Larry W. Chang, MD, MPH


April 28, 2009

Global Health: Evolving Paradigms

Global health is in a period of significant growth and dynamism. As a field it is attracting nearly unparalleled interest and funding, along with its fair share of controversy. A partial list of evolving paradigms in global health reveals why so many minds are turning their attention to this arena.

Bottom-Up vs Top-Down Approaches

Bottom-up approaches in global health attempt to grow interventions in the communities that they will most affect. In contrast, top-down approaches believe that interventions will be most effective when coordinated and implemented through centralized agencies or individuals. Two fascinating recent books on global development strongly argue each of these divergent viewpoints, and highlight health interventions to make their points.[1,2] William Easterly argues that bottom-up approaches to health and development, such as focusing on individualized clean water strategies, are the keys to sustainable success. Jeffrey Sachs, on the other hand, believes bold, comprehensive multi-sectoral reforms guided by multinational bodies such as the United Nations are fundamental to realizing substantive change.

Evidence in the field of health for these approaches varies (and can be quite difficult to obtain). However, 1 interesting study in South Africa shows that a bottom-up approach could be an effective intervention to improve public health outcomes. This cluster-randomized study, which provided micro-financing, gender and HIV training, and community mobilization in the intervention arm, was able to reduce intimate partner violence, although it did not lower HIV incidence.[3] Micro-financing, in which small loans are given to poor individuals or groups, is a structural intervention that leverages the entrepreneurship of the poor to improve health outcomes. This type of study is a good example of the creativity and increasingly multidisciplinary nature of modern global health interventions.

"Siloed" vs Comprehensive Approaches

Echoing the top-down vs bottom-up debate is a debate over whether organizations should pursue disease-specific missions or focus more on comprehensive strengthening of healthcare systems. This controversy was perhaps most markedly demonstrated by arguments to end UNAIDS, and ensuing defenses of the agency.[4] The remarkable growth in funding for AIDS treatment programs has made them good test cases for the 1-disease vs many-diseases approach.

For example, the US President's Emergency Plan for AIDS Relief (PEPFAR) dramatically increased funding for AIDS treatment and has resulted in tremendous advances in this disease area. However, opponents have argued that the narrowness of this global health program has diverted resources and attention toward AIDS at the expense of other common and still grossly underfunded ailments such as childhood diarrheal diseases, thus creating an unsustainable system that has resulted in poorer overall health outcomes.[5] In response, some AIDS advocates argue that there are moral and pragmatic imperatives for targeted AIDS funding, and that global health funding is not a zero sum game (eg, money going toward one cause is not necessarily being taken from another). This debate is often a passionate one and will benefit from thoughtful studies that provide evidence for various approaches. It will be particularly interesting to watch the new administration's actions in this area and the perspective President Obama brings to this discussion.[6]

Funding Successes and Challenges

As mentioned above, funding for global health has increased dramatically over the past decade. This funding has come not only from initiatives such as PEPFAR, but also from the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the World Bank, the Gates Foundation, the Carter Center, and many other individuals, organizations, and national and multinational entities. This relative wealth has transformed some previously under-resourced areas of global health.

A good example of this transformation is the neglected disease of guinea worm (dracunculiasis). Guinea worm received a "game-changing" financial boon from the Carter Center, and as a result, this disease is currently on the verge of eradication.[7] New cases of guinea worm are down an estimated 99%, and eradication is on the near horizon. Such an accomplishment would make guinea worm only the second disease (after smallpox) eradicated by intentional human intervention.

However, in the midst of this relatively plush time in funding for global health, there are cautionary notes. A constant concern is whether money is being spent wisely. Justifiably, many are also worried about the sustainability of current efforts and what might happen if the world's attention shifts away from global health programs. In the midst of the current global economic crisis, concern about the shifting priorities of funding organizations is particularly acute.

Information Communications Technology

Much of the developing world is beginning to reap the benefits of improving information communications technology (ICT). A recent report published by the public-private alliance of the United Nations and Vodafone foundations discussed ways to leverage the rapid growth of mobile phone ownership to improve health outcomes, highlighting innovative programs such as a text messaging service in Thailand to improve adherence to tuberculosis medications.[8]

Additionally, much of the developing world, and Africa in particular, has been cut off from the broadband revolution and reliant on expensive satellite technology for Internet access. However, multiple undersea cables are currently snaking their way across seabeds and ocean floors to better connect Africa to the developed world. These fiberoptic connections will usher in a new era where Internet access will be more readily available and affordable, offering unprecedented opportunities to pragmatically and creatively leverage ICT to improve global health. In parallel with this growth in ICT, is an increase in ICT companies participating in global health, some of whom do not have obvious connections to healthcare. For example, the philanthropic arm of Google,, is pioneering technology-based approaches to improving disease surveillance.[9]

The Young

King Holmes has called the young people of America "Generation G" for the global generation, describing what he feels is a cultural shift in the younger generation toward global perspectives and altruistic aims.[10] Indeed, interest in global health among students and trainees appears to be increasing. A recent review noted that over one fourth of students entering medical residencies already have international health experience, and many, if not a majority, of medical students choose their residencies based to some degree on the quality of the international experiences offered.[11] If the rapid growth in global health programs and centers at American universities is any indication, global health is on the minds of students and trainees, as well as their teachers and mentors. The interest and enthusiasm of young people may be what maintains the impressive momentum being experienced in the global health field.

While this list by no means seeks to be comprehensive, it hopefully provides a sense of the energy that has developed over the past several years in global health. While the mostly positive trajectory of global health may be slowed or even temporarily reversed by world events such as the global economic crisis, the continuing globalization of the world through technology, trade, and travel, in conjunction with a world-savvy generation of young adults, promises that the field of global health will continue to attract an increasingly large, sophisticated, and receptive audience.


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