International Collaboration for Global Public Health

International Collaboration and the Rise of Globalization and Global Health

Long Tradition of International Collaboration

In this lesson, we will discuss international collaboration for global public health. There is a long tradition of global collaboration in biomedicine and public health. Examples range from medical outposts in rural communities run by foreign missionaries (Good 1991) to the early infectious disease programs of the Rockefeller Foundation (Fosdick 1989) and from medical services and training programs for indigenous populations set up by colonial authorities (Marks 1997) to the Pan American Health Organization (PAHO) established by a collective of sovereign governments (Cueto 2007).

Understanding Collaboration in Global Public Health

Two complementary sets of factors provide context for understanding collaboration in global public health: first, the factors that inform globalization generally and global health specifically; second, the factors that shape ethical standards for global health programs generally and global health research specifically. Good examples of both factors are reflected in this chapter’s case studies.

The Rise of Globalization and Global Health

Collaboration in global health, as we know it today, began taking shape after World War II when new laws and institutions were established to govern relations among countries. The war’s end was marked by efforts to establish a body that would facilitate peaceful relations among member countries. In 1945, the United Nations (U.N.) was established “to save succeeding generations from the scourge of war” and to “promote social progress and better standards of life” (United Nations 1945).

Various U.N. agencies were set up to realize these goals — most prominently the World Health Organization (WHO), founded in 1948 “to act as the directing and coordinating authority on international health work” (World Health Organization 1948). Yet even as these institutions were being established, their ability to encourage international collaboration was hampered in two ways. First, most low- and middle-income countries (LMICs), which bear the bulk of today’s global disease burden, were under colonial rule for the first decade of the U.N.’s existence. Hence, these countries were unrepresented in the new organization. In later years, the principle of self-determination (i.e., the right of “peoples” to govern themselves and choose their developmental priorities) and the efforts of nationalist movements secured political independence and membership in the international community. Second, the escalation of the Cold War in the founding years of the United Nations introduced ideological rivalries into its workings. These rivalries often impeded coordinated actions involving health. For example, the 1950s and 1960s were marked by the superpowers’ competitive attempts to eradicate specific (often communicable) diseases (e.g., the United States targeted malaria while the Soviet Union focused on smallpox) (World Health Organization 2008b).

The fall of the Berlin Wall in 1989 and the collapse of the Soviet Union shortly thereafter marked the end of the Cold War. These events led more countries to adopt liberal and capitalist principles. On the one hand, the absence of a drawn-out ideological battle led to constructive deliberation and global action in public health. For example, in 2000, all members of the United Nations General Assembly declared their commitment to achieving eight objectives (the Millennium Development Goals) by 2015— half of which pertained to health. Also, significant efforts were widespread to address the HIV/AIDS epidemic through such mechanisms as the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the more recently established Global Fund to Fight AIDS, Tuberculosis, and Malaria. On the other hand, the growing influence of liberal and capitalist principles in the global environment of the 1990s affected the extent to which governments (especially those of low- and middle-income countries) were involved and able to collaborate in public health. Generally associated with neoliberal principles, governments’ public policy role has reduced. In the following we will explore some arguments about the governments’ role in global health.

The Role of Governments and Guiding Principles

The Role of Governments Overview

As mentioned, as a result of adopting neoliberal principles, governments’ public policy role has been reduced. One may wonder, who should be “in charge” of public and global health? Can non-governmental organizations (NGOs) like the Gate Foundation play the primary role? Can communities or individuals play the primary role? Can scientists and health care professionals (HCPs) be the ones “in charge”? All the above-mentioned players are important, at the same time, but for a number of reasons, it is important for us to recognize the special duty of governments in global health. Individuals and non-governmental organizations cannot take the governments' place in global health. Let’s discuss the arguments favoring governments’ heavy involvement in global health.

The Collective Health Argument

The first argument is that even with their reduced profile in national health systems, governments continue to bear primary responsibility for population health. Individual citizens can take responsibility for personal health, but certain health benefits (e.g., clean air, safe roads, potable water) can only be secured through organized, collective efforts generally involving the exercise of public authority.

As such, in the interest of global health, a country’s public health institutions should be robust - equipped to protect population health, reduce disease, and administer programs that save money and lives (Frieden and Koplan 2010). This case needs to be made for low- and middle-income countries (LMICs) especially, otherwise, neoliberal principles guiding globalization may further weaken emergent, poorly governed, or underfunded health systems.

The Coordination Argument

The second argument favoring active engagement of governments in national health systems is their longstanding ability to enter binding legal agreements with each other and other stakeholders. A government’s continued involvement is indispensable to shaping broad-based and sustainable solutions to the challenges of global public health. The broad scope of a government’s responsibilities (and authority associated with performing these responsibilities) enable it to coordinate public health efforts involving public, private, and civic institutions.

The Accountability Argument

The third argument supporting government engagement in global public health is based on democratic theory. Put simply, a country’s citizens can hold their governments accountable for failure to meet health commitments. In contrast to governments that are accountable to their entire populations, nongovernmental organizations stakeholders in global health answer to narrower constituencies (i.e., corporations to their stockholders, non-governmental organizations to their funders, and foreign health organizations to their home governments). Because public health is of general concern, a level of accountability is essential for the entire health system to function properly. The involvement of governments is, therefore, critical both to ensure the widest participation possible in formulating health policies and to sustain such policies despite shifting interests or diminishing profits of partners.

Guiding Principles: Human Rights (Part 1 of 2)

Human rights constitute a compelling ethical framework for global collaboration. Based on an ethical vision discernable in early Greco-Roman writings, these principles matured in the work of such social contract theorists as Thomas Hobbes, Jean-Jacques Rousseau, and John Locke. The modern view of human rights presupposes that all persons, simply for being human, have inherent dignity.

Guiding Principles: Human Rights (Part 2 of 2)

This dignity constitutes the normative foundation for people having certain inalienable rights. The terms inherent and inalienable mean such dignity and rights belong to people naturally and are, certainly, not bestowed by a political authority. According to human rights theory, a political authority has no ethical basis for arbitrarily depriving individuals of these rights (not having granted such rights in the first place). But because some needs are common and not all goals can be met individually, people choose to surrender certain rights to a public authority established to ensure these ends are realized. Feature ethical issues that are illuminated but sometimes complicated by the human rights framework.

Guiding Principles: Social Determinants of Health (Part 1 of 3)

You may remember in the last lesson, we discussed the wealth level of a country or region does not necessarily correspond with its population’s health condition or longevity. Indeed, social justice theory tells us that equity is a more important factor to public health than many have recognized. This view is captured by the social determinants of health (SDH) framework. Social determinants of health is based on social justice. The guiding principle of social determinants of health is equity.

Guiding Principles: Social Determinants of Health (Part 2 of 3)

As with public health, social determinants of health emphasizes population health and prevention. However, social determinants of health go beyond traditional public health approaches because, in addition to deploying interventions aimed at reducing population mortality and morbidity, social determinants of health targets “the social context and conditions in which people live” (Blas et al. 2011). These contextual factors and conditions that affect health outcomes in a given population are called social determinants of health. These include such factors as housing, education, transportation, employment, insurance coverage, and access to health care. For example, women’s literacy rate is associated with the decrease of infant mortality. This is a good example to show that education is associated with health.

Guiding Principles: Social Determinants of Health (Part 3 of 3)

The social determinants of health framework stands on 40 years of research demonstrating that clinical care alone cannot improve health outcomes unless social factors are addressed. Statistical associations between social disadvantage and poor health became increasingly clear, impelling the inference that closing the gap in health status between populations required corresponding improvements in the social contexts of disadvantaged populations. Thus, equity is the primary principle to consider. This applies in domestic as well as global context.

1. Case Studies

2. Case 3: Drug Trials in Developing Countries

We will conclude this lesson by investigating two case studies, in them many ideas and principles we discussed in the class throughout the semester are involved. In this case study, we will discuss the outsourcing of clinical trials and the ethical complications of such activities. Clinical trials outsourced to India offer, in addition to business opportunities for clinical research management, the prospect of health infrastructure development and collaborative research. Since 2005, drug trials in India have increased as foreign drug companies eagerly take advantage of the favorable research environment (British Broadcasting Corporation [BBC] News 2006; Russia Today 2010; Overdorf 2011; John 2012). These advantages include highly qualified English-speaking doctors, a large and diverse population, and lower costs and relative freedom from burdensome regulations for privately funded research trials (World Health Organization (WHO) 2008). As a result, clinical research organizations working on behalf of pharmaceutical companies frequently approach doctors in private or government practice to recruit patients for drug trials, often offering attractive payouts per recruit and promising coauthorship and publication credits as incentives.

3. Case 3: Questions (Part 1 of 2)

Please read Case 3 in the reading carefully. If you haven’t read it yet, select the link “Drug Trials in Developing Countries.” Now, consider the following questions using the knowledge we learnt in this course throughout the semester.

First, who are the stakeholders in this case, what is at stake for each of them, and what values does each bring to the situation?

Second, what are the risks and benefits of enrolling impoverished, uneducated patients living in developing countries in clinical drug trials? What are the barriers to obtaining true informed consent from these patients, and what can be done to overcome these barriers?

Three, what are the ethical implications of tying a researcher’s compensation to the number of subjects enrolled? Should this practice be permitted?

4. Case 3: Questions (Part 2 of 2)

Four, are multinational pharmaceutical companies that benefit from cost-effective drug trials in developing countries obligated to improve the lives of people living in those countries?

Five, who should be held responsible for adverse events due to a drug trial conducted by a multinational company in a country where there is limited health insurance, no social security, and poor enforcement of regulations? What international or grassroots efforts might help ensure accountability for adverse events? You may find out that the idea of informed consent is involved here, and the situation is further complicated by the fact that a subject recruited for a drug trial described here may misunderstand the drug trial, which is health research as health care. As you may recall from previous lessons, research trials do not benefit the subject directly. Read the case closely again to see if you can identify any other issues we discussed in the class.

5. Case 4: Ethical Issues in Responding to International Medication Stock-Outs

Tuberculosis (TB) is a ubiquitous, slow-growing bacteria that kills 1.4 million people annually. The control of tuberculosis requires the availability of medication for months of treatment. An intact and predictable supply chain of medicine is essential. One barrier to tuberculosis control in low-resource countries, as well as in the United States, is intermittent unavailability of tuberculosis medication, an occurrence known as a stock-out. Let’s explore the case of stock-out and especially its influence in low-resource countries.

6. Case 4: Questions

Please read Case 4 in the reading carefully. If you haven’t read it yet, select the link “Ethical Issues in Responding to International Medication Stock-Outs.” Now, consider the following questions.

First, what are some risks and benefits of your involvement with the stock-out conference and contact with the media? What ethical concepts should inform your decision? Would your decision change if your colleagues or sponsoring organization urged you to say nothing?

Second, does it matter ethically if the stock-out pertained to antimalarial medications; that is, a medication outside your research area (TB medication)? Why or why not?

Third, knowing that you have ready access to anti-tuberculosis medication for research participants, should you broaden the inclusion criteria to allow more patients to receive guaranteed treatment? Why or why not?

Fourth, do you have an ethical duty to report the stock-out if local health officers will not do so? As you may see here, Social Determinants of Health is relevant as public policy, supply chain and other factors are detrimental to public health. Try to identify what other ideas or concepts we studied in this course is relevant here. We will see more case studies in our final assignment.

7. Wrap-Up

In this lesson, we reviewed the long tradition of international collaboration in public health, the two sets of factors underlie international health care and the arguments for governments’ role in international health care. We then visited the two guiding principles in global public health: Human Rights and Social Determinants of Health. In the end, we looked at two case studies of clinical drug trial and stock-out.