Official US Government Global Health Program

Is there one?  One would hope so given our superpower status (at least until China cashes in the US treasuries it holds).  Obviously many government agencies, branches, and departments have some role in affecting the health of the rest (majority) of the world’s population.  Prominent are the USAID, USDA, and the departments of Defense and State, and less prominent are the Peace Corp, FDA, CDC, and NIH (e.g., the new NIH Therapeutics for Rare and Neglected Diseases).  Last May (2009), one of our national think tanks (image of brains floating in a vat), the Institute of Medicine (sister to the National Academies of Science and Engineering, IOM), released a report advocating for a national program on global health (IOM Report).  Called “The US Commitment to Global Health- Recommendations to the New Administration,” it followed a similar report in 1997 (the recommendations of which apparently had no effect), was funded by multiple government agencies and five foundations (Gates, Google, Merck, Wellcome Trust, and Rockefeller), and had esteemed authors and reviewers.  Just to note, all the authors and reviewers were from academia, NGOs, or PDPs (product development programs); not one from a for-profit or corporation except for two reviewers (Pepsi and ExxonMobil).  I suspect that the biotech/pharma industry would have something to contribute (Not interested?  Not invited?)

The report had a stirring bottom line:  that the US needs to “live up to its humanitarian responsibilities” and “highlight health as a pillar of US foreign policy” (page 1).  It states this highlighting should include:

– creation of a White House level interagency group chaired by a senior official [a “global health” czar?];

-doubling the US’s global health-dedicated spending from $7.5B in 2006 to $15B in 2012; and

-allocation of this budget across programs supporting the 2000 Millennium Development Goals (MDG) and non-communicable diseases (most would be applied to HIV/AIDS, malaria, and TB).

While it would be nice to have some high level coordination, visibility, and advocacy, is the recommended spending in proportion to the problem and to the potentially available resources?  As noted in the report, although the US government spends the greatest absolute amount of any country on global health aid, it is at the bottom of the developed countries in terms of percentage of gross national income (0.16% compared to an average of 0.45%) and does not spend close to the MDG target of 0.54% of GNI.  And the US effort is more narrowly focused than that of the Gates Foundation’s whose spending of $1.7B per year demonstrates a greater breadth, depth, and inventiveness, the last not a strong point of the government (my posting of November 24).  Perhaps funds could be found by re-programming some of the budget for new weapons like the Joint Strike Fighter which has a current estimated procurement cost of $250B (about $100M per plane).

I was also amazed that the report didn’t mention some of the innovations in the funding, delivery, and research in global health and use them as exemplars for the US effort.  Specifically,

– the success of the Global Alliance for Vaccines and Immunization in increasing childhood immunization rates funded through the International Finance Facility for Immunizations (my posting of January 21);

– the progress in health care delivery using profit incentives (my posting of December 17)

– the potential for emerging pharmaceuticals market (my posting of October 20); and

– the Gates Foundation’s efforts to stimulate innovation through small grants with simplified applications and rapid review (for academic researchers at least, my posting of November 24).

Moreover, the report only mentions a possible role of for-profits in addressing global health; the strongest statement is on page 6:  “Through new models of collaboration, the private sector is responding to pressures and opportunities to apply technology and business acumen to enduring social problems.”  No specifics are offered on what the global health czar should do or say to involve the private sector in the government effort or what the government could do to aid their response.

I am clearly not an expert on government policy (I’d need at least a PhD and a government grant to be one), but here are several of my wild-and-crazy suggestions:

– the NIH SBIR and STTR programs could have set-asides for global health product development (my posting of November 5);

– the TRND, now funded at $24M for both rare and neglected disease therapeutic discovery, could be more generously funded and offer no-cost screening services to all PDPs;

– the current r and d tax credits could be amplified in some way for companies developing global health products, and the credits could be transferable to generate income for companies with no tax liability;

– the FDA’s much-lauded priority review voucher program could be extended to include the granting of priority review “options” to companies whose products reach pre-approval milestones;

– the FDA could grant drugs for neglected diseases some type of  exclusivity for US markets similar to that granted orphan drugs;

– recipients of Federal funding could be required to provide no cost licenses to Federal inventions to companies developing global health products (my posting of November 12); and

– the USAID could ramp up its support for innovation in diagnostics and services by streamlining and making more competitive its grants and contracting process and hold the recipients accountable for delivery of results.

Unfortunately, the IOM report and recommendations seem to me to be more of the status quo and therefore disappointing.  I am not sure if the authors intended irony by using as a preface a quote from the philosopher/poet/scientist Johann Wolfgang von Goethe:  “Knowing is not enough; we must apply.  Willing is not enough; we must do.”  But it’s ironic to me.

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