The Challenge of Financing Global Health

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This transcript is from a CSIS event hosted on May 14, 2024. Watch the full video here.

J. Stephen Morrison: Good morning. Good afternoon. Good evening. I’m J. Stephen Morrison. I’m senior vice president here at the Center for Strategic and International Studies, CSIS, in Washington, D.C. This is a program of the CSIS Bipartisan Alliance for Global Health Security.

We’re delighted today to be able to host Angela Apeagyei and Chris Murray from the Institute for Health Metrics and Evaluation at the University of Washington, I’ll introduce them momentarily, to welcome their colleagues who are here. We have been in the habit for several years – this is the 15th year of the Financing Global Health Report from IHME. And congratulations to Angela and Chris and the team for this report. This as we’ll hear, this is the 15th year.

We were in the habit, pre-COVID, of hosting the annual rollout of the report. COVID got in the way. And now we’re back in the swing. And so, we’re very happy that we’ve been able to resume this partnership. We typically do this with the Kaiser Family Foundation and Jennifer Kates. Jennifer can’t be with us today, sends her regards. In the future I’m sure we’ll be able to bring Kaiser Family Foundation back to the stage with us.

Special thanks to my colleagues, Maclane Speer, Sophia Hirshfield, Micheala Simoneau, Carolina Andrada. From our production team, special thanks to Theo Michell, Dwayne Gladden, and Qi Yu for all their great work in pulling this whole thing together. And on the side of IHME, we’re very grateful to Rhonda Stewart for helping us pull the pieces together for today’s event. And delighted to see Joe Dieleman back here with us.

Angela Apeagyei is a research assistant professor at IHME in Seattle. She co-leads the Development Assistance for Health Resources Tracking Team, which is a very important team within the IHME ranks, and fundamental to the production of this report. She holds a Ph.D. in global health management and policy from Tulane School of Public Health, has a master’s in international development economics from Yale, and graduated with a degree in economics from Oberlin.

Chris Murray is a professor and chair of health metrics sciences at the University of Washington in Seattle, and director there at the Institute for Health Metrics and Evaluation. He’s a physician and a health economist. He’s pioneered the work of the global burden of disease, injuries, and risks, GBD, which is, as I understand it, approaching, it’s 28th or 29th year. Is that correct?

Christopher Murray: More than 30.

Dr. Morrison: More than 30 years. And has been obviously at the center of the production of the Financing Global Health Reports. And during COVID, we worked very closely with him as he spearheaded new modeling approaches to the COVID – to the COVID intervention?

So, what we’re going to do here today, Angela is going to come forward and present an overview, with some slides, of the – of the report. And then we’re going to gather here and have a conversation for the balance of the hour. And we’ll leave some space towards the end for those in the audience who care to pose some remarks and questions. There’s a microphone right here. Please do join us in that phase, those who are here in person, and just keep your interventions brief, please. Thank you.

So, Angela, please come and join us. Thank you so much for being with us.

Angela Apeagyei: Thank you, Steve. I am delighted to be able to be part of this in-person public lunch for the Financing Global Health Report.

Before I get into the details of the results from our analysis, I would like to acknowledge three important groups of people. Steve and everyone at CSIS who has contributed to the strong partnership with IHME, thank you. It’s indeed an honor to be back here today. To the Gates Foundation, who have funded IHME generously and funded this work, thank you. And, most importantly but certainly not the least, to the team at IHME who are behind this important global public good, including Joe Dieleman and Chris Murray, who have led this work in the past.

This year marks the 15th year of IHME’s publication of the Financing Global Health Report. This is a flagship report at IHME that looks at the global health spending trends and levels, especially in low- and middle-income countries. This year, we focused on the important topic of debt burden and development assistance for health. COVID-19 upended most of our lives as we know it and had a huge economic and social toll. Many countries took out loans in order to shore up their economies. In the next few slides, I will go over what has happened with development assistance for health during and after the pandemic, and what is currently happening, as well as the implications for rising interest rates on development assistance for health as well as government spending on health.

In 2023, a total of $64 billion was contributed towards development assistance for health. And this is financial and non-financial resources transferred to international development agencies to low- and middle-income countries, primarily with the intention of improving or maintaining health. This slide, you see, tells two important stories. One, the evolution of development assistance for health over time. Particularly highlighting the dramatic increase in year on year development assistance for health as a result of the health-related response to the COVID pandemic, as well as the subsequent decline towards pre-pandemic levels in the levels of development assistance for health. Suggesting that the response was similar to the panic and neglect approach that has been used in the past. And so as the emergency phase of the pandemic has ended, resources are now being redirected towards other areas.

Secondly, the figure highlights the different areas of health activities that this funding has supported. Again, related to the COVID-19 pandemic, we see that a lot of the funding in 2020 and 2021 went towards the COVID-related response. We also see that other disease areas, such as HIV/AIDS, may have suffered some reductions around those things. We do note that current data for 2023 suggests that as the pandemic response has died down there’s resurgence in funding for HIV/AIDS and the other areas.

Moving on to the implications of this in relation to the rising interest rates. Up until recent times, the interest rates in most advanced countries had been at historic lows. And this figure highlights how interest payments have increased in relation to levels in 2019. We see from the figure that, in relation to 2019 across all income groups, interest payments have increased, especially for low-income countries. That’s highlighted in the green line. And this pattern has implications for both development assistance for health and government spending for health going forward.

We unpack these pathways in these next two slides. So to start with, what we did to understand the implications of the increased interest payments for government health spending, we examined this through estimating expected increases or growth in government health spending going forward. And the figure highlights the results of that analysis. We can see from the results that, in general, the expected growth in government health spending is rather tepid, especially for low-income countries. We have only about a dollar increase in expected health spending when compared to the per-person spending in 2000. This is all quite concerning.

For understanding development assistance for health and what we can expect there, we looked at two different scenarios. One scenario, looking at the implication if governments or donor countries maintain the levels of support they have in the past. And that’s reported in the black line. And here, we see that if donors continue to maintain that support, we expect that about 50 billion dollars will be raised for development assistance for health in 2030. However, if donors reprioritize other sectors and reallocate resources away from health, we’re at risk of – we see only about $37 billion being allocated to health.

And what does this all mean for the future of global health financing? We see that there are imminent threats to the availability of financial resources for global health. And this is both domestically and internationally. And in order to be able to maintain or secure the gains in global health that have been made, intentional advocacy will be prudent going forward. Thank you. (Applause.)

Dr. Morrison: Thank you, Angela. Thank you and congratulations again. I mean, the picture that you’re painting in this report is quite mixed. I mean, there’s a – there’s a certain realism to it, in terms of the scenarios – you know, the optimistic scenario is still might quite modest, right? Four-point-nine percent growth over the next 11 years. That’s not much. And then the more pessimistic one is one of regression by $11 ½ billion. So, it’s very cautionary, very realistic in that regard. And on the other hand, you’re saying that we went from – 2019 was at 49.3 billion dollars. We jumped to 84 billion dollars. That was a massive expansion. And then, as COVID faded, there was a sharp contraction. But that contraction brought us down to almost 65 billion dollars. So that contraction brought us down to a level today that’s 33 percent higher than what it was in ’19.

So, it says that something stuck, right? That there’s been a jump up, a bump up on the investments. But I also sense that – in the report that you’re suggesting, well, you know, maybe that’s not secure. Maybe climate is going to take a bigger and bigger bite out of resources. Maybe we have other forces – the interest – putting such emphasis on interest, on the debt. That’s novel. It’s surprising, I think, for a lot of us. To put so much emphasis on that was really quite illuminating. So, Chris, tell us your – tell us your reflections on filling in on what we’ve just heard from Angela.

Dr. Murray: You know, I think there could be scope to be somewhat even more pessimistic than what Angela’s showed us in those graphs. Because, you know, we haven’t been reminding people of the extraordinary success around global health investments of the last two or three decades, where there’s just been – you know, if you take the graph of under-five mortality, despite COVID, it’s just kept marching down. Go back to when Niger had an under-five mortality rate of 350. And now there’s essentially almost nowhere on the planet that’s above 100 per thousand live births.

So huge progress. It’s continued even in the poorest parts of the world. Yet, there’s this sense that other problems, particularly when you step outside the U.S., are more important, more urgent – and particularly climate. And now, add to that wars and humanitarian crisis. So, unless we make a very good case on what the world gets from these critical investments, it seems like there’s real risk on the horizon for global health.

Dr. Morrison: We had talked a little earlier about, you know, a pessimistic scenario would be one where you say, you know, the interest in in global health has peaked. We’re in a – we’re in a twilight period. We’re in the period of multiple replenishments coming forward in this year and next, some new ones, some big ones. We’ve already seen the difficulty in getting a five-year reauthorization of PEPFAR. The best that could be accomplished was one. That was a very ominous signal.

So, we may be heading into some rude surprises in terms of the gap between what is – really what the aspirations are across Global Fund, and Gavi, and the new funding mechanisms for WHO, the World Bank IDA replenishment, versus what’s really possible. And we’re in a period of a populist critique of foreign aid, right? And we’re in a period of multiple elections happening in which there’s questions being raised about what’s the value, what’s the end game, how does this fit a national security strategy that has us in, you know, a strategic competition with China and other adversaries?

So, there’s a lot swirling around there. I take your point that the approach – Angela closed with we need – we need a better advocacy. Which begs the question of, OK, what would the elements of that look like? And you’re suggesting one is, come back to reminding all of us of the remarkable gains. I think that’s a very important – that’s a very important point. We’re aware of that, but I don’t think that’s being advertised and introduced. But what are some of the other elements that you think should be put into an updated strategy in order to be more optimistic and leaning forward more positively, and not just being pessimistic here? Because it’s not preordained that we’re going to see that decline, but there’s this distinct possibility of that. Your thoughts, Angela?

Dr. Apeagyei: So, thanks, Steve. I think one way in which we can make sure that the gains that have been made in global health are sustained is strengthening our arguments, including providing more detail that links how important it is for national security. I think coming off of the COVID pandemic response, there’s enough evidence of how important it is to make sure that health systems around the world are robust and can detect some of these emerging pathogens. And so, I would say, get some more data that helps us make that link, in a self-interest kind of way, to the citizens, is an important approach.

Dr. Morrison: Thank you. Chris, your thoughts?

Dr. Murray: You know, I think there’s still an ongoing set of new intervention strategies that are coming from investments in R&D. You know, we obviously saw during the COVID pandemic the rollout of mRNA vaccines. But it’s not the only innovation that’s out there for global health. So, I think part of the argument is we have some new opportunities to make improvements and to do that at an even more attractive, cost-effective framework. So that’s part of it. I do think we should – because I think it’s true – link investments in health to helping the hardest-hit countries in the future from climate change, manage their health problems. Particularly the food security part of it. And so that can be an argument as well for managing those two problems in some sort of joint way.

Dr. Morrison: So, climate’s not necessarily – not strictly a threat to health – to health funding. It’s generating health implications. And we’ll be seeing this in terms of increased migration. We’ll be seeing it in terms of infectious disease, extreme weather impacts, and like. And you’re saying, the mitigation agenda is one where there’s going to need much more attention on what the health impacts are.

Dr. Murray: Careful of language because I think some people hear “mitigation,” they think just about decreasing –

Dr. Morrison: No, I mean –

Dr. Murray: – greenhouse gases. But, you know, from the modeling it seems like the biggest pathway for climate on health is actually the food security pathway. And there’s a lot of role for intervening on malnutrition, both in children and adults, to help avoid that health burden. And so, yes, it could be – if you – if we marshal the evidence, and we figure out how to make that case, it can actually help on the health side.

Dr. Apeagyei: Tying the point Chris just made about food security to an earlier point, that the area with both the remaining highest burdens is around the Sahel and the desert areas. I see the great opportunity there in making that case related to providing more support to resolve the food security issues and helping simultaneously deal with the health limitations in the – in the Sahel and other areas that still have heavy burdens of disease.

Dr. Morrison: Now, we are in a period of very large geopolitical wars, right? We’re in the period of Ukraine. We’re seeing the continued war, Hamas-Israel, the possibility of it widening with the Iranian confrontation. We just saw the passage of the $95 billion package of assistance, that included 8 or 9 billion dollars on humanitarian assistance. So, these wars are long lasting. They’re long lasting. They’re big. They’re generating huge human costs. And the price of addressing those is turning out to be very high.

Now, when Global Fund was launched, when PEPFAR was launched, that was the period of the Iraq War and the period of the Afghanistan War. I mean, we had the – what seemed then to become the forever wars. But we were able to deal with those realities simultaneously. How do you see dealing with the pressures coming out of these big geopolitical wars on budgets, on attention spans, and the like? How do you see – what’s the way to navigate that reality today?

Dr. Murray: Part of it is the numbers, because we think of wars and all the terrible destruction associated with them, but still, there’s far more people who are dying from some of the major global health challenges every day then they are dying from the conflicts. So, you sort of got to make the case, not to ignore the conflicts or the humanitarian imperative, but if you care about saving lives and preventing harm, there is this huge still-unfinished agenda. And so, it’s back to sort of reminding people of the core case that was made more than two decades ago to expand global health. And we made progress. The investments have been successful. But there is this need to keep going and get the job done.

Dr. Morrison: Angela, your thoughts?

Dr. Apeagyei: I think, given what you said about limited resources, limited attention, it might be useful to find areas of synergy and opportunities where we can be a little more efficient with the resource – the limited – very limited resources that are available, in trying to solve both perhaps humanitarian health problems in a humanitarian context, right? In that sense, leveraging the same dollars to try and address issues that are intersectoral.

Dr. Morrison: The climate issue is going to be a tricky one, right? I mean, the – we’re launching some work on climate and health this summer for the next couple of years, and when we look at this, consciousness around the connection between climate and health has risen but we don’t have a clear strategy. There’s scattered initiatives here and there. It’s not clear what – which interventions are going to be the most effective with regard to health. And then we – as a country, we’re very divided about what climate – about climate change. So, you’re sort of pushing – you’ve got the notion of creating a bipartisan consensus around climate and health; it’s going to be a challenge trying to do that because people are understandably a little hesitant to sort of take this on at this point in time. Say a bit about the complexities of climate and climate health.

Dr. Murray: Well, we are spending a lot of time thinking about this because – for two reasons.

First, you know, as part of not the financing work, but part of the global burden of disease work, we forecast out into the future. We’re actually publishing this week our global forecast around the burden of disease from everything out to 2050. And as you go farther out – which the climate community, you know, does out to 2100 – you have to ask: What are all the pathways by which climate change can and is likely to influence health? And so, the direct effects of heat are pretty straightforward to capture – you know, heatwaves and sort of increased risk of NCDs and other diseases. It gets trickier when you get into things like floods, storms, you know, wildfires. But again, there’s climate modelers who tell us about some trajectories for that, and we can figure out the health risks. And they’re important, but they’re not huge.

The big – the big pathway that we – our attention’s drawn to is this pathway through some places becoming unlivable and, therefore, people either stay in those environments – this is in the Sahel, in parts of India, the Middle East, Central America – and end up with greatly elevated rates of child and adult malnutrition, or they migrate. And so, there’s a lot of work to be done to figure that out. But either way, there’s a potentially pretty big health effect through the pathway of malnutrition, increasing infectious disease deaths, and/or large numbers of people moving, new stress on the – on the health systems and infrastructure for schools where they move to in shorter periods of time than people are normally. You know think of public infrastructure adjusting to it.

So early days, I think, to figure out all these different pathways. But when you see the – like, the floods right now in Brazil, I think we will see more in the public consciousness the sort of immediate effects of some of the climate changes – or potentially, you know, because of attribution issues. And it’ll just keep coming back into the public consciousness.

Dr. Morrison: And as we were discussing earlier – and I think you made reference to this, Angela – some of the areas like West Africa, Francophone West Africa, are, in fact, really in the firing line on these phenomena, but they’re places where we’ve disinvested or not invested historically as a priority, and the security environment has deteriorated. The governing environment has deteriorated. The U.S. has been thrown out of Niger in terms of its security engagement. The French have been thrown out. Russians are back in – back in spades. How are we supposed to – and yet, that’s sort of a showcase – when you think about climate now, that’s sort of a showcase of what we – of what the future may look like. The barriers, the obstacles politically and in terms of security are fairly formidable. Say a bit about that. Like, how do you begin to make the case for taking another look at what it means for these parts of the world?

Dr. Apeagyei: I think our best case is being made in the real implications of inactions that we can see, right, over time in the Sahel and some of these other areas that you already highlighted. And so, finding a way to bring – it’s easy, I think, for us to be removed from the direct impacts of some of these activities because we are not closely engaged. And so, finding a way to bring some of this reality into the corridors that we live in, I think, will help bring back the focus, bring back the agency of the importance of addressing some of these issues.

Dr. Morrison: Thank you.

I want to shift the conversation to the – to the political environment here. I mean, a couple of things that have happened of late have sort of drawn our attention to the question of trying to sustain bipartisan support for global health. I mean, the success of over 20 years of investing in PEPFAR, investing in the Global Fund, investing increasingly in Gavi, other areas has rested on a – on a foundation of strong bipartisan support and support coming from foundations, from industry, from public health advocates, from the faith community.

Some of that is really starting to unravel. I mean, we – the one-year reauthorization for PEPFAR was a reflection of several things. One was post-Dobbs the abortion debate comes forward as a – as a vehicle for critiquing – inaccurately, but critiquing – and that gained political will. We’ve seen the changes in the Republican Party itself, and there’s been a generational change. Many of the folks who were present as advocates, present as members of Congress, present as leaders are retiring, and there’s – so there’s a generational shift. There’s the polarization and partisanship that came out of COVID around many of the interventions around COVID that – there was a bit of a spillover effect there, too, onto global health.

So, all of these things have created a more difficult environment. Many of the conservative critics of foreign aid are emphasizing now: How does this investment fit with our confrontation with China? What is the endgame? Do we have a long-term endgame? And how do we begin to update our understanding of what the value of the investment is over the long term?

So, it would seem when you look at the environment here in the United States and you look at these critiques that there’s a need to kind of update the rationale in the dialogue. If we’re going to keep a bipartisan basis, we’re going to have to have a different kind of conversation around these investments in order to move things forward into this next phase. Angela, your thoughts?

Dr. Apeagyei: I think I would go back to a strategy Chris mentioned earlier, which is that we do have new interventions. We’ve also made a lot of progress in the recent past. And to a certain degree, it would be unfortunate if we are not able to find a way to work together to sustain all these gains so that the gains will be lost, and whenever the environment changes, we’ll have to start a little from the scratch and reinvest. And so, I think highlighting how much progress has been made with all the previous investment, as well as the new opportunities we have given all the improvements in technology, to do even more good will be an important way to try and bring renewed energy into bipartisan engagement.

Dr. Morrison: Chris, do you think we have an opening for a different kind of dialogue with conservatives around the future?

Dr. Murray: So, I think there if you – maybe we need to focus more on the problems that you can only solve if you have a global response. You know, obviously, climate, antimicrobial resistance –

Dr. Apeagyei: Pandemics.

Dr. Murray: – pandemics. You can’t solve those problems sort of country by country. And there – you can start to make a case for some of the other big challenges that are out there, but those are – most people would understand that that has to be a sort of coordinated global response. And I wonder if that’s the area to look for some sort of bipartisan support of those. But it might mean – if you do that, if you go the route of where, you know, some sort of – I will use the word with trepidation – collective response is required, that might actually lead you down a path of different priorities than we currently have on global health. But maybe that’s one strategy for building bipartisan engagement.

Dr. Morrison: Yeah.

I was struck in reading your – in reading your report no reference to China in that, really. And why is that? And what – where does China fit in this – in this conversation?

Dr. Murray: Well, Angela will answer. (Laughter.) Your take on Chinese investments?

Dr. Apeagyei: Yeah. Yeah. We do – we do – in the reports, we do not call out China, that’s true. But China is included in the estimates that we generate in the overall calculation of development assistance support, so that’s one area.

I think in terms of the challenges we have going forward, you’re right, China’s engagement with low- and middle-income countries is one area that I think in most circles had been thought of as being a little controversial. That said, I think a lot of their investments are related to infrastructural activities. They do have some significant interests – thinking of the Silk Road Initiative here – in health as well. But I think in the – in the short – in the short interim, the focus is more on the infrastructural investment, and perhaps the inroad there will be finding ways to equip national governments to manage that relationship.

Dr. Morrison: Do you think we need a new dialogue with China on some of these things?

Dr. Murray: I think it’s very hard to ignore China just in terms of its size, its increasing footprint in research, AI. And you know, they’re trying to convince people of their success around COVID management – a separate debate as to that success – in reaching out to other countries. And so, yeah, we need to have a strategy of how we think about engagement with China.

Dr. Morrison: You know, one of the – this is part of the work of our alliance, is looking at the – in terms of U.S.-China dialogue around health, global health, and global health security. At a senior level, at a ministerial level, there has been no dialogue now for five years. That’s a kind of profound reality. And with the deadlock over COVID origins in Wuhan and the politics in this town or China breaking that and getting back into a dialogue that would clearly serve the self-interest of both countries – it’s in their security interest – is proving to be really difficult.

We’ve got 10 different working groups operating now between the Chinese and the U.S. on very sensitive and complicated areas where there’s not a lot of trust, but 10 working groups. Health, there is no working group. There’s been a conscious decision to say, nope, we’re not going to go there. We’ll go there on military, cyber, trade and investment, many other things. But we’ve got this void. We’ve got this gap that’s emerged out of COVID that’s sort of blocking this sort of senior-level dialogue.

Let’s talk about the diplomatic environment. We’re on the edge. We’re heading toward the World Health Assembly. We’ll see what happens in the pandemic treaty negotiations, what outcomes there are, and the negotiations over the international health regulations. We have that coming forward. We have the antimicrobial-resistance high-level meeting and a bunch of other meetings that you’re involved in that are the prelude to that.

Should we be hopeful in this phase about what may come? These negotiations have been hard-fought, difficult. They’ve gone on for over a two-year period on the pandemic treaty in the IHR. But we’ll soon be seeing what may come out of it. Are you optimistic, Angela?

Dr. Apeagyei: I am generally an optimistic person. But in this instance, I want to say I am, yeah, cautiously optimistic. That’s a hard word to even come out, only because the news coming out of some of these meetings and dialogue doesn’t give much hope for optimism here. So –

Dr. Morrison: What do you think is the blockage on progress?

Dr. Apeagyei: Oh, I think, at least related to the pandemic treaty, I think countries are so invested in their own self-interest and not seeing the value there may be in externalities and connection and collaboration for the global interest.

Dr. Morrison: OK. So we’re at a certain risk that this investment of diplomacy – this is a big diplomatic enterprise, right –

Dr. Apeagyei: Yes. Yes.

Dr. Morrison: – coming out of this historic COVID experience may or may not generate –

Dr. Apeagyei: No.

Dr. Morrison: – results. What’s your thoughts?

Dr. Murray: I think it’s – we’re missing a key ingredient in – throughout the whole process, which is a shared understanding of what went wrong during COVID. In fact, it’s really hard to imagine you can get a lot of meaningful consensuses on action when people have very different views of the mistakes.

Dr. Morrison: How do you describe the chasm?

Dr. Murray: Well, there’s – you know, the view that it was the failure of early detection and sort of traditional finding cases and isolating them early on, and therefore the solution is early detection and what I would think of as traditional epidemic response would be – and coordination in that task.

And then hopefully, in that vein, you don’t have to worry about nonpharmaceutical interventions and, you know, did mandates work or not, and some of the controversies swirling around those. And you don’t have to go down the route of some of the more contentious issues around mandates to get vaccinated, right. So, there’s that side; you know, focus on the early – you know, the sort of seven-by-seven-by seven type mantra.

And then there are people who, I think, are convinced, you know, maybe inappropriately, that we – there was this huge overresponse in terms of the nonpharmaceutical interventions and they weren’t really well justified scientifically and broke trust with the public. And so, I think, underneath the controversy – obviously, there’s issues of sovereignty – is people’s interpretation of what would we have done differently in December of 2019 into January that would have changed the outcome.

And so, I think you just end up moving down to this less and less content in what people can agree on because of that difference of analysis of what happened.

Dr. Morrison: Yeah. And what can we hope for out of the high-level meeting on antimicrobial resistance? What do you think, Angela? This is going to be on the margins of the U.N. General Assembly in September.

Dr. Apeagyei: I think Chris is more involved in that conversation.

Dr. Morrison: Should I put that question to him?

Dr. Apeagyei: Yes. (Laughs.)

Dr. Morrison: OK, OK.

Over to you, Chris.

Dr. Murray: Well, you know, the aspirations are lower than a treaty. I’m pretty hopeful, actually, that the work is being done to bring AMR to people’s attention. You know, there’s some package around antibiotic stewardship, One Health, and, maybe most importantly, expanding access generally to antibiotics, not just about AMR, and also the innovation pipeline. So, I think it will have a positive outcome in the sense – but, you know, it’s relative to a lower bar of expectation than people have for the pandemic treaty.

Dr. Morrison: Good. Well, I’m glad to hear that.

So, let’s – while we’re on the optimism side of the equation here, which is how we want to close this conversation, I want to invite anyone from our audience who cares to offer a question or comment. There’s a microphone there. We’ve got a few more minutes here in this program. What should we be focused on in terms of sources of optimism and hope in this period, looking ahead?

Dr. Apeagyei: Again, the new tools in the toolbox.

Dr. Morrison: What specifically gives you the most hope in terms of new technologies or new approaches?

Dr. Apeagyei: I mean, this is not as new, but the HPV vaccine –

Dr. Morrison: Which is getting a resurgent – resurgent levels of commitment and interest.

Dr. Apeagyei: Yes, because that provides some opportunities for hopefully having a generation that doesn’t have to have Hepatitis-C and things like that.

Dr. Morrison: Yes.

Dr. Apeagyei: In addition to that, I think there are opportunities for AI. I’m not as well invested in that space to know the exact ways. But I think there’s a lot of investment that are happening to – especially maybe more applicable in lower-income situations with less resources and being able to leverage a lot of the current technology to leapfrog on some of the interventions that have already existed, but have faced challenges in uptake as well.

Dr. Morrison: Chris, your thoughts? Is AI going to offer a counterbalancing positive impact to the greater stress over resource levels and political commitments?

Dr. Murray: I think AI will just have huge effects. Many will be enormously positive, right? We should be able to deliver even to – you know, anywhere where there’s connectivity. And that’s also something that’s increasingly available; AIDS and diagnosis treatment planning. It’ll accelerate, quite likely, some of the biological innovation pipeline; so, simplify imaging, you know, remotely, all these things. It'll come pretty steadily, I think, over the next five, 10 years.

And then there’s all the risks with AI. So it’ll be a – it is both a huge potential accelerator of progress and also a huge potential risk for, you know, malicious use of AI for bioterrorism, for other things.

Dr. Morrison: Yeah.

Well, we’ve got a few minutes left. I’d like you to talk a little bit about some of the other important related work that’s coming forward. You’ve got a blizzard of work coming out. So, tell us if you have a – give us a few of the top line.

Dr. Murray: Sure. Well, thanks, Steve.

The – we are at the end of a sequence of what we call the capstone papers on the current cycle – the Global Burden of Disease studies, so GBD 2021 started publishing in March on demography, on fertility, which is its own interesting topic, and then on causes of death, you know, the full burden in terms of tallies? And now risk factors this week and forecasting will come out Thursday/Friday. And –

Dr. Morrison: What can we expect in that?

Dr. Murray: Well, I think the forecasting is –

Dr. Morrison: Give us a preview.

Dr. Murray: – really, really interesting because we’ve built up – you know, we started forecasting – interestingly, the first forecasts around burden were in 1997 using a super-simplistic model where there was income, education, and tobacco, and that was the only drivers of health outcomes. And then again at WHO we did another round, but it was – there’s never been another set of full burden forecasts since 2004. So 20 years in the making, an interesting modeling framework that answers both what we think is likely to occur, and then a huge what-if platform where you can turn the dials and say: What if we had a New Zealand – well, former New Zealand-style tobacco-free cohort? What if we did a much better job on air pollution, et cetera?

So what’s in the actual paper is the reference or probabilistic forecast for every country out to 2050 by cause. And then there is a small number of scenarios just sort of getting at the potential to alter the trajectory. That small number of scenarios includes a big NCD package, which has huge potential benefits, and then others around environmental risks.

The headline message is despite all the doom and gloom that we’ve been talking about, despite capturing the effects of heat – the direct effects of heat, we do expect continued progress just as we’ve had for the last, you know, 70 years. And that progress will be slower than in the past – and I’ll come back to what’s driving that – but progress, nevertheless. There will still be large disparities in 2050 between the poorest countries and the richest, but narrowing, right? So it’s generally pretty positive, right, compared to some people who are coming at these issues thinking we are going to see no progress.

Big caveats. The slowdown, where is it coming from? Big chunk of that is the nexus of diet, physical activity, obesity, and blood sugar driving huge expansion of diabetes; and then there’s a component around drug use, which in some countries is exploding and related; and then a component around rising mental disorders and other forms of addiction that all make the progress that we will see less than it could have been. And so, you know, that’s the flavor.

And I think the thing I’m most excited about is that we’re now already lining up a series of other what-if-type analyses. You know, a more comprehensive view of all the pathways for climate coming later this year, we hope. What about AMR trends, building that into the forecasts? We have some U.S. policy-related forecasts for the – for the U.S. across states. And already getting requests from different governments for tailored what-if to their context.

Dr. Morrison: Thank you.

Angela, closing words on the pipeline for your work, things that you’ve got in the works that we haven’t talked about.

Dr. Apeagyei: We’re hoping we can do some work trying to understand how climate change issues impact development assistance for health support as well. So given the interest at least globally, I think that should be meaningful going forward, so.

Dr. Morrison: When will we see that, would you guess?

Dr. Apeagyei: Cautiously, maybe next year, in a year or two. We still need to locate some funding for that work, so.

Dr. Morrison: Yes.

Dr. Apeagyei: Mmm hmm. Mmm hmm.

Dr. Morrison: OK. Well, this has been great. Thank you both. Thank you both for coming to CSIS –

Dr. Apeagyei: Thank you, Steve.

Dr. Morrison: – to be with us today. Congratulations on the – on the report. It’s a terrific piece of work, as usual. And congratulations on all the other great work that IHME is doing. And come back soon. Thanks.

Dr. Murray: Thank you, Steve.

Dr. Apeagyei: Thank you. (Laughs.)

Dr. Morrison: Thank you. (Applause.)