What Will Happen to Specialized Health Agencies with a Major U.S. Foreign Assistance Reform?

My colleague Steve Radelet testified eloquently before the House Foreign Affairs Subcommittee on Africa and Global Health today, making a strong case for shaping up U.S. foreign assistance programs, and development policy more generally, in pretty fundamental ways. The "asks," as we say in Washington: A global development strategy; a new Foreign Assistance Act reflecting the realities of 2009 rather than, say, 1961; a consolidated foreign assistance architecture that's fully professional and capable of responding in nuanced ways to country contexts; full engagement with multilateral institutions; and resources commensurate with a strong and effective set of policies and programs. This should be music to the ears of many of those who work in the field of development and/or bemoan the distance between the potential for positive U.S. engagement and the reality.For global health, there's no question that it would be of great value to have greater coherence in U.S. activities, and for development as a whole to have a higher political profile and be better resourced. But as grand plans are made and, hopefully, brought to fruition, we need to protect and even enhance the role of the best-performing elements in the current fragmented system. In other words, we want to make sure that a coherent whole is more than the sum of the parts, not less.Let's take the Centers for Disease Control, for example, which brings to U.S. global health programs a storied history of international public health achievement (remember smallpox?) and a set of technical skills that are unique and invaluable. These are the folks who know how to conduct and train others to undertake public health surveillance programs, control outbreaks of infectious disease, design large-scale public health education and prevention programs, implement international health regulations, strengthen public health laboratories . . . and on and on. In other words, if you've got a public health problem, you want the CDC on your team.CDC's global health program has expanded dramatically in the past several years, implementing a significant share of PEPFAR activities, and providing technical support for the President's Malaria Initiative. While some of what CDC has been asked to do has gotten away from core areas of technical strength, on balance the contributions have been enormous and the agency has more than demonstrated that its one of the most important U.S. assets in global health. So, in the search for more coherence and better coordination, how can we make the most of these special skills?Or let's look at the Food and Drug Administration, which has specialized expertise in ensuring the safety of the U.S. (and, by extension, global) drug supply. It's hard to overstate the FDA's importance as a main gatekeeper for drugs that have applications in the developing world, or its potential to provide training and technical support to counterpart agencies around the world. Like what the CDC has to offer, these are capabilities that cannot and should not be duplicated in an enhanced version of USAID, if that's where the winds are blowing. Nor should the FDA and/or CDC be treated as subcontractors on development programs. Rather, they should be welcomed to the table as partners under a unified set of global health goals and strategies.And then there's the National Institutes of Health, whose international reach goes from training of scientists from developing countries to the funding and/or conduct of clinical trials in Africa, Asia and elsewhere. NIH is not typically thought of as part of the development apparatus of the U.S., for understandable reasons, but it has tremendous (already partially realized) potential for enhancing diplomatic efforts through scientific exchange, generating new knowledge from global health programs, and supporting breakthroughs in basic and translational science that have global benefits. Neither leaving NIH alone to do its own thing, nor forcing its international activities under some all-powerful development agency, serves a purpose. Instead, it makes sense to look for linkages between what's done by the NIH and what the needs and opportunities are in the development realm. A logical starting place for this is full engagement of the Fogarty International Center in sorting out where global health fits within the larger development enterprise.This is all easier to say than to do. By their nature as parts of a large bureaucracy, CDC, FDA and NIH occasionally see as Job One the protection of their own budgets and territory, and at times balk at being part of someone else's plan (much better, of course, to have others part of YOUR plan!). The relationship between USAID and CDC has been particularly challenging because both have large field footprints, and the corresponding potential to step on each other’s toes.Working together under one strategic framework will necessarily mean giving up a little autonomy, but that should be balanced by the value of a clear recognition of the special skill set that these agencies bring to the field of global health, and an appreciation of their legitimacy as authoritative voices in specific areas of public health, drug supply and biomedical research. These are assets that could and should be seen as complements to others' expertise in economic and social development.