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Global Health's Role in Development

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Thomas J. Bollyky, director of the Global Health program and senior fellow for global health, economics, and development at CFR, as well as adjunct professor of law at Georgetown University, discusses global health and its role in development.

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Speaker

Thomas J. Bollyky

Senior Fellow, Global Health, Economics, and Development and Director of the Global Health Programs, Council on Foreign Relations; Adjunct Professor of Law, Georgetown University

Presider

Irina A. Faskianos

Vice President of National Program and Outreach, Council on Foreign Relations

FASKIANOS: Good afternoon from New York, and welcome to the CFR Fall 2019 Academic Conference Call Series. I’m Irina Faskianos, vice president of the National Program and Outreach here at CFR.

Today’s call is on the record and the audio and transcript will be available on our website, CFR.org/Academic. As always, CFR takes no institutional positions on matters of policy.

Thomas Bollyky is director of the Global Health Program and senior fellow for global health, economics, and development here at CFR. He’s also an adjunct professor of law at Georgetown University. He has directed the first CFR-sponsored independent task force devoted to global health entitled The Emerging Global Health Crisis: Noncommunicable Diseases in Low- and Middle-Income Countries and is the author of the book Plagues and the Paradox of Progress: Why the World is Getting Healthier in Worrisome Ways.

Prior to coming to the Council, Mr. Bollyky was a fellow at the Center for Global Development and director of the Office of the U.S. Trade Representative. He has testified multiples times before the U.S. Senate and his work has appeared in a variety of publications. In addition, he has served at the National Academy of Medicine, has been a consultant to the Bill and Melinda Gates Foundation, and was a temporary legal advisor to the World Health Organization.

Tom, thanks very much for speaking with us today. It would be great if you could talk about the global health gains that we have made internationally, and how and if they have resulted in broader development gains such as job opportunities, infrastructure, and governance.

BOLLYKY: Great. Thank you so much for that kind introduction and thank you all for joining. It was great and exciting to see such a terrific group assembled for this call.

So today, I’m going to be answering the question has the world getting healthier meant it’s getting wealthier, and what have been the benefits of our gains against infectious disease and child mortality for broader social and economic development. I’m going to do that by drawing from the research for my book that Irina kindly mentioned, which was just released in paperback and focuses on the history of the global decline in infectious diseases and how that decline has reshaped economies and societies.

And with that, let me start with the good news, which is the healthier part. In 1950, there were a hundred countries where one out of five children perished before their fifth birthday. Today, that happens nowhere. So once that had happened in nearly every nation in sub-Saharan Africa, South Asia, and Southeast Asia. That’s not the case anymore.

For the first time in recorded human history, viruses, bacteria, and other infectious diseases do not cause the majority of death and disability in any region of the world, and in the past those health—such health improvements were the path to a broader prosperity and well-being.

So the economist, Robert Gordon, has studied the decline of infant mortality between 1890 and 1950 as one of the single most important facts in the history of American economic growth. Robert Fogel, also a Nobel Prize-winning economist, has estimated, based on changes in body size and calorie consumption, that better nutrition in the United Kingdom nearly doubled the labor output of working-age adults between 1780 and 1980.

Chad was poor than—rather, China was poorer than Chad and Benin in the 1950s, really, all the way through the 1970s when it undertook a(n) all-out peasant-based war against infectious diseases that helped create the conditions for its eventual economic rise. But that’s not what we’re seeing in many of the countries enjoying health benefits—their health gains today and to illustrate that point I’m going to highlight the case of Niger.

Here, too, let’s start with the good news and it’s very good news. Average life expectancy in Niger since 1980 has increased by more than twenty-one years from an average of thirty-nine years of age to a little over sixty. Over the same time, child mortality has fallen by nearly three-quarters. The burden of infectious diseases are down by more than a third.

But the government of Niger just spends $17 per person per year on health. It is poorer on a per capita basis today than it was in 1980. A student entering school in Niger can expect just five years of schooling, which is tied for the lowest amount of education in the world. The total fertility rate remains over seven total births per woman as it did in 1980. Out of the hundred and ninety countries U.N. ranks on human development, Niger finishes second to last.

So what explains the differences from what’s happening in Niger versus China or the U.S. or other countries that enjoyed their health benefits in the past, and what I argue in this book is part of the answer is with the way that progress has occurred.

Most people don’t realize—I’m sure many of the people on the call do but most people don’t—that more than 60 (percent) or about 60 percent of the gains we’ve had in life expectancy in the United States since 1870 happened before the widespread availability of antibiotics or the development of most vaccines.

What drove progress, largely, public health and societal development. So changing social norms around hygiene and the value of children, advent of housing laws and child labor laws that restricted overcrowded tenements and restricted the use of children in factories, public health innovations like the pasteurization of milk, which reduced the bovine transmission of TB, labor regulations that, again, reduced overcrowding in factories, sanitation, chlorination, and filtration of water—those sorts of things drove most of the decline of infectious diseases and child mortality. Sanitation and filtration, chlorination alone are attributed with reducing child mortality by as much as 40 percent in the early twentieth century.

So the combination of better health and these broader social developments were a path to prosperity. It meant that with fewer children there would be a rising young generation of young adults to work in factories and join the assembly lines.

With fewer children dying, parents generally had fewer of them, which meant that that freed up women to join the labor force and left more resources to improve the health and education of the children that one does decide to have. With the reductions in infectious diseases, large cities were able to grow, and cities, for most of history, have been a source of prosperity.

But also, some of the secondary benefits of the way health declined were that the municipal financing models and referenda that supported the construction of sewers and safe water systems in cities set a precedent for other urban public investments like roads, railways, and ports.

The compulsory social regulations around housing and immunization for smallpox served as a precedent for compulsory social regulations around education. So this started to change after World War II and as there was increased use in—of antibiotics and vaccines, which is good because they work, but according to demographer Samuel Preston, even between 1950 and the end of World War II and 1970, only about half of the life expectancy gains in low- and middle-income countries are attributed to those medicines.

So a lot of it was driven by shoe leather public health measures. This really starts to shift into 1970s and ’80s with the child survival revolution and its focus on pediatric vaccinations and smallpox eradication campaign, which saved tens of millions of people.

HIV, as this audience will know well, transformed global health, leading to a surge in aid not just for addressing HIV but for other diseases as well, and with these more effective medicines and more generous international aid programs, this has allowed us to make remarkable progress against infectious diseases and child mortality in deeply poor countries with dysfunctional governments and limited infrastructure.

But the challenge is too many of these have remained deeply poor countries with dysfunctional governments and limited infrastructure. When you don’t have that broader social, societal, and economic development, many of the good things that go along with less infectious disease and less child mortality, like a rising young adult population, less deadly cities, and a shift in health needs to adults, these become potential drivers of instability and poverty rather than just the path to prosperity that they once were.

I’m just going to mention a couple facts for each of these three categories and then, really, we’ll look forward to summing up and your questions.

So on the young adult side, between 2015 and 2050 the World Bank estimates that the working age—the number—the population joining the working-age population will be 2.1 billion people. That means that current employment rates in low- and middle-income countries nearly nine hundred million people without jobs.

Each year for the next ten years, sub-Saharan Africa will add eleven million young adults to its workforce and, currently, the region of sub-Saharan Africa is producing about one (million) to two million jobs annually. In the past, whether it was the textile mills of Lancashire or the steel mills of Bethlehem, Pennsylvania, or the iPhone factories of Shenzhen, manufacturing really was the way we employed a rising and adult workforce.

But the prospects of that happening in many, although not all, sub-Saharan African countries is dim. Manufacturing represents the same share of economic output in sub-Saharan Africa as it has since the 1960s, just 7 percent. Some of the reasons are limited infrastructure and in some countries too much corruption and labor—and too cumbersome labor regulations, business regulations.

But the biggest factor really is that sub-Saharan Africa—the countries of sub-Saharan Africa are competing against countries that enjoyed their health gains earlier and have large workforces like China and Vietnam and Bangladesh, and in that sense the child survival revolution may have come to too many sub-Saharan African nations late.

On the city side, with the decline of infectious disease and child mortality, it’s become possible for poorer and poorer nations to urbanize. It’s worth remembering that for most of human history there were no large cities unless they were primate cities or industrial centers that could draw migrants from the countryside, and this is because cities were generally deadly to their inhabitants.

But with the decline of infectious disease and child mortality, it’s been possible for cities to grow much faster and even without migration, and most of the urbanization that we’re seeing driven in low- and middle-income countries today is attributable to natural growth, so the excess of the birth rate over the death rate so as opposed to migrants coming from the countryside.

And that’s produced a faster rate of population growth. In London’s fastest decade of growth, which was in the 1890s, it added ninety-three thousand new residents per year. In New York, where I’m from, its fastest decade of growth in the 1920s New York was adding two hundred twenty thousand people per year. Between 2000 and 2010, Dhaka added four hundred fifty thousand new residents per year. Delhi added six hundred twenty thousand new residents—people per year of that decade.

So just a much faster rate of growth, and that growth is outpacing urban economies and infrastructure and one result of that has been the expansion of slums and slum populations. The U.N. projects that there are nearly nine hundred million people living in slums currently. But that’s expected to go to close to two billion by 2030. There are countries like the Central African Republic where nearly its entire urban population—96 percent—lives in slums.

If this pattern persists, these fast-growing cities may be anomalous in that they’re not just the first low-income large cities in world history; they may be the first cities in world history to make their residents poorer instead of wealthier.

Last thing I just want to focus on is health systems. Many of us think of the West Africa Ebola outbreak as exposing the limits of the health systems to benefit from our global health progress on pediatric infections and HIV and other areas, that when confronted with an emerging infection those health systems were not able to make those adjustments.

But it’s really the day-to-day toll of chronic diseases—cancer, diabetes, heart disease—where you really see the real damage. The growth of noncommunicable diseases in poorer countries is three to four times as fast as have been seen ever in wealthy countries. I’ll give you an example of that, to pick on Bangladesh, is Bangladesh will go from having 28 percent of its overall health burden in 1990 be attributable to these noncommunicable diseases. By 2040, it’ll be 82 percent, which is, roughly, what it is in the United States. But Bangladesh will traverse that epidemiological path in fifty years whereas it took two hundred years in the United States, and they’ll do it significantly poorer and with a less robust health system, and that’s being driven primarily by demography.

Bangladesh added thirty-eight million adults between 1990 and 2015 and adults have health—have adult health needs, noncommunicable primarily, and when you have poor populations that can’t purchase care out of pocket and governments that aren’t paying for it, people get sick earlier, they get diagnosed late, and suffer worse consequences as a result.

So the lesson that I would draw from this for does healthier mean wealthier is that, unfortunately, to date that question remains to be seen. For those that are searching for a direct mechanical relationship between better health and wealth, that’s probably the wrong way to think about it.

Improved health creates an opportunity which, when paired with the right social and industrial policies in a conducive international environment, can lead to great prosperity and it has in the past and there’s a(n) opportunity for it to do so now.

But to capitalize on that, we need to embed our global health programs in a larger development strategy that recognizes when you save the lives of children they become adults, and adults need employment opportunities and higher quality education and health systems that can support their needs as adults, and that’s not where we’ve seen investments over the last twenty or thirty years.

The good news is there are a lot of programs that can contribute to this and I’m happy to talk about those when we get to the questions and answers. So let me stop there.

FASKIANOS: Tom, thanks very much for that great overview. Let’s open it up to the group for questions.

OPERATOR: Thank you. At this time we will open the floor for questions.

(Gives queuing instructions.)

We’ll take our first question and that is from Washington and Jefferson College. Please go ahead.

Q: Hello. It is great to hear from Mr. Bollyky and we appreciate all he’s done.

My quick question is, would African development be affected by the general condition of health beyond what it was in the past two or three decades?

BOLLYKY: Forgive me. You broke up there for a second. You said that would African region benefit—

Q: Would African development—yeah, will African development be affected by the health conditions of Africa today more than it were two decades ago?

BOLLYKY: So I think so. I mean, there’s—again, I think where African development is currently for many countries is we’re at a inflection point where you have a—the beneficiaries of past health programs are reaching adulthood and looking to join the workforce, and in the past what you’ve seen is that in nations like China, which is significantly poorer than a lot of African nations when it began its rise and not a country that anybody would hold out as promising in the 1970s, you know, it did help create a labor force that, with the right social and economic policies and a conducive international environment, could lead to broader prosperity.

So continued help, moving forward, in many African nations I think is important as a form of human capital, and investments in that and the World Bank had a great world development report last year talking about the need to—the health contribution in terms of allowing students to be educated and increasing the productivity of workers.

So I think that’s important, particularly as you have this influx of workers coming in. What I don’t think is that health is sufficient, and most of our investments over—we’ve heavily indexed on health on its own in our development programs. It represents, depending on the year, as much as 70 percent or more of U.S. development assistance.

And as somebody who works in health, I think that’s been very important. But I think the assumption coming in would be that those health investments would be catalytic of broader development of prosperity and I think there’s some emerging evidence that suggests that has not been true to the same extent as the past.

That’s not because, in my view, of the nature of the countries involved but because the international environment is also a little less conducive than it was for China. They are competing against other large manufacturing powers. They are rising at a point where there’s an increasing amount of protectionism against low-wage manufacturing and lower-income countries. That was not true when China was enjoying its rise. There are also more restrictions on migration, which creates a—can limit a release valve for a fast-growing and adult population.

And then, of course, there’s the issue of climate change, which for countries that have a significant portion of their economy associated with agriculture are hurting, in particular, create risks in terms of reducing the ability to employ people.

FASKIANOS: Thank you. Next question.

OPERATOR: Thank you. We will take our next question from Tufts University. Please go ahead.

Q: Yeah, this is Pearl Robinson. That was a masterful overview.

The question I had, when you talked about global health policy, are you including public health as well as treatment and, if so, what’s the relative mix and does that matter in terms of outcome?

BOLLYKY: Great. I, certainly, include it. It hasn’t always been included as heavily in what has been funded through development assistance. That has started to shift recently. As much as 30 percent of development assistance for health—foreign aid for health—currently goes to health systems strengthening, which is not quite the same as public health but at least focuses on supporting primary health systems and broader health policy measures for populations.

That said, of that 30 percent of development assistance that goes towards health systems strengthening, most of that is still going around focus areas like HIV and vaccinations, so supporting the broader systems that support international development goals around those particular concerns.

It’s still an advance in the past over the programs that choose to be far more targeted on just providing treatment or vaccination and now supporting the broader health systems. But you know, as I mentioned, in terms of the West Africa outbreak, there have been some real limitations to those programs in building broader health systems.

We’ve seen a shift in the last five years to try to account for that and fund more of what you’re suggesting, and I think the jury is still out yet how effective those investments have been.

Q: Can I just do a quick follow-up? You took Niger as the example.

FASKIANOS: Sure.

Q: So there are lots of African countries and there is a lot of variation in the quality of the health care systems and even of governance. So what countries would be on the higher side of being better at this than Niger?

BOLLYKY: Great. So and there are pockets, and I want to say there are pockets of good news more generally and I want to give it appropriate due in these remarks. So while we haven’t seen the kind of prosperity associated with improved health that we saw in the past, we have seen a significant reduction and the decline of extreme poverty and that is something worth highlighting.

So 2015, for the first time in history less than 10 percent of the world’s population is living in extreme poverty and a significant share of that was driven—those declines were driven in sub-Saharan African nations. So that’s something worth highlighting. There are countries that have done a better job in building health systems than building an economy.

A lot of people focus on Rwanda as one of them, Ethiopia to a lesser extent, but to some degree as another that have not only had these dramatic health improvements but have had some broader programs.

The question that you have with Rwanda and Ethiopia that leads some people to have concerns is that there are some concerns with those governments, which are not fully democratic. So they do hold multi-party elections but nobody would—historically, nobody would identify them as free and fair. Ethiopia—that is starting to potentially change and we have seen some reforms there but that’s certainly not the case in Rwanda.

And the question is, is in the past for places that have more autocratic governments over a longer period of time the—you’ve seen bursts of good broader development but they haven’t necessarily held up in as many nations.

So, you know, there are countries, of course, like China or Cuba that people point out—point to as potential exceptions. Singapore is another. But at least in the case of China and Cuba there is some indication on health that they don’t do as well on these noncommunicable diseases—these conditions that people suffer as adults.

There’s a great quote by a Cuban health activist that Cuba is a great place to be a child but a terrible place to have cancer, and I think there is some truth to that. So we’ll see if those—that holds true for the countries that have progressed well in sub-Saharan Africa but may not have these more democratic forms of government.

FASKIANOS: Thank you. Next question.

OPERATOR: (Gives queuing instructions.)

We’ll take our next question from Washington and Lee University. Please go ahead.

Q: Thank you for your address.

My question pertains to health concerns of the refugees, internally-displaced persons, and immigration occurring due to political security situations, for instance in Syria, Middle East, Afghanistan, or even in—(inaudible). These refugees are not part of any governmental health screen and put sustainable drain on largely insufficient health infrastructure in immigrant countries. Although briefly addressed earlier, what, in your opinion, can be done to address the health concerns of these groups?

BOLLYKY: Great. Well, the good news I have for you is we’re about to release a paper on that very subject, so stay tuned. But to preview it in terms of our paper—it’s actually a pair of papers—but the one that I worked on is focused primarily, again, on these noncommunicable diseases and that comes up because many of the countries that have large displaced populations, in particular, Syrian refugees, are from countries that at least formally were middle- or upper middle-income countries, so have health problems or a health burden that one would traditionally associate with a country of that amount of wealth, and you have large displaced populations and a lot of our refugee health systems aren’t set up to support those kinds of health needs.

They’re, largely, set up to address diseases that are associated with crowding people together and impoverished populations, which happens, too, you know, even in these wealthier or refugees from middle-income countries. But how do—how do we adjust these systems to address the needs of chronic patients has been a real challenge.

Largely, that is being—there’s support internationally but it’s been difficult because many of these populations are what the U.N. would consider more persistent refugees and which, if I recall off the top of my head and you’ll correct me if I have this wrong, is populations that have been displaced for seven or more years.

So we’re starting to see populations of substantial duration in countries and that imposes a big burden on the international funding that exists to support them, leaving aside that their health needs are different than in the past but also in their host nations.

It’s a real challenge that I think that we have been slow to address and hasn’t gotten the same amount of attention as other international health concerns like emerging infections. So I appreciate the question.

FASKIANOS: Thank you. Next question.

OPERATOR: Thank you. We’ll take our next question and that is from Wheaton College. Please go ahead.

Q: Yes. Hello, Tom. Hello.

BOLLYKY: Yes. Hi.

FASKIANOS: Hi. Go ahead.

Q: OK. Tom, thank you for the great report out.

I just had two data questions and one paradigm. Just to confirm, did you say two billion people living in swamps by 2050, or slums? I couldn’t make that out.

BOLLYKY: Well, the U.N. projects that there will be two billion people living in slums by 2030.

Q: And then you also mentioned nine hundred million unemployed. Was that the young adults as a subset of that, or is that nine hundred million unemployed young adults by 2040?

BOLLYKY: No, that’s the World Bank’s projection. So they project between 2015 and 2050 2.1 billion working-age adults will be added to the population in low- and middle-income countries and that current employment rates in those countries nine hundred million of those 2.1 billion people will not find employment.

Q: Got it. OK. And in your paradigm of does healthier mean wealthier, so assuming the vision is to go from healthy children to prosperous adults and, again, this is from the Wheaton College WiN Hub Social Entrepreneur Club and GCSEN Foundation, so we’re thrilled to be participating.

And it sounds like, in the conversations, much of it is about generating employment. And I was wondering if you could speak to any conversations around the role of the social entrepreneur, entrepreneur inoculation rates or formation rates that could lead to more closed-loop, zero-waste, local-economy initiatives. Is that something that can complement the World Bank and the U.N. top-down approach, especially as we look at these numbers of potentially rising healthier adults who will not be employed, which could lead to social catastrophe? So I’d love your thoughts on that.

BOLLYKY: Great. So I think the focus is really two-fold: one is on the focus of the youth employment, and that is a rising concern. When one writes a book, you—you know, or at least when I wrote this book I anticipated it would be controversial, and this discussion of the limitations of the way we’ve pursued global health would be particularly controversial amongst those that have invested in our current way of doing it.

And I was surprised that, really right around the time of the release of the book, you saw a greater focus, for instance, on the World Bank, on human capital and youth employment. The Bill and Melinda Gates Foundation released its social goals, paper report last year that really focused on fast-rising young adult populations in—particularly in sub-Saharan Africa, the potential that has to undo all the progress that has occurred over the last twenty years, so I do think there has been greater attention to the issue of youth employment.

And the other piece that, again, the World Bank has focused on—and some other actors, including the Gates Foundation, as well—is how do we invest in these rising young adult populations to best equip them to—equip them to find that employment, or to start new businesses. So that’s been a lot around educational quality, voluntary family planning, promoting the availability and use of contraception, and again, chronic care models.

On the broader social entrepreneurship as a way of supporting these, you know, I think we are really in early days to some degree. We have great history in spurring improvements that involve technology and nature, so with health and agriculture we have a great history as an international—or collective action has a great history in fields that have a strong scientific basis.

We don’t have as great a history on things that involve people rather than nature, like education, or governance, or promoting entrepreneurships, so I think this is—this is an area where it is right for pilots and innovation. So I’m pleased to hear that it’s a focus for what you all are doing.

FASKIANOS: Thank you. Next question.

OPERATOR: Thank you. We will take our next question, and that is from Brigham Young University. Please go ahead.

BOLLYKY: Hello?

Q: Hello.

FASKIANOS: Yes, go ahead.

Q: OK, so I’m wondering if you can speak a little bit more about the role of global supply chains in doing health development, especially in, like, the land-locked regions of sub-Saharan Africa.

BOLLYKY: So do you mean from the trade perspective how to—

Q: Yeah, like we trade—

BOLLYKY: —engage those who—

Q: And how do we help get, like, the things from—how do we help get medicines, and expertise, and all those things that we may have but are having trouble—might have trouble actually reaching, or it becomes a lot more expensive to get these supplies out to those areas?

BOLLYKY: Great. No, it’s a great question.

So I view the issue as going both ways, as perhaps you were suggesting. The first is the issue of how to involve more countries, particularly in the sub-Saharan Africa region, in the global economy. And I think the emphasis currently has been on more regional economic integration. So the movement of an African Free Trade Area recently is something that people like myself cheer as a potential avenue for that, and may offer an ability to help grow economies that may not be—because of the higher cost of doing business and other barriers—as able to compete in high-income, wealthy markets, at least in the short term because, as I mentioned at the outset, there is a lot more trade protectionism than there was in the 1970s and ’80s when China was rising. So that creates an additional barrier. And to the extent that regional economic integration can help extend some of these supply chains, global value chains into lower income nations in sub-Saharan Africa and involve them in manufacturing and the global economy, I think that could be something that might be helpful.

In terms of the other way, which is how do we get goods and services, including medicines, into more infrastructure-limited settings, whether it be because they are landlocked or they’re just simply deeply poor, and they haven’t had—don’t have the same degree of infrastructure as you’ve seen in some other settings.

This is something that we have gotten better at; it’s something we continue to work on. So people see there is—you know, in this country we’re looking at starting to use drones for delivery. That has been going on in some sub-Saharan African nations for a few years now. People have innovated in terms of how to bundle medicines with consumer goods that are already reaching rural settings and landlocked places, so there’s been a lot of investment in trying to figure out these supply chain issues.

The challenge that one largely has in this case is, you know—for the commercial products is largely because everybody along the chain gets paid, and there are a lot of inefficiencies to having more philanthropic-funded programs that, you know, don’t necessarily have that infrastructure in place. So trying to innovate around that has been a big focus.

One thing to mention, though, is—you know, again, it’s not something that’s particular to these countries, that somehow they’re different from countries in the past, and that’s why they’re not seeing these supply chains arise or enjoying the benefits. You know, people as recently as twenty years ago weren’t delivering many medicines to these settings. So having the pharmaceutical regulatory and distribution supply chains weren’t a(n) obvious target for investment when there weren’t medicines coming there anyway. So a lot of this has really been cobbled together in a very short period of time and, you know, I think we’ve in some ways made an impressive amount of progress, particularly on the delivering to countries. What I think we have not done as well—as good of a job is integrating them so they themselves can contribute and compete internationally economically.

Q: Thank you.

FASKIANOS: Thank you. Next question.

OPERATOR: (Gives queuing instructions.)

We’ll take our next question from Kentucky Wesleyan College. Please go ahead.

Q: Considering the increase in organization in the workforce and stuff at Saharan African nations, as well as the limited impact of international aid, what sort of domestic policies can these nations put in place as a means to fix their economic situations themselves?

BOLLYKY: Great. Well, so a couple of things to say there: one to take the broader point building on the theme that you ended with—that they themselves can address—I think historically the focus of global health has been how to circumvent the state, how do we deliver vaccines, and medicines, and food into settings that may be deeply poor, and in some cases, may have dysfunctional governments with limited infrastructure.

The future of global health is how do we enable and empower the state. Many of the challenges on the health side that face countries are ones that fundamentally have to be addressed by local actors in the government. No one can—no donor is going to maintain your primary health care system. For rising non-communicable diseases, whether it’s tobacco laws, or smoke-free places, those types of measures, that’s something that only can be done by local governments and national governments. So that really does need to be the focus.

That’s true on a lot of these economic issues as well where the issue is, you know, how do we again promote or facilitate more trade integration, friendlier business environments to reduce the costs of potentially moving manufacturing to those settings, how do we help support through—whether it be loans or investments in, you know, improving infrastructure that again can reduce the cost of economic development in settings.

You know, one innovation that was done in the Obama administration but has been popular in the Trump administration, as well, has been Power Africa in supporting electrification and power generation in sub-Saharan Africa. These are all sensible investments but, you know, again, fundamentally we have to shift the way we’ve thought about these programs about, again, empowering local governments with evidence and catalytic investments for recognizing fundamentally that many of the challenges that these countries now face need to be addressed primarily by those governments, and creating accountability, and helping provide the means to help support them in their effort to do so.

FASKIANOS: Thank you. Next question.

OPERATOR: Thank you. We will take our next question from Washington & Lee University.

Q: In your article The Future of Global Health is Urban Health you talk about how the creation of easily enforceable property rights could help health in slum communities immensely. And I was wondering, what’s the best practice for granting those property rights in a way that doesn’t just push out the poorest people who can’t afford to pay the new required rates into new, informal slums, thus replicating the problem in different areas?

BOLLYKY: Yeah, no, it’s a great question.

So the issue around enforceable and more easily tradable property rights is many of the people who build homes in slums don’t necessarily—in many cases don’t own the rights to that property. So it can be moved out now.

And the question is, is how to create value in those investments that benefits some of those residents, but also inspire people to make investments in those communities that they’re doing now. So that’s the challenge around—that might be addressable through more enforceable, easily tradable—more easily tradable property rights. That said, it is by no means a panacea, and you of course also need to have investments in trying to assure the availability of more affordable housing.

The part that comes across on these issues, though, as you start to push issues around urban health, is that many of the challenges you see facing low- and middle-income countries—for instance, around affordable housing of course in urban settings among vulnerable populations—are the same challenges we face here. We have started a series at the Council where we’re trying to connect international efforts around pressing global health concerns to some of the concerns that we’re dealing with domestically.

And one of my favorite meetings that I’ve held here at the Council was having Alex Ezeh, who I think is one of the world’s leading experts on urban health, and used to run a think tank in Nairobi, and focused a lot on issues around slum health in particular. We connected him with the person who is the medical director for healthcare for the homeless in Baltimore, and it was a(n) amazing conversation about the challenges that both had faced in their work, and how similar that they were.

What comes across from that is a lot of it really are broader social programs less than health specifically, and that these programs are highly contextual. The idea that somehow—and I think global health has become enamored over time in the idea of magic bullets, and silver bullets, and identifying what works and applying it everywhere. The reality is, for many of these challenges, the solutions are highly contextual and need to be found by local actors. And the issue is, you know, how do we—how do we equip them in doing so.

So on the—on more easily transferable property rights, it has worked in some settings, and people view it, but it’s a—it’s one of a package of solutions that need to be brought to bear on the challenge.

Q: Thank you.

FASKIANOS: Thank you, next question.

OPERATOR: Thank you. We will take our next question, and that is from Wheaton College.

Please go ahead.

Q: Hi. My name is Khadija Mohato (ph) and I’m from Wheaton College.

I had a question on a different perspective. I work with a lot of students, and I want to be able to communicate with them how important this concept overall is. And I was thinking about the aspect of dietary restrictions and how individuals can control their health internally based on what they put into them.

So do you know of any research or anything supporting the idea of, you know, eliminating what you put into—what you eat to better your health in a way to connect, to be more involved with the whole health crisis overall?

BOLLYKY: Great. So historically a lot of the focus in global health and development has been more on the challenge of undernutrition, so this has certainly been—the primary focus of what has been funded by the U.S. government is on undernutrition and, to some degree, malnutrition—so focusing on vitamin deficiencies and addressing those types of concerns.

We are still pretty early days on the issue of promoting more diet diversity. When you look at some of the statistics that come out on nutritional challenges for low and middle-income countries, what’s really interesting about it is you would expect it would reflect more the expansion of the availability of red meats, and excessive sodium consumption, or sugar-sweetened beverages. And there is an increase in those areas. But the primary challenge really is the disappearance—or limited availability of healthy things, so fresh fruit and vegetables, legumes, which have a real tie bot developmentally but also with heart disease. It’s been—it’s more the disappearance of healthy commodities that are a challenge for low- and middle-income countries than these unhealthy products.

So there are some efforts, and USAID has started to have some programs on diet diversity. There are a number of NGOs that focus on promoting Mediterranean diets and healthier diets as a way of, you know, slowing the rise of non-communicable diseases in low- and middle-income countries.

There have also been efforts to address the challenge of the rise of unhealthy foods, and one of the things that has been accompanied with an increase in young adults in low- and middle-income countries, sub-Saharan Africa in particular, is that of course means you start to attract the multinational industries that primarily sell to young adults. That’s tobacco, but also some of the food and beverage industries.

So while the prevalence of those unhealthy habits is still relatively low in comparison to our country, they are rising, and there have been increased efforts to look at ways of slowing that rise, whether that’s through fiscal measures like taxes or other programs that—you know, restrictions on advertising or other things that can be done to promote more moderate—use of those products in moderation, and in the case of tobacco, to not use them at all.

Q: Thank you.

FASKIANOS: Thank you. Next question.

OPERATOR: Thank you. We will take our next question, and that is from the University of Texas. Please go ahead.

Q: Sir, to what extent is the Council on Foreign Relations, say in conjunction with the United Nations, promoting the development or extension of volunteer services to address health issues such as those provided by the Doctors Without Borders, sir?

BOLLYKY: Thank you for the question.

So I will not speak for the United Nations, although I think in—you know, my sense is, depending on the circumstance, that they’ve welcomed the contribution of Doctors Without Borders. You know, the Council doesn’t take any institutional position, so—on that. We don’t take any official position on anything, whether that be—in this case—around the use of volunteer health services.

For myself personally what I can say is there is no question that Doctors Without Borders played a critical role in the West Africa Ebola outbreak and in many other areas. Years before I joined the Council, I worked in South Africa. The book actually opens with—the first chapter opens with a discussion of my time down there at the height of the HIV crisis, and really, the area that was doing the most innovation around how to address that HIV crisis was in Khayelitsha. It’s a slum area and was being run by Doctors Without Borders in terms of the health services to address HIV. So I think they have a fantastic record on global health and a lot to be proud of, but again, from the Council—I can’t speak from the institutional perspective, but that’s certainly my perspective.

Q: Thank you, sir.

FASKIANOS: Thank you. Next question.

OPERATOR: Thank you. We will take our next question, and that is from Kentucky Wesleyan College. Please go ahead.

Q: The Trump administration has changed U.S. policies in many areas. What’s its record with regard to global health? What are the achievements? What are the failures or drawbacks?

Thank you.

BOLLYKY: So on global health directly, I think it’s fair to—well, a couple different things. For the Trump administration, I think, the White House itself has, for several different budget cycles in a row, promoted cutting global health funds.

That said, Congress has not gone along with those cuts. There has been bipartisan support for U.S. investments in global health. Historically, investments in global health have been quite bipartisan and supported by politicians of both sides. The PEPFAR program, of course, was famously started by George W. Bush, and maintained support through the Obama administration.

That said, there are two areas where I think the Trump administration has, in particular, continued to invest and prioritize in global health. There has been some amount of funds that have continued to go toward global health security and then towards the second area being the Ebola outbreak in the Democratic Republic of Congo, in particular.

So there has been support in those cases. I won’t say it matches quite the support that the U.S. government provided with the West Africa outbreaks in 2013 to 2015 for either global health security or those affected countries in particular. But there has been support. And the president—and the White House—deserves credit for maintaining that support.

I think more broadly the administration has promoted—in terms of its Africa strategy, which is not the sum of global health, but many of the countries that we invest in in global health are on the African continent, so it’s relevant. There has been a call for moving away from more foreign aid to more infrastructure investments in a way of trying to be more competitive with the areas that China is investing in.

I haven’t seen a lot in a shift in money in that regard, although there is a new investment financing mechanism that the Trump administration has supported to replace OPIC. You know, maybe we’ll see more facilitating of business and infrastructure in that setting.

So in sum I think there has been—the support hasn’t matched past administrations, but they haven’t really—while you haven’t seen the increases—whether it’s despite the White House or with tacit approval, you haven’t seen quite the cuts that have been threatened in those budgets. And so we’ll see if that remains the case moving forward.

FASKIANOS: Thank you, Tom.

I wanted to just close with one question to you about—to talk a little bit about your career and any professional advice—I mean, you’ve had—you have a law degree, you are working in the global health space—and just to leave the group with a few words about what they should be pursuing.

BOLLYKY: Great. Well, to explain myself a bit, I guess, of how did a lawyer end of working in global health, I had been a biomedical engineer in terms of what I was studying in college, and I worked in the New York City Department of Health at the height of the HIV crisis there, so before the availability of antiretroviral medicines. And it was a searing experience to see that and its toll on the city and really, to me, demonstrated the potential value of policy as a way of moving forward with addressing those kinds of health challenges.

So I actually went to law school to work in global health; afterwards went to sub-Saharan Africa where I was part of the legal team that did the constitutional court litigation around truth and access; again, a lot of this is described in the book—for those of you that are interested in what we talked about today, and particularly connecting some of these thoughts in global health over the last twenty or thirty years.

In terms of my advice moving forward, I, you know, admire all of you that are doing education around these programs. I teach myself. I tend to really focus on a skills-based approach to global health. I think people that have been able to contribute the most in the field really bring heart skill to addressing that and contextual knowledge to that, and that’s obviously something that can be brought to bear.

I have found my time in global health quite rewarding in the sense that it combines the morally compelling with the technically challenging, and I don’t know what more one would want for their career. So I feel very lucky to be able to have done this work and to be able to do it here at the Council.

FASKIANOS: Wonderful, and obviously, with our Global Health program here at the Council, we’re devoting a lot of calories to this. Our president, Richard Haass, thinks this is incredibly important.

So I commend to all of you Tom Bollyky’s book Plagues and the Paradox of Progress. It is now, as he said, in paperback, so it is at a lower price, so go out and get it.

Also, as Tom mentioned earlier in the call, he is coming out with additional resources, a global health tracker, and other reports, so please visit CFR.org frequently. You can sort—you can go to Tom Bollyky’s bio page or else sort by region and functional areas to get more information on the latest resources.

So Tom Bollyky, thanks very much again for being with us today, and to all of you for your great questions.

Our next call will be on Wednesday, November 20, at 12 p.m. Eastern time. Amy Zegart, Davies Family Senior Fellow at the Hoover Institution will be leading the conversation on “National Security and Silicon Valley.” So I hope you will join us for that.

In the meantime, please follow us at @CFR_Academic on Twitter, and visit CFR.org, as I said before, for information on new CFR resources and upcoming events. Additionally, we are launching in November a microsite for Election 2020 where we will be tracking all of the candidates’ statements on foreign policy, and indeed, many of the candidates have already answered about ten questions that we posed to them—about half of the candidates have answered questions on matters of foreign policy, so you should go there to check it out. You can get to it from our homepage at CFR.org.

So thank you again to all of you, to Tom, and we look forward to speaking with you again on November 20.

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