Burden of disease and inherently global health issues
should both be considered
When the G8 countries met in Canada in 2002 the topics of security, health,
and Africa figured prominently. The three issuesare related.
Africa's human health is reeling from HIV/AIDS andother infectious
diseases, posing national and regional securityrisks. The
continent's economic health is stagnant or eroding,the result of
structural adjustment programmes,1 domestic
conflicts,corruption, and deteriorating human health. Recognising
the complexitiesof these entwined relations, the G8 Africa action
plan includeda commitment to support health research on diseases
prevalentin Africa. How well G8 member nationsCanada,
the United States,England, France, Germany, Italy, Japan, and Russiaabide
by thiscommitment is a matter of time and lobbying efforts. But whatform should this new health research investment take? Should it
emphasise specific diseases affecting poor people most, as favoured
by the Commission on Macroeconomics and Health of the World Health
Organization?2 Should it heed the call of
biotechnology researchers,who have tabled their list of "top 10"
research investments forglobal health, which range from better
diagnostic devices andrecombinant vaccines against HIV/AIDS to
simpler vaccine devicesreplacing needle injections?3
Both lists are consistent with the "burden of disease" approach to research
priorities. This approach has become an importantvehicle for
exposing the imbalance between research investmentand disease
burden, the "10/90 gap"less
than 10% of worldwidehealth research is devoted to diseases that
account for 90% ofthe global burden of disease.4
The burden of disease approachhas helped efforts to create and
finance new programmes for treatmentand prevention of disease (for
example, the Global Fund to FightAids, Tuberculosis and Malaria) or
for vaccine research (for example,the Global Alliance for Vaccines
and Immunisation), however inadequatethese commitments are at
present. But is the burden of diseaseapproach sufficient to sustain
improvements in human health? Wethink not and propose its
integration with a different conceptualisationof global health that
emphasises the social, environmental, andeconomic contexts in which
health, disease, and healthcare interventionsare
embedded.
The social and environmental contexts that determine disease are no longer
simply domestic but increasingly global. The boxlists what we
consider the main inherently global health issues,a term describing
health determining phenomena that transcendnational borders and
political jurisdictions. Considerable researchexists on each of
these issues, although not always with healthas a principal outcome.
Greater attention in research is requiredto the linkages between
these issues and to their economic andpolitical drivers that are,
like the issues, increasingly globalin scope. Such drivers include
macroeconomic policies associatedwith international finance
institutions, liberalisation of tradeand investment, global trade
agreements, and technological innovations,all of which are creating
greater interdependence between peopleand places.5
Assessing how these inherently global health issuesaffect health is
a complex task. Recent work on locating theseinherently global
health issues in comprehensive health frameworks, 56 however, will prove useful in identifying
specific research questionsthat are useful to policy makers and
civil society.
Inherently global
health issues
Environmental global degradation
Greenhouse gas emissions (climate change)
Biodiversity loss
Water shortage
Decline in fisheries
Deforestation
Socioeconomic issues
Increasing poverty
Financial instability (capital markets)
Digital divide
Taxation (tax havens, transfer pricing)
Cross cutting issues
Food (in)security
Trade in health damaging products (tobacco, arms, toxic waste)
Governance
War and conflict
Research into these inherently global health issues does not exclude a burden
of disease emphasis on vulnerable groups andspecific diseases. At
issue is the extent to which research aboutthe burden of health
should be required to include analysis ofinherently global health
issues. For example, the HIV/AIDS pandemic,particularly in Africa,
affects several vulnerable groups, particularlywomen. Poverty, war
and conflict, and ecological degradation areall important
co-factors. Liberalisation, structural adjustmentprogrammes, and the
aid policies of wealthy nations, which constraintaxation revenue and
equitable access to health services, arealso determinants. Trade
agreements underpinning the HIV/AIDSpandemic relate to intellectual
property rights (patents) andaccessibility of drugs, as well as the
decline in "special anddifferential" exemptions that poorer
countries can invoke to protecttheir still developing domestic
economies to ensure greater growthand fairer distribution of its
benefits. No single research projecton HIV/AIDS should be expected
to incorporate all of these elements.A singular focus on HIV/AIDS,
however, obscures the importantrole of these and other co-factors of
inherently global healthissues.
Global health research outside a context in which policy makers, civil
society, and the media are engaged risks generatingmore knowledge
but little action. To minimise this, we suggestseveral principles by
which global health research might be prioritised:
Research on inherently global health issues that reduce the burden of
disease, and vice versa
Research that represents concerns or questions defined by developing
countries
Research that increases equity in health outcomes between groups within
nations
Research that solidly engages civil society, and
Research that increases equity in knowledge capacities between developed
and developingcountries.
These principles guide the development of our own global health research
projects, with support from several of the CanadianInstitutes of
Health Research (the national health research grantingbody). We
invite other health researchers and funders to considerdoinglikewise.
Ronald Labonte, director.
Saskatchewan Population Health and Evaluation Research Unit, University of
Saskatchewan, Saskatoon, Canada S7N 5E5
Jerry Spiegel, assistant professor.
Liu Institute for Global Issues, University of British Columbia, Vancouver,
Canada V6T 1Z2
Breman A, Shelton C. Structural adjustment and health: a
literature review of the debate, its role-players and presented empirical
evidence. Cambridge, MA: Commission on Macroeconomics and Health, 2001.
(Paper No WG6:6.)
Daar AS, Thorsteinsdóttir H, Martin DK, Smith AC, Nast S,
Singer PA. Top ten biotechnologies for improving health in developing
countries. Nature Genetics 2002; 32: 229-232[CrossRef][ISI][Medline].
Labonte R, Spiegel J. Setting global health priorities for
funding Canadian researchers: a discussion paper prepared for the institute
on population and public health. Saskatchewan Population Health and
Evaluation Research Unit, www.spheru.ca
(accessed 10 Feb 2003).
Labonte R, Torgerson R. Frameworks for analyzing the links
between globalization and health. Discussion paper prepared for the
globalization, trade and health group, World Health Organization.
Saskatchewan Population Health and Evaluation Research Unit,
www.spheru.ca (accessed 10 Feb 2003).
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