Global health in times of austerity

In my last entry I tried to make the case that Office of Global Health Diplomacy could improve American delivery of health aid.  However, in my argument, I failed to make the case as to why, especially in times of austerity, the US should continue to invest in global health at all.

Personally, I have never had a hard time justifying global health spending.  At a gut level, it has always seemed to me that healthcare is not a commodity but a right and that this is no less true in Haiti or Angola than it is in Boston or New York.  But a gut feeling isn’t an argument.  And when domestic social spending is on the chopping block, it is important to advocate for this agenda in concrete terms.

Discussing global health begins with an ethical point: (though I will spare you the trolley car arguments that ethicists and philosophers like to wax on about)

Spending on global health is more than just a good thing to do, it’s the fair thing to do

In one of his essays, Paul Farmer (founder of Partners in Health) writes that “its less about assisting the distant needy and more about remaking a broken world.”  Though Farmer is specifically referring to universities and their obligation to the poor populations they study, his words apply equally well to governments.


Poverty and inequality are not accidents of history.  In the US and throughout the developed world, our wealth, security and even medical knowledge is often due to sacrifices that were made (often involuntarily) by the poor within and beyond our borders.

We need not look back to the time of slavery to see evidence of this (though that might be a perfectly reasonable place to begin).  As recently as the mid-1990s there were ongoing drug trials in the developing world in which HIV positive expectant mothers were randomly selected to not receive any treatment at all, despite the fact that there existed proven treatments to reduce the rate mother-to-child transmission of HIV.  Effectively, the development of drugs to be used by Americans and Europeans, while financed by Western governments, was paid for in African and Asian lives.

It is only fair that those who bear the heaviest cost of drug development also benefit from what it yields. And this argument holds true not just for the HIV positive trial participant but also for the miner who digs for products used in our CT scanners and for the laborer who assembles the parts.

Arguments of justice, however, inexplicably can get lost in political noise that favors arguments of efficiency and popularity.  Yet even by these metrics, global health fares well.

Global health spending is cost-effective spending

This is not to say these interventions are perfect or even easy, but many global health programs funded by the US treat and save lives for mere dollars.  The Disability Adjusted Life Year (DALY) is a common metric used for determining cost-effectiveness. The cost of averting one DALY essentially reflect the cost of preserving one year of healthy life.  This number can be calculated for various treatments in order to compare cost effectiveness with which an intervention preserves health.

Coronary artery bypass surgery (CABG), a widely accepted procedure for severe heart disease, costs more than $25,000 per DALY averted. In comparison, immunizing children with standard vaccines costs 2-20$ per DALY averted.  Even global health interventions thought to be expensive, such as treatment of HIV (treatment costs approximately $350-500 per DALY averted), compare favorably to procedures such as CABG which are commonly done in the US.

While I do not believe that cost-efficiency should be the driving argument for health spending – and I certainly don’t believe we should stop funding CABG surgery in the US – these numbers demonstrate a simple point: global health interventions are cheap.  As we look to make our spending more efficient, reducing what we spend on HIV or on maternal health would serve only to cut some of the most efficient spending that the US engages in.

Finally, global health is popular

In the intransigent political climate that seems to have taken over, little seems capable of drawing bipartisan support.  Funding healthcare in the developing world may be an exception. Former Senate Majority Leader Bill Frist (a Republican) wrote several months ago about “why deficit hawks should lay off global health initiatives.”  While Frist’s reasoning differs in part from mine, he justifies global health spending for reasons that would appeal to both Democrats and Republicans, noting that global health would improve national security and protect American families.

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Source: Kaiser Family Fund:  2012 Survey of American on the US Role in Global Health. May 2012

Despite having advocates on both sides of the aisle, global health has become very vulnerable to funding cuts.  On the surface, this appears to be consistent with the views of over half of the Americans who, according to a recent Kaiser Family Fund poll, think that the US spends too much on foreign aid.  A closer look at the poll, however, shows that this number is rooted in an overwhelming misperception on how much the US spends on foreign aid.  Further, it applies more generally to non-health-care forms of aid.  The same survey (shown above) found that 66% of Americans think that the US spends too little or about the right amount of money to improve health in developing countries. Moreover, this opinion was shared by a majority of people in both parties.

Global health spending shouldn’t hinge on popularity.  After all, history has taught American’s over and over that what is right isn’t always popular.  This time, however, it just might be so.

While the US contemplates what cuts must be made in this austere environment, it will be tempting to point to global health as charity spending to be reserved for times of plenty.  This is wrong. Funding a clinic in Uganda or providing ARVs in Cambodia is fundamental to what American’s believe is the right thing to do and a small step towards remaking a world broken by a repeated assault of injustice. The contribution that the US government makes towards treating diseases in other countries is more than just symbolic. It saves real lives and it moves us closer to the just world that we all imagine.


One comment

  1. Kewal Saluja

    Your arguments are very strong – I may be biased in saying what I am going to say (being your dad) – but I can’t help in saying that I loved the very thoughtful reasoning.

    In your second reasoning, when you argue about cost, some will disagree with you as they assign different values to the life for different people in different countiries (rich and western countries v/s poor and third world countries) but I am sure they will have difficulty in saying so and hence will use some different argument.

    You indicated Frist supported global health using a different reasoning my recollection is Frist has an MD degree – and I am glad he is supportive.

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