Addressing the UN General Assembly Special Session on HIV/AIDS in June 2001, UN Secretary-General Kofi Annan declared, “For there to be any hope of success in the fight against HIV/AIDS, the world must join together in a great global alliance.” Earlier, in September 1995, US President Bill Clinton’s Committee on International Science, Engineering, and Technology designated infectious disease as a threat to national security. By the turn of the century it seemed possible that years of neglecting the surging HIV pandemic and other lethal infectious diseases might be reversed. Large-scale initiatives from multilateral agencies, deep-pocketed foundations, and the US government infused hope into an area that has historically been underfunded and overshadowed.

But today the optimism is dangerously close to slipping away. Now that real money is on the table, the entire global health effort seems to be descending into bureaucratic and economic quicksand similar to that which has trapped other international development programs for decades. Programs are competing with each other, and key donors are shying away from the multilateral Global Fund in favor of bilateral programs. Implementation of the World Health Organization’s (WHO) program to put three million people on life-saving HIV/AIDS treatment by 2005 is proving staggeringly difficult and demoralizing for much of the WHO staff. US President George W. Bush’s Emergency Plan for AIDS Relief (PEPFAR) has become so highly politicized that its achievements are obscured by controversy. Similarly, the Global Fund has become a lightning rod for debate regarding nearly every aspect of public health funding and implementation. Tuberculosis experts, having long struggled to implement so-called Directly Observed Therapy using very cheap drugs for only months per patient, now shake their heads and say, “I told you so: the drugs are not the issue; it is the infrastructure.”

The approaches and effectiveness of the major players in the global health arena must be reexamined. As these efforts move forward, new avenues of communication and cooperation must be established to mitigate current obstacles while capitalizing on new opportunities.

The Problem

It will never be possible to create a disease-free world or to eliminate the potential for the emergence of new deadly microbes. Policies aimed at such goals will always fail. For example, scientists now understand that the Ebola virus is an ancient organism that has for centuries infected isolated individuals in central Africa. That cannot be stopped. But scientists also understand that Ebola epidemics have occurred when individuals infected with the virus entered desperately poor hospitals, where dearths of sterilizing equipment and basic protective gear conspired to offer the virus spectacular opportunities for transmission. Inadequately supplied hospitals act as disease amplifiers, giving the isolated infection opportunity to become a full-blown epidemic.

With very few exceptions, the disease amplifiers in the world today are manmade and therefore humanly controllable. Within health systems, they include lack of infection control in hospitals, reuse of syringes, and unscreened blood supplies. More broadly, exotic animal markets, unclean urban water supplies, lack of proper sewage systems, and unstable, conflict-ridden environments provide excellent breeding grounds for infectious diseases to spread and wreak havoc on already vulnerable populations. Yet it would be shortsighted to think of infectious disease as a problem for solely the poor and powerless. These diseases do not discriminate; they are undeterred by state borders, party affiliation, or socioeconomic status. With air travel and human migration on the rise, so too is the possibility that deadly microbes can and will circumnavigate the globe with speed and precision.

Global health investment is therefore an issue not only for do-gooders. A self-interest component to the global health debate has clearly emerged—thankfully, because purely altruistic efforts often fall short of international support and sustainability. The interconnected nature of the world makes ignorance of issues such as deadly infectious diseases not only immoral, but self-destructive. This argument is neither new nor unique. However, for much of the last century, the health community scrambled to get access to small amounts of funding to prevent and treat malaria, tuberculosis, HIV/AIDS, vaccine-preventable illnesses, and a host of other killers, even as leaders in the wealthy world declared microbial threats were, from their standpoint, conquered. It has long been argued that detailed, multilateral global surveillance efforts are imperative to stem the global spread of deadly diseases. But when epidemics of Ebola, nipah, hantavirus, and other deadly diseases broke out in the early and middle 1990s, WHO and the US Centers for Disease Control (CDC) had to go begging for funds for scientists’ plane tickets and laboratory supplies. Disease surveillance was haphazard at best.

It would be impossible to reverse the rising death toll of HIV/AIDS without attacking its partner diseases, most significantly tuberculosis. HIV-weakened immune systems make individuals more susceptible to tuberculosis. WHO estimated in 2004 that tuberculosis accounted for approximately 13 percent of AIDS deaths worldwide. “The world has made defeating AIDS a top priority. This is a blessing. But tuberculosis remains ignored,” warned former South African President Nelson Mandela at the 2004 Bangkok AIDS meeting. The window of opportunity to control tuberculosis is closing as drug-resistant forms of the bacterium emerge all over the world. We now have drugs that can cure non-resistant forms of tuberculosis infection for as little as US$10 per patient in developing countries. Yet, Mandela noted, a very simple and inexpensive strategy for control and cure of tuberculosis has been failing in much of the world, pilloried by funding shortfalls and desperately inadequate health infrastructures.

Lack of funding and infrastructure has, in turn, created human resource shortfalls that have nearly crippled the capabilities of institutions endeavoring to create sustainable programs that can be administered with local participation and ownership. A “brain drain”—or, better put, “talent drain”—is removing health professionals from already understaffed programs and countries. A 2004 report from the Joint Learning Initiative, a research group of more than 100 global health scholars and practitioners, estimated that Africa needs approximately one million more health care workers to deliver adequate care to its people. The report draws attention to the massive flow of experienced health care workers in developing countries who are leaving their homelands to find better paying jobs in the developed world—where health care workers are also in short supply.