New perspectives in global health

Perhaps at no other time in our history has so much scrutiny been aimed at health care in the context of our global world. The term “international health” has long been unofficial shorthand for public health interventions in the developing world. Health care was part of the fabric of individual communities, different from continent to continent and country to country, and separate.

The new director-general of the World Health Organizations acknowledged that other players now have tremendous influence in driving the global health agenda. (Copyright 2006, World Health Organization)

Today the old notion of international health is being made obsolete, replaced by a more encompassing view of global health that better captures how the forces of globalization, technological progress, and economic development are influencing health care around the world. Global health now refers to a vast landscape in which public health is merely one element.

More than that, the health of nations can no longer be viewed in isolation, separate from countries an ocean apart, thriving or decaying based only on what occurs within national borders. We know that disease and the bugs that cause them are mobile, and do not recognize the borders they cross. Slave ships carried mosquitoes and, with them, yellow fever to the New World. SARS made its trip on a commercial airliner. HIV has transported itself in every way possible. But today we see that there is another mobile aspect of global health: people and the services they can offer, as well as people for the services they want.

In this HMI World Forum, we take a brief look at three major issues that have significant import for global health in general and for the health of individual nations of people. Doing so, we raise more questions than we answer. First, the emergence of powerful new players in global health raises big questions about how to develop sustainable health care infrastructure in the developing world, while addressing major disease challenges. Second, while we chase down the origins of disease in villages and laboratories, a crippling worldwide shortage of capable health workers becomes ever more acute. And third, somewhere between the richest and poorest countries of the world, doctors and patients are forming a mutually beneficial partnership. The popular term is medical tourism, but that will certainly be revised as the health care systems in emerging economies become health destinations known far and wide for the quality of their services.  

The Gates Foundation has become one of the strongest voices in global health. (Copyright 2006, World Health Organization)

New players on the scene of global health
As she prepared to take office as Director-General of the World Health Organization (WHO), Dr. Margaret Chan acknowledged that WHO is no longer the sole guardian of global health. “Some 60 years ago when the World Health Organization was established, WHO was the organization in international health. But when you look at the landscape now, it is very different. There are many key players who are quite influential.”

Indeed, as HIV, avian flu, and other health threats cross geopolitical boundaries, WHO has been joined in its efforts by not only well-known advocates like the World Bank, UNICEF, the Bill and Melinda Gates Foundation, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, but also the Global Alliance for Vaccines and Immunization, an explosion of NGOs, and more than 50 public-private partnerships.

The Gates Foundation has been at the head of a surge in fundraising by both private philanthropists and top donor governments. For the first time ever, money for global health programs isn’t in short supply, though making sure that the money makes it to beneficial use is still difficult in some cases. 

Notwithstanding that point, there is no question that there is tremendous commitment to improving health. Among the organizations on the scene, what should their priorities be? And who should set them?

Patty Stonesifer, CEO of the Gates Foundation, has said that in this era of partnerships, "no single institution has to solve every problem or do all the work.” Fair enough, but what about those partnerships? Africa and India are full of organizations focused on HIV and AIDS, but the ability to coordinate their efforts and share information has not yet matched the commitment of funds or ideals. 

Focus is another question. Laurie Garrett, a senior fellow at the Council on Foreign Relations, argues in the January-February 2007 issue of Foreign Affairs that the major global health organizations have focused too much on narrow, disease-specific problems rather than tackling public health in general. She worries that high-profile organizations have concerned themselves with numerical targets for bednet distribution or increasing the number of HIV patients on antiretroviral therapy, at the expense of developing prolonged systems-building interventions that poor nations require for sustainable public health improvements.

Writes Garrett, “Few donors seem to understand that it will take at least a full generation (if not two or three) to substantially improve public health—and that efforts should focus less on particular diseases than on broad measures that affect populations’ general well-being.”

But are efforts aimed at single diseases necessarily the opposite of those broader measures? Take the rollout of antiretroviral therapy, for example. In the countries where this has been most successful, such as Malawi, the complexity involved with providing the drugs has helped create some of the building blocks for a primary care system. These disease-specific interventions have helped reduce the barriers between health care workers and patients (many are both), and doing so helped to start an infrastructure that people look to access when they are ill.

Garrett is right to bring up the prickly issue of accountability with regards to the Gates Foundation and its contemporaries. The best intentions of the best funded won’t solve anything if they do not carefully consider their priorities, evaluate the programs designed to meet those priorities, and analyze their outcomes. This is all the more crucial if one considers the tremendous power these organizations have in setting the agenda for global health.

Global shortage of health care workers looms large
As we enter 2007 we are short an estimated four million health care workers, according to widely accepted estimates.  And as the world’s population ages, that number is only expected to grow. Superbugs, viral epidemics, and baby boomer maladies continue to demand the majority of ink devoted to global health. But the global shortage of health care workers is perhaps the most pressing health care challenge of the day.

The shortage of health care workers in the U.S., UK, Canada, and Australia could have a devastating effect on lower and middle-income countries, according to research by Fitzhugh Mullan, MD. In the October  27, 2005 issue of the New England Journal of Medicine. Mullan concluded that international medical graduates (IMGs) constituted between 23 and 28 percent of the physician workforce in these countries, with lower-income countries contributing between 40 (in Australia) and 75 percent (in the UK) of the IMGs.

Garrett, in Foreign Affairs, cites a report estimating that by 2020, the U.S. could be short up to 200,000 doctors and 800,000 nurses. How will U.S. hospitals fill close the gap? No doubt by continuing to recruit health care professionals from countries that can ill afford to lose them. They have the support of the U.S. Congress, which instead of discouraging this activity, has helped to clear many of the barriers to importing medical staff.

Rhetorically members of Congress have used the old canard about inviting the disadvantaged into the land of opportunity, with little regard for how this method of staffing U.S. hospitals will hurt health care systems in other countries—a cataclysmic ignorance of the global character of health care.

One can hardly fault those health care workers who make their way to the U.S. or UK to practice their trade. Many leave countries ravaged by war and political unrest, or public health care systems that exist in a shambles. From a career standpoint, the U.S. offers opportunities for postgraduate education and training that are nonexistent at home. This goes for nurses as well as doctors.

What can countries like the U.S. and the UK—both with health care systems that are often tagged with the word crisis—do to stench the flow of health care professionals from countries that cannot afford to lose them? Are they obligated to do anything? When it comes to filling those open positions, does the old rule apply: First do no harm?

Medical tourism is going mainstream
Let’s return for a moment to the discussion of terms with which we began. International health, we suggested, was an obsolete piece of terminology, better suited for a world community that wasn’t a community at all, really, just a disparate collection of cultures and traditions, demographics and disease patterns—all of it well defined by dividing lines on a map.

Global health, we said—that is the world we are living in today. The Asian virus that takes a late-night flight to the West. The x-ray administered in Boston, read in Bangalore.

And so it is with disease and technology, so it is with patients. Not everything, it turns out, goes west. And not everything, as well, can be neatly divided between the established economies and the developing world.

For the last two years stories of medical tourism have been showing up more and more in the media. Media in the countries that are attracting patients from the West have been creating a buzz, touting high-tech high-touch services, low costs, and high levels of patient satisfaction. The western media, meanwhile, have treated medical tourism more like a novelty, with local newspaper dispatches on the adventures abroad of retired apple farmers and self-employed carpenters in need of hip replacements and heart valves.

Now the storylines are evolving again, as anecdotes of individual patients become part of a discussion of how health care systems in developing and emerging economies are growing and improving, while the United States and the United Kingdom suffer from problems related to cost and service availability. One story’s theme is, “Now you can.”  The other’s is, “Not today.”  A handful of years ago these were different stories playing out worlds apart. Now they are converging narratives.

These narratives are set in some surprising locales: India, Singapore, Thailand, and more. International health was based on a distinction between OECD countries and everybody else—global health is a bit more complicated.

In the October 19, 2006 New England Journal of Medicine, Mark D. Smith, MD, MBA used the term “medical refugees” to describe patients seeking health care in foreign countries. This was another important shift in wording, because in writing about medical tourists, Smith was not referring to patients taking a quick flight to have elective plastic surgery on the cheap. His highly charged terminology pointed to the desperation felt by an increasing number of patients hard-pressed to meet their basic health care needs.

In 2007, we will see more stories of medical tourism, but what will they be about? More adventures abroad, certainly, but also likely are stories of U.S. employers looking to foreign health destinations as an alternative to health coverage. There are already studies of lower- and middle-income workers in the United States deciding to forgo the health insurance provided by their employers due to the rising premiums.

In India, Wockhardt Hospitals, Ltd. is at the center of private sector growth that could help foster improvements throughout the country’s health care system.

Wockhardt Hospitals, Ltd. is one health care organization in India that is capitalizing on the demand for services. Vishal Bali, the group’s CEO, says there has been a 45 percent increase in the number of American patients seeking care in the network’s 10 hospitals over the past two years. He cites two major factors: cost (think $8,000 for coronary bypass surgery, or $6,500 for a joint replacement) and what he calls the “Indian advantage,” referring to the confidence many Americans have in Indian physicians because they have been treated by them in the U.S.

One might hope also for more stories that focus on the quality data generated by these international hospitals. While anecdotal accounts have been largely positive, outcomes data will be important not only for the hospitals’ continued success, but also to help drive home the point that health care systems in emerging countries around the world are developing rapidly.

As medical tourism hits the mainstream—becoming a viable choice for more Western patients—how will patients identify high-quality facilities? The stamp of approval signified by accreditation will be one way. Wockhardt’s hospitals are accredited by Joint Commission International, and more than 80 hospitals in Thailand, Singapore, China, Saudi Arabia, and other developing or emerging economies have earned accreditation.

Bringing it all together
Bill Gates versus AIDS, a worldwide shortage of health care workers, and affordable hip replacement surgery—what’s the connection?

When the new Director-General of the World Health Organization marveled at the fact that the WHO had acquired a lot of competition in the field of global health, she was right. But she could have gone a bit further—the definition of global health, not merely who gets the job of overseeing it, seems open for discussion. 

It is not a question to be answered in this space, or any space this size. But each of the issues discussed above touches an important corner of global health. More questions are raised than answered. How far can a dollar go in combating HIV and AIDS in the developing world, when groups coordinate their efforts? What will it take to stop the brain drain of health care professionals from the poorest countries of the world? Can anything? And how will the growth of privately-run hospitals in the emerging economies that can attract foreign patients help drive country-wide improvements in health care?

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