I recently gave a keynote speech at the World Innovation Summit for Health on “The Future of Aid for Health.” When I agreed to give the speech, which built on the work of a commission I chaired several years ago on Global Health 2035, I did not imagine the degree of uncertainty that the U.S. election would bring to the global health area and indeed to the global community.
We are in uncharted territory. No one can know what the attitude of the new U.S. administration will be to funding foreign assistance of any kind or to global cooperation in the health area. Certainly an “America first” strategy is not highly propitious. Global health has been an area of bipartisan cooperation with major initiatives launched during both Democratic and Republican administrations, and it has some congressional champions in both parties, so perhaps things will work out.
Rather than dwelling on political uncertainties I could not dispel, I chose to concentrate on something that should be a priority for those concerned with reducing premature death around the world, for those looking to foreign assistance as forward defense of U.S. interests, and to those primarily interested in reducing budgets — assuring the optimal allocation of aid resources.
My argument was simple. The world needs to move decisively away from the current regime, where 80 percent of health assistance is devoted to supporting national health care delivery and only 20 percent is devoted to global service delivery, toward a model where half of assistance is devoted to global goods.
In part this is because of the problematic aspects of continuing foreign assistance to national governments for health that raises issues of fungibility, sustainability and of distortion of countries’ exchange rates. Mostly, though, it is because of the overwhelming return on investments in global goods that bear on health.
I noted that:
- investments in the development of the polio vaccine had returns orders of magnitude greater than investments in more iron lungs.
- Dean Jamison, Victoria Fan and I demonstrated that the expected costs of global pandemics, like the Spanish flu after World War I, are in the same general range of those associated with climate change even though they receive almost no policy attention.
- research on tobacco and its health impacts, if fully acted on, could avert 200 million tobacco-related deaths over this century. And the set of issues around sugar and obesity are today in a place similar to where tobacco issues were 50 years ago.
- Many believe that antimicrobial resistance — the development of bacteria that are resistant to antibiotics — is the largest health risk facing humanity in coming decades and that much too little is being done to address it.
I am reasonably confident about my judgment regarding health assistance priorities, though aspects of my argument are certainly open to debate. I am certain though that foreign assistance priorities should be based on analysis, evidence and argument. The more morally important the issue, the more important is rigorous analysis and debate.
While I have often disagreed with particular judgments or been distressed that political considerations sometime carried the day, my experience in policymaking in the United States and at the international level is that reason has always had its day in court and usually carried the day.
I desperately hope this tradition continues. But when the president-elect of the United States is someone who believes that vaccines cause autism, that President Obama was born in Kenya, and that global climate change is a hoax, I am far from certain how decisions will be made going forward.
Lawrence H. Summers, the Charles W. Eliot university professor at Harvard, is a former treasury secretary and director of the National Economic Council in the White House. He writes occasional posts on Wonkblog about issues of national and international economics and policymaking.