Health

Noncommunicable Diseases

  • Health
    The Quest to Save 100 Million Lives (and Prevent Pandemics)
    It is not an obvious moment for a new global health initiative, let alone one that focuses on cardiovascular disease. Rising populism and nationalism in wealthy nations is undermining support for the use of international aid to promote better health in poorer populations. With the prospect of aid retrenchment on the horizon, many in the global health community have called for prioritizing existing programs on infectious diseases, child, and maternal health. Despite staggering increases in the rates of diabetes, cancers, and cardiovascular diseases in developing nations, the share of donor support that goes to addressing these noncommunicable diseases has fallen in recent years. Tom Frieden, the former director of the U.S. Centers for Disease Control and Prevention (CDC), recently announced a new initiative, called Resolve to Save Lives, that runs counter to all these trends.  Frieden spoke at a session of the Global Health, Economics, and Development Roundtable Series at CFR's headquarters in New York to discuss this new initiative, and to explain why he believes it can prevent 100 million deaths from cardiovascular disease in poorer nations and help control outbreaks of emerging infectious diseases before they become pandemics. 
  • Global
    Global Hearts: Confronting the Cardiovascular Disease Crisis
    Play
    Experts discuss the growing crisis of noncommunicable diseases, specifically cardiovascular diseases, and the initiatives by the World Health Organization and the Centers for Disease Control and Prevention in countering these threats globally.
  • Noncommunicable Diseases
    New, Cheap, and Improved
    Overview In recent years, frugal and reverse innovation have gained attention as potential strategies for increasing the quality and accessibility of health care while slowing the growth in its costs. The notion that health technologies, services, and delivery processes developed for low-income customers in low-resource settings (known as "frugal innovations") might also prove useful in other countries and higher-income settings (a process some call "reverse innovation") is not new.  The demand for these types of innovation is increasing, however, as developed and developing countries alike strain to cope with the staggering economic and social costs of noncommunicable diseases (NCDs). Increased attention on innovation is welcome—particularly when it is in service of improving the economic opportunities of the world's poorest and increasing their access to much-needed health-care products and services. The trick will be to ensure that the focus on reverse and frugal innovation goes beyond the latest buzzword and translates into real investments and results. With this goal in mind, this paper seeks to answer three practical questions regarding reverse and frugal innovation and NCDs: Are reverse and frugal innovations likely to be important for addressing the NCD challenges facing the poor in high- and low-income settings? Which pressing NCD challenges are reverse and frugal innovations best suited to help solve? What measures can donors, private companies, and nongovernmental organizations (NGOs) take to facilitate the use of reverse and frugal innovations to solve those problems? The answers to these questions may contribute to the ongoing efforts of donors, investors, NGOs, and governments to move frugal and reverse innovation out of the realm of promising ideas and anecdotes and into broader practice to tackle the global challenge of NCDs.
  • Global
    NY Event: Addressing the Chronic Disease Crisis in Developing Countries
    Play
    Task Force Co-Chair Thomas E. Donilon, Task Force Project Director Thomas J. Bollyky, and Task Force Member Barbara Byrne, join Juju Chang, coanchor of ABC News' Nightline, to discuss the CFR-sponsored Independent Task Force Report on Noncommunicable Diseases (NCDs).
  • Noncommunicable Diseases
    A Rising Global Health Threat
    The biggest threats to global health are not pandemics, but rather, cancer, heart disease, diabetes, and other noncommunicable diseases, says CFR’s Thomas J. Bollyky.
  • Noncommunicable Diseases
    The Emerging Global Health Crisis
    Rates of heart disease, cancer, diabetes, and other noncommunicable diseases (NCDs) in low- and middle-income countries are increasing faster, in younger people, and with worse outcomes than in wealthier countries. In 2013 alone, NCDs killed eight million people before their sixtieth birthdays in developing countries. A new CFR-sponsored Independent Task Force report and accompanying interactive look at the factors behind this epidemic and the ways the United States can best fight it. The co-chairs of the Task Force are Mitchell E. Daniels Jr., Purdue University president, former Indiana governor, and former Office of Management and Budget director, and Thomas E. Donilon, distinguished fellow at CFR and former national security advisor to President Barack Obama. Thomas J. Bollyky, CFR senior fellow for global health, economics, and development, directed the project. The bipartisan Task Force, CFR's first devoted to a global health issue, is composed of a distinguished group of experts that includes former government officials, scholars, and others. NCDs will affect U.S. interests because of their human, economic, and strategic consequences. "More patients will get sick, suffer longer, require more medical care, and die young. Given the scale of these trends, the results will reverberate," the Task Force warns. It is projected that the NCD epidemic will inflict $21.3 trillion in losses in developing countries over the next two decades—a cost nearly equal to the entire economic output of those countries in 2013. "These economic consequences will undercut potential U.S. trade partners and allies and may reduce domestic support for governments of U.S. strategic interest." The Task Force says the United States and like-minded partners can help developing countries meet the NCD challenge at relatively modest cost and "slow the rise of this epidemic, lessen its worst effects, and help provide national governments with the time and technical assistance needed to tackle this emerging crisis sustainably on their own." The U.S. government should take two immediate steps, the Task Force says: examine its global health priorities and spending and ensure their continued effectiveness; and convene governments and other potential partners from around the world to develop a plan for collective action on NCDs in low- and middle-income countries. The Task Force encourages the United States to focus on the NCDs and risk factors most prevalent among the working-age poor in developing countries. Low-cost interventions are available and should be integrated into existing U.S. global health efforts. Based on these criteria, the Task Force maintains that: In the short term U.S. leadership would have a significant effect on cardiovascular disease, tobacco control, liver cancer, and cervical cancer. "Low-cost, prevention-based solutions exist for each challenge and the United States is in the position to help local governments implement them." In the medium term U.S. leadership would make a tremendous difference to address diabetes and treatable and curable cancers, such as leukemia and breast cancer. "The Task Force has identified several NCD challenges for which effective interventions are widely used in the United States and other high-income countries, but not yet sufficiently low cost or usable in low-infrastructure settings . . .With U.S. leadership, more population and implementation research, and collaboration with private sector and philanthropic partners, progress on adapting these interventions for cost-effective, low-infrastructure use is foreseeable in the near term." U.S. collaboration with developing countries and the private sector may help ameliorate poor diets and nutrition, physical inactivity, and obesity. It could also help integrate mental health into primary care and provide low-cost chronic care programs and technologies. "There is no long-term treatment solution to the challenge of NCDs. Only prevention can reduce the burden of these diseases and lower their associated health-care costs to sustainable levels. This is true in the United States, but particularly so for developing countries with limited resources." Read the Task Force report, The Emerging Global Health Crisis: Noncommunicable Diseases in Low- and Middle-Income Countries. See also an annex with research methodology and profiles of nearly fifty priority countries. Explore the online interactive based on the Task Force. Read the accompanying op-ed by Mitchell E. Daniels Jr., Thomas E. Donilon, and Thomas J. Bollyky. This project is made possible in part through generous support from Bloomberg Philanthropies. Professors: To request an exam copy, contact [email protected]. Please include your university and course name. Bookstores: To order bulk copies, please contact Ingram. Visit https://ipage.ingrambook.com, call 800.234.6737, or email [email protected]. ISBN: 978-0-87609-616-1
  • Noncommunicable Diseases
    The Emerging Crisis: Noncommunicable Diseases
    Overview The gravest health threats facing low- and middle-income countries are not the plagues, parasites, and blights that dominate the news cycle and international relief efforts. They are the everyday diseases the international community understands and could address, but fails to take action against.ca Once thought to be challenges for affluent countries alone, cardiovascular diseases, cancer, diabetes, and other noncommunicable diseases (NCDs) have emerged as the leading cause of death and disability in developing countries. In 2013, these diseases killed eight million people before their sixtieth birthdays in these countries. The chronic nature of NCDs means patients are sick and suffer longer and require more medical care. The resulting economic costs are high and escalating. Unless urgent action is taken, this emerging crisis will worsen in low- and middle-income countries and become harder to address. The Disease Divide Cancer, diabetes, stroke, and other NCDs long ago became challenges for developed countries, but the epidemiological transition happening now in developing countries differs in speed, scale, and consequence. Rates of NCDs are rising fast in low- and middle-income countries. NCDs are also arising in younger populations in developing countries. Most of the death and disability from NCDs in these nations occurs in working-age people, under the age of sixty. In low-income countries, particularly in Africa, that proportion rises to 80 percent or more. NCDs are also yielding worse outcomes in low- and middle-income countries. NCDs that are preventable or treatable in developed countries are often death sentences in developing countries. Cervical cancer can largely be prevented in developed countries, but it is the leading cause of death from cancer in women in sub-Saharan Africa and South Asia. Ninety percent of children with leukemia in high-income countries can be cured, but 90 percent of those with that disease in the world’s twenty-five poorest countries die from it. Nine out of ten chronic obstructive respiratory deaths worldwide occur in developing countries. Drivers of an Epidemic The rise of NCDs in low- and middle-income countries is not merely a byproduct of success. Recent declines in infectious disease in developing countries help explain why more people who would have once succumbed in childhood or adolescence to plagues and parasites now get NCDs later in life instead. Declining infectious disease rates do not, however, explain why so many people in these countries are developing NCDs so much younger and with such worse outcomes than in wealthier nations. Rates of obesity, consumption of fatty foods, and physical inactivity in these countries have grown, but remain much lower than in high-income countries. Premature death and disability from NCDs is increasingly associated with poverty in emerging nations, just as it is in wealthy countries. The factors fueling the soaring rates of NCDs are dramatic changes in urbanization, global consumer markets, and longevity that occurred in wealthy nations over decades, but are happening simultaneously and much faster in still-poor countries. By the Numbers     Urbanization, trade, and the global integration of consumer markets have done much good in developing countries: improved sanitation; lifted millions from poverty; and increased food production. But these trends have also transformed the health risks that low- and middle-income countries face. Inhabitants of densely packed urban areas often face pollution outdoors and the burning of fuels indoors, are more likely to buy tobacco products, and less likely to have access to adequate nutrition. Between 1970 and 2000, cigarette consumption tripled in developing countries. Super- and mega-markets have penetrated every region of the world, even rural areas. Many vegetables and fruits are disappearing from diets globally. Nearly a quarter of premature deaths in developing countries are now attributed to high blood pressure, smoking, and diet. The health systems in developing countries have not kept up. Most are built for acute care, not chronic or preventative care. Medicines are purchased out of pocket in many countries and are often unaffordable to the poor. Developing country government health spending tripled over the last twenty years, but remains low. All the governments in sub-Saharan Africa together spend about as much on health annually as the government of Poland. Health spending by all developing country governments, representing 5.7 billion people, is less than is spent by the governments of Canada, France, Germany, and the United Kingdom, with a total population of 245 million. With little access to preventative care and more exposure to behavioral health risks, working-age people in developing countries are more likely to develop an NCD. Without access to chronic care and limited household resources to pay for medical treatment, these people are more likely to become disabled and die young as a result.  Chronic Diseases and their Costs The increase in rates of premature NCDs in low- and middle-income countries mean more patients are getting sick, suffering longer, requiring medical care, and dying younger. Given the scale at which this is happening, those effects reverberate. At the household level, NCDs consume budgets through out-of-pocket health-care costs and foregone income for patients and caregivers. To cover these costs, households take unsecured loans, deplete savings, or sell assets, all of which put families on precarious financial footing. The rates of catastrophic health expenditures in India for households with a male family member suffering from cancer or heart disease are 44 percent and 24 percent, respectively. At the national level, NCDs lower productivity and competitiveness in developing countries and increase health and welfare expenditures. High rates of premature death and disability from NCDs undermine the economic benefits that would otherwise accrue to these countries from having more working-age people in the labor force as a result of reductions in child mortality and better family planning. At the global level, the World Economic Forum (WEF) projects that NCDs will inflict $21.3 trillion in losses in developing countries over the next two decades—a cost nearly equal to the aggregate economic output of these countries in 2013. For these reasons, the WEF has ranked NCDs as a greater threat to global economic development than fiscal crises, infectious diseases, natural disasters, and crime and corruption. The Response to Date The last time that the world confronted a health challenge that caused a large number of premature adult deaths disproportionately in developing countries was HIV/AIDS. The United States led the global response to that disease and the world rallied to its side. The international response to HIV/AIDS expanded treatment to millions, saved many lives, and inspired a dramatic increase in global support for addressing other public health challenges from malaria to family planning to maternal and child health.  It is an accomplishment of which the United States and its international partners may feel deeply proud. Cardiovascular diseases, cancer, diabetes, and other NCDs are rising fastest in the same populations and countries in which the United States and the international community have invested to address HIV/AIDS and these other global health needs. The interactive map below depicts global changes in the disability and death (as measured in disability-adjusted life years or DALYs) between 1990 and 2010 from communicable diseases, which include all infectious diseases such as HIV/AIDS, malaria, and tropical viruses, and various NCDs.     Consider the forty-nine countries in which the United States devoted five million dollars or more in aid for health in 2013 (designated on the map as “U.S. priority countries"). NCDs accounted for 28 percent of the premature (under-age-sixty) deaths in these countries. That rate was 3.5 times greater than premature deaths from HIV/AIDS in these U.S. priority countries and 1.6 times as many premature deaths as malaria, tuberculosis (TB), and HIV/AIDS combined. The patients affected by NCDs and the communicable diseases targeted by global health programs are often the same. The average ages of death from HIV/AIDS and TB globally are 38.6 and 52.9, respectively. These are also the age groups suffering the worst effects of NCDs in developing countries. U.S. and international global health initiatives have not yet adjusted to these changing health needs. The United States has no dedicated programs or budget to address NCDs in developing countries. Despite the efforts by the World Health Organization, the United Nations, and NGOs to raise the priority of these diseases, international donor aid and a well-prioritized agenda for collective action on NCDs likewise remain elusive. Country Case Studies     The Task Force The urgency of this situation led the Council on Foreign Relations to convene an Independent Task Force on Noncommunicable Diseases—its first ever devoted to a global health matter. The charge of the Task Force was to assess the case for greater U.S. engagement on the NCD crisis in developing countries and to recommend a practical and scalable strategy for intervention. Read the final report of the Independent Task Force on Noncommunicable Diseases The principal U.S. interest in addressing HIV/AIDS, malaria, under-nutrition, and poor maternal health lies not in the direct threat that these diseases and conditions pose to Americans, which is modest, but rather in improving the fortunes of the developing countries and people that suffer unnecessarily from them. The same interests exist with NCDs. As the scale and consequence of this NCD epidemic grows rapidly in developing countries, so does the threat to U.S. interests. The United States cannot solve the NCD crisis emerging for developing countries. Ultimately, that responsibility lies with the national and local governments of those countries. Yet, working with likeminded partners, the United States can help slow the rise of this epidemic, lessen its worst effects, and provide national governments with the time and technical assistance needed to tackle this emerging crisis sustainably on their own. Recommendations for Action There is much the United States can do to help enable developing countries to meet the NCD challenge at relatively modest cost. The Task Force advocates that U.S. efforts focus on the specific NCDs and risk factors that are especially prevalent among working-age poor in developing countries and for which there are low-cost interventions that can leverage existing U.S. global health platforms. Based on that strategy, the Task Force has made a series of specific recommendations for U.S. action on NCDs and provided an investment case for each. Those recommendations fall in three categories: Challenges where U.S. leadership would make a tremendous difference now: primary and secondary prevention of cardiovascular disease; tobacco control; hepatitis B vaccination; and human papillomavirus (HPV) vaccination and cervical cancer screening. Challenges where U.S. leadership would make a tremendous difference soon: adapting diabetes treatment and diagnostic and curative care for breast cancer, leukemia, and other treatable and curable cancers for use in low-resource settings. Shared challenges where U.S. collaboration with developing countries and the private sector may help: population-based strategies to reduce poor nutrition, physical inactivity, and obesity; integration of mental health into primary care; and lower-cost chronic care. Progress Is Possible An NCD crisis in developing countries is not inevitable. Despite much higher rates of obesity and physical inactivity, premature death and disability from NCDs has declined dramatically in the United States and other high-income countries. The difference? Mostly cheap and effective prevention policies and off-patent tools that are not widely in place in developing countries, but could be with well-established global health strategies. The interactive below shows the deaths that would be averted in just the forty-nine countries where the United States currently has significant global health investments if those countries achieved the same rates of premature mortality as the average high-income country between 2000 and 2013. If those outcomes could be achieved or even approached, the results would be comparable to other successful U.S.-supported initiatives on childhood immunization and HIV. The Task Force is under no illusion that the recommendations and strategies outlined in its report would be alone sufficient to stem the tide of NCDs in developing countries. Building health systems, allocating scarce resources, and enforcing public health laws and consumer protections are decisions for national governments alone. Yet, the priorities of the United States and global health actors deeply influence those decisions. The recommendations and strategies outlined in this report would save lives, demonstrate the feasibility of progress on NCDs, and catalyze broader action. The time to act is now.
  • Health
    How to Save Electronic Cigarettes
    The popularity of e-cigarettes presents an enormous opportunity for public health, which the United States is at risk of squandering by regulating these products as tobacco, writes CFR’s Thomas Bollyky.
  • Health Policy and Initiatives
    The Global Health Regime
    This page is part of the multimedia Global Governance Monitor. Scope of the Challenge Despite medical advances and improvements in sanitation, water supply, nutrition, housing, and education, poor health continues to plague many countries in the world today. Infectious diseases kill approximately fifteen million people each year, and more than four million die from AIDS, malaria, or tuberculosis alone. A disproportionate share of this suffering occurs in developing countries. New threats, such as severe acute respiratory syndrome (SARS) and recombinant flu strains, continue to arise. Meanwhile, health conditions traditional to wealthier nations—including tobacco consumption, obesity, diabetes, and other noncommunicable diseases (NCDs)—are increasingly prevalent in the developing world. Global public health continues to be undermined by negative environmental, political, and economic factors from pollution to violent conflict to limited food production, and even a new, man-made threat—the specter of biological attacks. The expansive and evolving nature of global health challenges exerts constant pressure on national governments charged with safeguarding citizens' health and on the international institutions engaged in controlling the cross-border spread of disease and curbing dangers from noncommunicable diseases. Public health actors are generally motivated by a mix of development, humanitarian, economic, and security interests. Public attention to global health has grown at an unprecedented pace over the past half century. A surge in both funding and staffing has helped successfully eradicate smallpox, decrease AIDS mortality, and raise average global life expectancy from forty to sixty-five years. The shift has rightly been called a public health revolution. The surge in funding has spawned numerous organizations dedicated to improving public health worldwide. Some, though, have overlapping mandates, and coordination efforts are at times limited. Additionally, programs focused on alleviating specific diseases can often siphon resources from local infrastructure and reduce comprehensive health services. More needs to be done to coordinate actors and improve coherence across the global health landscape. Through centralized fora like the World Health Organization (WHO), countries should clarify priorities for the global health agenda, allocate more attention to health-related needs, advocate for greater accountability among nongovernmental organizations, and improve the monitoring and evaluation of global health initiatives. Meanwhile, as the global economic slump continues to linger, international institutions need to help ensure sustained financing for global health, improve alignment of recipient- and donor-country priorities, increase harmonization of multiple donor efforts, and engage the private sector to help mitigate persistent inequities in the development and delivery of resources to meet global public health challenges. Strengths & Weaknesses Overall assessment: Unprecedented focus and funding, yet anarchic The institutional landscape for global health is more populated, diverse, and better resourced than it was twenty years ago. The traditional multinational institutions that first dominated after World War II—primarily the World Health Organization (WHO)—have been joined by a panoply of new multilateral initiatives, public-private partnerships, foundations, faith-based organizations, and nongovernmental organizations. Yet the effectiveness of this increase in players and resources is often diluted by an uncoordinated and incoherent system. The WHO remains the primary organization involved in global health, responsible for health-related activities within the United Nations (UN). It plays a leadership role, spearheading research, policy, and country-level training and support. But the array of new players with expertise on global health is staggering. Within the UN, the Joint United Nations Program on HIV/AIDS (UNAIDS) and the UN Children's Fund (UNICEF) focus on particular global health issues. Other international organizations and programs with at least a partial mandate to address global health matters include the Food and Agriculture Organization (FAO), World Trade Organization (WTO), International Labor Organization (ILO), UN Environment Program (UNEP), and the World Bank. Multilateral funding mechanisms have also appeared, such as the Global Alliance for Vaccines and Immunization (GAVI), and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund). Regional organizations, including the European Union (EU), the Association of Southeast Asian Nations (ASEAN), the African Union (AU), and the Pan American Health Organization (PAHO)—have also become players in global health. Their combined work has strengthened systems, ensured universal health accessibility, and facilitated dialogue among member states, international institutions, and nonstate actors. Meanwhile, donor governments have launched major bilateral global health efforts (such as the U.S. President's Emergency Plan for AIDS Relief, or PEPFAR), and a growing number of departments, including military and security agencies (such as the U.S. Department of Defense), have become involved in global health. All these official actors share space with a burgeoning number of nongovernmental organizations (NGOs), faith-based organizations, and foundations dedicated to advancing global health. A rise in global health initiatives has accompanied this proliferation of actors. Three of the eight UN Millennium Development Goals (MDGs) focus squarely on health objectives, and another four relate to the social determinants of health. The Group of Eight (G8) now regularly places public health on its annual summit agenda, and the new Group of Twenty (G20) prioritized global health at its 2011 summit in France. In 2000, the UN Security Council declared HIV/AIDS a threat to international peace and security. The multilateral Health Eight (H8)—a group of eight organizations working on global health issues—was also established to coordinate global health initiatives and determine uniform international health priorities. In all, more than forty bilateral donors, twenty-five UN agencies, twenty global and regional funds, and ninety global initiatives target health activities and assistance. This institutional richness creates huge coordination challenges, not least for developing countries on the receiving end of outside attention. As a partial response, the International Health Partnership and related activities (the so-called IHP+) seeks to coordinate the activities and funding commitments of outside actors around country-led strategies. New treaties have been negotiated to help strengthen aspects of the global health regime. The revised International Health Regulations (IHR 2005) established rules and processes that allow the WHO and its member states to identify and respond to international public health emergencies more effectively. The regulations require state parties to report significant disease events and to develop and maintain core public health surveillance and response capacities. Similarly, the Framework Convention on Tobacco Control (FCTC), adopted by the WHO in 2003, is the first international convention under Article 19 of the WHO Constitution. It has helped to mobilize an unprecedented, worldwide anti-tobacco movement. In addition, the Global Code of Practice on the International Recruitment of Health Personnel [PDF], adopted by the WHO in 2010, aims to mitigate the imbalances of health workers between developed and developing countries. Much-needed funding has also increased. International financial support for global health efforts ballooned from $5.6 billion in 1990 to over $27 billion in 2010, thanks in part to the development of innovative financing mechanisms. Of special note is the prominent role that NGOs, including philanthropic foundations and private corporations, play in championing and financing public health programs. The Bill and Melinda Gates Foundation, in particular, provides approximately 5 percent of all funding for global health assistance. This surge in resources has contributed to several notable successes, including expanded access to medicines, improved disease detection, and growing community participation. Despite this progress, several significant weaknesses are apparent. First, inadequate coordination and leadership threaten the efficacy of today's global health institutions. Although effective coordinating bodies have sprung up, much of the activity in the field of global health reflects poorly integrated, donor-driven, disease-specific initiatives, often with weak accountability. Such a patchwork has led one prominent scholar to describe the system not as a regime, but as a loosely configured complex. Second, increases in funding and the proliferation of organizations and initiatives have not adequately addressed continued health disparities between affluent and poor countries. Many of the benefits derived from globalization have disproportionately accrued to wealthy countries, leaving poor nations vulnerable to acute and chronic health threats. Given these challenges, progress toward achieving the health-related MDGs—including a 75 percent reduction in maternal mortality between 1990 and 2015—has been slow. Additional weaknesses in global health governance include inadequate disease surveillance, inequitable access to vaccines and other essential medicines, a focus on single diseases rather than public health systems, and comparatively little donor attention and resources devoted to noncommunicable diseases. Moving forward, the United States and stakeholders worldwide face three main challenges: first, to reinvigorate the resources needed to address an expanding agenda; second, to minimize health disparities between rich and poor countries; and, third, to correct an absence of coordination and leadership. Targeting noncommunicable diseases: Growing awareness, but still too little Noncommunicable diseases have traditionally received little attention from the international community, yet they pose an important and growing threat to public health. In 2008, the World Health Organization (WHO) reported that chronic, noncommunicable diseases are the leading cause of death globally, despite being mostly preventable. As a result, the WHO is increasing its efforts to target noncommunicable diseases around the world. Traditionally, noncommunicable disease—cardiovascular problems, diabetes, cancer, and chronic respiratory illness, to name a few—have been considered diseases of affluence because they reflect ill health resulting from improved living standards. Today, their prevalence is more global. They correspond to shifts in diet and nutritional standards as well as to aging, because older populations have higher levels of cardiovascular disease and cancer. Although noncommunicable diseases remain the leading cause of death in the West, risk factors stemming from tobacco and alcohol consumption, unhealthy diets, and physical inactivity are increasingly driving mortality rates in poor countries, hampering socioeconomic conditions for growth and development. In the South Pacific region, for instance, noncommunicable diseases account for 75 percent of annual fatalities. In countries with a burgeoning middle class—namely, India and China—food consumption patterns have changed in favor of a higher protein-filled diet, but this has been accompanied by a massive increase in per capita consumption of salt, sugar, and trans fats, which contribute to the onset of noncommunicable diseases. Aware of the growing threat, the WHO created the Global Strategy on Diet, Physical Activity, and Health [PDF] (DPAS) in 2004, aimed at raising awareness and reducing the health risk factors associated with sedentary lifestyles and a poor diet. The DPAS has engaged relevant figures around the world, including national governments, private actors, and United Nations agencies—such as the Food and Agricultural Organization (FAO) and the Codex Alimentarius Commission—to promote awareness of the harmful effects of poor lifestyle choices and to incorporate health policies at the country level. Implementation, however, has been slow as the WHO also continues to allocate a substantial amount of resources to a multitude of other international health concerns. This is especially so among low- and middle-income countries, where noncommunicable diseases compete for resources allocated to prevalent infectious diseases. The DPAS also prompted controversy from companies concerned about adopting restrictions on marketing certain food and beverage products. The WHO has also begun to focus on obesity and alcohol consumption. For the latter, based on consultations with states, it has drafted a global strategy [PDF] on harmful use of alcohol. In January 2010, the WHO executive board adopted a resolution recommending the World Health Assembly adopt this strategy. On obesity, the WHO has recognized the problem as growing and in some countries acute. Its efforts, however, are limited to advocacy and the collection and analysis of relevant data. In some cases, it has joined forces with regional organizations. One such example is the European Union (EU), which adopted measures to counteract obesity (drafted by the WHO regional office for Europe) within the EU Charter. The private sector has started to take a more active role in responding to the noncommunicable epidemic. Companies like Pepsi and Nestle are making efforts to limit sugar, salt, trans fats, and net calories in their food and drink products. According to Derek Yach, Pepsi's director of global health policy, major companies are also showing leadership [PDF] in developing products based on organic ingredients and using their marketing capital to promote a healthy lifestyle and diet. Despite roadblocks, significant progress has also been made in rallying global support against tobacco. The WHO's most significant achievement has been the Framework Convention on Tobacco Control (FCTC)—the first convention adopted under Article 19 of the WHO Constitution—which came into force in 2005 and as of 2010 has more than 160 state parties. The FCTC requires signatories to restrict the influence of the tobacco industry on national health policies and ensure that safeguards are in place to protect the public from secondhand smoke. Other provisions include limiting or banning advertising and ensuring clear health warnings on tobacco products. The WHO has developed guidelines for meeting obligations and provided assistance to enable implementation. According to the WHO, most parties have "passed or are renewing and strengthening national legislation and policies" related to the treaty. That said, raw figures point to an uphill battle on tobacco use. Given rising populations in developing countries, overall tobacco use is increasing and efforts to curtail it remain underdeveloped. Further showing its commitment to combat NCDs, in September 2011, the United Nations held its first Noncommunicable Disease Summit to address the threat posed by NCDs within developing, low-, and middle-income countries (LMICs). Although the summit presented an opportunity for NCDs to gain prominence within the global health community, the lack of outcome disappointed many public health experts who had hoped for concrete and time-specific goals to reduce the prevalence of NCDs. This conference was part of the World Health Organization's 2008-2013 Action Plan [PDF] for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. Continuing the battle against HIV/AIDS: Unprecedented support, but still inadequate Responding to the Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) pandemic has been a critical challenge for nearly three decades. In 1986, the World Health Organization (WHO) created the Global Program on AIDS (GPA). Initially, GPA—and the Joint United Nations Program on HIV/AIDS—tried to create national AIDS commissions in every country, run at the highest levels of government. These strategies, however, were not effective in stemming the growth of the pandemic. In 1996, research showed the efficacy of highly active antiretroviral therapy (HAART), marking a turning point in the HIV/AIDS pandemic. By 1999, the HIV battle shifted away from prevention toward treatment, and in particular to getting HAART into poor countries. This prompted attacks on provisions of the World Trade Organization (WTO) Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) on the grounds that the high cost of patented HAART—then averaging from $10,000 to $20,000 per patient annually—was immoral. Accordingly, Merck initiated efforts to promote universal access to HIV treatment, and later the William J. Clinton Foundation negotiated dramatic price reductions and generic manufacturing of antiretroviral drugs (ARVs). The efforts have brought the annual cost of treatment to less than $300 per patient. Further reductions are expected. Multilateral action on the disease accelerated in 2001, with a groundbreaking UN declaration that instructed all countries to fight HIV/AIDS through prevention, treatment, and long-term care. This new attention spurred the establishment of the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) at the Genoa Summit of the Group of Eight (G8) in 2001. Along with the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and World Bank's Multi-Country HIV/AIDS Program (MAP) for Africa, the Global Fund has been an important advocate of prevention, counseling, care, and treatment programs. But economic difficulties in major donor countries have intensified debates about how best to spend existing resources in the face of increasing demand. After committing to help achieve "universal access" to HIV treatment—defined as ten million people by 2010—and to double aid for health and poverty reduction to $50 billion per year, the G8 backed off its pledge and restated its goal in June 2011 as fifteen million people by 2015. Despite these setbacks, funding for HIV/AIDS has suffered the least from contracted foreign aid budgets. A record 1.4 million began treatment in 2010, reflecting the continued increase in access to care for HIV/AIDS. Private actors have helped bridge some of the gaps in financing. Sustained efforts by foundations, faith-based organizations, and nongovernmental organizations, for example, have been critical in achieving the yearly decrease in new infections globally. Independent organizations, such as the International AIDS Vaccine Initiative and the Global HIV Vaccine Enterprise, have also contributed to the effort of developing an HIV vaccine. Growing evidence, however, indicates that prevention efforts have been too limited. HIV incidence in the United States rose by nearly 50 percent between 2005 and 2009. The large numbers of new infections globally each year—2.5 million in 2011—are increasing the number of people in need of ARVs, even as the availability of ARVs stagnates or declines. Intravenous drug users continue to be at high risk, and antinarcotics politics complicate prevention. In Africa, Asia, and Eastern Europe, blood supplies remain unsafe and syringes are often reused. Furthermore, failure to tightly integrate tuberculosis and HIV diagnosis and treatment has sparked a tuberculosis pandemic, marked by increasing rates of drug-resistance in tuberculosis strains. In response, the Joint United Nations Program on HIV/AIDS has called for a "prevention revolution" [PDF] to halve the number of infections by 2015. Secretary-General Ban Ki-moon hailed an overall global decline in HIV infections in the 2011 Report on AIDS. At the release of the report, the UN also launched its third major initiative to fight HIV/AIDS that set a target of zero new infections and zero AIDS-related deaths by 2015. However, Secretary-General Ban Ki-moon acknowledged financial hurdles, noting that resources to fund AIDS relief plateaued at $16 billion in 2007. In May 2009, the World Bank published an independent evaluation of its $2.46 billion HIV/AIDS portfolio, which included 106 projects in sixty-two countries. A quarter of the programs were deemed unsatisfactory or moderately unsatisfactory. The report concluded that the World Bank had underinvested in prevention programs for high-risk groups, inadequately monitored projects, and overestimated the capacity of nongovernmental organizations to design and implement AIDS interventions. The report recommended bolstering health ministries and civil society organizations, as well as more diligently monitoring and evaluating. Over the past five years, life-saving drugs have been made more available by a factor of one hundred due to increased donor funds; defiance of HIV drug patents by the governments of Brazil, Thailand, and South Africa; and continued activism by civil society groups. New initiatives and medicine also show promise. A new study of a microbicide gel showed that the treatment could stop HIV transmission to women in 39 and 54 percent of cases. Additionally, in July 2010, federal researchers released findings of antibodies that were effective at neutralizing 90 percent of HIV strains that lead to AIDS, inspiring optimism that a vaccine might soon be achieved. In addition, the Medicines Patent Pool was set up in July 2008 and aims to increase access to treatment by promoting price reductions of existing antiretroviral drugs, stimulating the production of newer first- and second-line drugs and increasing the number of generic producers of these medicines. The first major agreement between a pharmaceutical company and the Patent Pool was finalized in July 2011, with assistance from the United Nations. Recently, Johnson and Johnson agreed not to enforce its patents on darunavir, a common retroviral, amid calls for other HIV medicines to be added to the Patent Pool. UNAIDS also enacted Treatment 2.0 [PDF], a new approach to simplify treatment and increase access to medicine, in order to decrease costs, reduce the burden on health systems, and improve the quality of life for people living with HIV. Modeling suggests that, compared with current treatment approaches, Treatment 2.0 could avert an additional 10 million deaths by 2025. Still, two broad challenges persist. First, the demand for ARVs far exceeds the supply. Approximately 5.2 million [PDF] people have accessed HIV treatment in low and middle-income countries, up 30 percent from 2009, but more than double that need treatment immediately. Furthermore, price reductions for treatment have been negotiated for only a small subset of drugs, while newer, simpler, and more palatable formulations remain unaffordable in most high-prevalence countries, including Swaziland and Botswana. Finding a balance between market-driven innovation that creates new drugs and the imperative to ensure access to HIV/AIDS medicine and vaccines in low- and middle-income countries remains elusive. With that said, international efforts, led by UNAIDS, to provide universal access to HIV treatment by 2015 remain on track. Management of acute pandemics: Testing surveillance and alert systems; response systems under stress Pandemic preparedness requires a standardized outbreak alert system linked to concrete actions by national and local health authorities. In 2000, the World Health Organization (WHO) established the Global Outbreak Alert and Response Network (GOARN)—a decentralized network of technical experts and regional surveillance programs from the United Nations, civil society partners, and academic centers—designed to detect and coordinate the response to disease outbreaks. The WHO also established a six-level pandemic alert system for influenza based on the geographic spread of the disease and its human transmissibility. This system, however, has been criticized for failing to consider the severity of each virus, to link threat levels to tangible actions, and to harmonize existing country alert systems. By contrast, the U.S. alert system has five threat levels that correspond to deaths from infection, but fails to consider human-to-human transmission or geographic spread. Efforts to improve and synchronize the alert systems are underway, and will ideally convey the severity of infection, risk of death, geographic spread, and contagiousness in a combined metric, as well as suggest clear actions linked to threat levels. Following the severe acute respiratory syndrome (SARS) and h2N1 (avian flu) outbreaks, the WHO redoubled efforts to modernize its surveillance and warning systems. In 2007, WHO member states adopted the International Health Regulations (IHRs) for pandemic preparedness and response. The regulations have helped facilitate coordination among states, but pandemic management is still relatively haphazard. The revised IHRs require governments to report public health emergencies of international concern to the WHO within twenty-four hours, permit use of nongovernmental disease detection data to supplement government data, and obligate countries to improve their capacity to respond to health crises. The revisions—which require all signatories to comply with core surveillance and response capacity requirements by 2012—are legally binding but contain no provisions for enforcement. Country compliance with the IHRs has been mixed. In the 2009 H1N1 (swine flu) outbreak, Mexico exceeded IHR obligations by implementing a rapid domestic response, communicating with neighboring states and the WHO, and sharing viral samples with other national and multinational health authorities. Unfortunately, Indonesia performed less admirably during the various h2N1 (avian flu) outbreaks. Even after the revised IHRs went into force, Indonesia refused to report new cases. Fearing that multinational corporations would use the samples to develop a vaccine (and turn a profit by selling it back to affected countries), the Indonesian minister of health justified his refusal to share samples by invoking "viral sovereignty"—the principle that infectious diseases belong to the countries in which they are discovered endemic. This is a troubling principle that could undercut timely international cooperation and monitoring in future crises. The episode underscored the need for mechanisms to persuade recalcitrant states to cooperate on critical matters of global health. But the WHO has also been criticized for sounding false alarm bells. Critics have attacked its handling of the 2009 H1N1 pandemic for causing undue panic. The Council of Europe investigated [PDF] the WHO on grounds of misconduct, finding that the WHO exaggerated the dangers of the pandemic and above all lacked transparency throughout the process. The WHO was also under investigation by the Review Committee established under the revised IHRs for its use of the revised regulations and its overall actions during the 2009 pandemic. The committee ultimately concluded that the adoption of IHR 2005 helped make the world better prepared to cope with public health emergencies, even though the core national and local capacities called for in the IHR are incomplete and nonexistent in many regions around the world. Disputes over intellectual property protection are another major obstacle to combating acute pandemics. Emerging market countries—notably Indonesia, Thailand, China, India, Brazil, and Malaysia—have criticized the World Trade Organization's (WTO's) Trade-Related Aspects of Intellectual Property Rights (TRIPS) provisions, which are frequently blamed for drug and vaccine pricing that keeps some medicines out of the reach of much of the world's population. Since the Doha Declaration in 2001, the same criticisms have been levied against the European Union, United States, and Japan to insert enhanced intellectual property provisions into trade agreements, most notably the Anti-Counterfeiting Trade Agreement. Addressing neglected tropical and other infectious diseases: Growing attention, but still addressed weakly The global health agenda has not adequately focused on some of the infectious diseases that continue to plague, debilitate, and kill millions in the developing world. Diarrheal and enteric diseases include some types of hepatitis, salmonella, cholera, typhoid, and an array of other viral, bacterial, and parasitic pathogens. They remain the second-leading cause of fatality for children, killing nearly 1.7 million every year, and are the greatest contributor to childhood malnutrition. Worldwide, diarrheal diseases account for 4 percent of all deaths and 5 percent of health-related disabilities. Yet, unlike HIV/AIDS, these diseases pose no serious threats to the national interests of powerful countries, perhaps accounting for the neglect. Relative to the global impact of these diseases, funding and dedicated advocates have been lacking historically. The situation, however, is improving. The Bill and Melinda Gates Foundation is investing in research and development for new treatments, along with improved delivery for existing interventions, such as making vaccine distribution and administration less costly. The foundation is also trying to promote and implement structural solutions, such as improved access to fresh water, sanitation systems, and nutrition. Advances have also been made in vaccination, with the Global Alliance for Vaccines and Immunizations leading the way. In July 2011, the United Nations Foundation and GAVI pledged $4.3 billion toward vaccinating 250 million children by the year 2020. These vaccines will help protect against a variety of preventable, life-threatening diseases, including vaccines against diarrhea and pneumonia, which are not readily available to children in developing countries. Vaccine pledges are a significant step toward ensuring comprehensive global childhood immunization, which is one of the most cost-effective and sustainable methods for improving health worldwide. Another subset of problematic infections is known as neglected tropical diseases (NTDs). NTDs thrive in specific climates, are often linked with impoverished environments, and tend to be spread by insects, contaminated water, or infested soil. They currently affect more than one billion [PDF] of the world's poorest people, many of whom suffer from multiple NTDs. In the past few years, great strides have been made in understanding the complexity and character of NTDs. Their direct link to poverty has led the World Health Organization (WHO) to consider poverty control [PDF] part of its global health strategy. The WHO has also launched a comprehensive Preventive Chemotherapy and Transmission Control (PCT) program that works with national governments to train health specialists and advocate disease control measures. In partnership with the WHO, numerous NGOs have begun to develop initiatives to eradicate and eliminate NTDs. The Carter Center, for instance, has helped eradicate Guinea worm in some twenty countries and eliminate onchocerciasis (river blindness) in much of the Americas. The Gates Foundation has also prioritized NTDs. In addition, the Mectizan Donation Program, established by Merck in 1987, began donating mectizan for treatment of onchocerciasis, and Merck has since partnered with GlaxoSmithKline to provide albendazole to treat lymphatic filariasis (elephantiasis) in coinfected individuals. As part of its new Global Health Initiative (GHI), the U.S. government has pledged to increase funding for research and treatment of NTDs, and it plans to increase funding from $15 million in 2006 to $155 million in 2011. Targeted diseases include trachoma, schistosomiasis, onchocerciasis, lymphatic filariasis, and soil-transmitted helminthiases. However, this new focus on NTDs and other initiatives, combined with the effects of the economic crisis in donor countries, has meant the potential shift of resources away from other health efforts. NTDs are starting to make their way onto the global health agenda, but the crux of the problem is in delivering [PDF] needed medications and therapies to affected communities and addressing infrastructure issues. For the most part, NTD drugs are inexpensive, but serious supply shortages and distribution challenges persist. Additionally, financing to purchase existing drugs is often limited. Despite commitments by the donor community and the Group of Eight, these tropical infections and their underlying causes will need additional, sustained focus and funding. Managing biosecurity: Rudimentary mechanisms The international community continues to lag in its efforts to deter—and prepare for—the use of biological weapons. Existing governance mechanisms reflect Cold War concerns about state proliferation of weapons, rather than the threat of terrorism by nonstate actors. The stakes of such negligence are high. Depending on the severity of the pathogen, a biological agent deployed as a weapon—whether improvised or stolen—could conceivably kill millions, bring global commerce to a grinding halt, and have lingering effects for generations. Smaller-scale attacks, like the 2001 anthrax scare, can cause widespread panic and disruption, even when the death toll is relatively low. Managing biological weapons is made more complex by the nature of the threat. Even if existing multilateral agreements were entirely effective, biological agents cannot be managed without local controls and cooperation among nonstate actors. Most biological agents are manufactured and housed in the private sector (particularly in laboratories, hospitals, and universities), which requires enhanced coordination with each of type of facility. Inspections are all the more difficult because the equipment, materials, and agents used for weapons are often also appropriate for legitimate commercial use. Despite calls from United Nations (UN) secretary-general Kofi Annan in 2006, no global forum convenes all the relevant actors to promote a dialogue on safeguards for biological agents. Moreover, the rapid dissemination of weapons-manufacturing information and the ease with which materials can be obtained have rendered the threat of biological weapons more diffuse. Over the last decade, it has become simpler to manipulate viral and bacterial genes to increase their harmfulness and transmissibility. A movement is also growing that promotes in-house production of life forms and open-source sharing of biological "recipes" online. On the positive side, arrangements to counter the threats of biological weapons have emerged. These include UN Security Council Resolution 1540, which obligates UN member states to prohibit nonstate actors from acquiring, pursuing, or obtaining weapons of mass destruction. Additionally, the Global Health Security Initiative, which is an informal partnership among national health ministries from eight countries (including the United States), the European Commission, and the World Health Organization (WHO) seeks to strengthen global preparedness against biological threats. The reporting requirements of the revised IHRs now apply to acts of biological terrorism, and Interpol has bolstered its efforts to prevent bioterrorism. In the United States, the Obama administration has released a National Strategy for Countering Biological Threats and a first-of-its-kind National Health Security Strategy. Under the leadership of WHO, the international community increasingly recognizes the importance of public health surveillance and intervention capabilities in countering the biological weapons threat. The WHO's Global Outbreak and Response Network(GOARN) is part of a global early warning and surveillance network that can identify unusual disease events rapidly, although it does not provide specific response protocols. The main international legal instruments relevant to combating bioattacks at the global level remain the 1925 Geneva Protocol and the 1972 Biological and Toxin Weapons Convention (BTWC), both of which ban states from using biological weapons but are widely considered inadequate and flawed. The Geneva Protocol prohibits use of biological weapons in warfare, but lacks [PDF] any institutional capacity to monitor compliance. The BTWC goes further in banning development, production, acquisition, and stockpiling of biological weapons but also lacks the rigorous system of inspections that would be necessary for monitoring compliance. Efforts to add a protocol to the BTWC, which would address this shortcoming by establishing a mechanism for information exchange and routine inspections of facilities, have failed. Currently, only about half of BTWC signatories submit voluntary monitoring reports. Unlike the nuclear and chemical weapons regimes, the BTWC lacks a permanent institutional structure that could help implement the convention and promote peaceful use of biotechnology. It includes a provision whereby a state party can appeal to the UN Security Council to enforce the convention against an alleged violator; however, no state has yet done so. The BTWC has an Implementation Support Unit (ISU), but it has a limited mandate and a staff of only three. Discussions on modernizing the BTWC—through new lab safety standards, new reporting requirements, increased enforcement of safety measures, and bolstering of the ISU—have failed to translate into concrete revisions of the convention. Nearly ten years after the 2001 U.S. anthrax attacks, controversy continues to surround the Federal Bureau of Investigation's handling of the matter, indicating the need for greater U.S. government—as well as global—attention to biosecurity issues. It will be imperative at the Seventh Review Conference of the BTWC in December 2011, to agree on new security standards for laboratories that work with high-risk agents and enforce standards more rigorously. Yet such steps are fraught with technical and practical complexities. These include how to define potential biological agents, how to surmount the financial and legal burdens associated with implementation, and how to balance these goals with other objectives, such as development of medical countermeasures and disease surveillance. Developing health systems in poor countries: Minimal progress Poor countries often suffer from inadequate health systems. These weaknesses typically include shortages of health professionals, chronic underfunding, dilapidated or nonexistent infrastructure, and a persistent lack of access to essential medicines, including vaccines. Margaret Chan, director general of the World Health Organization (WHO), has identified weak health systems as the greatest threat to global health goals. Although most countries have adopted the principle of health as a fundamental human right, too few developing nations have actually strengthened their health systems. A significant portion of global health financing today is dedicated to vertical, disease-specific programs and initiatives. These include the President's Emergency Plan for AIDS Relief (PEFPAR), the President's Malaria Initiative (PMI), the Global Fund for AIDS, Tuberculosis, and Malaria (Global Fund), and several Bill and Melinda Gates Foundation initiatives. PEPFAR alone is contributing $48 billion to research, care, prevention, and treatment of HIV over a period of five years. In 2011 President Obama's proposed budget included almost $7 billion for PEPFAR, representing a 1.8 percent increase on the previous year. However, according to some activists, this increase actually represents a 'step backwards' due to increasing demand for treatment and inflation. Furthermore, additional focus has been placed toward improving MDGs 4 and 5 relating to maternal and child health. A 2010 MDG Summit and a 2010 G8 Summit further committed to providing additional funding to support childbirth, maternity, and early childhood health. But such programs often reflect donor priorities rather than local needs and are often independent, uncoordinated, and unaccountable, either to their intended beneficiaries or to taxpayers. Rather than respond to host country requests, donors often impose their own funding priorities, and programs tend to be poorly integrated into local public health systems. Funders and implementers have a vested interest in minimizing failures, and host countries are wary of holding donors to account for fear of driving away badly needed resources. What accountability exists comes in the form of self-regulation, uneven oversight from funders, and monitoring by (typically overstretched) health ministries in host countries. In sum, incentives for honest evaluations are few. Some argue for greater coordination between vertical—or disease-specific—and horizontal programming. One initiative, known as fifteen by 2015, aims to reallocate 15 percent of current funding by 2015. Meanwhile, President Obama in 2009 launched the Global Health Initiative (GHI), which targets health systems as well as single diseases. In March 2011, the Obama Administration released the GHI Strategy Document [PDF], illuminating key aspects of the GHI approach and strategy. The report emphasized shifting U.S. health to an impact-based approach and focusing on areas where large, substantial health gains can be achieved. Unfortunately, health systems in most developing countries depend on volatile donor funds. In 2006, donors supplied more than 40 percent of health system funds in eight African countries; many more African nations rely on external funding for more than 30 percent of their budgets. Donor support for health systems is critical, but donors must beware of generating negative, unintended consequences. Governments receiving development assistance for health tend to invest 43 percent fewer of their own resources for health-related activities according to a Lancet study. To combat this risk, donors' governments will need to expand their country-level monitoring of how assistance impacts healthcare. The emigration of qualified health professionals can also undermine health systems. The WHO warns that countries with fewer than 2.3 health professionals per thousand inhabitants will struggle to provide essential primary care services. The relevant figures for Africa and Southeast Asia are 1.3 and 1.7, respectively. Most low- and middle-income countries train far too few health professionals annually, and many locals who are trained immigrate to countries with higher salaries and better working conditions. For example, between 1993 and 2002, half of the doctors and one-third of all nurses educated in Ghana emigrated immediately. According to Michael Clemens at the Center for Global Development, 15 percent of registered nurses and 30 percent of doctors from sub-Saharan African work outside the continent. There is no easy solution to this brain drain. Restricting health worker emigration is not logistically feasible, and everyone has the right to pursue a better life. In May 2010, the World Health Assembly adopted the Global Code of Practice on the International Recruitment of Health Personnel [PDF] that aims to balance the interests of health workers with those of countries that lose them and receive them. Another initiative, the Global Health Workforce Alliance, seeks to develop country coordination and a code of ethical international recruitment. A few attempts have been made to regulate migration of health professionals at national and regional levels. South Africa and the United Kingdom signed a Memorandum of Understanding (MOU) in 2003, in which the UK agreed to ethical recruitment practices, technical assistance, partnerships between hospitals, and time-limited placements of staff trained in South Africa. Countries in the Caribbean established uniform professional qualification standards for health workers and created a common market that permits their free movement in the region. Pending rigorous assessments, these approaches may provide models for developing countries. Facilitating access to vaccines: Record progress, but more attention needed Vaccines are often effective in preventing disease. The H1N1 (swine flu) pandemic revealed how rapidly a vaccine could be developed and manufactured on a large scale with the support of major developed economies. Nonetheless, the 2009 scare also highlighted critical gaps in financing and in the equitable distribution of much-needed vaccines around the world. International efforts to control disease through vaccination are not new. In 1974, the World Health Organization (WHO) launched the Expanded Program on Immunization (EPI) to help vaccinate children in developing countries. Since 1970, the program has provided regular vaccinations through regional WHO branches. The most successful WHO achievement has been on smallpox, which in 1979 became the first infectious disease to be eradicated. More recently, international commitment has been jumpstarted by a joint WHO-United Nations Children's Fund initiative, the Global Immunization Vision and Strategy (GIVS), which looks to increase vaccine coverage by 2015 to meet the Millennium Development Goals [PDF]. According to the WHO's flagship publication on the issue, the last decade showed remarkable progress for vaccines. Some 120 vaccine products are now on the market, and eighty more are in the late stages of research and development. Moreover, scientific improvements (such as adjuvant compounds) have extended short supplies more than tenfold by stimulating the immune systems of recipients, making them more likely to ward off targeted infectious diseases (measles, polio, diphtheria, and the like). Newer vaccines—like those recently adopted to combat meningitis and pneumonia are becoming more effective and cheaper to produce and disseminate. Financing for vaccines has increased dramatically in the last few years, due partly to innovative financing and partly to new contributions. Most recently, at the 2010 World Economic Forum, the Bill and Melinda Gates Foundation announced a pledge of $10 billion over the next decade for research, development, and delivery of vaccines for poor countries. Such new financing has helped alleviate some shortfalls, but more funds are needed. According to the United Nations, national governments support about 40 percent of the costs for routine immunizations. For many developing countries, sustaining this commitment will be difficult. Multilateral funding is not enough to close the gap. The Global Alliance for Vaccines and Immunizations (GAVI) was able to overcome its $4.3 billion funding shortfall in June 2011 at its first pledging conference. The pledges bring GAVI's total available resources for the period 2011 to 2015 to $7.6 billion. Yet, the pharmaceutical industry relies on a handful of firms to produce all the vaccines needed to meet global demand. Declining profitability from production suggests the need for stronger manufacturer incentives. In response, the Center for Global Development, in partnership with public and private donors, helped promote the Advance Market Commitments (AMCs) for Vaccines. These firm commitments from multilateral donors incentivize manufacturers to develop vaccines that might otherwise be ignored. GAVI's Advance Market Commitment is piloting a new vaccine for pneumococcal disease (a common cause of pneumonia), though it has been criticized for protracted distribution timelines, and even accused of coercing developing countries to accept the new vaccine instead of an existing, less expensive alternative. Another innovative financing mechanism launched by GAVI (with the World Bank as treasurer) is the International Finance Facility for Immunization (IFFIm). The mechanism makes use of pledges to issue bonds that generate readily available cash for immunization needs. To date, it has raised $5.9 billion in pledges to be paid over twenty years. Inequities in access to resources for pandemic management unfortunately persist. The 2009 swine flu outbreak is the most recent reminder. At first, access to H1N1 vaccine was largely restricted to high-income countries. Almost a year elapsed between the emergence of H1N1 in North America and the first population-based distribution of H1N1 vaccines in Africa. By the spring of 2010, the pandemic had petered out in high-income countries, which were then willing to donate unused stocks to poor countries. Additionally, negotiations on sharing viruses and the benefits from their use have not progressed. Multilateral talks have been deadlocked, which only increases the challenge of vaccine distribution, particularly in developing countries. Progress in developing vaccines for pandemics also continues to be a major challenge. Established in 1996, the International AIDS Vaccine Initiative (IAVI) develops and assesses candidate HIV vaccines and addresses previous impediments to developing vaccines. To date, IAVI has six vaccines in early-stage clinical trials in eleven countries. GlaxoSmithKline and the PATH Malaria Vaccine Initiative (MVI) have been working toward a vaccine targeted for infants and children in sub-Saharan Africa since 2001. The vaccine, known as RTSS is in the final stage of trials and, if results remain positive, will be ready for distribution by 2015. Ensuring effective and sustainable financing: Significant progress, but uncertain future and fragmented focus Development assistance for global health more than doubled between 2001 and 2007. The budget reached [PDF] $27 billion in 2010, fueled primarily by new financing mechanisms, though the growth rate has plateaued in the wake of the financial crisis. The current regime, however, may be neither sustainable nor appropriate given the lingering effects of the global recession, escalating deficits, domestic healthcare shortfalls in developed countries, shifting priorities, and a greater donor focus on climate change. The multitude of health actors does raise awareness and funding for global health, but activity lacks coordination and monitoring. Of the five largest financing mechanisms, one is bilateral (the President's Emergency Plan for AIDS Relief, or PEPFAR), one is multilateral (the World Bank), one is a private foundation (the Bill and Melinda Gates Foundation), and two are public-private partnerships (the Global Alliance for Vaccines and Immunizations, or GAVI, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, or Global Fund). Perhaps the biggest challenge is identifying sustainable, predictable, and adaptable funding streams. Most international health financing comes from national governments, which are unpredictable from year to year and complicate long-term, strategic approaches. As a result, efforts taken to increase funding from national governments for domestic health priorities must continue as they have in Rwanda, India, China, and Indonesia. In principle, the donor community has committed to work with developing countries to implement the 2005 Paris Declaration, a set of guidelines to improve the effectiveness of development assistance. The emphasis is on developing country priority-setting, aligning donor funds to grantee agendas, harmonizing donor initiatives, monitoring program results, and establishing accountability between donors and recipients. A recent study of the declaration's impact, however, found that only 45 percent of development aid arrived on time and that many development programs continued to undermine local program work. In 2011, the Busan Outcome Document [PDF] of the High-Level Forum on Aid Effectiveness recommitted governments to the Paris Declaration's core principles of strengthening country ownership and developing partnerships and, for the first time, included emerging countries such as the BRICS as well as civil society organizations and private funders. However, despite monitoring mechanisms such as the 2011 Survey on Monitoring the Paris Declaration, many original goals of the Paris Declaration have not been met. In 2007, several initiatives were launched to enhance coordination among major donors. The International Health Partnership and related initiatives (IHP+) aims to expand on the Paris Declaration principles and provide recipient governments with a greater stake, by focusing donor assistance on a centralized national health plan and budget. Similarly, the Health Eight (H8) partnership brings together eight major health organizations (the World Health Organization, United Nations Children's Fund, United Nations Population Fund, United Nations Joint Program on HIV/AIDS, Global Fund, GAVI, the Gates Foundation, and the World Bank) to strengthen efforts toward achieving the Millennium Development Goals (MDGs). Progress, however, remains mixed. The 2011 MDG report indicated [PDF] that nutrition, universal primary education, and child mortality were in danger of falling short of their 2015 targets. In early 2011, WHO Director General Margaret Chan highlighted "serious funding shortfalls" in a speech addressing how to more effectively use existing financing. Continued economic difficulties in major donor countries have intensified the debate about how best to spend increasingly scarce resources. While the global financial crisis did not freeze increases in health funding, it has slowed its growth—from 13 percent annually in 2004 to 2008 to 6 percent in 2009 and 2010. Given that major new financing is unlikely in the near term, progress in providing health services in developing countries will require efficiencies in existing assistance levels, including through better alignment of donor and recipient priorities, enhanced coordination among the largest programs and institutions, rational divisions of labor at the national and local levels to reduce redundant services, and an improved evidence base to identify cost-effective interventions. Some innovative financing approaches exist. The intergovernmental group UNITAID seeks to improve treatments for HIV/AIDS, malaria, and tuberculosis (primarily in low-income countries) through more affordable mechanisms. Since 2006, UNITAID has also committed more than $955 million [PDF] to partners worldwide. Additionally, in March 2010, the Millennium Foundation launched Massive Good to help raise more funds for UNITAID. The initiative centers on the travel industry, giving anyone who buys an airline ticket online the option to donate to UNITAID. By November of 2011, however, the campaign was discontinued. The International Finance Facility for Immunization of GAVI, mentioned earlier, was also innovative in raising quick cash for global health needs. U.S. and International Global Health Policy Issues Should the United States develop an integrated, coherent global health strategy? Yes: An integrated approach is necessary in today's interconnected world. Programs that focus on a wide range of diseases and help bolster other countries' health infrastructures are the only way to combat the litany of global health threats. Efforts will be ineffective without supporting national health systems, and funding must be given to programmatic issues that focus on maternal and child health to prevent diseases before they start. President Obama's Global Health Initiative—with its goals to improve health systems and fight diseases in coordination—is a step in the right direction but if it falls short, then it must be replaced with a coherent alternative. Important single-issue programs will remain a significant portion of the budget, but the strategy on the whole will be more flexible and more capable of addressing multiple issues—not only disease, but human rights, women's rights, country ownership of health issues, and international health governance as well. No: A broad strategy takes away focus and funding from what single-issue programs already do well. The President's Emergency Plan for AIDS Relief (PEPFAR) and the President's Malaria Initiative have succeeded because of their relatively narrow focus, and the guarantee that funding would go directly to combating the targeted disease. Also, a mandate on a single disease does not mean that a program does not have an integrated approach. In PEPFAR's case, for example, efforts have involved childcare, hiring additional healthcare workers, and addressing the challenges of food and nutrition in addition to direct treatment. If single-issue programs are embedded in a broader strategy, there is no guarantee that such an integrated approach to disease will result, and critics contend that PEPFAR may end up competing with other diseases and issues for funding. In the end, a single comprehensive program with a large budget may face more funding challenges than multiple, smaller, single-issue programs where less money can have a more direct effect. Should the United States push for a broader institutional focus to combat noncommunicable diseases (NCD) across the globe? Yes: In 2008, the World Health Organization (WHO) reported that chronic, noncommunicable diseases are the leading cause of death globally, despite being mostly preventable. As a result, the United States should join forces with the WHO in increasing its efforts to target noncommunicable diseases around the world. Noncommunicable diseases also remain the leading cause of death in the West, as risk factors stemming from tobacco and alcohol consumption, unhealthy diets, and physical inactivity are increasingly driving mortality rates. In the United States alone, NCDs and other chronic diseases such as stroke account for 70 percent of deaths, limit the activities of tens of millions more Americans, and cost the U.S. economy over 1.5 trillion annually. According to the U.S. State Department, six strategies need to be implemented by the United States in order to curb the growth of NCDs in the United States and across the globe: collaboration across policy sectors, prioritizing high-impact and affordable strategies, knowledge sharing, greater scale and geographic spread for NCD programs, and an enhanced media presence. No: Unlike illnesses caused by a mosquito, a virus or an infection, noncommunicable diseases (NCD) are linked to factors like food, tobacco, environmental pollution and a lack of exercise. Therefore, many people believe that NCDs are developed as a result of irresponsible personal choices, and thus governmental money should not be allocated towards alleviating these self-inflicted diseases. In addition, the U.S. budget has little room to fund initiatives targeting the elimination of NCDs as the financial crisis drags on and should prioritize more pressing issues. At the same time, others believe that the private sector, such as the recent initiatives launched by Pepsi and Nestle to limit sugars, is a more efficient and cost-effective medium to prevent the spread of NCDs in the United States and abroad. Should the G20 assume leadership in setting the global health agenda for the donor community? Yes: In September 2009, the Group of Twenty (G20) replaced the Group of Eight (G8) as the world's premier economic forum, raising speculation that the G20 would become the steering group for other areas, including global health. Some proponents of the change note that the G20 includes developing countries—including South Africa, India, Brazil, and China—with health concerns not currently represented by the G8. Others note that the G8 has been neglecting its health agenda since the global recession. If the G8 continues to wane [PDF] in momentum and legitimacy, the G20 might become a natural forum for setting the global health agenda, ensuring the involvement of important nontraditional donors, and play a role beyond donor coordination. In 2004, the WHO's assistant director general outlined [PDF] three areas where G20 engagement would benefit the global health agenda: drawing attention to country and regional health crises; raising awareness for neglected health priorities; and holding leaders accountable for their health commitments. No: The G8 remains the source of the overwhelming majority of official development assistance, including global health, and thus should remain the focal point for such efforts. The G8 also has a consistent record of prioritizing global health over the past decade, even if G8 members have sometimes failed to follow through on financial commitments. In the absence of firm leadership from the World Health Organization, the G8 has routinely driven the agenda for response mechanisms needed to address the most pressing global health problems. In 2001, G8 leaders supported the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria, backed initiatives to relieve debt in developing countries, and endorsed Kofi Annan's call to fight infectious diseases at a rate of $7 to 10 billion annually. In 2005, the G8 summit held at Gleneagles, Scotland, promised "universal access" to HIV treatment—defined as 10 million people by 2010—and a doubling of aid for health and poverty reduction to $50 billion per year. These impressive commitments have proven difficult to recreate in the G20, which has to balance the interests of a larger and more diverse membership. While commitments were not met on time due to the financial crisis, the G20 is even more unlikely to build such unified pledges from its membership and ensure follow through. Should the United States ratify the World Health Organization Framework Convention on Tobacco Control? Yes: The World Health Organization Framework Convention on Tobacco Control (FCTC) is the first international treaty adopted under Article 19 of the WHO Constitutive Act. It views tobacco use as a global problem that demands coordinated solutions, and seeks to reduce both supply and demand for tobacco products by limiting advertising and indoor smoking, encouraging states to raise tobacco taxes, placing prominent warnings on cigarette packages, and preventing smuggling. According to the Centers for Disease Control and Prevention (CDC), more deaths occur annually due to tobacco use than by all deaths from human immuno-deficiency virus (HIV), illegal drug use, motor vehicle injuries, suicides, and murders combined. All state parties to the FCTC are required to harmonize their national tobacco regulations to certain minimum standards. Former president George W. Bush signed the FCTC in 2004, but the U.S. Senate has not yet ratified it. The WHO argues that ratification could give further strength to existing domestic efforts to reduce tobacco use and exposure, which according to the Centers for Disease Control and Prevention causes approximately 443,000 deaths annually, and is the leading cause of preventable death in the United States. The FCTC would provide an additional opportunity for the United States to lead by example. As a nonparty, the United States cannot participate in implementing and shaping the FCTC. No: Since its entry into force in 2005, the FCTC has encountered problems related to national implementation. Of the nearly 174 parties to the treaty, only a handful have enacted full indoor smoking bans. In short, the success of the convention remains unproven and tobacco use is still a leading preventable cause of death worldwide. Some critics add that FCTC goals could be accomplished by national governments on their own and that the most effective way to achieve anti-tobacco goals like those in the FCTC is through domestic regulation. Finally, given the enormous size of the U.S. tobacco industry, ratification requirements for strict regulations in tobacco-growing U.S. states could also translate to job losses. Should the United States maintain its leadership role in promoting intellectual property rights for pharmaceuticals? Yes: Intellectual property rights give the pharmaceutical industry incentives to innovate, research, and develop new medicines. Without protection from the United States Trade Representative [PDF], the industry would not be able to pay for developing new drugs and conducting clinical trials. Moreover, the debate between intellectual property rights and health equity distracts from a discussion of the real obstacles to universal access to essential medicines, which include weak financing, procurement, and distribution systems in many countries. The vast majority of drugs on the essential medicines list is already off patent and has been for years. Patent pooling for essential medicines is therefore unlikely to improve access. No: U.S. regulations supporting intellectual property deprive access to essential medicines, particularly for new drugs needed in pandemic emergencies either through local manufacturing or parallel importing. Preferential trade policies shackle medical innovation and protect monopolies that do not favor fair competition and pricing. In essence, policies that prevent developing countries from importing generics more cheaply or manufacturing drugs locally raise concerns about health equity and justice. Some experts have argued for a more nuanced approach that balances the protections offered by patents with more robust public health considerations within the intellectual property system. Recent Developments January 2014: India eradicates polio India reported 741 cases of polio in 2009—making it the country with the highest number of reported cases of the disease in the world at that time. It has now been three years since the last reported case was a patient who contracted polio in 2011. Several factors contributed to India's success including the use of a bivalent oral polio vaccine beginning in 2010 and the tailoring of vaccine delivery campaigns to particular areas of the country. The Indian government also integrated these strategies with a "holistic approach" into community health work with initiatives to encourage local adoption of regular hand-washing and other critical hygiene and sanitation practices. September 2013: Global Health Investment Fund JPMorgan Chase & Co. and the Bill & Melinda Gates Foundation partnered to launch the Global Health Investment Fund in September 2013. The Fund will provide individual and institutional investors with the chance "to finance late-stage global health technologies" that could prove to be lifesaving in developing countries. It has already procured $94 million in pledged funds to date from a combination of groups including the Children's Investment Fund Foundation, Grand Challenges Canada, and the German Ministry for Economic Cooperation and Development. June 2013: New coronavirus spreads The novel coronavirus (nCoV), responsible for the emergence of the Middle East Respiratory Syndrome, also known as MERS, has spread from Saudi Arabia, where it originated in June 2012, to six other countries including France, Italy, and the United Kingdom. The virus has infected fifty-four people to date, over half of whom have died. MERS is genetically related to the Severe Acute Respiratory Syndrome (SARS), which killed about 774 people in a global epidemic in 2003. However, a total of eight thousand people were infected with SARS at that time, underscoring concern over the high mortality rate of MERS. At the closing of the sixty-sixth World Health Assembly, WHO Director General Margaret Chan warned state regulators over the new threat. "Any new disease that is emerging faster than our understanding is never under control," said Chan. "These are alarm bells and we must respond. The novel coronavirus is not a problem that any single affected country can keep to itself or manage all by itself." From June 4-9, a joint mission between the Saudi government and World Health Organization met in Riyadh to assess the disease's patterns of transmission. May 2013: Price cut for cervical cancer vaccines Cervical cancer vaccines for poor countries will now cost less than $5 per dose, under an agreement negotiated between the GAVI Alliance and two major pharmaceutical firms that produce human papillomavirus (HPV) vaccines, Merck and GlaxoSmithKline. More than 85 percent of women who die from cervical cancer each year reside in low-income countries, where vaccines are far too expensive for most people to afford. The reduced cost of the vaccines, which run about $130 per dose in the United States, will allow millions of girls to protect themselves against deadly strains of HPV. While the price cut will apply first to demonstration sites in Africa and Southeast Asia, the GAVI Alliance aims to make the reduced price available to 30 million girls worldwide by 2020. May 2013: Deadly bird flu rattles China A new strain of deadly bird flu rattled China in the spring of 2013. A total of 129 people were infected and 32 of those who contracted the disease died, as of mid 2013. The new virus, H7N9, largely affects poultry but spreads more easily to humans than previous bird flus. Moreover, Chinese authorities and health experts suspect that human-to-human transmission already has taken place. While officials from the World Health Organization and U.S. Centers for Disease Control and Prevention emphasize the lack of evidence for an imminent pandemic, there is no certainty that the virus could not mutate, causing widespread contagion. April 2013: 5.5 billion pledged to eradicate polio The World Health Organization (WHO) and partner groups affiliated with the Global Polio Eradication Initiative (GPEI) released a $5.5 billion vaccination and monitoring plan to eradicate polio within the next five years. Funders have already pledged three-fourths of the total cost: the Bill & Melinda Gates Foundation agreed to give $1.8 billion; a handful of donor governments—including Britain, Germany, Nigeria, Norway, and Pakistan—offered just over $2 billion; and a small assembly of private foundations has supplied an additional $335 million. Since the mid-1980s, when polio eradication efforts began in earnest, the incidence of the disease has dropped to record lows. The disease is now endemic in only three states—Afghanistan, Pakistan, and Nigeria—with a mere nineteen cases reported so far in 2013. The plan calls for vaccinating over 250 million children where the disease still lingers, as well as establishing monitoring and surveillance systems in over seventy countries. "After millennia battling polio," said WHO Director-General Margaret Chan, "this plan puts us within sight of the endgame." April 2013: India rejects patent protection for drugmaker The Indian Supreme Court rejected patent protection for Glivec, a major cancer drug produced by Swiss drugmaker Novartis. The ruling paves the way for local Indian manufacturers to continue providing cheap generics to large swaths of the developing world. India is one of the world's leading producers of generic medicines, and as such has received credit for broadening access to life-saving drugs for millions of people. Whereas Glivec can cost up to $70,000 per year, for instance, an Indian generic version of the drug can cost as little as $2,500 per year. Options for Strengthening the Global Public Health Regime Introduction U.S. and international action is needed to ensure aggressive pursuit of health agendas, improved representation of health issues in international fora, and increased coordination between donors and recipients. These recommendations reflect the views of Stewart M. Patrick, director of the program on international institutions and global governance, and Laurie A. Garrett, senior fellow for global health. Strengthen commitment toward development goals As the global economic slump lingers, and as the United States and Europe confront sovereign debt challenges, it has become virtually certain that most health-related United Nations Millennium Development Goals (MDG) will fail to achieve their desired targets. While President Obama addressed these concerns in his speech at the 2010 MDG review summit, it is unknown as of yet whether his promise for more effective U.S. leadership and his call for greater global participation in development will be fruitful. The United States and other world actors should avoid the temptation either to give up on the MDGs or to spin the breakdown of the 2015 target as a success. Instead, they should set a realistically achievable 2020 target with definite strategy and clear financing. The lessons of the first MDG project need to be applied to future endeavors, and the United States can take a lead role. Include global health on G20 agenda Global economic realities have forced the rise of the Group of Twenty (G20) over the Group of Eight (G8) as the most prominent forum for multilateral cooperation on financial and economic issues. Over time, the G20 agenda should gradually expand to address global health issues. To date, the new grouping has focused overwhelmingly (and understandably) on the response to the economic crisis, leaving health and broader development matters to the G8. Going forward, the G8 will likely retain an important role as a forum for major donor countries, including mobilizing major pledges of health-related development assistance. At the same time, the G20 offers an important forum for engaging an emerging set of nontraditional donors—including China, India, and Brazil—in forging global agreement on standards of development cooperation. As evidenced by the meeting of health ministers from Brazil, Russia, India, China, and South Africa (BRICS) in Beijing in July 2011 where those nations pledged support, emerging nations are increasingly active in developing countries. The G20 would serve as an ideal forum to leverage their support and integrate their efforts into a global strategy drawing on developed and emerging nations alike. The G20 also offers an opportunity to extend multilateral cooperation well beyond the limits of foreign assistance. Expand the evidence base for health interventions Disappointingly, only limited monitoring, evaluation, and reporting on global health programs and interventions have been undertaken to date. Little is therefore known about nonmedical interventions, models of care, and program implementation. The United States should insist on an empirical assessment of all global health programs to improve the evidence base for the efficacy of interventions and encourage its development partners to do the same. Programs should collect and report process indicators as well as data on outcomes. Partners should be encouraged to conduct implementation research and share results to better capitalize on successes and learn from mistakes. A recent Lancet article showed disappointing effectiveness in major child health campaigns in West Africa led by UNICEF, highlighting the need for regular monitoring and evaluation of health programs. Strengthen regional approaches and cooperation on health Although regional organizations have over the past fifteen years begun to engage in health issues, their efforts remain uneven. Some regions, such as Latin America and Europe have strong systems, while others are far too weak. This often means continued reliance on global structures and initiatives that limit rapid and effective response to health emergencies. Global health initiatives should help build and employ regional capacity, tapping the strengths of existing regional organizations where possible to reinforce and consolidate ongoing efforts and to develop more inclusive objectives. For example, some experts advocated shifting more control of avian influenza outbreaks away from the World Health Organization and toward the Asia-Pacific Economic Cooperation forum and the Association of Southeast Asian Nations, which have the regional clout, political trust, and financial capacity necessary to manage vaccine stockpiles and encourage viral sharing for pandemics concentrated in the Asia region. Anticipate effects of climate change on health Countries and international institutions need to understand the impact of climate change on global health and prepare for the anticipated consequences. As weather patterns change, major storm events multiply and temperatures increase, likely triggering an increase in instances of drowning and heat stroke. These will add pressure to the emergency response mechanisms of even the most developed countries. Food insecurity and changing patterns of infectious disease (such as malaria) will also tax health systems. In some cases, population relocation may often be the only viable preventive option. In 2008, the World Health Organization's (WHO's) World Health Day focused on the health implications of climate change, but much more research and negotiation are needed to generate the necessary knowledge, infrastructure, agreements, and institutions to prepare for the health effects of climate change. The potentially devastating correlation between climate and health can be seen with the Somalia famine in which crop failure as part of prolonged drought has given rise to a cholera epidemic and has contributed to nearly 50 percent of the population suffering from acute malnutrition. Strengthen the International Health Regulations to prevent pandemics The revised International Health Regulations (IHRs) aim to bolster global pandemic preparedness and response among 194 state parties, both in the interest of public health and to minimize interruptions to global travel and commerce. The regulations have helped facilitate international coordination, but pandemic management is still haphazard. The United States should work to further strengthen the IHRs and harmonize pandemic alert systems. Country compliance with the IHRs has been mixed, underscoring the need for additional mechanisms to persuade recalcitrant states to cooperate and ease the flow of crucial information and viral samples for potential pandemic emergencies. Develop a new pharmaceutical R&D and patent regime outside the WTO The World Trade Organization (WTO) is no longer at the forefront of discussions on intellectual property issues related to health. The Doha Round of trade negotiations invested little time on Trade-Related Aspects of Intellectual Property Rights (TRIPS) provisions or on intellectual property right issues more broadly. The international health community should shift its attention toward trade agreements through TRIPS+ provisions and non-WTO forums that include intergovernmental negotiations on benefit sharing and virus sharing. These new mechanisms will help bolster research and development and use external funding to price essential medicines affordably. Become self-sustaining in meeting U.S. domestic health worker demand The most recent estimates indicate that approximately 25 percent of all doctors in the United States are foreign trained, and 66 percent of these are from low and middle-income countries. According to an Association of American Medical Colleges (AAMC) report, the United States will reach a shortage of 91,500 doctors by 2020. The AAMC predicts Americans will need an additional 45,000 primary care physicians and 46,000 surgeons and medical specialists. These estimates are higher than previously expected and is the combined result of an aging baby boom generation and increasing health care costs. The demand for healthcare workers will only increase now that the U.S. health reform bill has passed, putting thirty to fifty million more citizens on insurance or public rolls in the United States. The United States, arguably the best in the world at professional health training and tertiary education, should set a target for self-sufficiency in the education of health professionals. Building this capacity plays to a major U.S. strength.
  • Pharmaceuticals and Vaccines
    Preventing Pharmageddon: Treatment Access for Noncommunicable Diseases
    A global fight over access to medicines is brewing. In the past year, India, China, and Indonesia have undertaken measures to circumvent patents on medicines for diabetes, cancer, and cardiovascular and chronic respiratory illnesses—the noncommunicable diseases (NCDs) increasing rapidly in developing countries. A decade ago, a crisis over access to patented HIV/AIDS drugs transformed global health, elevating the infectious diseases ravaging developing countries as a foreign policy issue and mobilizing billions of dollars to develop and deliver new therapies. As litigation, trade tension, and controversy mount over NCD treatment access, addressing this latest pharmageddon will require another transformation in global health, this time focusing on low-cost interventions and patient-centered, rather than country-focused, strategies. The Treatment-Access Crisis Over HIV/AIDS International controversies over treatment access in developing countries are a recent development. Few medicines existed for malaria, tuberculosis (TB), and other infectious diseases prevalent in these countries. Most treatments dated back to the colonial era, developed for foreign militaries or veterinary products. Fewer than forty of the 1,400 drugs approved for human use between 1975 and 1999 were for diseases relevant to developing countries. Two developments led to an international controversy of treatment access in the late 1990s. First, lifesaving antiretroviral medicines (ARVs) were developed for HIV/AIDS, a disease that gained prominence in the United States and Europe but exploded into a pandemic that ravaged developing countries, particularly in sub-Saharan Africa. Second, global trade talks established the World Trade Organization (WTO) and the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), which mandated minimum standards of intellectual property (IP) protection, including pharmaceutical patents, in member countries. Pharmaceutical companies, fearful of undercutting remunerative markets in rich countries, charged consistent prices for their patented ARVs internationally. In 1998, ARVs cost more, on a GDP per capita adjusted basis, in South Africa than in Sweden or the United States; as a consequence, just ten thousand of the nearly four million South Africans living with HIV/AIDS had access to the medicines that could save their lives. In South Africa and Brazil, patients and advocates protested an international IP system that prioritized profits over lives and had failed to incentivize research to meet their general health needs. These protests spread and disrupted international health conferences and the 1999 Seattle WTO ministerial conference. Bitter disputes erupted over compulsory licenses, a means provided in the TRIPS agreement for governments to license a patented innovation without the consent of the patent holder. Between 2001 and 2005, WTO members issued seventeen compulsory licenses, most involving ARVs. Popular support for the drug industry suffered and developing countries pushed to renegotiate the TRIPS agreement. The treatment-access crisis over HIV/AIDS catalyzed a surge in global health resources. International aid for health tripled between 2001 and 2010 to $28.4 billion. Annual funding for R&D on HIV/AIDS, malaria, TB, and other neglected diseases surged thirty-fold, to more than $3 billion. The U.S. government, the Bill & Melinda Gates Foundation, and other donors established institutions such as the Global Alliance for Vaccines and Immunization and the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) to deliver effective treatment to millions in developing countries. Negotiations, competition, and voluntary price reductions lowered the price of ARVs in poor countries from $12,000 per year in 2001 to $200 per year in 2005. Between 2006 and 2011, the compulsory licensing of patented medicines declined dramatically. The Emerging Treatment-Access Crisis Over NCDs The controversy over the affordability of patented medicines in developing countries reemerged in 2012. India issued a compulsory license on a late-stage kidney and liver cancer treatment and has announced plans to issue similar licenses on a leukemia drug and two breast cancer therapies. Indonesia issued compulsory licenses on seven drugs, including a treatment for liver cancer–causing hepatitis B. China amended its patent law, making it easier to issue compulsory licenses for medicines. The Philippines modified its laws to limit the patentability of incremental improvements to already-patented products. These moves highlight four emerging issues in the access-to-medicines debate. First, the days of potential compulsory licensing disputes being limited to medicines used to treat or diagnose infectious diseases such as HIV/AIDS, malaria, and TB are over. According to the World Health Organization (WHO), 80 percent of deaths from NCDs now occur in developing countries, up from 40 percent in 1990. By 2030, NCDs will be the leading cause of death and disability in every region of the world. A recent report by Harvard University and the World Economic Forum projects that over the next two decades, NCDs will inflict $14 trillion in economic losses on the developing world. Second, better diets and healthier habits—the population measures that have been the focus of international NCD initiatives—are critical, but will not solve the problem. Governments in emerging economies are under increasing pressure to better address the health needs of their ailing citizens. Prevention efforts offer only limited benefits to those suffering from NCDs in the poorest countries, where consumption of processed foods and tobacco is low. Third, pricing pharmaceuticals for large middle-income countries such as India, China, and Indonesia is a challenge. On one hand, these are fast-growing economies with resources. China and India have international aid agencies and space programs. IMS Health projects that annual pharmaceutical spending in middle-income countries will double by 2016 to more than $300 billion. On the other hand, half of the world's population that lives on less than two dollars per day resides in India and China, with much of the remainder living in other middle-income countries—Pakistan, Nigeria, and Indonesia. NCDs are growing fastest in these countries. Mexico, India, and China are investing to expand the coverage of medicines in their public health sectors, but most drug purchases still occur out of pocket. Expenditures on medicines are already high. Fourth, conflicts over compulsory licensing of NCD medications are likely to increase unless other strategies can meet developing country needs on NCDs. International trade law is fairly permissive on compulsory licensing. A WTO member may issue a compulsory license on any patent, including for NCD medicines, provided that the member satisfies the few conditions and procedural requirements of the TRIPS agreement. In the end, countries' use of compulsory licensing depends on political will. It is not surprising that middle-income countries with sizable NCD epidemics and pharmaceutical industries have been the first to act. These countries rely on imported patented drugs to treat cancers, and have health and industrial policy interests in encouraging cheaper domestic production. The pipelines of multinational drug firms are heavily invested in oncology and diabetes, and developed countries will fight to preserve those investments. In a new fight pitting patients against patents, firms may be reluctant to develop or register lifesaving NCD therapies for use in countries with a high risk of compulsory licensing. Support for international IP protection—upon which drug firms and so many other U.S. industries heavily rely—will diminish. Yet the IP alternatives that health activists advocate for spurring drug innovation, such as prizes and R&D treaties, have not attracted donor or multilateral support. Preventing the emerging pharmageddon will depend on finding other ways to meet the NCD treatment needs of emerging nations. Preventing Pharmageddon A variety of motivations fueled global health investment over the last decade, including humanitarian concerns and the advent of the Millennium Development Goals in 2000. The catalyst, however, was the legitimate critique that emerged during the HIV/AIDS treatment-access crisis that the international systems for trade, IP, and medical R&D were not responding to the needs of developing countries and their citizens. Fortunately, global health programs need not duplicate the massive resources mobilized to address HIV/AIDS and other infectious diseases to counter the rising tide of NCDs in low- and middle-income countries. To make progress, the United States should take the following low-cost steps: Leverage Existing Procurement Vehicles. Many effective NCD therapies—insulin, beta blockers, and ACE inhibitors—are off patent, but often unavailable in developing countries. A recent study showed that improving access to a generic multidrug regimen for high-risk cardiovascular patients in these settings would save as many as eighteen million lives. Pooled procurement and financial incentives, such as advance market commitments, can help scale up manufacturing of these treatments, ensure their affordability, and facilitate their purchase by developing countries. The United States supports these procurement vehicles and should encourage their expansion to include NCD medicines. The U.S. Food and Drug Administration should help ensure the safety and quality of procured products as it does in the PEPFAR program. Support Intra-Country Differential Pricing. Differential pricing of patented medicines would be more sustainable if based on the income status of the patient, rather than the country involved. Pharmaceutical companies should charge different prices for drugs to be used by higher-income patients covered by insurance plans or treated in private hospitals and those to be used by lower-income patients treated in public clinics or resource-poor rural settings. Firms should adopt differentiated packaging to help prevent arbitrage. Participating developing countries should commit contractually to ensure that the product is only used in its intended market segment. Adapt Treatment for Low-Resource Settings. Tremendous resources have been dedicated to NCD R&D globally, but not to the development of therapies usable in poor settings. In contrast to the $3 billion spent annually on neglected-disease R&D, the international organization PATH estimates that $30 million would enable product-development partnerships to adapt essential NCD drugs and diagnostics for use in low-infrastructure settings. The U.S. Department of State should expand the treatment platforms used by PEPFAR to help countries deliver these frugal NCD innovations.
  • Noncommunicable Diseases
    Big Data, Better Global Health
    A comprehensive new study of the world’s health status has the potential to dramatically improve how developing countries address surging problems like noncommunicable diseases, writes CFR’s Thomas Bollyky.
  • Noncommunicable Diseases
    Is there a Seat at the Table for the Food & Beverage Industry in the Global Fight against Obesity?
    Podcast
    THOMAS BOLLYKY: Good afternoon, I am Tom Bollyky, Senior Fellow for Global Health, Economics and Development. This event is entitled, "Is There a Seat at the Table for the Food and Beverage Industry in the Global Fight Against Obesity?" As many of you probably know, obesity has become a worldwide epidemic at this point, affecting wealthy and poor countries alike. World Health Organization (WHO) estimates that obesity has doubled over the last three decades. United States is an early adopter, of course, of the obesity epidemic, but its epidemic is no longer the fastest-growing. Changes in global food production and diet are driving obesity in low- and middle-income countries as well. WHO estimates that obesity is now the fifth-largest cause of death worldwide, causing 2.8 million deaths per year. The role of the food and beverage industry in that epidemic is a subject of much debate. For its partisans, the food and beverage industry has necessary expertise and is a willing and capable partner in the fight against global obesity. For its opponents, the food and beverage industry is hopelessly conflicted on this issue and has quietly undermined, both domestically and internationally, efforts against obesity. Just this past week, Margaret Chan, Director-General of the WHO, felt obliged to release a statement disavowing press reports that the WHO had accepted money from the food and beverage industry but confirming that the Pan American Health Organization had accepted money. The Pan American Health Organization, for historical reasons, has a certain amount of independence from the WHO, and they had accepted a few hundred thousand dollars from Coca-Cola, Nestle and Unilever to support chronic disease programs. I'm very pleased today that we have two truly excellent speakers representing both sides of this debate. I believe strongly they're both the best representatives of those two sides of the debate, so I'm thrilled that they agreed to be here and participate in this event. And to run through their backgrounds briefly – you have their bios before you; I'm sure many of you know them. Kelly Brownell is the James Rowland Angell Professor of Psychology at Yale University. He also serves as the professor of epidemiology and public health and the director of the Rudd Center for Food Policy & Obesity. As you'll see from his bio, he's a recipient of many rewards, an author of more than a dozen books – KELLY BROWNELL: Not rewards. MR. BOLLYKY: I'm sorry, awards. (Laughter.) MR. BROWNELL: I wish. MR. BOLLYKY: Awards. (Laughter.) Author of over 350 scholarly articles; Time magazine listed Kelly as one of "The World's 100 Most Influential People" and cited him as a "moral entrepreneur." Derek is an equally accomplished expert in public health. He is the Senior Vice president of the Vitality Group. Until recently, he was the Senior Vice President of Global Health and Agricultural Policy at PepsiCo. He remains on Pepsi's Scientific Board. Previously he headed global health at Rockefeller Foundation and was a former Executive Director of Noncommunicable Diseases and Mental Health at the WHO. Some of you may not know they're former colleagues at Yale. I believe they actually have co-authored one paper together at some point. But they have promised – (laughter) – promised to put that shared history aside and relentlessly go after the jugular in a furious battle for your hearts and minds here today, which leads me to the rules of this debate. It is going to be a formal debate. This is very unusual for the Council. But if there were a subject in global health that needed a formal debate, this is it. The way this will go is we will debate two propositions here today. I will read the first proposition, take an informal vote from you, the audience, to get a sense of the temperature in the room on these topics. Each speaker will have four minutes to make his arguments and two minutes to make a rebuttal. We will then repeat the same pattern for the second proposition. Kelly will go first for the first proposition. Derek will go first for the second. We will reserve 20 minutes at the end for questions and answers from the audience. Now for the Council's disclaimer: If you have a cellular phone, please turn it off. I don't know if it affects the sound system or not; it's just very rude. (Laughter.) This meeting is on the record. Participants are welcome to use and cite the information received here today and attribute the information to whoever speaks at the meeting. Members of the press are present at this meeting and may be recording this event for their purposes. All right. With that, I will turn to the first proposition, which I will read and then take a vote from the room. The first proposition is: There is a fundamental and irreconcilable conflict between the food and beverage industry's interest and public health policy interests on obesity. Now, just an informal sense of the room. If you favor this proposition, please raise your hand. All right. And with that, I will turn it over to Kelly for his first four minutes of remarks. MR. BROWNELL: Thank you, Tom, and thank you for inviting me to this event and for having it in the first place. It's very nice that this group is taking up the issue, which I think is terribly important. I'll begin with the premise that there are three major world food problems, each a potential catastrophe in its own right. One is obesity and overnutrition, one is hunger and undernutrition – those affect about the same number of people worldwide – and the third is the impact of modern food production on sustainability, climate change and issues of the environment. I propose to you that the food industry can play a productive role and has, in some cases, in two of those but not in the third. Certainly there have been issues regarding food fortification where the industry has been helpful. There are industry advances in helping address the hunger issues worldwide, although there are some complexities there. But could I convince you that obesity is a different kettle of fish, that obesity is different in fundamental ways from the other two and industry has not played a constructive role and shows very little sign of doing so? The bare-bones fact is that industry has to sell more food. If it's going to make quarterly profits, it has to sell more food. The only way that that assumption could be different is if the industry can sell less but better food and people are willing to pay an extraordinary amount for it. There is a niche of people who do that, but the vast majority of people in the population do not, and there's no sense that worldwide this is likely to be much of a sizeable group. If the industry is in pursuit of selling more food, what must they do? Well, they can sell more food if the world population grows, and that is happening. But they can also encourage the existing people in the population to eat more food, and the industry has become remarkably clever at that. Marketing is overwhelming, especially the marketing of unhealthy foods to children, which raises very interesting ethical and perhaps even legal issues. The marketing of unhealthy food in the developing world is appalling, in my mind, and I think the greatest shame of all that the food industry has to face is the food colonization of the developing countries. If you look at the changing food norms in the United States, how have they changed in years? Now, some of us in this room are old enough to remember a time when a Coke or a Pepsi came in an 8-ounce bottle, a 6 ½-ounce bottle before that. The default serving size is now 20 ounces. People tend to consume whatever is in a bag or a bottle, a box. The fact that the 20-ounce big serving is now the default has, by definition, increased consumption of sugared beverages, a victory for the industry but not for public health. Let's look at how other food norms have changed. Not only portion sizes have changed, but let's look at time of day. I remember 20, 25 years ago, maybe, one of the fast food companies introduced fast food for breakfast. I forget which company it was, but people thought they were crazy, they would go out of business, because what Americans would eat fast food for breakfast? And look how that norm has changed. You may have seen the very deliberate attempt by the fast food companies now to establish the eating of fast food between midnight and breakfast time to be a legitimate event. Taco Bell calls this the "fourth meal." Where we eat has become different. When I was a child, people did not eat in their automobiles. They typically didn't eat standing up or at their desk. The time of day, the portion sizes, where we eat, how we eat has all been specifically and very deliberately recalibrated in the United States. And people in developing countries should see this as coming to a theater near you. So when the industry is in the pursuit of selling more food, which by definition they have to do, how do you do that? Well, you change norms, but you also engineer foods to taste particularly good, so you increase levels of sugar, fat and salt to make them as highly palatable as possible. These constituents of the food supply, particularly sugar, with new evidence would suggest can act on the brain much like traditional substances of abuse, raising questions about whether these foods are engineered deliberately, if not inadvertently, to hijack the brain and create this need that people have to consume these products in excess amounts. The industry has every motivation in the world to sell as much of these type of foods as possible. Just so happened there was a Duane Reade right next to the hotel I was staying in, and I went and looked to see how much Coke and Pepsi cost compared to bottled water, and you could buy a 2-liter bottle in that Duane Reade today of Coke or Pepsi – they were about the same price – for about $2.19. The 1-liter bottle of water was the same, $2.19. Well, the sugared beverages begin as water, and then you have to do something to them to create sugared beverages; presumably they should cost more. Why would they price them so attractively? People do not overconsume water; they do overconsume the sugared beverages. Hence, the industry has the motivations that are consistent with its business aims but inconsistent with public health. And therefore, I think, the goals are irreconcilably in conflict, at least for now. MR. BOLLYKY: Great. Derek? DEREK YACH: Thanks, and also thanks to the Council for hosting this and all hosting in this room where we can be inspired with David Rockefeller looking down at us, who epitomizes what needs to be done in terms of private-public partnerships and has for seven decades. I'm obviously thrilled to see so many people coming from diverse sectors: the food and beverage industry, NGOs, corporates, governments, academic friends. Welcome to this table. And I have no doubt that if we actually spent more time together, we'd be able to make some progress. I'm going to include under the category of the food and beverage industry the manufacturers, retailers, restaurants and food service providers. And I suspect that there are many here who would focus on the contribution that the industry makes to provide a wide range of snacks and treats of low to no nutritional value. Kelly addressed that. That is important to address, but it does miss a bigger point that he separated. Through the totality of its efforts over the last decades, the food industry has provided a sustainable source of nutritious and affordable foods and beverages to people. The successful physical and intellectual development of people around the world has relied upon that progress for almost a century. The food and beverage has been key to ending famine in all but a few countries, establishing safe and secure food supplies, and as the 1993 Nobel Prize winner Robert Fogel so well documented, laid the basis for intergenerational improvements in health and economic development in Europe and worldwide. This broader context and the continued need for some actions cannot be fully – must be fully understood as we build responses in ways to address obesity as we try and approach food security. I think we've started seeing some edging towards obesity solutions, which I'll refer to. I believe support for proposition one is misplaced. The view is supported – that view is supported by many governments. It assumes – the proposition assumes that the problems related to obesity can be isolated from a wider set of issues and benefits involving the food and beverage industry, as Kelly maintained you could. And more fundamentally, it assumes that the food and beverage industry constitutes the sole or only cause of obesity. Many have characterized obesity as a truly wicked problem, one that is difficult or impossible to solve due to the incomplete, contradictory and changing requirements. Wicked problems are resistant to effective resolution because of complex interdependencies. Efforts to solve one aspect may reveal or create other problems. In 2007, the U.K. Foresight Report, chaired by the chief scientific officer to the U.K. prime minister, illustrated how truly wicked obesity is. Sir David King stressed that no one policy will fix the problem of obesity, that the epidemic had indeed been caused by human biology coming out of step with the structure of society, including the role of industry, but that solutions will take time and needed to be implemented through what he called our structured, comprehensive collaboration. The report explicitly mentioned actions that should be taken alone and in concert with government, and I won't go into what they are. He drew very important analogies between obesity control and tackling climate change, another wicked problem. Both require unprecedented cross-departmental and intersectoral collaboration within government and partnerships over the long term with industry. The collaboration with industry on climate change started even as many in industry still denied the evidence on the links between industrial action and climate change and were still dependent on business models that promoted increased consumption and use of resources related to climate change. Think what Kelly said: The business model is fundamentally flawed. That was the case in climate change. Participants in the annual Clinton Global Initiative meetings in New York cannot but be impressed by the speed of scale of new initiatives led by CEOs of energy, insurance, technology and related companies working closely with local and national governments in countries as diverse as the U.S., Brazil, China, Saudi Arabia, Denmark and more. They are betting big time on the emergence of a green economy that will encourage and sustain their new business models. The active involvement of insurers and co-insurers has brought new analytics to the business model with a focus on embedding risk into long-term growth. What has this to do with obesity? Well, the multinational food and beverage model has favored the quality – quantity over the quality, and like the energy sector, increasingly recognizes that to change, it has to change its business model. And I witnessed much of that change starting to happen in the last five years. The intent of leading food and beverage companies to address obesity has increased sharply with change under way: R&D, linked product formulation aimed at calorie reduction, shifts in marketing, industry alliances. Just five years ago, there was no International Food and Beverage Alliance that was transforming the way marketing is happening. There was no Healthy Weight Commitment Foundation across industry that is explicitly reducing calories in the supply – food supply of the USA, giving numbers to it and having the Robert Wood Johnson Foundation stand independently as assessor of it. There was no Alliance for a Healthier Generation that has led to 140,000 schools in this country eliminating soft drinks with very clear evidence of changes in calories. At the same time, there have been sharp increases in individual company activities. And of course I have to quote the company I know best: PepsiCo's pledge to remove and eliminate the direct sale of full-calorie sodas from all schools worldwide has made progress and is in effect in 100 countries around the world. In the U.S., the total volume of PepsiCo beverages sold that are in the mid- and low-calorie range has sharply increased from 25 percent five years ago to 50 percent today and is likely to reach 75 percent within the next five to eight years. That represents millions of calories removed from beverages and suggests in time that nonalcoholic, nondairy beverages will constitute a minor source of calories in the diets. It's happening even in a recession, and it's happening even where the pressures are high for short-term gains. Despite this, I think the progress has been motivated by many of the indexes we have out there that reward companies for change and are leading to investor performance. The Dow Jones Sustainability Index, the Global Reporting Initiative and the new GAIN initiative, which colleagues in the audience may talk about, all are acting to reward and show which companies are making progress. MR. BOLLYKY: Derek, if you'll sum up – MR. YACH: OK. In a major report by Bank of America Merrill Lynch out recently called "Globesity," unlike 10 years ago, they argued that there are companies who are actively engaged in addressing obesity over the next 25 years and named many of the food companies, including PepsiCo, along with pharmaceutical weight management, as being those to invest in if you want to invest in the companies that have the best chance of addressing it. Let me just end off with the words of President Clinton when he addressed his advisory committee earlier this week, because I believe very strongly in the vision that he put out. He summarized what he saw as the key to tackling the most complex and pressing problems of our time, and his words were: We need a network of creative collaboration between those who disagree on some things but can and must work together on other things. That's my view and a better way forward than accepting proposition one. Thank you. MR. BOLLYKY: Great. Kelly, two minutes, please. MR. BROWNELL: Thank you. Derek began his comments by talking about the contribution of the food industry to correcting world hunger. And I agree; there are some notable advances the food industry has made in that arena. However, correcting hunger is consistent with the food industry aim to sell more food. Now we're at a different place in world history where selling more food is a problem rather than helping correct a problem. Derek also mentioned that the food industry shouldn't be singled out as the sole cause of the obesity problem. I don't know anybody in the public health profession who would disagree with that premise. There are obviously many causes; governments and public health officials are working on all of them. And to talk about the food industry role doesn't imply that they are the only cause. Derek talked about the environmental – the polluting industry denying claims between their industrial acts and negative impacts on the environment. How different is that from leading officials of the food industry now denying links between consumption of their foods and risks for things like obesity and diabetes when the risk for these things is quite clearly established in science? It is true that industry is behaving differently now than they did some time ago, and the question is why. Are they motivated to address public health issues? Should they score good-guy points, or are they being bludgeoned into having to act in the ways that Derek mentioned? The obesity problem has been a major source of death and disability in the United States for about 30 years, even going back a little bit more. And during that 30-year period, the industry did everything it could to sell more unhealthy food, particularly to children. Now, in recent years they are showing some signs of change, but not, I don't think, because of good will or corporate design that this is a good business model. I think they're being forced to do it. Some companies, like Pepsico, are doing it better than others, but there are many laggards out there as well. And I'll end with the following example. Derek said that the food industry embarked on this benevolent event, the beverage companies, by getting beverages out of, I think you said, 140,000 schools in the United States. Well, this becomes – you remember the old Whac-a-Mole game in the arcade that you played, where you knock down one mole and another one pops up, and they keep popping up and keep popping up until you're overwhelmed and you lose the game. So yes, they have withdrawn some of their beverages from schools. But this was in advance of legislation and regulation occurring all over the country that was requiring it. So they simply got out ahead, scored public relations points for it. But what about marketing of sugared beverages to children in other ways? We've done a major report on this. I'll be happy to point you to it online. And it shows that the exposure of American children to marketing messages for sugared beverages is as high as it's ever been and in some cases higher. Thank you. MR. BOLLYKY: Great. Thank you. Two minutes, Derek. MR. YACH: Yeah, I think when Edison turned on the light bulb and created General Electric over a century ago, the first goal was to try and expand as many light bulb consumers worldwide and increase energy consumption. That was General Electric then. General Electric today is a leader in sustainable development and thinking dramatically about how to continue to become one of the great profitable companies on the planet, continuing to provide energy but to provide it in a different, sustainable way using a different business model. It can happen. I think the fundamental question that also needs to be asked is what's the alternative if you don't have the food and beverage industry at the table? The alternative is to go down a heavily regulated approach. And in the recent New England Journal of Medicine, there were two wonderful debates between Tom Farley arguing for regulations – soda taxes, regulating portion sizes, so on – and Brian Wansink cautioning against that route, arguing basically, quoting a wonderful line by Benjamin Franklin, a man convinced against his will is of the same opinion still. Wansink's research has highlighted the range of simple interventions that nudge people into healthy choices and set them on a healthier default option to lead healthier lives. That is fundamentally where I stand. And I think that if we were to ask the question, what would happen if we used a mix of Farley and Wansink's best ideas together in ways that drew upon the power of markets, smarter incentives for food companies to change, subsidies for healthy food, shifts in defaults to reverse supersizing, more activity built into our daily lives, better use of social networks, rewards for health professionals and teachers who promote healthy eating and more activity, all supported by continuous communications and social marketing focused on key health messages developed by the best marketing gurus, not public health people, I suspect we would see real, faster and more sustainable progress. Let me end by saying that Tom mentioned that we wrote an article a few years ago. Well, it wasn't that long ago. It was in Nature Medicine in 2006. We said then, unlike all other public health problems, there's still no demonstrated decline in overweight or obesity in any large country outside of a war or famine. That's still correct. This suggests that a higher degree of experimentation that draws on sound economic and behavioral theory is needed, as was the case with tobacco in the early '70s. I agree that's needed. That's why I've moved to an area where the focus of the work is on behavioral economics and actuarial science to change behavior. But critically, Kelly and I both wrote that unlike the case of tobacco, market-led solutions, along with public policies, may combine to make healthy choices the economically easy and readily available choices. I believed this when I was at WHO and led efforts to engage the food company CEOs in building broader coalitions. I believed it when I wrote it with Kelly at the Rudd Center. I drew upon this insight in the last five years with Pepsico to motivate for internal change and external engagement and still continue to believe it. Thank you. MR. BOLLYKY: Great. Well, let's see, audience, are you swayed at all? If we could take an informal vote on the proposition again – let me read it out just quickly. The proposition is, again: There is a fundamental and irreconcilable conflict between the food and beverage industry's interests and public health policy interests on obesity. Can we see a show of hands if you support that proposition? Maybe slightly more are for the proposition now. All right, well, let's move on to the second proposition. Again, I will read this. We will do an informal vote and then lead with Derek. The second proposition is, drilling down in a little more detail on this: Governments and intergovernmental institutions should not allow any person employed by the processed food and beverage industry or any entity working to further its interest to be a member of any body, committee or advisory group that sets, recommends or implements public health policies with respect to obesity. Again, can we see a show of hands in the audience? Do you want me to read it again? I see at least one person who wants me to read it again. It's slightly longer, so I'll give it one more try: Governments and intergovernmental institutions should not allow any person employed by the processed food and beverage industry or any entity working to further its interests to be a member of any body, committee or advisory group that sets, recommends or implements public health policies with respect to obesity. Again, may I see a show of hands from the audience for the members of the group here that favor this proposition? All right, fewer are for this proposition. So I think Kelly will have his work cut out for him. But we start with Derek. Four minutes, please. MR. YACH: Yeah, I would be happy to give you a minute to reflect deeply on the chilling effect that this would have on public policy across the realm. (Pause.) (Laughter.) I'm not going to address the complexity of implementing such a policy, nor the near impossibility of spelling out who's covered by the very wide scope of the potential entities that are implied in proposition two. That itself would leave you with no choice but to reject the proposition. Let me rather ask what might happen to the quality of policy decisions made by leading policy groups like the National Institutes of Health (NIH), the Institute of Medicine (IOM) or WHO if proposition two was accepted and what they might mean for people's health. Aaron Kesselheim, writing in a recent edition of The New England Journal, reported results of a randomized study involving 500 internists. They assessed scientific abstracts dealing with new drug treatments. They were given trials with three levels of methods rigor – good, medium, low – at three sources of funding – NIH, industry, none – none stated. The findings showed that the internists were half as willing to prescribe drugs from industry-funded study at each level of methods rigor. Think about that. They concluded that physician skepticism may have consequences for patient health, since many effective treatments would be overlooked. I suspect the same might be true if we did these on food-based solutions. I'll explain what this means. Darren Zinner, writing in Health Affairs, showed that 50 percent of academic life scientists in the U.S. have industry relationships, and those that do are more scientifically productive. Citation indices, international presentations and patent filings are substantially higher. The nonconflicted pool, those who don't have relationships with industry, are less productive and less cutting-edge. Relying on them for IOM, NIH and WHO or related advisory structures would potentially limit public policy staying current and being based on the latest evidence. Instead of boycotting the most productive and probably the most creative scientists, better means of preventing undue and potentially conflicting influences are needed. The IOM processes seem ahead of the game on this, and NIH's efforts to continuously review how to limit conflicts through measures that go beyond disclosure – beyond disclosure are worth pursuing as a better means of maintaining access to excellence in the policy realm. And in the discussion, we talk about how do you go beyond disclosure. I don't want to fall into the trap created by proposition two in the way it's framed. It implies that academics really have no competing interests while industry for-profit scientists and those linked to them do. Richard Smith, the previous editor of the British Medical Journal, and Richard Feachem, ex-dean of the London School of Hygiene, World Bank health director and the first head of the Global Fund on AIDS, Malaria and TB, somebody known, I think, to this audience well, writing in PLOS Medicine earlier this year, questioned the related assumptions that academics are neutral, disinterested, unbiased and supportive of the public interest. Public choice theory suggests that academics seek to maintain and increase their own influence in different ways. They foster links to WHO, foundation boards and NIH and IOM committees to further their career. They highlight how leading medical publications practice academic boycotts against scientists working for nonprofit groups. I've experienced this firsthand while I was at Pepsico, with articles submitted to The Lancet, the BMJ, JAMA, to mention a few, being rejected on the grounds of my being affiliated to industry before the manuscript was even sent for peer review. Proposition two would reduce industry investment and engagement in the very solutions we need to tackle obesity. To mention just one under way, EPOD is a set of community-based interventions applied in over a hundred communities in five countries around the world to prevent obesity in children. It's not known well here, but it should be, and it was exemplified in a major NIH meeting as one of the only solid examples of progress in obesity worldwide. It is the largest such initiative anywhere, and a recent review published last week in Obesity Reviews concluded that its success was based on four key factors: political commitment at the local and the national level, private and public partnerships, social marketing and evaluation, along with the content of the program. The program's detailed methods were outlined in articles and supported and co-authored by the co-chair of the International Obesity Task Force, Boyd Swinburn, one of our great leaders in obesity control and the NGO movement in the academics, and Susan Jebb, a lead researcher on obesity and the central person in the U.K. government's Task Force on Obesity, both being respected scientists. Evidence suggests that EPOD is underpinning progress in reducing obesity in kids in France and in many other countries. From the start well over a decade ago, it's been an effective private-public partnership. I could give many other examples of where R&D from industry and their knowledge in science are well ahead of what is available in the public sector. Collaborative arrangements could stimulate better and faster solutions, as they have done in many areas of public health. In summary, proposition two could systematically hamper the public health community from gaining access to insight and innovative ideas that could lead to better health policies and more effective interventions to address obesity. There are ways and means of strengthening concerns about conflict of interest, but boycotts are not the way to go. We need more, not less engagement. Reject proposition two to make that possible. Thank you. MR. BOLLYKY: Kelly, four minutes, please. MR. BROWNELL: Thank you. When I read this proposition, I thought this was going to be extremely hard to defend because making a blanket rule that under no conditions at any time in history should anybody be involved is, as I said, difficult to defend. But I do think extreme caution should be exercised in having members of industry involved with policy decisions, and here's why. It really comes down to a matter of trust. If industry is going to be sitting at the table helping make public policy decisions about issues that affect their business model, then can they be trusted to act in the public's interest or in the interest of the corporation? There are a number of case examples recently of whether industry might be trusted. You may know that the city of Philadelphia came very close to passing a tax on sugar-sweetened beverages. Shortly after the tax was to be reintroduced by the mayor after it hadn't passed the first time around, the beverage industry – the trade association of the beverage industry gave a $10 million gift to the Children's Hospital of Philadelphia. Now, did that have a chilling effect on the hospital's ability to speak out against this issue? One can only speculate. Did it create beneficial public relations points for the industry that might have helped defeat the tax? One has to ask. So that $10 million given to the children's hospital creates a clear conflict of interest for the hospital. The hospital may do $10 million worth of good, but how much bad gets done if something like a tax or other public health measures get defeated? That's example number one. A soda tax was also being considered in a small town outside of Berkeley, California, Richmond, California. It was defeated in a recent ballot initiative. But the industry came in and was said to spend about – spend about $2 million on what was thought to be about 7,000 people in Richmond, California, that were going to vote against this by creating something called the Community Coalition Against Beverage Taxes. Now, one can imagine what "community coalition" means here. It means the beverage industry. And this is stunningly akin to what the tobacco industry did to fight public health initiatives early on. Another example – and this'll be the final one that I'll give. Due to the stimulus of the White House, a number of government agencies got together in what was called an interagency working group to create guidelines for what foods might be marketed to children. These were only to be voluntary guidelines, by the way. These government agencies, the Food and Drug Administration, the U.S. Department of Agriculture, the Federal Trade Commission and others, officials from these organizations, got together and proposed what most public health officials considered quite reasonable guidelines. And again, they were only to be voluntary. And you – as you know, people in regulatory positions in Washington tend to be fairly risk-averse and aren't likely to go out on the line to propose anything radical. The industry came down on this in an exceptionally hard way, putting pressure at all levels of government, so the whole process has essentially been frozen, and it's unlikely that those interagency working group guidelines will go forward. So if this is an industry looking to be trusted, there's evidence out there about whether they're behaving in a trustworthy way. And I think we see example after example of this happening. One was the one I mentioned earlier about marketing to children. If the industry – the beverage industry was going to withdraw its products for schools – from schools and be true to the public health aims of this, it wouldn't ramp up its food marketing in other venues to keep that child market so protected. So the industry, I think, can be accused, rightfully so in at least some cases, of doing things that might look good but in fact aren't if you go further down the road. So in my mind, the industry players should be allowed at the table, but not now. There will be a time when the threat of regulation and government legislation and perhaps even litigation will be so severe that there probably won't be any choice but the industry to behave in a cooperative way. At that point, I believe they should be invited to the table. MR. BOLLYKY: Great, thanks, Kelly. Derek, two minutes, please. MR. YACH: The issue of trust is critical. And I'm thrilled we have Richard Edelman sitting in front of me glaring, trying to actually, I think, send over some vibes from the outcome of the Edelman Trust Barometer – (laughter) – which has been monitoring trust worldwide and shows that it's not just industry that has a problem with trust; it's government. And it's collapsed worldwide. And there are good reasons for it. So I don't think that we're going to solve the problems by using an argument of who we trust more than others, as opposed to putting in place means of assuring that you limit conflict, that you limit practices that we may not agree with. Do I believe that many of the lobbying practices of the food industry, or in fact of many industry, maybe most industries, are acceptable? No, I don't. That obviously needs to change. That's going to be a bigger task that we all need to be – try and change to ensure maximum transparency. Do I believe that the front groups created are acceptable, whether it's front groups to promote the value of destroying the environment or promote some dietary practices that may lead to obesity or many other pharmaceutical practices or – again, I don't think that's acceptable. But that doesn't mean that you're going to be willing to boycott the active engagement of those in industry, using the right means of protecting conflicts of interest. If I look to the structure of advisory boards I've had the privilege to sit on even while at Pepsico, the most extreme was the Institute of Medicine, where you had to go through a process of having your name put up in a public domain to ask whether there were concerns, and there are categories of deemed unavoidable conflict where there is knowledge and capability within industry that, if brought to bear in the public sector, could accelerate solutions, not retard them. I think we need to think about how we can reduce barriers of having that kind of input put on the table while simultaneously pushing ahead to better control the lobbying practices that Kelly spoke about. I don't think the two are in conflict. I learned a long time ago, actually from a good friend of Clarence Pesson sitting in the front row, somebody who this room probably knows, Harlem Cleland, many years ago, a great person at the State Department I think in the '60s, '70s, who, in a meeting that Clarence hosted way back, was asked, what is the central issue you've learned in trying to resolve complex disputes between parties who can't talk together, who should be kept apart? And he summarized it really in two words: constructive ambiguity. (Laughter.) We have to recognize that while we can't always have everything correct at the table, drawing the opponents into the debate from both sides changes them forever and gets them more engaged in solutions that neither party will be aware of. As a South African, I know that all too well, having seen what it meant if things went wrong in my own country, and I don't think obesity is a bigger problem to tackle than the problem of what could have happened in South Africa if you hadn't gone down the route of constructive engagement. Thank you. MR. BOLLYKY: Great. Kelly, two minutes, please. MR. BROWNELL: Thank you. When Derek was making his initial comments about industry funding and conflicts of interest, he made the point that industry-funded scientists are more productive and more highly esteemed in the field than people not funded by industry. One wonders about the causal arrow there, because of course, industry is not going to choose to seek out to fund the low performers, the low-productive people, the people who will have no value back industry if they're signed on as advisory group members, as scientists of published studies and things like that. So my guess is that's a spurious relationship, and the causal arrow goes from productivity to industry funding rather than the other way around. It's also become appealing for the people who favor industry involvement in things to dismiss the apparent and sometimes blatant conflicts of interest by saying the people who aren't funded by industry have biases too. And in some ways, they're basically showing that everybody is a human being. Of course we're all biased in some way. Of course we all have opinions. Of course we're all motived to have our work funded and things like that. So you begin with a certain level of human being bias. But then the question is whether adding industry money on top of that creates unacceptable levels of bias that distort public policy, distort drug approval, distort those sort of things. Then if that – if the answer to that is yes, then you've got real problems, and I propose to you that that's the case. So I believe, again, that industry has an enormous amount of creativity within it. There is a great deal of possibility for coming together with industry to form solutions, and I think there are signs of that happening in some cases. But the question is whether this should occur under conditions where money changes hands. If scientists wanted to serve on advisory boards for industry, fine. Pay their own way, don't take speakers' fees, don't have any money changing hands. If industry wants to fund money instead of giving money to particular scientists to produce particular outcomes and studies, put it into a pool that's monitored by some group like the National Institutes of Health. That could then fund individuals to do research so the industry isn't – the researchers aren't accountable to industry to produce certain results so they keep gravy train coming. OK, I'll stop there. Thank you. MR. BOLLYKY: Great. Thank you. Quickly, let's do a vote because I want to get to the Q&A. I'll read it quickly again: Governments and intergovernmental institution should not allow any person employed by a processed food and beverage industry or any entity working to further its interest to be a member of any body, committee or advisory group that sets, recommends or implements public health policies with respect to obesity. Can I see a show of hands for those that favor this proposition? I think we're about – maybe actually a few more who are now for the proposition. MR. BROWNELL: No, that's at least double the support, actually. (Laughter.) MR. BOLLYKY: Before I turn it over to Q&A let me tell you where these propositions came from – these propositions are taken either verbatim from the Framework Convention on Tobacco Control itself or the guidelines issued by the conference of parties. The only changes that were made were basically to do a find and replace for the 'tobacco industry' with the 'food and beverage industry' and 'obesity' with 'tobacco control.' (Mild laughter.) So I leave you with that to think about. And with that, I ask those who'd like to speak to raise their hands. When the microphone comes to you and I call on you, if you could just state your name and your affiliation. Rachel? Q: So I'm Rachel Robbins, most recently with International Finance Corporation, and – as the private sector arm of the World Bank Group – MR. : (Off mic.) Q: It's not on? (Off mic.) OK. OK. So I'm Rachel Robbins, most recently with International Finance Corporation, which is the private sector arm of the World Bank Group. And we obviously believe very closely in public-private partnerships and the role of the private sector in addressing social issues in a sustainable way. So my question is really for Derek. I think both acknowledged what the private sector can bring to the issue, but there is the conflicts question. So Derek, what are the steps that could be taken, in addition to disclosure, to allow the private sector to add the value and address the concerns? MR. YACH: Yeah. I think there are procedural issues. For example, disclosure needs to be much more aggressively pursued. I think – I suspect at the moment we're not fully disclosing and people don't fully disclose when they have worked for or are working for industry. We also need to expand what we mean by disclosure. I think a look at Richard Feachem and Richard Smith's article suggest that we need to balance what is a narrow assumption that if you're working for industry, you've got to declare conflict; if you're not, you have no conflict. I think – be more sophisticated about it. But then I think there's a deeper question: Which part of the policy process is it OK for the industry to be engaged in, and which part of the policy process should actually be kept out of the realm? And that includes the realm of protection against undue lobbying and so on. And I've always felt that there are three processes of policy development. There is the development phase: When you're looking at all the options on the table, industry has to be there because they can put on the table options that the public sector will not even dream of are possible. There is the middle part, which is the part when you have to go into closed doors and do the hard politic and what's going to make it. Industry should be out of the room when that happens. When the decision is made and the implementation phase happens, industry has to be at the table on implementation. And I think that uses their capabilities without having the undue influence at a critical point. MR. BOLLYKY: Kelly, would you like to answer that questions as well? MR. BROWNELL: Well, it was – (inaudible) – really admire what you just said. And it seems like when you said the industry should be out of the room when the policy decisions made are made or voted on is absolutely what this proposition was all about. MR. : (Off mic.) MR. BROWNELL: So it – that's an interesting thing to think about. So again, I think industry has a role to play here. What's fascinating to me is that these propositions came out of the Framework Convention for Tobacco Control. So one question is, how different can the food industry be than the tobacco industry? Are the people who run it more moral, more ethical, more public health-minded? Or are they – are they governed by the same set of industry and financial contingencies that make certain behaviors inevitable in that industry? Now, one could claim that food and tobacco are different substances, and clearly, they are. And the old argument that, well, you don't have to smoke, but you have to eat comes up every single meeting. And I – if I hadn't said it, I'm sure somebody here would have, and that's absolutely true. But it doesn't mean that you have to drink Coke, and it doesn't mean you have to eat Cheetos and things like that. And so the question is, can we expect anything out of the food industry other than what we saw in the tobacco and alcohol industry? Because they're governed by the same set of rules. MR. BOLLYKY: Great. I saw Laurie first, then Richard, then Mike and then the gentleman back there. MR. BOLLYKY: We have – just to give you a sense, we have 10 minutes left, so if you can try to keep your questions short. Q: I'm very glad that we're not revisiting the Dan White "Twinkie defense" for the assassination of Mayor Moscone and Harvey Milk in San Francisco. Just two quick questions, one to each of you. Kelly, you opened by telling us that – oh, I'm Laurie Garrett of the Council – you opened by telling us that you've gone to Duane Reade and found that on a volume basis, Coca-Cola and Pepsi were half the cost of bottled water. Since Coca-Cola and Pepsi are the two biggest manufacturers of bottled water in the United States, are you implying there is a sort of conspiratorial and deliberate thing in price control and something of that nature? And to Derek, it's been widely reported in the business and financial press that the board of directors of Pepsi put a lot of pressure on your CEO to – because there was a sense – there was a split within the board, it was – it is reported, that the so-called healthy product line was underperforming and underselling and perhaps should be dismissed or discarded or paired back because it wasn't profitable. That seems to go right to premise number one that we debated. So I wonder if you could clarify that. MR. BOLLYKY: Great question. Kelly? MR. BROWNELL: OK, the bottled water issue. I can't look into the minds of the industry people and know intent. But if you look at the water costing less than Coke or Pepsi and the fact that more manufacturing is required to produce the latter rather than the former, you have to wonder what's up and what would motivate industry to do that. And my own guess – but again, I can't know the motives of the industry – is, as I said, people don't overdo it with water; you drink until you're hydrated, and then you stop. But with things like Coke and Pepsi and the other sugared beverages or just exemplars of that larger category, people go beyond the point where they need to be hydrated because the taste is so good, possibly because of the activity of sugar on the brain, triggering the same pathways that traditional substances of abuse do, and the very heavy and gratuitous addition of a known addictive substance, caffeine. MR. BOLLYKY: Great. Derek. MR. YACH: Thanks for that really nice question, Laurie. (Laughter.) Anybody who knows Laurie knows you can expect that. I think, Laurie, first, Indra Nooyi gets the arc of history. She knows exactly where the long-term future lies. I think the entire board and all the senior executives I know also understand better the long-term. It is inevitable that the demand and the supply of healthy food has to increase. The question is one of a short-term nature. How do you deal with a reality of us being in an unprecedented period of recession when commodity prices have changed dramatically forever and the very business models that underpin healthy food have to be rethought in fundamental ways? The good news is that that past is now past. The February period, when we had all the hype and discussion, is there. If you look at what's on the shelves, I mentioned the transformation of Pepsi's core brand. Who would have thought you'd be at 50 percent by volume being low and mid-calorie, 75 percent in a few years? Who would have thought – anybody Mountain Dew drinkers or be a Mountain Dew drinker in this room? Well, they're a very particular group. Who would have thought that Diet Mountain Dew would become a billion-dollar brand among the same population who drink Mountain Dew, and that would happen in a relatively short time? Or who thought that Trop50 would come from nothing to be a brand that's taking off or that would be in the chick pea and hummus business, which would be the largest hummus business and healthy food in the world, now showing good returns on investment, or that we would have launched a dairy business focused on some of the low-fat and healthy dairies with Muller that is also doomed to take off for the quarter-billion dollar investment in upstate New York? That doesn't sound like a company that's stepping away from the healthy food future but one that's continuing and accelerating the transformation. And I might add that unlike what Kelly would lead you to believe, the food industry hasn't been increasing the levels of salt, sugar and fat in their brands; it's been reducing them. And it's actually got a scorecard it can give you on the rate of reduction, which may not be as fast as everybody wants, but it is pretty much going down. MR. BOLLYKY: Great. I'm going to take questions in two. We have about five minutes left. So Richard first. Q: Very quick: Kelly, you made the assertion that you do not believe that food companies can have a – MR. BOLLYKY: The microphone's coming. Q: Sorry. Sorry. Sorry. Sorry. MR. BOLLYKY: And if you could just state your name. Q: Yes. Richard Edelman. You made the assertion that food companies cannot get forward on the basis of higher-priced lower quantity foods. I'd like to know your evidence for that claim because in fact, I do believe that PepsiCo was trying to do the opposite, and they're also trying to go into different categories where that has been evident to work. MR. BROWNELL: All right. It's a wonderful question. MR. BOLLYKY: Great. Go ahead. MR. BROWNELL: And I would be absolutely delighted if it turned out I was wrong on this and that people were willing to pay for quality rather than quantity of food. There certainly is a market niche for this, and I think none of the companies want to be left out of this movement. So you have the Whole Foods catering entirely to that kind of group. You have McDonald's offering yogurts and things like that. So all – every company is doing this, more or less, and they don't want to – they don't want to miss the niche. But the question, is that niche big enough to really constitute a public health advance, and is the industry doing what it can to get people away from the unhealthy foods and toward those foods, or whether they're just meeting a need that exists anyway. MR. BOLLYKY: Great. Mike and then the gentleman back there. Q: Mike Hodin, the Council. So I guess my question is a – is a prior one, which seems to be the undercurrent. Namely, what do we think this animal, the horrible, evil – what used to be the multinational, today is the global corporation, what do we think the character of the global corporation is? And if we think it is one that is like the '50s or even '60s, that leads you down one path. If you think that it is one that is of a 21st century model with a different set of motivations, a different set of stakeholders, a diversity of opinion, people, ideas and globalization, a very interesting kind of character and makeup, perhaps that leads down to a different path. And so the profound structural shift of what we know today as the 21st century global corporation, which is different than the one that appeared in the literature of global reach and the others that we know from the '50s and early '60s, might go to a place where we define trust and motive a little bit differently. MR. BOLLYKY: OK. And the gentleman back there. Q: Hi. I'm Sanjay, Sanjay Sinho, from American India Foundation. I just wanted to ask on the second proposition, because I think the way the second proposition read, it was very difficult to sort of agree to it. And specifically, I'm a believer in collaboration, and I always feel that the best collaborations are, in the collaboration which happens with partners which have maximum tolerable unlikeness. I think the maximum tolerable unlikeness principle really helps in collaboration, so I didn't agree. But at the end of the debate I agreed with the proposition. Kelly, you did a great job. (Chuckles.) But I do want to ask you, you said that maybe they don't require a seat on the table now but maybe later. So what would be your time frame, and what benchmarks would you think would be when the food and beverage industry would be adequately sort of mature to have a seat on table? MR. BOLLYKY: Great. I'm actually going to take this gentleman's question here because he's the last one and then allow you to answer the three questions in your summing statements, because we have about three minutes left. MR. BROWNELL: Oh, OK. Thanks. Q: Question – (inaudible) – MR. BOLLYKY: Just your name and affiliation, please? Q: Nick Freudenberg, City University of New York, School of Public Health. What if we were to offer the food and beverage industries a choice: Either they and their representatives can participate in scientific and policy debates, or they can contribute through lobbying and campaign contributions, but not both. What would you think of offering them that choice? MR. BOLLYKY: Great. So to recap the questions: Have corporations changed over the last 30, 40 years; what time frame would you be thinking would it be acceptable for industry to be at the table in this policy debate; and then the choice on lobbying or participation in advisory boards. MR. BROWNELL: Me first? MR. BOLLYKY: You first. MR. BROWNELL: OK. First, I don't profess to be an expert on corporate behavior, but my outside looking-in opinion is that they are changing, and there are some really very well-minded people and obviously bright, committed people inside the corporations. And if there is a – MR. : (Off mic.) MR. BROWNELL: OK, good. MR. : (Chuckles.) MR. BROWNELL: No, I think – (chuckles) – no, I think that that's really important. In fact, that makes me quite open to collaborating with industry and interacting, so – at our center, for example, we've had delegations come from PepsiCo, from other companies, General Mills, Kellogg, Post – I can go on with a long list. And we're more than happy to talk and try to interact in as constructive way as possible. We just don't want money changing hands because I think that's what – that's what starts to affect things. Derek mentioned that we need stronger rules for disclosing when money changes hands, which I agree with, but there is a fundamental problem with looking at things that way. If there weren't anything wrong with it, why would you have to disclose it in the first place? And then is the resolution to that problem disclosing the ill behavior or trying to get of it? And that becomes interesting. And then there is also something funny about saying – (inaudible) – I was going to say, there is interesting research showing that disclosure may make things worse, that an audience who hears a message where the person has disclosed a conflict of interest will discredit the source, but only a small amount, but the source who's made the disclosure feels licensed to make their message even stronger, and so the disclosure doesn't seem to have a beneficial effect overall. MR. BOLLYKY: Kelly, can I get you to answer the question on timing, then I'll let Derek answer the choice, because I think we're out of time. MR. BROWNELL: The question on – MR. BOLLYKY: On timing. MR. BROWNELL: OK, I – MR. BOLLYKY: The gentleman back there. When is it acceptable for the industry to participate? MR. BROWNELL: Oh, yes, yes. Thank you, I forgot. Yes. I think we're getting close to the point where industry can probably be engaged in a constructive way because I think the pressure on industry, at least in the United States, is increasing, and there is a great threat of regulatory threat, I think. And there might even be litigation threats that would bring industry to the table more readily. So I think industry, until it's forced to change, won't, but now that it's being forced to change, will. And the time is probably pretty close. But at the moment we have to be pretty darn careful. MR. BOLLYKY: Great. Derek, can you – on the choice between lobbying and advisory committees. MR. YACH: Yeah. I'll take the first, and I would hope companies would. I think the companies of the 21st century that are going to succeed are going to want to put their scientists, the technical expertise, in close proximity to others to find solutions and realize there is plenty of money to be made when you actually apply your minds to doing it, and the lobbying stuff can then start falling away. MR. BOLLYKY: Great. And with that, I would like to close. First of all, join me in thanking these very brave and effective speakers. (Applause.) And thank you all for coming. (END)
  • Global
    Noncommunicable Diseases in the Developing World
    Podcast
    Thomas Bollyky, CFR's senior fellow for global health, economics, and development, leads a discussion on the rise of noncommunicable diseases in the developing world, attitudes towards them, and solutions for addressing them, as part of CFR's Academic Conference Call series. Learn more about CFR's resources for the classroom at Educators Home.
  • Public Health Threats and Pandemics
    More with Less
    Overview Natural and human-made disasters are increasing around the world. Hurricanes, typhoons, earthquakes, tsunamis, droughts, and resultant famine, floods, and armed conflicts are constant reminders of the frailty of our human race. Global warming may cause whole island states to be submerged as the oceans rise. In the past these acute and recurring crises have been met by the international community responding to UN and media appeals. The economic collapse of nations is now a reality; some of those most affected had been traditional, generous donors to disaster relief operations. It is unlikely-probably impossible-that they will be able to continue to contribute overseas when their own domestic needs are unmet. A recent New York Times front page report suggested that one of the few domestic issues to have bipartisan support was to cut the foreign aid budget. This book analyzes the global economic forecast and the United Nations pattern of philanthropy, provides a case study of how one nation with a tradition of giving will cope in the face of a marked reduction in flexible funds, and then provides thoughtful chapters on new approaches to disaster preparedness and disaster response. Among the contributors are the director of UNESCO, the UN undersecretary-general for humanitarian assistance, the secretary-general's special representative for disaster risk reduction, and fresh suggestions from three well-known global entrepreneurs. In his chapter, "Non-communicable Diseases and the New Global Health," CFR Senior Fellow Thomas J. Bollyky discusses the rise of noncommunicable diseases in low- and middle-income countries, United Nations' efforts to address this rapidly emerging health problem, and paths for collective action. All royalties from this book go to the training of humanitarian workers.