If I am correct that ameliorating the most common causes of disease, disability, and premature death require global solutions, then the future is demoralizing. The States that bear the disproportionate burden of disease have the least capacity to do anything about it. And the States that have the wherewithal are deeply resistant to expending the political capital and economic resources necessary to truly make a difference to improve health outside their borders. When rich countries do act, it is often more out of narrow self-interest or humanitarian instinct than a full sense of ethical or legal obligation. The result is a spiraling deterioration of health in the poorest regions, with manifest global consequences for cross-border disease transmission and systemic affects on trade, international relations, and security.

Suppose that States were convinced that amelioration of global health hazards was in their national interests or that they otherwise accepted the claim that they have an ethical or legal obligation to act. Would the consequent funding and efforts make a difference? If past history is any guide, the answer is no. Most development assistance is driven by high profile events that evoke public sympathy, such as a natural disaster in the form of a hurricane, tsunami, draught, or famine; or an enduring catastrophe such as AIDS; or politicians may lurch from one frightening disease to the next, irrespective of the level of risk ranging from anthrax and smallpox to SARS, Influenza A (H5N1), and bioterrorism.