Public Health in the 21st Century

Public health has the potential to improve the lives of millions around the world. However, there are many factors and challenges that must be considered when working to improve the health of populations.

To prepare for this Discussion, select one public or global health topic of interest to you that you feel will be significant over the next 30 years from the wide range of public and global health challenges you have learned about in this course. Search for articles in the Walden University Library, as well as online, to learn more about the topic you have selected. For suggestions to help with your search, visit the Library at

http://library.waldenu.edu/908.htm

By Day 4, post a comprehensive response to the following:

What global health Issue, identified in the Report of the CISIS Commission on Smart Global Health Policy, do you think we will, most likely, see significantly reduced orincreased in the 21st century? Provide evidence from credible sources to support your prediction.

1. Provide a brief explanation of your chosen health topic and a description of the population affected.
2. Describe the 1) economic, 2) individual liberty, 3) moral/religious, and 4) political factors that contributed to the health problem. What challenges face public health professionals trying to address this issue today and in the future?
3. How should the ideals described in the Fundamental Principles of the International Red Cross and Red Crescent Movement (p. 23 of “Haiti—From sustaining lives to sustainable solutions: the challenge of sanitation”) be applied to this public health challenge?
4. How can future US global health strategies, identified in your resources, make a difference in the health topic you feel will be significant over the next 30 years?

Resources to files below:

International Federation of Red Cross and Red Crescent Societies. (2010). Haiti – From sustaining lives to sustainable solutions. The challenge of sanitation. (PDF)

Fallon, W. J, & Gayle, H. D. (2010). Report of the CISIS commission on smart global health policy: A healthier, safer and more prosperous world. Center for Strategic & International Studies. (PDF)

pecial report, six months on

Haiti
From sustaining lives to sustainable solutions:

the challenge of sanitation

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P.O. Box 372
CH-1211 Geneva 1

Switzerland
Telephone: +41 22 730 42

Telefax: +41 22 733 039

E-mail: secretariat@ifrc.org
Web site: http://www.ifrc.org

International Federation of Red Cross
and Red Crescent Societies, Geneva, 20

Copies of all or part of this document may be made for non-
commercial use, providing the source is acknowledged. The
International Federation would appreciate receiving details
of its use. Requests for commercial reproduction should be
directed to the International Federation at secretariat@ifrc.org.

Strategy 2020 voices the collective determination
of the International Federation of Red Cross and Red
Crescent Societies (IFRC) in tackling the major challenges
that confront humanity in the next decade. Informed by
the needs and vulnerabilities of the diverse communities
where we work, as well as the basic rights and freedoms
to which all are entitled, this strategy seeks to benefit all
who look to Red Cross Red Crescent to help to build a
more humane, dignified, and peaceful world.

Over the next ten years, the collective focus of the IFRC
will be on achieving the following strategic aims:

1. Save lives, protect livelihoods, and strengthen
recovery from disasters and crises

2. Enable healthy and safe living

3. Promote social inclusion and a culture
of non-violence and peace

strategy20

Notable
achievements,
but substitution
is not the
answer

The IFRC wishes to acknowledge the input and support of the following:

The Haitian Red Cross, its remarkable volunteers and staff
The British Red Cross
The IFRC’s Haiti delegation, particularly the water and sanitation team
The IFRC’s Water, Sanitation, and Emergency Health Unit
Oxfam GB in Haiti
DINEPA and the WASH cluster’s sanitation technical working group in Haiti
The World Bank

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P.5

Top line messages

P.

Before the earthquake

Tentative steps in the face of chronic under-development

P.11

Six months on:
notable achievements, but substitution is not the answer

P.

The challenges of the next 6–12 months
Taking the first steps towards sustainable sanitation solutions

P.20

The next ten years

Innovation is the key

P.22

Haiti earthquake operation in figures

P.15 P.22P.20

Contents

P.O. Box 372
CH-1211 Geneva

Switzerland
Telephone: +41 22 730 4222
Telefax: +41 22 733 0395
E-mail: secretariat@ifrc.org
Web site: http://www.ifrc.org

The challenges
of the next 6–12
months

Haiti
earthquake
operation in
figures

The next
ten years:
innovation is
the key

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International Federation of Red Cross and Red Crescent Societies

From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

Sanitation services can be defined as safe excreta disposal, solid
waste disposal, medical waste disposal, control of vectors such as
flies, mosquitoes and rats, provision of handwashing and bathing
and laundry facilities, promotion of good hygiene practices and
management of dead bodies. Safe excreta disposal entails both
ensuring that facilities including toilets are constructed, and that
men, women and children use them correctly.

Mass Sanitation Module Guidelines, IFRC (2010)

5
International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

Today, six months on, the effects of the magnitude 7.0 earthquake that struck
Haiti on 12 January remain horrifyingly visible. Large parts of Port-au-Prince,
Léogâne and Jacmel are in ruins. Rubble and rubbish lie piled in the streets.
Hundreds of thousands of people are living under tents and tarpaulins, huddled
together on street corners, vacant lots, parks and public squares, anywhere that
offers space for families to shelter.

• Sanitation saves lives. Without it, there is a risk of a secondary
disaster, in which the people who have survived the earthquake
could succumb to preventable disease.

• The IFRC is calling on the international community to
recognize sanitation as one of the absolute priorities in Haiti’s
reconstruction, and to ensure that sufficient resources are
devoted to it.

• The current situation is not sustainable. The IFRC and other
agencies providing water and sanitation services on behalf
of the Haitian authorities are currently stretched beyond their
capacity and mandate.

• Haitian authorities must receive funding and support to build
their capacities to provide the improved sanitation services the
Haitian population needs and deserves.

• access to appropriate sanitation is also a dignity and protection
issue, particularly for women and children. Community
participation is essential to identify ways to ensure that people
feel safe when using sanitation facilities – toilets and showers –
both at night and in the day.

• Innovative solutions for future sanitation provision are needed.
For example research is needed into potential solutions such
as small bore sewerage, large-scale composting of waste, or
establishing biogas production.

Top line messages

International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

Six months on, a large proportion of sanitation services (and two-thirds of the
water trucking) continue to be provided by international partners. This is not
sustainable. The IFRC calls upon the international community to recognize
sanitation as one of the absolute priorities in Haiti’s reconstruction and ensure
that sufficient resources are devoted to it. Initial planning is underway, and
this needs to be supported.

We also call upon those allocating funds to ensure that Haitian authorities
receive the funding and support they need to provide the improved sanitation
services the Haitian population needs and deserves.

Generally after a natural disaster, talk is about helping the country build back
to pre-disaster levels of service. Given the poor water and sanitation coverage
in Haiti before the earthquake, there now exists a real opportunity to build back
much better. The Haitian authorities must be supported to provide innovative
and sustainable systems that will enable large numbers of Haitian people to
have safe and reliable sanitation, in some cases for the very first time.

Eritrea 3 5 143

Niger 3 7 7

Chad 5 9 640

Ghana 6 10 1,465

Ethiopia 4 11 6,858

Sierra Leone – 11 14

Madagascar 8 12 1,353

Togo 13 12 222

Burkina Faso 5 13 1,365

Guinea 13 19 991

Haiti 29 19 -162

Congo – 20 –

Rwanda 29 23 38

Somalia – 23 605

Côte d’Ivoire 20 24 1,905

Improved sanitation
coverage (%)

Number of people who
gained access to improved

sanitation (thousands)

1990 2006 1990 – 2006

Table 1: Countries with low improved
sanitation coverage

7
International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

With the government and local authorities as devastated as the country – ministries
and their offices collapsed, employees killed, documentation and equipment
lost – international organizations have been working together to support the
government to provide survivors with the bare essentials: tarpaulins and tents
to keep out the rain, healthcare, access to clean water and sanitation services.

In Haiti, providing clean water and sanitation services is an enormous task.
Before the earthquake, safe water access was amongst the lowest in Latin
America and the Caribbean,2 whilst access to sanitation was amongst the lowest
in the world (see table 1).3 The earthquake has made a bad situation so much worse.

This report focuses on one area of work; the provision of sanitation services.
Sanitation demonstrates all the challenges and opportunities of responding to
this catastrophic disaster in terms of health services, shelter etc. So often the
neglected twin of water provision – which generally receives more attention
and most of the available funding – effective sanitation is vital.

A key call of this report is that equal emphasis must be given both now and in
the future to improving sanitation facilities. This will be instrumental in
reducing disease, ensuring a healthy future and assuring the dignity of those
whose lives have been affected by the tragedy of the earthquake.

ACF 824

ACTED 871

CARE 698

HAVEN 1,072

Oxfam 1,373

Red Cross Red Crescent 2,671

Save the Children 900

Top seven organizations
providing sanitation services1

Approx. number of
latrines constructed

Table 2: largest providers of sanitation services
in post-earthquake Haiti

1 Taken from DINEPa statistics June 14, 2010, amended with up-to-date figures from IFRC, Haiti. DINEPa points out that the figures
are very approximate and many organizations are under-reporting construction. The DINEPa report suggests that 11,234 latrines
were reported to have been constructed, although there were no details as to how many were still serviceable.

2 Mcleod, C, Haiti: Exploring Water & Sanitation, University of Pennsylvania (2009)
http://www.pgwi.org/. This report further points out that Haiti is in the region of the world with the highest available average water per person.

3 Progress in Drinking Water and Sanitation: special focus on sanitation, WHO/UNICEF (2008)
http://www.who.int/water_sanitation_health/monitoring/jmp2008/en/index.html

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International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010
Before the earthquake

Tentative steps in the face of chronic
under-development
In 2008, Haiti was “the only country in which access to improved
sanitation4(had) significantly decreased over the past decade.”5 Its improved
sanitation coverage rate was ranked 11th worst in the world – on a par with
DR Congo and Somalia.6 The existing water regulatory agencies had no
responsibility for sanitation, resulting in the absence of any sewage systems
and individual families arranged their own sanitation according to their economic
means. Those households with toilets or latrines would, when they could afford
it, pay for emptying services, including employing bayacou (night soil collectors
who emptied tanks by hand), although many latrine pits were extremely deep
and could go for years without being emptied.

Fewer than 70 per cent of people living in urban environments had regular
access to safe water, so it is no surprise that the incidence of diarrhoeal disease
was high. Haitian children commonly had four to six episodes of diarrhoea
per year (several times higher than the expected annual incidence among young
children in industrialized countries) and watery diarrhoea caused between five
and 16 per cent of child deaths.7

The situation was similarly bleak when it came to garbage collection. Many
older Haitians speak of Port-au-Prince as once being a relatively clean city,
with regular rubbish collections and street cleaning services. However, 30
years of chronic under-resourcing saw these services diminish and piles of
rotting rubbish became a familiar sight all around the capital city.

There were hopeful signs when, in 2009, a new water and sanitation regulatory
authority was created. DINEPA’s8 mandate was to reform the drinking water
and sanitation sector, starting by harmonizing the existing organizations that
had responsibility for water and sanitation services. This process had only just
begun when the earthquake struck.

4 i.e. facilities of a safe standard
5 Mcleod, ibid, p.11
6 WHO/UNICEF (2008), ibid, see table above
7 CDC: http://www.bt.cdc.gov/disasters/earthquakes/haiti/waterydiarrhea_pre-decision_brief.asp
8 Direction National de l’Eau Potable et de l’assainissement

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International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

The earthquake devastated already fragile water and sanitation systems near the
epicentre and left more than 1.5 million9 vulnerable people without access to
safe drinking water or a toilet, and at risk of water- and sanitation-related
diseases. Further from the epicentre there was less direct damage to these systems,
but people fled Port-au-Prince to virtually all corners of Haiti, compromising
already poorly functioning water and sanitation systems in outlying areas and
making poor hygiene practices unavoidable for many people.

Despite being badly affected by the earthquake, losing employees, assets and
documentation, DINEPA took the leadership of the WASH cluster – the
mechanism put in place to harmonize water, sanitation and hygiene interventions
throughout Haiti following the earthquake.10 For the first six months DINEPA
trucked approximately one-third of all the subsidized water to camps in the
affected areas.

The sanitation programmes of the International Red Cross and Red Crescent
Movement have made a significant contribution to improving the living conditions
of those affected by the earthquake. In collaboration with the Haitian Red
Cross Society, the Austrian, British, French and Spanish Red Cross societies
have so far provided sanitation facilities (toilets and showers) to 85,000 people
across a number of different camps, in Port-au-Prince, Jacmel, Léogâne, Petit-
Goâve and Grand-Goâve.

9 Taken from OCHa’s Humanitarian Bulletin, 19 June 2010
10 For more information see http://www.humanitarianreform.org/humanitarianreform/Default.aspx?tabid=76

“Minimum water supply needs are being met for 1.2 million
people, with the Cluster having reached its Phase One target of
distributing 5 litres of safe drinking water per person per day…
and (is) providing enough latrines with access to about 200 people
per facility. With 16,500 more latrines either under construction
or in the pipeline, this figure is projected to reduce to 100 per
latrine by October.” The Bulletin notes that construction rates are
severely under-reported and use is overestimated, which “may
imply that user ratios may have already reached acceptable
bounds of 50 to 100 users per toilet.”

OCHa, Humanitarian Bulletin, June 19 2010
http://www.reliefweb.int/rw/rwb.nsf/db900sid/
MINE-86kR32?OpenDocument&RSS20&RSS20=FS

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International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

Elie Michel balances gingerly on narrow planks of
wood as he fills up the tank with water. The 22-year-old
explains, “We’re waiting for a truck to come and pump
the faeces out of these tanks. We add water to make
the waste more liquid so it’ll be easier to drain out of
the tank. Then another truck will move the empty tanks
and we can put in new ones.”

Elie works with the Spanish Red Cross, which provides
water and sanitation services in 32 camps across
Port-au-Prince. He has a three-month contract that he
hopes will be renewed. Together with his mother, who
has a small trading business, he is able to provide for
the basic needs of his younger brother and sister. The
four of them live together in a tent in Portail Léogâne,
downtown Port-au-Prince.

When asked about the risks of becoming ill through his
work, Elie says, “We have equipment and protective
gear. I’m not worried. It’s a dirty job but somebody has
to do it. I’d like to have a better job but I’m happy doing
this for the time being. My dream is to be a policeman
but there are no opportunities right now, so I’ll stick
with the Red Cross.”

He is proud of the work that he and his colleagues are
doing. “We’re a team – the driver, the technician and
me. We install toilets in the camps and we maintain
them.” Despite Elie’s enthusiasm, the job can be
frustrating. He explains, “We’re repairing this one
because people wrecked it. It’s upsetting after all the
work we put into constructing them.”

In some camps, sanitation committees have been set
up to encourage residents to maintain the facilities
installed by the Red Cross Red Crescent. Hygiene
promotion activities are also organized to ensure
people know how to use the toilets properly.

Even so, Elie finds people’s attitudes can be
demoralizing. “People complain about the smell
coming from the toilets. Depending on the wind, the
smell can be really strong, but then you have to ask
why people are throwing all kinds of waste into them
that shouldn’t be there in the first place.”

“It’s a dirty job,
but somebody has to do it.”

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International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

Six months on:
notable achievements, but
substitution is not the answer

Six months after the earthquake, and despite intensive efforts by DINEPA and
humanitarian agencies, the IFRC estimates that around half the directly affected
population (and particularly those living in smaller, informal and hard-to-reach
locations) has not seen any improvement in their sanitation and water situation.
The authorities, together with the international aid community, are still months
away from meeting these overwhelming needs.

In the last month or so, some encouraging improvements in the environmental
health of Port-au-Prince have been spotted. Large bins provided by SMCRS11
– the metropolitan authority responsible for garbage collection – are appearing
on street corners and teams of SMCRS street cleaners have started clearing
gullies and drains of rubbish. Anecdotal evidence suggests that some streets
are cleaner now than before the earthquake, with fewer piles of garbage in evidence.

At the same, time it is clear that the provision of safe water and appropriate
sanitation has done much to secure the situation of many vulnerable people.
Although the numbers of toilets come nowhere near meeting SPHERE standards
(an internationally recognized set of universal minimum standards for disaster
response), there are signs of improved sanitation. Camp residents no longer need
to queue to use a toilet and there have been no major outbreaks of diarrhoeal
disease. Organizations working in sanitation in Haiti suggest that some of the
SPHERE indicator target figures need to be put into context, taking into account
the daily comings and goings of significant numbers of residents, many of
whom return home to use the toilet, whilst the numbers of permanent camp
residents is unclear.

However, it is no exaggeration to say that the sanitation situation for most
Haitians affected by the earthquake is considerably worse now than it was
before the quake.

For the humanitarian community, the first phase of response focused on numbers
of toilets being constructed. The emphasis now also includes guaranteeing
usability of the facilities provided, as well as upgrading and replacing existing
facilities. In this, hygiene promotion to ensure that toilets are properly used
and kept clean is key, together with carrying out regular inspections and swiftly
carrying out repairs when needed.12 Efforts in hygiene promotion (particularly
focused on children) must be accompanied by the reliable provision of clean
water and soap; increasing awareness of the importance of washing hands after
visiting the toilet or preparing food will be futile if water and soap are not available.
Reinforcing hygiene promotion activities through the school curriculum should
be encouraged where possible.

“The IFRC estimates that
around half the directly
affected population has
not seen any improvement
in their sanitation and
water situation.”

11 le Service Métropolitain de Collecte des Résidus Solides
12 In mid-June, DINEPa started conducting twice-weekly inspections of sanitation facilities in all 1,300 camps.

International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

Ensuring access to appropriate sanitation is also a protection and dignity issue,
particularly for women and children. Even in camps that have adequate toilet
coverage, women are often afraid to use the toilets at night, given the distance
they may need to walk and the absence of lighting. Instead, they prefer to use
plastic bags or other receptacles in the privacy of their shelters. Some camp
committees have put in place volunteer camp security systems to try to reduce
the opportunities for violence. Anecdotal evidence suggests that despite this,
women do not feel confident to leave their homes at night to visit the toilet.
Organizations providing toilets and showers must consult with camp residents
to identify ways to ensure that people feel safe to use the facilities night and day.

Substitution cannot continue long term. Substitution cannot continue long
term. The IFRC and other agencies providing water and sanitation services are
currently supplying services on behalf of the Haitian authorities and are
stretched beyond their collective capacity and mandate. The current approach
is one of containment; buying time whilst longer-term decisions are made.
This situation cannot continue forever. Whilst the government and WASH
cluster are developing plans for the transition of responsibilities for water
provision, plans for sanitation are still in their infancy. A dual approach giving
equal prominence to funding both sanitation and water provision is required
to secure the health of people affected directly and indirectly by the earthquake.

International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

Jean-David Dieudonné was unemployed before the
earthquake, but he used to help his mother with
her small trading business. His wife left the country
seeking better opportunities in Santo Domingo, capital
of the Dominican Republic. Since the earthquake, he
has been lucky to find work in the camp where he lives.

He works as a hygiene promoter with the British Red
Cross at a camp known as La Piste. He says, “I started
working here two months ago. Before the earthquake
I used to live nearby in Pont Rouge but now I live here
at the camp.”

Jean-David works six days a week and earns 550
Haitian dollars a month. It’s enough to support himself
and his ten year-old son.

“I’m happy to be part of a team that is teaching people
to be healthy. We encourage people to come to the
meetings we organize. We talk to them about how to
keep clean and wash their hands to prevent disease.
We use theatre to show people how to use the toilets
properly,” he says.

According to Jean-David, the hygiene promotion
activities have had an impact on people’s behaviour
already. “I can see a difference. Before we started this
work, we would sometimes find human faeces on the
ground in the camp, but we don’t see that anymore.
People use the toilets now, and use paper to wipe
themselves – before they used cardboard or anything
else they could find. Until the earthquake happened,
many people had never really learnt about sanitation.
Now, as a result of our hygiene promotion activities,
people are changing their behaviour.”

As a resident in La Piste, Jean-David is not only a
promoter of good hygiene but also benefits from the
services provided by the British Red Cross. “I used to
have a toilet in my house, but the ones we have here
in the camp are better. People used to complain about
the pit latrines we had at first in the camp because
there were lots of flies and the rain got into them, but
now they’ve been replaced with the elevated toilets,
they’re much better.”

Hygiene promotion
at Camp La Piste

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International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

Every morning at 8am, Jasmin Herline and fellow
Automeca camp resident Lucia Toussaint clean the
toilets in block 2. Much to their dismay, the toilets are
always in a mess again the following morning.

“I ask myself, ‘Would people take better care of the
toilets if they were in their own homes?’ Maybe it’s
because the toilets are provided for free that people
think it’s OK to treat them badly.”

Jasmin moved to the camp with her extended family,
including her parents, brother, sister, husband and her
two children in the aftermath of the earthquake. Previously
her home was on the road that leads to the airport.

“I lived near the toilets when they were first installed and
I volunteered to help take care of them because it’s a
service that the Red Cross provides us with.” Soon the
British Red Cross began paying a salary of 250 Haitian
gourdes per day to the hard-working teams who clean

the toilets. Part of their job is to inform the Red Cross
when the tanks are full so that they can be emptied.

In her old home, Jasmin cleaned her own toilet with the
same attention to detail that she does now. “I use this
toilet so I make sure it’s clean,” she says.

In some camps, residents return to their abandoned
homes to use the toilets rather than use the ones
installed for communal use. Jasmin thinks this might
be due to security issues. “There are no security
patrols in the evening so it’s dangerous to go out to
the toilet. Even the men don’t feel safe going out in
the dark. I use a vase in my tent and throw it out the
next morning.”

The Automeca camp has a committee and organizes
volunteer security patrols during the day, but it’s
difficult to get volunteers to work at night as they fear
for their safety.

Sanitation technicians –
doing the work that nobody
else wants to do

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International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

The challenges
of the next 6–12 months

Taking the first steps towards
sustainable sanitation solutions

The focus of the first six months has been on assuring a minimum level of human
and solid waste management in the camps. During the next 6–12 months,
DINEPA and organizations such as the IFRC will increasingly focus attention
on addressing the health and hygiene issues of people moving to transitional
shelters and those returning to their homes. This will include repairing usable
toilets in homes that have been classified as structurally sound or reparable, as
well as improving existing services in the camps.

It is clear that finding sustainable solutions in sanitation, in the short and
longer term, can only follow once solutions are found to shelter issues such
as rubble clearance and making resettlement options available to homeless people.
Working in an integrated manner and increasing the scale and speed of
interventions will be essential. It is worth noting that the current delays being
experienced by agencies bringing vital equipment into Haiti are impacting
their abilities to deliver sanitation, as well as other services. Waiting for vehicles
such as de-sludging pumps to clear customs and be registered is significantly
holding up some operations. Speeding up the registration and import of essential
equipment should be prioritized.

One of the key lessons learned in the first months of the earthquake response
operation was the need for flexibility regarding the individual context of
each camp and neighbourhood; determining the most appropriate solution
to residents’ sanitation needs. Each camp has different characteristics and
may need a different approach; agencies must build their approaches on what
will work in that context.

Improving the sanitation habits of people, whether they are living in camps
or returning home, is an approach being advocated by the WASH cluster, of
which IFRC is a part. If, for example, people were using a sludge collection
system at home before the earthquake, then ensuring this is done regularly,
hygienically and that the sludge is dumped appropriately may be a good solution
once they return home.

International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

Nicolette Bernard is a 30-year-old qualified nurse who
leads a team of 10 Red Cross hygiene promoters at
the Automeca camp. “I love what I do. It’s about giving
information, education and encouraging behaviour
change. I love the contact with the people. My job now
is more rewarding than my previous job, as I see a
change in people’s behaviour,” she says.

Before the earthquake, Nicolette worked at the
maternity ward of the St. Croix hospital in Léogâne. At
the time of the earthquake she was at home in Port-
au-Prince and ran to safety in a nearby field. At first,
she helped at a local hospital, but then made contact
with the Haitian Red Cross through her sister, who has
been a volunteer for many years.

“The Red Cross needed help so I volunteered as
a translator with the health team. Then one day
Mrs Ferna Victor, Branch Director of the Haitian Red
Cross, told me the British Red Cross was looking for
nurses for hygiene promotion.”

Nicolette manages a team of hygiene promoters, toilet
cleaners and inspectors who work together to ensure
that camp hygiene is maintained at an acceptable level.
The hygiene promoters use lively songs and interactive
practical demonstrations to spread their message and
focus particularly on the children. Camp residents
are encouraged to form sanitation committees to
clean their toilets on a regular basis. Toilet inspectors
make daily rounds to ensure the structures are well
maintained and that doors and roofs don’t disappear.
This is easier said than done; in some camps such as
La Piste, toilet doors have disappeared only days after
being installed.

Nicolette laments the breakdown in the provision
of sanitation services over the years: “In the 1980s,
the capital was a lot cleaner. But overpopulation
and reduced public spending led to poorer levels of
hygiene.”

Nicolette and her team are working to change poor
hygiene habits and improve the landscape. “People
used to leave their garbage all over the place even
though there were bins around. Now they use the bins.”

Making it fun
to learn about hygiene

CASe STudy
©
I
F
R
C

International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

Whilst the IFRC works mainly in larger camps and neighbourhoods, other
agencies and NGOs are working in small camps that are not accessible to
larger de-sludging machines. They have also taken this “improve on what exists”
approach, consulting with camp dwellers to learn and build upon their own
practices. They are currently piloting a number of different options. These
include field-testing the distribution and safe collection of biodegradable
bags13 in locations where there appears to be no other viable solution (for
example, no space for more conventional toilets), installing toilets that use
little or no water,14 and investigating options to introduce manual de-sludging
pumps that would improve upon the bayacou system of toilet clearance used
prior to the earthquake.

In camps where several agencies have responsibility for sanitation provision, a
common approach on the ground must be adopted. In some cases, different
agencies have differing means of responding (for example, some pay for toilet
cleaning whilst others prefer a community support approach). This can lead to
difficulties and tensions, which must be avoided. A unified approach should be
taken, led by the needs on the ground.

City-wide solid waste management, such as collecting garbage from bins and
transporting it to the dump site, is clearly not the responsibility of those agencies
currently providing sanitation services. Key to moving forward here will be
the leadership and commitment of the appropriate authorities, together with
the capacity-building support of the international community so that they can
manage this task effectively. SMCRS is increasing its capacity to manage solid
waste and keep streets clean, but it needs the resources to sustain these
improvements, increasing the regularity of garbage collection, maintaining
infrastructure and equipment, training and retaining staff for the long term.
Support for an initial large-scale, cash-for-work scheme to clear all ravines,
gullies and drainage ditches would enable SMCRS to maintain a cleaner
environment, as well as reducing Port-au-Prince’s vulnerability to flooding in
the event of heavy rains or hurricanes.

Support should also be given to SMCRS to improve the existing waste disposal
site for Port-au-Prince. Currently, both solid and human waste – including
faeces in plastic bags, a commonly used option in Haiti – is indiscriminately
dumped at Truitier, just outside the city. Those who have visited the site describe
it as “worse than hell”: a huge area of stinking and slowly smoking garbage,
picked over for recyclable material by people who live nearby. Enabling the
separation of solid and human waste will be vital.

In the next six to 12 months, DINEPA and the agencies working in the provision
of sanitation services will need to confront a number of dilemmas:

How to stabilize the sanitation services in the short term in camps that are
precariously located and absolutely unsustainable in the long term without
inadvertently giving messages that it is appropriate and acceptable for people
to live in these locations. In larger camps, agencies are preoccupied with how
to avoid inadvertently contributing to the creation of long-term slum areas.

13 Including the use of PeePoo bags which speed up the decomposition of faeces – http://www.peepoople.com/showpage.php?page=5_0
14 For more information on Ecosan toilets, see WaSHlink – http://washlink.wordpress.com/category/toilet/ecosan/

International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

How to put in place a coherent and coordinated strategy for more sustainable,
lower-cost15 medium- and longer-term options for excreta disposal for urban
earthquake-affected populations, displaced populations, and returnees. Using
de-sludgable toilets is a suitable solution for the emergency and recovery phases
of the emergency, however, it may not be a sustainable option because of cost
and logistical considerations.

How to accurately measure the coverage of sanitation facilities in camps given the
difficulties in ascertaining exactly how many people are living permanently in
any given camp and lack full access to toilets. Methods to determine appropriate
toilet coverage per location, including observation and surveying, are required,
focusing on toilet usability rather than the number of toilets originally built
– which may not be serviceable due to theft or misuse.

How to build community engagement in camps that are not established communities,
which is a particular challenge for agencies more used to working in rural
settings. Whilst some smaller neighbourhood camps (groups of neighbours
occupying space near their homes) may be tight-knit communities, many of
the larger camps are not communities but collections of displaced people. In
the months to come, including those people living in the camps will be critical.
In La Piste camp, for example, both the Spanish and British Red Cross societies
are developing ways of engaging women in the camps. Other organizations
have had some success creating mothers’ groups in the camps. Each camp
requires an individual approach.

How to interact with camp committees that may be self-appointed rather than
representative. Whilst some committees are genuinely working hard for the
best interests of camp residents, others may be motivated by self-interest, which
agencies cannot support. Working through the women’s groups mentioned above
may be an approach to avoid unwittingly supporting undemocratic committees.

After six months of intensive work on the ground, some of the 48 WASH agencies’
plans to increase sanitation work are being severely hampered by difficulties in
finding staff. In mid-June, Relief Web16 was advertising 21 vacant positions for
senior water and sanitation professionals for Haiti, (four for IFRC programmes),
whilst IFRC had 11 positions advertized on its own internal job vacancy site
JobNet. Engaging camp dwellers where possible in community mobilization
and non-technical roles will free up senior staff, but unless the staffing shortages
are urgently met, the water and sanitation situation of many Haitian people
will be adversely affected. Identifying new sources for personnel is a priority; the
funds are there to do a good job, but little can be achieved without the staff in place.

15 after the earthquake, private de-sludging companies were charging 40 USD per de-sludge per cubicle. Currently, rates are around
14 USD per de-sludge per cubicle. It is estimated that over 800 m3 of excreta sludge is being transported out of Port-au-Prince each day.
16 amongst other things, ReliefWeb advertises job vacancies: http://www.reliefweb.int/rw/res.nsf/doc212?OpenForm

19
International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

Paul Ladouceur has been a Haitian Red Cross
volunteer for 14 years. He started working with the
French Red Cross as a hygiene promoter in 2003.
Since the earthquake, teams of volunteers like Paul
have been working in camps across Port-au-Prince
encouraging communities to keep their environment
clean and healthy.

Every Saturday, Red Cross volunteers organize a
“clean-up day” in the camps, providing residents with
forks and spades to shovel up the waste that litters the
camps. The plastic bags, bottles and human waste are
then taken in wheelbarrows to a truck that dumps it at
the main garbage disposal site in Port-au-Prince.

An earnest and studious man, Paul joins the families in
raking up the dirt in the burning midday sun.

“It is vital that the residents take responsibility for the
cleanliness of the camp and for their health. Disease
prevention is better than cure.”

The volunteers also encourage the communities to dig
ditches for the water to run off after the rains. The camp
is not low-lying, so there is no great risk of flooding, but
Paul says people are concerned about the impact of
heavy rains that fall during the hurricane season. He
gives them advice about not seeking shelter under
trees, but in strong buildings such as schools and
churches instead.

The volunteers run competitions between the different
blocks in the camps and at the end of the day the
residents organize festivities such as theatre, dance or
music. It helps to foster a sense of community for a
group of people who have been brought together by a
force of nature.

Cleaning up the camps
CASe STudy

20
International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010
The next ten years

Innovation is the key
There are huge challenges in meeting the long-term sanitation needs for Haiti,
but at the same time great opportunities exist to make substantial improvements
to the sanitary environment of Port-au-Prince and beyond. The key is to support
the Haitian authorities in investigating and putting in place pioneering sanitation
solutions. The crucial starting point is to ensure that equal importance, support
and funding is channelled to sanitation as well as the provision of water
in tackling the long-term rebuilding of Haiti.

Sustainable sanitation depends upon sustainable housing plans. Developing
a comprehensive resettlement plan, together with urban planning for Port-
au-Prince, are vital steps to finding durable and integrated shelter and sanitation
solutions. As plans are put in place to upgrade different neighbourhoods, there
is an opportunity to integrate sanitation together with plans for houses, roads,
water, electricity and communications – substantially improving life for many
of Haiti’s citizens.

Valuable lessons can be learned from other cities affected by devastating
earthquakes, including Managua, Nicaragua in 1972 and Arequipa, Peru in
2001. The Managua earthquake left more than half the population homeless
and 70 per cent of buildings destroyed or severely damaged.17 Some sources
estimate that rebuilding the capital took 38 years and misguided urban planning
decisions were said to have resulted in major social upheaval in the years following
the disaster. Looking at sanitation, there are valuable lessons to be learned
from countries such as India, Tanzania and Brazil where innovative approaches
to providing sanitation in crowded urban environments are being developed
and implemented.

Transporting and dumping human waste is costly. Given the high water table
throughout low-lying areas of Port-au-Prince, putting in a conventional sewage
system may be out of the question. But specialists suggest that more innovative
solutions, including small-bore sewerage, make more sense in Haiti. There
may also be opportunities for sanitation systems to provide sustainable livelihoods,
converting the health risks that excreta represent today into jobs tomorrow.
Large-scale composting of waste for agricultural use or production of biogas
are two options that require investigation for viability in Haiti, given that
transporting and dumping human waste is costly.

An absolute priority in solid waste management is clearing the rubble. Apart
from impeding the flow of traffic and the reconstruction of homes and permanent
buildings, piles of rubble are becoming part of the scenery, with people learning

17 Mallin, J, The Great Managua Earthquake, http://www.ineter.gob.ni/geofisica/sis/managua72/mallin/great01.htm.
See also http://www.mcclatchydc.com/2010/02/15/85144/haiti-quake-fear-what-if-recovery.html
comparing Managua and Port-au-Prince.

International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

to live around them, attracting yet more garbage. Developing Haiti’s capacity
to manage the solid waste it produces – through, perhaps, large-scale recycling –
rather than continuing to dump it represents an enormous opportunity to
improve the environmental health of Haiti.

As plans are made for the allocation and distribution of funds pledged towards
rebuilding Haiti, the WASH cluster’s sanitation working group has started to
identify the key components for a long-term sanitation strategy for Haiti. A
number of the following elements will form part of this strategy.

The long-term institutional support and funding to the Haitian authorities
responsible for the provision of sanitation services throughout the country is
essential, so that sanitation policy can be reviewed, staff capacity expanded
and equipment provided. A key step is to support DINEPA’s top priority of
identifying an appropriate site for sludge treatment, as well as investigating the
most appropriate technologies to do this. DINEPA also needs to develop its
capacity to deliver sanitation services; currently, it has many staff focusing on
water, but only one focusing on excreta disposal.

Supporting the development of a thriving private sector will also be important,
particularly in stimulating the local production of septic tanks, toilets and other
hardware, and providing support to bayacou. Agencies are currently discussing
different approaches to repairing individual toilets in homes – such as giving
cash grants or vouchers together with technical advice and follow-up.

Investment in formative research is needed now in areas such as the barriers
and motivational factors to achieving improved sanitation within Haitian society,
the ability and willingness to pay for it, and whether there is an openness to
adopt innovations such as the agricultural use of human-derived fertiliser or
the conversion of excreta into energy through biogas production. All these issues
must be properly researched, together with a better understanding in how to
carry out urban mass sanitation, given that most experience to date stems from
rural and peri-urban situations.

Haiti is still in the first phase of recovering from the devastating effects of the
12 January earthquake, but now is the time to look forward – to the next six
months and also to the next 10 or 20 years. The decisions made now will have
the most profound influence in helping the country deliver a prosperous future
for its citizens. Making sure that sanitation is given equal priority and funding
to the provision of water – and seizing opportunities to put in place innovative
long-term approaches to solid and human waste management in Haiti requires
immediate action, research and planning.

22
International Federation of Red Cross and Red Crescent Societies
From sustaining lives to sustainable solutions: the challenge of sanitation in Haiti • Special report, six months on • July 2010

Haiti earthquake
operation in figures

(Figures accurate to 30 June 2010)

Health
95,000 people have received treatment at Red Cross Red Crescent healthcare facilities.

1,000 to 2,000 patients seen each day.

152,342 people vaccinated against measles, diphtheria and rubella.

More than 16 million community health awareness text messages have been sent.

Water, sanitation and hygiene promotion
300,000 men, women, and children reached by hygiene promotion activities.

Everyday, the Red Cross Red Crescent trucks 2.4 million litres of water to 94 water points in camps in Port-au-Prince
– enough for 280,000 people.

2,671 latrines have been built.

Shelter
120,000 families – or 597,000 people – have received Red Cross Red Crescent emergency shelter materials.

The Red Cross Red Crescent is committed to building 30,000 transitional shelters.

Relief
955,000 relief items – hygiene kits, kitchen sets, jerry cans, buckets, blankets and mosquito nets – have been distributed.

disaster preparedness
With the hurricane season looming, the IFRC is prepositioning relief items in ten high-risk regions for 25,000 families
(125,000 people) across Haiti.

Tens of thousands of SMS messages in Creole are being sent asking people if they want information on how to be
prepared during the peak of the hurricane season.

Logistics
Over the course of the operation, more than 11,000 tons of Red Cross Red Crescent aid has arrived in Haiti.

The Fundamental Principles
of the International Red Cross
and Red Crescent Movement

Humanity
The International Red Cross and Red Crescent Movement,
born of a desire to bring assistance without discrimination
to the wounded on the battlefield, endeavours, in its
international and national capacity, to prevent and alleviate
human suffering wherever it may be found. Its purpose
is to protect life and health and to ensure respect for the
human being. It promotes mutual understanding, friendship,
cooperation and lasting peace amongst all peoples.

Impartiality
It makes no discrimination as to nationality, race, religious
beliefs, class or political opinions. It endeavours to
relieve the suffering of individuals, being guided solely by
their needs, and to give priority to the most urgent cases
of distress.

Neutrality
In order to enjoy the confidence of all, the Movement
may not take sides in hostilities or engage at any time in
controversies of a political, racial, religious or ideological
nature.

Independence
The Movement is independent. The National Societies,
while auxiliaries in the humanitarian services of their
governments and subject to the laws of their respective
countries, must always maintain their autonomy so that
they may be able at all times to act in accordance with the
principles of the Movement.

Voluntary service
It is a voluntary relief movement not prompted in any
manner by desire for gain.

unity
There can be only one Red Cross or Red Crescent Society
in any one country. It must be open to all. It must carry on
its humanitarian work throughout its territory.

universality
The International Red Cross and Red Crescent Movement,
in which all societies have equal status and share equal
responsibilities and duties in helping each other, is worldwide.

19
9

6
0

0
7
/2

0
1
0

2
0

0
The International Federation of
Red Cross and Red Crescent
Societies promotes the
humanitarian activities of National
Societies among vulnerable
people.

By coordinating international
disaster relief and encouraging
development support it seeks
to prevent and alleviate human
suffering.

The International Federation,
the National Societies and the
International Committee of
the Red Cross together constitute
the International Red Cross and
Red Crescent Movement.

Haiti: From sustaining lives to sustainable solutions –
the challenge of sanitation

A publication from the International Federation
of Red Cross and Red Crescent Societies (IFRC)

For more information, please contact:

IFRC Americas Zone
Tel: + 507 380 0250

IFRC Geneva Secretariat
Media service duty phone
Tel: + 41 79 416 38 81
Email: media.service@ifrc.org
www.ifrc.org/haiti

IFRC Water, Sanitation and Emergency Health Unit
Tel: + 41 22 730 42 18

REPORT OF THE CSIS COMMISSION ON

Smart Global Health Policy

A HEAlTHIER,
SAFER, ANd
MORE PROSPEROuS
WORld

COCHAIRS
William J. Fallon & Helene D. Gayle

1800 k STREET NW, WASHINgTON dC 20006

P. 202.887.0200 F. 202.775.3199 | WWW.CSIS.ORg

Ë|xHSKITCy065974zv*:+:!:+:!
ISBN 978-0-89206-597-4

REPORT OF THE CSIS COMMISSION ON

Smart Global Health Policy
A HEAlTHIER,
SAFER, ANd
MORE PROSPEROuS
WORld

COCHAIRS
William J. Fallon & Helene D. Gayle

About CSIS At a time of new global opportunities and
challenges, the Center for Strategic and International
Studies (CSIS) provides strategic insights and
policy solutions to decisionmakers in government,
international institutions, the private sector, and
civil society. A bipartisan, nonprofit organization
headquartered in Washington, DC, CSIS conducts
research and analysis and develops policy initiatives
that look into the future and anticipate change.

Founded by David M. Abshire and Admiral Arleigh
Burke at the height of the Cold War, CSIS was
dedicated to finding ways for America to sustain its
prominence and prosperity as a force for good in
the world. Since 1962, CSIS has grown to become
one of the world’s preeminent international policy
institutions, with more than 220 full-time staff
and a large network of affiliated scholars focused
on defense and security, regional stability, and
transnational challenges ranging from energy and
climate to global development and economic
integration.

Former U.S. senator Sam Nunn became chairman
of the CSIS Board of Trustees in 1999, and John
J. Hamre has led CSIS as its president and chief
executive officer since April 2000.

COCHAIRS
William J. Fallon (Cochair), Admiral, U.S. Navy (Retired)
Helene D. Gayle (Cochair), President & CEO, CARE

COMMISSIONERS
Rhona S. Applebaum, Vice President, The Coca-Cola Company
Christopher J. Elias, President & CEO, PATH
Representative Keith Ellison (D-MN)
William H. Frist, former U.S. Senate Majority Leader
Representative Kay Granger (R-TX)
John J. Hamre, President & CEO, CSIS; former U.S. Deputy Secretary of Defense
Peter Lamptey, President, Public Health Programs, Family Health International
Margaret G. McGlynn, former President, Global Vaccines & Infectious Diseases, Merck and Co.
Michael Merson, Director, Global Health Institute, Duke University
Patricia E. Mitchell, President & CEO, The Paley Center for Media
Surya N. Mohapatra, Chairman, President & CEO, Quest Diagnostics, Inc.
Thomas R. Pickering, Vice Chairman, Hills & Company
Peter Piot, Director, Institute for Global Health, Imperial College London; former Director of UNAIDS
Karen Remley, Commissioner, Virginia Department of Health
Judith Rodin, President, The Rockefeller Foundation
Joe Rospars, Founding Partner, Blue State Digital
Robert E. Rubin, Cochairman, Council on Foreign Relations; former U.S. Secretary of the Treasury
Senator Jeanne Shaheen (D-NH)
Donna E. Shalala, President, University of Miami; former U.S. Secretary of Health and Human Services
Senator Olympia Snowe (R-ME)
Debora L. Spar, President, Barnard College
Rex Tillerson, Chairman & CEO, Exxon Mobil Corporation
Rajeev Venkayya, Director, Global Health Delivery, Bill & Melinda Gates Foundation

CSIS COMMISSION ON SMART GlObAl HEAlTH POlICy

CSIS does not take specific policy positions;
accordingly, all views expressed herein should be
understood to be solely those of the author(s).

Library of Congress Cataloguing-in-Publication
Data CIP information available on request.
ISBN 978-0-89206-597-

Center for Strategic
and International Studies
1800 K Street, NW
Washington, DC 20006
Tel: (202) 775-3119
Fax: (202) 775-3199
Web: www.csis.org

Photo Credits

Cover: Polio Vaccination in Nepal, CSIS Global Health Photo Contest 1st
Place Winner, Susheel Shrestha, 2008.

Page 3: 159-5 Lagos, Nigeria, Kunle Ajayi, 2006/Daily Independent,
courtesy of Photoshare, 2010.

Pages 4, 5, 7, 9, 13, 20, 23, 27, 33, 34, 35, 40: Commissioners, Liz Lynch/
CSIS, 2009.

Pages 8, 12, 16, 23, 26, 32, 33, 38: Commissioners, Kaveh Sardari/CSIS,
2009.

Page 7: Commission in Kenya, Evelyn Hockstein/CARE, 2009.

Page 9: Mother and Child, CSIS Global Health Photo Contest Finalist,
Mohammad Rakibul Hasan, 2009.

Page 11: U.S. Navy Petty Officer 2nd Class Timothy Hall, DoD photo by
U.S. Navy Seaman Apprentice Bradley Evans, Defense.gov, 2009.

Page 17: A girl in primary school, Bandar Abbas, © UNICEF Iran,
Shehzad Noorani.

Page 18: Epidemia de Pánico, Eneas (CC BY-NC 2.0).

Page 24: Portrait of Woman and Child, Sri Lanka, Dominic Sansoni/World
Bank.

Page 24: Malaria Bed Net, Talea Miller, PBS Online NewsHour (CC BY-
NC 2.0).

Page 28: Commissioners, Daniel Porter/CSIS, 2009.

Page 29: Commissioners, Indra Palmer/CARE 2009.

Page 39: Keith Ellison in Kenya at Ifo Camp Verification Center, Jennifer
Cooke/CSIS, 2009.

CONTENTS

Opening Letter

Synopsis

Part I: A Quantum Leap Forward

Part II: A U.S. Global Health Strategy

1. Maintain our commitment to the fight
against HIV/AIDS, malaria, and tuberculosis

2. Prioritize women and children in U.S. global
health efforts

3. Strengthen prevention and health emergency
response capabilities

4. Ensure that the United States has the capacity
to match our global health ambitions

5. Make smart investments in multilateral
institutions

Part III: Closing Thoughts

Endnotes

Appendix

Acknowledgments

6 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

The 25 commissioners who signed this report
joined together in the spring of 2009 with a sense
of optimism, purpose, and engagement. We firmly
believed the United States can better the lives of
the world’s citizens and advance its own interests by
investing strategically in global health—even at a time
of global economic recession and exceptional domestic
challenges. One year later, we remain convinced not
only of this statement’s veracity, but of its urgency. But
truly remarkable gains for global health will only be
achieved through a smart, long-term U.S. approach
that harnesses all of America’s assets and expertise—in
better partnerships with friends and allies.

The Commission was an experiment. At the outset,
we wondered whether two dozen diverse individuals—
accomplished opinion leaders and high-level strategists
of varied political stripes, drawn from backgrounds
in business, finance, Congress, media, philanthropy,
foreign affairs, security, government, and public
health—could reach consensus on a long-term plan
for the United States to save and enhance the lives of
millions of people around the world through global
health. We have not answered all the questions that
emerged, nor have we devised perfect solutions. But
we believe we have put forward a compelling, concrete,
and pragmatic plan of action.

We owe this achievement to the dedicated commitment
of our fellow commissioners, as well as the extensive
and generous support we’ve received from countless
experts. We approached this task humbly, with
gratitude and respect for those who have worked long
hours in hospitals and clinics, laboratories, and in the
field to make this world a healthier place. Our report
builds upon their knowledge and experience.

The Commission convened for full-day deliberations
on June 10 and October 16, 2009. In August, some
of us traveled to Kenya to view first-hand the impact
of U.S. global health investments, as well as our future
challenges. Over 10 months, we held numerous
conference calls and expert consultations, each with
a high level of commissioner participation. We also

benefitted significantly from the willingness of senior
officials in the White House, the U.S. Department of
State, the U.S. Agency for International Development,
and the U.S. Department of Health and Human
Services, including the Centers for Disease Control
and Prevention and National Institutes of Health, to
share their perspectives with us.

Throughout the course of the Commission’s work, we
were determined to connect with the growing numbers
of Americans, particularly students, who are passionate
about global health. With the help of the staff of Blue
State Digital, we created an interactive Web site, www.
smartglobalhealth.org, which allowed us to exchange
ideas with thousands of people who proposed
questions for deliberation, anecdotes and photos from
the field, and most importantly, fresh, critical insights.
Their input is reflected in the report, including the
stunning cover photo! We also traveled to two major
centers of American global health work—the Research
Triangle in North Carolina and the California Bay Area—
for public consultations. These honest and substantive
conversations with the public informed our work as well.

The report that follows represents a majority consensus
among the commissioners. We did not insist that
each commissioner endorse every point contained in
the document. In becoming a signatory to the report,
commissioners signal their broad agreement with its
findings and recommendations.

This is a good moment to pause, set aside our immediate
concerns or diverse views, and reflect on just how much
our nation has achieved, especially in the past decade, in
saving and enhancing the lives of millions of individuals.
As we examine how we can better organize and apply
ourselves, make the best use of our assets, and be more
effective in our actions, let us imagine what the global
health outlook could be in 2025, if only we set clear and
realistic goals and stay on course to achieve them.

Sincerely,

Admiral William J. Fallon (ret.) Dr. Helene D. Gayle
Cochair Cochair

Opening Letter from the Commission Cochairs

William J. Fallon Helene D. Gayle

Senator Olympia
Snowe (R-ME)

Debora L. Spar Rex Tillerson Rajeev Venkayya

Joe Rospars Robert E. Rubin Senator Jeanne Shaheen
(D-NH)

Donna E. Shalala

Thomas R. Pickering Peter Piot Karen Remley Judith Rodin

Margaret G. McGlynn Michael Merson Patricia E. Mitchell Surya N. Mohapatra

William H. Frist Representative Kay
Granger (R-TX)

John J. Hamre Peter Lamptey

Rhona S. Applebaum Christopher J. Elias Representative Keith
Ellison (D-MN)

CSIS Commission on Smart Global Health Policy

8 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

Synopsis

9SynopSIS

As the United States applies smart power
to advance U.S. interests around the world,
it is time to leverage the essential role that
U.S. global health policy can play.

Americans have long understood that promoting
global health advances our basic humanitarian values
in saving and enhancing lives. In recent years, support
for global health has also proven its broader value
in bolstering U.S. national security and building
constructive new partnerships.

A smart, strategic, long-term global health policy will
advance America’s core interests, building on remarkable
recent successes, making better use of the influence
and special capabilities of the United States, motivating
others to do more, and creating lasting collaborations
that could save and lift the lives of millions worldwide.
It will usher in a new era in which partner countries take
ownership of goals and programs, in which evaluation,
cost effectiveness, and accountability assume vital roles,
and in which a focus on the health of girls and women
becomes a strategic means to bring lasting changes.
And it will enhance America’s influence, credibility, and
reservoir of global goodwill.

The CSIS Commission on Smart Global Health Policy
calls on Washington policymakers to embrace a five-
point agenda for global health—a mutually reinforcing
set of goals to achieve U.S. ambitions and partner
country needs.

1. Maintain the commitment to the
fight against HIV/AIDS, malaria, and
tuberculosis

It is critical that the United States keep its HIV/AIDS,
malaria, and tuberculosis programs on a consistent
trajectory, even in the face of a grave fiscal situation
and competition from other worthy priorities. Today,

more than 2.4 million persons living with HIV are
directly supported by the United States with life-
extending antiretroviral treatment (ART). Many others
are ready to begin treatment. If we continue investing
steadily in these programs, the Obama administration
can realize its goal of funding antiretroviral treatment
for more than 4 million people over the next five years;
and our AIDS and malaria platforms can expand
successfully into other health areas, in partnership with
able international alliances like the Global Fund to
Fight AIDS, Tuberculosis and Malaria.

It won’t be easy. Over the past year, the pace of growth
in treatment has slowed. Budgets have tightened.
Concerns have mounted over the long-term cost
of treatment, especially if resistance develops to
current medications. In this difficult climate, tensions
have risen among global health advocates. But
compassionate, realistic, patient U.S. leadership can
transcend fragmentation, ameliorate conflict across
health constituencies, and ensure that immediate
budgetary woes do not derail our efforts. We can
leverage our existing disease-focused investments to
create lasting health systems, with long-term solutions
based on steady growth that reduce mortality and
illness, and build partner country capacities.

2. Prioritize women and children in U.S.
global health efforts

The United States should move swiftly and resolutely
to bring about major gains in maternal and child
health, through proven models of care prior to,
during, and after birth, and through expanded access
to contraceptives and immunizations. A doubling
of U.S. effort—to $2 billion per year—will catalyze
inspiring results. Direct U.S. investments are best
focused on a few core countries in Africa and South
Asia where there is clear need, the United States can

“We have before us the chance to accelerate our recent historic successes in advancing
global health. If Americans seize this moment, take the long strategic view, make the
commitment—with our friends and allies—the lives of millions will be lifted in the coming
decades. The world will be safer and healthier. Our nation will have shown its best.”
— Helene D. Gayle

10 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

make a distinctive contribution, partner governments
are willingly engaged, and there is a genuine prospect
of concrete health gains and increasing country
capacities. At the same time, renewed emphasis on
U.S. investments through multilateral channels can
enable us to reach a broader population in need.

Closing gaps in the critical services and protections
provided to mothers and children is a smart, concrete,
and effective means to strengthen health systems
and lower maternal and child mortality and illness.
Affordable tools exist to reduce infant deaths in
the first month of life; expanded immunizations
can improve child survival; and expanded access to
contraceptives can bolster women’s health.

U.S. leadership in collaboration with others will lift
the lives of the next generation of girls and women,
strengthen families and communities, and enhance
economic development worldwide. It will also
accelerate progress toward the major Millennium
Development Goal (MDG) of improving maternal
mortality, where efforts during the past two decades
have yielded scant gains.

3. Strengthen prevention and capabilities
to manage health emergencies

Disease prevention offers the best long-run return on
investment. Millions of children die from the effects of
malnutrition; greater investments in nutrition can save
them. Behavior changes can significantly lower the rate
of new HIV infections, curb tobacco use, and reduce
premature death from chronic disorders, which are
rising steeply in developing as well as middle-income
countries. Better lifestyle choices can be advanced
through sustained education. Now is the time for the
United States to share expertise, best practices, and
data, and advance the newly launched Global Alliance
for Chronic Disease.

Meeting emerging threats requires long-range
collaborative investments: building preparedness
among partner countries to prevent, detect, and
respond to the full range of health hazards, including
infectious diseases; and creating reliable opportunities
for poor countries to access affordable vaccines
and medications that will be crucial in combating
pandemics. Strengthening the shared oversight of
food and drug safety is also essential in an increasingly
integrated global marketplace.

4. Ensure the United States has the
capacity to match our global health
ambitions

In an era where much more is possible in global health,
and much more is at stake, the U.S. government needs
greater predictability, order, evaluation, leadership,
partnerships, and dialogue with the American people.

An essential step is to forge a global health strategy,
organized around a forward-looking commitment
of about 15 years, careful planning, and long-term
funding tied to performance targets. Such an approach
could preserve our gains and provide the long-term
predictability and time to achieve substantial progress
in reaching our core goals: improving maternal and
child health, access to contraceptives, preparedness
capacities, control of infectious diseases, and means
to address chronic disorders. Strengthening skilled
workforces and infrastructure around these objectives
typically requires 15 to 25 years. The Commission
recommends that a deputy adviser at the National
Security Council (NSC) be charged with formulating
global health policy; overseeing its strategy, budget, and
planning; and ensuring a strong connection between
the president, the NSC, the Office of Management
and Budget (OMB), and the diverse agencies and
departments responsible for implementation. The

“A smart global health policy can leverage the immense capabilities and generosity of the
U.S. government and the American people. It can vastly improve the lives and personal
security of millions of people and in the process, help to increase worldwide economic
and political stability.” — William J. Fallon

11SynopSIS

Commission further recommends that an Interagency
Council for Global Health be established, reporting
to the NSC deputy adviser. Leadership for this
Interagency Council should be provided by the
Departments of State and Health and Human
Services—the two departments that account for the
overwhelming majority of global health resources
and programs—and should facilitate coordination by
setting benchmarks, reviewing progress, improving
data, and building accountability.

The Commission recommends that a senior global
health coordinator, located in the Office of the
Secretary of State, coordinate day-to-day operations
and implementation of the president’s six-year,
$63-billion Global Health Initiative. The Department
of State has been performing this role to date and has
shown commendable progress in persuading relevant
agencies and departments to work together.

Our in-country ambassadors, as “honest brokers”
at ground level, should lead the integration of our
health, climate change, food security, and other
development programs.

In the face of our current fiscal constraints, we will
need to stay on course to fulfill the president’s Global
Health Initiative (FY2009–FY2014). Over the longer
period, 2010 to 2025, a reasonable growth target is for
U.S. annual commitments to global health to be in the
range of $25 billion (inflation adjusted) by 2025.

There is much to be gained if the administration and
Congress both alter their practices to allow for multiyear

budgeting of long-term global health programs, as well
as for support of innovative financing methods. The
Commission recommends that Congress establish a
House/Senate Global Health Consultative Group for
the next three years to advance long-range budgeting,
promote the implementation of an integrated, long-
term U.S. global health strategy, and improve cross-
committee congressional coordination.

For the first time, the National Institutes of Health
(NIH) has made global health one of its top five
priorities. NIH is now poised to better leverage the
exceptional science and research strengths of our
nation to benefit U.S. global health programs through
operational research, cultivation of the next generation
of scientists in partner countries, and accelerating
the development and delivery of new vaccines and
treatments. These efforts will achieve maximum
benefit if they are closely integrated into a U.S. global
health strategy.

Congress is in the midst of overhauling the
authorities and resources of the U.S. Food and Drug
Administration (FDA), which regulates all U.S. drugs
and 80 percent of the U.S. food supply. Congress
should give the FDA the means to work with our
trading partners, particularly developing countries, to
improve inspection and quality control of food closer
to its place of origin and better coordinate food and
drug safety efforts with regional and multilateral health
and economic institutions.

12 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

Information technology can be applied in several
ways to assess and enhance health programs. A new
measurement paradigm, using proven methods to
document “hard” health outcomes—in terms of lives
saved, diseases and disabilities prevented, and increased
partner government capacities to deliver health
services—will be essential. This step is necessary to
build confidence, generate better data, and strengthen
a culture of measurement and accountability, for
the U.S. and partner governments and other health
organizations. Well-planned evaluations of ongoing
health programs can also provide information
that program managers could use to improve
implementation. The U.S. government can more
systematically tap the special competencies of the
U.S. private sector to strengthen the performance of
U.S. global health programs—for example, through
better utilization of expertise in systems design (supply
chains, workforce training and retention, marketing
campaigns, use of information tools); the placement
of talented business leaders onto boards; and the
development of health insurance in developing
countries. This will build on the results-oriented
approach and private-sector best practices that imbue
the Millennium Challenge Corporation (

MCC

Cabinet officials and other U.S. leaders of global
health programs should more regularly and actively
communicate with—and convey U.S. achievements
with more certainty to—university and faith
communities, philanthropies, leaders in industry and
science, and health implementers. These constituencies
are eager to join a richer and more active two-way
dialogue and to acquire a greater voice and ownership
of U.S. global health approaches. Moreover, they are
fundamental to building an enduring American base of
support for global health.

“When the U.S. devotes resources to global health, we are establishing global partnerships.
These are not only humanitarian investments; we are ensuring the security and prosperity
of nations around the world.” — Representative Kay Granger

5. Make smart investments in
multilateral institutions

The Commission recommends that the United States
bolster its collaboration with partner institutions
capable of achieving significant health outcomes: the
World Health Organization (WHO); the World Bank;
the GAVI Alliance; the Global Fund to Fight AIDS,
Tuberculosis and Malaria; and traditional UN agencies
such as UNICEF. The United States will continue
to put a strong focus on its direct investments, since
such a bilateral approach affords greater control and
accountability and strengthens bilateral partnerships
and goodwill, but multilateral approaches offer a vital
and necessary complement. By pooling resources and
efforts with others, the United States is better able
to build health systems, extend the reach of vaccine
and infectious disease programs beyond U.S. partner
countries, devise alliances to meet trans-sovereign
challenges, and mobilize resources and leadership
among our partners. By championing the achievement
of the Millennium Development Goals by 2015, the
United States can demonstrate both its leadership and
the heightened value it places on multilateralism. At
the same time, we need to look realistically beyond
2015 to the considerable additional work that will
likely be required over the following decade to
consolidate and sustain MDG progress.

Enhanced U.S. leadership and engagement
multilaterally will be crucial in three areas: finance,
coordination, and strategic problem solving.

Finance: It is in our long-term interests to make
substantial financial commitments and to make
a stronger diplomatic effort to improve these
organizations’ performance and governance. The
Commission recommends that the United States
increase the share of global health resources dedicated
to multilateral organizations from 15 to at least 20

13SynopSIS

percent, while also enlisting commitments from other
donors, recipient partner governments, and emerging
powers—working bilaterally, through the G-8, and
increasingly through the G-20. The United States
should press the World Bank to significantly step up
its role in building health systems. Finally, the United
States should support, both materially and politically,
promising innovative financing options that could
enable the future mass-scale delivery of life-saving
vaccines or other innovations.

Coordination: The United States’ commitment
to work with others is essential to untangle the
counterproductive proliferation of uncoordinated
donor demands for data. This obstacle to efficiency,
in part exacerbated by U.S. programs, results
in duplicated effort and wasted resources. The
United States could work more closely with other
governments, donors, and organizations in support of
strengthened national health plans aiming for greater
efficiency and streamlined efforts.

Strategic problem solving: The United States can
join with key world leaders, possibly through fresh
global health summits, to seek concrete solutions
to challenges such as the health workforce deficit,
drug resistance to existing therapies, global pricing
of commodities, metrics, and long-term financing.
High-level leadership can pragmatically tie health
investments to improved water, sanitation, and
nutrition. U.S. leadership can also substantially
accelerate efforts to curb global tobacco use: by
ratifying and advancing the Framework Convention
on Tobacco Control; sharing best practices through
the WHO; encouraging partner governments to make
regulatory reform a high priority; and spotlighting

the burdensome long-term health costs of tobacco
use versus the short-term economic gain of increased
production, domestic sales, and exports.

If we pursue these steps, we can accomplish great
things in the next 15 years.

We can cut the rate of new HIV infections by two-
thirds, end the threat of drug-resistant tuberculosis, and
eliminate malaria deaths.

We can significantly expand access to contraceptives,
which will substantially improve the health of mothers
and their families.

We can reduce by three-quarters the 500,000 mothers
who die each year in pregnancy; save over 2.6 million
newborn babies from perishing in their first month of life;
and significantly reduce the more than 2 million deaths
of children under five years of age caused each year by
vaccine-preventable diseases.

Using existing medicines, we can control or eliminate
many neglected diseases that affect billions of people in the
developing world.

We can help build the basic means to detect and respond
to emerging health hazards and build a better system for
ensuring access to essential vaccines and medications when
severe pandemics strike.

And with U.S. assistance, developing and middle-income
countries alike can greatly reduce the premature death and
illness associated with diabetes, cardiovascular disease,
tobacco use, and traffic accidents.

Put simply, we can give global public health an excellent
prognosis for lasting progress.

“Public health conditions in developing countries are critical not only to those countries
but, in an increasingly inter-connected world, to the industrial countries as well. Disease
can spread rapidly with modern transportation, trade and travel; and the industrial
country economies are ever more dependent on developing country supply chains, with a
corresponding interest in minimizing disruptions or productivity losses due to disease. The
Commission’s report sets forth a plan for thoughtfully increasing health care assistance and
for making that assistance more effective.” — Robert E. Rubin

14 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy8 CSIS Commission on Smart Global health policy

I | A Quantum Leap Forward

15a Quantum leap foRwaRd

Over the past decade, the United
States has jump-started an historic
health transformation in poor villages,
communities, and countries worldwide.
American engagement, in partnership
with others, has saved and lifted human
lives on a scale never known before. In the
past, such impressive humanitarian gains
might have been seen merely as “soft,” yet
we now understand their benefits include
advancing economic development and
regional stability. More than ever, we
realize that U.S. global health programs are
a vital tool in a smart power approach to
promoting U.S. interests around the world.

We have come a long way. In 2000, Washington
policymakers were debating whether the United States
could muster even a $100-million contribution to the
global fight against HIV/AIDS. Today, the United
States is investing more than $8 billion each year to
protect poor people from HIV, malaria, tuberculosis,
and other threats to a healthy life. If we include U.S.
clean water, sanitation, and other investments, U.S.
commitments exceed $10 billion per year.1

Today, owing to sustained antiretroviral treatment
(ART), more than 4 million mothers, fathers,
daughters, and sons have escaped premature death
from HIV and returned to productive lives. The
United States can proudly and accurately claim that it
directly supports over 2.4 million of these individuals.2
Millions of Zambians, Rwandans, Ethiopians, and
Tanzanians now also live free of the threat of malaria,
thanks to rapidly expanded distribution and use of bed
nets, medications, and insecticidal sprays.

Millions of poor children around the world have been
immunized against measles and polio this decade
with support from the United States. They now
have an opportunity to live full lives, free of these
crippling diseases.

But the United States did not bring about these
changes just by injecting aid dollars. High-level,
persistent U.S. leadership has been indispensable.

Through that leadership, America has rallied global
opinion behind the moral call to reduce the stark
health inequities that divide the world’s rich from its
poor. It has helped the world to confront the reality
that unchecked disease can threaten global stability.
It has catalyzed a new global will for action and
shattered the old conventional wisdom that ART
is too expensive and too difficult to administer in
remote communities. It has sparked unprecedented
investment in the science and research that can lead to
new vaccines and medications for the world’s deadliest
and most costly diseases. And it has helped spur other
donors and international organizations to do far more:
today, the total external investment in global health
exceeds $22 billion per year—still less than needed,
but 20 times more than was available in 2000.3

It has also revealed how U.S. health investments
advance America’s standing and interests in the world.
In the 2007 Pew Global Attitudes Survey, for example,
8 of the 10 countries with the most favorable opinion
of the United States were African states where the
United States has made the greatest health efforts.4

Meanwhile, deaths related to HIV declined by over
10 percent in 12 countries targeted by the President’s
Emergency Plan for AIDS Relief—the majority in

“Smart power is neither hard nor soft—it is the skillful combination of both. Smart power means developing an integrated
strategy, resource base, and tool kit to achieve American objectives, drawing on hard and soft power. It is an approach that
underscores the necessity of a strong military, but also invests in alliances, partnerships, and institutions at all levels to expand
influence and establish the legitimacy of American action. Providing for the global good is central to this effort because it
helps America reconcile its overwhelming power with the rest of the world’s interests and values.” — CSIS Commission on
Smart Power, 2007

16 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

eastern and southern Africa.5 These health gains have
bolstered regional stability and economic growth,
demonstrating the interdependence of human security
and state stability in fragile regions, and the powerful
impact of “soft” health investments.

The Roots of Success

Recent gains were built on the remarkable
achievements of earlier decades. The
eradication of smallpox in the 1970s,
advances in prevention and treatment
of common childhood illnesses, and the
dramatic progress in controlling polio since
the late 1980s inspired many to ask: why
can’t we do more?

But the tipping point came earlier this decade through
new commitments and financial support from
traditional donor countries and new leadership in the
countries most burdened by ill health and poverty.
Across Africa, Asia, and in many other developing
areas, a new generation of leaders, activists, scientists,
and health experts rose to meet the challenge. Within
the G-8 and the UN General Assembly, among
wealthy donors, across civil society groups and through
new global alliances—most importantly the Global
Fund and the GAVI Alliance—it became possible
to leverage political will and resources, create a new
understanding of the acute burden of infectious
diseases, and open new channels to prevent and
control them.

Most significantly, the American people came to
believe that global health is a worthy, collective good
that must include strong U.S. engagement and that
U.S. leadership on global health is among the best uses
of U.S. smart power—one that can generate dynamic
new partnerships that encompass more than the health
arena. Across presidential administrations and in the
Congress, global health has been largely immune to
political polarization and indeed has become a zone
of exceptional bipartisan consensus. The President’s
Emergency Plan for AIDS Relief (PEPFAR) and the
President’s Malaria Initiative (PMI) are two signature
White House initiatives launched by President George
W. Bush and now sustained by President Barack

Obama through his administration’s emerging six-year,
$63-billion Global Health Initiative. Through these
endeavors, the United States proved that multiyear
plans, geared to achieve concrete results—and
calculated in billions versus millions—create powerful
credibility, momentum, and leverage.

America’s nongovernmental, philanthropic, and faith
communities also embraced the cause of global health.
Many prominent opinion leaders made innovative,
substantive contributions, while also shaping
Americans’ outlook: Bill and Melinda Gates, backed
by their foundation and now supported by Warren
Buffet, have been an especially powerful force, along
with Bono and the One Campaign; the Reverend Rick
Warren and the Saddleback Church; former president
Bill Clinton and the Clinton Global Initiative; former
president Jimmy Carter and the Carter Center; and
Ted Turner and the UN Foundation. Across America,
countless small nonprofit health and development
groups and grassroots activists acquired a new voice,
advocating expanded U.S. engagement in global health
and a two-way dialogue between the U.S. government
and engaged citizens on future strategies.

On American campuses, interest surged among
youth and faculty alike, and promising global health
programs proliferated.6 In the private sector, biotech
firms and pharmaceutical companies forged dynamic
alliances with universities to create knowledge,
innovation, skills, jobs, and long-range global
partnerships. Their impact can be seen in New York
City and Atlanta, North Carolina’s Research Triangle,
California’s Bay area, the Seattle metro area, and the
Boston corridor, to name the most prominent.

17a Quantum leap foRwaRd

In 2008–2009, the prestigious U.S. Institute of
Medicine, with support from diverse U.S. agencies and
private funders, assembled a cross section of the world’s
leading global health experts that critically affirmed
U.S. global health achievements during the past decade
and provided a set of concrete recommendations that
informed the design of President Obama’s Global
Health Initiative.7

The American public applauded these efforts. Surveys
affirmed that in good economic times and bad,
Americans believe U.S. investments in global health
are a worthy use of scarce U.S. dollars and generate
results that enhance human lives. In early 2009, even
as U.S. unemployment was accelerating, a Kaiser
Family Foundation survey showed that two-thirds of
Americans supported maintaining or increasing U.S.
funding to improve health in developing countries.8

Keeping Our Eyes on the Prize

Now, as we look to the next 15 years, the
challenge is to solidify and expand the
progress we have made. If we succeed, we
will see historic gains not just in reducing
mortality and illness but also in building
resilient, competent health systems—as
well as major advances in gender equity,
economic development, and human
security.

Ensuring that women have full access to AIDS
treatments and are empowered—economically, legally,
and politically—can enhance their access to other
health services and enable them to be more successful
mothers and wage earners. Preventing malaria can
unlock economic productivity by liberating parents to
work full days at full strength. The world will continue
to surprise us with threats like H1N1, avian influenza,

“Investing in the health of women and girls around the globe is one of the most effective, yet
under-utilized, tools for encouraging social stability and economic prosperity in the developing
world. When women are empowered and healthy, families and communities will thrive. A
strong commitment to addressing maternal and child health will save countless lives and is one
of the smartest development investments we can make.” — Senator Jeanne Shaheen

SARS, extensively drug-resistant tuberculosis, and
more. Yet, creating laboratories and surveillance
systems will help communities and nations shield
themselves against the pathogens of the future, before
these invisible threats do irreparable harm. But taking
the next leap forward will not be easy.

First, disease treatment alone will not create the long-
lasting solutions the world so desperately needs. In the
case of HIV, for example, new infections will continue
to far outpace the numbers of people receiving
treatment unless prevention becomes a true priority
and more effective programs are in place. Prevention is
just as crucial with many other diseases; new vaccines
against diarrheal disease and pneumonia and access to
clean water can avert millions of childhood deaths, and
public education programs can significantly reduce
countless millions of deaths and illness due to smoking
and alcohol abuse. Better safety efforts will reduce
contamination of both food and drugs.

Second, while the past decade has seen tremendous
progress, many gaps and disparities persist. Thanks
to a strong global effort, a mother and her family in
Kenya might now be able to go to a clinic and receive
tests and treatment for HIV. But that same family
might still lack access to bed nets and medications
for malaria or the treatment and care required for
tuberculosis. They might still lack access to basic
prevention and treatments for the parasitic diseases
and diarrhea that so disrupt and limit the lives of the
poor. And while deaths from AIDS and malaria have
gone down, other health issues—maternity care, for
example—have been neglected. To families around the
world, the consequences are all too real: every minute,
one mother dies giving birth, while another 30 suffer
serious complications as a result of their pregnancy.9
Each year, 4 million newborns die in their first month
of life—roughly the number of all babies born in

18 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

the United States. All of these outcomes are largely
preventable with existing tools.

Third, the world will not wait. The earth’s population
is projected to rise faster than ever before, from 6.8
billion today to 8.1 billion in 2025, and possibly
stabilize at 9.1 billion in 2050. Most of that growth
will be in poor, densely populated urban areas that
are prone to infectious disease outbreaks. As we
witnessed in early 2008, when food riots erupted
in over 33 countries, these overburdened cities can
be flashpoints for political violence. And whereas
industrialized countries will see their populations aging
and their birthrates declining, developing countries
will continue to have the world’s highest birthrates and
most youthful populations.10 In Africa, South Asia,
and other low-income regions, women’s health status
and that of their families will benefit directly and
considerably from better access to contraceptives.

The poorest 2 billion people are also likely to
experience high rates of traffic deaths and

injuries

and
to have rising premature death rates from diabetes and
cardiovascular disease, connected to tobacco use, poor
diet, and obesity.

Fourth, there is no guarantee that the consensus
that enabled our current progress will last. At
home, we face a weak economy, stubbornly high
unemployment, division over reform of our own
health system, record deficits, and a swiftly rising
national debt. The dire fiscal situation is leading to an
intensifying discussion of possible tax increases and
spending cuts. Bipartisanship has frayed on multiple
fronts; bipartisan unity on global health could be the
next casualty. The ongoing debate over the future
of U.S. foreign aid may distract policymakers from
health priorities, even as American global health

advocates are fragmented, anxious, and engaged in a
polarizing competition for funding.

Americans firmly support U.S. investments in global
health, yet they are relatively unaware of the actual
impacts of the more than $30 billion the United
States has expended on HIV/AIDS and malaria
since 2003. Advocates struggle to find compelling
language to describe the global health challenges,
opportunities, and risks that lie ahead. And while
experts acknowledge the need for a new evaluation
paradigm that ties goals to measurable results, they are
hampered by a lack of agreed methods and standards,
quality data, and established analytic capacities.

Internationally, we face potentially daunting long-
term carrying costs for ART, influenced in part by
rising rates of drug resistance to current medications.
Improving maternal and child health, another global
imperative, is a complex, long-term project that
will require patience, perseverance, and new models
that succeed. Economically strapped countries may
not be able to fulfill their pledges to commit more
of their budgets to health. At the same time, many
face internal political barriers to better governance
and resist changing laws to guarantee gender equity,
to better protect women and girls, and to end
discrimination and stigma.

The Time to Act

These challenges are formidable. And
yet, if we act now, we know they can be
overcome.

First, we have more interventions today than ever
before. We have learned a vast amount about how
to deliver treatment, especially for those living with
HIV, tuberculosis, and malaria.We are learning more

“The president’s six-year, $63 billion Global Health Initiative promises broad developmental
benefits that extend well beyond important health services. Its success will be enhanced through
broad-based expert advice—of the kind this Commission has gathered—and by adopting a
business mindset of accountability, systems planning and careful measurement of true health
impacts. I am very hopeful.” — Rex Tillerson

19a Quantum leap foRwaRd

“On U.S. college campuses we’re finding that our students have an unconsummated desire for
sacrifice and service. They want to make a difference in the world. It’s the role of universities
to develop global health education, research and service-learning opportunities that meet this
desire while also adding value to communities in which students serve. ” — Michael Merson

about how to effectively prevent disease through
changes in behavior and links with other development
challenges. New vaccines have become available, and
several others are expected to become available in
the next few years. Critical health messages are now
reaching remote communities through the use of new
low-cost technologies such as cell phones and simple
computers. Operational research is showing us how to
deliver interventions more effectively. And, especially
in a time of budgetary restraint, global public health is
a “best buy”—one that can bring preeminent benefits
to the larger U.S. development and poverty-alleviation
agenda, buoying education, agriculture, infrastructure,
and sanitation priorities.

Second, we know the long-term, strategic, integrated
use of U.S. smart power has a multiplier effect.
Investments in global health bring greater shared

global security. Consistent, high-level U.S. leadership
can inspire other donors and partner governments to
reach their targets, convince private industry to create
and deliver low-cost vaccines and medications, and
spur greater efficiency in programs funded by multiple
donors such as the GAVI Alliance and the Global
Fund. To give just one example, in October 2009,
when the United States committed 10 percent of its
H1N1 vaccine stockpiles to the developing world, 10
other countries joined with similar pledges.

Third, the international health community
increasingly recognizes the need to streamline cross-
cutting donor demands and to create new evaluation
tools that better track performance and build
accountability. There is also a new understanding
that national governments must shoulder higher
responsibilities, while donors must make greater

The Consortium of Universities for Global Health
(CUGH) comprises more than 50 schools with global
health programs, working collectively to define the field,
standardize curricula, expand research, influence policy,
and coordinate projects in less-developed countries.

A CUGH study shows that the number of students
enrolled in U.S. and Canadian global health programs
doubled from 1,286 to 2,687 between 2006 and
2009. Spurred by this surge in interest, 20 universities
from the United States and Canada came together in
September 2008 to form a coordinating entity.

The Consortium held its first annual meeting at the
National Institutes of Health in September 2009,
attracting 250 representatives from 58 universities.

The meeting featured panels on public engagement
and global health financing, a conversation among five
university presidents, a keynote address by the Office
of Management and Budget’s special adviser on health
policy, Ezekiel Emanuel, and a briefing for Congress
organized by CSIS on the powerful opportunities for
students to do health work abroad.

The CSIS Commission was impressed by the
Consortium’s potential capacity to organize a critical
and excited constituency—future global health
leaders—operating at the intersection of research,
education, and volunteerism. The collective passion,
commitment, and knowledge it embodies will make
CUGH an important partner in shaping global
health policy.

CONSORTIuM OF uNIvERSITIES FOR GlObAl HEAlTH

20 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

direct investments in their partner countries’ staff and
infrastructure.

If the United States commits now to a 15-year
leadership plan, imagine the results:

Our leadership and engagement can help the world’s
countries cut the rate of new HIV infections by two-
thirds, end the threat of drug-resistant tuberculosis,
and eliminate malaria deaths.

We can end the chronic neglect of women and girls
and nurture a new generation of adolescent girls and
young women who are healthy, in control of their lives,
and fully able to contribute to their communities.

We can significantly expand access to contraceptives
that can substantially improve the health of women
and their families.

We can cut maternal deaths by three-quarters
and newborn deaths by two-thirds. And we can
significantly reduce the more than 2 million deaths of
children under five years of age caused each year by
vaccine-preventable diseases.

Using existing medicines, we can control or eliminate
many neglected diseases that affect billions of people in
the developed world.

We can share with developing nations the basic
means to detect and respond to new disease threats,
engage them in open information exchange when
new pathogens emerge, and win their participation in
global deliberations over access to essential vaccines
and medications when severe pandemics strike.

With U.S. assistance, developing and middle-income
countries alike can greatly reduce the premature death
and illness associated with diabetes, cardiovascular
disease, tobacco use, and traffic accidents.

Put simply, we can give global public health an
excellent prognosis for lasting progress. And 15 years
from now, in 2025, we could celebrate a world where
public health has become the norm, not a luxury—and
developing countries have risen from aid dependency
to balanced cooperation with donors in creating health

systems that are accessible, effective, and built to last.

“As important as it is for the U.S. to increase its investments in global health, it’s equally
important to direct these resources to programs and interventions that will have the greatest
impact. Childhood immunization, antenatal care and other approaches to prevention stand out
as “best buys” in health, and should be core elements of any U.S. strategy. ” — Rajeev Venkayya

8
6
4
2

0
low InCome
CountRIeS

loweR
mIddle InCome
CountRIeS

uppeR mIddle
InCome
CountRIeS

hIGh InCome
CountRIeS

Total deaths (millions)

Chronic diseases include cardiovascular diseases, cancers, chronic
respiratory disorders, diabetes, neuropsychiatric and sense organ
disorders, musculoskeletal and oral disorders, digestive diseases,
genito-urinary diseases, congenital abnormalities and skin diseases.

pRoJeCted deathS
by maJoR CauSe
and World Bank income group, all ages, 2005

communicable diseases,
maternal and perinatal
conditions, and
nutritional deficiencies

chronic diseases *

injuries

21a Quantum leap forward

II | A U.S. Global Health Strategy

22 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

The smart use of U.S. power matters
profoundly to millions of men, women,
and children around the world. During the
previous decade, we expanded the realm
of the possible in saving and bettering
the lives of the poor. If the United States
pursues a long-term strategic approach to
global health, in concert with others, the
future is bright. But what exactly should
that approach look like? How can we turn
these ideas into action?

The first step is to develop and fund a U.S. global
health strategy for 2010–2025 that advances smart
power’s dual mission of improving the health of the
world’s poor and bolstering U.S. interests and standing
in the world.

The strategy should be rooted in the following
principles.

• Match our ambitions with long-term commitment
at the highest levels of U.S. leadership. We need
to be certain that we have sufficient, predictable
resources to sustain our efforts over the long haul.
We also need confidence that we are making true
progress in enhancing the health of individuals and

strengthening the institutions and services that are to
keep people healthy. If we only prepare for the short
term, securing lasting global health improvements
will be impossible.

• “Trust but verify.” We have learned that partner
countries usually know what is in their best interests
and that by listening to what countries need, and by
making direct investments over a long period, we can
lift the lives and health of families in the developing
world. We know that developing countries, given
the right conditions, can improve their own
governance, commit more of their own resources
over time, and escape dependency. But we also need
a new evaluation framework rooted in realism and
patience, concrete “hard” health outcome goals to
measure progress, mutual accountability, and new
evaluation tools to verify progress. This framework
will need to be built sequentially over a number of
years, but important building blocks can be put in
place now, and existing measurement and evaluation
competencies within the U.S. government can be
leveraged more strategically and effectively. If we are
to have reciprocal relationships that bear fruit over
time, we must hold both ourselves and our partner
countries truly accountable.

500,000

2,000,000

1,500,000

1,000,000

500,000

Jan. 23, 2004

date of initial funding
Sept. 30, 2004 maR. 31, 2005 Sept. 30, 2005 maR. 31, 2006 Sept. 30, 2006 maR. 31, 2007 Sept. 30, 2007 maR. 31, 2008 Sept. 30, 2008

(Celebrating Life: The U.S. President’s Emergency Plan for AIDS Relief 2009 Annual Report to Congress,
http://www.pepfar.gov/documents/organization/113827 )

2,007,800

1,640,000

1,385,500

1,101,000

822,000

561,000
401,000

235,000155,000

NuMbER OF IN dIvIduAlS RECEIvING ANTIRETROvIRAl
TREATMENT IN THE 15 PEPFAR FOCuS COuNTRIES
(Total of both upstream and downstream USG-supported interventions)

23a u.S. Global health StRateGy

• Build on existing successes. This means reinforcing
America’s new assets—PEPFAR, PMI, and the
Millennium Challenge Corporation (MCC)—
while leveraging critical global partnerships
with the GAVI Alliance, the Global Fund, the
World Health Organization (WHO), and other
UN agencies. It also means championing the
Millennium Development Goals (MDGs) that we
and the world embraced in 2000, the best agreed
framework for organizing conversations among
partner governments, independent groups, other
donors, and international agencies. In 2010, as we
enter the final five years of the MDG compact,
attention will turn increasingly to taking stock of
progress and disappointment. While much progress
has been made since 2000—for instance in battling
infectious diseases—high rates of maternal death
and complications from birth remain unchanged
across most developing countries. The United States
should play an active role in the evolving global
deliberations over a new shared vision that will
strengthen accountability and maximize progress
toward full achievement of the MDGs by 2015.

• Prioritize prevention. Averting disease and disability
through behavioral choices is the most effective and
affordable tool for building healthy futures. Yet,
too often, emphasizing prevention is mistakenly
perceived as a trade-off with treatment. We must
push back against that false argument. We can and
must prevent and treat simultaneously. But there

is no better way to save lives and resources than to
prevent people from getting sick in the first place.

• Be targeted. We need to focus the majority of our
resources on those developing countries where the
suffocating burden of bad health, today and into the
future, is concentrated; where the United States is
best positioned to contribute, directly and through
partners, in reducing premature death and undue
illness and suffering; and where the United States
can build lasting partnerships. In other developing
and middle-income countries that are not U.S.
focal countries, we should use U.S. expertise, data,
and influence to help public health officials reverse
the rising tide of premature death associated with
diabetes and cardiovascular diseases, tobacco use,
alcohol abuse, and road accidents.

• Embed our global health investments within the
larger development enterprise. A dollar directed
toward health should not stand alone in its own
stovepipe; it should be spent in ways that reinforce
a united U.S. effort to promote development. In
each country, there should be careful planning with
partner governments to link health dollars to the
dollars that go to nutrition, water, and sanitation; to
empowering women; and to building health systems
and human security against the toll of droughts and
floods, surprise pathogens, and conflict.

With these principles in mind, our national strategy
should have the following five key elements.

24 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

“It is difficult to imagine the public health needs of the 300,000 Somalis in the Dadaab
refugee camp in northeastern, Kenya which I visited in August 2009. The United States
should continue to engage in successful partnerships to bring health care to this fragile,
conflict-prone region and to build sustainable infrastructure that will meet the challenges
faced by such a vulnerable population.” — Representative Keith Ellison

1. Maintain our commitment to the
fight against HIV/AIDS, malaria, and
tuberculosis

We should use existing vehicles, most notably
PEPFAR, PMI, and the Global Fund, to accelerate
treatment while stepping up internationally
coordinated prevention efforts, especially in southern
and eastern Africa. If we continue steadily investing in
these programs, the Obama administration can realize
its goal of increasing the number of people receiving
U.S.-supported treatment to 4 million over the next
five years,11 and our AIDS and malaria platforms can
branch successfully into other health areas.

A top priority should be ending mother-to-child
transmission of HIV, expanding male circumcision,
and acquiring the data and implementing approaches
to prevent new infections, especially among girls
and women.12

Ensuring a consistent trajectory is essential, even in
the face of a grave fiscal crisis and competition from
other worthy health priorities; stalled progress will
only risk regression across these three major infectious
diseases. AIDS advocates are particularly anxious:
the steep growth rates in AIDS treatment are now
slowing, and concerns are mounting over the long-term
costs of treatment and the risk that future resistance
to medications could send those price tags higher.
The United States will need to be simultaneously
compassionate and realistic, with a can-do commitment
to long-term solutions for reducing mortality and illness
overall—including by achieving greater efficiencies and
better long-term pricing and financing. Fragmentation
and conflict across global health constituencies will
serve neither these constituencies nor the people who
desperately need their help.

2. Prioritize women and children in U.S.
global health efforts

Building on the rising tide of global awareness and
will, the United States should act immediately to
bring about major gains in maternal and child health,
together with expanded access to contraceptive
commodities. A doubling of U.S. effort—to $2 billion
per year—will have a catalytic impact.13 To be most
effective, we need to focus patiently and deliberately
on a few core countries in Africa and South Asia. This
new priority for the United States will address a glaring
global gap, directly contribute to building health
systems, motivate others to do more, significantly
enhance the well-being of the next generation of girls
and women, and strengthen families, communities,
and economic development.

Maternal mortality remains a profound challenge
and represents a shocking global health disparity: in
the industrialized world, a woman’s risk of dying in
pregnancy or childbirth is 1 in 7,300; in Asia, it is
1 in 120; and in sub-Saharan Africa it is 1 in 22. In
many cases, preventive solutions are clear, but access
problematic. Improving maternal mortality requires
a complicated and interlinked set of interventions
that are supported and sustained over time, including
heightened efforts to improve local transport.

Existing, effective models for managing prenatal and
postnatal care need to be expanded and deepened. The
U.S. Agency for International Development (USAID)
and the Centers for Disease Control (CDC) should
form a joint initiative to expand the availability of
proven models for prenatal care, emergency services
for pregnant women, and interventions that minimize
post-birth complications. At the same time, they
should significantly expand access to contraceptives,
so women can be empowered to decide family size and
when they wish to have their next child.

25a u.S. Global health StRateGy

Access to safe, affordable, and voluntary family
planning has been shown to profoundly affect the
health of mothers and their children. For every $100
million invested in family planning, 4,000 maternal
lives are saved, 70,000 infant deaths are prevented, and
825,000 abortions are averted.14

Infant and child health are obvious companion
elements. Every hour, more than 1,100 children
under the age of five perish—nearly 500 of

them infants in their first month of life. This is
unacceptable. It is estimated that a package of 16
simple, known, and cost-effective measures could
prevent nearly 3 million of the estimated 4 million
deaths in the first month of life. These interventions
include the promotion of breastfeeding, early
detection of complications, extra care of low-weight
babies, and warming the newborn.15

In August 2009, a delegation of CSIS commissioners,
led by Cochairs Gayle and Fallon, traveled to Kenya.
Kenya has been the recipient of multiple U.S.
investments in health. Over the course of its three-
day visit, the delegation focused on the impacts of
these health partnerships; the possibilities for greater
integration of U.S. support; and Kenyan perspectives
on planning for long-term sustainability.

The Kenyan case vividly illustrates the many significant
gains of recent years, as well as the tough work that lies
ahead. Among the delegation’s key impressions:

• Combined U.S. investments in health have
dramatically improved HIV treatment and prevention,
advanced gender equality, and helped build incipient
indigenous capacities. These achievements reflect
the hard work of an integrated and innovative U.S.
mission team that has been creative in building
partnerships and coordinating investments.

• Governance issues continue to inhibit an effective
national approach to public health. Too few Kenyan
leaders are committed to health; 35 percent of the
health budget goes unused each year; and the internally
divided Health Ministry—a political consequence
of the 2007 postelection violence—has increased
costs, confused local health officials, and lessened
accountability. Current and future efforts will only be
sustainable with more effective Kenyan governance.

• Though U.S. resource flows are dominated by HIV
assistance, integration of efforts has successfully
bolstered non-HIV services as well, particularly family
planning and tuberculosis; but long-term management
and expansion of integration efforts remain uncertain—
on both the U.S. and Kenyan sides.

• U.S. partnerships have also created a growing
surveillance network and base of
epidemiological analysis—achievements that will
be critical to ongoing efforts to respond to health
challenges and measure outcomes.

• U.S. partnerships have helped train a growing cadre
of technical and health professionals, but retaining
health personnel, including through incentives and
adequate pay, remains difficult.

• The donor community currently shoulders 98
percent of the HIV treatment burden, raising serious
concerns about the sustainability of the growing
“HIV mortgage.”

• Multiple human security challenges affect health
outcomes and compete for Kenyan policymakers’
attention and resources. These include severe food
insecurity, chronic water scarcity, spillover from
regional conflicts, and a growing humanitarian crisis
among refugees.

COMMISSION TRIP TO KENyA

26 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

An additional 2 million children under the age of five
could be saved each year through expanded access to
immunizations against the major causes of vaccine-
preventable deaths, including pneumonia, diarrhea,
and measles. Pneumonia, the single largest cause of
death in children under five, is responsible for one-
fourth of all child deaths. Rotavirus, the most common
cause of severe diarrhea in children, is responsible
for 500,000 childhood deaths and 2 million
hospitalizations each year. Averting these deaths, and
achieving the MDG of reducing childhood mortality
by two-thirds, can only be achieved with increased
support for immunization programs.

Beyond its most obvious benefits, immunization
also provides opportunities for program integration
within and across the health sector. New innovations
and partnerships are already expanding access to
vaccines. The GAVI Alliance, for example, has reached
an additional 256 million children with life-saving

vaccines over the last nine years.16 While at present
there is no effective vaccine against malaria, promising
clinical trials are under way. A sustained U.S. effort
that focuses on decreasing maternal and neonatal
deaths, expanding access to family planning, and
increasing the availability of essential immunizations
is achievable, would have dramatic health impacts,
and would set the stage for better integration and
strengthening of country health systems.

3. Strengthen prevention and health
emergency response capabilities

Prevention of disease and illness offers the best return
on investment. Behavior changes and changing societal
norms can significantly lower the rate of new HIV
infections, curb tobacco use, and reduce premature
death from chronic disorders.

There is no time to waste. Tobacco deaths are
projected to rise from 5.4 million in 2005 to 6.4
million in 2015 and 8.3 million in 2030. Projections
suggest that by 2015, 50 percent more people will
die of tobacco than of HIV/AIDS.17 Premature death
from cardiovascular diseases, diabetes, and cancer is
rising steeply in both developing and middle-income
countries. The moment for the United States to share
expertise, best practices, and data is now.

Meeting emerging threats requires long-range U.S.
collaborative investments: building preparedness
among partner countries to detect and respond to
pandemic diseases and other dangerous pathogens;
and creating reliable opportunities for poor countries
to access affordable vaccines and medications
that will be crucial in combating various diseases.
Strengthening the shared oversight of food and drug
safety is also essential in an increasingly integrated
global marketplace.

“Despite recent progress in expanding global access to vaccines, over 2.3 million
children under the age of 5 die every year due to vaccine-preventable illnesses.
Supporting immunization is one of the most cost-effective approaches to improving
the health of individuals and the economic development of low-income countries.”
— Margaret G. McGlynn

15-24 25-34 35+
30

0.0
Sub-
SahaRan
afRICa

South
and
S.e. aSIa

n. afRICa
and weSt
aSIa

latIn
ameRICa
and
CaRRIbbean

CentRal
aSIa

all
CountRIeS

Percentage of married
women with unmet need

(Center for Global Development, “Start with a Girl,”
http://www.cgdev.org/content/publications/detail/1422899)
Source: Sedgh, Hussain et al. 2007 (Rosen 2009)

unmet need foR ContRaCeptIon
amonG maRRIed women by
aGe and ReGIon

27a u.S. Global health StRateGy

The emergence in this decade of SARS, H5N1 (avian),
and H1N1 (swine-origin) influenza has increased
our awareness of the interdependence of human and
economic security, the moral and ethical questions
surrounding the equitable distribution of critical
health commodities, and the need for more systematic
global preparation for sudden-onset public health
crises. Creating capacities in developing countries to
respond to emerging disease threats is simultaneously
an investment in the well-being of the world’s poorest
individuals and in America’s self-interest.

Ultimately, decreasing the time required to recognize
and respond to emerging health problems within
developing countries will improve the overall health of
the entire global community.

To reach this goal, the United States should draw
systematically on its domestic preparedness experience
and its expertise in training field epidemiologists and
other public health workers. In particular, the CDC
should expand its Field Epidemiology and Laboratory
Training Program (FELTP) in priority developing
countries to enhance the collection of surveillance data
to guide long-term policy formulation, further the
use of communication technology to share essential

data among field partners, improve the planning and
evaluation of disease control efforts, and sharpen
detection of—and response to—newly emerging
threats to health. At the same time, the MCC
should launch an initiative focused on three critical
dimensions of health systems: financial management,
program management, and procurement.

4. Ensure that the United States has
the capacity to match our global health
ambitions

Improve the U.S. organizational structure

The U.S government is already exceptionally well
equipped to pursue an ambitious long-term global
health strategy.

For decades, the Department of Defense’s network
of overseas medical research laboratories has carried
out quality research on infectious diseases. The CDC
has earned an unparalleled reputation for technical
expertise across a full spectrum of public health
challenges, and in the past decade, it has expanded
its international contributions, including training in
disease surveillance, and become the trusted counsel to
many health ministries. USAID has helped introduce

Source: WHO vaccine-preventable diseases: monitoring system 2009 global summary
(Living Proof Project, Immunization Progress Sheet, http://www.gatesfoundation.org/livingproofproject/Documents/progress-against-immunization )

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

60%

40%

20%

Hepb3 = Hepatitis B vaccine

Hib3 = Influenza type B vaccine

DTP3 = Diptheria, tetanus and pertussis vaccine

Percentage of Coverage

ImmunIZatIon CoVeRaGe ContInueS to RISe
WHO/UNICEF Coverage Estimates for 1990-2008, as of August 2009

28 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

health services in impoverished communities,
promoted the reform of health systems, and cultivated
extensive ties to civil groups integral to community
empowerment and development.

The National Institutes of Health (NIH) has been
a global locomotive for scientific research and has
quietly underwritten the careers of many talented
scientists from the developing world. The Department
of Agriculture has a key role to play in promoting
nutrition, as does the Food and Drug Administration
(FDA) in promoting the safety of food and drugs.

Yet, paradoxically, despite these abundant assets, the U.S.
government is constrained organizationally from pursuing
a common, integrated approach to global health.

Until now, there has not been a single, coherent U.S.
global health strategy around which to align different
efforts. U.S. agencies have underinvested in impact
evaluation, and they often operate side by side with each
other and with other major bilateral and multilateral
agencies with no common set of outcome measures.

None of the U.S. agencies responsible for implementing
our global health agenda embraces global health as its
predominant mission. Within our government, we have
seen the clear advantages to the success of PEPFAR
in concentrating authority in the Office of the Global
AIDS Coordinator, beginning in 2003. Similarly,
the U.S. interagency team charged with coordinating

the U.S. response to pandemic influenza and other
emerging threats has performed increasingly well since
early in this decade, when there was a special, post-9/11
mobilization to deal with anthrax, and subsequently
SARS and avian influenza. But despite these gains,
considerable fragmentation persists.

U.S. agencies compete with one another, backed
by separate mandates, authorities, hierarchies, and
legislative ties. In any given program or country,
USAID and CDC are just as likely to pursue separate
and uncoordinated priorities as they are to cooperate.
The NIH and its researchers are typically disconnected
from the U.S. agencies that operate programmatically
on the ground. Military and civilian agencies are
often uncomfortable cooperating with each other,
even while they each separately attempt to track
and prepare for emerging disease threats in the same
vulnerable regions, and even as they each puzzle over
how to use health investments wisely to pull countries
out of conflict. Senior leaders in Washington may
have one set of global health priorities, while U.S.
ambassadors and aid officials posted abroad may have
another. Likewise, there has been no clear definition
of the optimal division of responsibilities between
U.S. agencies and international or multilateral
organizations.

Efforts to bolster government efficiency rarely excite or
inspire the media or the public. But until we address
our current organizational weaknesses, no U.S. global
health strategy is likely to succeed. If our government
remains poorly organized to deal with global health
challenges, we will not be able to prepare effectively
for contingencies, make mid-course corrections, or
respond to unforeseen threats.

We do not need to create entirely new agencies or
institutions to manage these problems, as most of
the building blocks are already in place. Instead, we
should organize ourselves more logically and efficiently,
strengthening our planning, coordination, and
communications systematically across the full range of
government players.18 While there is a striking need,
for instance, for an independent evaluation group, it
need not be a new government entity per se. More

29a u.S. Global health StRateGy

“If we take the next step to build a truly integrated U.S. senior leadership team
focused on global health, we will substantially advance our ability to save and
enhance lives.” — Donna Shalala

important is that it be sufficiently resourced and have
the mandate and means to carry out objective analyses.

Organizational reform of the U.S. approach to global
health could take place at a time when a broad debate
is unfolding over the ultimate purposes of U.S.
foreign assistance, writ large: to whom it should be
accountable, how it should be structured, and how
best it should be modernized and streamlined. That
debate has recurred at many different points over
the past several decades, and it continues to weigh
heavily in shaping an effective U.S. foreign policy
and development approach that can best serve U.S.
national interests and lift people’s lives worldwide.

Currently, two important reviews are under way: one
led by the White House, in the form of a Presidential
Study Directive; and one by the State Department,
the first Quadrennial Diplomacy and Development
Review (QDDR). Each is expected to issue findings
in 2010. Yet, reordering how the U.S. government’s
global health business gets done need not await the
larger quest to upgrade U.S. foreign aid. Indeed, efforts
undertaken now to bring greater unity, rigor, and
clarity of purpose to global health programs can spur
broader foreign aid reform.

Reform should begin with the creation of a global
health management team charged with translating
national policy goals into an interagency planning
process. Its leadership should rest in the Executive
Office of the President, where a deputy adviser at the
National Security Council should be charged with
formulating U.S. global health policy; overseeing its
strategy, budget, and planning; and ensuring a strong
linkage between the highest levels responsible for
policy—the president, the NSC, and the Office of
Management and Budget (OMB)—with the diverse

operational departments and agencies responsible for
implementation.

The Commission further recommends that an
Interagency Council for Global Health be established,
reporting to the NSC deputy. Leadership of this
Interagency Council should be provided by the
Departments of State and Health and Human
Services—the two departments that account for the
overwhelming majority of global health resources
and programs19—and should facilitate coordination
by setting policy benchmarks, reviewing progress,
improving data, and building accountability.

In addition, the Interagency Council should work to
improve cooperation at all levels. It could encourage
better collaboration between U.S. military and civilian
organizations, enhance coordination between scientists
and health practitioners, and encourage and coordinate
private-sector support for global health initiatives.

The Interagency Council could further elevate
international food and drug safety into the global
health fold, better link ambassadors and their country
teams with Washington policymakers, and align
health investments with broader development aims,
such as nutrition, access to water and sanitation, and
empowerment of women and girls.

The Interagency Council should be composed of
senior coordinators from each relevant agency—
individuals with the highest trust and confidence
of their respective cabinet secretaries and agency
administrators and empowered with appropriate
budget authorities to execute the council’s decisions.
Given the substantial funding and programmatic
responsibilities currently residing at the Department
of State, USAID, the Department of Agriculture,
and the Department of Health and Human Services
and its constituent agencies (NIH, FDA, and

30 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

that a senior global health coordinator, located in the
Office of the Secretary of State, coordinate day-to-
day operations and implementation of the president’s
$63-billion Global Health Initiative. The Department
of State has been performing this role to date and has
shown commendable progress in persuading relevant
agencies and departments to work together.

CDC), it will be particularly important that these
representatives report directly to their relevant cabinet
secretary. The Interagency Council will need also to
reach beyond this core to the Departments of the
Treasury, Homeland Security, and Defense, the Office
of the U.S. Trade Representative, and the National
Intelligence Council. The Commission recommends

“Our report provides a roadmap to help catalyze a new era in global health as we build
on the remarkable success of existing initiatives such as the President’s Emergency Plan
for AIDS Relief and the Global Fund. By increasing coordination, cooperation and
accountability—and prioritizing such goals as improving the health of women and
children—we can not only improve the health of millions, but also foster economic
development and security.” — Senator Olympia Snowe

PEPFAR: President’s Emergency Plan for AIDS Relief; PMI: President’s Malaria Initiative; NTD: Neglected Tropical Diseases Initiative;
MCC: Millennium Challenge Corporation; OGHA: Office of Global Health Affairs; OPHS: Office of Public Health and Science;
OGAC: Office of the Global AIDS Coordinator; OES: Bureau of Oceans, Environment, and Science.

(“The U.S. Government’s Global Health Policy Architecture,” Kaiser Family Foundation, April 2009)

SChematIC of the u.S. GoVeRnment’S G lobal health aRChIteCtuRe

THE WHITE HOuSE

GHI

State
OGAC
OES

Ambassadors
Missions

HHS OGHA OPHS

uSAId

bureaus for: Global Health;
Economic Growth,
Agriculture and Trade;
democracy, Conflict and
Humanitarian Assistance

PMI

NTd

PEPFAR

Avian Influenza
Action Group

Water for
Poor Act

defense

uSdA

Homeland
Security

labor

Commerce

EPA

Peace Corps

CdC

NIH

FdA

HRSA

CONGRESS

dEPARTMENT

INdEPENdENT AGENCy

dEPT. OPERATING uNIT

MulTI-AGENCy INITIATIvE

MCC

31a u.S. Global health StRateGy

At the Department of Health and Human Services, a
priority should be to ensure that the Office of Global
Health Affairs is fully staffed with senior talent.

Our in-country ambassadors, as “honest brokers”
at ground level, should lead the integration of
health, climate change, food security, and other
development programs. Embassy planning teams, led
by ambassadors, should be responsible for developing
individual country strategies with our partner
governments, formalizing them through country
compacts, and securing the ongoing political support
of senior partner government officials. This will be
particularly important as PEPFAR proceeds with its
aim of working more actively through ministries of
health and other public-sector partners on the ground.
In our key partner countries, the U.S. ambassador will
increasingly be expected to make promoting the U.S.
health agenda a top concern.

At home, cabinet officials and other U.S. leaders of
global health programs can more systematically and
actively reach out—and convey U.S. achievements
with more certainty—to university and faith
communities, leaders in industry, science, the media
and foundations, and health implementers. These
constituencies are eager to join a two-way dialogue
and to acquire a greater voice and ownership of U.S.
global health approaches. That will require a conscious
and sustained effort by the U.S. government to
nurture, build up, and leverage public support for U.S.
leadership on global health.

Ensure adequate long-term financing

Long-term planning for U.S. funding is as important
as better internal organization and, like measurement,
must be part of a more formal accountability

framework. We have seen that a dollar invested in
global health benefits us in multiple ways. Sustained,
predictable financing can secure those benefits, spur
other donors, and motivate partner governments to
make larger, long-term investments of their own. But
achieving that goal will require care and realism that
takes account of the current very difficult budgetary
constraints, while at the same time laying the
groundwork for a stable trajectory of long-run funding.

In the first and second phases of PEPFAR and now
through President Obama’s Global Health Initiative,
the United States has started to budget over an
extended multiyear framework and to distinguish
between funds that sustain and consolidate existing
priorities and those that enable programs to grow. This
promising new approach should now be expanded
to include multiyear funding of programs (such
as ongoing antiretroviral treatment) where current
uncertainty is problematic and counterproductive.

“The time has come for a new long-term global partnership and improved coordination
between the U.S., other bilateral and multilateral agencies, and developing countries. The
new partnership should ensure local ownership, leadership and capacity for sustainable
health and development programs.” — Peter Lamptey

32 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

Specifically, the Obama administration should push
past its current five-year planning horizon and develop
a framework for setting program and budget targets
through about 2025. Such an explicit commitment,
even though it would extend well beyond the tenure
of any single administration, can help consolidate
the attention of the American people and sustain the
bipartisan political support that will be necessary in the
decades ahead.

Such an approach will provide the long-term
predictability and time to achieve substantial progress
in reaching our core goals: improving maternal and
child health, access to contraceptives, preparedness
capacities, control of infectious diseases, and means
to address chronic disorders. Strengthening skilled
workforces and infrastructure around these objectives
typically requires 15 to 25 years.20

Ample, predictable long-term funding, tied to
performance targets, is essential to U.S. effectiveness.
In the face of the current fiscal crisis, we should
preserve our gains and stay on course to fulfill the
president’s six-year, $63-billion Global Health
Initiative (FY2009–FY2014). Over the longer period,
2010 to 2025, we should aspire for U.S. annual
commitments to global health to be in the range of
$25 billion (inflation adjusted) by 2025.

Funding allocations should focus dollars where the
United States can have the greatest impact—that is,
countries with the heaviest disease burdens and the
greatest willingness to make their own public health
investments. Clear agreement on mutual goals as
well as funding levels to be invested should be spelled
out in mutual accountability compacts with partner
governments.

Our multilateral partners have a critical role to play.
Currently, 15 percent of U.S. health aid is provided
through multilateral channels.21 This level should
rise to at least 20 percent over the next three years
and be concentrated on U.S. core programmatic
priorities—maternal and child health, infectious
diseases, prevention, and preparedness. Even as it earns
credibility and goodwill, this modest increase will help
achieve greater coordination, streamline effort, and
promote efficiency at the country level, providing a
further incentive for multilateral institutions to work
more closely with the United States.

The United States will achieve far greater predictability
and integration of U.S. funding if Congress increases
its focus on global health as a new, interdisciplinary
foreign policy priority. To achieve this goal, Congress
should establish a House/Senate Global Health
Consultative Group for the next three years, with
membership including the chairs and ranking minority
members of relevant committees. This Consultative
Group should be charged with reviewing progress in
implementing an integrated, long-term U.S. global
health strategy, generating concrete options for long-
range budgeting, and otherwise improving cross-
committee congressional coordination.22 It should have
its own small budget and staff and be empowered to
hold hearings, travel, issue reports, and liaise closely
with the Obama administration, but not to alter
existing committee jurisdictions.23

The United States should also systematically explore
how it can contribute to innovative approaches to raise
additional revenue for global health. Over the next
decade, one or more of these approaches might succeed
on a significant scale.24

“Having spent the week after the January 12 earthquake in an operating room in the Baptist
Mission Hospital in Haiti, I have been immersed in the needs of patients who are suffering from
lack of proper health care and access to basic needs such as food and water. This disaster is a
clarion call to the immediate needs of all those who are suffering from disease and extreme poverty
around the world.” — William H. Frist

33a u.S. Global health StRateGy

For example, the first advance market commitment
(AMC) was developed earlier in this decade as a
collaborative effort across a number of governments
and other partners, including the World Bank and the
GAVI Alliance. The core concept was to line up donor
funding, amounting to $1.5 billion, to stimulate the
pharmaceutical sector’s research and development of a
new childhood vaccine against pneumonia. That initial
effort has just become operational and is projected to
save the lives of millions of children under the age of
five over the next two decades.

A second AMC is now under discussion, potentially
focusing on either tuberculosis or malaria. U.S.
support could potentially accelerate this process, but
legislative action would be required, including the
creation of a reserve fund within the U.S. Treasury or
the establishment of a financial guarantee by the World

Bank or other international organization, before the
United States could make a legally binding multiyear
commitment.

Other new finance mechanisms have also gained
momentum and are worthy of serious U.S.
consideration. Under the International Financing
Facility (IFF), for example, bond financing backed by
donor governments provides access to funds to pay
for the distribution of important health products such
as childhood vaccines, while spreading the costs to
donors over a 20-year period. An initial IFF focused
on the introduction of childhood vaccines through the
GAVI Alliance was launched in 2006 with the support
of a number of European governments and the Bill
& Melinda Gates Foundation. In September 2009,
another coalition of European governments launched
a subsequent IFF valued at $1 billion to support the
strengthening of health systems. As with the AMC,

“The nature of our world has changed. Emerging challenges are forcing us to rethink our approach to global
affairs. If we can capitalize on U.S. health leadership and build the right types of alliances with partners around
the world, we can make a tremendous difference in people’s lives and also create a model for how to tackle many
of the trans-sovereign challenges of this century. ” — John Hamre

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Source: The Institute for Health Metrics and Evaluation, University of Washington; The Economist 2010

RaISInG It
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Development Assistance for Health, by channel of assistance

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34 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

U.S. support for an IFF mechanism would require
adjustments to longstanding U.S. financial regulations,
as well as careful consideration of the specific health
programs that would benefit and what their long-term
recurrent costs might be.

In the past, a combination of legislative, bureaucratic,
and philosophical barriers prevented the IFF and
the AMC concepts from being seen as feasible in
the United States. Both mechanisms require some
modification of the current budget process to
allow the U.S. government to enter into multiyear
financial commitments. In addition, in order to build
congressional support, the pharmaceutical industry
would need to commit—as part of an innovative
financing scheme that includes incentives for industry
participation—to make the types and levels of
contributions that would ensure affordable and wide
access to the target vaccines and other medications.

But the time has come for the United States to
reexamine its ability to engage with both approaches.
The AMC could play a pivotal role in ensuring that
the next generation of childhood vaccines achieves
its full potential in reducing childhood illness and
death. Likewise, given the U.S. commitment to the
strengthening of health systems, it will be important to
fully explore how the new IFF could help support this
common goal.

In 2007, with French leadership, 13 countries
launched the UNITAID program, a modest tax on
individual airline ticket purchases that has generated
over $1.2 billion for medications for HIV/AIDS,
tuberculosis, and malaria. UNITAID, now housed at
the WHO, has used its considerable spending power
to lower prices, reformulate medicines to be more
easily used by children, and ensure long-term financing

of treatment. Beginning in 2010, Americans will be
able to make voluntary contributions whenever they
make travel reservations with Expedia, Opodo, or
Travelocity, among others.25

As a complement to generating new funds through
innovative mechanisms, performance-based financing
holds the promise of “getting more health for the
money” by increasing efficiencies and results in
global health programs. Put simply, performance-
based financing provides financial and other types
of incentives to patients for seeking essential care
and to health care workers for achieving good
health outcomes. USAID has obtained dramatic
improvements in system performance in several
countries in awarding bonuses to clinics that
serve poor families with vaccinations, nutritional
supplements, and deliveries, and it should expand on
this experience by offering support for such programs
in country compacts.

Finally, in view of the proliferation of promising new
approaches that have emerged in recent years to make
health dollars go further, it is important that the U.S.
government organize itself to better understand its
options and systematically act in this area. Just as the
Commission has recommended a new government-
wide approach to health metrics, it advocates a
similar approach for introducing innovative financing
mechanisms and practices in program design. The
deputy adviser at the National Security Council and
the Interagency Council should form a committee to
examine the feasibility of establishing a U.S. Center
for Innovative Financing and Practices in Global
Health, which could operate in cooperation with
external partners, review the most promising ideas and
experiences, develop clear U.S. policy positions, and
engage with partners on implementation. That same

“The global media and technology revolution presents new opportunities for innovative strategies
in global health. Global connectivity means more accurate and relevant information sharing in
the field; new technologies enable new solutions to many global health challenges; and better and
more broad-based media attention helps build a base of American popular support for long-term
global health policies.” — Patricia E. Mitchell

35a u.S. Global health StRateGy

committee could engage with Congress beginning
in 2010 to advise on how to feasibly structure U.S.
support of the next AMC and whether similar support
for the IFF is warranted and possible.

Bring U.S. science and safety into the U.S. global
health strategy

Another top priority in the next 15 years should be to
take full advantage of the United States’ exceptional
assets in science and research, closely integrating them
within the U.S. global health strategy to support health
field programs and strengthen developing country
health systems.

For the past few decades, the NIH’s Fogarty
International Center has quietly and skillfully
stewarded a generation of developing-country
research scientists. That invaluable training effort
should be expanded substantially to underwrite the
next generation of skilled scientists in the developing
world, preparing them to carry out research that
will bring forward the next generation of medicines,
prevention, and diagnostic tools for both infectious
disease and chronic disorders. In early 2009, the head
of NIH announced that global health would be among
the five top priorities in the coming years. This is a
major, welcome change in policy, with the potential
to significantly strengthen the United States’ long-
range global health strategy, but it still remains to be
seen how much of the NIH’s annual budget of more
than $30 billion will be committed to global health,
through which institutes, for which precise objectives,
and guided by what long-term strategy.

One promising development came in mid-2009
with the announcement by the NIH’s National
Heart, Lung and Blood Institute of active support
for the new Global Alliance for Chronic Disease. As

NIH further develops its plans, one priority should
be to support applied research that examines the
downstream efficacy of U.S.-supported programs.
More broadly, NIH plans should closely align with
the U.S. global health strategy.

Food and drug safety are now recognized to be global
health issues. Unsafe food and drugs exact a significant
human and economic toll across the board—in
developed, middle-income, and developing countries.
Given the increasing complexity and volume of
international trade, no single national regulator alone
can ensure the safety of food and drugs used by its
citizens. There is, however, an enormous opportunity
for U.S. leadership in addressing the issue. Congress
is in the midst of overhauling the authorities and
resources of the FDA, which regulates all U.S. drugs
and 80 percent of U.S. food supply. Congress should
give the FDA the means to work more effectively
with our trading partners, particularly developing
and middle-income countries, to improve their food-
inspection and quality-control capacities—close to
the place of origin—and better coordinate food and
drug safety efforts with regional and multilateral health
and economic institutions. As with NIH, FDA’s plans
should be integrated within the U.S. global health
strategy.26

Build a new measurement framework

Putting in place a new measurement framework
must also be prioritized—not as an end in itself, but
as part of greater accountability architecture among
donors and partners. That step will require creating
an authoritative group within the U.S. government
charged with overseeing the evaluation of the outcomes
of U.S. investments in global health, promoting
measurement capacity in partner countries, and sharing

“Technology and innovations are key to smart global health. In the future, the use of novel
diagnostics and the application of mobile phones and handheld computers will transform the
system to one where patients are informed and empowered, and physicians and health systems
are engaged in understanding broad-based interventions for a wide spectrum of diseases,
including sexually transmitted infections, pandemics like H1N1 and chronic diseases.”
— Surya N. Mohapatra

36 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

its findings with Congress and the administration. This
group should have access to expertise from outside the
U.S. government, be staffed by a small, skilled core of
professionals, and have the ability to field mobile teams
for first-hand, in-country assessments.

To be effective, this group will need to be linked
directly to the Interagency Council. There are several
possible models, including placing an independent
group within the Institute of Medicine or the
Government Accountability Office; creating a standing
consortium of independent experts managed by a small
secretariat; relying on a competitive bidding process to
contract for specific assessments; or establishing a free-
standing independent entity in concert with a small
number of like-minded donors.

The Epidemiologic Intelligence Service (EIS) of the
CDC has demonstrated over several decades how
to recruit, train, and retain local personnel with the
competencies and skill sets to conduct epidemiologic
investigations and surveillance. That experience could
be translated into a new initiative, led and staffed
by appropriate experts, to train a cadre of program
monitoring and evaluation experts. This effort could
be extended to train overseas partners, much as CDC’s
Field Epidemiology and Laboratory Training Programs
already do. Focused initiatives in selected high-
investment African countries could create greater data
collection and analysis capacity.

Harness the expertise of the U.S. private sector

The private sector has special competencies that
the U.S. government could tap to strengthen the
performance of U.S. global health programs over
time. The Office of the Global AIDS Coordinator
and the PMI have each in recent years launched
innovative collaborations, including PEPFAR’s supply

chain management contract and accelerated work to
strengthen partner country laboratories, joint business-
government country planning on malaria and HIV
control, and the AIDS Free Generation initiative to
advance HIV prevention among youth using media
and game technology.27 The Millennium Challenge
Corporation has also gone a considerable distance to
incorporate a results-oriented approach and private-
sector best practices into its operations. These provide a
very promising foundation; manifold opportunities for
private-sector collaboration are still to be developed.

Initiatives will be most effective if they are practical
and deliver concrete measurable outcomes; if they
enable African and other developing-country private
sectors to expand their delivery of health services
and commodities; if they hold the promise to be
scaled and sustained over time; if they focus on
programmatic areas where performance has been
chronically weak; and if they truly leverage business
models, processes, and special attributes such as
leadership, organizational and managerial skills, and
marketing, negotiating, and financial acumen. Core
business competencies and the business mindset align
closely with the Global Health Initiative’s objectives
of building accountable, self-reliant health services,
tracked through “hard” outcome measures.

The administration could place more business leaders into
key positions in the U.S. government and multilateral
organizations—as board members, special advisers,
and department and agency leaders. As with other
senior appointed and confirmed positions in the U.S.
executive branch, special care will be needed to match
an individual’s skills and leadership style with the critical
needs and culture of the organization in question.

“Encouraging a full pipeline of new vaccines, diagnostics and treatments will require the
ability to craft new and complex partnerships between the private and public sectors in the
U.S. and the developing world that balance sustainability, accessibility and health impact.”
— Christopher J. Elias

37a u.S. Global health StRateGy

The U.S. private sector can contribute substantially
to the design and strengthening of systems—in
both the public and private sectors. This approach
might involve programs to train and retain a skilled
workforce; supply chains for medical commodities;
expanding the economic scale of private rural clinics
and pharmacies; marketing campaigns; integration of
databases into a workable national architecture; and
full use of emerging technology, including information
tools for remote diagnostics, clean water filtration, and
disposable needles and syringes.

Developing countries, bilateral donors, and multilateral
organizations—especially the World Bank—are
increasingly keen to develop health insurance in
developing countries, as a means of creating greater
sustainability for health programs. Insurance
mechanisms, if successful in the future in developing
societies, can create higher market demand for health
services, spread risk and promote health equity through
increased coverage, stimulate private-sector responses,
and in the end contribute substantially to self-reliance.
Circumstances vary dramatically across Africa, Latin
America, and South Asia. The United States, despite
weaknesses in our own system and ongoing debate
over domestic health reform, can actively contribute,
with private business input, to ongoing deliberations
on future options to advance health insurance over the
long term in developing countries.

An advisory group (like that for the Export-
Import Bank and the Overseas Private Investment
Corporation) might usefully bring a business
perspective into discussions of how better to
incorporate business sector approaches to meet the
Global Health Initiative’s evolving goals.

The advisory group might also help consolidate a
global health fellows program through which critically
needed business personnel such as health economists
could be detailed to a U.S. agency, or U.S. government
personnel could be assigned to a business to become
more skilled, for instance, in logistics.

The State Department’s existing Franklin Fellows
Program could be expanded to bring mid- and upper-
level professionals from the private sector into one-year
fellowships within the State Department, with a special
focus on global health policy and programs. Similarly,
American Association for the Advancement of Science
(AAAS) science and technology policy fellowships
might be used to place scientists and engineers from
the private sector into the Departments of State and
Health and Human Services and key agencies like NIH
and CDC. USAID’s Global Development Alliance
could be used to bring additional business expertise
into USAID.

One important job for the Interagency Council
on Global Health would be to better integrate and
coordinate existing efforts and create a long-term
vision of the support that business can provide to
strengthen U.S. global health programs. There is at
present no single entity in charge of private-sector
cooperation, though the Office of the Global AIDS
Coordinator and USAID each has staff responsible
for managing partnership initiatives with the business
sector. There is also the U.S. Advisory Council
on Foreign Assistance, which draws advice from
heads of the major nongovernmental organizations
that implement U.S. development and emergency
programs. At the Department of State, there is
the newly established ambassador-at-large with
responsibility for global partnerships.

“Our report emphasizes the importance of global health both for people all around the world
and as a central feature of our foreign policy. A serious initiative by the United States and others,
perhaps at a summit during the annual United Nations General Assembly meeting, to assure
that the Millennium Development Goals will be met, particularly on health, would make an
invaluable contribution.” — Thomas R. Pickering

38 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

5. Make smart investments in
multilateral institutions

A critical dimension of how we organize ourselves as a
government is whether we are equipped adequately to
advance our global health agenda through multilateral
channels. Multilateralism matters profoundly to global
health outcomes, for health challenges have no respect
for national boundaries. Likewise, meaningful global
health solutions are by definition collaborative.

Fortunately, in the field of global health, there are
proven, trusted international institutions that can bring
solutions to scale, and mobilize the broad, sustained
resources required for success. Fortunately, too, the
United States enjoys a measure of cachet in this realm;
the Obama administration’s stated preference for
multilateral approaches to the world’s most urgent
problems has raised the hopes of the global health
community for U.S. leadership.

Over the last decade, the United States has helped
build innovative, effective alliances on behalf of global
health. With active U.S. support, the G-8 mobilized
high-level political energy and money around solving
the poor world’s health problems and provided the
strategic push to create the GAVI Alliance and the
Global Fund. In 2000, the UN General Assembly
adopted the Millennium Development Goals, which
contain the critical global health targets. That in
turn inspired a UN special session in 2001, which
set ambitious new targets for HIV/AIDS treatment,
prevention, and care.

Over its six-decade history, the WHO has struggled
to reach its true potential. It has been less than fully
effective in setting standards and norms, and it has often
had a weak and underfinanced headquarters staff whose
mandate has been stretched over too many priorities,
often reflective of donor earmarking. In recent years,
it has migrated into health systems strengthening,

“The individuals charged with delivering health care on the ground in some of the poorest parts
of the world are faced with such a jumble of objectives and criteria from different donors that
their jobs are made almost impossible. We need to focus seriously on remedying this problem.”
— Debora Spar

the typICal SpaGhettI C haRt
A map of multiple, uncoordinated donor requirements of partner country governments

CIdA
GTZ

RNE

SIdA
NORAd

uSAId

CCM
NCTP

dAC

uNTG

PEPFAR

GFATM

GFCCP

MOF

MOEC

CTu
CCAIdS

NACP

lOCAlGvT CIvIl SOCIETy PRIvATE SECTOR

INT NGO

SWAP

PRSP

MOH

WHO
uNAIdS

T-MAP

3/5

Wb
uNICEF

PMO

HSSP

From a presentation to the CSIS Commission on Smart Global Health Policy, June 10, 2009, CSIS, by Joy Phumpahi, World Bank

39a u.S. Global health StRateGy

humanitarian response, human rights, and trade—areas
better led by other international institutions.

At the same time, over the past decade, the WHO has
assumed a strengthened leadership role in updating
norms and standards for essential health services,
advanced polio eradication and tobacco control, put a
spotlight on drug-resistant tuberculosis, and sought to
lower prices for essential medicines.

Much to its credit, the WHO has also rallied countries
to better prepare for global disease threats. In the era of
HIV, SARS, avian influenza, and most recently H1N1,
the WHO has proved its value as a lead international
organization committed to advancing health security.
A wide consensus has emerged over the need to bring
about, with WHO leadership, the timely sharing of
biologic specimens, put a spotlight on strengthening basic
surveillance and response capacities across the spectrum
of countries, and press for a coordinated international
diplomatic effort to assure low- and middle-income
countries have affordable access to the vaccines and
antiviral medications that will avert a human catastrophe,
if and when a severe pandemic strikes.

There is more the United States can and should do to
improve its multilateral approach to saving lives and
helping establish self-reliant, resilient health systems.

Past U.S. diplomatic efforts—even the most
successful—were often ad hoc. They often suffered
from insufficient staff, weakly articulated goals, and
too shallow a bench of senior diplomatic talent skilled
in multilateral health issues.

Greater U.S. investments in focused diplomatic
leadership, in the long-term cultivation of relations,
and in building knowledge of multilateral institutions
will make it easier to improve these institutions’
performance, moving us nearer to our national and
collective global health goals.

First, the United States should enhance its strategic
global health leadership at established fora such as
the G-8, G-20, and UN General Assembly. It should
also promote special annual summits dedicated
to strategic global health dialogue and focused on
forging pragmatic solutions to chronic problems such
as how to ensure affordable pricing of vaccines and
medications; how to cope with rising resistance to
medications; how to allow for the global exchange of
health information through common data standards
and interoperable technologies; how to bring more
rigor and accountability to the MDGs; how to ease the
health workforce deficit; and how to better coordinate
donor engagement toward common goals.

U.S. leadership can substantially accelerate efforts to
curb global tobacco use by ratifying and advancing
the Framework Convention on Tobacco Control;
sharing best practices through the WHO; encouraging
partner governments to make regulatory reform a
high priority; and spotlighting the burdensome long-
term health costs of tobacco use versus the short-term
economic gain of increased production, domestic sales,
and exports.28

In addition, through its board membership with the
World Bank, the GAVI Alliance, the Global Fund and
WHO, and UNICEF, the United States should press
for a strategic coordination of effort across the four
institutions and a greater concentration on the core
competencies of each. The World Bank should become
more engaged over the long term in strengthening
health systems. The GAVI Alliance should remain
tightly focused on vaccines, while the Global Fund
should do the same in the delivery of services on HIV/
AIDS, tuberculosis, and malaria. To the extent that
the GAVI Alliance and the Global Fund venture into
health systems, it should be explicitly in support of
their respective missions.

“A key aspect of the modern world is the globalization of health. Therefore health must
be part and parcel of the foreign policy of any country. This groundbreaking report will
hopefully be followed by similar efforts in other countries.” — Peter Piot

40 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

The United States can simultaneously support health
systems strengthening and promote a greater unity of
effort among the World Bank, the GAVI Alliance, the
Global Fund, the WHO, and other donors by engaging
seriously in the International Health Partnership
(IHP+) process. Through the IHP+ process, country
governments and development partners sign a compact
in support of a national health plan that aims for greater
efficiencies and a streamlining of donor requirements.
Eighteen countries have signed onto the IHP+ process,
16 of which will revise their national plans in 2010.
Although there is understandable skepticism and
uncertainty that this process will leverage meaningful
change in donor and partner country behaviors, the
attempt to harmonize donor funding commitments,
focus efforts around country-led health strategies, and
clarify health goals is potentially quite valuable. The
United States, in good faith, should test the proposition
that this approach can bring significant gains by actively
supporting IHP+ compacts in select African countries
where the United States is a major health sector donor.

The World Bank is well-positioned to play a stronger
role in building robust health systems, owing to its
wide-ranging expertise outside the medical field,
its ability to work across sectors, its existing health
programs in many key African countries and its
regional hubs in Dakar and Nairobi, and its record
of designing integrated frameworks. Health systems
development requires the combination of skills and
approaches that the Bank can assemble: systems
managers, procurement, supply chain and finance
experts, communications systems, monitoring and
evaluation capacity, and long-term planning for
human resource needs.

Currently, the Bank meets ad hoc financing requests
from ministers of health; supports specific disease
campaigns such as river blindness, HIV/AIDS, and

malaria; and supports the reform of health systems
in accordance with its July 2007 health systems
strengthening strategy, which emphasizes performance-
based financing and maternal and infant health. An
expanded Bank role will require careful diplomatic
effort to build a strategic alliance between the Bank
and WHO and bring the GAVI Alliance and Global
Fund into a common approach. It will be critical that
an expanded Bank role signal new resources directed
toward health systems strengthening and not substitute
for resources from other programs.

The United States should also spur timely action to
improve performance of both the Global Fund and
the GAVI Alliance. Each is well beyond its start-up
phase, and each still faces unresolved issues of mandate,
governance, and financing. In 2010, donors will need to
replenish their Global Fund pledges for the next three
years and address a serious resource shortfall at the GAVI
Alliance that could prevent countries from introducing
life-saving vaccines against causes of pneumonia and
diarrhea. More thought and effort are needed on country
eligibility requirements and steps to graduate countries,
especially those in the middle-income tier. In addition,
both the GAVI Alliance and the Global Fund need to
focus attention around long-term financial planning and
the best means to compare costs and returns and to bring
about higher efficiencies in pricing and procurement.

With respect to the WHO, the United States should
make targeted, expanded investments in WHO’s
core functions—especially health security and norm
setting/guidelines plans—and link that shift to the
streamlining of WHO’s Geneva operations. As part of
that new compact, the United States should increase
the numbers of experts it details to the WHO. Over
the last few decades, this sharing of U.S. talent has
provided a vital service to the WHO and fortified the
U.S.-WHO relationship.

“The rapid spread of H1N1 influenza infection to all corners of the earth this year brings
home the need for international surveillance networks. The health of Virginians is tangibly
and integrally linked to the health of people of many countries, as we face the realization of
infection spread through travel in our increasingly mobile world.” — Karen Remley

41a u.S. Global health StRateGy

From its inception, the Commission wanted a new
approach to the challenge of improving global health.
To that end, instead of looking to a narrow panel of
health practitioners and policymakers, CSIS recruited
25 diverse opinion leaders from public health, foreign
policy, Congress, business, and media, and then looked
outward to the general public. To bolster transparency,
CSIS built an online forum, www.SmartGlobalHealth.
org, with the assistance of BlueStateDigital, facilitating
the exchange of ideas between commissioners and a
broader public audience interested in global health.

To expand the Commission’s work beyond Washington,
the site offered users access to Commission meetings,
recorded interviews with global health leaders, and
videos of CSIS events. Two-way conversations on
metrics and evaluation, pandemic preparedness, global
health gaps, and public health in Kenya provided a
forum for users to share their ideas with experts and
receive detailed feedback in response. Throughout the
Commission’s trip in Kenya, photographs, blogs, and a
frequently updated Twitter feed allowed site visitors to
travel alongside commissioners and react to the mission
in real time. Four powerful micro-documentaries
exposed the human side of the Commission’s work to an
audience that ranged from public health professionals
to high school students. More than 3,000 people joined
the site as regular users.

One highlight of the Commission’s public outreach
and exchange was an essay contest, inviting people
to answer the question, “What is the most important
thing the United States can do to improve global
health in the next 15 years?” Over 1,000 responses
arrived from all 50 states and 43 countries, with
contributors sharing compelling personal narratives
ranging from field work in Sudan to the view outside
the writer’s window. Common themes emerged on
water and sanitation, food security, vaccination,
education, good governance, and transformative
volunteer experiences. The exercise highlighted the
growing interest in the global health field, especially
among students, and the respondents’ desire to
participate actively in finding and delivering global
health solutions.

The four winning essays can be found in the Appendix
on page 45.

Geographic spread of entrants to the essay contest

SMARTGlObAlHEAlTH.ORG

“Two-way engagement—especially with those whose lives and experience intersect
with global health issues—is the right way to craft better policy. This Commission has
already established a toehold in the minds of today’s influencers and tomorrow’s leaders.
Through the essay contest we’ve seen that there is deep passion among this critical
constituency. It’s my hope that this community will work together to realize the changes
we recommend in this report.” — Joe Rospars

42 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

III | Closing Thoughts

43CloSInG thouGhtS

During the last decade, the United States
devoted high-level leadership and billions
of dollars to improve the lives of the
world’s poorest individuals. Our global
health endeavors have enabled us to create
new partnerships, advance fundamental
humanitarian goals, and pursue key
strategic objectives—raising aspirations
about what is achievable in global health
and inspiring other nations and leaders to
step up their own efforts.

The United States’ bold commitment was based
on sound evidence of the effectiveness of health
interventions and the wisdom that investments
in global health have a multiplier effect on our
development dollars. Today, global health has the
potential to become a critical component of the
United States’ smart power approach and a valued,
conspicuous element of U.S. foreign policy.

The world’s expectations for U.S. leadership are high,
but we can and should rise to meet them. Huge gains
are within reach if we organize around a smart strategy
that looks ahead 15 years, focuses our resources on
core countries where we can have the greatest impact,
and streamlines our efforts both internally and
multilaterally. We will be most successful if we sustain
and build on our successes in HIV/AIDS, tuberculosis,
and malaria; adhere to a rigorous measurement

framework; better harness the private sector’s expertise;
prioritize the prevention of new threats rather than
emergency responses to them; and put the needs of
women and children first.

The powerful engagement of the U.S. public—
particularly the nongovernmental, business,
philanthropic, faith-based, and university communities,
as well as individual Americans—will remain critical
in driving our response. Policymakers should build
new, two-way dialogues with the growing numbers
of Americans who care passionately about our role
in promoting health in the world. The noble goal of
reducing death and disease among the world’s poorest,
and creating more resilient and self-sufficient partner
countries, reflects America at its best.

Our Commission was proud to come together—
across sectors, disciplines, and party lines—to map a
course to a healthier global future. We are convinced
that goal is achievable. We hope all Americans will
help to make it so.

“At a time of tremendous need and increased urgency, this seminal document charts
a clear course of action that provides greater focus and more leveraged investment in
global health.” — Judith Rodin

“As citizens of the world, global health must be a concern to everyone. In today’s environment,
we are all one and must align and act immediately to advance improvements. This report outlines
a plan that can be used as a roadmap to improve the health of those most in need—those most
vulnerable—and help rewrite the future health status and lives of so many, especially our children.”

— Rhona Applebaum

44 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

1 Jennifer Kates, Julie Fischer, and Eric Lief, The U.S. Government’s Global
Health Policy Architecture: Structure, Programs, and Funding (Washington,
D.C.: Henry J. Kaiser Family Foundation, April 2009), 1.

2 Hillary Rodham Clinton, “Remarks on Development in the 21st
Century” (speech delivered at the Center for Global Development,
Washington, D.C., January 6, 2010).

3 Jennifer Kates, Eric Lief, and Jonathan Pearson, Donor Funding for Health
in Low- & Middle-Income Countries: 2001–2007 (Washington, D.C.:
Henry J. Kaiser Family Foundation, July 2009), 7.

4 Pew Global Attitudes Project, Global Unease with Major World Powers:
47-Nation Pew Global Attitudes Survey (Washington, D.C.: Pew Global
Attitudes Project, June 2007).

5 Eran Bendavid and Jayanta Bhattacharya, “The President’s Emergency
Plan for AIDS Relief in Africa: An Evaluation of Outcomes,” Annals of
Internal Medicine 150, no.10 (May 19, 2009): 688–695.

6 Michael H. Merson and Kimberly Chapman Page, The Dramatic
Expansion of University Engagement in Global Health: Implications for U.S.
Policy (Washington, D.C.: CSIS, April 2009).

7 Institute of Medicine, The U.S. Commitment to Global Health:
Recommendations for the Public and Private Sectors (Washington, D.C.:
National Academies Press, 2009).

8 Henry J. Kaiser Family Foundation, Survey of Americans on the U.S. Role
in Global Health (Washington, D.C.: Henry J. Kaiser Family Foundation,
May 2009).

9 UN Population Fund (UNFPA), Maternal Mortality Update 2004:
Delivering into Good Hands (New York: UNFPA, 2004), 9.

10See Jack C. Goldstone, “The New Population Bomb: The Four
Megatrends That Will Change the World,” Foreign Affairs 89, no. 1
(January/February 2010): 31–43.

11Office of the Global AIDS Coordinator, “The U.S. President’s Emergency
Plan for AIDS Relief: Five-Year Strategy,” Washington, D.C., December
2009.

12See Lisa Carty and Phillip Nieburg, Prevention of New HIV Infections:
Priorities for U.S. Action (Washington, D.C.: CSIS, January 2010).

13Although U.S. funding for maternal health, child survival, and family
planning was essentially flat-lined between FY2001 and FY2007,
Congress has increased funding for these programs in recent years, albeit
at a slower pace than other U.S. global health activities. Family planning
funding has risen from an average of $391 million annually (FY2001–
FY2008) to $455 million in FY2009. The proposed budget request for
family planning for FY2010 is $475 million. Maternal and child health
funding rose from $295 million in FY2001 to $495 million in FY2009,
with a proposed budget request of $525 million for FY2010. See Henry
J. Kaiser Family Foundation, “The U.S. Global Health Initiative (GHI)
Budget Analysis,” Washington, D.C., December 2009, http://www.kff.
org/globalhealth/upload/8009-C .

14Joseph Speidel, Steven Sinding, Duff Gillespie, Elizabeth Maguire,
and Margaret Neuse, Making the Case for U.S. International Family
Planning Assistance (Baltimore, Md.: Bill and Melinda Gates Institute for
Population and Reproductive Health, January 2009).

15Joy Lawn et al., “The Executive Summary of the Lancet Neonatal Survival
Series,” The Lancet 365, issue 9462 (March 2005), http://www.who.int/
child_adolescent_health/documents/pdfs/lancet_neonatal_survival_exec_
sum .

16GAVI Alliance, “The GAVI Alliance: Saving children’s lives and protecting
people’s health by increasing access to immunisation in poor countries,”
Geneva, October 2009, http://www.gavialliance.org/resources/3EN_
GAVI_Alliance10_09_web .

17Colin Mathers and Dejan Loncar, “Projections of Global Mortality
and Burden of Disease from 2002 to 2030,” PLoS Medicine 3, no. 11
(November 2006): e442.

18Harley Feldbaum, “Building U.S. Diplomatic Capacity for Global
Health” (paper prepared for the CSIS Commission on Smart Global
Health Policy, Washington, D.C., October 2009).

19Kates et al., The U.S. Government’s Global Health Policy Architecture, 9.

20It took Thailand, one of the most successful case studies in maternal
health, 18 years to reduce its maternal mortality ratio by three-quarters.
A similar reduction in Matlab, Bangladesh, took 21 years. In Sri Lanka,
maternal mortality fell from 1,500 to 300 deaths per 100,000 live births
over a 25-year period. See Carine Ronsmans and Wendy J. Graham,
“Maternal Mortality: Who, When, Where, and Why,” The Lancet 368,
issue 9542 (September 30, 2006): 1189–1200.

21Nirmala Ravishankar et al., “Financing of Global Health: Tracking
Development Assistance for Health from 1990 to 2007,” The Lancet 373,
issue 9681 (June 20, 2009): 2113–2124.

22More than 15 congressional committees have jurisdiction and oversight
over global health programs. See Kates et al., The U.S. Government’s Global
Health Policy Architecture, 2.

23A slightly analogous precedent was set in 1985 through the establishment
of the Senate Arms Control Observer Group, an interim congressional
entity authorized to observe international arms negotiations between
the United States and the Soviet Union and serve as an important link
between the Senate and Reagan administration. Populated by the majority
and ranking minority leadership of key Senate committees, the group
spanned different committees of relevance to the negotiations without
interfering with lines of jurisdiction. The group was supported through a
modest budget and staff.

24Robert Hecht, Amrita Palriwala, and Aarthi Rao, “Innovative Financing
for Global Health: A Moment for Expanded U.S. Engagement?” (paper
prepared for the CSIS Commission on Smart Global Health Policy,
Washington, D.C., January 2010).

25See Philippe Douste-Blazy and Daniel Altman, “A Few Dollars at a
Time: How to Tap Consumers for Development,” Foreign Affairs 89,
no. 1 (January/February 2010): 2–7. “Another initiative, (Red), collects
donations from companies that sell goods and services under its (Product)
Red brand, which is advertised to consumers as a charitable endeavor.
Participating brands include household names such as American Express,
Apple, Converse, Gap and Hallmark. Together, they have raised $130
million in three years.”

26See Thomas J. Bollyky, Global Health Interventions for U.S. Food and Drug
Safety (Washington, D.C.: CSIS, November 2009).

27Office of the Global AIDS Coordinator, “Public Private Partnerships,”
Washington, D.C., December 2009, http://www.pepfar.gov/ppp/index.
htm.

28See Benn McGrady, U.S. Engagement in International Tobacco Control
(Washington, D.C.: CSIS, June 2009).

Endnotes

45appendIx

STudyING ANd PRACTICING
MEdICINE OvERSEAS

Annie Dude
MD/PhD Student at the University of Chicago

When I recall my time studying medicine overseas—in
India, the Dominican Republic, and Mexico—what
I remember are the vivid faces. Of patients, yes, but
the ones that stand out most are the faces of my
colleagues: the animated laugh of the man who runs
a disease surveillance lab in the Dominican Republic,
who taught me about malaria; the serious expression
on my fellow medical student Brahma’s face as he
translated for me on the wards, guiding my hand as
I palpated a woman’s tumor; the tears in my friend
Marisela’s eyes as she tells me how a patient of hers
died in her arms after a car accident because her
hospital had run out of blood. Having learned so
much from them, I ask if there is anything I can do in
return. Almost all of these young doctors give the same
answer: “Give me the books you used to study for the
U.S. Medical Licensing Exam.” Rather than remain in
their countries, the dream for most is to emigrate to
the United States or to Europe as quickly as possible.

Part of me judges: Shouldn’t you stay here, take care
of your people? I can put up with cold showers for a
summer, can’t you? While some of my friends mention

money, for most they seek to practice medicine in the
United States for reasons beyond creature comforts.
They are faced with the terrible conundrum of
realizing that, like me, they receive excellent medical
training, but unlike me, their hands are often tied:
they lack medicines, supplies, facilities, sometimes even
electricity or clean water. They have the knowledge to
recognize the illness but not the means to impart the
cure. To me, it might seem a waste to a nation to have
trained a physician whose main goal is to leave, but I
morally can’t ask someone to do something I won’t do
myself. I am not poring over yellowing copies of the
Journal of the American Medical Association in a dank
medical school library, by flashlight when the power
is out, wondering if I will ever get the opportunity
to employ the treatments described therein. I am not
wringing blood out of old sheets between surgeries.
I am not choosing which of my patients gets the last
vial of antibiotic. I too could get used to sweltering
wards, third-hand textbooks, stepping over patients on
my way to work because of overcrowding, but I will
never face the dilemma my sister’s friend in Uganda
described when he elected not to go into pediatrics: “I
could not stand to watch other children die because
their parents couldn’t pay me, and I couldn’t bear to
watch my own children starve, because I gave away my
services for free.”

“What is the most important thing the United States can do to improve
global health in the next 15 years?”

In its search for fresh ideas, the Commission put this question to the visitors of its interactive Web site,
www.smartglobalhealth.org, and received over 1,000 responses from all 50 states and 43 countries. The personal
narratives the Commission received are testament to the passion, insight, and pioneering ideas of those in the
United States and throughout the world who wish to improve health across geographic and socioeconomic
boundaries. The contest’s four winning essays are below.

Appendix

46 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

What doctors in other countries need to stay are the
means to make a decent living, the supplies to allow
their patients to get well, or at least to die with dignity,
and opportunities to participate in the larger medical
community through education and research. The United
States might supply all the money and all the drugs, but
what we really need in order to accomplish anything
useful overseas are partners. Partners that speak the local
language, that have the trust of the local population,
that can tell us as outsiders the best way to go about
solving problems. The most important thing the United
States can do to improve global health in the next 15
years is to invest in long-term partnerships with medical
professionals and institutions overseas. Hundreds of
these partnerships already exist on a small scale among
universities, churches, and community groups here and
abroad. In India, I lived at a hospital envisioned, funded,
and built by a cardiologist raised in Hyderabad, but who
now works at the University of Pittsburgh. Local people,
who previously shunned hospitals as “the places where
people go to die,” had begun coming in droves once
they realized the pharmacy always had drugs and the
operating room lights stayed on. This partnership benefits
us too: I went with a team from Pittsburgh to learn
about implementing vaccination and safe motherhood
campaigns in rural villages. The goal was to start a similar
program in a housing project back in Pennsylvania.

Will this strategy entice doctors and other professionals
to remain in their own countries? In the words of my
colleague in India, Dr. Ravi Himagalore, who trained
along with his wife in Chicago but had just returned
to Hyderabad: “10 years ago I would have stayed away.
These opportunities did not exist. Now I can come
back, take care of my patients in the way I was trained to
do, write research papers. Best of all, I can live near my
mother—she watches my daughter while I am at work!”

IMPROvING GlObAl HEAlTH
THROuGH SCIENTIFIC dEvElOPMENT

Andrew S. Robertson
JD Student at the University of California, Berkeley

In late 2005, I traveled to Entebbe, Uganda, to
participate in the first of a series of H5N1 influenza
regional training workshops for African scientists. At the

time, the U.S. government was engaging the developing
world to educate scientists about the pathology,
epidemiology, and detection of the growing H5 threat.
During my presentation on the U.S. international bird
flu strategy, I grew concerned that many in the audience
looked skeptical. Finally, a doctor from south Sudan
stood and asked, “Why is it that the U.S. considers H5
to be a priority for African countries?” I answered with
mortality statistics from past influenza pandemics, but
the purpose behind the question was clear. Bird flu was
important, but it was a Western priority. The workshop
participants came from countries with their own
health crises, such as endemic disease, famine, drought,
poverty, and conflict, and wanted to learn how to
confront these challenges head-on. They hadn’t come to
Entebbe that week to learn about U.S. policies on bird
flu—they had come to learn about the science.

Strengthening scientific research capacity in low- and
middle-income (LMI) countries is the single best
way for the United States to improve global health
over the next 15 years. Currently, building research
infrastructure—including institutional and regulatory
frameworks, academic institutes, and sufficiently skilled
people to conduct and publish research—is overlooked
by a majority of global health programs. Most
programs in LMI countries are planned and operated
by developed nations and reflect the donor country’s
priorities, values, and politics. Programs that develop
local research capacity and scientific infrastructure
are desperately needed, and over 15 years can create a
powerful, sustainable weapon against global disease.

The benefits of scientific development have been
widely acknowledged. Increased science capacity will,
for example, strengthen neglected disease research
and drug development, boost human capital and
infrastructure, build up disease surveillance capabilities,
and develop scientifically sound health care policies.
Significantly, increased science capacity also allows
developing countries to determine their own health
priorities. While the past decade has seen an increase
in funding for a few specific diseases—most notably
HIV/AIDS, tuberculosis, and malaria—these initiatives
left traditional health indicators such as maternal and
child health and vaccination coverage underfunded and
understaffed. As new health challenges emerge due to

47appendIx

factors like overpopulation and climate change, a local,
educated infrastructure, in coordination with established
global health authorities, can help countries identify
their own funding priorities and increase the impact of
their global health programs.

But critically, a long-term investment in science
capacity within developing countries will also help
address the root causes of global health disparities.
Research programs can build a developing nation’s
economy by driving social and technological
innovation. The diplomatic effects of cross-border
research programs have been shown to strengthen
international ties and help mitigate regional conflict.
Developing a strong science program will help retain a
nation’s best thinkers, adding to the next generation of
social advocates and political leaders.

These advantages extend from the collaborative and
thesis-driven nature fundamental to scientific research.
Scientific development addresses both the immediate
challenges in global health as well as the underlying
conditions in which those challenges emerged.

There are signs that many developing countries are
making deeper investments in national science, but
progress is mixed. Countries such as Cuba, India, and
China have seen notable growth in national research
programs over the past 10 years with impressive results,
yet most developing countries invest less than 1 percent
of their GDP in R&D (versus 2.5 percent in the United
States). While the number of researchers in developing
countries has increased by 45 percent over the past
decade, per capita this number is only one-tenth that
of developed nations. Universities in countries such
as Nigeria and Kenya are struggling to keep talented
scientists from emigrating to developed nations, and
often faculty vacancies can reach as high as 40 percent.
Sustaining a science program capable of impacting
health issues is nearly impossible under these conditions.

At the end of the Entebbe workshop, a Nigerian
scientist shocked me by mentioning that her
research department could not afford access to many
important science and medical journals. As a former
geneticist, I knew that access to scientific literature is
crucial, and barriers could cripple research through
academic isolation. The United States has made

some contribution to building science overseas, but
more must be done. Developing scientific capacity
requires long-term political commitment, national
research strategies, budget lines, skills development,
incentives for private investment, the ability to use
external knowledge, and a culture of inquiry. Genuine
partnerships between the United States and LMI
countries can train young researchers, build basic
and applied research institutes, and link developing
countries to the global medical, scientific, and public
health communities. But through significant, sustained
investment by the United States, in-country scientific
research programs will emerge as the single most
effective tool in global health.

1J. Coloma and E. Harris, “From Construction Workers to Architects:
Developing Scientific Research Capacity in Low-Income Countries,”
PLoS Biology 7, no. 7 (2009): 1–4.

2See UN Educational, Scientific and Cultural Organization [UNESCO],
“Declaration on Science and the Use of Scientific Knowledge,” Paris,
1999, http://www.unesco.org/science/wcs/eng/declaration_e.htm. K.
Annan, “A Challenge to the World’s Scientists,” Science 299, no. 5612
(March 2003): 1485.

3C. Piller and D. Smith, “Unintended Victims of Gates Foundation
Generosity,” Los Angeles Times, December 16, 2007, http://www.latimes.com/
news/nationworld/nation/la-na-gates16dec16,0,3743924.story.

4UNESCO, “A Global Perspective on Research and Development,” UIS
Fact Sheet, October 2009, http://www.uis.unesco.org/template/pdf/S&T/
Factsheet_No2_ST_2009_EN .

REduCING GlObAl HEAlTH
dISPARITIES THROuGH RESEARCH,
EduCATION, ANd INTERNATIONAl
COllAbORATION

Michael Strong
Postdoctoral fellow at Harvard Medical School

Throughout the past century, great strides have
taken place in our ability to both recognize and treat
diseases affecting global health. As a community,
we have progressed from knowing very little about
the etiological agents of diseases such as tuberculosis
and malaria to understanding much about the
biology and the causative agents of disease. Such
efforts have culminated with the elucidation of
the genome sequence of a host of deadly human
pathogens including those that cause tuberculosis
(M. tuberculosis), malaria (P. falciparum), and AIDS
(HIV). Such efforts promise to provide clues to better
combat these deadly diseases in the coming years.

48 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

Although we have learned much about the causative
agents of infectious diseases as well as methods to
combat them, there remains a vast chasm separating
the quality of health care for individuals in developed
countries versus developing countries. There are many
factors contributing to these disparities including
inadequate access to medical facilities, physicians, and
medications; poor nutrition; misinformation about
disease and prevention; environmental and economic
factors; cultural attitudes; and living conditions.
Diseases such as AIDS, tuberculosis, and malaria are
ravaging many parts of the world, and as a result, there
is immediate need to address these diseases using a
three-tiered approach, focusing on research, education,
and international collaboration.

Research
There is no doubt that research has led to innumerable
breakthroughs in our efforts to combat disease.
Breakthroughs have ranged from the discovery of new
antibiotics to the development of vaccines. Even so,
there are huge challenges that remain to be adequately
addressed. We still do not have an effective vaccine
or drug regimen to eradicate AIDS; drugs that were
once effective for fighting tuberculosis are rendered
ineffective with the emergence of multidrug-resistant
(MDR) and extensively drug-resistant (XDR)
tuberculosis, and millions of individuals are still dying
from dehydration-related diseases, often attributed to
contaminated water or food sources.

An increased commitment to research is greatly needed
in order to guarantee the discovery and development
of the next generation of antibiotics, vaccines,
diagnostics, and therapeutics. Funding for basic
science research, as well as clinical and translational
research, is essential, for it is the basic science research
that serves as the foundation on which medical
breakthroughs are built. We must also be committed
to funding research efforts beyond the borders of our
own country, particularly in countries that are most
affected by endemic disease affecting global health,
because it is in these areas where we will learn the most
about these diseases and have the greatest potential for
discovery and impact.

Education
Second, we must do more to educate individuals
regarding global health issues at home and abroad. Most
of our citizens care deeply about health issues, but need
to be reminded about the prevalence and devastation
of disease outside of our borders. A renewed global
health educational campaign will have great impacts,
ranging from increasing the number of people wanting
to be involved in global health projects to increasing the
funding for global health projects through philanthropy
and government-sponsored projects. We can learn lessons
from other successful awareness campaigns and should
strive to educate and involve a larger segment of the U.S.
population in regard to global health issues. In turn, these
endeavors will increase education and awareness abroad,
since these efforts will help infuse both people and funds
into international global health programs.

International Collaboration
Third, we must encourage more people to become
involved in international collaborations, particularly
with individuals in countries most affected by global
health disparities. This can be done through increased
funding for multinational endeavors as well as increased
opportunities in which individuals can connect. These
efforts can be stimulated by holding more scientific
symposiums in developing countries and by creating
Internet-based platforms where people can connect with
like-minded individuals across the globe. Collaboration
can take many forms, ranging from shared scientific
pursuits to a common interest in global health, but we
must increase the frequency of international exchanges in
order to more rapidly achieve the overall goal of finding
solutions to combat global health disparities and disease.

As a scientist conducting research on tuberculosis for
the better part of a decade, I have been struck by the
dedication and hard work put forth by those pursuing
solutions to combat devastating diseases affecting global
health. I have been most impressed by those individuals
who have made an effort to bridge geographic boundaries
to collaborate and work in countries where diseases such
as tuberculosis, malaria, and AIDS are rampant. It is my
hope, that in the next 15 years, more individuals will
become involved in the global health movement, to help
reduce global health disparities and to devise solutions to
raise the quality of life and health care for all individuals,
unrestrained by geographic boundaries.

49appendIx

SWIMMING AGAINST THE TIdE
IN bOlIvIA

Rodrigo Arnez Rojas
Attending clinical psychiatrist at the Center for
Mental Health San Juan de Lios, La Paz, Bolivia

The most important thing the United States can do to
improve global health over the next 15 years is to help
people realize that health is not only a human right
in an abstract sense but a daily reality—with numbers
and figures both in health indicators and statistics as
well as in economic expense that have a direct impact
on their lives. People must gradually come to terms
with the reality that their actions can have meaningful
effect not only on their own health but on health
policy, governance, and accountability.

I live and work in Bolivia, one of South America’s
most troubled countries in terms of child and maternal
health, life expectancy, general access to health care
of any type, and health infrastructure and resources.
I cannot say that I am among those who felt destined
for medicine from childhood, but I do remember the
emotional impact and admiration the first time I saw
Eugene Smith’s photo essay “Country Doctor.” I didn’t
think then of becoming a doctor, that would be later,
but I felt that somehow I wanted to be like that man.
Being a doctor means different things to different
people, and the reasons why one decides to become
one vary accordingly. Yet I’ve found good doctors tend
to have a common desire and willingness to make a
difference and will strive in that direction tirelessly.
It’s the same with nurses, therapists, social workers,
and many other people involved in health—that same
dogged persistence to go the extra mile, to try and
“save” someone. Nationality, race, professional degree,
experience, and field of work may vary, but eventually
one will find the same basic feeling and determination
to help others. Sadly, after a while, one will also find
the same frustration and anger at not being able to
do more, not because it couldn’t be done, but because
someone wouldn’t let you or because things “just don’t
work that way in the system.”

I’ve been up the Madidi River and into the jungle
to places where people accept the death of a child
as a circumstance of life that has to them the same

inevitability as poverty or abandonment or floods.
I’ve seen people in need of help be turned away from
hospitals because they could not afford a minimal cost,
and I’ve also asked medical students, nurses, or strangers
to donate blood for someone they had never met but
needed it. I’ve had to tell patients and their families that
even though much more could be done if we lived in a
different country, we’d do what we could with what we
had and hope for the best. I’ve tried desperately, many
times in vain, to convince patients not to abandon their
treatment when the cost was so high it was running the
entire family into the ground. I’ve seen my colleagues
grow tired and jaded, accepting the inevitability of
preventable death or disease in our people as endemic
and beyond their power to change. Now, I am at a
midpoint in my life and career—and also a crossroads.
I have concluded a medical specialty, have returned to
my country, and have worked side by side with others to
try and change things for the better. The road so far has
not been easy, and I’ve already had more than my share
of dealing with negligent or corrupt authorities. I’ve
listened to the endless promises of dubious politicians,
realizing how fast one can become skeptical and cynical
after being used by them to promote their agendas.

So, how can one change this? How can one fight and
reign in a corrupt and failed administrative system
that has historically served to enrich a few in countries
such as my own across the globe? At this point in
time I think the best solution, the smartest and most
powerful one, is to make information truly transparent
and accessible to the people. At present, the average
Bolivian citizen would have great difficulty knowing
how much aid money the United States has sent to
our country, how and for what this money is being
used, and what the decisionmaking processes are in
regard to these resources. If this information was made
available and accessible, people would eventually start
asking where all the money is going and what results
are being obtained—as well as who is responsible
for administering these resources. If government
functionaries are identifiable, if invested financial
figures are accessible, and if health impact indicators
are available, society as a whole is then empowered to
approve or reject government action. We can make a
difference by helping people realize their true potential
and right to make a difference for themselves.

50 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

The CSIS Commission on Smart Global Health
Policy was codirected by J. Stephen Morrison,
senior vice president and director of the CSIS
Global Health Policy Center, and Lisa Carty, deputy
director and senior adviser with the CSIS Global
Health Policy Center. Together they authored this
report with guidance and substantial input from the
commissioners.

There are too many other debts to account for! By
definition, we cannot adequately register our gratitude
to the many friends and colleagues who came to our aid.

First in line is the staff of the CSIS Global Health
Policy Center, indefatigable in making the
Commission succeed: Karen Meacham, Emily
Poster, Daniel Porter, and Elizabeth Morehouse.
The Commission is especially indebted to Suzanne
Brundage for her ingenuity, insights, and tireless
efforts to facilitate its work and keep its deliberations
on track. Not far behind are Andrew Schwartz and
Louis Lauter of CSIS and Vinca La Fleur and David
Litt of West Wing Writers.

This was a busy Commission. Between April and
December 2009, the Commission convened for two
full-day sessions in Washington, D.C.; traveled to
Kenya to examine the impact of U.S. global health
investments and to New York and Geneva for expert
consultations with multilateral institutions; and held
public consultations in Research Triangle, North
Carolina, and in the California Bay Area. In addition
to these meetings, the Commission cochairs and
codirectors directly engaged with senior Obama
administration officials, congressional staff, and
representatives from academia, nongovernmental
organizations, the private sector, and the broad and
rich global health policy and advocacy community.

Across this spectrum, we sought out the best thinking
on how to craft a long-term U.S. global health strategy.
At each encounter, we were blessed with generosity,
expertise, and wisdom.

The Commission is especially indebted to the stalwart
allies of the CSIS Global Health Policy Center:
Katherine Bliss, senior fellow and deputy director of
the CSIS Americas Program; Jennifer Cooke, director
of the CSIS Africa Program; Janet Fleischman, senior
associate of the CSIS Global Health Policy Center;
Jennifer Kates, vice president and director of HIV
policy at the Henry J. Kaiser Family Foundation; Ruth
Levine, vice president and senior fellow at the Center
for Global Development; Allen Moore, distinguished
fellow at the Stimson Center; Phillip Nieburg, senior
associate of the CSIS Global Health Policy Center;
James Peake, former U.S. secretary of veterans affairs;
Steven Phillips, medical director for global issues and
projects at the Exxon Mobil Corporation; Ed Scott,
founder and chairman of the Center for Interfaith
Action on Global Poverty; and Jeffrey Sturchio,
president and CEO of the Global Health Council.

The Commission reached out to several experts
to prepare careful analytical work to inform its
deliberations. Two of our commissioners joined
the fun: Christopher Elias authored “Policies and
Practices to Advance Global Health Technologies”;
and Michael Merson, with Kim Chapman Page,
authored “The Dramatic Expansion of University
Engagement in Global Health.” Other authors/papers
include: Katherine Bliss, “Enhancing U.S. Leadership
on Drinking Water and Sanitation and Health in
Latin America and the Caribbean”; Jennifer Cooke,
“Public Health in Africa”; Harley Feldbaum, “U.S.
Global Health and National Security Policy”; Janet
Fleischman and Allen Moore, “International Family

Acknowledgments

51aCknowledGmentS

Planning: A Common-Ground Approach to an
Expanded U.S. Role”; Charles Freeman and Xiaoqing
Lu Boynton, “China’s Health Amidst the Global
Economic Crisis”; Robert Hecht, Amrita Palriwala,
and Aarthi Rao, “Innovative Financing for Global
Health: A Moment for Expanded U.S. Engagement?”;
Kathleen Hicks, Eugene Bonventre, and Stacy
Okutani, “U.S. National Security and Global Health”;
Jennifer Kates, Julie Fischer, and Eric Lief, “The U.S.
Government’s Global Health Policy Architecture:
Structure, Programs, and Funding”; and Gaudenz
Silberschmidt, “The European Approach to Global
Health.” All of these analyses are available online at
www.smartglobalhealth.org.

Fortunately for us, senior members of the Obama
administration were very open to engage on future
choices for U.S. global health approaches. We wish to
single out for thanks Jacob Lew, deputy secretary of
state for management and resources; Ezekiel Emanuel,
special adviser for health policy to the director of the
White House Office of Management and Budget;
Gayle Smith, special assistant to the president and
senior director at the National Security Council;
Thomas Frieden, director of the Centers for Disease
Control and Prevention; and Eric Goosby, U.S.
Global AIDS Coordinator. We are also grateful for the
support received from Dana DeRuiter of the National
Security Council; Sarah Handy and Anne Yu of the
Centers for Disease Control and Prevention; and Dana
Hyde and Jennifer Klein of the Department of State.

Many prominent individuals took time out to share
their extensive reflections: Mark Dybul, codirector of
the Institute for National and Global Health Law at
Georgetown University and former U.S. Global AIDS
Coordinator; Laurie Garrett, senior fellow for global
health at the Council on Foreign Relations; David
Lane, president and CEO of the ONE Campaign;
Chris Murray, director of the Institute for Health
Metrics and Evaluation at the University of Washington;
and Joy Phumaphi, former vice president for human
development at the World Bank. We all benefited from
the insights of Caroline Reynolds of the World Bank;
British Robinson of the Office of the Global AIDS
Coordinator; and Rachel Wilson of PATH.

The Bill and Melinda Gates Foundation is a pivotal
partner of the CSIS Global Health Policy Center—and
the Commission. We were delighted that Rajeev
Venkaaya agreed to be a commissioner and are grateful
as well for the support of Tachi Yamada, Joe Cerrell,
Sally Canfield, Todd Summers, Dan Kress, Deb
Derrick, and Owen Ryan.

For several years CSIS has also had a close and
flourishing relationship with the Henry J. Kaiser
Family Foundation. The Foundation provided
innovative background analyses to the Commission,
under Jennifer Kates’s direction. Drew Altman,
president and CEO, and Mollyann Brodie made a
highly compelling presentation to the Commission in
June on evolving American opinion. Matt James and
Peter Long facilitated a rich evening of dialogue with
Bay Area experts.

Our colleagues in North Carolina and California
were key to the Commission’s public outreach efforts.
Special thanks are owed to Mike Merson and Geelea
Seaford of the Duke University Global Health Institute;
Representative David Price (D-NC); David Hartman,
former host of Good Morning America; Haile Debas
and his colleagues Paula Murphy, Chuck Smukler, and
Robert Mansfield of the University of California, San
Francisco, Global Health Sciences; and Martin Brennan,
executive director of the International House at the
University of California, Berkeley.

Jodee Winterhof and Sarah Lynch of CARE went
the extra distance in partnering with us on the
Kenya trip. Also ready to help on the ground were
Ambassador Michael Rannenberger; Rob Breiman
and Kayla Laserson of the Centers for Disease
Control and Prevention in Kenya; and Warren “Buck”
Buckingham, director of the President’s Emergency
Plan for AIDS Relief (PEPFAR) for Kenya. We are
deeply grateful to the many Kenyans who took the
time to share their personal stories and convey to us
how U.S. health investments have impacted their lives.

Many in Geneva gave generously of their time during
a Commission visit in November, including David
Hohman and Simon Bland at the U.S. and UK
missions, respectively. At the GAVI Alliance, we owe

52 RepoRt of the CSIS CommISSIon on SmaRt Global health polICy

special thanks to Tony Dutson and Carole Presern; and
at the World Health Organization, to Andrew Cassels,
Ian Smith, Ala Alwan, Keiji Fukuda, and Daisy
Mafubelu, among others.

We held rich conversations on the role of multilateral
institutions in global health with Michel Kazatchkine,
executive director of the Global Fund to Fight
AIDS, Tuberculosis, and Malaria, and his colleagues
Christoph Benn and Rifat Atun; and with Julian Lob-
Levyt, CEO of the GAVI Alliance, and his colleague
Alex Palacios.

Our congressional commissioners were vital and ably
supported by their talented and committed staff:
Chad Kreikemeier with Senator Jeanne Shaheen (D-
NH); Theresa Vaughter, Rachel Carter, and Catherine
Knowles with Representative Kay Granger (R-TX);
Kari Moe and Zahir Janmohamed with Representative
Keith Ellison (D-MN); and Bill Pewen with Senator
Olympia Snowe (R-ME).

Our ongoing dialogue with the broad base of
Americans passionate about global health would
not have been possible without the assistance of
BlueStateDigital staff: Gene Koo, Emily Murphy,
Stephen Muller, and Sam Graham-Felsen. The Glover
Park Group was also very helpful: Beth Tritter, Jason
Boxt, Sam Hiersteiner, and Nicholas Stark.

Within CSIS, credit is due to Jon Alterman, Alison
Bours, James Dunton, Michelle Holder, Russ Oates,
and Teresita Schaffer, as well as to CSIS Global
Health Policy Center interns Rebecca Auerbach, Seth
Gannon, Brittany Goettsch, Marguerite Lauter, Marie
Ridoff, Katie Steckler, and Cathryn Streifel.

REPORT OF THE CSIS COMMISSION ON
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