The Relevance of Global Health in the Post-2015 Era

(This post is based on a talk given at a Globemed USC event April 12, 2014)
Nearly 15 years ago the nations of the world came together at the dawn of the new century and took a look around them. They were not happy with what they saw. Hundreds of millions of people around the world continued to live in extreme poverty, millions of children were dying before they reached their 5th birthday and millions of those who did survive lacked access to education. Mothers were dying at alarming rates during childbirth, hunger and avoidable communicable disease ravaged communities, and sub-Saharan Africa stood in the midst of a horrific uncontrolled epidemic of HIV. Basic human rights—the rights of each person on the planet to health, education, shelter, and security—were lacking for over a billion members of the global community.
In response, at the Millennium Summit in September 2000 the largest gathering of world leaders in history adopted the United Nations Millennium Declaration, committing their nations to a new global partnership to reduce extreme poverty and setting out a series of time-bound targets, with a deadline of 2015. These targets have become known as the Millennium Development Goals, or MDGs. The MDGs gained international credibility and have facilitated laudable poverty-reduction outcomes.
Notably, health held prominence within the MDGs framework.  Four of the eight goals were health focused – eradicating extreme hunger, reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria and other disease. Moreover, a fifth goal, ensuring environmental sustainably, referred in practice to improving access to clean water and sanitation. Consequently, support for health work in low-income countries, particularity around those specific issues identified in the goals, has grown significantly over the past decade and a half with substantial increases in funding and political attention. This investment has even reached universities, with hundreds of new institutes and centers dedicated to promoting health in developing countries popping up around the world–including here at USC.
The investment in the health of the world’s poorest has yielded significant results. Between 2000 and 2010, mortality rates from malaria fell by over 25 percent, averting some 1.1 million deaths, and between 1995 and 2011, a total of 51 million tuberculosis patients were treated, saving 20 million lives. Globally, new HIV infections declined by 33% between 2001 and 2012 and in 2010, the world met the MDG target on access to safe drinking water. Between 2000 and 2010, over 200 million slum dwellers gained access to improved water sources, sanitation facilities, durable housing or sufficient living space exceeding the MDG goals of bringing 100 million people out of extreme poverty,
However, as the MDGs enter into the last year before their deadline, countries are falling short on other targets. Despite progress in the reduction of preventable infant and maternal mortality, limited access to antenatal care and skilled birth attendance remains problematic in rural areas, particularly in sub-Saharan Africa. 
There is clearly unfinished work from the MDGs to be carried forward into the next generation of global development. Today, the international community is actively engaged in consultations and conferences developing a new vision for global development.  This next generation of global development goals is often referred to as the post-2015 development agenda. The global context through which the post-2015 development agenda is being configured is markedly different from that which framed the MDG era. Key features of our changing world include the economic shift of many populous countries into middle-income status; the dramatic rise in life expectancy; ubiquitous connectivity through transportation and communications technologies; rapid urbanization; and the rise of environmental threats that affect every person on earth – the greatest among them being climate change.  
Given today’s pressing global challenges, the post-2015 development goals will speak to much more than just the completion of the MDG agenda. A key shift in the post-2015 development agenda is the mergence of the MDGs with the Sustainable Development Goals (SDGs)—based on the agenda articulated in the 2013 UN Conference on Sustainable Development (Rio+20).  Rather than focusing only on poverty-reduction in low- and middle-income countries, the new global development agenda, as framed through the SDGs, is global, addressing the global implications of development for all states, and integrating economic development, social inclusion, environmental sustainability, and good governance. While the work of the MDGs transforming low-income countries will need to be continued, and extended to meet the basic needs of the billion poor in middle-income countries, the emerging SDGs will also make universal claims to economic development, environmental sustainability, and social inclusion – implying the need to create change in even the richest countries on earth.
The question becomes, where will health feature in the new broader global development agenda? There is much speculation that health has had its moment in the spotlight and that it is likely to succumb to competition from other issues demanding attention.  In the final report of the High-Level Panel of Eminent Persons on the Post-2015 agenda, health was relegated to the annex – along with all other specific targets. Instead the report focused on five transformative shifts that were central to their vision of global change – equity, sustainable development, economic growth and jobs, peace and governance, and a new global partnership.
Of course, health can be readily subsumed within such a framework. However, if health is to retain its prominence in the post-2015 development era, it must be demonstrated to be integral to, and not merely an indicator of, social sustainability. In other words, not only does economic, social and environmental sustainability create health and wellbeing – but that the active protection of the health and well-being of a population is integral to its social, economic and environmental sustainability.
I often speak to USC students about what “global health” means. Is it the same as tropical medicine of the 1950s? Or international health of the 1970s and 1980s?  I argue, sometimes un-popularly within the broader global health community, the field of global health is fundamentally different from past international health work.  It is within the context of the post-2015 development agenda that the difference and significance of this definitional debate becomes apparent.
On the one hand, we have traditional international health approaches reflected in the siloed, disease-specific goals and targets encompassed with the MDGs.  Although this approach has served some specific areas of intervention well, approaches to sustainable organizational and individual behavior change have largely failed. The approach is often based on a traditional understanding of international aid – an understanding rooted in the dated and defunct notion of helping those who can’t help themselves – (people much different from you and me) and on delivering a technical “fix” off a checklist (think vaccines, nets, drugs, housing and water pumps). The inability of international health programs to integrate with broader sustainable development approaches threatens to sideline health within the emerging development agenda.
On the other hand, our understanding of global health as taught here at USC emphasizes the strategic shifts required to retain health within the SDG vision of the future. Global health reframes health in terms of social sustainability, addresses health universally in our inter-connected world, and demands close collaboration with colleagues in other technical sectors including energy, law, finance, and governance.  It is a natural progression in the way we have approached health over time – from clinical medicine in the 1800s, to public health in the 1900s, to sustainable development in the 21st century.
Students, you are graduating into a post-2015 world. Health must be integrated into each element of sustainable development – economic, social and environmental – not quarantined from them.  You must be ready to bring global health into this new paradigm – to present health and your training and skills as a precondition for social sustainability, critical for the natural environment, and key to progress and prosperity. You can start here at USC where every discipline comes together on campus – together our Trojan community can find the answers to the “World We Want.”
I would like to close by emphasizing that environmental sustainability is under “severe threat” as growth of global emissions of carbon dioxide continues to accelerate. Emissions today are approximately 50 percent higher than in 1990. The 2013 UN report on the state of the world warned, “Forests continue to be lost at an alarming rate. Overexploitation of marine fish stocks is resulting in diminished yields […] birds, mammals and other species are heading for extinction at an ever faster rate, with declines in both populations and distribution.”  
With climate change and environmental degradation threatening global growth and security— and consequently all of our health—the global community must prioritize the issue and global health can and should strongly contribute to this agenda. To date, however, discussions on climate change have failed to prioritize the impact of climate change on health – particularly in least developed countries. This failure to anticipate climate-related disease burdens is likely to be extremely costly for health interests.
Recently many of you had the opportunity to meet with Stephen Lewis as part of the USC Institute for Global Health’s lecture series. Lewis is a key figure in global health and human rights, having spent his career fighting at the highest level of politics for women and those suffering from HIV. His message to you was clear – the earth is dying and as a consequence so are we all. He urged you, and I am going to echo his call, to focus your careers on ensuring that the earth and human kind survives. The global health community will not be able to do this alone. However, it will be an essential partner in collecting the evidence-base, translating the evidence into effective policy solutions, and advocating like mad to ensure that policy changes are made before human health as we know it is lost forever.  

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