One of the first examples of East-West collaboration on global health dates back almost two centuries when, in 1840, the Ottoman Empire convened Austria, Belgium, France, England, Greece, Prussia, Russia, Sardinia and Italy to coordinate national efforts for tackling infectious diseases and set standards for quarantine regulations1. At that time, the industrial revolution, which led to an increase in the urban population, unhealthy living conditions and malnutrition, created an environment conducive to the spread of infectious diseases such as cholera, typhus and tuberculosis. Concurrently, developments in the transport sector – such as railways and steamships – meant infectious diseases spread rapidly across the world.
Today, as in 1840, the reason for collaborating on global health issues is clear: cooperation amongst national governments to tackle a common health issue is the fastest and most effective approach. Nevertheless, international collaboration can only occur when the following three conditions are met:
First, countries recognize they must address a common challenge, which extends beyond their border. Joining forces can strengthen national action and help accelerate response by learning best practices from other countries.
Second, countries recognize they share common traits, which can be used as the basis for developing common rules and standards. In turn, newly adopted standards further foster integration as similarities increase.
Third, the agreed actions do not compete or undermine other objectives or actions being pursued by countries. For example, efforts to address pollution and its related diseases – a policy area in which global cooperation is crucial – may be hindered by a country’s objective to increase industrialization in highly polluting sectors.
Countries have created institutions and mechanisms to find common solutions for key and emerging global health challenges. This has occurred at the multilateral, regional, and bilateral level leading to a multitude of processes. The World Health Assembly, together with other fora such as those held by specialized agencies of the United Nations and the Organisation for Economic Co-operation and Development (OECD), are notable examples of intergovernmental organisations whose objective is to promote cooperation and translate evidence into practical policy solutions. An additional approach used by countries to interact and take collective decision-making is to create status-based fora that are not managed by a permanent Secretariat such as the Group of 20 (G20). Countries have also created ad hoc institutions to manage specific functions in their global health response. The Global Fund to fight AIDS, Tuberculosis and Malaria or Gavi, the Vaccine Alliance, are examples of organisations whose objective is to mobilize resources for infectious diseases and to improve access to vaccines. Each example mentioned above are mechanisms in which East-West cooperation on medical science plays a crucial role.
The remainder of this document looks at the benefits of improved cooperation, with a specific focus on East-West cooperation, and discusses how to achieve cooperation by co-developing mechanisms targeting global health. The analysis focuses on two key areas where East-West cooperation may produce significant advantages for global health: i) tackling infectious diseases such as antimicrobial resistance (AMR); and ii) designing cities that promote population health. In addition, this article proposes an additional priority area for policy action in which, so far, East-West cooperation has been underexploited but could produce a significant impact: tackling overweight and its associated non-communicable diseases (NCDs) such as cardiovascular diseases, cancers and diabetes. These examples are based on OECD’s experience in supporting countries’ implement better policies for a healthier life.
As the COVID-19 pandemic has painfully reminded us, infectious diseases are a global health issue in which cross-country collaboration is essential. Similar to COVID-19, AMR – the ability of bacteria to resist antimicrobials – is a complex issue of global concern with potentially dramatic health and economic consequences. Almost one in five bacterial infections is resistant to antibiotics across OECD countries, with resistant rates even higher outside the OECD – for example, AMR prevalence in India, China and Russia is above 42%, and as high as 80-90% for some antibiotic-bacterium combinations.2 The OECD projects that, over the next 30 years, superbug infections will claim the lives of 2.4 million people in Europe, North America and Australia if no action is taken, and that dealing with the complications of AMR will cost USD 3.5 billion a year to the healthcare budgets of these countries3. The burden will be significantly higher outside OECD countries.
In response to this global challenge, countries stepped up action by promoting prudent use of antibiotics and implemented actions to prevent the spread of infections. Governments have also boosted investments to promote research and development (R&D) of new antibiotics, vaccines and diagnostics. Bringing to the market a sufficient number of new products requires significant resources. Further, better coordination of investments help reach a ‘critical mass’ to restart the R&D pipeline. In 2017, G20 countries decided to set up a new organisation – the Global AMR R&D Hub (the Hub) – to facilitate an efficient allocation of resources and support international collaboration4. The organisation, ‘light’ in its infrastructure, creates a place where countries can discuss R&D priorities and build a common ground. Organisations such as the Hub can play a significant role in accelerating East-West collaboration, both at the technical and decision-maker level. The process under which the Hub was developed is particularly interesting as it entailed close collaboration and co-development by G20 countries, and other partners that subsequently became members of the Hub. For example, as part of the process, countries, with the support of relevant intergovernmental organisations, had to agree on the Hub’s role including priority action areas and scope. This process, in itself, gave countries the opportunity to understand each other’s priorities and ‘lay the ground’ for future collaboration. It is now a task of the Hub – and its board members representing the member countries – to develop common standards and actions that will cement this common ground.
Successful East-West collaboration for global health can be also nurtured by sub-national authorities, in particular when promoting healthy cities. Cooperation among cities has enormous potential to shape people’s health as well as global cooperation. Cities account for the vast majority of the global population with about 80% and 60% of the population in OECD countries and China living in urban settings, respectively5. How cities are designed and managed has deep implications on people’s health. For example, cities are an important contributor to air pollution, a risk factor for many NCDs including, cancers and respiratory diseases6. Cities are also the backbone of national healthcare systems, with a higher number of hospital beds per capita and, often, higher quality treatments compared to non-urban areas7. Enforcement of policies to promote healthier lifestyles such as limiting second-hand smoke, promoting active mobility and reducing speeding or drink driving, typically falls to local administrations as opposed to national governments.
To respond to common challenges and share best practices for climate action and a healthier future, a number of city networks have emerged. Two of the most recognized networks are the C40 Cities and the Partnership for Healthy Cities. Both networks bring together many of the world’s largest cities, nearly 100 cities in the case of the C40 Cities, including those in western and eastern hemispheres. Cities who are part of the network establish city-to-city collaborations to share ideas and to sustain a shared purpose. Peer-to-peer engagement and capacity building are at the basis of these collaborations.
In the short-term, investing in city-to-city networks produces a significant return on investment for people’s health; while, in the long-term, they can improve bilateral relations. Many of the activities supported by city networks are high-impact best practices, which modify people’s lifestyles and tackle risk factors to population health. Equally important, these joint activities create an ideal opportunity to forge relationships and promote like-mindedness among local administrators. The common ground created by these joint activities can survive in the longer term when, for example, these administrators are promoted to national-level positions. This is particularly true in China, where national-level policy-makers with executive power are typically appointed after a career administrating provinces or key cities. For example, at least 14 out of 21 Ministers currently serving in China’s Central Government held responsibilities at the sub-national level before their ministerial appointment.
Looking at underexplored areas for East-West collaboration, tackling overweight and unhealthy diets are among the most promising given it meets many of the criteria underpinning successful cross-country collaboration. First, overweight is highly prevalent, with almost 33% and 66% of people in China and the OECD being overweight, respectively. In G20 countries, overweight-related diseases reduce life expectancy by 2.5 years and account for 9% of the yearly budget of healthcare systems8. At a macroeconomic level, the OECD evaluates that, over the next 30 years, the Gross Domestic Product (GDP) of G20 countries will be 3.5% lower than it would be otherwise due to overweight and its consequences, including reduced productivity due to a less healthy workforce.
Second, the globalization of food systems and the ‘westernization’ of the Chinese diet pose similar problems across both hemispheres. The determinants of overweight are multiple and interlinked, but it is widely accepted that consumption of processed food containing high levels of sugar, salt, calories and saturated fat is a key modifiable factor underpinning overweight.8 Food production is a globalized business9, with large multinationals accounting for a significant share of global sales of food10, including in Asian countries as a growing share of population consume western-style food products11.
Third, countries have identified similar solutions, with a growing interest for policies promoting food reformulation to improve the nutritional profile of food products. For example, in the 2018 G20 meeting, Health Ministers selected healthier nutrition and tackling childhood overweight among the key topics of discussion12.
To support global action, including dialogue at the G20, the OECD put forward a proposal for a global deal between national governments and industry to reduce calorie content in relevant processed food by 20%. In practical terms, the proposal would entail strengthening and scaling up to the global level the calorie reformulation initiative pioneered by the United Kingdom13. While a global deal to reduce calorie content in relevant foods by 20% would not address all the causes underpinning the obesity epidemic, the OECD calculates that, if such plan was to be implemented in 42 countries worldwide, it would prevent the development of up to 1.1 million NCD cases per year. In addition, about USD PPP 13.2 billion could be saved each year across the same countries, which corresponds to a 0.21% reduction in total health spending. Finally, countries could expect an additional 0.51% growth in their GDP, a value similar to Chile’s whole economy (i.e. about USD 456 billion). Setting up a mechanism to coordinate the activities that aim to reach this global deal would provide further opportunity to reinforce East-West collaboration on this global health challenge.
Moving from a common interest to a successful collaboration is not straightforward and many practical issues may arise. The inclusion of China as an active member in the global order as well as China’s growing active engagement with the global community can be considered successes for western countries. However, different approaches to tackling global health challenges between East and West countries will likely remain in the near future, a situation that countries should understand. Although these different approaches make collaboration more difficult, they can also lead to better overall outcomes as they tend to be complementary and, overall, they can produce a higher impact on public health14. Compared to other strategic areas, collaboration on global health issues is less prone to conflict although, in some cases, scepticism regarding the potential of East-West collaboration continues, as recently displayed by discussions on the origins of the COVID-19 pandemic and on lessons from this pandemic15. More generally, ideological and strategic differences remain between western countries and China on the management of certain global health issues, for example, with regards to foreign assistance to low-income countries16.
The examples discussed in this article were selected given that, compared to other global health issues, they are less contentious, do not create competition between countries and advantages would be mutual. Therefore, they are likely to help countries work together to fight common threats to population health. To move forward countries should foster bonds built on transparency, trust and mutual goals.
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Michele Cecchini is responsible for the programme on Public Health at the OECD – the Organization for Economic Co-operation and Development. Michele’s research interests include priority setting and programme evaluation of policies influencing population health. Michele represents OECD in the board of the Global AMR R&D Hub and holds a position of adjunct professor in applied health economics at the School of Public Health of the University of Siena (Italy).
Previously, he held a visiting position at the Duke-NUS Graduate Medical School in Singapore and served as a temporary advisor to a number of government and international agencies, including WHO, IARC, the EC and the World Bank. Michele is a medical doctor specialized in public health and holds a master’s degree from the London School of Economics and the London School of Hygiene and Tropical Medicine and a PhD from Imperial College London.