What 2006 Means for 2007 in Global Health

Five big stories from 2006, and perhaps one that didn't get many headlines, stand out as harbingers of what's ahead in 2007.

1. Playing Chicken with Avian Influenza: The projected death counts keep creeping up -- most recently hitting approximately 62 million for an all-out flu pandemic, according to Chris Murray and others in the Lancet (free registration required). Alongside the scary estimates of potential damage have been scary press reports of outbreaks of bird-to-person transmission, and scientists' persistent (and scary) warnings about the inevitability of eventual human-to-human spread. So far, international efforts to prepare have been anemic and markedly lacking in a global vision. Witness the U.S. State Department's proud announcement on December 11 that money for pandemic flu assistance had reached a grand total of $434 million -- a figure that's less than one-tenth of the overall Congressional appropriation for pandemic flu, which itself is considered far too little. Given the overwhelming odds that the flu pandemic will start and pick up momentum in low-income countries in Asia and Africa, if ever there were an opportunity for enlightened self-interest to come into play, this is it. One item to watch in 2007: Will an understanding of the global nature of infectious disease be reflected in the work of the U.S. Biomedical Advanced Research and Development Agency, recently established as a vehicle for $1 billion of R&D funding for bioterrorism countermeasures and pandemic flu vaccines, diagnostics and therapeutics?
2. XDR-TB: And speaking of scary, extremely drug resistant tuberculosis debuted on the world stage this year, upstaging its now tame-sounding predecessor, multi-drug resistant TB. XDR-TB is essentially untreatable, with patients failing all front-line drugs and two or more of the six classes of second-line drugs; it now accounts for something like 2 percent of all multi-drug resistant cases. The story for 2007 inevitably will be about its spread and -- we can hope -- also about vigorous and adequately funded efforts to slow the development of resistance to anti-TB drugs, which results from incorrect drug prescribing practices, non-adherence by patients, poor quality drugs, and erratic drug supply. With drug resistance a sentinel indicator of failing health systems and supply chains -- and a cause of significant concern not only for TB but also for AIDS and malaria -- all the new monies for drugs should be geared, in part, to specific efforts to delay as long as possible the onset of resistance.
3. Comment dire "more money for drugs" en francais? UNITAID! And for vaccines, in English? IFFIm! And in the universal language of advertising: (RED)!: With the hoopla of innumerable launches and the star power of everyone from Bill Clinton to Bono to the Pope (not to mention Gordon Brown and Jacques Chirac), three "innovative financing mechanisms" rolled out in 2006. UNITAID, promoted by the French government, turns levies on airline tickets into purchases of drugs to treat AIDS and, in the future, malaria and TB. The The International Financing Facility for Immunization, or IFFIm, championed by the Brits and implemented by the GAVI Fund, uses future aid spending as the collateral for capital market finance today, to be spent on a combination of vaccines and other inputs to strengthen immunization programs. The (PRODUCT) RED Campaign lets socially-minded consumers (or those who like the color red) contribute to a cause while buying a lot of cool red stuff (see Gap, AmEx, Apple and others for details). All the new funding vehicles promise a bump-up in the amount of money available for key health inputs in developing countries, and the benefit of predictable funding. And all are hitched firmly to an emerging concept of consumption with a conscience (sort of): Can it be that the more we get, the more we give?
4. Gates Foundation to Warren Buffett: Supersize Me: The World's Second Richest Man Warren Buffett chose to share his enormous wealth through annual donations to the foundation of World's Richest Man, livening up a news cycle or two in late June. After a ramp-up to accommodate the new grant-making, this will effectively double the Foundation’s annual outlays, which at $1 billion-plus already dwarf many other international sources of support for global health programs. More changes are ahead, with the announcement that Bill Gates will devote himself full-time to the Foundation starting in July 2008, and a portfolio that is expanding into agriculture, microfinance and other financial services for poor people, and limited ventures into water and sanitation as well as education. While 2007 will no doubt bring a spate of new Foundation-supported initiatives, the real story may be in how other organizations react to the Gates Foundation's dominant position in philanthropy: To what extent will the Foundation's interests drive the global health agenda? In global health, who's going to play the role that Apple's Steve Jobs has played in the personal computer world? [Full disclosure: Much of the health policy work at CGD is supported by a grant from the Gates Foundation.]
5. Who's Who at WHO: With Director-General J.W. Lee's death at the time of the World Health Assembly in May, WHO faced an unanticipated leadership transition in 2006. The politicking for D-G candidates geared up quickly, featuring weekly nudges by the Lancet in support of Mexico's Minister of Health, Julio Frenk, and a high-profile Africa-China Summit on Strategic Cooperation only days before the election of the China-supported Margaret Chan. The incoming D-G takes up her post in January, and will start to shape the work program and high-level management composition. By the time of the next World Health Assembly mid-year, we should be able to see a clear direction for her tenure, and observe the extent to which she's able to define a productive working relationship with the many other new players in the global health zone: Joy Phumaphi, now moving from the WHO to the World Bank as Senior Vice President for Human Development; Tadataka (Tachi) Yamada, who joined the Bill & Melinda Gates Foundation as President of the Global Health Program in February; and the to-be-selected director of the Global Fund to Fight AIDS, TB and Malaria.

And perhaps the most under-reported story of the year, with the greatest consequences over the long haul, is about the financial implications of the impressive scale-up in AIDS treatment. With the significant funding of the Global Fund, the U.S. President's Emergency Plan for AIDS Relief, the World Bank's Treatment Acceleration Program and other programs, augmented by large bilateral and private efforts, the number of people on antiretroviral therapy has increased at a rapid clip (see the graph below, courtesy of UNAIDS). In Africa, virtually all of these patients receive drugs that are purchased using aid monies. So we are in the unprecedented situation of having large numbers of identifiable individuals in poor countries whose lives depend directly, and for years, on continued funding from donor governments and charities -- many of whom mobilized resources initially on the basis of a sense of "emergency." The actions to establish UNITAID and (RED) are partial responses to a growing (if not yet completely articulated) recognition of this situation, but as more and more people start on treatment -- and with about 3 million people in Africa acquiring the infection each year -- this is a story that can only get bigger.Did I miss something? What do you think are the top global health stories for 2006 - or for 2007?