Chapter 002. Global Issues in Medicine (Part 13) Conclusion: Toward a Science of Implementation Public-health strategies draw largely on quantitative methods—from epidemiology and biostatistics, but also from economics. Clinical practice, including internal medicine, draws on a rapidly expanding knowledge base but remains focused on individual patient care; clinical interventions are rarely population-based. In fact, neither public-health nor clinical approaches alone will prove adequate in addressing the problems of global health. There is a long way to go before evidence-based internal medicine is applied effectively among the world's poor. Complex infectious diseases such as AIDS and TB have proven difficult but not impossible to manage; drug resistance and a lack of effective health systems have further complicated such work. Beyond communicable disease, in the arena of chronic diseases (e.g., cardiovascular disease), global health is a nascent endeavor. Efforts to address any one of these problems in settings of great scarcity need to be integrated into broader efforts to strengthen failing health systems and to alleviate the growing personnel crisis within these systems. For these reasons, scholarly work and practice in the field once known as international health and now often designated global health equity are changing rapidly. Such work is still informed by the tension between clinical practice and population-based interventions, between analysis and action. Once metrics are refined, how might they inform efforts to lessen the premature morbidity and mortality registered among the world's poor? As in the nineteenth century, human rights perspectives have proven helpful in turning attention to the problems of the destitute sick; such perspectives may also inform strategies of delivering care equitably. A number of university hospitals are developing training programs for physicians with interests in global health. In medical schools across the United States and in other wealthy countries, interest in global health has been exploding. An informal survey at Harvard Medical School in 2006 revealed that nearly one- quarter of the 160 entering students either had significant global health experience or were planning a career in global health. A similar sea-change among trainees has been reported at other medical schools. Half a century or even a decade ago, such high levels of interest would have been unimaginable. Persistent epidemics, improved metrics, and growing interest have only recently been matched by an unprecedented investment in addressing the health problems of poor people in the developing world. Ours is a moment of opportunity. To ensure that the opportunity is not wasted, the basic facts need to be laid out for specialists and laypeople alike. More than 12 million people die each year simply because they live in poverty. An absolute majority of these premature deaths occur in Africa, with the poorer regions of Asia not far behind. Most of these deaths occur because the world's poorest do not have access to the fruits of science. They include deaths from vaccine-preventable illness; deaths during childbirth; deaths from infectious diseases that might be cured with access to antibiotics and other essential medicines; deaths from malaria that would have been prevented by bed nets and access to therapy; and deaths from water-borne illnesses. Other excess mortality is attributable to the inadequacy of efforts to develop new tools. Those funding the discovery and development of new tools typically neglect the concurrent need for strategies to make them available to the poor. Indeed, some would argue that the biggest challenge facing those who seek to address this outcome gap is the lack of practical means of distribution in the regions most heavily affected. The development of tools must be followed in short order by their equitable distribution. When new preventive and therapeutic tools are developed without concurrent attention to delivery or implementation, we face what are sometimes termed perverse effects: even as new tools are developed, inequalities of outcome—less morbidity and mortality among those who can afford access, with sustained high morbidity and mortality among those who cannot—will grow in the absence of an equity plan to deliver the tools to those most at risk. Preventing such a future is the most important goal of global health. Further Readings Cohen J: The new world of global health. Science 311:162, 2006 [PMID: 16410496] Desjarlais R et al (eds): World Mental Health: Problems and Prio rities in Low-Income Countries. New York, Oxford University Press, 1995 Farmer PE: Infections and Inequalities: The Modern Plagues , 2d ed. Berkeley, University of California Press, 2001 ——— : From "marvelous momentum" to healthcare for all. Response to Garrett L: The challenge of global health. Foreign Affairs 86:155, 2007 Fauci AS et al: Emerging infectious diseases: A 10- year perspective from the National Institute of Allergy and Infectious Diseases. Emerg Infect Dis 11:519, 2005 [PMID: 15829188] Garrett L: The challenge of global health. Foreign Affairs 86:14, 2007 Hotez PJ et al: Neglected tropical diseases and HIV/AIDS. Lancet 368:1865, 2006 [PMID: 17126708] Jamison DT et al (eds): Disease Control Priorities in Developing Countries, 2d ed. Wash ington, DC, Oxford University Press and The World Bank, 2006 Kim JY et al (eds): Dying for Growth: Global Inequality and the Health of the Poor. Monroe, ME, Common Courage Press, 2000 Lopez AD et al: Global and regional burden of disease and risk factors , 2001: Systematic analysis of population health data. Lancet 367:1747, 2006 [PMID: 16731270] Murray CJL, Lopez AD (eds): The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 19 90 and projected to 2020. Cambridge, MA, Harvard University Press, 1996 Sachs J, Malaney O: The economic and social burden of malaria. Nature 415:680, 2002 [PMID: 11832956] World Bank: World Development Report 1993: Investing in Health . New York, Oxford University Press, 1993 World Health Organization: Macroeconomics and Health: Investing in Health for Economic Development . Geneva, Commission on Macroeconomics and Health, 2001 ———: World Health Report 2006: Working Together for Health . Geneva, World Health Organization, 2006 . also from economics. Clinical practice, including internal medicine, draws on a rapidly expanding knowledge base but remains focused on individual patient care; clinical interventions are rarely. for physicians with interests in global health. In medical schools across the United States and in other wealthy countries, interest in global health has been exploding. An informal survey at. Chapter 002. Global Issues in Medicine (Part 13) Conclusion: Toward a Science of Implementation Public-health strategies