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global health response paper LAUREN E.

SILVER

Based on the readings this week, it seems that from the age of colonialism to present day,
the paradigm for addressing worldwide health issues has evolved from:

1) protecting imperial health (i.e., protecting the well-being of imperial populations for
invading, conquering, and exploiting colonized populations), to

2) protecting international health (i.e., expanding local public health efforts to protect the
well-being of colonial populations during increasing economic competition between
empires, primarily to sustain trade and profits), to

3) protecting global health (i.e., promoting social and economic development to address
the broader determinants of health, a notion first spearheaded on a large scale by the
Rockefeller Foundation beginning in 1913 and more formally declared by the Declaration
of Alma-Ata in 1978).

Although the paradigm for addressing worldwide health issues has evolved from one
based on narrow self-interest in which the role of public health in human well-being
was a low-order consideration (Birn et al., 2009) to one emphasizing that healthis a
fundamental human right (Declaration of Alma-Ata), the primary strategies and
interventions deployed by major global health players have failed to evolve at the same
pace.

By way of example, the Declaration of Alma-Ata asserts that governments have a
responsibility for the health of their people which can be fulfilled only by the provision of
adequate health and social measures, emphasizing the particular importance of a
comprehensive primary health care approach. While some major global health players,
such as the World Health Organization (WHO), support the primary health care approach
in theory, the majority of global health activities and funding structures continue to
emphasize selective primary health care.

In contrast to a comprehensive approach, the selective primary health care strategy
pursue[s] the fight against a limited number of diseases by concentrating on specific
interventions thatwould be most cost-efficient (Italian Global Health Watch, 2008).
Created in 2002, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF)
exemplifies the selective primary health care approachit is a vertical, segmented
program that targets specific, high-profile diseases in developing nations without also
addressing the more systemic public health problems that these nations face, such as a
limited infrastructure, an inadequate health care workforce, and lack of political will and
leadership to prioritize health sector reform (Italian Global Health Watch, 2008; Garrett,
2007). One unintended outcome of the GF has been that the large inflows of donor
assistance targeted to these diseases have weakened the infrastructure [of nations] and
drained the human resources required for preventing and treating common diseases that
may kill many more people (Italian Global Health Watch, 2008).

Evidence of the limitations of the vertical approach to intervening in global healthand
its unintended consequencesis growing. In How Fight to Tame TB Made it Stronger,
global health response paper LAUREN E. SILVER

published in the November 23, 2012 issue of the Wall Street Journal, authors Geeta
Anand and Betsy McKay describe how the World Health Organization (WHO) and aid
groups primary strategy for combating tuberculosis (TB) may have backfired in the very
countries with populations most afflicted by the infectious disease. Until recently, the
collective WHO and aid group effort against TB entailed identifying the easiest-to-cure
patients infected with traditional, treatable strains of the disease and prescribing a six-
month course of standard medicines, an approach that sought to make diagnosing and
treating TB simple-to-understand and cheap enough to work in the worlds poorest
places.

In poor countries across the world, though, an epidemic of new, multi-drug resistant
(MDR) strains of TB has emerged. Recent research shows that in India, where 2.2 million
of 8.7 million new cases of TB in 2012 originated, anywhere from 7 to 25 percent of TB
patients are drug-resistant. India began combating TB with the help of the WHO in 1997,
relying primarily on the WHOs simple approach to treating regular TB only. At the time,
the WHO decided that tackling MDR was unfeasible in places with poor infrastructure,
little money, and millions of patients lacking even basic treatment. Even though the
WHOs simpler strategy to fight TB reduced the overall number of regular TB cases
since the 1990s, rates of drug-resistant TBthought to be much more lethalhave
climbed across 35 countries. In India, officials have been unable to move quickly to
address drug-resistant TB due, in large part, to a lack of basic infrastructure, including
limited disease surveillance, lack of accredited laboratories for testing for and diagnosing
diseases, and treatment delays.

This article is striking in that it highlights, as did the Global Fund effort, how our views
on the goals of global health do not align with the methods we use to address global
health concerns. More specifically, the article highlights the shortcomings of vertical
programming and, yet, vertical programming and selective primary health care continue
to dominate how major global health players address worldwide health concerns.

Birn et al. (2009) point out global health, as a form of development, raises central
questions regarding the hows of the field. Specifically, how are activities of the field,
such as disease campaigns, implemented and how do these activities lead to path
dependence? In political science, the theory of path dependence refers to the notion
that current policy and programmatic decisionsand, therefore, the structure of new
policies and programsare influenced and even constrained by past policy decisions,
even if the context of policy decision-making has changed from one time period to the
next. In other words, there is a process of policy feedback through which policy builds
on policy (Beland and Hacker, 2004). Based on the readings path dependence may help
explain our continued reliance on vertical global health interventions. If targeting low-
hanging fruitspecific diseases for which evidence-based and cost-efficient treatments
existhas always been the norm, then switching gears to a more comprehensive
approach may be all the more difficult, even despite widespread recognition that targeting
the broader determinants of health will be our best bet.

Link to article:
global health response paper LAUREN E. SILVER

http://online.wsj.com/article/SB10001424127887324894104578115232206834770.html

Other sources:

Beland, D. & Hacker, J. S. (2004). Ideas, private institutions, and American welfare state
'exceptionalism': The case of health and old-age insurance, 1915-1965. International
Journal of Social Welfare, 13, 42-54.

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