These are some notes on global public health as part of a larger project. The final results will likely not be published here (but I will try to link to them from here when they’re done), but this is the most convenient place for notes.
What exactly has happened in global health and what’s in store for the future?
New question as of December 2016. HT Vipul Naik.
Global health as a success story
Part of my interest in global health comes from the view that global health is seen as a success story in philanthropy. To use the language of cause prioritization, global health is a successful and “safe” cause. This section collects information on to what extent this is true.
From “Philanthropy’s success stories” on the GiveWell blog:
Philanthropy has some extremely impressive accomplishments. Among other things, foundations have been (in my view) reasonably credited for leading the way on building schools and hospitals in the rural Southern U.S., piloting the shoulder line on U.S. roads, successfully advocating for federal legislation in areas including health care for the homeless and nuclear deproliferation, the research that led to the Green Revolution, and many major advances in medical research (including the first combination drug therapy for AIDS and the development of the pap smear). There are many other projects that sound like they may have been impactful, but which the Casebook doesn’t give enough context on for me to have a strong view.
The most impressive achievements (in my view) are concentrated in the sectors of research (particularly medical research) and health care.
Global health as a “boring” cause
This section considers whether global health has become successful to the point where it is considered “boring”.
One evidence is the existence of donor fatigue.
James Grant also often refers to a “silent emergency” (e.g. here).
When and how did global health become a movement?
Some relevant Quora questions I’ve asked that might spring up useful information:
- When did global health charities start to emerge?
- How did global health become “commodified” (through a movement advocating donations)?
- How did global public health become so popular?
Initial hypotheses (after reading the Wikipedia section):
- The push toward global health was crisis-driven, in the sense that outbreaks somewhat unrelated to the rest of global health were responsible for kick-starting interest in the rest of the area. The analogy here is that things like natural disasters influence people to donate more money.1
- Somehow organizations like the WHO formed and convinced people to donate more money.
It’s important to distinguish between government interest and public interest in global health. It seems that government interest came first, followed by public interest. There is also “philanthropic interest” from individuals with a lot of money.
This page provides an outline of how government bodies formed, but not a lot of underlying motivation.
‘The World Health Organization and the Transition From “International” to “Global” Public Health’:
“International health” was already a term of considerable currency in the late 19th and early 20th century, when it referred primarily to a focus on the control of epidemics across the boundaries between nations (i.e., “international”). […] “Global health,” in general, implies consideration of the health needs of the people of the whole planet above the concerns of particular nations. The term “global” is also associated with the growing importance of actors beyond governmental or intergovernmental organizations and agencies—for example, the media, internationally influential foundations, nongovernmental organizations, and transnational corporations.
On potential motivations for countries like the US:
In 1955, Candau was charged with overseeing WHO’s campaign of malaria eradication, approved that year by the World Health Assembly. The ambitious goal of malaria eradication had been conceived and promoted in the context of great enthusiasm and optimism about the ability of widespread DDT spraying to kill mosquitoes. As Randall Packard has argued, the United States and its allies believed that global malaria eradication would usher in economic growth and create overseas markets for US technology and manufactured goods. It would build support for local governments and their US supporters and help win “hearts and minds” in the battle against Communism. Mirroring then-current development theories, the campaign promoted technologies brought in from outside and made no attempt to enlist the participation of local populations in planning or implementation. This model of development assistance fit neatly into US Cold War efforts to promote modernization with limited social reform.
Interesting note on WHO’s funding:
Another symptom of WHO’s problems in the late 1980s was the growth of “extrabudgetary” funding. As Gill Walt of the London School of Hygiene and Tropical Medicine noted, there was a crucial shift from predominant reliance on WHO’s “regular budget”—drawn from member states’ contributions on the basis of population size and gross national product—to greatly increased dependence on extrabudgetary funding coming from donations by multilateral agencies or “donor” nations. By the period 1986–1987, extrabudgetary funds of $437 million had almost caught up with the regular budget of $543 million. By the beginning of the 1990s, extra-budgetary funding had overtaken the regular budget by $21 million, contributing 54% of WHO’s overall budget.
Best-selling books and news magazines were full of stories about Ebola and West Nile virus, resurgent tuberculosis, and the threat of bioterrorism. The message was clear: there was a palpable global disease threat.
This Harvard course spends quite a bit of time on the role of missionaries. I’m not sure if it’s worth looking into.
From this chapter:
501(c)(3) and 501(c)(4) came along in 1954.
On the role of legislation:
It is no accident that the impressive proliferation of registered tax-exempt nonprofits in the United States from fewer than 13,000 in 1940 to more than 1.5 million at the end of the century coincided with legislative and regulatory policies that defined and systematically favored nonprofits and those who contributed to their support. Nor is it a coincidence that ownership of hospitals shifted from predominantly public and proprietary in 1930 to nonprofit by the 1960s to proprietary by the century’s end with changes in tax and health policy.
Soon after the US was founded, US federal and state governments tried to stop charities and corporations for fear of losing power to them. Also:
At the end of the eighteenth century, indigenous philanthropy and voluntarism were still embryonic. Most philanthropy was devoted to public institutions—municipal governments, schools and colleges, and religious congregations (most of which were tax-supported). Voluntary participation in organizations was restricted to fraternal associations, local social clubs, a handful of medical societies, and the secretive political societies that would eventually form the basis for political parties. The absence of a legal infrastructure to enforce charitable trusts, as well as broad hostility to ward corporations, discouraged private initiatives professing to benefit the public.
By the 1830s, recognizably modern forms of fund-raising had begun to emerge, as institutions actively solicited contributions and bequests from local and national constituencies and such public figures as the evangelist Lyman Beecher (1775–1862) toured eastern cities raising funds for schools and colleges in the newly settled western states. Increasingly well-informed about current events, Americans were quick to respond to disasters and liberation movements with generous “subscriptions.” An 1845 survey of Boston charity gives a good idea of the range of organizations and causes to which citizens donated money: in addition to generous support for major institutions such as schools, colleges, libraries, and hospitals, Bostonians gave money to build churches and seminaries; to sustain domestic and foreign missionary societies; to erect public monuments; to relieve the suffering of fire victims in Mobile, Alabama, in Fall River and Pittsfield, Massachusetts, and in Hamburg, Germany; for the abolition of slavery; and for the “diffusing of information among immigrants” (Eliot 1845).
On the influence of slavery to other domains (pg 40):
The emergence of slavery as the central issue in American politics helped to nationalize public life, shifting power to national associations, national political organizations, and publications that commanded national audiences. This helped other reform issues to command national attention and to elicit action by the federal government. Among the more notable of these was the movement for more humane treatment of the insane, led by New Englander Dorothea Dix (1802–1887; Marshall 1937; Wilson 1975; Snyder 1975).
From “The Great Dispensary in the Sky: Missionary Medicine” by Vaughan:
Throughout most of the colonial period and throughout most of Africa, Christian missions of one sort or another provided vastly more medical care for African communities than did colonial states. It was not until the 1930s, and in many places until the 1950s and 1960s, that secular medicine reached rural communities in any form other than the ‘great campaigns’ against epidemic disease which I have described in the last chapter. It was missionaries who in East and Central African from the late nineteenth century pioneered the setting up of rural hospitals and rural clinics, who trained African medical personnel, who introduced ‘western’ midwifery and childcare practices, and who dealt with chronic and endemic disease. […]
If it is true that, for most Africans before the Second World War, any prolonged encounter with biomedicine came in the form of an experience of mission medicine, it is also true that for church-going Britons of this period one of the most popular representations of Africa and of Africans came via the accounts in missionary journals of the woes of the ‘sick continent’, and the trials, tribulations, and triumphs of heroic medical missionaries.
From A Mighty Purpose (a book about James Grant) by Adam Fifield:
- pg 52–53 (and subsequent pages, which give details): talks about the importance of focusing on the most important parts of a problem instead of trying to do everything. (Also that in the case of global health, these things could already be solved with existing technology instead of new technology.) Also how there was no “political will” to solve the problem of children’s health despite all the technology and capability being there. (This became GOBI.)
From the opening of Portfolios of the Poor:
Public awareness of global inequality has been heightened by outraged citizens’ groups, journalists, politicians, international organizations, and pop stars. Newspapers report regularly on trends in worldwide poverty rates and on global campaigns aimed at halving those rates. A daily income of less than two dollars per person has become a widely recognized benchmark for defining the world’s poor.
What does the success of global health tell us about other movements?
Specifically, I’m interested in anti-aging.
Some parts of early history of philanthropy are less relevant. For instance, the way in which nonprofits became codified in US law was important the first time around (i.e. for currently-existing philanthropy), but is less relevant for newer developments like anti-aging, since these laws are already in place.
- Which diseases did global health focus on and why?
- What does the global fight against disease look like? What does it look like generally and for each disease?
- How do diseases vary based on various parameters (e.g. microbe type, transmission method, contagiousness, lethality)?
- What are the “crucial considerations” in global health? In other words, what are those things that, if we don’t know the answers to them or of their existence, could imply that we are doing global health “all wrong”? Plausible examples: “Malaria in the US was eradicated through DDT and swamp drainage. Why then do we keep hearing about bednets? Here the crucial consideration is the history of eradication of a disease; how do we know we aren’t doing things really wrong if we don’t know how they successfully worked in the past?” “Some interventions in global health have an effect on population growth. How can we have an opinion on those interventions if we don’t have an opinion on population growth?” Sort of along the same lines is “Are GiveWell Top Charities Too Speculative?”
This quote in particular seems to provide evidence for this position:
The palpable tension, between managing episodic, acute, frightening, deadly and dramatic pandemics and the arduous path to ameliorating the chronic maladies and social conditions that kill many more people but in far less dramatic ways, has always shaped the agenda of the World Health Organization. Yet the historical record amply demonstrates how international efforts to control infectious disease, beginning in the mid-nineteenth century and extending to the present, have dominated global health policies, regulations, agendas and budgets, often at the expense of addressing more chronic health and environmental concerns. 5,6 How these challenges have affected present circumstances and created demands for an entirely new conception and execution of 21st century global health efforts will be the focus of this paper.