- [narrator] for decades, the u.s. has been a leader in promoting global health. it does so through foreign aid designed to improve the welfare of others, as well as through emergency assistance to fight epidemics like zika and ebola. but foreign assistance has fallen out of favor with some in washington, who argue the u.s. should help itself before helping others. that puts them in confrontation with policy makers who say aid is a good strategy, keeping americans safe from epidemics at home and improving the health, economies, and security of neighbors abroad. does investing in global health improve america's security and other national interests? global health: preventing pandemic, next on great decisions. - [voiceover] great decisions is produced

by the foreign policy association, in association with thomson reuters. funding for great decisions is provided by pricewaterhousecoopers, llp. - [narrator] promoting global health has long been a shared goal of the international community. - when the plague hit europe in the 14th century, about a third of europe perished in roughly 18 months time. that plague created a lot of institutions that had never existed before. the notion of sanatoriums, of special quarantine centers, of having border checks for people coming through with diseases. - [narrator] at the dawn of the 21st century, the aids pandemic would give global health efforts a new importance as a matter of u.s. national security. - vice president gore and then-u.s. ambassador to the u.n.

richard holbrooke came to the u.n. security council in january of 2000. for the first time in history, an issue of public health was brought to the security council for deliberation. - what president clinton was able to do was to understand, i think better than many people, the various parts of what our national security was about. that it wasn't just about having a strong military, which is obviously very important, but understanding that the conditions in other countries affect our national security. - [j.] the watershed moment was president george bush's state of the union address, january 28, 2003. - i asked the congress to commit 15 billion dollars over the next five years, including nearly 10 billion dollars in new money to turn the tide against aids in the most afflicted nations of africa and the caribbean. (applause) - it marked the moment where the u.s.

was committing to move from millions to billions and to put millions of people on antiretroviral therapy. - [narrator] the president's emergency plan for aids relief, or pepfar, represented the largest ever global health initiative dedicated to a single disease. - he had that vision that the united states could play that catalytic role in fighting aids, and he implemented it. and we're all the beneficiaries of that. millions of people have been saved by pepfar. - it said, somehow we're gonna go there as a collective u.s. government, bringing together the strengths of all of the agencies, and we're gonna go from 50,000 people on treatment to two million people on treatment. - a hundred years from now, people will look back and realize that we lived through one of the great pandemics of global history. death toll from aids as a percentage of population as a gross number really is one of the most terrible things the world has seen since the black plague

of the middle ages. - [narrator] in 2014, the global health security agenda elevated global health as a priority among the world's leaders. - there are 55 total countries including the united states that made commitments to the global health security agenda. it's really about helping build the capacities to comply with international health regulations. - if you think about world health like we are just one big organism, we're only as strong as our weakest link, and our weakest link are a bunch of countries in africa and asia where the health care systems are not in very good shape and where diseases can spread and ultimately reach other countries. - we always worry about biological attack, but i don't have to worry about something that dark to be really worried. it doesn't take ill intent for sickness to be a great concern. - we all understand intuitively that isis in syria is a threat to american interests, or the taliban in afghanistan is.

well, ebola in west africa is even more of a threat to our national interests, and maybe the greatest international security threat the world has faced in recent years. - [narrator] while epidemics like zika, malaria, and sars have emerged, so too have the agencies and initiatives to combat infectious diseases. increases in funding earned the first decade of the 21st century the title global health's golden age. - the idea of the golden age for global health is really built around this incredible scale up of support, both from governments like the united states, from private foundations like the aids foundation, and others, and the new financing mechanisms like the global fund. - we spend around 10 billion dollars on global health, and that's about a quarter of our overall foreign assistance dollars, and we spend less than 1%

of our national budget every year on foreign assistance. - [narrator] some law makers see the u.s. as over-engaged throughout the world, arguing that foreign aid represents tax dollars better spent at home. - the notion that the united states should be borrowing from china, a poor country in the world, to then hand out aid to other countries around the world is foolhardy. now, some people will say it's beyond economics, it's really about geopolitics and influence, and that is an argument i'm sure many people would like to have, but from a purely economic perspective, this is not a sustainable model that can work over the long term. - the amount we spend taking care of them overseas is less than a half a percent of our national budget. at any given time, depending on congressional whim, it can be as low as less than 0.2% of the budget

going for global health, so it's a trivial amount of money. - a country always has to take care of its own issues. i mean every country does, every country always responds in its own self-interests. there's nothing wrong with that. but that doesn't exclude the help that we need to continue to give other countries, because the pandemic health issue and threat is very real. the world now is completely, completely interconnected. - [narrator] supporters of u.s. engagement in global health point to the economic effect aid can have benefiting the u.s. in the long run. - 11 of our 15 biggest trading partners actually were once recipients of u.s. foreign aid. so there's a real economic reason about why we need to be invested in global health.

countries that have gotten rid of their malaria epidemics are growing at five times the rate of countries that are affected by malaria. - some of the sub-saharan african countries that 10 years ago were predicted to sink into absolute catastrophe with their national security in peril, their economies in peril, because their young adult labor force had infection rates of 10%, 20%, even in south africa 25%, those economies are now cooking. - making all of the world and all of the world's people healthier is in our self-interest because it will make a world in which people will be better able to produce things, to buy things, to be free to add to our intellectual as well as our physical capital. - [narrator] in recent years global health has made important strides. child mortality is down, and the eradication of polio

is within reach. - the number of children who die before the age of five has fallen by more than half since 1990. that's more than six million kids a year saved. there's been this child mortality revolution around the world because of really simple interventions. - it was a very ambitious effort to think about eradicating polio. this has happened only once before with a human disease, and that's smallpox, which was very notorious. - [narrator] aids-related deaths are also in decline. - now 14 years later, we're talking about controlling one of the largest pandemics that the globe has ever seen with our current tools and without a vaccine and a cure. - we're talking about breaking completely the backbone of this epidemic by reducing by 50% the mortality rate due to hiv/aids. - [narrator] as the percentage of the population

unserved by global health efforts shrinks, the challenge of reaching the most vulnerable members of society is growing. - increasingly i believe that global health efforts are reaching the poorest of the poor and also those who live in remote conditions, but we do have a long way to go. - if we're not doing everything we can to reach people most at risk, including the marginalized, we're frankly just wasting u.s. taxpayers' money because we're not driving towards the end of epidemics if we're not reaching everybody. - we are seeing in eastern europe, central asia increase of 60% of new infection during the last six years because people who inject the drugs don't have access. they are considered as criminal, they are hiding themselves. and we know also in many other places we have bad laws which are not allowing people when they are gay to have access to services.

- [narrator] despite advances, critics say the global health system is unprepared for crises. - we have standards laid out under the international health regulations for what the basic requirements are for being prepared for emerging pandemics and other pathogens. countries are not fulfilling those requirements. - we are really in an interconnected world today. we are in a different world. i personally believe that if we don't have a better mechanism for monitoring emerging epidemic, we will face a major problem of controlling new epidemics. - there are people who worry about the intentional biological threat, and the people who worry about the naturally occurring epidemic. and really a lot of the risks are the same, and while there's some differences, it'd be better if we kind of had the two groups combine forces and think about this as a single threat.

- [narrator] for the first time in history, a majority of the global population resides in urban areas. this rapid pace of urbanization complicates pandemic preparedness. - most of these viruses or bacteria that have pandemic potential, they start in animals. they're zoonotic diseases. and so this recipe of urbanization, globalization, and the right environmental ecosystem is just setting us up for a spillover event, meaning a virus spill that moves from an animal to humans. - with all the success of connecting those areas to urban areas to promote the sale of goods, to promote the transport of people, also unfortunately promotes the transport of disease. - if it's a disease spread by respiratory channels, that means many, many, many more people are exposed. and i mean, we saw that in sars in hong kong. it would be catastrophic if we had a disease that spread more quickly or easily

than most of what we've seen so far. - [narrator] preparing for and fighting disease outbreaks enjoys widespread support, but structural criticisms of global health efforts remain. - as the hiv/aids threat subsided, and we moved from a raging emergency to a system of chronic management of a chronic problem over a long period of time, people began to critique this and say, "wait a second, "is this an open-ended long-term entitlement "that the american people have signed on to?" - we are living in a world where there's so many communicable diseases, ebola, zika, take your pick. there is an absolute argument to be made for us intervening in those types of things. but that's a very, very different thing from making the argument that there should be some kind of a structural, long-term, open-ended commitment to funding programs when the donors don't have money.

- in hiv/aids, we have 57% of the total resources coming from domestic fund. that is showing that the transformation is happening. it's not completely there--we need to push to make sure that more and more resources would come from domestic resources. - others question how global health priorities are set and how well we monitor those investments. - any big program that's handling billions of dollars isn't going to be perfect in the way that it uses every dollar. what we need to make sure of is that we're vigilant in rooting out any misuse of funds and also asking ourselves where our approaches aren't working. - we've learned a lot from fighting malaria, tb, hiv/aids, but we cannot create for each disease a new organization. we need to have a platform which will reinforce

a systemic approach. - when i look at other areas of development, i can see that in the global health area we tended to evaluate less than other areas. we counted a lot of stuff, but we weren't showing what the attributable impact was of the money that we were spending. and i think now that's come to a head. - [narrator] thanks to air travel, a virus can be transmitted around the world in less than 48 hours. to policy makers, stopping epidemics in their tracks and preventing them from breaking out in vulnerable countries is the best way to protect americans while doing good in the world. - well, i'll tell you the first reason, which is that's who we are, those are our values. now let me describe the importance of foreign aid to global health problems in a sense in a more defensive way, just rephrase what we use in the war on terrorism

and say we should try to stop an infectious disease epidemic overseas before it has a chance to come here to the united states. - because we connect so much now, the reality is something could spread that may have spread at a normal speed before will now spread incredibly fast. some diseases have an incubation period that is much slower than our transportation. - now we are trying to build up health capacity, infrastructure, in countries like liberia. one of the problems is that it's not sexy to build up that kind of health capacity, and so there are proposals to cut that kind of spending. - anything that imagines controlling disease at borders, you know, tsa spotting ebola--i don't think so. anything that imagines that america can be safe only based on domestic spending is ludicrous.

- [narrator] the moral argument for saving lives is augmented by the benefits of soft power to improve the image of the u.s. overseas. - perceptions of the united states in developing countries were pepfar was very active is radically different than in other developing countries. - you only have to go to sub-saharan africa as an american and tell them that you're from the united states, and from the president to a person in the farthest rural community will say thank you for helping us. when no one else came, you came. - [narrator] in 2014, an ebola outbreak showcased the dangers of infectious diseases in the era of mega cities and transatlantic flights. with its first recorded case in rural guinea, the epidemic quickly spread to bustling lagos, and a handful of cases crossed the ocean making their way to the u.s. - i grew up in nebraska, and a lot of

my midwestern neighbors were questioning why is the u.s. getting involved in this? and that conversation switched the minute that we started to see the quick transfer of the ebola crisis on a plane in new york, in chicago, in houston. - it came to my home state in texas. mr. duncan took a flight from liberia, and 24 hours later he landed in dallas. and about a week later he was ill, reported to an emergency room in a hospital in dallas, texas. - he was misdiagnosed by the american healthcare system, sent home with asprin, and ultimately died of ebola, having been inappropriately diagnosed and inappropriately treated. - the biggest threat we faced was an ebola outbreak in nigeria, which would have led to a real global epidemic. and the reason that was brought under control was because a decade earlier, under president bush, the united states had made a major investment in fighting aids. - people of africa are fighting hiv/aids with courage.

and i'm here to say you will not be alone in your fight. - and thanks to that investment, there were trained epidemiologists in nigeria, trained public health responders in nigeria. - [narrator] often taken for granted, antibiotics have changed the way the world responds to infection, but antibiotic resistance is growing. - my fear is that we don't do anything until we're scared. and i hope people are feeling scared now because there's already antibiotic-resistant gonorrhea, there's already strains of disease that can kill you if you get just a scratch. - we will see millions of deaths from infectious agents that our antibiotics or antimicrobials cannot deal with. we have significant discussions with member states, and we do have plans of actions at the global level. - after a pandemic flu, the biggest global health threat that's facing the world as a whole

is that we would lose our arsenal of antibiotics to respond to infection. - [narrator] other infectious diseases such as a deadly strain of influenza pose a greater threat than ebola. - i worry a lot about another influenza pandemic. the 1918 so called spanish flu is the terrible example. one of the worst, if not the worst, natural disasters in all of human history. - it's probably the least understood, least studied, least publicly aware major historical event. more americans died in 1918 from spanish flu than died in world war i and world war ii combined. every couple years we see the risk of a more dangerous kind of flu spreading very quickly and the possibility that one of those flus will have a high degree of lethality and a quick rate of spread is a very simple basic risk. - in 1957 we had another flu pandemic

that probably killed up to 1.5 million. so these are really massive killers, and we believe that yes, that there will be a pandemic. - we don't have the right kind of infectious disease response capability in the united states. we don't have adequate resources devoted to that. most major cities have no more than one or two hospital beds to treat a dangerous infectious disease in isolation. - [narrator] the debate over global health continues to evolve, with a dizzying array of agencies and initiatives. global health is not just washington's domain. - it's exciting to see how countries like china, for instance, are stepping up their level of investment on global health, but when one considers the resources that we have, the expertise that we have, the history of involvement on the ground at the grassroots level, no one works the way that we do on these issues.

- there's a lesson here which history has shown that if the u.s. government is not leading in global health programs, very few others will follow. - the government, yes, is the largest provider of resources, but there's an incredible amount of private funding both private philanthropic funding from organizations like the bill and melinda gates foundation, but also from individual donors. - someone has to bring that together as a whole to make sure that the individual pieces come together. - [narrator] often the debate over american funding of global health collides with u.s. culture wars. - since the years of president george w. bush, there has been some emerging bipartisan consensus on some kinds of global health spending, but there is one huge exception to this bipartisan consensus, and that's reproductive health. - we see republican administrations

putting in place policies which restrict funding for family planning, say, and democratic administrations overturning those policies and putting in funding and policies in place to support family planning. - [narrator] following a recent flattening of global health spending, it is unclear whether the golden age of global health is coming to an end or just beginning. - having reached the point where the golden age is over, the jury is still out, but what is clear is that we have not only an unfinished agenda for the core global health programs that have been the focus of this ramp-up, we have a whole host of other issues which are now cropping up. chronic diseases, heart disease, cancer, in countries where communicable diseases have been the overwhelming concern previously. - some people think that maybe the low-hanging fruit has already been picked, and that we're not gonna get as much bang for the buck

in future investments in global health. it used to be pretty easy to save human life for about a $500 investment. now that's hard. you're probably gonna have to spend $3,000, $4,000, maybe $5,000, but i think that there's still a lot of low-hanging fruit around. nutrition, for example, is something that we're increasingly become aware has a huge tie in to global health. - western countries now are struggling with their own problems. they have massive debts, they have significant growth problems in terms of growth going down in a very meaningful way, they have real issues around technology and automation, we haven't even discussed demographics and the aging population and what drag that's going to be in terms of health care. - any new administration comes in with their own set of priorities. i'm optimistic that as this administration continues to think about what its priorities are, it'll realize what a wise investment global health has actually been.

- [narrator] with pandemic preparedness in the balance, the security of americans is becoming increasingly tied to global health. time will tell if the prescriptions are adequate. - [voiceover] great decisions is america's largest discussion program on global affairs. discussion groups meet in community centers, libraries, places of worship, and homes across the country to discuss global issues with their community. participants read the eight-topic briefing book, meet to discuss each topic, and complete a ballot which shares their views with congress. to start or join a discussion group in your community, visit greatdecisions.org or call 1-800-477-5836. great decisions is produced by the foreign policy association in association with thomson reuters.

funding for great decisions is provided by pricewaterhousecoopers, llp.

hello and welcome to nhk "newsline." i'm keiko kitagawa in tokyo. we start with a civil war in syria where the the risk of a clash between new clear powers is increasing. u.s. president donald trump has warned russia that a military strike over suspected chemical attack is imminent. on wednesday, trump responded to a russian threat that it would shoot down incoming u.s. missiles in syria and target their laun s