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• Published: 07 April 2020

What is global health? Key concepts and clarification of misperceptions

Report of the 2019 GHRP editorial meeting

• Xinguang Chen 1 , 2 ,
• Hao Li 1 , 3 ,
• Don Eliseo Lucero-Prisno III 4 ,
• Abu S. Abdullah 5 , 6 ,
• Jiayan Huang 7 ,
• Charlotte Laurence 8 ,
• Xiaohui Liang 1 , 3 ,
• Zhenyu Ma 9 ,
• Zongfu Mao 1 , 3 ,
• Ran Ren 10 ,
• Shaolong Wu 11 ,
• Nan Wang 1 , 3 ,
• Peigang Wang 1 , 3 ,
• Tingting Wang 1 , 3 ,
• Hong Yan 3 &
• Yuliang Zou 3  

Global Health Research and Policy volume  5 , Article number:  14 ( 2020 ) Cite this article

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The call for “W orking Together to Build a Community of Shared Future for Mankind” requires us to improve people’s health across the globe, while global health development entails a satisfactory answer to a fundamental question: “What is global health?” To promote research, teaching, policymaking, and practice in global health, we summarize the main points on the definition of global health from the Editorial Board Meeting of Global Health Research and Policy, convened in July 2019 in Wuhan, China. The meeting functioned as a platform for free brainstorming, in-depth discussion, and post-meeting synthesizing. Through the meeting, we have reached a consensus that global health can be considered as a general guiding principle, an organizing framework for thinking and action, a new branch of sciences and specialized discipline in the large family of public health and medicine. The word “global” in global health can be subjective or objective, depending on the context and setting. In addition to dual-, multi-country and global, a project or a study conducted at a local area can be global if it (1) is framed with a global perspective, (2) intends to address an issue with global impact, and/or (3) seeks global solutions to an issue, such as frameworks, strategies, policies, laws, and regulations. In this regard, global health is eventually an extension of “international health” by borrowing related knowledge, theories, technologies and methodologies from public health and medicine. Although global health is a concept that will continue to evolve, our conceptualization through group effort provides, to date, a comprehensive understanding. This report helps to inform individuals in the global health community to advance global health science and practice, and recommend to take advantage of the Belt and Road Initiative proposed by China.

“Promoting Health For All” can be considered as the mission of global health for collective efforts to build “a Community of Shared Future for Mankind” first proposed by President Xi Jinping of China in 2013. The concept of global health continues to evolve along with the rapid development in global health research, education, policymaking, and practice. It has been promoted on various platforms for exchange, including conferences, workshops and academic journals. Within the Editorial Board of Global Health Research and Policy (GHRP), many members expressed their own points of view and often disagreed with each other with regard to the concept of global health. Substantial discrepancies in the definition of global health will not only affect the daily work of the Editorial Board of GHRP, but also impede the development of global health sciences.

To promote a better understanding of the term “ global health” , we convened a special session in the 2019 GHRP Editorial Board Meeting on the 7th of July at Wuhan University, China. The session started with a review of previous work on the concept of global health by researchers from different institutions across the globe, followed by free brainstorms, questions-answers and open discussion. Individual participants raised many questions and generously shared their thoughts and understanding of the term global health. The session was ended with a summary co-led by Dr. Xinguang Chen and Dr. Hao Li. Post-meeting efforts were thus organized to further synthesize the opinions and comments gathered during the meeting and post-meeting development through emails, telephone calls and in-person communications. With all these efforts together, concensus have been met on several key concepts and a number of confusions have been clarified regarding global health. In this editorial, we report the main results and conclusions.

A brief history

Our current understanding of the concept of global health is based on information in the literature in the past seven to eight decades. Global health as a scientific term first appeared in the literature in the 1940s [ 1 ]. It was subsequently used by the World Health Organization (WHO) as guidance and theoretical foundation [ 2 , 3 , 4 ]. Few scholars discussed the concept of global health until the 1990s, and the number of papers on this topic has risen rapidly in the subsequent decade [ 5 ] when global health was promoted under the Global Health Initiative - a global health plan signed by the U.S. President Barack Obama [ 6 ]. As a key part of the national strategy in economic globalization, security and international policies, global health in the United States has promoted collaborations across countries to deal with challenging medical and health issues through federal funding, development aids, capacity building, education, scientific research, policymaking and implementation.

Based on his experience working with Professor Zongfu Mao, the lead Editors-in-Chief, who established the Global Health Institute at Wuhan University in 2011 and launched the GHRP in 2016, Dr. Chen presented his own thoughts surrounding the definition of global health to the 2019 GHRP Editorial Board Meeting. Briefly, Dr. Chen defined global health with a three-dimensional perspective.

First, global health can be considered as a guiding principle, a branch of health sciences, and a specialized discipline within the broader arena of public health and medicine [ 5 ]. As many researchers posit, global health first serves as a guiding principle for people who would like to contribute to the health of all people across the globe [ 5 , 7 , 8 ].

Second, Dr. Chen’s conceptualization of global health is consistent with the opinions of many other scholars. Global health as a branch of sciences focuses primarily on the medical and health issues with global impact or can be effectively addressed through global solutions [ 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ]. Therefore, the goal of global health science is to understand global medical and health issues and develop global solutions and implications [ 7 , 9 , 15 , 17 , 18 , 19 ].

Third, according to Dr. Chen, to develop global health as a branch of science in the fields of public health and medicine, a specialized discipline must be established, including educational institutions, research entities, and academic societies. Only with such infrastructure, can the professionals and students in the global health field receive academic training, conduct global health research, exchange and disseminate research findings, and promote global health practices [ 5 , 15 , 20 , 21 , 22 , 23 ].

Developmentally and historically, we have learned and will continue to learn global health from the WHO [ 1 , 4 , 24 , 25 ]. WHO’s projects are often ambitious, involving multiple countries, or even global in scope. Through research and action projects, the WHO has established a solid knowledge base, relevant theories, models, methodologies, valuable data, and lots of experiences that can be directly used in developing global health [ 26 , 27 , 28 , 29 ]. Typical examples include WHO’s efforts for global HIV/AIDS control [ 13 , 30 , 31 , 32 ], and the Primary Healthcare Programs to promote Health For All [ 33 , 34 ].

The definition of Global Health

From published studies in the international literature and our experiences in research, training, teaching and practice, our meeting reached a consensus-global health is a newly established branch of health sciences, growing out from medicine, public health and international health, with much input from the WHO. What makes global health different from them is that (1) global health deals with only medical and health issues with global impact [ 35 , 5 , 36 , 10 , 14 , 2 ] the main task of global health is to seek for global solutions to the issues with global health impact [ 7 , 18 , 37 ]; and (3) the ultimate goal is to use the power of academic research and science to promote health for all, and to improve health equity and reduce health disparities [ 7 , 14 , 15 , 18 , 38 ]. Therefore, global health targets populations in all countries and involves all sectors beyond medical and health systems, although global health research and practice can be conducted locally [ 39 ].

As a branch of medical and health sciences, global health has three fundamental tasks: (1) to master the spatio-temporal patterns of a medical and/or health issue across the globe to gain a better understanding of the issue and to assess its global impact [ 40 , 41 , 42 , 43 ]; (2) to investigate the determinants and influential factors associated with medical and health issues that are known to have global impact [ 15 , 40 , 41 , 42 , 43 ]; and (3) to establish evidence-based global solutions, including strategies, frameworks, governances, policies, regulations and laws [ 14 , 15 , 28 , 38 , 44 , 45 , 46 , 47 ].

Like public health, medicine, and other branches of sciences, global health should have three basic functions : The first function is to generate new knowledge and theories about global health issues, influential factors, and develop global solutions. The second function is to distribute the knowledge through education, training, publication and other forms of knowledge sharing. The last function is to apply the global health knowledge, theories, and intervention strategies in practice to solve global health problems.

Understanding the word “global”

Confusion in understanding the term ‘global health’ has largely resulted from our understanding of the word “global”. There are few discrepancies when the word ‘global’ is used in other settings such as in geography. In there, the world global physically pertains to the Earth we live on, including all people and all countries in the world. However, discrepancies appear when the word “global” is combined with the word “health” to form the term “global health”. Following the word “global” literately, an institution, a research project, or an article can be considered as global only if it encompasses all people and all countries in the world. If we follow this understanding, few of the work we are doing now belong to global health; even the work by WHO are for member countries only, not for all people and all countries in the world. But most studies published in various global health journals, including those in our GHRP, are conducted at a local or international level. How could this global health happen?

The argument presented above leads to another conceptualization: Global health means health for a very large group of people in a very large geographic area such as the Western Pacific, Africa, Asia, Europe, and Latin America. Along with this line of understanding, an institution, a research project or an article involving multi-countries and places can be considered as global, including those conducted in countries involved in China’s Belt and Road Initiative (BRI) [ 26 , 48 , 49 , 50 , 51 ]. They are considered as global because they meet our definitions of global health which focus on medical and health issues with global impact or look for global solutions to a medical or health issue [ 5 , 7 , 22 ].

One step further, the word ‘global’ can be considered as a concept of goal-setting in global health. Typical examples of this understanding are the goals established for a global health institution, for faculty specialized in global health, and for students who major or minor in global health. Although few of the global health institutions, scholars and students have conducted or are going to conduct research studies with a global sample or delivered interventions to all people in all countries, all of them share a common goal: Preventing diseases and promoting health for all people in the world. For example, preventing HIV transmission within Wuhan would not necessarily be a global health project; but the same project can be considered as global if it is guided by a global perspective, analyzed with methods with global link such as phylogenetic analysis [ 52 , 53 ], and the goal is to contribute to global implications to end HIV/AIDS epidemic.

The concept of global impact

Global impact is a key concept for global health. Different from other public health and medical disciplines, global health can address any issue that has a global impact on the health of human kind, including health system problems that have already affected or will affect a large number of people or countries across the globe. Three illustrative examples are (1) the SARS epidemic that occurred in several areas in Hong Kong could spread globally in a short period [ 11 ] to cause many medical and public health challenges [ 54 , 55 ]; (2) the global epidemic of HIV/AIDS [ 13 ]; and the novel coronavirus epidemic first broke out in December 2019 in Wuhan and quickly spread to many countries in the world [ 56 ].

Along with rapid and unevenly paced globalization, economic growth, and technological development, more and more medical and health issues with global impact emerge. Typical examples include growing health disparities, migration-related medical and health issues, issues related to internet abuse, the spread of sedentary lifestyles and lack of physical activity, obesity, increasing rates of substance abuse, depression, suicide and many other emerging mental health issues, and so on [ 10 , 23 , 36 , 42 , 57 , 58 , 59 , 60 ]. GHRP is expecting to receive and publish more studies targeting these issues guided by a global health perspective and supports more researchers to look for global solutions to these issues.

The concept of global solution

Another concept parallel to global impact is global solution . What do we mean by global solutions? Different from the conventional understanding in public health and medicine, global health selectively targets issues with global impact. Such issues often can only be effectively solved at the macro level through cross-cultural, international, and/or even global collaboration and cooperation among different entities and stakeholders. Furthermore, as long as the problem is solved, it will benefit a large number of population. We term this type of interventions as a global solution. For example, the 90–90-90 strategy promoted by the WHO is a global solution to end the HIV/AIDS epidemic [ 61 , 62 ]; the measures used to end the SARS epidemic is a global solution [ 11 ]; and the ongoing measures to control influenza [ 63 , 64 ] and malaria [ 45 , 65 ], and the measures taken by China, WHO and many countries in the world to control the new coronaviral epidemic started in China are also great examples of global solutions [ 66 ].

Global solutions are also needed for many emerging health problems, including cardiovascular diseases, sedentary lifestyle, obesity, internet abuse, drug abuse, tobacco smoking, suicide, and other problems [ 29 , 44 ]. As described earlier, global solutions are not often a medical intervention or a procedure for individual patients but frameworks, policies, strategies, laws and regulations. Using social media to deliver interventions represents a promising approach in establishment of global solutions, given its power to penetrate physical barriers and can reach a large body of audience quickly.

Types of Global Health researches

One challenge to GHRP editors (and authors alike) is how to judge whether a research study is global? Based on the new definition of global health we proposed as described above, two types of studies are considered as global and will receive further reviews for publication consideration. Type I includes projects or studies that involve multiple countries with diverse backgrounds or cover a large diverse populations residing in a broad geographical area. Type II includes projects or studies guided by a global perspective, although they may use data from a local population or a local territory. Relative to Type I, we anticipate more Type II project and studies in the field of global health. Type I study is easy to assess, but caution is needed to assess if a project or a study is Type II. Therefore, we propose the following three points for consideration: (1) if the targeted issues are of global health impact, (2) if the research is attempted to understand an issue with a global perspective, and (3) if the research purpose is to seek for a global solution.

An illustrative example of Type I studies is the epidemic and control of SARS in Hong Kong [ 11 , 67 ]. Although started locally, SARS presents a global threat; while controlling the epidemic requires international and global collaboration, including measures to confine the infected and measures to block the transmission paths and measures to protect vulnerable populations, not simply the provisions of vaccines and medicines. HIV/AIDS presents another example of Type I project. The impact of HIV/AIDS is global. Any HIV/AIDS studies regardless of their scope will be global as long as it contributes to the global efforts to end the HIV/AIDS epidemic by 2030 [ 61 , 62 ]. Lastly, an investigation of cardiovascular diseases (CVD) in a country, in Nepal for example, can be considered as global if the study is framed from a global perspective [ 44 ].

The discussion presented above suggests that in addition to scope, the purpose of a project or study can determine if it is global. A pharmaceutical company can target all people in the world to develop a new drug. The research would be considered as global if the purpose is to improve the medical and health conditions of the global population. However, it would not be considered as global if the purpose is purely to pursue profit. A research study on a medical or health problem among rural-to-urban migrants in China [ 57 , 58 , 60 ] can be considered as global if the researchers frame the study with a global perspective and include an objective to inform other countries in the world to deal with the same or similar issues.

Think globally and act locally

The catchphrase “think globally and act locally” presents another guiding principle for global health and can be used to help determine whether a medical or public health research project or a study is global. First, thinking globally and acting locally means to learn from each other in understanding and solving local health problems with the broadest perspective possible. Taking traffic accidents as an example, traffic accidents increase rapidly in many countries undergoing rapid economic growth [ 68 , 69 ]. There are two approaches to the problem: (1) locally focused approach: conducting research studies locally to identify influential factors and to seek for solutions based on local research findings; or (2) a globally focused approach: conducting the same research with a global perspective by learning from other countries with successful solutions to issues related traffic accidents [ 70 ].

Second, thinking globally and acting locally means adopting solutions that haven been proven effective in other comparable settings. It may greatly increase the efficiency to solve many global health issues if we approach these issues with a globally focused perspective. For example, vector-borne diseases are very prevalent among people living in many countries in Africa and Latin America, such as malaria, dengue, and chikungunya [ 45 , 71 , 72 ]. We would be able to control these epidemics by directly adopting the successful strategy of massive use of bed nets that has been proven to be effective and cost-saving [ 73 ]. Unfortunately, this strategy is included only as “simple alternative measures” in the so-called global vector-borne disease control in these countries, while most resources are channeled towards more advanced technologies and vaccinations [ 16 , 19 , 74 ].

Third, thinking globally and acting locally means learning from each other at different levels. At the individual level, people in high income countries can learn from those in low- and mid-income countries (LMICs) to be physically more active, such as playing Taiji, Yoga, etc.; while people in LMICs can learn from those in high income countries to improve their hygiene, life styles, personal health management, etc. At the population level, communities, organizations, governments, and countries can learn from each other in understanding their own medical and health problems and healthcare systems, and to seek solutions for these problems. For example, China can learn from the United States to deal with health issues of rural to urban migrants [ 75 ]; and the United States can learn from China to build three-tier health care systems to deliver primary care and prevention measures to improve health equality.

Lastly, thinking globally and acting locally means opportunities to conduct global health research and to be able to exchange research findings and experiences across the globe; even without traveling to another country. For example, international immigrants and international students present a unique opportunity for global health research in a local city [ 5 , 76 ]. To be global, literature search and review remains the most important approach for us to learn from each other besides conducting collaborative work with the like-minded researchers across countries; rapid development in big data and machine learning provide another powerful approach for global health research. Institutions and programs for global health provides a formal venue for such learning and exchange opportunities.

Reframing a local research study as global

The purpose of this article is to promote global health through research and publication. Anyone who reads this paper up to this point might already be able to have a clear idea on how to reframe his/her own research project or article to be of global nature. There is no doubt that a research project is global if it involves multiple countries with investigators of diverse backgrounds from different countries. However, if a research project targets a local population with investigators from only one or two local institutions, can such project be considered as global?

Our answer to this question is “yes” even if a research study is conducted locally, if the researcher (1) can demonstrate that the issue to be studied or being studied has a global impact, or (2) eventually looks for a global solution although supported with local data. For example, the study of increased traffic accidents in a city in Pakistan can be considered as global if the researchers frame the problem from a global perspective and/or adopt global solutions by learning from other countries. On the other hand, a statistical report of traffic accidents or an epidemiological investigation of factors related to the traffic accidents at the local level will not be considered as global. Studies conducted in a local hospital on drug resistance to antibiotics and associated cost are global if expected findings can inform other countries to prevent abuse of antibiotics [ 77 ]. Lastly, studies supported by international health programs can be packaged as global simply by broadening the vision from international to global.

Is Global Health a new bottle with old wine?

Another challenge question many scholars often ask is: “What new things can global health bring to public health and medicine?” The essence of this question is whether global health is simply a collection of existing medical and health problems packaged with a new title? From our previous discussion, many readers may already have their own answer to this question that this is not true. However, we would like to emphasize a few points. First, global health is not equal to public health, medicine or both, but a newly emerged sub-discipline within the public health-medicine arena. Global health is not for all medical and health problems but for the problems with global impact and with the purpose of seeking global solutions. In other words, global health focuses primarily on mega medical and health problems that transcend geographical, cultural, and national boundaries and seeks broad solutions, including frameworks, partnerships and cooperation, policies, laws and regulations that can be implemented through governments, social media, communities, and other large and broad reaching mechanisms.

Second, global health needs many visions, methods, strategies, approaches, and frameworks that are not conventionally used in public health and medicine [ 5 , 18 , 22 , 34 ]. They will enable global health researchers to locate and investigate those medical and health issues with global impact, gain new knowledge about them, develop new strategies to solve them, and train health workers to deliver the developed strategies. Consequently, geography, history, culture, sociology, governance, and laws that are optional for medicine and public health are essential for global health. Lastly, it is fundamental to have a global perspective for anyone in global health, but this could be optional for other medical and health scientists [ 40 , 41 ].

Global Health, international health, and public health

As previously discussed, global health has been linked to several other related disciplines, particularly public health, international health, and medicine [ 3 , 5 , 7 , 18 , 22 ]. To our understanding, global health can be considered as an application of medical and public health sciences together with other disciplines (1) in tackling those issues with global impact and (2) in the effort to seek global solutions. Thus, global health treats public health sciences and medicine as their foundations, and will selectively use theories, knowledge, techniques, therapeutics and prevention measures from public health, medicine, and other disciplines to understand and solve global health problems.

There are also clear boundaries between global health, public health and medicine with regard to the target population. Medicine targets patient populations, public health targets health populations in general, while global health targets the global population. We have to admit that there are obvious overlaps between global health, public health and medicine, particularly between global health and international health. It is worth noting that global health can be considered as an extension of international health with regard to the scope and purposes. International health focuses on the health of participating countries with intention to affect non-participating countries, while global health directly states that its goal is to promote health and prevent and treat diseases for all people in all countries across the globe. Thus, global health can be considered as developed from, and eventually replace international health.

Challenges and opportunities for China to contribute to Global Health

To pursue A Community with a Shared Future for Mankind , China’s BRI , currently involving more than 150 countries across the globe, creates a great opportunity for Chinese scholars to contribute to global health. China has a lot to learn from other countries in advancing its medical and health technologies and to optimize its own healthcare system, and to reduce health disparities among the 56 ethnic groups of its people. China can also gain knowledge from other countries to construct healthy lifestyles and avoid unhealthy behaviors as Chinese people become more affluent. Adequate materials and money may be able to promote physical health in China; but it will be challenging for Chinese people to avoid mental health problems currently highly prevalent in many rich and developed countries.

To develop global health, we cannot ignore the opportunities along with the BRI for Chinese scholars to share China’s lessons and successful experience with other countries. China has made a lot of achievements in public health and medicine before and after the Open Door Policy [ 49 , 78 ]. Typical examples include the ups and downs of the 3-Tier Healthcare Systems, the Policy of Prevention First, and the Policy of Putting Rural Health as the Priority, the Massive Patriotic Hygiene Movement with emphasis on simple technology and broad community participation, the Free Healthcare System for urban and the Cooperative Healthcare System for rural residents. There are many aspects of these initiatives that other countries can emulate including the implementation of public health programs covering a huge population base unprecedented in many other countries.

There are challenges for Chinese scholars to share China’s experiences with others as encountered in practice. First of all, China is politically very stable while many other countries have to change their national leadership periodically. Changes in leadership may result in changes in the delivery of evidence- based intervention programs/projects, although the changes may not be evidence-based but politically oriented. For example, the 3-Tier Healthcare System that worked in China [ 79 , 80 ] may not work in other countries and places without modifications to suit for the settings where there is a lack of local organizational systems. Culturally, promotion of common values among the public is unique in China, thus interventions that are effective among Chinese population may not work in countries and places where individualism dominates. For example, vaccination program as a global solution against infectious diseases showed great success in China, but not in the United States as indicated by the 2019 measles outbreak [ 81 ].

China can also learn from countries and international agencies such as the United Kingdom, the United States, the World Health Organization, and the United Nations to successfully and effectively provide assistance to LMICs. As China develops, it will increasingly take on the role of a donor country. Therefore, it is important for Chinese scholars to learn from all countries in the world and to work together for a Community of Shared Future for Mankind during the great course to develop global health.

Promotion of global health is an essential part of the Working Together  to Build a Community of Shared Future for Mankind. In this editorial, we summarized our discussions in the 2019 GHRP Editorial Board Meeting regarding the concept of global health. The goal is to enhance consensus among the board members as well as researchers, practitioners, educators and students in the global health community. We welcome comments, suggestions and critiques that may help further our understanding of the concept. We would like to keep the concept of global health open and let it evolve along with our research, teaching, policy and practice in global health.

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The work is funded by the journal development funds of Wuhan University.

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Xinguang Chen, Hao Li, Xiaohui Liang, Zongfu Mao, Nan Wang, Peigang Wang & Tingting Wang

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Xinguang Chen

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Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK

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Abu S. Abdullah

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Chen XG wrote the manuscript. LI H organized the meeting, collecting the comments and editing the manuscript. Lucero-Prisno DE integrated all the comments together. Abdullah AS, Huang JY, Laurence C, Liang XH, Ma ZY, Ren R, Wu SL, Wang N, Wang PG and Wang Tt all participated in the discussion and comments of this manuscript. Laurence C and Liang XH both provided language editing. The author(s) read and approved the final manuscript

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Chen, X., Li, H., Lucero-Prisno, D.E. et al. What is global health? Key concepts and clarification of misperceptions. glob health res policy 5 , 14 (2020). https://doi.org/10.1186/s41256-020-00142-7

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National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Global Health; Committee on Global Health and the Future of the United States. Global Health and the Future Role of the United States. Washington (DC): National Academies Press (US); 2017 May 15.

Global Health and the Future Role of the United States.

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10 Summary of Conclusions and Recommendations

The global vision that has brought improved travel and trade and increased interdependency among countries also calls for a common vision of health around the world. All countries are vulnerable to the ever-present threats of infectious disease, outbreaks, and epidemics. At the same time, there are opportunities for shared innovation and universal purpose as many countries that suffer from similar disease burdens strive to develop best practices and strong health systems for their citizens.

Throughout this consensus study, the committee emphasized the need for a more holistic examination of problems and challenges in global health. Such an approach applies not only to issues of global health security but also to the external factors that influence health security, such as the building of general capacity in countries and the creation of strong societies that foster stability, healthy lifestyles, and accessible economic opportunities. Unless core capacities and strong health systems are developed around the world, the global risk of infectious disease will continue to threaten the health and security of the United States. Beyond the imperative of addressing infectious disease threats, it is necessary to understand the fundamental connection between health and economic prosperity. In addition to the economic costs of responding to infectious disease outbreaks, the increasing prevalence of chronic or noncommunicable diseases (NCDs) has negatively affected global economies—compromising societal gains in life expectancy, productivity, and overall quality of life ( WEF, 2017 ).

Many countries currently face the dual burden of a rapid increase in NCDs, such as cardiovascular disease (CVD) and cancer, and the continuing need to eliminate infectious diseases, such as malaria and tuberculosis (TB), in addition to the priority of reducing the burden of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Moreover, some countries are considered to bear a triple burden, as traumatic injury has been found to be the second leading cause of premature death in young men after HIV/AIDS ( Marquez and Farrington, 2013 ). Combined, these three disease burdens can stall the progress of a country's development and significantly affect its ability to become a strong trading partner or a business or travel destination. The cost of productivity losses associated with disability, unplanned absences, and increased accidents can be as much as 400 percent higher than the cost of treatment ( WEF, 2010 ). Research also shows that investors are less likely to enter markets where the labor force suffers a heavy disease burden ( Bloom et al., 2004 ). Human capital clearly contributes significantly to economic growth, and it follows that having a healthy population is critical for economic prosperity. This point has been demonstrated in recent years: between 2000 and 2011, 24 percent of income growth in low- and middle-income countries (LMICs) resulted from improvements in health ( Jamison et al., 2013 ).

The root causes of all three of these health burdens are often linked by such underlying social factors as poverty, education, and location ( Frenk and Gómez-Dantés, 2016 ; Marmot, 2005 ). This commonality suggests that methods for prevention are linked as well, and the tools used to prevent one burden can help to prevent the others, emphasizing the need for holistic examination of programs. Over the last few decades, the United States has demonstrated remarkable leadership in global health. Notable progress has been achieved by such initiatives as The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and the President's Malaria Initiative (PMI), as well as the nation's commitment to such multilateral organizations as the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); Gavi, the Vaccine Alliance; and, more recently, the Global Health Security Agenda (GHSA). Similarly, progress has been achieved by efforts to combat antimicrobial resistance (AMR) at the national and international levels. Against the backdrop of an influential legacy on the global health stage, the new U.S. administration faces the choice of whether or not to ensure that the gains won with billions of U.S. dollars, years of dedication, and strong programs are sustained and poised for further growth.

• CHANGING THE WAY THE UNITED STATES ENGAGES

The committee has focused this report where it believes the United States can have the most immediate and substantial effect despite the limited resources available. Throughout the report, the committee has highlighted four priority areas that demand continued attention from U.S. global health investment within a two-pronged approach of securing against global threats (areas 1 and 2), and promoting productivity and economic growth in other countries (areas 3 and 4):

achieving global health security (including addressing pandemics and AMR)

maintaining a sustained response to the continuous threats of communicable diseases such as HIV/AIDS, TB, and malaria

saving and improving the lives of women and children

promoting cardiovascular health and preventing cancer

In addition, the committee has underscored the imperative to change the way the United States does business in global health, highlighting an immediate need to focus on ensuring protection against global threats and enhancing productivity and economic growth in all countries. To these ends, a more systematic, proactive, and integrated approach is needed that includes long-range planning and vision; greater application of rigor and measurement in achieving return on investment; and cooperation with all global health partners to leverage the respective strengths of each, including the advancement of innovation through the private sector and political commitment to achieving global goals on the part of national governments and multilateral partners. This shift in approach places the focus on prevention and preparedness, with a vision of investing in cross-cutting infrastructure in three areas: catalyzing innovation in health systems through medical product development and digital health, enabling more flexible financing mechanisms to fund global health programs, and maintaining U.S. global health leadership internationally. The outcome of this approach will be resilient countries with positive health outcomes, resulting in turn in robust trade partners, safer travel destinations, and more active collaborators in preventing and controlling global health problems that affect citizens in every country, at every income level.

• SECURING AGAINST GLOBAL THREATS

Many laudable public health successes have been achieved at the global, regional, national, and community levels. However, the world continues to evolve, and public health measures must change accordingly. The global community is no safer from infectious disease today than it was 20 years ago when the Institute of Medicine report America's Vital Interest in Global Health ( IOM, 1997 ) was written. The U.S. Army recently estimated that if a severe infectious disease pandemic were to occur today, the number of U.S. fatalities could be almost double the total number of battlefield fatalities sustained in all of the nation's wars since the American Revolution ( GAO, 2017 ). Poverty and climate change have led to greater risk of mosquito-borne illness in the southern United States ( Hotez et al., 2014 ); AMR has been elevated to a global crisis by the United Nations (UN) ( UN, 2016 ); and the largest outbreak of influenza A (H7N9) to date is currently occurring in China ( Iuliano et al., 2017 ). The risk of transnational outbreaks may be greater today than ever before given recent dramatic increases in international trade and travel, urbanization, and population density, as well as critical biodiversity loss worldwide. Strong public health infrastructure is essential to combat these threats successfully wherever they may emerge. While the burden of infectious diseases rests predominantly with low-income countries, where limited resources and weak health care systems are unable to control and prevent them, these are global threats that can significantly affect any country, including the United States, and that need to be understood as a threat to U.S. national security.

As noted above, the costs of infectious diseases extend beyond human suffering and mortality through indirect impacts on economies. In just a few short months, for example, the 2003 outbreak of severe acute respiratory syndrome (SARS) cost the world between $30 and $54 billion ( Fan, 2003 ; World Bank, 2013 ). During the Ebola outbreak, which involved just four domestic cases, the United States spent $1.1 billion on domestic response ( Epstein et al., 2015 )—120 percent of the annual public health and health care preparedness budget for state and local health department and hospital capacity. 1 Between October 2014 and December 2015, $119 million was spent just on domestic migration and quarantine activities, such as airport screening and follow-up of potentially sick passengers, costing an average of more than $4,000 per passenger ( CDC, 2016 ). 2 And direct costs for just two Ebola patients treated at the specialty center in Nebraska were estimated at more than $1 million ( Gold, 2014 ).

Looking forward, a moderate influenza pandemic 3 is projected to cost the world $570 billion annually in terms of income loss and mortality ( Fan et al., 2016 ) with some estimates as high as $2 trillion ( Burns et al., 2008 ). Furthermore, the threat of AMR continues to grow because of poor stewardship, weak surveillance systems, and a lack of second-line therapeutics in the development pipeline. And in addition to naturally occurring threats is the potential for terrorist use of man-made biological weapons. Regardless of whether epidemics or biosecurity threats originate naturally or through human engineering, it is critical for the United States to recognize the severity of these threats and take proactive measures to build capacities and establish sustainable and cost-effective infrastructure to combat them.

Coordination of International Health Emergency Response

As experienced during the Ebola outbreak in 2014, the U.S. population's indifference to remote diseases can quickly turn to panic when even a single suspected case is reported within U.S. borders. The U.S. government implements extreme, government-wide responses to such occurrences—costing tremendous amounts of time and money—in a piecemeal, reactive fashion that can actually impede swift and efficient action, delaying response and discouraging private-sector involvement. While multiple agencies can bring unique expertise to a U.S. government–led response, it is difficult to execute a coordinated emergency plan in the midst of a crisis without a clear chain of command, a dedicated budget, and designated leadership. There is a need for a framework to guide international response to public health emergencies, similar to the domestic National Response Framework. While the Obama administration attempted this level of coordination on the fly with the creation of an Ebola czar, it would be more effective to consider the need for coordination in advance.

In addition to coordination, rapid access to funds during a response is of paramount importance to mobilizing assets and implementing needed interventions. After 7 months of disagreement and delay in fulfilling President Obama's request for $1.9 billion in Zika funding, Congress finally approved $1.1 billion with the passing of H.R. 5243 4 ( Wexler et al., 2016 ). Before this approval was secured, agencies were forced to shift funds from other accounts for Zika-related activities, including by borrowing money from the Ebola supplemental funding and from the U.S. Centers for Disease Control and Prevention's (CDC's) state-level emergency public health care preparedness account ( Epstein and Lister, 2016 ; Kodjak, 2016 ). While the appropriate focus is on prevention and preparedness, some level of response will always be necessary. To enable swift and rapid response when necessary, the committee supports the creation of a public health emergency response fund, to be used only in declared health emergencies.

Finally, the development of needed vaccines, therapeutic agents, and diagnostics is severely inadequate to enable the United States and the world to respond effectively to these global health threats. Currently, product development for response to pandemic and bioterror threats depends on the interagency Public Health Emergency Medical Countermeasures Enterprise, which is limited by annual appropriations and dependent on the goodwill of industry partners. Adequately protecting U.S. citizens requires long-term planning and vision that enables the development of strong and comprehensive capabilities to detect and diagnose pandemic threats wherever they occur, ensure the availability of needed medical products, reduce the risk of transmission, and properly treat and care for infected patients here in the United States. A critical medical product development fund supporting long-term, stable research and development through the engagement of industry, academia, and other partners would ensure the development of critical drugs, vaccines, and diagnostics.

Preparedness and Capacity Building for Global Health Security

Public health infrastructure in most countries, including the United States, is extremely underresourced or nonexistent, making levels of preparedness, even for everyday emergencies, decades behind where they should be and allowing for significant risks when a disaster does strike. Funding levels for U.S. health preparedness have been severely reduced since the Public Health Security and Bioterrorism Response Act was enacted in 2002. A dual focus on health preparedness at home and abroad is essential to reduce the risk of outbreaks and the transmission of infectious disease to U.S. citizens. To this end, it is necessary to build core preparedness capacities and public health infrastructure in the United States and in LMICs, supported by such partnerships as the GHSA.

While a portion of the Ebola supplemental funding was directed toward nonspecific capacity building over 5 years, the sustainability of funding thereafter is unclear. This sustainability is also vulnerable to new or reemerging diseases; Ebola funding was the first coffer proposed to be tapped upon the emergence of Zika ( Epstein and Lister, 2016 ). By contrast, a sustained level of investment in multidisciplinary One Health systems 5 can result in $15 billion in annual expected benefits from the prevention of mild pandemics and other major outbreaks ( World Bank, 2012 ). Assuming that improved systems could detect and control even half of incipient pandemics, the rates of return are well above those on nearly all other public spending and private capital markets ( World Bank, 2012 ), making this capacity building a smart investment. Enabling the right institutional capacity to reduce health risks, respond to emergencies, and innovate to improve the actions taken can dramatically improve the prevention and control of and response to health threats. At the same time, it is essential to remain engaged and coordinated with domestic and international stakeholders, including the World Health Organization (WHO), the UN Secretary-General's Committee on AMR, and the GHSA.

Recommendation 1: Improve International Emergency Response Coordination

The administration should create a coordinating body for international public health emergency response that is accountable for international and domestic actions and oversees preparedness for and responses to global health security threats. This body should have its own budget, experience with handling logistics, and the authority necessary to coordinate players across the government at the deputy secretary level. This coordinating body should do the following: Oversee the creation of an International Response Framework to guide the U.S. response to an international health emergency. Through this framework, this body would coordinate and direct activities involved in international response and preparedness, but would not duplicate functions already established in the Office of the Assistant Secretary for Preparedness and Response, the U.S. Centers for Disease Control and Prevention, the U.S. Agency for International Development, or the U.S. Department of Defense. Oversee three separate funding streams, dedicated to investments in preparedness, emergency response, and critical medical product development. The Office of Management and Budget should conduct an analysis to determine the appropriate levels for these three funding streams, commensurate with the associated risk, understanding that predictable and timely funds for these three purposes are critical. Align and coordinate efforts with effective multilateral organizations to reduce duplication and promote efficiency in building capacity and resilience in other countries.

Recommendation 2: Combat Antimicrobial Resistance

The U.S. Department of Health and Human Services, the U.S. Department of Defense, the U.S. Department of Agriculture, and the U.S. Agency for International Development (USAID) should continue to invest in national capabilities and accelerate the development of international capabilities to detect, monitor, report, and combat antibiotic resistance. Efforts to this end should include the following: Enhance surveillance systems to ensure that new resistant microbial strains are identified as soon as they emerge. Assist low-income countries in improving infection control and antimicrobial stewardship. USAID should leverage current supply chain partnerships with other countries to strengthen antibiotic supply chains, thus reducing the use of illegitimate antimicrobials and improving drug quality. Incentivize the development of therapeutics (including alternatives to antibiotics), vaccines, and diagnostics for use in humans and animals.

Recommendation 3: Build Public Health Capacity in Low- and Middle-Income Countries

The U.S. Centers for Disease Control and Prevention, the National Institutes of Health, the U.S. Department of Defense, and the U.S. Agency for International Development should expand training and information exchange efforts to increase the capacity of low- and middle-income countries to respond to both public health emergencies and acute mass casualty disasters. This training and information exchange should encompass core capacities such as surveillance, epidemiology, and disaster and injury care response, as well as enhanced capabilities to improve communication and information pathways for the dissemination of innovative findings.

Maintaining a Sustained Response to Continuous Threats: HIV/AIDS, Tuberculosis, and Malaria

Considerable successes have been achieved in slowing the advancement of HIV/AIDS, TB, and malaria worldwide, as evidenced by the millions of lives saved. However, these diseases are continuing health threats that can jeopardize global security and inflict a high cost on the economies of the countries in which they are prevalent. As of the end of 2015, there remained more than 36.7 million people living with HIV/AIDS globally ( UNAIDS, 2015b ), and there were more than 1.1 million deaths from AIDS ( UNAIDS, 2015a ). In 2015, 1.4 million people died from TB ( WHO, 2016b ), and 429,000 people died from malaria ( WHO, 2016d ). Complacency toward these diseases can lead to severe risk and harm for the entire global community, as all three are capable of developing strains resistant to currently available treatments. Should that occur, an even more lethal resurgence of these diseases would likely take place, threatening all progress made on these diseases in previous decades.

PEPFAR has played a key role in successfully slowing the HIV/AIDS epidemic globally since 2003, reducing new infections, and helping to save millions of lives around the world ( PEPFAR, 2017 ). In addition to this progress on its primary goal, studies have shown that the countries in which PEPFAR is active had better opinions of the United States ( Daschle and Frist, 2015 ) and also saw 13 percent increase in employment rates among men compared to non-PEPFAR countries ( Wagner et al., 2015 ).

As a truly bipartisan, collaborative program that has undergone transitions and shifts throughout the last 15 years, PEPFAR has adapted its focus to changes in the HIV/AIDS epidemic from that of a highly lethal, rapidly spreading emergency to one that requires sustaining care while targeting at-risk populations. Yet this work is far from finished, as 2 million new HIV infections still occur each year, and millions are without access to treatment ( PEPFAR, 2017 ). The next phase of PEPFAR will continue to require cross-sector and data-driven efforts to dramatically reduce the number of new HIV infections and AIDS-related deaths globally by 2030. However it will also rely on continued and expanded partnerships with the private sector and communities. A promising example is PEPFAR's multidisciplinary Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women (DREAMS) partnership, which focuses on lowering rates of HIV infection in young women by addressing multiple factors outside of the health sector that affect rates of infection (e.g., enabling and encouraging them to stay in school, addressing gender-based violence, and changing community norms). Given the substantial reduction in the costs of drugs used to treat HIV/AIDS, the increased involvement of private-sector partnerships, and the effect of treatment on preventing new infections, program ownership should continue shifting to host countries where possible. PEPFAR also should leverage its existing structures and platforms to address other priority health issues for its HIV-infected patient population, based on country needs.

Recommendation 4: Envision the Next Generation of PEPFAR

With its next reauthorization, Congress should fund The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) at current levels, and allow for more flexibility within the PEPFAR program by continuing to relax specific funding targets for all program areas. Continued accountability, efficiency, and measurement of results should be emphasized. In the future, moreover, PEPFAR should focus on the following key areas: Ensure that national governments assume greater ownership of national HIV/AIDS programs through joint planning and decision making, and that they increase domestic funding to help cover the costs of prevention and treatment. Adapt its delivery platform to become more of a cost-effective, chronic care system that is incorporated into each country's health system and priorities. Continue to support the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), and rely on it for specific functions where it has the comparative advantage. Such functions could include the Global Fund's efficient procurement of products and multipartner efforts to encourage countries to transition to domestic sources of funding. Enhance emphasis on primary prevention through multisector efforts, including strong interventions against gender-based violence, given that many new HIV infections are occurring in adolescent girls.

Tuberculosis

Unfortunately, TB has not shown the same progress in treatment and prevention as HIV/AIDS and has been a historically underfunded disease. In 2015, there were 10.4 million new cases of TB and 1.4 million attributable deaths ( WHO, 2016b ). Further complicating efforts to combat this disease is the rapid rise of multidrug-resistant strains of TB (MDR-TB). The current available drug regimens for TB, MDR-TB, and a more severe extensively drug-resistant TB (XDR-TB) are lengthy and complex and frequently have low success rates ( WHO, 2016b ). Furthermore, treatment for MDR-TB and XDR-TB can cost 100 times as much as treatment for nonresistant TB ( Laurence et al., 2015 ; Nieburg et al., 2015 ; Pooran et al., 2013 ). With few drugs available to treat MDR-TB and XDR-TB and little progress on new treatment options, TB and its drug-resistant strains pose a growing threat to the health and health security of all countries, including the United States. TB has been a priority for the United States since passage of the Foreign Service Act of 1961, and in 2010 the U.S. Agency for International Development (USAID) laid out a sweeping strategy 6 for combating global TB. Of the $4 billion authorized over 5 years to implement this strategy, however, only 40 percent was ever appropriated. The U.S. government's underprioritization of TB undercuts its capability to reduce the global burden of disease. Accordingly, the U.S. government should reevaluate its investment in and strategies for combating TB.

Recommendation 5: Confront the Threat of Tuberculosis

The U.S. Centers for Disease Control and Prevention, the National Institute of Allergy and Infectious Diseases, and the U.S. Agency for International Development should conduct a thorough global threat assessment of rising tuberculosis (TB) levels, including multidrug-resistant TB and extensively drug-resistant TB. They should then execute a plan of action, including governance structure and priority activities, for developing and investing in new diagnostics, drugs, vaccines, and delivery systems.

Commensurate with the dedicated investment in combating malaria by the global community are tremendous successes in preventing and controlling the disease, with an estimated 41 percent reduction in incidence since 2000 and a 62 percent reduction in mortality rates globally ( WHO, 2016d ). This progress has been possible in large part because of increases in programmatic and financial support—from $100 million in 2000 ( WHO, 2013 ) to $2.9 billion in 2015 ( WHO, 2016d ;). Through PMI and the Global Fund, which accounted for an estimated 35 percent of global funding for malaria efforts in 2015, the United States has, both directly and indirectly, been a major contributor to this success ( WHO, 2016d ). While the investment in malaria may appear costly, a cost–benefit analysis modeling the effect of global reduction and elimination of the disease found that the net gains in economic output would be worth $208.6 billion ( Purdy et al., 2013 ).

As a result of these investments, elimination of malaria has become a realistic goal for many countries. Some countries can now declare themselves malaria-free, a welcome status for not only healthier communities but also healthier economies. Additionally, since 2006, all 15 PMI countries have seen up to 50 percent reductions in child mortality due to malaria infection ( USAID, 2014 ). However, malaria still imposes a major burden of disease, with 212 million cases occurring in 2015 ( WHO, 2016d ), further imposing a financial burden on families and country economies. Malaria can cost families 25 percent of their income through lost days of work and prevention and treatment costs, and since 2000, average annual costs to sub-Saharan Africa totaled nearly $300 million simply for case management ( UNICEF, 2004 ; WHO, 2015a ). Given these high costs to individuals and countries and the threat of drug-resistant strains, a sustained, dedicated focus on malaria should continue.

Recommendation 6: Sustain Progress toward Malaria Elimination

Relevant agencies of the U.S. government should continue their commitment to the fight against malaria through the President's Malaria Initiative and collaborative work with all partners toward elimination of the disease.

• ENHANCING PRODUCTIVITY AND ECONOMIC GROWTH

The general health and well-being of other countries, including their burden of NCDs such as CVD and cancer, may at first glance not appear to be the top priority of donor countries such as the United States. However, investing in countries' prosperity and stability can result in greater order and predictability in the world, as well as promote U.S. health and prosperity and create more reliable and durable global partners. Premature death and disability stemming from NCDs coalesce to contribute to decreased productivity, decreased gross domestic product, and overall higher costs of health care because existing health systems are not designed to care for chronic disease in an integrated and holistic fashion ( OECD, 2011 ).

As prevention is always less costly than treatment, efforts to prevent premature death and disability from NCDs ideally begin at birth and continue across an individual's life course. Cost-effective investments made during a child's early years can mitigate deleterious effects of poverty and social inequality, often resulting in long-lasting gains through adulthood. Healthy behaviors formed during childhood also can have long-term effects. Interventions carried out during the very early years can even translate into lifelong benefits in terms of labor market participation, earnings, and economic growth, generating returns of up to 25 percent ( Gertler et al., 2014 ). Furthermore, the private sector has a clear interest in preventing NCDs as globalization continues to encourage international travel and trade. Multinational companies have workforces in many regions of the world and have interests in a productive and capable employee base, which also results in societies that are attractive places to locate their businesses.

Saving and Improving the Lives of Women and Children

Remarkable strides have been made in reducing mortality among women and children worldwide. Through the launch of the Ending Preventable Maternal and Child Death initiative, USAID has saved the lives of 46 million children and 200,000 women since 2008 ( USAID, 2017 ). Yet global mortality rates for both mothers and children under 5 are still unacceptably high, with maternal mortality at 216 deaths per 100,000 births and child mortality at 41 deaths per 1,000 live births. As a result, each year 5.9 million children die before their fifth birthday ( WHO, 2016a ), and an estimated 303,000 women die from causes related to pregnancy and childbirth ( WHO, 2016c ). The majority of these deaths are preventable through interventions whose effectiveness is supported by extremely strong evidence, but challenges remain around how to scale up these interventions. Accelerating investments in cost-effective, evidence-based interventions is critical to sustain the progress made thus far and further avoid preventable deaths of infants, children, adolescents, and pregnant and lactating women.

Recommendation 7: Improve Survival in Women and Children

Congress should increase funding for the U.S. Agency for International Development to augment the agency's investments in ending preventable maternal and child mortality, defined as global maternal mortality rates of fewer than 70 deaths per 100,000 live births by 2020 and fewer than 25 child deaths per 1,000 live births by 2030. Investments should focus on the most effective interventions and be supported by rigorous monitoring and evaluation. These priority interventions include immunizations; integrated management of child illness; nutrition (pregnant women, newborns, infants, children); prenatal care and safe delivery, including early identification of at-risk pregnancies, safe delivery, and access to emergency obstetrical care; and access to contraceptives and family planning.

The committee found that while continued investment in the survival agenda is critical, it is only part of the challenge. Without proper progress in development in the first 1,000 days of life, many adverse consequences resulting from disease and malnutrition can follow a child through life. Strong neurological evidence demonstrates long-term mental and physical effects of such early risk factors as poor nutrition, lack of nurturing care, and lack of immunizations ( Sudfeld et al., 2015 ). In LMICs, extreme poverty and stunting causes 250 million children (43 percent) younger than 5 fail to reach their developmental potential ( Black et al., 2017 ). Building empowering, nurturing, and cognitively enriching environments (which include responsive and emotionally supportive parenting, opportunities for play and learning, and support for early education) for vulnerable children under 5 and their mothers requires an agenda that incorporates the health, education, and social services sectors. Thus, a thrive agenda is an important focal point for investment in addition to the existing survival agenda.

Recommendation 8: Ensure Healthy and Productive Lives for Women and Children

The U.S. Agency for International Development, The U.S. President's Emergency Plan for AIDS Relief, their implementing partners, and other funders should support and incorporate proven, cost-effective interventions into their existing programs for ensuring that all children reach their developmental potential and become healthy, productive adults. This integration should embrace principles of country ownership, domestic financing, and community engagement. These interventions should include the following: Provide adequate nutrition for optimal infant and child cognitive development. Reduce childhood exposure to domestic and other violence. Detect and manage postpartum depression and other maternal mental health issues. Support and promote early education and cognitive stimulation in young children.

Promoting Cardiovascular Health and Preventing Cancer

NCDs such as CVD, chronic obstructive pulmonary disease, and lung cancer kill 40 million people globally each year, almost three-quarters of whom are in LMICs ( WHO, 2015b ). Of these deaths, 17 million are considered “premature.” The annual global cost of CVD alone is estimated to rise to more than $1 trillion in 2030 ( Reddy et al., 2016 ). Additionally, more people are dying from cancer in LMICs than from AIDS, TB, and malaria combined, with the total annual cost in 2010 approximated at $1.16 trillion 7 —more than 2 percent of total global gross domestic product ( Stewart and Wild, 2014 ). Between 30 and 50 percent of cancer deaths are preventable through prevention, early detection, and treatment. This means that more than 2.4 million annual deaths are avoidable, with an approximate $100–$200 billion in global economic savings to be achieved ( Stewart and Wild, 2014 ). Yet many health care systems in these countries are not designed to manage NCDs, and they have difficulty integrating various platforms across disease types. The lack of a properly trained workforce and of the effective population-level policies described in Chapter 6 is also a challenge for LMICs, and indeed for countries at all income levels. With conditions across the NCD spectrum also affecting populations in the United States, this is a clear area for shared innovation to tackle common problems. Greater awareness of successful interventions and best practices for combating CVD, cancer, and other NCDs can reduce duplication and allow for more rapid information exchange, leading more quickly to solutions.

Unfortunately, many efforts to combat NCDs are incorporated into other programs as an afterthought, and there is no overall coordination mechanism or strategy for a global focus on these diseases. However, U.S. programs have established strong networks and knowledge bases in many countries through decades of global health efforts by various agencies, through such program areas as PEPFAR and maternal and child health efforts. These existing platforms can serve as opportunities in which to integrate prevention and treatment efforts for NCDs. Additionally, as noted earlier, recent years have seen strong interest from the private sector in addressing the global burden of these diseases because of their clear effects on workforce productivity; however, there is no synergy among private-sector efforts across countries or health systems. The knowledge base acquired by U.S. agencies and programs should be leveraged and paired with private-sector interest and community-level commitment to mobilize and coordinate high-impact, evidence-based interventions that can be applied in all countries. Absent such concerted efforts, these diseases will continue to result in high rates of premature death and lost productivity, reversing the recent gains in and trends toward improved economic growth and stability in many countries.

Recommendation 9: Promote Cardiovascular Health and Prevent Cancer

The U.S. Agency for International Development, the U.S. Department of State, and the U.S. Centers for Disease Control and Prevention, through their country offices, should provide seed funding to facilitate the mobilization and involvement of the private sector in addressing cardiovascular disease and cancer at the country level. These efforts should be closely aligned and coordinated with the efforts of national governments and should strive to integrate services at the community level. The priority strategies to ensure highest impact are Target and manage risk factors (e.g., smoking, alcohol use, obesity) for the major noncommunicable diseases, particularly through the adoption of fiscal policies and regulations that facilitate tobacco control and healthy diets; Detect and treat hypertension early; Detect and treat early cervical cancer; and Immunize for vaccine-preventable cancers (specifically human papilloma virus and hepatitis B vaccines).

• MAXIMIZING RETURNS ON INVESTMENTS

The committee identified opportunities for changing the way the United States operates in the arena of global health and finances relevant programs to maximize the returns on U.S. investments through improved health outcomes and cost-effectiveness. If the United States can transition from its traditional siloed and reactive approach to global health to a more proactive, systematic, and sustainable approach, the committee believes U.S. investments will have an even more significant positive impact on the four priority areas outlined in this report—achieving global health security, maintaining a sustained response to the continuous threats of communicable diseases, saving and improving the lives of women and children, and promoting cardiovascular health and preventing cancer. To maximize the returns on investments in these four areas and achieve better health outcomes and more effective use of funding, the United States will need to

• catalyze innovation through the accelerated development of both medical products and integrated digital health infrastructure;
• employ more nimble and flexible financing mechanisms to leverage new partners and funders in global health; and
• maintain U.S. status and influence as a world leader in global health while adhering to evidence-based science and economics, measurement, and accountability.

Catalyze Innovation

Achieving the improvements in global health called for by numerous previous reports will require changing the way global health business is conducted to better enable innovation. Given the multisectoral nature of health, simply addressing individual challenges in a singular, siloed manner will never solve the overall problem. Challenges in the development process for vaccines and drugs to prevent and treat infectious and neglected diseases have plagued researchers and developers since before HIV/AIDS captured the world's attention in the 1980s. Additionally, health systems in LMICs are typically underresourced and lack basic infrastructure, making it difficult to provide all types of care and public health protections, such as surveillance or access to specialty care. Unless researchers, regulators, health providers, and private-sector partners are encouraged to think more creatively to solve these complex problems and enable changes in current processes, new and innovative models will be difficult to achieve. The committee believes that the creation of an environment that enables innovation can accelerate the development of critical medical products and make it possible to augment public health services through technology such that they can be provided in a more sustainable manner.

Development of Medical Products

Global health priorities will be difficult to achieve without safe and effective drugs, vaccines, diagnostics, and devices. The private sector is an essential player, together with academia, civil society, and government, in ensuring that required products are developed and manufactured. However, the markets for many global health products are uncertain or risky, making it difficult for private-sector development and manufacturing partners to justify their shareholders' investments. For example, industry considers investments in innovations to address unpredictable and fast-moving pandemics high-risk, especially given the experience of several firms with investing millions of dollars in the development of vaccines against SARS and Ebola only to find that the government was no longer interested in these products ( Ebola Vaccine Team B, 2016 ; Osterholm and Olshaker, 2017 ). Through regulatory or market incentives, the U.S. government can reduce or share the burden of development costs and risks with industry, effectively “pushing” a product through the pipeline. Similarly, the U.S. government can reduce market risk (creating market “pull”) by increasing the certainty, speed, or volume of the purchase of products. In the absence of these push and pull interventions, the United States and other governments risk spending far more than is necessary to prevent, detect, respond to, and treat disease outbreaks by using suboptimal tools.

In addition to market forces, human and institutional capacity for research and development (R&D) underpins the ability of the private sector, academia, civil society, and governments to develop priority technologies. This R&D capacity is needed in countries where outbreaks begin and disease burdens are high. Helping to build the capacity for LMICs to conduct clinical trials using their own workforces and facilities is both more efficient and more cost-effective than trying to export foreign human capacity and technical infrastructure for every disease outbreak. The necessary capacity includes laboratory capacity, the ability to collect baseline data on disease burden, and an appropriately trained research-competent workforce. Building this capacity also enables sustainability and encourages innovation by creating environments in which local researchers can solve local problems. The U.S. government has an opportunity to streamline processes, reduce costs, and create more appropriate incentives that will enable industry, academia, and others to contribute to the development of priority innovations for global health.

Recommendation 10: Accelerate the Development of Medical Products

U.S. government agencies should invest in a targeted effort to reduce the costs and risks of developing, licensing, and introducing vaccines, therapeutics, diagnostics, and devices needed to address global health priorities by enabling innovative approaches for trial design, streamlining regulation, ensuring production capacity, creating market incentives, and building international capacity for research and development. This effort should include the following: Enabling innovative approaches for trial design: The U.S. Food and Drug Administration (FDA), the Biomedical Advanced Research and Development Authority (BARDA), the U.S. Department of Defense (DoD), and the National Institutes of Health (NIH) should actively encourage public- and private-sector product development efforts using innovative product development approaches, including platform studies, adaptive trial designs, pragmatic trials, and improved biomarker development. BARDA should assess expanding its list of priority products for codevelopment with industry, taking into account global health priorities. Streamlining regulation: FDA should receive adequate resources to improve the tropical disease priority review voucher program and should assess the application of the provisions outlined in the Generating Antibiotic Incentives Now Act to neglected tropical diseases beyond those on the qualified pathogen list. Ensuring production capacity: BARDA should increase its efforts to promote adequate global manufacturing capacity for priority technologies (e.g., Centers for Innovation in Advanced Development and Manufacturing). Creating market incentives: The U.S. government should invest in generating and disseminating accurate and transparent market estimates and should use the purchasing power of U.S. government agencies and global partnerships such as Gavi, the Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as such creative financing mechanisms as volume guarantees, to reduce market uncertainty for priority health products. Building international capacity for research and development: The U.S. Centers for Disease Control and Prevention, NIH, and DoD should increase the number of people and institutions in partner countries capable of conducting clinical trials for global health priorities (e.g., through funding partnerships with academic institutions). This effort should encompass providing support for sustainable core capacities such as drug, vaccine, and diagnostic research capabilities and building the skills of principal investigators.

Development of Integrated Digital Health Infrastructure

Digital health efforts have shown promise in reducing costs and promoting health across the United States and the globe. However, many such investments have been siloed and shortsighted in their approach, often focusing on single diseases or sectors and missing opportunities to develop a sustainable, integrated platform. Growing mobile and internet connectivity worldwide, along with positive disruptive advances in the information and communications technology sector, provide a timely opportunity for the United States to reexamine its investment and development approaches to digital health efforts in other countries. A renewed focus should include goals of reducing fragmentation, improving integration of programs, and maximizing reusability to improve returns on investments. An emphasis on health systems innovation through technical assistance and public–private partnerships in digital health can lead to better care and more effective care delivery at lower cost.

Given the proliferation of digital health applications and platforms in countries across the world, created by public- and private-sector players alike, there is a need for a common digital health framework that can be applied to different country contexts, allowing for easier replication of best practices and information sharing. At the country level, cross-cutting digital health platforms should be interoperable and yet adaptable to local requirements and sovereignty. Such platforms should address each country's health care priorities during steady-state times, thereby incentivizing country coinvestment and ownership, while at the same time serving as a resilient system to facilitate controlled sharing of data across countries, thereby enhancing surveillance, coordinated responses, and delivery of services during an emergency. The U.S. government has the opportunity to leverage government content expertise and private-sector talent to build on recent and ongoing efforts, including legislation 8 aimed at improving and integrating efforts to incorporate internet access into education, development, and economic growth programs. Digital health efforts can be woven into each of those sectors with a holistic and cross-cutting perspective. New and existing U.S. investments should be buttressed by cross-cutting platforms and should assist in making these technological advances available to interested countries to improve their own health systems in a manner that is interoperable and scalable for future-minded solutions.

Recommendation 11: Improve Digital Health Infrastructure

Relevant agencies of the U.S. government should convene an international group of public and private stakeholders to create a common digital health framework that addresses country-level needs ranging from integrated care to research and development. The U.S. Agency for International Development (USAID) and the U.S. Department of State should incentivize and support countries in building interoperable digital health platforms that can efficiently collect and use health data and analytic insights to enable the delivery of integrated services within a country. USAID's Global Development Laboratory should provide technical assistance to countries in the development and implementation of interoperable digital health platforms co-funded by the country and adaptable to local requirements. U.S. agencies should expand on the “build-once” principle of the Digital Global Access Policy Act and align U.S. funding in digital health by multiple agencies to reduce fragmentation and duplication, as well as maximize the effectiveness of investments. The provision of this funding should employ methods that reflect smart financing strategies to leverage private industry and country cofinancing (see Recommendation 13).

Employ More Nimble and Flexible Financing Mechanisms

In the changing landscape of globalization and growth in middle-income countries, traditional aid models are also changing. As a global health leader, the United States should adapt its spending accordingly. Current U.S. global health financing is focused largely on immediate disease-specific priorities. This financial support is seen as development and humanitarian assistance for strategic partner countries. Instead, programs should focus on long-term goals of building global health systems and platforms that are disease-agnostic and can respond rapidly and flexibly to emerging threats that potentially impact the entire world, including the United States. There are innovative mechanisms for making present funds more effective, and opportunities exist for creative partnerships with new players and investors to develop better programs and goals. Existing platforms such as PEPFAR can be augmented through public–private partnerships to improve health outcomes in countries, such as efforts made in the last decade on generic drugs and strengthening of supply chains ( Waning et al., 2010 ). There is also potential in incentivizing the private sector to invest in global health, both for social benefit and for positive long-term business outcomes. Governments can crowd-in additional funding sources by increasing the demand for goods through public funds, and sharing risk in various ways, which then catalyzes private investment that would not have otherwise taken place ( Powers and Butterfield, 2014 ). Overall, by conducting more strategic and systematic assessments, the U.S. government can make long-term investments in global health that contribute to global public goods rather than short-term expenditures. These long-term investments should maintain a focus on global health security; disease prevention and control; cross-cutting health systems innovation; and R&D for essential vaccines, drugs, diagnostics, and devices.

In addition to pursuing more systematic spending, the United States needs to consider that many countries continue to grow economically, and their needs will change from direct support for the procurement of drugs, diagnostics, and other commodities to technical support and sustainable financing from multiple sources. Thinking more strategically about how to help growing middle-income countries transition out of bilateral aid programs and optimize their use of domestic resources in a sustainable way will be an important future role of the United States. Assisting interested countries in structuring debt ratios and tax initiatives, along with implementing other innovative mechanisms, can build stronger and more holistic health systems and provide multiple returns on investments. The U.S. government should review the wide variety of mechanisms that have been implemented by partners around the world as it explores options for expanding and diversifying U.S. global health funding to increase its effectiveness.

Recommendation 12: Transition Investments Toward Global Public Goods

The U.S. Agency for International Development, the U.S. Department of State, and the U.S. Department of Health and Human Services should, together, systematically assess their approach to global health funding with an eye toward making long-term investments in high-impact, country-level programs. The focus should be on programs that both build national health systems and provide the greatest value in terms of global health security (to prevent pandemics), as well as respond to humanitarian emergencies and provide opportunities for joint research and development for essential drugs, diagnostics, and vaccines that will benefit many countries, including the United States.

Recommendation 13: Optimize Resources Through Smart Financing

Relevant agencies of the U.S. government should expand efforts to complement direct bilateral support for health with financing mechanisms that include results-based financing; risk sharing; and attracting funding from private investment, recipient governments, and other donors. The U.S. Agency for International Development (USAID) and The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) should structure their financing to promote greater country ownership and domestic financing. Assistance should be provided in developing innovative financing products/modalities and in working with the finance sector to push the envelope on innovative sources of financing, crowding in private-sector capital. USAID and PEPFAR should engage with ministries on system design and financing to assist in plan design, model refinement and expansion, return-on-investment analysis, and financial plan execution. USAID should expand the use and flexibility of such mechanisms as the Development Credit Authority, and the U.S. Department of the Treasury, the U.S. Department of State, and USAID should motivate the World Bank; the International Monetary Fund; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and Gavi, the Vaccine Alliance, respectively, to promote transitioning to domestic financing, assist countries in creating fiscal space for health, leverage fiscal policies to improve health, and attract alternative financing sources.

Maintain U.S. Global Health Leadership

Finally, given the extremely interconnected nature of the world today, it is critical for the United States to continue to be a leader in global health. Adequately protecting U.S. citizens at home and abroad requires not only investment in U.S. infrastructure, but also continued awareness of global issues and active engagement in the international global health arena. There have been continuing calls for management and operational reforms of WHO, and while the committee agrees on the need for reform, it also recognizes that WHO performs many essential functions—for example, setting such standards as International Health Regulations. In addition, many other UN agencies and international organizations and partnerships formed in the last few decades are crucial in providing support to countries around the world. The success of all of these multilateral entities, such as the Global Fund, will help the U.S. government accomplish its global health goals and maximize its returns on investments.

Many of the events and elements of the changing global health landscape described throughout this report have created an environment for a centralized and comprehensive strategy for U.S. global health diplomacy. The United States has an opportunity to solidify its leadership and take a more deliberate foreign policy approach, including the creation of a system to support a more sustainable global health workforce in the United States. The limited number of noncareer health appointments currently available abroad are ad hoc and do not facilitate institutional knowledge or a promising career track for health professionals. Also needed is better bidirectional communication between health and diplomacy professionals and increased cross-disciplinary training. Greater flexibility for U.S. health professionals to work abroad, with emphasis on country and cultural competence and understanding, can allow for better sharing of information and more coordinated response during an outbreak or other emergency. It also could enable long-term partnerships focused on developing cures for such diseases as HIV/AIDS and cancer. Strengthening relations with countries through a strong, centralized office of global health diplomacy can create a coordinating health role for U.S. embassies while also improving situational awareness and networking with other sectors connected to health, such as finance and energy.

Recommendation 14: Commit to Continued Global Health Leadership

To protect itself from global threats, benefit from successes achieved in global health programs, and maintain a strong research and development pipeline, the United States should commit to maintaining its leadership in global health and actively participating in global health governance, coordination, and collaboration. To this end, the U.S. Department of State and the U.S. Department of Health and Human Services (HHS) should do the following: Use their influence to improve the performance of key United Nations agencies and other international organizations important to global health, particularly the World Health Organization (WHO). WHO is in need of greater resources to address the health challenges of the 21st century, and many of its priorities align with those of the U.S. government. However, U.S. government financial contributions to WHO should come with a requirement that the organization adopt and implement the much-needed management and operational reforms identified in recent reports. Remain involved in and firmly committed to innovative global partnerships that further U.S. global health goals, such as the highly successful Gavi, the Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as promising new entities such as the Global Health Security Agenda and the Global Financing Facility. Implement a more strategic approach to achieving global health goals. This new approach should include the commitment of the U.S. Department of State to creating a global health career track and congressional action to enable the establishment of a cadre of global health experts within HHS through an amendment to the Foreign Service Act. This would create the environment necessary to expand the health attaché program, particularly in middle-income countries.

• A BLUEPRINT FOR ACTION

The committee's 14 recommendations are directed toward a wide range of U.S. government entities. In Table 10-1 , the recommendations pertinent to each entity are summarized to form a blueprint for action to achieve global health security and enhance productivity and economic growth worldwide.

Report Recommendations Outlined by Entity.

• Black MM, Walker SP, Fernald LC, Andersen CT, DiGirolamo AM, Lu C, McCoy DC, Fink G, Shawar YR, Shiffman J, Devercelli AE, Wodon QT, Vargas-Baron E, Grantham-McGregor S. Early childhood development coming of age: Science through the life course. The Lancet. 2017; 389 (10064):77–90. [ PMC free article : PMC5884058 ] [ PubMed : 27717614 ]
• Bloom DE, Canning D, Jamison DT. Health, wealth, and welfare. Finance and Development. 2004; 41 (1):10–15.
• Burns A, van der Mensbrugge D, Timmer H. Evaluating the economic consequences of avian influenza. Washington, DC: World Bank; 2008.
• CDC (U.S. Centers for Disease Control and Prevention). CDC's response to the 2014–2016 Ebola epidemic—West Africa and United States. Atlanta, GA: U.S. Centers for Disease Control and Prevention; 2016.
• Daschle T, Frist W. The case for strategic health diplomacy: A study of PEPFAR. Washington, DC: Bipartisan Policy Center; 2015.
• Ebola Vaccine Team B. Plotting the course of Ebola vaccines: Challenges and unanswered questions. Minneapolis: Center for Infectious Disease Research and Policy, University of Minnesota; 2016. [January 10, 2017]. http://www ​.cidrap.umn ​.edu/sites/default/files ​/public/downloads ​/ebola_team_b_report_2-033116-final ​.pdf .
• Epstein SB, Lister SA. Zika response funding: Request and congressional action. Washington, DC: Congressional Research Service; 2016.
• Epstein SB, Lister SA, Belasco A, Jansen DJ. FY2015 funding to counter Ebola and the Islamic State (IS). Washington, DC: Congressional Research Service; 2015.
• Fan E. SARS: Economic impacts and implications. Manila, Philippines: Asian Development Bank; 2003.
• Fan VY, Jamison DT, Summers LH. The inclusive cost of pandemic influenza risk. Cambridge, MA: National Bureau of Economic Research; 2016.
• Frenk J, Gómez-Dantés O. False dichotomies in global health: The need for integrative thinking. The Lancet. 2016; 389 (10069):667–670. [ PubMed : 27771016 ]
• GAO (U.S. Government Accountability Office). Defense civil support: DoD, HHS, and DHS should use existing coordination mechanisms to improve their pandemic preparedness. Washington, DC: U.S. Government Accountability Office; 2017.
• Gertler P, Heckman J, Pinto R, Zanolini A, Vermeersch C, Walker S, Chang SM, Grantham-McGregor S. Labor market returns to an early childhood stimulation intervention in Jamaica. Science. 2014; 344 (6187):998–1001. [ PMC free article : PMC4574862 ] [ PubMed : 24876490 ]
• Gold J. “Statement of Chancellor Jeff Gold, M.D. University of Nebraska Medical Center, Omaha, Nebraska before the Committee on Energy and Commerce Subcommittee on Oversight & Investigations” (Date: 11/18/2014) Hearing on “Update on the U.S. Public Health Response to the Ebola Outbreak.”. 2014. [January 15, 2017]. https: ​//energycommerce ​.house.gov/hearings-and-votes ​/hearings ​/update-us-public-health-response-ebola-outbreak .
• Hotez PJ, Murray KO, Buekens P. The Gulf Coast: A new American underbelly of tropical diseases and poverty. PLOS Neglected Tropical Diseases. 2014; 8 (5):e2760. [ PMC free article : PMC4022458 ] [ PubMed : 24830815 ]
• IOM (Institute of Medicine). America's vital interest in global health: Protecting our people, enhancing our economy, and advancing our international interests. Washington, DC: National Academy Press; 1997.
• Iuliano DA, Jang Y, Jones J, Davis TC, Wentworth DE, Uyeki TM, Roguski K, Thompson MG, Gubareva L, Fry AM, Burns E, Trock S, Zhou S, Katz JM, Jernigan DB. Increase in human infections with avian influenza (H7N9) virus during the fifth epidemic—China, October 2016–February 2017. Morbidity and Mortality Weekly Report (MMWR). 2017; 66 (9):254–255. [ PMC free article : PMC5687196 ] [ PubMed : 28278147 ]
• Jamison D, Summers L, Alleyne G, Arrow K, Binagwaho A, Bustreo F, Evans D, Freachern R, Ghosh G, Goldie S, Guo Y, Gupta S, Horton R, Kruk M, Mahmoud A, Mohohlo L, Ncube M, Pablos-Mendéz A, Reddy S, Saxenian H, Soucat A, Ulltveit-Moe K, Yamey G. Global health 2035: A world converging within a generation. The Lancet. 2013; 382 (9908):1898–1955. [ PubMed : 24309475 ]
• Kodjak A. Congress ends spat, agrees to fund $1.1 billion to combat Zika. 2016. [December 15, 2016]. http://www ​.npr.org/sections ​/health-shots ​/2016/09/28/495806979 ​/congress-ends-spat-over-zika-funding-approves-1-1-billion .
• Laurence YV, Griffiths UK, Vassall A. Costs to health services and the patient of treating tuberculosis: A systematic literature review. Pharmacoeconomics. 2015; 33 (9):939–955. [ PMC free article : PMC4559093 ] [ PubMed : 25939501 ]
• Marmot M. Social determinants of health inequalities. The Lancet. 2005; 365 (9464):1099–1104. [ PubMed : 15781105 ]
• Marquez PV, Farrington JL. The challenge of non-communicable diseases and road traffic injuries in sub-Saharan Africa. An overview. Washington, DC: World Bank; 2013.
• Nieburg P, Dubovi T, Angelo S. Tuberculosis: A complex health threat. Washington, DC: Center for Strategic and International Studies; 2015.
• OECD (Organisation for Economic Co-operation and Development). Health reform: Meeting the challenge of ageing and multiple morbidities. Washington, DC: Organisation for Economic Co-operation and Development; 2011.
• Osterholm MT, Olshaker M. Deadliest enemy: Our war against killer germs. New York: Little Brown and Company; 2017.
• PEPFAR (The U.S. President's Emergency Plan for AIDS Relief). PEPFAR 2016 annual report to Congress. Washington, DC: The Office of the U.S. Global AIDS Coordinator and Health Diplomacy, U.S. Department of State; 2017.
• Pooran A, Pieterson E, Davids M, Theron G, Dheda K. What is the cost of diagnosis and management of drug resistant tuberculosis in South Africa? PLOS ONE. 2013; 8 (1):e54587. [ PMC free article : PMC3548831 ] [ PubMed : 23349933 ]
• Powers C, Butterfield WM. Crowding in private investment. In: Shah R, Unger N, editors. Frontiers in development: Ending extreme poverty. Washington, DC: U.S. Agency for International Development; 2014.
• Purdy M, Robinson M, Wei K, Rublin D. The economic case for combating malaria. The American Journal of Tropical Medicine and Hygiene. 2013; 89 (5):819–823. [ PMC free article : PMC3820322 ] [ PubMed : 24197172 ]
• Reddy S, Riahi F, Dorling G, Callahan R, Patel H. Innovative approaches to prevention: Tackling the global burden of cardiovascular disease. Doha: World Innovation Summit for Health; 2016.
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This percentage was calculated by using fiscal year 2016 Public Health Emergency Preparedness program funding ($660 million) and Hospital Preparedness Program funding ($255 million) as the preparedness amounts. See Chapter 3 for more details.

During this timeframe, 29,000 people were monitored following screening at five major U.S. international airports. The monitoring included follow-up for 21 days, and a check and report Ebola kit including a thermometer, a prepaid cell phone, and educational materials.

A “moderate” influenza pandemic is defined as one in which global output is reduced by more than 2 percent.

Zika Response Appropriations Act, H.R. 5243. 2016.

Defined as the funding needed to bring major zoonotic disease prevention and control systems in developing countries up to World Organisation for Animal Health and World Health Organization standards. The World Bank report estimates that the required investments range from $1.9 billion to $3.4 billion per year.

See Lantos-Hyde United States Government Tuberculosis Strategy.

This figure is the sum of the costs of prevention and treatment, plus the annual economic value of disability-adjusted life years (DALYs) lost as a result of cancer. This value fails to estimate longer-term costs to families and the costs that patients and families attribute to human suffering.

Digital Global Access Policy Act of 2017, H.R. 600, 115th Congress.

• Cite this Page National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Global Health; Committee on Global Health and the Future of the United States. Global Health and the Future Role of the United States. Washington (DC): National Academies Press (US); 2017 May 15. 10, Summary of Conclusions and Recommendations.
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Global Health Care, Essay Example

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Introduction

Global health care is a challenging phenomenon that supports the development of new perspectives and approaches to solving global health concerns, including nutrition, infectious disease, cancer, and chronic illness. It is important to address global health as a driving force in international healthcare expenditures because it represents an opportunity for clinicians throughout the world to collaborate and to address global health concerns to achieve favorable outcomes. Global healthcare in the modern era includes the utilization of technology to support different population groups and to address different challenges as related to global health problems that impact millions of people in different ways. These challenges demonstrate the importance of large-scale efforts to eradicate disease, to prevent illness, and to manage disease effectively through comprehensive strategies that encourage communication and collaboration across boundaries.

Global health care incorporates a number of critical factors into play so that people throughout the world are given a chance to live and to lead a higher quality of life. The World Health Organization (WHO) is of particular relevance because this organization supports global health initiatives and large-scale impact projects throughout the world (Sundewall et.al, 2009). The WHO recognizes the importance of developing strategies to address global health concerns by pooling resources in order to ensure that many population groups are positively impacted by these initiatives (Sundewall et.al, 2009). The WHO also collaborates with government bodies throughout the world to address specific concerns that are relevant to different population groups, such as infectious diseases, many of which ravage populations in a significant manner (Fineberg and Hunter, 2013). In this context, it is observed that global health has a significant impact on populations and their ability to thrive, given the high mortality rates of some diseases in less developed nations (Fineberg and Hunter, 2013). Therefore, it is expected that there will be additional frameworks in place to accommodate the needs of populations and the resources that are required to achieve favorable outcomes (Fineberg and Hunter, 2013).

In addition to the WHO, there are many other international organizations that support global health and disease in different ways. For example, The United Nations Children’s Fund (UNICEF) supports large-scale global health efforts to support the world’s children (imva.org, 2013). UNICEF works in conjunction with many governments and other sources of funding in order to accomplish its objectives related to child health and wellbeing (imva.org, 2013). UNICEF spends significant funds on many focus areas, including the preservation of child health, nutrition, emergency support, and sanitation in conjunction with local water supplies (imva.org, 2013). In addition, the United States Agency for International Development (USAID) provides support in many areas, including a primary focus on healthcare in developing nations (imva.org, 2013).

Leininger’s Culture Care Theory is essential in satisfying the objectives of global health because it supports an understanding of the issues related to cultural diversity and how they impact healthcare practices throughout the world (Current Nursing, 2012). This theory embodies many of the differences that exist in modern healthcare practices and supports a greater understanding of the issues that are most relevant on a global scale (Current Nursing, 2012). This theory is applicable because it represents a call to action to consider cultural differences when providing care and treatment to different population groups, but not at the expense of the quality of care that is provided (Current Nursing, 2012). In many countries, the provision of care is largely dependent on cultural diversity and customs, which is essential to a thriving healthcare system; however, diversity must also incorporate the concept of providing maximum care for an individual in need of treatment (Current Nursing, 2012).

Professional nursing is highly relevant to global health because nurses address some of the most critical challenges in providing care and expanding access to treatment for millions of people throughout the world. However, it is also important for nurses working with global health initiatives to recognize the importance of these directives and to consider ways to improve quality of care without compromising principles or other factors in the process. These efforts will ensure that nurses maximize their knowledge and understanding of global health and its scope in order to achieve positive outcomes for people in desperate need of healthcare services throughout the world. Nurses must collaborate with small and large-scale organizations regarding global health issues so that population needs are targeted and are specific. These efforts will ensure that patients are treated in areas where healthcare access is severely limited.

Global health represents a significant set of challenges for clinicians throughout the world. It is important to recognize these concerns and to take the steps that are necessary to provide patients with the best possible outcomes to achieve optimal health. The scope of global health concerns is significant; therefore, it is important to address these concerns and to take the steps that are necessary to collaborate and promote initiatives to fight global health problems. When these objectives are achieved using the knowledge and expertise of nurses, it is likely that there will be many opportunities to treat patients and to educate them regarding positive health. With the assistance of large global organizations, nurses play an important role in shaping outcomes for women throughout the world.

Current Nursing (2012). Transcultural nursing. Retrieved from http://currentnursing.com/nursing_theory/transcultural_nursing.html

Fineberg, H.V., and Hunter, D. J. (2013). A global view of health – an unfolding series. T he New England Journal of Medicine, 368(1), 78-79.

Imva.org (2013). Bilateral agencies. Retrieved from http://www.imva.org/Pages/orgfrm.htm

Sundewall, J., Chansa, C., Tomson, G., Forsberg, B.C., and Mudenda, D. (2009). Global health initiatives and country health systems. The Lancet, 374, 1237.

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An essay on a topic of international health importance

• PMID: 21167589
• DOI: 10.1016/S0140-6736(10)62189-7
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World Health Organization (WHO) Essay

The World Health Organization ((WHO) is the organization of interest with an underpinning mission statement which “ seeks to publish and disseminate scientifically rigorous public health information of international significance that enables policy-makers, researchers and practitioners to be more effective; it aims to improve health, particularly among disadvantaged populations” (Bulletin of the World Health Organization, 2012).

The context of the mission statement is to provide scientifically tested and proven medical services particularly to disadvantaged populations in the world and in this case to the vulnerable girl child susceptible to early sex.

The WHO policy formulation is based on information about early girl child marriage, making it the core issue of discussion in this paper.

The core issue is pregnancy of the girl child leading to adolescent births. A significant number of girl children in poor countries get pregnant because of lack of contraceptives and reproductive health information. That is compounded with the disadvantage that the adolescent girl is not able to refuse sex leading to coerced sex.

Lack of knowledge of how to prevent early pregnancy and other effects including contracting HIV because of engaging in child sex compounds the problem further. The consequences include contraction of HIV and pregnancies which leads to the acquisition of abortion.

Statistical evidence shows that the number of children under the age of 19 giving birth to children is 16 million, with the girls under the age of 15 giving birth to 2 million yearly. Poor countries suffer the most because of lack of education and low use of contraceptives during sex.

Europe, Asia, and Latin America show a 42-60% rate of contraceptives use with Africa showing a low rate of 2-49% for partners in a relationship (World Health Organization,2010).

The underlying significance of the problem is demonstrated in the rising cases of abortion done in unhealthy backgrounds and use of poor crude methods to induce abortion.

The consequences are lasting health problems for the young girl, and sometimes when abortion is unsuccessful, the vulnerability and the impact of long lasting implications of poor health for the young mother and the child. That is in addition to complications experienced by the mother during pregnancy and childbirth.

According to the World Health organization (2012) report, the number of still born children because of child births is high, with the girl child mother susceptible to giving birth to a low weight child. The long term impact includes poor health for the child and the mother, in addition to retarding socio economic development.

In response to the above scenario, the WHO adopted, in May 2011, a number of polices and intervention programs which included the protection of the girl child from early child bearing, provision of reproductive health services and access to contraceptives, and making available and promoting information about reproductive and sexual health to the target population for all countries in the world.

The policies were published in the WHO evidence based guidelines on how to address the reproductive health problems discussed above (World health organization, 2008).

An example of the intervention program and success rates has not been demonstrated, but the guidelines provide the optimism that once the statistics are out, the fatalities will have significantly reduced. That could result into better health, informed public and especially the girl about the consequences of early sex.

World Health Organization (2010). Adolescent pregnancy . Web.

World Health Organization (2008). Adolescent Pregnancy. Web.

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• Published: 08 August 2018

Migration and health: a global public health research priority

• Kolitha Wickramage 1 ,
• Jo Vearey 2 ,
• Anthony B. Zwi 3 ,
• Courtland Robinson 4 &
• Michael Knipper 5  

BMC Public Health volume  18 , Article number:  987 ( 2018 ) Cite this article

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With 244 million international migrants, and significantly more people moving within their country of birth, there is an urgent need to engage with migration at all levels in order to support progress towards global health and development targets. In response to this, the 2nd Global Consultation on Migration and Health– held in Colombo, Sri Lanka in February 2017 – facilitated discussions concerning the role of research in supporting evidence-informed health responses that engage with migration.

Conclusions

Drawing on discussions with policy makers, research scholars, civil society, and United Nations agencies held in Colombo, we emphasize the urgent need for quality research on international and domestic (in-country) migration and health to support efforts to achieve the Sustainable Development Goals (SDGs). The SDGs aim to ‘leave no-one behind’ irrespective of their legal status. An ethically sound human rights approach to research that involves engagement across multiple disciplines is required. Researchers need to be sensitive when designing and disseminating research findings as data on migration and health may be misused, both at an individual and population level. We emphasize the importance of creating an ‘enabling environment’ for migration and health research at national, regional and global levels, and call for the development of meaningful linkages – such as through research reference groups – to support evidence-informed inter-sectoral policy and priority setting processes.

Peer Review reports

Migration and health are increasingly recognized as a global public health priority [ 1 ]. Incorporating mixed flows of economic, forced, and irregular migration, migration has increased in extent and complexity. Globally, it is estimated that there are 244 million international migrants and significantly more internal migrants – people moving within their country of birth [ 2 ]. Whilst the majority of international migrants move between countries of the ‘global south’ [ 2 ], these movements between low and middle-income countries remain a “blind spot” for policymakers, researchers and the media, with disproportionate political and policy attention focused on irregular migration to high-income countries. Migration is increasingly recognized as a determinant of health [ 3 , 4 , 5 ]. However, the bidirectional relationship between migration and health remains poorly understood, and action on migration and health remains limited, negatively impacting not only those who migrate but also sending, receiving, and ‘left-behind’ communities [ 1 ].

In February 2017, an international group of researchers participated in the 2nd Global Consultation on Migration and Health held in Colombo, Sri Lanka with the objectives of sharing lessons learned, good practices, and research in addressing the relationship between migration and health [ 1 ]. Hosted by the International Organization for Migration (IOM), the World Health Organization (WHO), and the Sri Lankan government, the Global Consultation brought together governments, civil society, international organizations, and academic representatives in order to address migration and health. The Consultation facilitated engagement with the health needs of migrants, reconciling the focus on long-term economic and structural migration - both within and across international borders - with that of acute, large-scale displacement flows that may include refugees, asylum seekers, internally displaced persons and undocumented migrants.

The Consultation was organised around inputs on three thematic areas: Global Health [ 6 ]; Vulnerability and Resilience [ 7 ]; and, Development [ 8 ]. These inputs guided working group discussions exploring either policy, research, or monitoring in relation to migration and health. This paper reports on the outcomes of the research group after an extensive period of debate at the Consultation and over the subsequent 9 months. We identify key issues that should guide research practice in the field of migration and health, and outline strategies to support the development of evidence-informed policies and practices at global, regional, national, and local levels [ 9 ]. Debate and discussion at the Consultation, and below, were guided by two key questions:

What are the opportunities and challenges, and the essential components associated with developing a research agenda on migration and health?

What values and approaches should guide the development of a national research agenda and data collection system on migration and health?

Our discussions emphasized that international targets, such as the Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC; Health target 3.8 of the SDGs), are unlikely to be achieved if the dynamics of migration are not better understood and incorporated in policy and programming. To address this, and in order to improve policy and programming, a renewed focus on enhancing our understanding of the linkages between both international and internal migration and health, as well as the outcomes and impacts arising from them, is urgently needed.

Migration and health research: Leave no-one behind

The Sustainable Development Goals (SDGs) identify migration as both a catalyst and a driver for sustainable development. A clarion call of the SDGs is to ‘leave no-one behind’, irrespective of their legal status, in order to achieve Universal Health Coverage (UHC) for all [ 10 ]. In many countries, however, equitable access to health services is considered as a goal only in relation to citizens. Additionally, internal migration is left out of programming and policy interventions designed to support UHC for all. While UHC aims at ensuring “everyone” can access affordable health systems without increasing the risk of financial ruin or impoverishment, the formulation of UHC remains unclear regarding non-nationals/non-citizens [ 11 ]. While many international declarations state that the right to health applies to all, including migrants and non-citizens, many national policies exclude these groups in whole or part [ 12 ].

In addition to international and internal migration, the health concerns associated with labour migration require attention; migrant workers are estimated to account for 150.3 million of the 244 million international migrants [ 2 ]. While labour migration leads to significant economic gains for countries of origin and destination, true developmental benefits are only realised with access to safe, orderly and humane migration practice [ 13 ]. Many migrant labourers work in conditions of precarious employment, within ‘difficult, degrading and dangerous’ jobs yet little is known about the health status, health outcomes, and resilience/vulnerability trajectories of these migrant workers and their ‘left behind’ families. Many undergo health assessments as a pre-condition for travel and migration, yet many such programs remain unlinked to national public health systems [ 14 ].

Our discussions highlighted the complex and heterogeneous nature of research on migration and health, with particular concerns raised around the emphasis on international rather than internal migration, in view of the greater volume of the latter. The need for a multilevel research agenda to guide appropriate action on international and internal migration, health, and development was highlighted. In order to account for immediate, long-term and inter-generational impacts on health outcomes, migration and health research should: (1) incorporate the different phases of migration (Fig. 1 ); (2) adopt a life-course approach; and, (3) integrate a social determinants of health (SDH) approach.

Factors influencing health and wellbeing of migrants and their families along the phases of migration

Unease was expressed about the increasingly polarised political viewpoints on migration, often propagated by nationalist and populist movements, which present real challenges to researchers. This may also be associated with a reluctance to finance research exploring discriminatory policies that limit the access of international migrants to health services and other positive determinants of health, including work and housing.

The increasing complexity of global, regional, and national migration trends, as well as disagreements about the correct way to define and label different types of migrants, create additional difficulties within an already tense and politically contested research domain. Associated with this are the particular challenges associated with collecting and utilising data on ‘irregular migrants’ – international migrants currently without the documentation required to legally be in a particular country. These undocumented migrants, often living in the shadows of society, are more vulnerable to poor health outcomes due to restrictive policies on access to health and social services, to safe working and living conditions, and/or a reluctance to access services for fear of arrest, detention and/or deportation [ 15 , 16 ]. Whilst arguments for improving access to health care for marginalised migrants are based on principles of equity, public health, and human rights, the importance of research on the economic implications of limiting access to care for international migrants was highlighted [ 2 ]. This challenging terrain generated a myriad of research questions during the group discussions (Table 1 ).

Towards a framework for advancing migration and health research

The consultation took into account the extensive research experience of the group (see Appendix ), as well as engagement with key literature and context-specific evidence [see, for example 1–7]. Discussion led to the development of a framework that brings together what we identify as the key components for advancing a global, multi-level, migration and health research agenda (Fig. 2 ). Two areas of focus to advance the migration and health research agenda were identified: (1) exploring health issues across various migrant typologies , and (2) improving our understanding of the interactions between migration and health . Advancing research in both areas is essential if we are to improve our understanding of how to respond to the complex linkages between both international and internal migration and health. This, we argue, can be achieved by moving away from an approach that exceptionalises migration and migrants, to one that integrates migration into overall health systems research, design, and delivery, and conceptualises this as a way to support the achievement of good health for all.

Advancing Migration and Health Research at National, Regional and Global Levels: a conceptual framework

Building from these focus areas, our framework outlines the essential components for the development and application of multi-level research on migration and health. First are key principles underlying research practice: promoting interdisciplinary, human rights oriented, ethically sound approaches for working with migrants. Second are multi-level stewardship functions needed to meaningfully link migration and health research to policy practice and priority setting, [ 17 ]. This includes establishing knowledge exchange mechanisms, financing, commissioning, and utilising research to guide evidence informed policies. This may better enable health systems to become ‘migration aware’ [ 18 ] or what the International Organization for Migration (IOM) terms ‘mobility competent’ - sensitive to health and migration [ 1 ].

Migration and health research: Two key focus areas

Migrant typologies.

To assist in understanding the associations between migration and health, our research must find ways to better capture and engage with complex, dynamic, and often intersecting migrant typologies. We must be careful not to cluster migrants and their associated lived experiences, to simple, reductionist categories such as internal versus cross-border or documented versus undocumented, or even refugee versus economic migrant [ 19 ]. However, we do need a way of categorising different migrant groups when, for example, exploring epidemiological profiles and associated burdens of disease. To do this, we need to develop a set of nuanced yet flexible typologies that are able to capture the contextually relevant factors affecting migrant experiences, at both the individual and population levels. As outlined in Table 2 , this will require careful consideration of multiple factors to assist us in improving our understandings of the ways in which diverse migrant groups are associated, or not, with various health and wellbeing outcomes. Definitions that are based on immigration status - such as ‘refugee’, ‘immigrant’ or ‘asylum seeker’ - will incorporate diverse sub-groups, often with different levels of health vulnerabilities and resiliencies based on their migration trajectory. For instance, a refugee entering a country with an offer of permanent resettlement or with a recognized temporary protected status, will have different opportunities and challenges than an asylum-seeker, or migrant worker, crossing a border possibly without documents or a clear pathway to needed healthcare and protections. Each of these migrating populations carry different health burdens (and resiliencies) from their country of origin, their social position and access to resources, and their migration experiences; and each will face different barriers and uncertainties as they seek access to services, support and integrate in host communities. The definitions of migrant groups adopted by states not only need clear elucidation but also need to reflect the context-specific conditions affecting health access and protection. In Europe, for example, the entitlements to health care for asylum seekers differ by country [ 20 ]. The Migrant Integration Policy Index (MIPEX) health strand was developed as a tool to monitor policies affecting migrant integration in 38 different countries [ 18 ]. It measures the equitability of policies relating to four issues: migrants’ entitlements to health services; accessibility of health services for migrants; responsiveness to migrants’ needs; and measures to achieve change. Such tools are important steps in assessing migrant integration and for implementing migrant-sensitive policies that are aligned with the person-centred UHC principles.

An awareness of this complexity underlies the need to document multiple migrant voices and migration experiences along the diverse trajectories when exploring associations between migration and health. This could, for instance, involve capturing the voices of children and other family members ‘left-behind’ as a result of labour migration, or of seasonal migrant workers. Research into the issues, policies and programmes that influence health and health literacy among migrant populations and the role that communities, households, industries, schools, and transnational networks play in promoting health also needs exploration.

Key challenges exist when attempting to use and compare migration data internationally, as a result of differences in the definition of who is an international migrant, non-national, or internal migrant; inconsistent data sources; and limited data coverage. A recent analysis of the availability, reliability and comparability of data on international migration flows in European countries noted that “comparing migration flows in various countries would be like comparing pears and apples” [ 21 ]. The use of standard indicators can result in unreliable data if migration dynamics are not considered. For example, measures of life expectancy are skewed if international migrants return to their home countries when they are seriously ill, but their departure is not accounted for in vital registration or other systems [ 21 ]. Reporting that is based on incomplete, poor quality or non-comparable population data that fails to measure and/or report migration can give rise to misleading conclusions and limits the validity of data interpretation.

Research at the nexus of migration and health

We recognise the bi-directionality of the relationship between migration and health. Our research should explore how different forms of migration influence health – at both individual and population levels - and how health status affects decisions to migrate and shapes post-migration experience. Migration trajectories can positively or negatively impact health outcomes, just as health status can affect migration outcomes; this two-way relationship should be better reflected in research. To support this, we must be sure to differentiate carefully between different migrant typologies – for example within or across international borders and for what purpose: work, family reunification, escape from persecution, flight from conflict or natural disaster, or to seek asylum. Each of these operates within substantially different contexts whether one takes the migrant and their health into account, or their rights and entitlements, or how they are seen by the dominant society or community to which they migrate. We recognise that being a migrant is not in itself a risk to health: it is the conditions associated with migration that may increase vulnerability to poor health [ 4 ]. Owing to the ways in which people move and the spaces they traverse or at which they arrive, migrants may reside in - or pass through - ‘spaces of vulnerability’ [ 22 ] – key spaces associated with potentially negative health outcomes – including along transport corridors, urban slums, construction sites, commercial farms, fishing communities, mines, and detention centres. Such spaces may contain a combination of social, economic and physical conditions that may increase the likelihood of exposure to violence and abuse and/or acquisition of communicable or non-communicable disease [ 22 ]. The daily stressors that may be experienced in these spaces are increasingly acknowledged to affect emotional wellbeing and mental health [ 23 ].

As migration is an ever-changing dynamic process, generating and maintaining timely and comparable migration data and improving relevant information systems is important. ‘Quick wins’ in obtaining migration and health data by integrating migration variables into existing national demographic and health surveys, for instance, were highlighted. National disease control programs such as tuberculosis, HIV and malaria control programs should also be encouraged to collect data on internal and international migration, especially in cross-border areas. Communicable disease control remains a key health concern associated with human migration. Our discussions recognised the importance of embracing systems-theory approach for improving understanding of how migration influences not only disease transmission but also health promotion, and health-care seeking behaviours. The importance of collecting such data with strict adherence to research ethics and human rights was emphasised.

Towards a multilevel migration and health research agenda

To effectively inform policies and programs on migration and health, it is essential to invest in evidence generation through research at local, national, regional, and global levels. Identified approaches include the establishment of research reference groups at each level to support, guide, and connect the development and application of research to support evidence-informed policy making at multiple levels. Mapping and analysis of key stakeholders, migration patterns, existing legal frameworks, data source, and research output via bibliometric analysis is needed. Multi-level migration and health policy and priority setting processes must be guided by interdisciplinary and multisectoral thinking in order to address the multiple determinants associated with the health of both internal and cross-border migrants.

Key constituencies need to be mobilised from academia, civil society, international organizations, the private sector including employer groups, trade unions and migrant worker networks. These groups may also play a role in commissioning or directly undertaking applied research in order to advance better outcomes for migrants and communities in both places of origin and destination. High-level political leadership and health and development champions should raise the visibility of migration and health research. It is important to utilise existing research structures and resources to support the development of a research agenda on migration and health, as well as to seek support for the development of dedicated research commissions on migration and health at multiple levels in order to harness evidence to drive policy-making and programme formation. For instance, the Government of Sri Lanka, with the technical cooperation of IOM, commissioned a National Migration Health Research Study in 2010 to explore health impacts of inbound, outbound, and internal migrant flows including those of left-behind migrant families. The research findings ultimately contributed to the formulation of an evidence-informed National Migration Health Policy and national action plan in 2013 [ 24 ]. The research was led through local research institutions and research process were linked to an inter-ministerial and inter-agency process chaired by the Minister of Health. This evidence informed policy making process also led to a number of national programs such as ‘the national border health program’ in 2013, revitalizing domestic legal frameworks on health security, and advancing health protection of migrant workers at regional inter-governmental initiatives such as the Colombo Process.

At the regional level, consultative processes are required to develop common approaches to migration and health, including communicable disease surveillance, monitoring of interventions, applied research collaboration across national borders and capacity building – particularly interdisciplinary postgraduate training. For instance, the Mekong Basin Disease Surveillance (MBDS) Consortium is a sub-regional co-operation spearheaded by health ministries from member countries Cambodia, China, Lao PDR, Myanmar, Thailand and Vietnam [ 25 ]. In relation to labour migration, regional processes – such as the Colombo Process [ 26 ] - should explore the management of overseas employment and contractual labour. In addition, migrant health-related concerns should be emphasised in the negotiation of free trade agreements that increase migration between states, such as the Post-2015 Health Development Agenda for a “ Healthy, Caring and Sustainable Community ” initiative of the Association of South-East Asian Nations (ASEAN) [ 27 ] and efforts to implement the “Health in all Policies” strategy of the European Union [ 7 ].

Methods to map human mobility for public health preparedness and response stemming from outbreaks and other health emergencies are needed in order to provide accurate information on population movements, for monitoring the progression of outbreaks, predicting future spread and allocating resources for surveillance and containment strategies. Human mobility was a critical factor in the spread of Ebola virus in the West African region.

A coordinated global research agenda on migration and health is urgently needed. Potential elements include collaboration with stakeholders involved in implementing global initiatives – such as the SDGs – to ensure that indicators and data collection strategies are sensitive to both internal and cross-border migration, and health related issues. Identification of datasets and data collection processes that can be adapted and mined for disaggregated health data related to migration are also crucial in advancing the evidence base. We support the development of a sustainable global reference group that can share research evidence, expertise and experience, develop methodological and ethical guidelines, undertake multi-country studies, provide training and build a global knowledge hub in migration and health. Such a group can also mobilise funders and development partners, collaborate with scientific and professional associations, and engage with journals and publishers to create awareness on the need to better promote migration and health research.

The ‘Migration, Health, and Development Research Initiative’ (MHADRI) is a global network of academics and other research partners who aim to advance migration and health research practice [ 28 ]. The research network was formed around the need to build a global alliance of migration and health researchers and provide a platform to share, collaborate, develop, mentor, advocate and disseminate inter-disciplinary research at the nexus of health and migration. A key goal of the network is to enable researchers from developing nations the opportunity to collaborate and promote research in the Global South. The network has grown to encompass 100 researchers globally, across diverse disciplines, geographic areas and stages of career. A global reference group would be well placed to develop good practice guides on data collection systems, research methods and ethics; research translation and dissemination; and, policy integration strategies.

Research principles

We identified core principles that should guide research on migration and health, and work with migrant populations: an ethically sound human rights approach to research that involves engagement across multiple disciplines. Researchers need to be sensitive when designing and disseminating research findings as data on migration and health may be misused, both at an individual and population level. Key questions related to how researchers can exercise their duty of care as they engage in research, and how we can promote careful use of data and research to make sure it does more good than harm. Activities associated with international migration sometimes take place in a climate of victim blaming, othering, and stigmatisation that prioritises purported national security concerns [ 29 ]. Pressing concerns were identified that relate to the ways in which researchers can navigate this increasingly challenging environment, and how trust can be established among different stakeholders – including with international migrant groups. Securitization agendas also affect the health of migrants by excluding, discriminating and/or blaming migrants as vectors of disease. Ethical approaches to research, with a clear commitment to universal human rights, are therefore paramount in a climate of increasingly restrictive immigration regimes.

Discussions also highlighted the challenges associated with the collection of data with and from migrant populations. These include sampling, biases, and practical barriers such as language and culture, as well as the challenges inherent in reaching people who are often highly marginalised and potentially criminalised. Particular attention needs to be given to ethical issues: protecting confidentiality and ensuring that participation in research does not have an adverse impact on migrants, especially irregular migrants, and that participants gain access to relevant services if required. The development of meaningful partnerships and respectful research practice with actors involved in the migration process will also improve the quality, reliability, legitimacy, and use of the data generated.

Contributions from a range of disciplines – such as anthropology, demography, sociology, law, political science, psychology, policy analysis, public health, and epidemiology – are required to unpack the complex relationships between migration and health. Approaches to “slow research” [ 30 ] may help increase the sensitivity of epistemologies and methods to local realities, intricate dynamics, and the multiple voices and perceptions of migrants, health professionals and other individuals involved [ 24 ]. However, the lack of dedicated research units, institutes or centres on migration and health - especially within lower-income country contexts - require existing researchers and scholars to consolidate and better engage with sub-regional, regional and global research networks to ensure capacity building, mentoring, and support. Sensitising the donor community to the migration and health agenda, especially those funding research, is paramount. Curriculum development and teaching support for building the next generation of migration and health researchers is critical to successfully building and sustaining future research on migration and health.

Stewardship elements

We discussed the importance of developing appropriate research translation and engagement activities in order to support key, identified stewardship functions [ 17 ] at the global, regional, national and local levels. Key gaps in stewardship related to the lack of major funding mechanisms for research at national, regional, and global levels, and the need to invest in capacity building for emerging researchers through training programs and support, especially for researchers in lower-income country settings. Collaboration is required to support relationships among researchers and with relevant stakeholders, particularly with migrant communities. This includes building inclusive migration and health research networks, developing communities of practice, and supporting collaborations with those working on other global health priorities. Our research also needs to include the experiences of service providers who engage with various migrant populations, such as those within the health care sectors, border management, law enforcement, and labour migration. The development of effective research translation and public engagement strategies for sharing research findings is critical: not only to shape multi-level policy processes but also public and political opinion.

There was clear consensus on our commitment to enhancing the quality and breadth of multi-level research evidence to support the development of improved responses to migration and health. The importance of an ‘enabling environment’ for migration and health research at local, national, regional and global levels was emphasised, as was the development of meaningful linkages – such as through research reference groups – to support evidence-informed and intersectoral policy and priority setting processes. Our research needs to be underpinned by a human rights approach to health and sound ethical practice. With adequate funding, capacity development, and support for academic freedom, we can improve the evidence base to guide policy and programming for migration and health at multiple levels and in so doing contribute to improving health for all.

Abbreviations

Association of South-East Asian Nations

International Organization for Migration, the UN Migration Agency

Mekong Basin Disease Surveillance

Migration, Health, and Development Research Initiative

Sustainable Development Goals

World Health Organization

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Acknowledgements

Members of the research stream at the 2nd Global Consultation on Migration and Health who participated and contributed to the discussions (see Appendix ).

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Contributions

All authors contributed to structuring and facilitating the research stream at the Global Consultation. KW, JV, AZ, CR, MK documented and synthesized the key themes emergent from the working groups and prepared ‘mind maps’. KW authored a section in the final report from the Global Consultation on behalf of the research stream, on which this article is based. JV wrote first draft of the article. KW and JV revised the article based on very helpful comments from two reviewers. All authors reviewed and approved the final manuscript.

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Members of the research stream at the 2nd Global Consultation on Migration and Health

In alphabetical order:

Ibrahim Abubakar (Director, Institute for Global Health, University College London, United Kingdom)

Anjali Borhade (Associate Professor, Indian Institute of Public Health, India)

Chee-khoon Chan (Research Associate, University of Malaya, Malaysia)

Julia Puebla Fortier (Executive Director, Diversity Rx - Resources for Cross Cultural Health Care)

Charles Hui (Associate Professor of Paediatrics and Chief of Infectious Diseases, University of Ottawa, Ottawa, Ontario)

Michael Knipper (Associate Professor, Institute of the History of Medicine of the University of Giessen, Germany)

Michela Martini (Migration Health Regional Specialist, IOM Regional Office for Horn, East and Southern Africa, Nairobi, Kenya)

Moeketsi Modisenyane, National Department of Health, South Africa

Davide Mosca (Director, Migration Health Division, IOM, Geneva, Switzerland)

Kevin Pottie (Associate Professor, Faculty of Medicine, University of Ottawa, Ottawa, Ontario)

Bayard Roberts (Director, The Centre for Health and Social Change at the London School of Hygiene and Tropical Medicine, London, United Kingdom)

William Courtland Robinson (Associate Professor, Johns Hopkins Bloomberg, School of Public Health, USA)

Chesmal Siriwardhana (Associate Professor, London School for Hygiene and Tropical Medicine)

Ursula Trummer (Head, Center for Health and Migration, Vienna, Austria)

Jo Vearey (Associate Professor, African Centre for Migration & Society (ACMS), University of the Witwatersrand)

Kolitha Wickramage (Migration Health and Epidemiology Coordinator, IOM, Manila, Philippines)

Anthony Zwi (Professor of Global Health and Development, The University of New South Wales, Sydney, Australia)

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Global inequities in access to drugs costs millions of lives each year.

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The World Health Organization estimates that at least one-third of the world’s population does not have access to essential medicines, resulting in millions of avoidable deaths each year from infectious diseases including malaria, tuberculosis, and HIV. Barriers to access to these medicines disproportionately affect people in low- and middle-income countries (LMICs) due to unaffordable drug prices, drug shortages, and poor distribution and manufacturing infrastructure. If the world is going to achieve global equity in drug access, and therefore decrease inequities in disease, these countries must be able to not only afford the drugs but deliver them to those who need them the most.

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Global projections of macroeconomic climate-change damages typically consider impacts from average annual and national temperatures over long time horizons 1 , 2 , 3 , 4 , 5 , 6 . Here we use recent empirical findings from more than 1,600 regions worldwide over the past 40 years to project sub-national damages from temperature and precipitation, including daily variability and extremes 7 , 8 . Using an empirical approach that provides a robust lower bound on the persistence of impacts on economic growth, we find that the world economy is committed to an income reduction of 19% within the next 26 years independent of future emission choices (relative to a baseline without climate impacts, likely range of 11–29% accounting for physical climate and empirical uncertainty). These damages already outweigh the mitigation costs required to limit global warming to 2 °C by sixfold over this near-term time frame and thereafter diverge strongly dependent on emission choices. Committed damages arise predominantly through changes in average temperature, but accounting for further climatic components raises estimates by approximately 50% and leads to stronger regional heterogeneity. Committed losses are projected for all regions except those at very high latitudes, at which reductions in temperature variability bring benefits. The largest losses are committed at lower latitudes in regions with lower cumulative historical emissions and lower present-day income.

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Investment incentive reduced by climate damages can be restored by optimal policy

Climate economics support for the UN climate targets

Projections of the macroeconomic damage caused by future climate change are crucial to informing public and policy debates about adaptation, mitigation and climate justice. On the one hand, adaptation against climate impacts must be justified and planned on the basis of an understanding of their future magnitude and spatial distribution 9 . This is also of importance in the context of climate justice 10 , as well as to key societal actors, including governments, central banks and private businesses, which increasingly require the inclusion of climate risks in their macroeconomic forecasts to aid adaptive decision-making 11 , 12 . On the other hand, climate mitigation policy such as the Paris Climate Agreement is often evaluated by balancing the costs of its implementation against the benefits of avoiding projected physical damages. This evaluation occurs both formally through cost–benefit analyses 1 , 4 , 5 , 6 , as well as informally through public perception of mitigation and damage costs 13 .

Projections of future damages meet challenges when informing these debates, in particular the human biases relating to uncertainty and remoteness that are raised by long-term perspectives 14 . Here we aim to overcome such challenges by assessing the extent of economic damages from climate change to which the world is already committed by historical emissions and socio-economic inertia (the range of future emission scenarios that are considered socio-economically plausible 15 ). Such a focus on the near term limits the large uncertainties about diverging future emission trajectories, the resulting long-term climate response and the validity of applying historically observed climate–economic relations over long timescales during which socio-technical conditions may change considerably. As such, this focus aims to simplify the communication and maximize the credibility of projected economic damages from future climate change.

In projecting the future economic damages from climate change, we make use of recent advances in climate econometrics that provide evidence for impacts on sub-national economic growth from numerous components of the distribution of daily temperature and precipitation 3 , 7 , 8 . Using fixed-effects panel regression models to control for potential confounders, these studies exploit within-region variation in local temperature and precipitation in a panel of more than 1,600 regions worldwide, comprising climate and income data over the past 40 years, to identify the plausibly causal effects of changes in several climate variables on economic productivity 16 , 17 . Specifically, macroeconomic impacts have been identified from changing daily temperature variability, total annual precipitation, the annual number of wet days and extreme daily rainfall that occur in addition to those already identified from changing average temperature 2 , 3 , 18 . Moreover, regional heterogeneity in these effects based on the prevailing local climatic conditions has been found using interactions terms. The selection of these climate variables follows micro-level evidence for mechanisms related to the impacts of average temperatures on labour and agricultural productivity 2 , of temperature variability on agricultural productivity and health 7 , as well as of precipitation on agricultural productivity, labour outcomes and flood damages 8 (see Extended Data Table 1 for an overview, including more detailed references). References  7 , 8 contain a more detailed motivation for the use of these particular climate variables and provide extensive empirical tests about the robustness and nature of their effects on economic output, which are summarized in Methods . By accounting for these extra climatic variables at the sub-national level, we aim for a more comprehensive description of climate impacts with greater detail across both time and space.

Constraining the persistence of impacts

A key determinant and source of discrepancy in estimates of the magnitude of future climate damages is the extent to which the impact of a climate variable on economic growth rates persists. The two extreme cases in which these impacts persist indefinitely or only instantaneously are commonly referred to as growth or level effects 19 , 20 (see Methods section ‘Empirical model specification: fixed-effects distributed lag models’ for mathematical definitions). Recent work shows that future damages from climate change depend strongly on whether growth or level effects are assumed 20 . Following refs.  2 , 18 , we provide constraints on this persistence by using distributed lag models to test the significance of delayed effects separately for each climate variable. Notably, and in contrast to refs.  2 , 18 , we use climate variables in their first-differenced form following ref.  3 , implying a dependence of the growth rate on a change in climate variables. This choice means that a baseline specification without any lags constitutes a model prior of purely level effects, in which a permanent change in the climate has only an instantaneous effect on the growth rate 3 , 19 , 21 . By including lags, one can then test whether any effects may persist further. This is in contrast to the specification used by refs.  2 , 18 , in which climate variables are used without taking the first difference, implying a dependence of the growth rate on the level of climate variables. In this alternative case, the baseline specification without any lags constitutes a model prior of pure growth effects, in which a change in climate has an infinitely persistent effect on the growth rate. Consequently, including further lags in this alternative case tests whether the initial growth impact is recovered 18 , 19 , 21 . Both of these specifications suffer from the limiting possibility that, if too few lags are included, one might falsely accept the model prior. The limitations of including a very large number of lags, including loss of data and increasing statistical uncertainty with an increasing number of parameters, mean that such a possibility is likely. By choosing a specification in which the model prior is one of level effects, our approach is therefore conservative by design, avoiding assumptions of infinite persistence of climate impacts on growth and instead providing a lower bound on this persistence based on what is observable empirically (see Methods section ‘Empirical model specification: fixed-effects distributed lag models’ for further exposition of this framework). The conservative nature of such a choice is probably the reason that ref.  19 finds much greater consistency between the impacts projected by models that use the first difference of climate variables, as opposed to their levels.

We begin our empirical analysis of the persistence of climate impacts on growth using ten lags of the first-differenced climate variables in fixed-effects distributed lag models. We detect substantial effects on economic growth at time lags of up to approximately 8–10 years for the temperature terms and up to approximately 4 years for the precipitation terms (Extended Data Fig. 1 and Extended Data Table 2 ). Furthermore, evaluation by means of information criteria indicates that the inclusion of all five climate variables and the use of these numbers of lags provide a preferable trade-off between best-fitting the data and including further terms that could cause overfitting, in comparison with model specifications excluding climate variables or including more or fewer lags (Extended Data Fig. 3 , Supplementary Methods Section  1 and Supplementary Table 1 ). We therefore remove statistically insignificant terms at later lags (Supplementary Figs. 1 – 3 and Supplementary Tables 2 – 4 ). Further tests using Monte Carlo simulations demonstrate that the empirical models are robust to autocorrelation in the lagged climate variables (Supplementary Methods Section  2 and Supplementary Figs. 4 and 5 ), that information criteria provide an effective indicator for lag selection (Supplementary Methods Section  2 and Supplementary Fig. 6 ), that the results are robust to concerns of imperfect multicollinearity between climate variables and that including several climate variables is actually necessary to isolate their separate effects (Supplementary Methods Section  3 and Supplementary Fig. 7 ). We provide a further robustness check using a restricted distributed lag model to limit oscillations in the lagged parameter estimates that may result from autocorrelation, finding that it provides similar estimates of cumulative marginal effects to the unrestricted model (Supplementary Methods Section 4 and Supplementary Figs. 8 and 9 ). Finally, to explicitly account for any outstanding uncertainty arising from the precise choice of the number of lags, we include empirical models with marginally different numbers of lags in the error-sampling procedure of our projection of future damages. On the basis of the lag-selection procedure (the significance of lagged terms in Extended Data Fig. 1 and Extended Data Table 2 , as well as information criteria in Extended Data Fig. 3 ), we sample from models with eight to ten lags for temperature and four for precipitation (models shown in Supplementary Figs. 1 – 3 and Supplementary Tables 2 – 4 ). In summary, this empirical approach to constrain the persistence of climate impacts on economic growth rates is conservative by design in avoiding assumptions of infinite persistence, but nevertheless provides a lower bound on the extent of impact persistence that is robust to the numerous tests outlined above.

Committed damages until mid-century

We combine these empirical economic response functions (Supplementary Figs. 1 – 3 and Supplementary Tables 2 – 4 ) with an ensemble of 21 climate models (see Supplementary Table 5 ) from the Coupled Model Intercomparison Project Phase 6 (CMIP-6) 22 to project the macroeconomic damages from these components of physical climate change (see Methods for further details). Bias-adjusted climate models that provide a highly accurate reproduction of observed climatological patterns with limited uncertainty (Supplementary Table 6 ) are used to avoid introducing biases in the projections. Following a well-developed literature 2 , 3 , 19 , these projections do not aim to provide a prediction of future economic growth. Instead, they are a projection of the exogenous impact of future climate conditions on the economy relative to the baselines specified by socio-economic projections, based on the plausibly causal relationships inferred by the empirical models and assuming ceteris paribus. Other exogenous factors relevant for the prediction of economic output are purposefully assumed constant.

A Monte Carlo procedure that samples from climate model projections, empirical models with different numbers of lags and model parameter estimates (obtained by 1,000 block-bootstrap resamples of each of the regressions in Supplementary Figs. 1 – 3 and Supplementary Tables 2 – 4 ) is used to estimate the combined uncertainty from these sources. Given these uncertainty distributions, we find that projected global damages are statistically indistinguishable across the two most extreme emission scenarios until 2049 (at the 5% significance level; Fig. 1 ). As such, the climate damages occurring before this time constitute those to which the world is already committed owing to the combination of past emissions and the range of future emission scenarios that are considered socio-economically plausible 15 . These committed damages comprise a permanent income reduction of 19% on average globally (population-weighted average) in comparison with a baseline without climate-change impacts (with a likely range of 11–29%, following the likelihood classification adopted by the Intergovernmental Panel on Climate Change (IPCC); see caption of Fig. 1 ). Even though levels of income per capita generally still increase relative to those of today, this constitutes a permanent income reduction for most regions, including North America and Europe (each with median income reductions of approximately 11%) and with South Asia and Africa being the most strongly affected (each with median income reductions of approximately 22%; Fig. 1 ). Under a middle-of-the road scenario of future income development (SSP2, in which SSP stands for Shared Socio-economic Pathway), this corresponds to global annual damages in 2049 of 38 trillion in 2005 international dollars (likely range of 19–59 trillion 2005 international dollars). Compared with empirical specifications that assume pure growth or pure level effects, our preferred specification that provides a robust lower bound on the extent of climate impact persistence produces damages between these two extreme assumptions (Extended Data Fig. 3 ).

Estimates of the projected reduction in income per capita from changes in all climate variables based on empirical models of climate impacts on economic output with a robust lower bound on their persistence (Extended Data Fig. 1 ) under a low-emission scenario compatible with the 2 °C warming target and a high-emission scenario (SSP2-RCP2.6 and SSP5-RCP8.5, respectively) are shown in purple and orange, respectively. Shading represents the 34% and 10% confidence intervals reflecting the likely and very likely ranges, respectively (following the likelihood classification adopted by the IPCC), having estimated uncertainty from a Monte Carlo procedure, which samples the uncertainty from the choice of physical climate models, empirical models with different numbers of lags and bootstrapped estimates of the regression parameters shown in Supplementary Figs. 1 – 3 . Vertical dashed lines show the time at which the climate damages of the two emission scenarios diverge at the 5% and 1% significance levels based on the distribution of differences between emission scenarios arising from the uncertainty sampling discussed above. Note that uncertainty in the difference of the two scenarios is smaller than the combined uncertainty of the two respective scenarios because samples of the uncertainty (climate model and empirical model choice, as well as model parameter bootstrap) are consistent across the two emission scenarios, hence the divergence of damages occurs while the uncertainty bounds of the two separate damage scenarios still overlap. Estimates of global mitigation costs from the three IAMs that provide results for the SSP2 baseline and SSP2-RCP2.6 scenario are shown in light green in the top panel, with the median of these estimates shown in bold.

Damages already outweigh mitigation costs

We compare the damages to which the world is committed over the next 25 years to estimates of the mitigation costs required to achieve the Paris Climate Agreement. Taking estimates of mitigation costs from the three integrated assessment models (IAMs) in the IPCC AR6 database 23 that provide results under comparable scenarios (SSP2 baseline and SSP2-RCP2.6, in which RCP stands for Representative Concentration Pathway), we find that the median committed climate damages are larger than the median mitigation costs in 2050 (six trillion in 2005 international dollars) by a factor of approximately six (note that estimates of mitigation costs are only provided every 10 years by the IAMs and so a comparison in 2049 is not possible). This comparison simply aims to compare the magnitude of future damages against mitigation costs, rather than to conduct a formal cost–benefit analysis of transitioning from one emission path to another. Formal cost–benefit analyses typically find that the net benefits of mitigation only emerge after 2050 (ref.  5 ), which may lead some to conclude that physical damages from climate change are simply not large enough to outweigh mitigation costs until the second half of the century. Our simple comparison of their magnitudes makes clear that damages are actually already considerably larger than mitigation costs and the delayed emergence of net mitigation benefits results primarily from the fact that damages across different emission paths are indistinguishable until mid-century (Fig. 1 ).

Although these near-term damages constitute those to which the world is already committed, we note that damage estimates diverge strongly across emission scenarios after 2049, conveying the clear benefits of mitigation from a purely economic point of view that have been emphasized in previous studies 4 , 24 . As well as the uncertainties assessed in Fig. 1 , these conclusions are robust to structural choices, such as the timescale with which changes in the moderating variables of the empirical models are estimated (Supplementary Figs. 10 and 11 ), as well as the order in which one accounts for the intertemporal and international components of currency comparison (Supplementary Fig. 12 ; see Methods for further details).

Damages from variability and extremes

Committed damages primarily arise through changes in average temperature (Fig. 2 ). This reflects the fact that projected changes in average temperature are larger than those in other climate variables when expressed as a function of their historical interannual variability (Extended Data Fig. 4 ). Because the historical variability is that on which the empirical models are estimated, larger projected changes in comparison with this variability probably lead to larger future impacts in a purely statistical sense. From a mechanistic perspective, one may plausibly interpret this result as implying that future changes in average temperature are the most unprecedented from the perspective of the historical fluctuations to which the economy is accustomed and therefore will cause the most damage. This insight may prove useful in terms of guiding adaptation measures to the sources of greatest damage.

Estimates of the median projected reduction in sub-national income per capita across emission scenarios (SSP2-RCP2.6 and SSP2-RCP8.5) as well as climate model, empirical model and model parameter uncertainty in the year in which climate damages diverge at the 5% level (2049, as identified in Fig. 1 ). a , Impacts arising from all climate variables. b – f , Impacts arising separately from changes in annual mean temperature ( b ), daily temperature variability ( c ), total annual precipitation ( d ), the annual number of wet days (>1 mm) ( e ) and extreme daily rainfall ( f ) (see Methods for further definitions). Data on national administrative boundaries are obtained from the GADM database version 3.6 and are freely available for academic use ( https://gadm.org/ ).

Nevertheless, future damages based on empirical models that consider changes in annual average temperature only and exclude the other climate variables constitute income reductions of only 13% in 2049 (Extended Data Fig. 5a , likely range 5–21%). This suggests that accounting for the other components of the distribution of temperature and precipitation raises net damages by nearly 50%. This increase arises through the further damages that these climatic components cause, but also because their inclusion reveals a stronger negative economic response to average temperatures (Extended Data Fig. 5b ). The latter finding is consistent with our Monte Carlo simulations, which suggest that the magnitude of the effect of average temperature on economic growth is underestimated unless accounting for the impacts of other correlated climate variables (Supplementary Fig. 7 ).

In terms of the relative contributions of the different climatic components to overall damages, we find that accounting for daily temperature variability causes the largest increase in overall damages relative to empirical frameworks that only consider changes in annual average temperature (4.9 percentage points, likely range 2.4–8.7 percentage points, equivalent to approximately 10 trillion international dollars). Accounting for precipitation causes smaller increases in overall damages, which are—nevertheless—equivalent to approximately 1.2 trillion international dollars: 0.01 percentage points (−0.37–0.33 percentage points), 0.34 percentage points (0.07–0.90 percentage points) and 0.36 percentage points (0.13–0.65 percentage points) from total annual precipitation, the number of wet days and extreme daily precipitation, respectively. Moreover, climate models seem to underestimate future changes in temperature variability 25 and extreme precipitation 26 , 27 in response to anthropogenic forcing as compared with that observed historically, suggesting that the true impacts from these variables may be larger.

The distribution of committed damages

The spatial distribution of committed damages (Fig. 2a ) reflects a complex interplay between the patterns of future change in several climatic components and those of historical economic vulnerability to changes in those variables. Damages resulting from increasing annual mean temperature (Fig. 2b ) are negative almost everywhere globally, and larger at lower latitudes in regions in which temperatures are already higher and economic vulnerability to temperature increases is greatest (see the response heterogeneity to mean temperature embodied in Extended Data Fig. 1a ). This occurs despite the amplified warming projected at higher latitudes 28 , suggesting that regional heterogeneity in economic vulnerability to temperature changes outweighs heterogeneity in the magnitude of future warming (Supplementary Fig. 13a ). Economic damages owing to daily temperature variability (Fig. 2c ) exhibit a strong latitudinal polarisation, primarily reflecting the physical response of daily variability to greenhouse forcing in which increases in variability across lower latitudes (and Europe) contrast decreases at high latitudes 25 (Supplementary Fig. 13b ). These two temperature terms are the dominant determinants of the pattern of overall damages (Fig. 2a ), which exhibits a strong polarity with damages across most of the globe except at the highest northern latitudes. Future changes in total annual precipitation mainly bring economic benefits except in regions of drying, such as the Mediterranean and central South America (Fig. 2d and Supplementary Fig. 13c ), but these benefits are opposed by changes in the number of wet days, which produce damages with a similar pattern of opposite sign (Fig. 2e and Supplementary Fig. 13d ). By contrast, changes in extreme daily rainfall produce damages in all regions, reflecting the intensification of daily rainfall extremes over global land areas 29 , 30 (Fig. 2f and Supplementary Fig. 13e ).

The spatial distribution of committed damages implies considerable injustice along two dimensions: culpability for the historical emissions that have caused climate change and pre-existing levels of socio-economic welfare. Spearman’s rank correlations indicate that committed damages are significantly larger in countries with smaller historical cumulative emissions, as well as in regions with lower current income per capita (Fig. 3 ). This implies that those countries that will suffer the most from the damages already committed are those that are least responsible for climate change and which also have the least resources to adapt to it.

Estimates of the median projected change in national income per capita across emission scenarios (RCP2.6 and RCP8.5) as well as climate model, empirical model and model parameter uncertainty in the year in which climate damages diverge at the 5% level (2049, as identified in Fig. 1 ) are plotted against cumulative national emissions per capita in 2020 (from the Global Carbon Project) and coloured by national income per capita in 2020 (from the World Bank) in a and vice versa in b . In each panel, the size of each scatter point is weighted by the national population in 2020 (from the World Bank). Inset numbers indicate the Spearman’s rank correlation ρ and P -values for a hypothesis test whose null hypothesis is of no correlation, as well as the Spearman’s rank correlation weighted by national population.

To further quantify this heterogeneity, we assess the difference in committed damages between the upper and lower quartiles of regions when ranked by present income levels and historical cumulative emissions (using a population weighting to both define the quartiles and estimate the group averages). On average, the quartile of countries with lower income are committed to an income loss that is 8.9 percentage points (or 61%) greater than the upper quartile (Extended Data Fig. 6 ), with a likely range of 3.8–14.7 percentage points across the uncertainty sampling of our damage projections (following the likelihood classification adopted by the IPCC). Similarly, the quartile of countries with lower historical cumulative emissions are committed to an income loss that is 6.9 percentage points (or 40%) greater than the upper quartile, with a likely range of 0.27–12 percentage points. These patterns reemphasize the prevalence of injustice in climate impacts 31 , 32 , 33 in the context of the damages to which the world is already committed by historical emissions and socio-economic inertia.

Contextualizing the magnitude of damages

The magnitude of projected economic damages exceeds previous literature estimates 2 , 3 , arising from several developments made on previous approaches. Our estimates are larger than those of ref.  2 (see first row of Extended Data Table 3 ), primarily because of the facts that sub-national estimates typically show a steeper temperature response (see also refs.  3 , 34 ) and that accounting for other climatic components raises damage estimates (Extended Data Fig. 5 ). However, we note that our empirical approach using first-differenced climate variables is conservative compared with that of ref.  2 in regard to the persistence of climate impacts on growth (see introduction and Methods section ‘Empirical model specification: fixed-effects distributed lag models’), an important determinant of the magnitude of long-term damages 19 , 21 . Using a similar empirical specification to ref.  2 , which assumes infinite persistence while maintaining the rest of our approach (sub-national data and further climate variables), produces considerably larger damages (purple curve of Extended Data Fig. 3 ). Compared with studies that do take the first difference of climate variables 3 , 35 , our estimates are also larger (see second and third rows of Extended Data Table 3 ). The inclusion of further climate variables (Extended Data Fig. 5 ) and a sufficient number of lags to more adequately capture the extent of impact persistence (Extended Data Figs. 1 and 2 ) are the main sources of this difference, as is the use of specifications that capture nonlinearities in the temperature response when compared with ref.  35 . In summary, our estimates develop on previous studies by incorporating the latest data and empirical insights 7 , 8 , as well as in providing a robust empirical lower bound on the persistence of impacts on economic growth, which constitutes a middle ground between the extremes of the growth-versus-levels debate 19 , 21 (Extended Data Fig. 3 ).

Compared with the fraction of variance explained by the empirical models historically (<5%), the projection of reductions in income of 19% may seem large. This arises owing to the fact that projected changes in climatic conditions are much larger than those that were experienced historically, particularly for changes in average temperature (Extended Data Fig. 4 ). As such, any assessment of future climate-change impacts necessarily requires an extrapolation outside the range of the historical data on which the empirical impact models were evaluated. Nevertheless, these models constitute the most state-of-the-art methods for inference of plausibly causal climate impacts based on observed data. Moreover, we take explicit steps to limit out-of-sample extrapolation by capping the moderating variables of the interaction terms at the 95th percentile of the historical distribution (see Methods ). This avoids extrapolating the marginal effects outside what was observed historically. Given the nonlinear response of economic output to annual mean temperature (Extended Data Fig. 1 and Extended Data Table 2 ), this is a conservative choice that limits the magnitude of damages that we project. Furthermore, back-of-the-envelope calculations indicate that the projected damages are consistent with the magnitude and patterns of historical economic development (see Supplementary Discussion Section  5 ).

Missing impacts and spatial spillovers

Despite assessing several climatic components from which economic impacts have recently been identified 3 , 7 , 8 , this assessment of aggregate climate damages should not be considered comprehensive. Important channels such as impacts from heatwaves 31 , sea-level rise 36 , tropical cyclones 37 and tipping points 38 , 39 , as well as non-market damages such as those to ecosystems 40 and human health 41 , are not considered in these estimates. Sea-level rise is unlikely to be feasibly incorporated into empirical assessments such as this because historical sea-level variability is mostly small. Non-market damages are inherently intractable within our estimates of impacts on aggregate monetary output and estimates of these impacts could arguably be considered as extra to those identified here. Recent empirical work suggests that accounting for these channels would probably raise estimates of these committed damages, with larger damages continuing to arise in the global south 31 , 36 , 37 , 38 , 39 , 40 , 41 , 42 .

Moreover, our main empirical analysis does not explicitly evaluate the potential for impacts in local regions to produce effects that ‘spill over’ into other regions. Such effects may further mitigate or amplify the impacts we estimate, for example, if companies relocate production from one affected region to another or if impacts propagate along supply chains. The current literature indicates that trade plays a substantial role in propagating spillover effects 43 , 44 , making their assessment at the sub-national level challenging without available data on sub-national trade dependencies. Studies accounting for only spatially adjacent neighbours indicate that negative impacts in one region induce further negative impacts in neighbouring regions 45 , 46 , 47 , 48 , suggesting that our projected damages are probably conservative by excluding these effects. In Supplementary Fig. 14 , we assess spillovers from neighbouring regions using a spatial-lag model. For simplicity, this analysis excludes temporal lags, focusing only on contemporaneous effects. The results show that accounting for spatial spillovers can amplify the overall magnitude, and also the heterogeneity, of impacts. Consistent with previous literature, this indicates that the overall magnitude (Fig. 1 ) and heterogeneity (Fig. 3 ) of damages that we project in our main specification may be conservative without explicitly accounting for spillovers. We note that further analysis that addresses both spatially and trade-connected spillovers, while also accounting for delayed impacts using temporal lags, would be necessary to adequately address this question fully. These approaches offer fruitful avenues for further research but are beyond the scope of this manuscript, which primarily aims to explore the impacts of different climate conditions and their persistence.

Policy implications

We find that the economic damages resulting from climate change until 2049 are those to which the world economy is already committed and that these greatly outweigh the costs required to mitigate emissions in line with the 2 °C target of the Paris Climate Agreement (Fig. 1 ). This assessment is complementary to formal analyses of the net costs and benefits associated with moving from one emission path to another, which typically find that net benefits of mitigation only emerge in the second half of the century 5 . Our simple comparison of the magnitude of damages and mitigation costs makes clear that this is primarily because damages are indistinguishable across emissions scenarios—that is, committed—until mid-century (Fig. 1 ) and that they are actually already much larger than mitigation costs. For simplicity, and owing to the availability of data, we compare damages to mitigation costs at the global level. Regional estimates of mitigation costs may shed further light on the national incentives for mitigation to which our results already hint, of relevance for international climate policy. Although these damages are committed from a mitigation perspective, adaptation may provide an opportunity to reduce them. Moreover, the strong divergence of damages after mid-century reemphasizes the clear benefits of mitigation from a purely economic perspective, as highlighted in previous studies 1 , 4 , 6 , 24 .

Historical climate data

Historical daily 2-m temperature and precipitation totals (in mm) are obtained for the period 1979–2019 from the W5E5 database. The W5E5 dataset comes from ERA-5, a state-of-the-art reanalysis of historical observations, but has been bias-adjusted by applying version 2.0 of the WATCH Forcing Data to ERA-5 reanalysis data and precipitation data from version 2.3 of the Global Precipitation Climatology Project to better reflect ground-based measurements 49 , 50 , 51 . We obtain these data on a 0.5° × 0.5° grid from the Inter-Sectoral Impact Model Intercomparison Project (ISIMIP) database. Notably, these historical data have been used to bias-adjust future climate projections from CMIP-6 (see the following section), ensuring consistency between the distribution of historical daily weather on which our empirical models were estimated and the climate projections used to estimate future damages. These data are publicly available from the ISIMIP database. See refs.  7 , 8 for robustness tests of the empirical models to the choice of climate data reanalysis products.

Future climate data

Daily 2-m temperature and precipitation totals (in mm) are taken from 21 climate models participating in CMIP-6 under a high (RCP8.5) and a low (RCP2.6) greenhouse gas emission scenario from 2015 to 2100. The data have been bias-adjusted and statistically downscaled to a common half-degree grid to reflect the historical distribution of daily temperature and precipitation of the W5E5 dataset using the trend-preserving method developed by the ISIMIP 50 , 52 . As such, the climate model data reproduce observed climatological patterns exceptionally well (Supplementary Table 5 ). Gridded data are publicly available from the ISIMIP database.

Historical economic data

Historical economic data come from the DOSE database of sub-national economic output 53 . We use a recent revision to the DOSE dataset that provides data across 83 countries, 1,660 sub-national regions with varying temporal coverage from 1960 to 2019. Sub-national units constitute the first administrative division below national, for example, states for the USA and provinces for China. Data come from measures of gross regional product per capita (GRPpc) or income per capita in local currencies, reflecting the values reported in national statistical agencies, yearbooks and, in some cases, academic literature. We follow previous literature 3 , 7 , 8 , 54 and assess real sub-national output per capita by first converting values from local currencies to US dollars to account for diverging national inflationary tendencies and then account for US inflation using a US deflator. Alternatively, one might first account for national inflation and then convert between currencies. Supplementary Fig. 12 demonstrates that our conclusions are consistent when accounting for price changes in the reversed order, although the magnitude of estimated damages varies. See the documentation of the DOSE dataset for further discussion of these choices. Conversions between currencies are conducted using exchange rates from the FRED database of the Federal Reserve Bank of St. Louis 55 and the national deflators from the World Bank 56 .

Future socio-economic data

Baseline gridded gross domestic product (GDP) and population data for the period 2015–2100 are taken from the middle-of-the-road scenario SSP2 (ref.  15 ). Population data have been downscaled to a half-degree grid by the ISIMIP following the methodologies of refs.  57 , 58 , which we then aggregate to the sub-national level of our economic data using the spatial aggregation procedure described below. Because current methodologies for downscaling the GDP of the SSPs use downscaled population to do so, per-capita estimates of GDP with a realistic distribution at the sub-national level are not readily available for the SSPs. We therefore use national-level GDP per capita (GDPpc) projections for all sub-national regions of a given country, assuming homogeneity within countries in terms of baseline GDPpc. Here we use projections that have been updated to account for the impact of the COVID-19 pandemic on the trajectory of future income, while remaining consistent with the long-term development of the SSPs 59 . The choice of baseline SSP alters the magnitude of projected climate damages in monetary terms, but when assessed in terms of percentage change from the baseline, the choice of socio-economic scenario is inconsequential. Gridded SSP population data and national-level GDPpc data are publicly available from the ISIMIP database. Sub-national estimates as used in this study are available in the code and data replication files.

Climate variables

Following recent literature 3 , 7 , 8 , we calculate an array of climate variables for which substantial impacts on macroeconomic output have been identified empirically, supported by further evidence at the micro level for plausible underlying mechanisms. See refs.  7 , 8 for an extensive motivation for the use of these particular climate variables and for detailed empirical tests on the nature and robustness of their effects on economic output. To summarize, these studies have found evidence for independent impacts on economic growth rates from annual average temperature, daily temperature variability, total annual precipitation, the annual number of wet days and extreme daily rainfall. Assessments of daily temperature variability were motivated by evidence of impacts on agricultural output and human health, as well as macroeconomic literature on the impacts of volatility on growth when manifest in different dimensions, such as government spending, exchange rates and even output itself 7 . Assessments of precipitation impacts were motivated by evidence of impacts on agricultural productivity, metropolitan labour outcomes and conflict, as well as damages caused by flash flooding 8 . See Extended Data Table 1 for detailed references to empirical studies of these physical mechanisms. Marked impacts of daily temperature variability, total annual precipitation, the number of wet days and extreme daily rainfall on macroeconomic output were identified robustly across different climate datasets, spatial aggregation schemes, specifications of regional time trends and error-clustering approaches. They were also found to be robust to the consideration of temperature extremes 7 , 8 . Furthermore, these climate variables were identified as having independent effects on economic output 7 , 8 , which we further explain here using Monte Carlo simulations to demonstrate the robustness of the results to concerns of imperfect multicollinearity between climate variables (Supplementary Methods Section  2 ), as well as by using information criteria (Supplementary Table 1 ) to demonstrate that including several lagged climate variables provides a preferable trade-off between optimally describing the data and limiting the possibility of overfitting.

We calculate these variables from the distribution of daily, d , temperature, T x , d , and precipitation, P x , d , at the grid-cell, x , level for both the historical and future climate data. As well as annual mean temperature, \({\bar{T}}_{x,y}\) , and annual total precipitation, P x , y , we calculate annual, y , measures of daily temperature variability, \({\widetilde{T}}_{x,y}\) :

the number of wet days, Pwd x , y :

and extreme daily rainfall:

in which T x , d , m , y is the grid-cell-specific daily temperature in month m and year y , \({\bar{T}}_{x,m,{y}}\) is the year and grid-cell-specific monthly, m , mean temperature, D m and D y the number of days in a given month m or year y , respectively, H the Heaviside step function, 1 mm the threshold used to define wet days and P 99.9 x is the 99.9th percentile of historical (1979–2019) daily precipitation at the grid-cell level. Units of the climate measures are degrees Celsius for annual mean temperature and daily temperature variability, millimetres for total annual precipitation and extreme daily precipitation, and simply the number of days for the annual number of wet days.

We also calculated weighted standard deviations of monthly rainfall totals as also used in ref.  8 but do not include them in our projections as we find that, when accounting for delayed effects, their effect becomes statistically indistinct and is better captured by changes in total annual rainfall.

Spatial aggregation

We aggregate grid-cell-level historical and future climate measures, as well as grid-cell-level future GDPpc and population, to the level of the first administrative unit below national level of the GADM database, using an area-weighting algorithm that estimates the portion of each grid cell falling within an administrative boundary. We use this as our baseline specification following previous findings that the effect of area or population weighting at the sub-national level is negligible 7 , 8 .

Empirical model specification: fixed-effects distributed lag models

Following a wide range of climate econometric literature 16 , 60 , we use panel regression models with a selection of fixed effects and time trends to isolate plausibly exogenous variation with which to maximize confidence in a causal interpretation of the effects of climate on economic growth rates. The use of region fixed effects, μ r , accounts for unobserved time-invariant differences between regions, such as prevailing climatic norms and growth rates owing to historical and geopolitical factors. The use of yearly fixed effects, η y , accounts for regionally invariant annual shocks to the global climate or economy such as the El Niño–Southern Oscillation or global recessions. In our baseline specification, we also include region-specific linear time trends, k r y , to exclude the possibility of spurious correlations resulting from common slow-moving trends in climate and growth.

The persistence of climate impacts on economic growth rates is a key determinant of the long-term magnitude of damages. Methods for inferring the extent of persistence in impacts on growth rates have typically used lagged climate variables to evaluate the presence of delayed effects or catch-up dynamics 2 , 18 . For example, consider starting from a model in which a climate condition, C r , y , (for example, annual mean temperature) affects the growth rate, Δlgrp r , y (the first difference of the logarithm of gross regional product) of region r in year y :

which we refer to as a ‘pure growth effects’ model in the main text. Typically, further lags are included,

and the cumulative effect of all lagged terms is evaluated to assess the extent to which climate impacts on growth rates persist. Following ref.  18 , in the case that,

the implication is that impacts on the growth rate persist up to NL years after the initial shock (possibly to a weaker or a stronger extent), whereas if

then the initial impact on the growth rate is recovered after NL years and the effect is only one on the level of output. However, we note that such approaches are limited by the fact that, when including an insufficient number of lags to detect a recovery of the growth rates, one may find equation ( 6 ) to be satisfied and incorrectly assume that a change in climatic conditions affects the growth rate indefinitely. In practice, given a limited record of historical data, including too few lags to confidently conclude in an infinitely persistent impact on the growth rate is likely, particularly over the long timescales over which future climate damages are often projected 2 , 24 . To avoid this issue, we instead begin our analysis with a model for which the level of output, lgrp r , y , depends on the level of a climate variable, C r , y :

Given the non-stationarity of the level of output, we follow the literature 19 and estimate such an equation in first-differenced form as,

which we refer to as a model of ‘pure level effects’ in the main text. This model constitutes a baseline specification in which a permanent change in the climate variable produces an instantaneous impact on the growth rate and a permanent effect only on the level of output. By including lagged variables in this specification,

we are able to test whether the impacts on the growth rate persist any further than instantaneously by evaluating whether α L  > 0 are statistically significantly different from zero. Even though this framework is also limited by the possibility of including too few lags, the choice of a baseline model specification in which impacts on the growth rate do not persist means that, in the case of including too few lags, the framework reverts to the baseline specification of level effects. As such, this framework is conservative with respect to the persistence of impacts and the magnitude of future damages. It naturally avoids assumptions of infinite persistence and we are able to interpret any persistence that we identify with equation ( 9 ) as a lower bound on the extent of climate impact persistence on growth rates. See the main text for further discussion of this specification choice, in particular about its conservative nature compared with previous literature estimates, such as refs.  2 , 18 .

We allow the response to climatic changes to vary across regions, using interactions of the climate variables with historical average (1979–2019) climatic conditions reflecting heterogenous effects identified in previous work 7 , 8 . Following this previous work, the moderating variables of these interaction terms constitute the historical average of either the variable itself or of the seasonal temperature difference, \({\hat{T}}_{r}\) , or annual mean temperature, \({\bar{T}}_{r}\) , in the case of daily temperature variability 7 and extreme daily rainfall, respectively 8 .

The resulting regression equation with N and M lagged variables, respectively, reads:

in which Δlgrp r , y is the annual, regional GRPpc growth rate, measured as the first difference of the logarithm of real GRPpc, following previous work 2 , 3 , 7 , 8 , 18 , 19 . Fixed-effects regressions were run using the fixest package in R (ref.  61 ).

Estimates of the coefficients of interest α i , L are shown in Extended Data Fig. 1 for N  =  M  = 10 lags and for our preferred choice of the number of lags in Supplementary Figs. 1 – 3 . In Extended Data Fig. 1 , errors are shown clustered at the regional level, but for the construction of damage projections, we block-bootstrap the regressions by region 1,000 times to provide a range of parameter estimates with which to sample the projection uncertainty (following refs.  2 , 31 ).

Spatial-lag model

In Supplementary Fig. 14 , we present the results from a spatial-lag model that explores the potential for climate impacts to ‘spill over’ into spatially neighbouring regions. We measure the distance between centroids of each pair of sub-national regions and construct spatial lags that take the average of the first-differenced climate variables and their interaction terms over neighbouring regions that are at distances of 0–500, 500–1,000, 1,000–1,500 and 1,500–2000 km (spatial lags, ‘SL’, 1 to 4). For simplicity, we then assess a spatial-lag model without temporal lags to assess spatial spillovers of contemporaneous climate impacts. This model takes the form:

in which SL indicates the spatial lag of each climate variable and interaction term. In Supplementary Fig. 14 , we plot the cumulative marginal effect of each climate variable at different baseline climate conditions by summing the coefficients for each climate variable and interaction term, for example, for average temperature impacts as:

These cumulative marginal effects can be regarded as the overall spatially dependent impact to an individual region given a one-unit shock to a climate variable in that region and all neighbouring regions at a given value of the moderating variable of the interaction term.

Constructing projections of economic damage from future climate change

We construct projections of future climate damages by applying the coefficients estimated in equation ( 10 ) and shown in Supplementary Tables 2 – 4 (when including only lags with statistically significant effects in specifications that limit overfitting; see Supplementary Methods Section  1 ) to projections of future climate change from the CMIP-6 models. Year-on-year changes in each primary climate variable of interest are calculated to reflect the year-to-year variations used in the empirical models. 30-year moving averages of the moderating variables of the interaction terms are calculated to reflect the long-term average of climatic conditions that were used for the moderating variables in the empirical models. By using moving averages in the projections, we account for the changing vulnerability to climate shocks based on the evolving long-term conditions (Supplementary Figs. 10 and 11 show that the results are robust to the precise choice of the window of this moving average). Although these climate variables are not differenced, the fact that the bias-adjusted climate models reproduce observed climatological patterns across regions for these moderating variables very accurately (Supplementary Table 6 ) with limited spread across models (<3%) precludes the possibility that any considerable bias or uncertainty is introduced by this methodological choice. However, we impose caps on these moderating variables at the 95th percentile at which they were observed in the historical data to prevent extrapolation of the marginal effects outside the range in which the regressions were estimated. This is a conservative choice that limits the magnitude of our damage projections.

Time series of primary climate variables and moderating climate variables are then combined with estimates of the empirical model parameters to evaluate the regression coefficients in equation ( 10 ), producing a time series of annual GRPpc growth-rate reductions for a given emission scenario, climate model and set of empirical model parameters. The resulting time series of growth-rate impacts reflects those occurring owing to future climate change. By contrast, a future scenario with no climate change would be one in which climate variables do not change (other than with random year-to-year fluctuations) and hence the time-averaged evaluation of equation ( 10 ) would be zero. Our approach therefore implicitly compares the future climate-change scenario to this no-climate-change baseline scenario.

The time series of growth-rate impacts owing to future climate change in region r and year y , δ r , y , are then added to the future baseline growth rates, π r , y (in log-diff form), obtained from the SSP2 scenario to yield trajectories of damaged GRPpc growth rates, ρ r , y . These trajectories are aggregated over time to estimate the future trajectory of GRPpc with future climate impacts:

in which GRPpc r , y =2020 is the initial log level of GRPpc. We begin damage estimates in 2020 to reflect the damages occurring since the end of the period for which we estimate the empirical models (1979–2019) and to match the timing of mitigation-cost estimates from most IAMs (see below).

For each emission scenario, this procedure is repeated 1,000 times while randomly sampling from the selection of climate models, the selection of empirical models with different numbers of lags (shown in Supplementary Figs. 1 – 3 and Supplementary Tables 2 – 4 ) and bootstrapped estimates of the regression parameters. The result is an ensemble of future GRPpc trajectories that reflect uncertainty from both physical climate change and the structural and sampling uncertainty of the empirical models.

Estimates of mitigation costs

We obtain IPCC estimates of the aggregate costs of emission mitigation from the AR6 Scenario Explorer and Database hosted by IIASA 23 . Specifically, we search the AR6 Scenarios Database World v1.1 for IAMs that provided estimates of global GDP and population under both a SSP2 baseline and a SSP2-RCP2.6 scenario to maintain consistency with the socio-economic and emission scenarios of the climate damage projections. We find five IAMs that provide data for these scenarios, namely, MESSAGE-GLOBIOM 1.0, REMIND-MAgPIE 1.5, AIM/GCE 2.0, GCAM 4.2 and WITCH-GLOBIOM 3.1. Of these five IAMs, we use the results only from the first three that passed the IPCC vetting procedure for reproducing historical emission and climate trajectories. We then estimate global mitigation costs as the percentage difference in global per capita GDP between the SSP2 baseline and the SSP2-RCP2.6 emission scenario. In the case of one of these IAMs, estimates of mitigation costs begin in 2020, whereas in the case of two others, mitigation costs begin in 2010. The mitigation cost estimates before 2020 in these two IAMs are mostly negligible, and our choice to begin comparison with damage estimates in 2020 is conservative with respect to the relative weight of climate damages compared with mitigation costs for these two IAMs.

Data availability

Data on economic production and ERA-5 climate data are publicly available at https://doi.org/10.5281/zenodo.4681306 (ref. 62 ) and https://www.ecmwf.int/en/forecasts/datasets/reanalysis-datasets/era5 , respectively. Data on mitigation costs are publicly available at https://data.ene.iiasa.ac.at/ar6/#/downloads . Processed climate and economic data, as well as all other necessary data for reproduction of the results, are available at the public repository https://doi.org/10.5281/zenodo.10562951  (ref. 63 ).

Code availability

All code necessary for reproduction of the results is available at the public repository https://doi.org/10.5281/zenodo.10562951  (ref. 63 ).

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Acknowledgements

We gratefully acknowledge financing from the Volkswagen Foundation and the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of the Government of the Federal Republic of Germany and Federal Ministry for Economic Cooperation and Development (BMZ).

Open access funding provided by Potsdam-Institut für Klimafolgenforschung (PIK) e.V.

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Extended data figures and tables

Extended data fig. 1 constraining the persistence of historical climate impacts on economic growth rates..

The results of a panel-based fixed-effects distributed lag model for the effects of annual mean temperature ( a ), daily temperature variability ( b ), total annual precipitation ( c ), the number of wet days ( d ) and extreme daily precipitation ( e ) on sub-national economic growth rates. Point estimates show the effects of a 1 °C or one standard deviation increase (for temperature and precipitation variables, respectively) at the lower quartile, median and upper quartile of the relevant moderating variable (green, orange and purple, respectively) at different lagged periods after the initial shock (note that these are not cumulative effects). Climate variables are used in their first-differenced form (see main text for discussion) and the moderating climate variables are the annual mean temperature, seasonal temperature difference, total annual precipitation, number of wet days and annual mean temperature, respectively, in panels a – e (see Methods for further discussion). Error bars show the 95% confidence intervals having clustered standard errors by region. The within-region R 2 , Bayesian and Akaike information criteria for the model are shown at the top of the figure. This figure shows results with ten lags for each variable to demonstrate the observed levels of persistence, but our preferred specifications remove later lags based on the statistical significance of terms shown above and the information criteria shown in Extended Data Fig. 2 . The resulting models without later lags are shown in Supplementary Figs. 1 – 3 .

Extended Data Fig. 2 Incremental lag-selection procedure using information criteria and within-region R 2 .

Starting from a panel-based fixed-effects distributed lag model estimating the effects of climate on economic growth using the real historical data (as in equation ( 4 )) with ten lags for all climate variables (as shown in Extended Data Fig. 1 ), lags are incrementally removed for one climate variable at a time. The resulting Bayesian and Akaike information criteria are shown in a – e and f – j , respectively, and the within-region R 2 and number of observations in k – o and p – t , respectively. Different rows show the results when removing lags from different climate variables, ordered from top to bottom as annual mean temperature, daily temperature variability, total annual precipitation, the number of wet days and extreme annual precipitation. Information criteria show minima at approximately four lags for precipitation variables and ten to eight for temperature variables, indicating that including these numbers of lags does not lead to overfitting. See Supplementary Table 1 for an assessment using information criteria to determine whether including further climate variables causes overfitting.

Extended Data Fig. 3 Damages in our preferred specification that provides a robust lower bound on the persistence of climate impacts on economic growth versus damages in specifications of pure growth or pure level effects.

Estimates of future damages as shown in Fig. 1 but under the emission scenario RCP8.5 for three separate empirical specifications: in orange our preferred specification, which provides an empirical lower bound on the persistence of climate impacts on economic growth rates while avoiding assumptions of infinite persistence (see main text for further discussion); in purple a specification of ‘pure growth effects’ in which the first difference of climate variables is not taken and no lagged climate variables are included (the baseline specification of ref.  2 ); and in pink a specification of ‘pure level effects’ in which the first difference of climate variables is taken but no lagged terms are included.

Extended Data Fig. 4 Climate changes in different variables as a function of historical interannual variability.

Changes in each climate variable of interest from 1979–2019 to 2035–2065 under the high-emission scenario SSP5-RCP8.5, expressed as a percentage of the historical variability of each measure. Historical variability is estimated as the standard deviation of each detrended climate variable over the period 1979–2019 during which the empirical models were identified (detrending is appropriate because of the inclusion of region-specific linear time trends in the empirical models). See Supplementary Fig. 13 for changes expressed in standard units. Data on national administrative boundaries are obtained from the GADM database version 3.6 and are freely available for academic use ( https://gadm.org/ ).

Extended Data Fig. 5 Contribution of different climate variables to overall committed damages.

a , Climate damages in 2049 when using empirical models that account for all climate variables, changes in annual mean temperature only or changes in both annual mean temperature and one other climate variable (daily temperature variability, total annual precipitation, the number of wet days and extreme daily precipitation, respectively). b , The cumulative marginal effects of an increase in annual mean temperature of 1 °C, at different baseline temperatures, estimated from empirical models including all climate variables or annual mean temperature only. Estimates and uncertainty bars represent the median and 95% confidence intervals obtained from 1,000 block-bootstrap resamples from each of three different empirical models using eight, nine or ten lags of temperature terms.

Extended Data Fig. 6 The difference in committed damages between the upper and lower quartiles of countries when ranked by GDP and cumulative historical emissions.

Quartiles are defined using a population weighting, as are the average committed damages across each quartile group. The violin plots indicate the distribution of differences between quartiles across the two extreme emission scenarios (RCP2.6 and RCP8.5) and the uncertainty sampling procedure outlined in Methods , which accounts for uncertainty arising from the choice of lags in the empirical models, uncertainty in the empirical model parameter estimates, as well as the climate model projections. Bars indicate the median, as well as the 10th and 90th percentiles and upper and lower sixths of the distribution reflecting the very likely and likely ranges following the likelihood classification adopted by the IPCC.

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Kotz, M., Levermann, A. & Wenz, L. The economic commitment of climate change. Nature 628 , 551–557 (2024). https://doi.org/10.1038/s41586-024-07219-0

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Accepted : 21 February 2024

Published : 17 April 2024

Issue Date : 18 April 2024

DOI : https://doi.org/10.1038/s41586-024-07219-0

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BGSU senior earns national award for innovative essay on AI in healthcare

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Paige Rothlisberger uses research to examine how healthcare leaders can prepare for AI-related innovation

#1 University in Ohio for Student Experience

Innovative engineering degrees, #1 public university in the midwest students would choose again for the fourth consecutive year.

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As Bowling Green State University senior Paige Rothlisberger began researching AI in physical therapy for an essay, she thought there was too much to be said to focus on only one area of healthcare. 

AI has the propensity to usher in big changes, so the topic is something healthcare administrators should be discussing thoroughly across multiple healthcare-related fields, she said. 

During Rothlisberger’s research, she came to the conclusion that, even with the possibility of processes changing, one thing should remain the same: Patients have to be at the center. 

As with any new introduction of technology, Rothlisberger said patients’ needs are the most important consideration.

“The patient truly has to be your first priority, so that was a light bulb moment for me to realize that AI and patient-centered care have to go together,” Rothlisberger said. “Everything I read about AI was all about processes and streamlining processes, how we can make something more efficient. Really, it all boils down to whether the patient comes first.”

The conclusions Rothlisberger, a native of Arlington, Ohio, who is graduating at Spring 2024 Commencement, made in her essay, “AI Powered Patient-Centered Care: A Call to Action for Innovation,” resonated with healthcare administrators. 

Her essay won first place in the undergraduate division of the nationwide Richard J. Stull Student Essay Competition, after which she was invited to Chicago to speak at the American College of Healthcare Executives’ 2024 Congress on Healthcare Leadership. 

Rothlisberger worked closely with Dr. Phillip Welch, an associate professor in the Department of Public and Allied Health , to apply classroom learning to healthcare administration as she crafted her essay.

Welch said Rothlisberger’s curiosity helped her work through several drafts of what became an essay that was honored on a national level. 

“Paige, like most people drawn to a university, is intelligent and inquisitive,” Welch said. “But she stepped outside her comfort zone, took extra initiative to enter the essay contest and was rewarded for doing so. This experience taught Paige the value of taking a chance. 

“The essay competition made Paige a stronger scientific writer, reinforced the importance of consulting academic literature when faced with problems and honed critical thinking skills.”

Due to the broad nature of AI, Rothlisberger said one of her goals for the essay was to spur discussion about how AI can work in healthcare, as its implementation will not happen overnight. 

“It’s just so complicated because you can’t just implement AI and have it all figured out — there are a lot of things that go into it, so these are conversations you have to have,” Rothlisberger said. “I went into the essay knowing that AI in healthcare is going to be implemented in stages and it is going to be very important to understand the details in each stage.”

Rothlisberger said AI has many possibilities within healthcare, but one way in which it could truly help patients is to streamline options after a diagnosis to help cater treatment to a patient’s unique needs and wants. 

“When you’re diagnosed with something, you have so many different options,” she said. “Maybe you have the option of something less invasive, the medication route or maintenance. One of the things I examined was using AI to filter what a diagnosis might look like along with the patient’s preferences and previous data to get a more tailored outcome for the patient rather than a one-size-fits-all solution.”

Through completing the paper and attending the Congress on Healthcare Leadership, Rothlisberger said the experience affirmed that she has found her career path.

“I just felt really proud to be a future healthcare administrator,” she said. “It’s definitely a rewarding field where people band together and it’s not competitive. Everybody wants to help each other out because that means you all go back to help your communities get better outcomes. This really established for me where I was going.”

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Updated: 04/29/2024 11:36AM