective public policies, legislation, multisectoral collaboration, and new drug development to support them. This global health crisis can be reversed through a thorough and collaborative effort from all stakeholders.
Innovative Financing: Opportunities and Challenges for the Future of Global Health.
The goals of reducing poverty, improving maternal and child health outcomes and decreasing the incidence of infectious diseases are laudable goals. The costs of these efforts are monumental. To date most developed countries have failed to meet the 0.7 % of gross national income committed to development at the 2002 International Conference on Financing for Development. Most developing countries have also failed to meet the budgetary goal of allocating 15 % of Gross National Product to social and healthy development as agreed to in 2001. In addition, to limited resources there is significant competition within countries for development resources.
It is within this funding gap that truly innovative mechanisms of funding global health are developing. By no means are these efforts meant to replace traditional development assistance, but they are meant to complement existing programs. The goal is to not only increase funding but also to leverage existing funding to be more productive in order to have a sustainable positive effect on global health.
A number of mechanisms for innovative financing have been developed over the last several years. These include voluntary micro-contributions by individuals on services including travel and mobile phone use, taxes on services such as airline tickets, branded trademark sales that direct a proportion of sales into financing programs, buy-down debt programs and the issuing of bonds in capital markets. Many additional mechanisms are being explored including levies on foreign exchange transactions, voluntary 1 % waiver of VAT and auctioning of permits to emit greenhouse gases. These efforts have raised over two billion dollars.
Innovative financing efforts have also proved to increase value for money of current funding levels by accelerating the implementation of programs in country with greater efficiency. The Pledge Guarantee of Health (PGH) has made it possible for governments to obtain funds based on pending commitments to allow the execution of critical health programs in both a timely and more efficient fashion. This type of financing effort has assisted programs including malaria net distribution ahead of peak infection periods and contraceptive implants to avoid stock-outs.
The opportunities presented by innovative financing are endless. No longer are we constrained by health models based upon large donor to developing country donations. Technology allows us to link individuals with means- to individuals with needs. We have the opportunity to make the health and well-being of our global neighbors our personal responsibility, and to participate in assisting them directly as evidenced by internet based efforts to provide maternal care funding through individual donations.
While financing options are limitless we are still faced by many challenges. Some groups continue to be at significant risk, particularly women and girls. MDG5, the reduction of maternal deaths and achievement of universal access to reproductive health, remains unmet and underfunded. We highlight these issues in a special section of this issue because in order to meet MDG5 we must explore additional innovative financing mechanisms. Increased awareness of violence against children and forced child marriage is necessary to promote future economic development in many countries. The advancement of women itself is a study in innovative financing. Increasing employment of women improves GDP. Improved economic status of women leads to direct, local reinvestment resulting in improved education and health services and reduction in poverty.
As we enter into a new year we need to be invigorated by the efforts of all of the authors featured in this edition of GHD news and look within ourselves for innovative solutions to the challenges that face us all.
— Joanne Manrique
The challenges present in global health are well recognized. Diabetes, cardiovascular disease and cancer have taken their places in the pantheon of scourges alongside the age-old challenges of infectious diseases, maternal and child health, sanitation and clean water. Donor and recipient governments, multinational agencies, NGOs and health workers all combine their efforts to combat global health issues. Can we affect the rate of these efforts in a positive fashion?
In the field of chemistry the addition of a catalyst to a chemical reaction increases the rate of reaction. Catalysts allow reactions to occur using less energy than the corresponding uncatalyzed reaction. Catalysts are not consumed in the reaction and thus they may participate in the acceleration of multiple reactions. The discovery and use of catalysts in manufacturing has revolutionized many technologies creating a rapidly growing industry. The principles of catalysis can be applied to the human condition and thus the identification of “catalysts for global health” is critical in affecting changes in the rate of implementing global health solutions. This issue of Global Health and Diplomacy highlights individuals and advances that are helping to accelerate our global efforts to improve the health of all.
Advances in technology are important catalysts for reducing mortality and morbidity. Efforts such as the Child Survival Call to Action have accelerated the distribution of vaccines and medications to prevent childhood mortality from pneumonia and diarrhea potentially saving hundreds of thousands of lives over the next several years. Initiatives to bring oral rehydration solutions with low osmolarity zinc supplementation to rural areas offers the opportunity to increase the use of a highly effective, yet potentially low cost, treatment of diarrhea.
Catalysts for changes in global health are also individuals. Many global leaders work tirelessly to accelerate the improvement in standards of health care within their home countries. His Excellency Macky Sall, President of Senegal, reviews the remarkable reductions in neonatal and under five mortality achieved through strategic planning and effective partnership. Dr. Ernest Bai Koroma, President of Sierra Leone, outlines his commitment to the expansion of the Free Health Care Initiative that creates a roadmap for creating a sustainable healthcare network to provide for the people of Sierra Leone. Its progress in increasing access and utilization of healthcare services including obstetrical care and the identification and treatment of malnutrition is remarkable.
The activity of catalysts can be affected by other substances including those that inhibit their activity. One of the great challenges to the achievement of universal health coverage in all countries is the potentially enormous costs. Recognition of these inhibitors can lead to development of policies that both limit their impact and create solutions. An example is the use of taxes on items such as cigarettes that can both generate income for the health care system while creating a negative reinforcement for unhealthy behaviors.
Promoters are substances that increase the activity of a catalyst. In fact all of the contributors to this edition of GHD are promoters of global health. Their innovative ideas, commitment and perseverance should serve as an inspiration.
The Millennium Development Goals, established in 2000, set forth a framework to encourage development by improving social and economic conditions in the world’s poorest countries. The MDGs have led to significant progress in the improvement of health in populations across the globe. Progress towards the achievement of the MDGs, however, has been uneven with some countries unlikely to accomplish some or all of the MDGs by 2015. While reductions in incident cases of malaria and AIDS related deaths in many areas have decreased significantly we continue to face unacceptable levels of maternal and child mortality.
As 2015 approaches we look to new leaders to shape the agenda that will define the post MDG era. To be successful this plan will need to incorporate an honest appraisal of the successes and shortcomings of the MDG results and build upon this foundation. Health is a critical part of sustainable development, thus, making this discussion of the utmost importance. Achieving our goals beyond 2015 will require leaders with vision, determination and commitment.
Looking into the post 2015 era requires global health leaders to prepare for health challenges not considered by the original MDGs. Specifically, the emergence of major non-communicable diseases (NCDs) including cancer, diabetes and cardiovascular disease that threaten population health and resources. Leadership will need to integrate the fight against traditional enemies like malaria and TB with surveillance programs to hasten early detection and treatment of the major NCDs. Without this commitment we risk trading one epidemic for another.
The MDGs emphasized the need for individualized policy solutions to meet a country’s specific challenges. Visionaries in the post 2015 era will look beyond the confines of health priorities alone to include health in a broader discussion of development. Already we see what these integrated approaches may look like in Nigeria where careful analysis of the country’s needs and priorities has helped to develop an ambitious plan to save one million lives by scaling up primary health services for women and children, while utilizing the revenue from domestic resources to create a sustainable funding model.
Leaders for the post 2015 era face great challenges. Changing economics will require that more be done with less, making the need for clear goals, improved management and greater accountability for performance and results critical for success. Leaders will need to avoid becoming mired in politics to move forward an aggressive agenda that places an emphasis on human rights and equalities. Leaders must be inclusive and co-operative to ensure that all organizations maximize their efforts to improve global health.
The post 2015 era faces many challenges that have not been completely addressed by the current MDGs. In this issue of Global Health and Diplomacy we hear from the voices of leadership for the current MDGs and the post 2015 era. Their commitment and intellect will help to guide the successes of the post 2015 era.
Janus, the two headed Roman god, had the ability to look both forward and backward in time simultaneously. This image is symbolic as we embark on a new year. We traditionally take time to reflect on the events of the previous year and look forward to the challenges of the next. We must evaluate our successes and our shortcomings to ensure continued progress. Sometimes this process can be difficult. It is only through honest and open review of our past that we can achieve success in the future.
As we approach 2015 there is an increasing need to evaluate our progress in the global achievement of the Millennium Development goals. The common beliefs enshrined in the MGDs have not changed since their inception. The world in which we live in has changed significantly. Changes in the global economies have created new pressures to use our resources more effectively.
Accountability and transparency are fundamental to accelerating progress in global health. It allows for recognition of global health programs where we have fallen behind in our goals. It allows us to accept that some strategies may not produce the desired results and make modifications necessary to continue with our achievement of the MDGs. In 2010 shortfalls in our commitments to maternal and child health were recognized by the Muskoka Initiative for Maternal, Newborn and Child Health and the UN Global Strategy for Women’s and Children’s Health. In 2011, the global health community took steps to ensure that initiatives launched in 2010 led to results by creating the Commission on Information and Accountability for Women’s and Children’s Health, led by Prime Minister Stephen Harper and President Jakaye Kikwete. This Commission has assembled an accountability framework that provides an outcome based system to monitor and review actions leading to adjustment of future strategies to accelerate progress for women’s and children’s health.
The principles of accountability and transparency are not only important in maternal and child health but also in continuing the fight against infectious diseases including malaria, HIV/AIDS and TB. Review of efforts to sustain universal coverage of malaria control interventions led to the recognition of financial shortfalls. Outcome based efforts led by President Ellen Johnson Sirleaf and global health partners led to identification of new strategies to improve procurement strategies to support the fight for eradicating malaria. Honest and accountable review of our global health efforts can also lead to innovative thinking to address challenges as evidenced by the African Leaders Malaria Alliance’s (ALMA) plans to develop innovative new funding streams to support malaria control.
Ultimately accountability requires metrics by which we can measure successes and failures. The Global Burden of Disease, Injuries and Risk Factors data provides a new standard for quantifying global health problems. It also helps to identify the areas of greatest need in a given region.
This issue of GHD News also provides a special focus on efforts to address tuberculosis, particularly in Afghanistan. While these articles highlight the challenges of drug resistance and the success of earlier diagnosis techniques it also brings focus to the personal challenges faced by much of the world’s population. The personal costs of tuberculosis are not only measured in mortality and morbidity data but also in the ability to pursue our dreams and those of our children.
Global health challenges do not discriminate. They affect all of us. In this issue of GHD News some of the authors share their own personal experiences with potentially life threatening complications which face all mothers around the world. It is only though accountable review of our global efforts on health that we can refine our plans to create healthier futures for all.