US as a global health leader: Q and A with Dr J Stephen Morrison

January / February 2014 | Volume 13, Issue 1

J. Stephen Morrison, Ph.D., is Senior Vice President and Director of the Global Health Policy Center at the nonprofit policy institution, the Center for Strategic and International Studies. He also recently joined the Fogarty Advisory Board. At CSIS, he testifies before Congress, directs high-level task forces and commissions, and frequently writes articles and comments in the media about U.S. foreign policy, global health, Africa and foreign assistance. He holds a doctoral degree in political science from the University of Wisconsin and taught for 12 years as an adjunct professor at the Johns Hopkins School of Advanced International Studies.

Why does the U.S. give priority to advancing global health?

The U.S. leads on global health because it is perceived to be in U.S. national interests. Fifteen years ago, a significant change occurred in how global health is viewed vis-à-vis U.S. foreign policy. Beginning late in the Clinton Administration, accelerating swiftly post-9/11 in the Bush Administration, and continuing robustly in President Obama's ongoing tenure, there has been recognition at the highest levels that U.S. leadership in advancing global health serves U.S. national interests in three critical ways: by investing in American humanitarian values; fostering the stability and security of communities; and undergirding economic growth. It is understood as essential to mitigate specific emerging threats: HIV/AIDS was the most powerful such threat that came into focus in the late 1990s. Malaria and tuberculosis, pandemic influenza and diverse emerging forms of resistance also came to be seen as health security threats warranting heightened attention. A strategic rationale for global health took form, paired with the assumption of real national interests and serious enduring threats; that may seem at odds with a conventional public health or biomedical perspective, but it has been fundamental to spurring sustained U.S. engagement.

Operationally, the U.S. role in the past decade and a half has rested on a few key elements:

• Leadership is the sine qua non: direct engagement by the President, his White House staff and cabinet officials. This was seen vividly at the end of 2013, during the three-year replenishment for the Global Fund to Fight AIDS, Tuberculosis and Malaria, held in Washington, D.C., when it was President Obama himself who drove the process forward, supported by Secretaries Kerry and Sebelius, National Security Advisor Rice, U.S. Ambassador to the U.N. Power and other senior officials. The end result was a commitment by the U.S. of at least $4 billion, matched by $8 billion in commitments by others (and another $1 billion if an additional $2 billion in matching contributions can be mustered.) That investment in high-level U.S. diplomacy had a profound impact: it overtly restored international confidence in the Global Fund, rallying the other major donors (France, the UK, Germany, Japan and the Scandinavian states).

• Resources, authority, focus, performance: The expanding U.S. role over the past decade and half in leading on global health was made possible by an unexpected, historic surge of funding - a rise in the aggregate annual investment of roughly $1 billion in 2000 to $8 billion by 2008 - along with a concentrated focus on infectious diseases and maternal and child health, concentrated authority in the Office of the Global AIDS Coordinator, and impressive gains in efficiency. On the latter score, the population receiving U.S.-supported antiretroviral treatment rose from 1.8 million to 6.8 million over the course of the first five years of the Obama administration, in the midst of a flat budget. That was a powerful factor in convincing Congress to stay the course.
  
  U.S. leadership has relied on an evolving smart integration of bilateral with multilateral solutions: in the latter case, most important was the U.S.-led rescue of the Global Fund, when it entered crisis in 2011, followed subsequently by the Fund's restructuring in 2012, and the steadily closer alignment of U.S. bilateral programs in HIV/AIDS, TB and malaria, and those undertaken by the Fund.

• Congress: Further, U.S. leadership has relied both on an unusual bipartisan compact with Congress, and a broad societal base of support, comprised of the faith community, universities, Bill and Melinda Gates, and the corporate sector, among others. Quite remarkably, even as Congress has experienced high turnover, bitter polarization and worsening budgets, it has been possible to preserve a consensus between the executive and congress on sustaining U.S. efforts in global health. Key to that has been demonstrating relatively rapid concrete results, in lives enhanced and saved; achieving higher and higher efficiencies; and leveraging other donors and partner governments to do more themselves. Travel to Africa, Asia and Latin America by congressional members and staff has proved invaluable in building excitement and firsthand knowledge.

How does NIH-funded global health research support this effort?

Most fundamentally, through long-term strategic investments in helping answer the questions for which we today lack answers - in terms of basic science, trials, product development, and operational research – in the very societies in Africa, Asia and Latin America where the most critical health challenges are concentrated, and where future solutions will be generated. If successful, NIH-supported research generates new knowledge, builds R&D capacity in partner countries, creates future health and science leaders and results in collaborations that enrich and strengthen both U.S. institutions and partner institutions in low- and middle-income countries.

But demonstrating the linkages between R&D and mainstream U.S. global health investments can be tricky, and requires a deft form of communication and argumentation. Research investments are often quiet, out of view, very long term by nature, highly technical and are often uncertain ventures, some of which may succeed, while many may not. In the midst of flat or contracting budgets, it becomes that much more imperative to convey effectively the value and dynamism of these investments to nontechnical audiences - in Congress, the media, and to the general American people. The Medical Education Partnership Initiative (MEPI) that supports education and training partnerships between African and American universities, funded through the President's Emergency Plan for AIDS Relief (PEPFAR) and administered through Fogarty and the Health Resources and Services Administration (HRSA), are a powerful creative instance of how the U.S. engagement in infectious disease programs can enlarge its reach to strengthen U.S.-African research collaborations. Similarly, the Pink Ribbon/Red Ribbon initiative bridged from the PEPFAR programs to encompass these pressing noncommunicable diseases.

What are some areas that need more global health research?

While there are high disease burdens (including rising noncommunicable diseases), extreme poverty and compelling research opportunities in emerging economies, especially lower-middle-income countries, these states fall largely outside the frame for U.S. global health investments, which overwhelmingly are directed to low-income countries. In these instances, the case needs to be made to Congress and elsewhere that these research and partnership opportunities do indeed advance U.S. national interests over the long term.

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