A mural of President Obama by artist Shepard Fairey
As Barack Obama is inaugurated as the USA's new President—amid the throes of a major global financial crisis—concerns have been raised around both the future financing of global health initiatives, and the likely approach of the new administration. The USA has clearly dominated the international playing field on global health in the past decade. The previous administration's annual overseas development assistance (ODA) for health reached record levels: US$7·5 billion in 2008 (30% of its ODA), driven by the President's Emergency Plan for AIDS Relief (PEPFAR), the world's largest development initiative. Any policy shifts are therefore likely to have widespread repercussions, particularly in resource-poor settings.
A preliminary report from the USA's Institute of Medicine
(IOM) highlights potential areas for the Obama administration to consider as it works towards defining its commitments to global health in 2009 and beyond. With 70% of all US funds currently going to HIV/AIDS programmes, the IOM calls for an expansion of US focus to other infectious diseases and health issues, including chronic diseases. It is critical of the lack of attention given to, for example, reproductive health—funding for which has remained largely stagnant—tuberculosis, malaria, and health-system strengthening. Both the IOM and many in the global health community remain critical of PEPFAR for failing on HIV prevention—placing too much focus on abstinence-only programmes. PEPFAR says it is now scaling up its support for national efforts to tackle opportunistic infections relating to HIV/AIDS, and addressing HIV/tuberculosis co-infection, and takes a central role in US efforts to “connect the dots” of international development by linking into initiatives of other US agencies and international partners.
In his end of year lecture at the National Institutes of Health
, Harold Varmus—co-chair of the IOM study—raised additional concerns around the poor focus to date on neglected tropical diseases, which, he noted, account for 56 million disability-adjusted life years (DALYS), more than malaria and tuberculosis combined. Worm infestation, he said, leads to over 200 million years of lost primary schooling and trachoma costs $5·3 billion in lost worker productivity. These are diseases that are easy to treat and prevent. Greater acknowledgement too that infectious-disease outbreaks—dominated by zoonoses—have significantly increased in recent decades, and that these infections do not remain within national boundaries, also needs consideration. The USA and the global health community must work better together to enhance the global capacity to respond to infectious disease threats, primarily through improving response and detection capabilities in resource-poor settings.
The IOM's full report, scheduled for release in April, will argue for a deeper commitment by the USA to global health, even in these times of financial crisis, calling for a doubling of spending to $15 billion by 2012. During his campaign Obama clearly signalled his strong commitment to overseas development, yet some have questioned the likelyhood of increased spending. For starters, expanding global-health budgets may prove a difficult sell to the American people, when at home they are seeing states cutting Medicare budgets. And even during good times, health financing by the USA and other advanced nations has historically remained well below prescribed levels
. Despite WHO Director General Margaret Chan's call on influential countries not to cut spending in the coming months, an unavoidable fact remains that in all three global recessions of the past 20 years overall ODA commitments have been reduced every time.
Many advocates in the USA are also hoping for more joined up thinking on domestic and foreign health-policy making—particularly on the issue of infectious diseases and migrants within US borders. Obama, again, has signalled that he is committed to tackling both domestic and global inequality. Infectious diseases, including dengue fever, Chagas disease, cysticercosis, leishmaniasis, and toxocariasis, are prevalent in the poorest populations
living in the USA, representing a major health disparity. The new administration must focus attention on the urgent plight of vulnerable migrants living in the USA with limited or no access to basic health care.
Any back-tracking on commitments by Obama and other international leaders risks seriously undermining the substantial advances made in the past decade on global health. The Obama administration must be vocal in its commitment from the outset, and work towards a re-engagement with the global health community—a relationship which has become strained in recent years—to ensure everyone works effectively together to define a future agenda.