For HIV, the growing demographic “youth bulge” will also result in lost investments if funds are not sustained. As of now, 43 percent of sub-Saharan Africa’s population is below the age of fourteen. While millions of children in this region have been born HIV-free thanks to anti-HIV initiatives, the epidemic will return in full force once the youthful population reaches adolescence if HIV-prevention programs are not adequately sustained, given empirically established patterns of somewhat older men transmitting HIV to younger women.
Absent the U.S. leadership to date that has spurred significant burden sharing, the threat of infectious diseases will only grow and further weigh down health systems and economies. While the United States has been at the vanguard against global infectious diseases through PEPFAR, PMI, the USAID TB program and financing organizations like the Global Fund, U.S. funding has plateaued in recent years. From 2006 to 2010, the United States’ global health funding practically doubled from $5.3 billion to $10 billion. However, since 2010 the amount contributed by the United States for global health funding has remained stagnant. While the House and Senate appropriations committees in July and September of 2017 rebuffed Trump administration proposals to cut contributions to the Global Fund and PEPFAR each by some 17–18 percent, even steady funding is not to be taken for granted.
While we have made admirable progress in reducing three massive killers over some fifteen years, investments are still much needed until epidemiological control is established. Given marked progress and strategic programs, ending these diseases as epidemics is within reach. Indeed, by addressing funding gaps, targeting hard-to-reach populations stricken with disease and ramping up prevention, progress could be accelerated. U.S. leadership could encourage even more domestic financing in countries with a high disease burden. Taking a page from the early George W. Bush administration, international financial institutions could provide targeted debt relief. That way, relieved countries could free up resources to address the epidemics. Innovative private finance should be increased.
Conversely, a retreat in investment would devalue the huge outlays to date, and produce human and economic costs that will plague the United States and world down the road. Let’s not stop a Marshall Plan for global health halfway to the finish line.
INVESTING IN the health of developing nations has been shown to encourage economic growth through reducing long-term health expenditures, increasing education and improving population productivity. Illness and poverty are often intertwined, as those who are burdened with disease face barriers to sustaining a job, and those who are impoverished lack the resources or access to services to support their health. Poor health and disease have global economic implications: in 2003, international business felt the repercussions for the severe acute respiratory syndrome (SARS) epidemic, which is estimated to have cost the world more than $30 billion in just a few months. Furthermore, the 2009 H1N1 outbreak cost Mexico’s economy $2.2 billion because of the economic disruption.
The presence of disease in a country impacts its economy because of its direct influence on the resilience of a nation’s workforce. Even short of mortality, malaria can be severely detrimental to a population’s productivity. By causing anemia, the disease can deplete working adults’ energy levels and cause loss of work days for enterprises. For children, malaria incidence can have cognitive developmental impact, further inhibiting their long-term ability to maximize their contribution to society—to apply their capabilities and thrive. With the highest incidence rates among individuals between the ages of fifteen and forty-nine, the majority of the working population, HIV can markedly inhibit one’s ability to work, absent antiretroviral therapy (ART). Children orphaned by AIDS also face the risk of losing necessary care and education, which can leave them ill-prepared to enter the workforce.
Research has repeatedly indicated that healthier populations stimulate the economy by living longer and saving more money. On an individual level, healthier people are economically more productive through their ability to work more efficiently, pursue education and spend personal income on goods as opposed to health-care costs. In poor countries, a 40 percent increase in life expectancy is correlated to a 1.4 percent increase in GDP per capita. The United States serves as an obvious example for this phenomenon, for it has been estimated that the increase in life expectancy from 1970 to 2000 alone contributed to an additional $3.2 trillion to the national economy.
Even addressing the burdens of one disease can have positive economic impacts. From 1965 to 1990, before there were more deliberate commitments to global health, a 10 percent reduction of malaria in endemic areas was associated with 0.3 percent higher economic growth.
Supporting global health helps to suppress epidemics and foster more resilient workforces—creating more opportunities for American businesses to invest and form meaningful international partnerships. Take, for instance, sub-Saharan Africa. From the perspective of an American interest, including that of the U.S.-headquartered business community, this is the region that has the greatest economic potential and highest rates of growth in the world. Fighting disease there has been an investment in serving that growth and interest. Supporting the health of struggling populations on a global scale has the potential to open valuable doors for economic opportunity and prosperity.
WHEN PROPOSING the PEPFAR program in his 2003 State of the Union address, then president George W. Bush stated, “Seldom has history offered a greater opportunity to do so much for so many.” By providing 11.5 million people with art, preventing HIV transmission to two million babies, and supporting HIV testing and counseling for 74.3 million people, PEPFAR has indeed achieved good for many. Global health aid serves to reinforce America’s role as a generous and humane guarantor of world order and has demonstrably built our soft power—global influence to persuade as well as militarily coerce.
Global health investments can benefit us as a nation by improving the United States’ standing among the leaders and populations of nations of strategic consequence. In the launch, conduct and outcomes of wars in Afghanistan and Iraq, President Bush’s presidency faced many points of heated criticism. Near the end of his presidency, a 2008 Pew Global Attitudes Project survey in twenty-four major countries around the world found that of the twenty-one outside sub-Saharan Africa, only in four (Britain, Poland, South Korea and India) did more than 50 percent of the population have a favorable view of the United States. In contrast, PEPFAR recipient countries reflected a different view. During the Bush administration, PEPFAR nations had a 68 percent approval rating of the United States, compared to the 46 percent global approval rating. This was particularly the case in sub-Saharan Africa. Among the positive developments that have coincided with this goodwill is the creation of the U.S. military’s African Command (AFRICOM) and success in eliciting African nations’ burden sharing in supplying their troops for multilateral peacekeeping missions.
In this regard, vital U.S. interests on the African continent—vis-à-vis China as a rapidly growing regional influence—point to further implications of global health policy. African nations hold vast economic potential. This is especially true in the sectors of agriculture, natural resources, energy production and infrastructure development. African maritime zones alone make up a total of thirteen million square kilometers, many of which are largely undeveloped with regard to infrastructure and resource exploration. Most of all, potential economic development on the continent would be deeply beneficial to the people of Africa. Yet it represents opportunities for the rest of the world too: less tapped and saturated economies for labor, along with resources and sales, hold the greatest lure—to the United States as well as to China.
The Chinese government has sensed Africa’s growing importance—especially as China’s own booming economy has an immense demand for the absorption of natural resources, from energy to minerals. The country has taken aggressive steps to ensure its stake in the continent’s potential. In 2003, Chinese investments and aid to Africa only totaled $70 million. Most recently, Beijing has promised a $60 billion loan and aid package to all the African countries combined. Along with this increase in assistance is a rise in economic interaction: Africa’s exports to China increased sixtyfold from 1998 to 2010 compared to the fivefold increase to the United States. If Washington keeps advancing health—specifically, a path to epidemiological control of HIV, TB and malaria in sub-Saharan Africa—it maintains an important form of influence on the continent. In the Trump era—even if it were to pursue the sort of business and infrastructure investments that China is making—the United States would lose an advantage in the battle for economic, diplomatic and strategic influence in Africa by decelerating its well-known investment in health.
Additionally, global health aid serves American interests as an underappreciated tool among the many efforts contributing to the diffusion of conflict and instability in partner nations. For instance, in PEPFAR countries, violence and political instability between 2004 and 2013 were reduced by 40 percent in contrast to 3 percent in non-PEPFAR countries. Furthermore, rule-of-law ratings also rose by 31 percent in PEPFAR countries during this time period versus only 7 percent in non-PEPFAR countries. U.S. programs focused on addressing particularly disruptive health phenomena facilitate peace, pluralism and prosperity consequential to our national interests.