The n e w e ng l a n d j o u r na l of m e dic i n e

Spe ci a l R e p or t

Investing in Global Health for Our Future

Victor Dzau, M.D., Valentin Fuster, M.D., Ph.D., Jendayi Frazer, Ph.D., and Megan Snair, M.P.H.

With connectedness among countries increasing,
the United States exists in a highly interdepen-
dent world. All countries are now vulnerable to
the ever-present threats of infectious disease out-
breaks and epidemics, as well as the continuous
challenges of malaria, tuberculosis, and human
immunodeficiency virusacquired immunode-
ficiency syndrome (HIVAIDS). Furthermore, the
increasing prevalence of chronic noncommuni-
cable diseases (NCDs) has negatively affected
global health and economies, compromising
societal gains in life expectancy, productivity,
and overall quality of life.1 In addition to resulting
in the loss of lives, these disease burdens can
stall the progress of a countrys development
and significantly affect its ability to become a
strong trading partner or a business or travel
destination. Human capital clearly contributes
substantially to economic growth, and it follows
that having a healthy population is critical for
economic prosperity. For all these reasons, the
health of other countries has a great influence
on the health, security, economy, and well-being
of the United States. At the same time, interdepen-
dency brings opportunities for shared innovation
and universal purpose in response to similar
disease burdens across countries.
The United States has long been a world
leader in global health, and its investment has
led to considerable success through programs
such as the Presidents Emergency Plan for AIDS
Relief (PEPFAR); the Presidents Malaria Initia-
tive (PMI); the Global Fund to Fight AIDS, Tuber-
culosis, and Malaria; and more recently, the
Global Health Security Agenda. As a result of
such successes, there has been strong bipartisan
support and relatively stable funding for global
health for the past 15 years. However, with the
change in presidential administration, and with
many new and recurring crises crowding the
policy agenda, the future direction of U.S. global
health is unclear.
In this context, the National Academies of Sci-
ences, Engineering, and Medicine was charged
with conducting a consensus study to provide
recommendations to the U.S. government and
other stakeholders to increase responsiveness,
coordination, and efficiency by establishing global
health priorities and mobilizing resources. With
support from a broad array of federal agencies,
foundations, and private partners, an ad hoc
14-member committee was appointed to carry
out this task over the course of 8 months. On
the basis of a rigorous and evidence-based con-
sensus process, the committee formulated a set
of 14 recommendations; we believe that the im-
plementation of these recommendations would
result in a strong global health strategy and allow
the United States to maintain its role as a global
health leader.2
Over vie w of Commit tee Rep or t
Prioritie s
The report recommends setting four main priori-
ties: pursuing global health security, addressing
continuous communicable threats, saving and
improving the lives of women and children, and
promoting cardiovascular health and preventing
cancer (Fig.1).
Ensuring Global Health Security
The U.S. Army recently estimated that if a severe
infectious disease pandemic were to occur today,
the number of U.S. fatalities might well be nearly
double the total number of battlefield fatalities
sustained in all U.S. wars since the American
Revolution.3 Regardless of whether epidemics or
biosecurity threats originate naturally or through
human engineering, it is critical for the United
States to recognize their severity and take pro-
active measures to build capacities and establish
sustainable and cost-effective infrastructure to
combat them.

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 Special Report

Although multiple agencies can bring unique

expertise to a U.S.-governmentled response to
Securing against Enhancing Productivity
an international health emergency, it is difficult Global Threats and Economic Growth
to execute an emergency plan in the midst of
a crisis without a clear chain of command, a Global Continuous Saving and Promoting
dedicated budget, and designated leadership. Health Security Communicable Improving the Cardiovascular
Threats Lives of Women Health and
The committee called for a coordinating body to and Children Preventing Cancer
oversee this type of response, guided by a newly
created international response framework. To
Maximizing Returns
rapidly mobilize assets and implement interven-
tions when necessary, the committee also sup- Catalyzing
Smart Financing
Global Health
Innovation Leadership
ports the creation of a public health emergency
response fund, to be used only in declared health
emergencies. This fund should be complement-
ed by parallel dedicated funding streams for the
development of needed vaccines, diagnostics, and Figure 1. Issues Addressed by the National Academies of Sciences,
therapeutics for global health threats, as well as Engineering, and Medicine Report on Global Health and the Future
of the United States.
supporting preparedness actions such as build-
ing public health infrastructure. A dual focus on
health preparedness through capacity building
at home and abroad is essential to reduce the than treating it. Cost-effective investments made
risk of outbreaks and the transmission of infec- during a childs early years can mitigate deleteri-
tious disease globally. ous effects of poverty and social inequality. In
fact, interventions carried out during the very
Addressing Continuous Communicable early years of life can translate into lifelong bene-
Threats fits in terms of labor-market participation, earn-
Although potential emerging or recurring pan- ings, and economic growth generating finan-
demics often captivate the media and dominate cial returns of up to 25%.7 Given the robust
the dialogue regarding global health threats, the evidence demonstrating the effectiveness of inter-
global community must not forget the persistent ventions for preventing maternal and child deaths,
health priorities the world has been addressing the committee agreed that accelerating invest-
for several decades: HIVAIDS, tuberculosis, and ments in this area will be vital. To avoid further
malaria. Each year, 2 million people around the preventable deaths, the committee recommended
world acquire HIV infection,4 and more people increased funding so that the U.S. Agency for
now die from tuberculosis than from AIDS.5,6 International Development (USAID) can augment
Complacency toward these diseases can lead to its investments. Ensuring that women and chil-
severe risk for the global community, since all dren thrive, however, is also critical: 250 million
three pathogens are capable of evolving into children under 5 years of age in low- and middle-
strains that are resistant to currently available income countries (LMICs) are failing to reach
treatments. The committee called for sustained their development potential owing to extreme
commitment to the PEPFAR and PMI programs, poverty and stunting.8 Building empowering, nur-
but also for broadening PEPFAR to make it more turing, and cognitively enriching environments
flexible and to incorporate chronic health condi- to prevent such stunting and promote healthy
tions. Finally, the committee recommended a and productive lives requires programs that span
thorough assessment of the tuberculosis threat the health, education, and social service sectors.
so that the world can plan for the true danger it
presents. Promoting Cardiovascular Health
and Preventing Cancer
Investing in Womens and Childrens Health Premature death and disability stemming from
Ideally, prevention efforts should begin at birth NCDs contribute to decreased productivity, de-
and continue throughout the course of each per- creased gross domestic product, and higher over-
sons life, since preventing disease is less costly all costs of health care because established health

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 The n e w e ng l a n d j o u r na l
systems are not designed to care for people with
chronic disease in an integrated and holistic
fashion.9 As more people survive infectious dis-
eases and age into adulthood, many develop
cardiovascular disease or cancer, conditions to
which global health programs are not devoting
adequate attention. The committee recommends
that national and donor governments and non-
governmental organizations address these priori-
ties through policy changes and community-
based programs that are integrated into existing
health services. The committee calls for USAID,
the Department of State, and the Centers for
Disease Control and Prevention (CDC) to provide
seed funding at the country level to facilitate
mobilization and involvement of the private sector
in addressing these issues. High-priority strate-
gies include the targeting and management of
risk factors, detection and treatment of early
hypertension and early cervical cancer, and im-
munization for vaccine-preventable infections,
such as human papillomavirus and hepatitis B
virus, that can lead to cancer.
Changing the Appr oach
and Ma ximizing Re t urns
The committee envisions its recommendations as
part of a more proactive, systematic, and cross-
cutting approach to global health; the core con-
cepts underlying its analysis are integration, capac-
ity building, and partnership. Though integration
can be difficult, and often must be considered
even before a program is developed, changes in
health system design can permit more holistic
care and result in greater effectiveness in improv-
ing health outcomes. Given that patients often
have both communicable and noncommunicable
diseases, integrating services by sharing loca-
tions, staff, systems, tools, and strategies can
increase effectiveness.10 For example, researchers
in Zambia noted that using the existing HIVAIDS
care infrastructure for cervical cancer screening
has positive effects on costs, reliance on avail-
able expertise, and sustainability.11
Similarly, building capacity throughout a coun-
trys health system can foster greater resilience
and an ability to respond to a range of chal-
lenges, whether an infectious disease outbreak
or an aging population with complex needs.
Successfully integrating a countrys programs
and building its capacity will require strong
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of m e dic i n e
multilateral partnerships such as the Global Fund
and Gavi, The Vaccine Alliance. LMICs may also
benefit from allocation of increased funds to
multilateral institutions, which can provide global
public services that many countries cannot man-
age independently, such as research and develop-
ment, knowledge sharing, shaping of the health
care market,12 and management of cross-border
challenges.13
Overall, the committee recommends contin-
ued U.S. government investment in global health
to maintain the success of recent decades, but
also calls for a reevaluation of the way global
health business is conducted, in order to improve
outcomes and cost-effectiveness. In doing so,
the committee recognizes that business as
usual will not be sufficient. The majority of
foreign aid, especially when directed toward
health, is an investment and should be treated as
such. The benefits for the United States are two-
fold: securing protection against global health
threats and promoting productivity and eco-
nomic growth in other countries. These benefits
can be increased through strategies that maxi-
mize returns on investment (Fig.2). To have the
greatest effect in the four described priority
areas, the committee identified three cross-cutting
strategies that can both maximize returns and
achieve better health outcomes: catalyzing inno-
vation through accelerated development of med-
ical products and building of integrated digital
health infrastructure; employing more nimble
and flexible financing mechanisms to leverage
new partners and funders in global health; and
maintaining the status and influence of the
United States as a world leader in global health
while adhering to evidence-based science, eco-
nomics, measurement, and accountability.
Catalyzing Innovation
In terms of medical product development, the
market for global health products suffers from
numerous failures including inadequate manu-
facturing capacity, a costly approval process, un-
certain commercial potential, and poor workforce
and laboratory capacities in LMICs. Because of
the dearth of available medical products, many
patients with tuberculosis, malaria, or other
potential pandemic diseases lack access to es-
sential medicines. Developing safe and effica-
cious products requires not only a secure mar-
ket, but also local research and development
 Special Report

capacity in countries where outbreaks begin and

Report Themes Recommendations
disease burdens are high.14 The U.S. government
can enable innovative approaches for trial de- Securing Improve coordination during international public health
emergency preparedness and response efforts.
sign, streamline regulation, and ensure produc- against
Global Reduce antimicrobial resistance through enhanced
tion capacity and market incentives in order to Threats surveillance, quality-controlled supply chains, and improved
accelerate the development of medical products. stewardship.

Equally critical in this process, and an ongoing
priority, is creating sustainable international
capacity for research and development, as the
Fogarty International Center of the National In-
stitutes of Health has been working to do.
In terms of technology, the proliferation of
digital health applications and platforms in coun-
tries around the world has resulted in increasing
fragmentation across sectors and organizations,
even as it has created opportunities for health
system innovation. Cross-cutting digital health
platforms should be interoperable and yet adapt-
able to local requirements and sovereignty. New
and existing U.S. investments can employ a vision
of building once, and U.S. and international
stakeholders can come together to create a com-
mon framework that could be used and adapted
worldwide in a manner that is scalable for future-
minded solutions.
Build public health capacity in other countries for better
response to infectious disease outbreaks and disasters.
Broaden PEPFAR to provide chronic care emphasizing
country ownership and partnership with the Global Fund.
Conduct a global threat assessment of tuberculosis; maintain
commitment to the Presidents Malaria Initiative.
Enhancing Accelerate investments in survival of women and children;
Productivity improve developmental potential and well-being.
and Promote cardiovascular health and prevent cancer by
Economic targeting risk factors and implementing best practices.
Growth
Maximizing Catalyze innovation to accelerate medical product
development and streamline digital health tools.
Returns
Use financing that envisions long-term goals and optimizes
resources using innovative methods and diverse sources of
capital.
Commit to U.S. global health leadership through multilateral
partnerships and creation of a U.S. global health workforce.

Optimizing Financing Figure 2. Recommendations of the National Academies of Sciences,

As many LMICs graduate from receiving devel- Engineering, and Medicine Ad Hoc Committee on Global Health
and the Future of the United States.
opment assistance, their governments can crowd
in other funding sources, such as the private
sector, by both increasing demand for goods
through public funds and sharing risk to cata- issues and active engagement in the interna-
lyze private investments that would not otherwise tional global health arena. The United States has
be made.15 Such efforts could include seeding an opportunity to solidify its leadership and take
investment funds, offering incentives to local a more deliberate approach to foreign policy. In
financial institutions through credit guarantees, addition to a continued commitment to interna-
or providing technical assistance to strengthen tional partnerships, the committee calls for the
business management in companies. In particu- establishment of a sustainable U.S. workforce in
lar, the committee recommends that the U.S. global health. In the absence of a health career
government should diversify its methods of track in the Foreign Service, the demand for U.S.
global health funding to be more targeted and global health expertise in host countries cannot
catalytic, thereby increasing the impact and cost- be sustainably filled, and the U.S. personnel who
effectiveness of its investments. Moreover, the are deployed often lack appropriate health or
U.S. government can conduct more strategic and diplomacy skills, which weakens U.S. global
systematic assessments and use them to make awareness and readiness.
long-term investments in global health that con-
tribute to global public good rather than short- Conclusions
term expenditures.
The United States cannot ignore the reality that
Committing to U.S. Global Health Leadership the health and well-being of other countries af-
Finally, protecting U.S. citizens at home and fect the health, safety, and economic security of
abroad necessitates continued awareness of global Americans. For many years, there has been strong

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 Special Report
bipartisan backing of U.S. engagement in global
health, with active support from the faith com-
munity, private industry, foundations, and civil
society. The committee believes that implement-
ing evidence-based interventions, modifying coun-
try engagement strategies, exploring new invest-
ment mechanisms, and taking a more proactive
and systematic approach to global health priori-
ties will make the U.S. governments efforts in
global health more effective and efficient. The
United States can preserve and extend its legacy
as a global leader, partner, and innovator in
global health through forward-looking policies,
a long-term vision, country and international
partnerships, and most important, continued in-
vestment. Doing so will not only lead to improved
health and security for all U.S. citizens but also
ensure the sustainable thriving of the global
population.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
The members of the Committee on Global Health and the
Future of the United States are Jendayi Frazer (cochair), Council
on Foreign Relations; Valentin Fuster (cochair), Mount Sinai
Medical Center, New York; Gisela Abbam, General Electric
Healthcare; Amie Batson, PATH; Frederick Burkle, Jr., Harvard
University; Lynda Chin, University of Texas System; Lia Haskin
Fernald, University of California, Berkeley; Stephanie Ferguson,
Lynchburg College and Stanford University; Peter Lamptey, FHI
360; Ramanan Laxminarayan, Centers for Disease Dynamics,
Economics, and Policy; Michael Merson, Duke University; Vasant
Narasimhan, Novartis; Michael Osterholm, Center for Infectious
Disease Research and Policy; and Juan Carlos Puyana, University
of Pittsburgh.
From the Office of the President, National Academy of Medi-
cine (V.D.), the Committee on Global Health and the Future of
the United States (V.F., J.F.), and the Health and Medicine Divi-
sion (M.S.), National Academies of Sciences, Engineering, and
Medicine, Washington, DC; Centro Nacional de Investigaciones
Cardiovasculares, Madrid (V.F.); and Mount Sinai Hospital (V.F.)
and the Council on Foreign Relations (J.F.) both in New York.
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The New England Journal of Medicine
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DOI: 10.1056/NEJMsr1707974
Copyright 2017 Massachusetts Medical Society.