What is the most important thing the U.S. can do to improve global health over the next 15 years?

The question of priorities for US global health policy is a critical one if we are to see substantial improvement in global health over the next 15 years. The breadth and complexity of what must be accomplished demands a cross‐cutting, strategic approach that will provide the greatest value‐added for health per dollar spent. As many dollars are already spent, for example on HIV through PEPFAR, I will take the question to mean, “What is the most important thing the US can do in addition to what it is already doing, to improve global health over the next 15 years.” To this end, I argue that a policy promoting research, development, and implementation of structural interventions in two key global health sectors, medication management and influenza control, will have the greatest overall benefit for global health in the coming 15 years. Structural interventions are policies and programs that change the contexts in which individuals engage in protective health behaviors such as avoiding infectious diseases, seeking treatment or improving healthy lifestyles. As such, structural interventions offer the promise of big gains by promoting high impact in the widest possible array of vulnerable populations of concern to the global health community. Despite this breadth, structural interventions must nonetheless be highly specified and focused on evidence‐based initiatives with feasible implementation strategies within realistic timeframes. The two sectors mentioned provide precisely this opportunity.

By structural intervention for medication management I mean a collection of policies that will enhance the effectiveness, reach and impact of medications by providing incentives for development, ensuring affordability, facilitating distribution, and optimizing adherence to medications. This sector lends itself to structural approaches and should include a three‐pronged strategy that reinforces innovation in pharmaceutical companies, relaxes intellectual property laws in order to expand access and affordability, and optimizes adherence to medication regimens. The first objective can be accomplished through the establishment of US‐funded pharmaceutical subsidiaries that would guarantee sufficient entry markets and returns on investment while patent terms are shortened and prices are discounted to reflect stable and increasing demand. The Clinton initiative has already set an example in this regard by shifting highly active antiretroviral therapy (HAART) from a niche market to more affordable mass market. This model should be continued and expanded. Critically, a focus on effective adherence interventions must constitute a central piece of this strategy as adherence is the modifiable variable that ultimately determines health outcomes. Typically adherence averages only 50%, that is 50% of medications taken as prescribed by a target population, yet the best treatment outcomes require much higher adherence. For example, HIV and TB outcomes are dependent on exceptional adherence, often in excess of 95% of medications taken according to prescription. The use of mobile phone technology provides the best way forward for promoting adherence in the most hard‐to‐reach and vulnerable populations. My work with HIV+ refugees and host communities who access HAART through advances in affordability and distribution has demonstrated to me the difficult conditions under which vulnerable populations must adhere to HAART.

My friendship with an entrepreneur who has developed a mobile platform that facilitates communications to vulnerable populations has highlighted for me the potential of developing adherence monitoring and intervention capabilities at the lowest cost by using mobile technology. While assisting with adherence, mobile phones can simultaneously support other health‐supporting initiatives related to employment, food aid, or communicating health messages in the event of outbreaks or other health emergencies. The seeds have been planted as nascent studies designed to investigate the effectiveness of mobile or PDA‐based interventions are underway. The US should support the development, testing, and implementation of more interventions that make use of mobile technology to enhance adherence. The ability to tailor health messages to populations, sub‐ groups, and even individuals at risk of suboptimal adherence is the way forward for ensuring hard won victories in drug development are translated into the best possible outcomes for vulnerable populations.

Influenza control is a second key sector that affords the best opportunity for well designed structural interventions to provide big gains for global health. The threat of a pandemic presents the greatest risk to vulnerable populations. The real threat of pandemic influenza in terms of morbidity, mortality, and even political stability lies in the developing world. The true toll of the 1918 flu pandemic was significantly underestimated as millions of additional deaths in the developing world went un‐ or undercounted. As the current novel H1N1 pandemic has shown us, interventions in influenza control including the production and distribution of antiviral agents and enhancing the capacity of local health facilities to deal with the treatment of influenza, will save millions of lives when the next virulent influenza pandemic strikes. This strategy will have the knock‐on effect of strengthening the basic health infrastructure that ultimately sustains global health in a stable and effective fashion.