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Stretching To Meet Global Health NeedsAT A RECENT Health Affairs conference celebrating the tenth anniversary of Narrative Matters, former Colorado Governor Richard Lamm offered a compelling description of the lives of policymakers—and, in particular, those concerned with issues of human health. Confronted with so many unmet needs, he said—clearly speaking from his own experience—leaves these lonely people constantly feeling as if they are "sleeping in a bed with a blanket that’s too short." They feel cold, uncomfortable, and even miserable as they toss and turn through long nights, struggling to make the blanket stretch further in multiple directions. And even as existing needs go unmet, new ones emerge, so continually that the misery is endless. This imagery seems especially appropriate in the context of this issue of Health Affairs, with its dual focus on financing the world’s response to HIV/AIDS and to neglected diseases of poor people and impoverished countries. In recent months, the global blanket has arguably shrunk amid a financial crisis followed by a sharp economic slowdown. New needs have emerged: among them, battling the H1N1 influenza virus. And to some degree, in the global HIV/AIDS response we are victims of our own success. More than four million people worldwide are now alive, and more or less well, because they are on antiretroviral drug therapy paid for largely by donor nations. It is increasingly hard to justify why, if these four million have won the life lottery, the other six million who need the drugs now—and the twenty-three million who will need them eventually—can’t be winners as well. The papers in the HIV/AIDS cluster underscore that global health policymakers face an urgent agenda for action. As Anil Soni and Rajat Gupta write, reports from Uganda and elsewhere indicate that some clinics are already not placing any new patients on antiretroviral therapy because funding is lacking. The World Bank and UNAIDS report that in twenty-two countries, HIV prevention and treatment programs will be "disrupted" in some way this year. The Global Fund to Fight AIDS, TB, and Malaria needs, by its own estimate, up to $3 billion more to pay for programs planned for 2010, and much more than $10 billion for its next "replenishment," or round of contributions from donors. And this is against the backdrop of a seemingly relentless rise in new HIV infections of an estimated 2.7 million per year. The longer-term financing challenges are no less dire, as Robert Hecht and colleagues discuss. Modeling they carried out for the AIDS 2031 project suggests that in the worst-case scenario, funding needed to fight the pandemic could reach $35 billion annually by 2031, up from the nearly $16 billion spent in low- and middle-income countries in 2008. But this scenario is not inevitable; the outcome can be shaped by intelligent human action. We need to make better use of what’s been shown to work in prevention and to deliver treatment far more efficiently and cost-effectively. Together with wise investments in developing new prevention and treatment tools, the world could cut the costs facing it by more than half. And that’s without what would be the indisputable "game changers": a safe and effective HIV vaccine or a treatment that eliminated the virus from the body—both critical goals that deserve major investments of their own. As our deputy editor Philip Musgrove stresses in his prologue to the HIV/AIDS papers, business as usual is simply not an option for global policymakers. We need both to stretch the existing blanket to alleviate the ravages of the pandemic, and to produce a bigger and better one. Even as we do that, however, we can’t take the immoral route of abandoning other health needs. Many have been with humankind for centuries, but for a host of reasons have now been assigned almost exclusively to the poor. Which takes us to the second cluster of papers, on so-called neglected tropical diseases, as the old, vaguely colonialist terminology has long described them. Many of these are conditions seemingly right out of the biblical Book of Job. Consider: Guinea worms, some up to three feet long and as wide as the wire of a paper clip, that cause writhing pain as they are extruded through the skin. Leprosy, the treatable bacterial disease that once ate off noses and caused unknown thousands to be consigned to leper colonies. Lymphatic filariasis, leading to grotesque elephantiasis, including of the male genitals. Trachoma, the leading cause of preventable blindness worldwide, that causes eyelashes to turn inward and scratch the cornea until the victim is sightless. Hookworm infection, the disease that, as Margaret Humphreys writes, helped give rise a century ago to the stereotype of the "stupid" U.S. southerner and even today impedes the cognitive development of tens of millions of children worldwide. Time again to stretch the blanket, as has been done successfully in recent years through a number of public-private disease-fighting partnerships among governments, nongovernmental organizations, global health agencies, and biopharmaceutical companies. Authors of Perspectives in this cluster of papers argue for an even more activist stance from U.S. public policy and measures that they think would produce more industry involvement, including research and development tax credits. Since some of these authors are from the industry itself, on one level their perspectives could be viewed as self-interested. On another, since the health of hundreds of millions might be improved, they might be also viewed as pragmatically magnanimous. Now a few words about the funding that enabled Health Affairs to produce these two thematic clusters. Here’s how we at the journal stretch our own blanket: We derive about three-quarters of our now roughly $9 million operating budget from grants and contracts from an array of foundations and corporations. The HIV/AIDS papers were produced under our current five-year grant from the Bill & Melinda Gates Foundation. Make no mistake: The foundation cares deeply about HIV and AIDS and wants global policymakers to do so as well. But we at Health Affairs also challenge anyone who cares about human health to read these papers and conclude that humankind can escape the critically important decisions that the cluster lays out. The cluster of papers and Perspectives on neglected diseases was produced under a grant from Global Health Progress, an initiative sponsored by Pharmaceutical Research and Manufacturers of America, or PhRMA. Among other objectives, the initiative seeks to donate and discount needed drugs, develop new diagnostics, research and develop new drugs, and strengthen health systems in poor and middle-income countries. The cynical will doubtless condemn Health Affairs for taking "industry" money and letting authors argue, among other things, for tax credits benefiting that industry. So be it. Life isn’t fair. And for billions of poor people around the world who will be harmed and killed by many of these conditions—neglected diseases and HIV/AIDS—life is most unfair of all.
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