Global health, it has been noted, is not a discipline; it is, rather, a collection of problems. A leading group of scholars have defined global health as the study and practice concerned with improving the health of all people and achieving health equity worldwide, with an emphasis on addressing problems that are transnational. No single review can do much more than identify the leading problems in applying evidence-based medicine in settings of great poverty or across national boundaries. This chapter introduces the major international bodies that address these problems; identifies the more significant barriers to improving the health of people who to date have not, by and large, had access to modern medicines; and summarizes population-based data on the most common health problems faced by people living in poverty. Examining specific problems—notably AIDS (Chap. 189) but also tuberculosis (TB, Chap. 165), malaria (Chap. 210), and key noncommunicable diseases—helps sharpen the discussion of barriers to prevention, diagnosis, and care as well as the means of overcoming them. The chapter then discusses the role of health systems and the problem of "brain drain" on those systems. It closes by discussing global health equity, drawing on notions of social justice that once were central to international public health but have fallen out of favor over the last several decades.
Concern about health across national boundaries dates back many centuries, predating the Black Plague and other pandemics. The first organization founded explicitly to tackle cross-border health issues was the Pan American Sanitary Bureau, which was formed by 11 countries in the Americas in 1902. The primary goal of what later became the Pan American Health Organization was the control of infectious diseases across the Americas. Of special concern was yellow fever, which had been running a deadly course through much of South and Central America and posed a threat to the construction of the Panama Canal. In 1948, the United Nations formed the first truly global health institution: the World Health Organization (WHO). In 1958, under the aegis of the WHO and in line with a long-standing focus on communicable diseases that cross borders, leaders in global health initiated the effort that led to what some see as the greatest success in international health: the eradication of smallpox. Naysayers were surprised when the smallpox eradication campaign, which engaged public health officials throughout the world, proved successful in 1979 during the Cold War. The influence of the WHO waned during the 1980s. In the early 1990s, many observers argued that with its vastly superior financial resources and close if unequal relationships with the governments of poor countries, the World Bank had eclipsed the WHO as the most important multilateral institution working in the area of health. One of the stated goals of the World Bank was to help poor countries identify "cost-effective" interventions worthy of international public support. At the same time, the World Bank encouraged many of those nations to reduce public expenditures in health and education as part of later discredited structural adjustment programs that were imposed as a condition for access to credit and assistance through international financial institutions such as the World Bank and the International Monetary Fund (IMF). At the same time, there was a resurgence of many diseases, including malaria, trypanosomiasis, are schistosomiasis, in Africa.Tuberculosis, an eminently curable disease, remained the world's leading infectious killer of adults. Half a million women per year died in childbirth during the last decade of the twentieth century, and few of the world's largest philanthropic or funding institutions focused on global health.
AIDS, first described in 1981, precipitated a change. In the United States, the advent of this newly described infectious killer marked the culmination of a series of events that discredited talk of "closing the book" on infectious diseases. In Africa, which would emerge as the global epicenter of the pandemic, HIV disease strained TB control programs, and malaria continued to take as many lives as ever. At the dawn of the twenty-first century, these three diseases alone killed an estimated 6 million people each year. New research, new policies, and new funding mechanisms were called for. The last decade has seen the rise of important multilateral global health institutions such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) and the Joint United Nations Programme on HIV/AIDS (UNAIDS); bilateral efforts such as the U.S. President's Emergency Plan for AIDS Relief (PEPFAR); and private philanthropic organizations such as the Bill & Melinda Gates Foundation. Yet with its 193 member states and 147 country offices, the WHO remains preeminent in matters relating to the cross-border spread of infectious diseases and other health threats. In the aftermath of the severe acute respiratory syndrome (SARS) epidemic of 2003, the International Health Regulations—which provide a legal foundation for the WHO's direct investigation of a wide range of global health problems, including pandemic influenza, in any member state—were strengthened and brought into force in May 2007.
Even as attention to and resources for health problems in poor countries grow, the lack of coherence in and among global health institutions may undermine efforts to forge a more comprehensive and effective response. The WHO is still woefully underfunded despite the ever-growing need to engage a wider and more complex range of health issues. In another instance of the paradoxical impact of success, the rapid growth of the Gates Foundation, which is clearly one of the most important developments in the history of global health, has led other foundations to question the wisdom of continuing to invest their more modest resources in this field. This indeed may be what some have called "the golden age of global health," but leaders of major organizations such as the WHO, the GFATM, the United Nations Children's Fund (UNICEF), UNAIDS, PEPFAR, and the Gates Foundation must work together to design an effective architecture that will make the most of the opportunities that now exist. ...