Toward a golden age: reflections on global health and social justice.

We are living in a time of unprecedented opportunity in global health. The past decade has seen bold health-related commitments from political leaders, such as the Millennium Development Goals and the 2005 pledge by heads of state and government to press toward universal access to HIV/AIDS treatment. Substantial new resources are flowing into the global health field. Between 2003 and 2005 alone, global spending on HIV/AIDS almost doubled, from US$4.2 to US$8.3 billion. Effective strategies have been developed to treat and prevent many of the greatest contributors to the global burden of disease. Investment in medical research by governments and donors like the Bill and Melinda Gates Foundation brings the promise of a new generation of products that, within eight to ten years, may dramatically bolster the world's arsenal in the fight against disease. At the same time, broad public interest in the health and well-being of poor and marginalized people in the developing world has exploded. Bill Foege, former Director of the US Centers for Disease Control and Prevention, has referred to this current period as the "golden age of global health" that he predicts will last at least until 2025.

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While all these developments are encouraging, there is an enormous gap between this growing political concern for global health and the actual health outcomes of vulnerable groups. The persistence of poor outcomes for so many in the face of huge new investments in global health is an ongoing tragedy. What is especially tragic is that, in many parts of the world, we are failing to intervene and save lives from conditions that could be prevented or remedied with existing--and often relatively simple--interventions. The World Health Organization (WHO) Commission on Macroeconomics and Health estimated that over eight million deaths per year could be averted with the effective delivery of proven health care services to affected populations. For these eight million souls, our inability to deliver costs them their lives. If we can find a way to export FedEx packages and cold Coca Cola to every corner of the world, surely we can find a way to dramatically improve our capacity to implement critical and often simple interventions.

Universities--as laboratories for ideas and training grounds for tomorrow's leaders--can play a major role in bridging this "delivery gap." But what have they been doing to help? Are there groups of scholars who, working together, might develop new insights, models of delivery, training materials and most importantly, mentor the next cadre of global health leaders who will become masters in global health delivery? Unfortunately, universities have not given high priority to healthcare delivery for predictable reasons. The gritty business of delivering health interventions has not attracted great interest in academic circles despite its inherent complexity and importance to the health of people everywhere, including wealthy countries. More to the point, the governmental institutions that could support scholars working on problems of global health delivery are woefully underfunded.

Now, as complex diseases that were once thought to be universally fatal in poor countries are beginning to be treated with an influx of significant new resources, our "failure to deliver" becomes even more problematic. In the case of drug resistant strains of tuberculosis that have been labeled "extensively drug-resistant tuberculosis" or "XDR-TB," both the moral imperative to treat those who are ill and enlightened self interest to protect citizens of developed countries has led to important gains in both financing and attention to the problem. In the realm of HIV treatment, we have swiftly moved from conventional wisdom that stated that treatment in resource-poor settings is not cost-effective or possible, to scaling up treatment for millions of HIV patients in low-and middle-income countries.

But how well can we be doing in tackling these extraordinarily difficult problems when we are failing to provide much more basic kinds of care? Indeed, some public health specialists have argued that we shouldn't think about problems like drug-resistant TB and HIV treatment access at all until we've become much better at delivering simpler interventions like vaccines. The argument that we need to pay more attention to the full range of health problems and not just on the big killers makes good sense. Yet I take issue with the notion that we must delay implementing complex interventions for HIV and XDR-TB until we are better at doing the simple things. We clearly have to do better on both the simple and complex tasks and, in the meantime, use the intense focus on HIV, TB, and malaria to launch a much broader effort to build effective health systems in poor countries. The explosion of interest in these three major killers has forced us to think about building systems that can respond to both acute and chronic problems, a goal that was once called "health for all" that we have been pursuing for at least three decades. We have never been closer to having the funding and political will to finally make a real run at this goal. But to succeed, we must intensify our efforts to tackle complex health problems in developing countries, and there are few that are more complex than XDR-TB and HIV treatment scale-up.

The threat of XDR-TB

At the beginning of this summer, news headlines made it clear just how much work lies ahead in global health. Andrew Speaker, a young lawyer from the US state of Georgia, flew from the United States to Europe and back, although he was suffering from an active case of tuberculosis (TB). In carrying out plans to marry his fiancee at a wedding on a Greek island, the young lawyer traveled on a plane from Atlanta to Paris and then took a circuitous route to return to the United States, thereby evading authorities who had discovered that his strain of tuberculosis was of the "extensively drug-resistant" XDR-TB variety. After a media blitz, Congressional hearings, and daily news developments, Speaker finally apologized on major television news broadcasts for putting his fellow passengers at risk of contracting XDR-TB. Many persons in the media expressed surprise that infectious diseases like tuberculosis are still a major problem in the world. Even more surprising was the realization that highly resistant forms of TB can afflict even young, seemingly healthy US lawyers.

It surprises many to know that seven years into the third millennium and several decades into the so-called "post-antibiotic era," infectious diseases are still a leading cause of adult mortality around the globe. Despite the US Surgeon General's claim in 1969 that "it's time to close the book on infectious diseases," the terrible mortality from tuberculosis, which is almost always curable with antibiotics delivered appropriately, serves as a standing rebuke to these words. Almost one-third of the world is infected with Mycobacterium tuberculosis, the organism that causes TB. During 2006, approximately 9 million people became sick with TB, and more than 1.6 million died from this illness. Poorly functioning health systems throughout the poor world ensure that less than half of all TB cases worldwide are properly diagnosed, and fewer than 60 percent of those are cured. Among regions in which HIV has established itself, the news is even worse. Between 1993 and 2003 in sub-Saharan Africa, TB incidence escalated by almost 250 percent. An estimated one-third of AIDS deaths can be attributed to TB.

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Grim epidemiologic profiles in the developing world coexist with half a century of breathtaking medical and scientific innovation. Indeed, the successive revolutions of antibiotic therapy, bioengineering, and genomics have spawned an especially bitter paradox: the regions most desperately in need of the results of innovation are precisely the places in which they are unavailable. Two hundred years ago, TB ravaged affluent and poor countries alike. Today, rates of TB have become telling indicators of a society's wealth or poverty. At present, 98 percent of worldwide deaths from TB are in developing countries. The poorest sectors of society are at greatest risk, but anyone living in a TB-endemic region can be affected.

XDR-TB is a form of tuberculosis that is resistant to the two most important "first-line" antituberculous medications as well as to two additional classes of "second-line" agents that are normally used only for cases that have already been proven resistant to the first-line agents. As of June 2007, XDR-TB was documented in 37 countries on six continents, including all the G8 countries.

With access to the best treatment in the world, Speaker has a good chance at full recovery. But what of poor people all over the world, many of whom are also living with HIV, which puts them at much greater risk of getting sick and dying from any form of TB? Even though there are more than 400,000 new cases of multidrug-resistant tuberculosis each year, the global public health and medical community has only been able to treat a total of approximately 21,000 over the last decade with WHO-approved treatments.